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Answering the Critics

"The insurance industry and the AMA have spent huge sums describing how bad the Canadian plan is, distorting the reality, even lying."

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Critics of the single-payer Canadian health care system insist that Canadians suffer intolerable waits for treatment and a shortage of technology that denies them the most advanced care. In educational materials created for Physicians for a National Health Program, doctors David Himmelstein and Steffie Woolhandler respond:

"Opponents of a single payer system have publicized the false notion that high technology is unavailable in Canada. In fact, compared to Americans, Canadians have higher rates of heart and/or lung, and liver transplants; slightly higher rates of bone marrow transplants; and comparable rates of kidney transplants.

"Canada has regionalized most of these services. A relatively small number of centers each perform a large number of procedures. Such regionalization improves the quality of care since high volume centers are better able to maintain competence, and minimizes cost by avoiding the unnecessary duplication of expensive facilities . . .

"In the United States excessive investment in high technology equipment sometimes worsens the quality of care. Research has shown that surgical teams must perform a minimum number of complex procedures each year in order to maintain their competence. . . . Yet, more than a third of California hospitals that perform open heart surgery have dangerously low volumes that raise both death rates and costs . . . "

Himmelstein and Woolhandler report that "for virtually all cardiac-related diagnoses and interventions, Canadians receive care at rates comparable to insured [their emphasis] Americans." Citing a study that compared elderly Americans covered by medicare with elderly Canadians, they note, "Hospital admission rates for both medical and surgical care were comparable with the single exception of coronary artery bypass graft surgery, which was substantially more common in the U.S. than in Canada. This procedure is almost certainly overused in the U.S."

In a 1991 study of the waits required for heart surgery, a Canadian doctor, C. David Naylor, found some value in delay: "No queues imply excess capacity. That is, one could only offer more or less immediate surgery to all cases, elective and urgent, if there were idle operating rooms and surgical staff, empty intensive care unit and ward beds, and so on. Indeed, delay may be beneficial for some elective cases. It offers the patient time for sober second thoughts, including a further trial of medical therapy and time to put affairs in order, given the minor risk of death at surgery and the certainty of some postoperative recovery time. . . . Combine excess capacity with fee-for-service payment of both surgeons and hospitals, as in the United States, and it is no surprise to find that U.S. [cardiac surgery] rates are extraordinarily high."

The U.S. General Accounting Office, in a study of the Canadian system not particularly friendly to that system, nevertheless reported, "There are more physicians per person in Canada than in the United States, and Canadians use more physician services per person than do U.S. citizens. Yet the cost of physician services per person in Canada was one-third less than in the United States.

"Residents of Canada make more physician visits and have longer hospital stays than do their U.S. counterparts," the GAO found. "Patients visit their family physician or other general practitioner with no evidence of queues or lengthy waiting times for appointments. For example, nearly all expectant mothers in [Ontario] receive prenatal care. In the United States, 76 percent of women who had live births in l988 received prenatal care starting in the first trimester [and] 6 percent started prenatal care during the third trimester or received none at all . . .

"Waiting lists or queues have developed for some specialty care services, such as cardiac bypass surgery, lens implants, and magnetic resonance imaging. Emergency cases, however, are treated immediately, bypassing the waiting lists."

The GAO said long waiting lists sometimes exist for diagnostic services such as CAT scans and MRIs because the equipment is in short supply. Himmelstein responds that the U.S., however, has an overabundance of such machines and "is not likely to destroy them all if we were to convert to national health care."

A l990 Harris poll showed that 48 percent of Canadians were "very satisfied" with the availability of high-technology tests, procedures, and equipment, compared to 58 percent of Americans. Critics say many Canadians cross the border seeking allegedly superior American care. The actual number may be tiny, despite aggressive marketing by American medical services, referrals by Canadian doctors, and the guarantee that the Canadian government will pay for everything but elective care. According to the GAO, the Ontario Ministry of Health estimated that in l990 it spent roughly l percent of its total provincial health care budget on care obtained in the United States.

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