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News Release

Canada's Single-payer health care scheme
a singular success

August 1993

The MRG Steering Committee wrote the following response to Jerome Arnett's attack on the Canadian health care system. The Wall Street Journal refused to publish the reply.

In the August 8, 1993 Wall Street Journal, Dr. Jerome Arnett presented a distorted picture of the Canadian health care system. As physicians with a combined experience of over 45 years working in family medicine, intensive care, and internal medicine in Canada, we would like to set the record straight.

Dr. Arnett quoted Canadian physicians and hospital administrators making remarks about how the Canadian health care system is in dire trouble. Understanding these comments requires some knowledge of their context. In the single-payer Canadian system, the government holds the purse strings, and negotiates on behalf of society with special interest groups, including physicians and hospital administrators. In contrast to American negotiations between a myriad of individual third-party payers and physician and hospital groups, the Canadian deliberations are conducted in the public eye.

This very visible negotiation requires that physicians and hospitals convince the public that they are entitled to a greater share of increasingly constrained public expenditures. How do they do this? They manufacture a sense of crisis. The required rhetorical flourishes in this public theatre should not confuse the external observer. Just because the boy is screaming wolf does not mean the wolf is really at the door.

So how should American observers obtain an accurate picture of what is happening in Canada? They should look at scientific surveys of Canadian physicians and (more important) Canadian patients, and compare them to what they find in similar surveys among Americans.

Despite the very real tensions created by attempts at cost control, both graduate physicians and physicians-in-training in Canada are extraordinarily satisfied with the system. For example, in one survey, 88% of Ontario physicians were either moderately satisfied or very satisfied with their ability to meet the needs and demands of patients. In another recent study, 79% of Canadian physicians were either "satisfied" or "very satisfied" with the quality of care they were able to provide, and 81% felt their patients had adequate access to specialist care. Only 18% of Canadian physicians-in-training think there is a serious problem with access to care in Canada, whereas 75% of U.S. physicians-in-training believe that Americans have a serious access problem.

Since cost containment pressures have put every country's health care system under siege, you will not find an overjoyed group of physicians anywhere. However, in contrast to what Dr. Arnett tells us, Canadian physicians have done well in maintaining their income and enjoy a mean net income of over $100,000. When you look at global ratings of satisfaction, Canadian physicians are consistently as or more satisfied than their American counterparts.

What's most important are the opinions, and the health, of Canadian patients. Writers like Dr. Arnett spend a great deal of time trying to convince Americans that Canadians have to put up with intolerable waits for quality care. They have the wrong audience: Canadians haven't heard yet. Ironically enough, more Americans than Canadians report not receiving needed care not only because of financial, but also non-financial barriers. In the most recent survey, 94% of Canadians rated the quality of care they received as good to excellent, and 85% said that they or their families had never had to wait an uncomfortable length of time for care. It doesn't take much insight to imagine what impoverished Americans would say if they had to answer such questions.

Canadians' reports of adequate care don't fit with Dr. Arnett's picture of endless waiting lists. That's because in reporting a single study of waiting lists, he doesn't mention the low response rates, distortions because of patients sitting on more than one waiting list, patients who will never go to surgery sitting on waiting lists, and he fails to distinguish urgent from elective procedures. In fact, a survey by the American General Accounting Office showed that there are no waiting lists at all for emergency procedures in Canada. Our own experience is that Canadian patients receive timely, high quality care, and have adequate access to high technology tests and procedures. The quality of Canadian medical care is reflected in Canadians' health. Canadians have a longer life expectancy and a 30% lower infant mortality than do Americans.

There are other distortions in Dr. Arnett's article. He presents the closure of Canadian hospital beds as a disaster, without mentioning that Canada has almost 40% more hospital beds per capita than the United States, and is moving to rationalize hospital care. He depicts a flood of dissatisfied Canadian physicians to the United States. We've already shown that rigorous surveys indicate that Canadian doctors are less dissatisfied than their American counterparts. In 1991, the last year for which we have data, more Americans physicians moved to Canada than the reverse. Many Canadian doctors who do go to the United States return to Canada, disgusted with the inequities in American health care.

The final issue is costs. Dr. Arnett cites rapid escalation of health costs in Canada. In fact, the single payer system has been extraordinarily successful at cost containment. Canada spends approximately 9% of its gross national product on health expenditure, while the United States spends over 13%. The biggest difference is the administrative savings in Canada, versus the administrative waste in the U.S..

What are the real differences between Canadian and American health care? Canadians have equal access to high-quality health care, as compared with the limited access to even basic primary care among millions of uninsured and underinsured Americans. Canadians are far more satisfied with their health care system than are Americans, and they are healthier. Finally, the single-payer system allows Canadians to have these benefits while controlling expenditures. It's sad that Americans, repeatedly exposed to distorted presentations such as Dr. Arnett's, may not realize the enormous benefits of a universal-access, single-payer health care system.

Gordon Guyatt M.D., F.R.C.P.(C.)
Haresh Kirpalani, B.M., M.R.C.P.
Mimi Divinsky, M.D., C.C.F.P.
For the Medical Reform Group of Ontario

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