Monday, July 9, 2007

An Update on Canadian Health Care

An Update on Canadian Health Care
Mimi Morton

I lived in Canada from 1970 until 1999 and had the benefits of its health care system. As a cancer survivor, I credit the Canadian system with saving my life. I can’t dredge up even one memory of bad care. Nonetheless, I know the system is flawed. As I was leaving Canada for the U.S., my Montreal surgeon, David Owen, told me, “Our system is broken.” He was referring to increased restrictions on his professional autonomy. The American health care system experiences restrictions of a different kind. U.S. insurance providers attempt to keep costs down by limiting patients’ claims rather than doctors’ protocols.

If Americans are ever to develop a truly universal, publicly-funded system, it will not be any more perfect than the Canadian one. To preview conditions we might face if we make health care a right rather than a privilege, I wanted to check in with the Canadian system now.

World Health Organization statistics have consistently shown that health outcomes are better in countries that cover all their citizens rather than in countries that do not. But most Americans have also heard horror stories about Canada, the same ones we tell about our own system: big city emergency room chaos, long waits for referrals, overworked general practitioners. I wanted to transcend hyperbole and talk to Canadians themselves.

The system that I left in 1999 was overworked and fraying around the edges but it still delivered quality care. As Canadians like to say, when you have it bad, the system is good to you. Call it triage if you wish, but when everyone is served, the worst cases must be seen first. I experienced this preferential treatment when I had cancer.

I’d heard that the 21st century was bringing Canada closer to a two-tiered system: the original public system is still in place but private insurance policies are increasingly utilized, principally to expedite care. In fact, private insurance companies have never gone out of business in Canada. From the 70s until the ‘90s, I paid into and received supplemental insurance through my Montreal teachers union that covered such amendments as high-priced specialty medicines and private hospital rooms.

Beyond such add-on insurance, full-service private group insurance is available for those who can pay. Michael Bantey, a corporate lawyer in his 40s, told me he stopped using the public system when he joined his firm and now pays into their private group policy which he considers superior to what he could get publicly. “I pay to have an MRI or whatever to avoid the six-month wait.” For my interviewees, the wait for access is the single biggest drawback of the public system.

Leila Basen, a Montreal screenwriter, told me a variation on this theme. When her daughter suffered a painful sports injury to her knee, she opted for a private MRI because she assumed the wait “might be ten months if we went through normal channels.” Because her daughter was in great pain, an orthopedic surgeon saw her immediately and her surgery took place within a month. Basen has supplemental insurance through her writers’ union which covered drugs but not MRIs. While she was happy with the timeliness of her daughter’s care, she acknowledges that the system can be difficult to access.

“’Did you have to give them an envelope?’ That’s an expression you hear from older people in Montreal.” Basen explained that this mild form of bribery is sometimes used in order to “jump the queue.” (I had never heard of the practice.)

However, when Hanford Woods, a former colleague of mine in Montreal, decided on hip replacement surgery in 2006, he found the wait reasonable and he was able to schedule the surgery at his convenience, during his vacation.

Perhaps the most caustic story came from the youngest person I interviewed, Alex Fellows, a thirty year old artist and writer. “I was hit by a car in 1999 (when he was 22). I crashed the front windshield and dented the roof as I rolled over the top. Some old lady had run a stop sign. The impact knocked both my shoes right off and shattered my front teeth. In the hospital I waited on a stretcher for about half an hour in a hallway next to other people moaning on stretchers. Eventually they took my x-rays real fast and everything checked out o.k. I was ready to go home, even though I was having trouble walking. I wasn’t offered to sit down anywhere or what to do when I got home. I asked if I could borrow a slipper because I had no shoe and it was raining outside. They gave me a bunch of doctor hair caps to use as shoes and showed me to the door, where I had to call a cab. At home, I passed out with a crazy headache. (This experience was) nothing that would shock any African, but it’s bad seeing I pay all these taxes and it’s such a fast-food health system.”

Harold Rich, a sixty year old pediatrician at the Montreal Children’s Hospital would dispute Fellows’ story as representative of emergency room care. “We try to provide the best care for everyone,” he said. “Without concern for money. “ He acknowledged that budgeting issues are chronic but that overall, both children and their parents are happy with the level of care. He added, “We offer excellent intensive ambulatory care.”

While Rich admires his hospital’s clinical practices, he is critical of what he describes as the “unfriendly” hospital ambiance: unaesthetic waiting rooms, poor food. He thinks that creature comforts could be improved. “It’s just a matter of will.” Nonetheless, hospital budgeting also must work on a triage principle in which funding for drapes and furniture comes at the bottom of the list.

Susie Gruber, a fifty-seven year old Montrealer who worked for many years as a receptionist at a CLSC, Quebec’s system of neighborhood clinics, tells me that the system is crowded. CLSCs no longer accept walk-ins. “It’s getting harder to be seen by a g.p. if you don’t have one,” she told me. “And, yes, the office waits can be long.”

In spite of their honest impressions of the system’s limitations, all of the people I interviewed, with the exception of the corporate lawyer, said they thought the system’s benefits far outweighed its problems.

Leila Basin told me the story of her other daughter who suffers from a rare congenital heart condition and has undergone multiple surgeries. She currently is seen by a comprehensive heart unit at the Royal Victoria Hospital where all her health needs are treated in one place by a team of specialists. Basen is impressed with the level of care and the innovative holistic approach.

Canada and the U.S. share more than just a common border. There is a great deal of professional interface between Canadian and American doctors. Many Canadians (such as the heart specialist Basen’s daughter works with) have studied in the U.S. just as American doctors study and work in Canada . As we struggle to reform our chaotic non-system, Canada provides us with valuable experience.

Granted, my interviewees were all urban residents of one province. Different Canadian regions may experience different challenges. Overall, my interviews did not uncover evidence of poor care but they did show the stresses a system withstands, particularly in access to primary care and expensive screenings, when patient volume is increased.

We already know that the American primary care system is over-utilized and understaffed as more medical students opt for lucrative specializations rather than family medicine/preventive care. American medical schools will need to encourage a more humanistic ethos if we are to train doctors to enter our own version of a universal public system in which medicine is more than just a business.