604
Canadian Family Physician•Le Médecin de famille canadien Vol 56: june • juin 2010The mirror south of the border
Catherine Varner
MDT
he current health care debate in the United States has had the effect of stoking our own debate on the Canadian health care system—and some mis- understandings about proposals for health reform in the United States have had the effect of perpetuating several myths regarding the Canadian health care system.The ongoing debate south of the border should give us pause as a profession, as it is leading to a distorted reflection of our health system and, ultimately, our- selves. Such misunderstandings no doubt affect the way Canadians view their health care system and might in turn create national negativity toward a system that is, in my view, working.
My perspective is that of an American-trained physi- cian who came to Canada to complete a family medi- cine residency. I trained in a public hospital in North Carolina that served many of that state’s uninsured. The uninsured of North Carolina are the working poor, as in most of the United States. Indeed, my patients’ sto- ries were tales of woe—inaccessible health care, end- stage presentations of preventable disease, and growing insurmountable debt.
For the first time in more than a decade, health care has become a potluck, church, and dinner table conver- sation in my home town. However, as I piled on another spoonful of baked beans at a wedding attended last July, the discussions I overheard were not belabouring the details of the contentious Health Care Reform Act;
rather, they were corroborating the media’s represen- tation of the “Canadian health care system”—refusal to treat based on advanced age, devastating wait times for emergent surgeries, or inaccessibility to state-of-the- art diagnostic testing. Being American and Canadian trained, I have found myself addressing many of the myths surrounding this contentious debate on both sides of the border at a number of social gatherings, as well as in the clinic.
Myth 1: The Obama administration is proposing a “Canadian system”
In opposition to the Health Care Reform Act, Republican Senator Judd Gregg said that a government insurance program being considered in the United States “is a slippery slope to a single-payer system like Canada or England.”1 Those who oppose this bill are quick to
compare its contents to a single-payer system. In real- ity, however, the bill adds to the hodgepodge, multipayer American system, hoping to insure the uninsured and making health insurance more affordable. In short, it means to expand health care coverage to the approxi- mately 40 million uninsured Americans2 by lowering the cost of health care and making the system more effi- cient. To that end, this includes a new government-run insurance plan to compete with private companies, a requirement that all Americans have health insurance, a prohibition on denying coverage because of pre-existing conditions and, to pay for it all, a surtax on households with an income above $350 000.3
As one of my medical school professors stated, the American health care system is not a system. I com- pare it with a nearby household in my hometown neigh- bourhood—with the passing of every year, an addition was hurriedly added with little attention to function or appearance. As time passed, an RV became amalgam- ated with the 4 multicoloured attachments in addition to a few tents and a garage. This house was quite a departure from my very traditional home life, but it was not ideal for a growing, busy family. Obama’s plan adds a brand-new RV to the house to replace the 40 million tents in the yard.
Myth 2: Too old for care
Even more stirring in the health care debate are cer- tain statements made by elected officials. For example, Republican Senator Mitch McConnell cited the case of a friend who had “just lost a friend of his in Canada because the government decided he was too old for a certain kind of procedure.”4
In the South, many of our stories begin with “I know a friend who has a friend,” which inherently gives only suspect merit to Senator McConnell’s comments.
However, this statement did create a stir among the church ladies with whom I shared a pew for most of my childhood and adolescence. One technology-savvy octogenarian wrote me an e-mail to confirm Senator McConnell’s statement—would I as a physician be forced by the government to refuse care to a patient on the basis of age in Canada?
Physicians in Canada have far less third-party inter- ference than physicians in the United States do. For multiple reasons, including greater physician autonomy and less fear of litigation, physicians in Canada are bet- ter able to provide evidence-based medicine, the corner- stone of medical practice.
La traduction en français de cet article se trouve à www.cfp.ca dans la table des matières du numéro de juin 2010 à la page e241.
Residents’ Views
College
•Collège
Vol 56: june • juin 2010 Canadian Family Physician•Le Médecin de famille canadien
605
Residents’ Views
Insurance company preapproval for certain proce- dures and diagnostic testing consumes a tremendous amount of physicians’ time and energy in the United States. My most vivid memory of this vetting process is of being in medical school and listening to an intensive care unit physician arguing with an insurance company agent for not allowing an emergent, life-saving organ transplant to take place. The US-based insurance com- pany refused to cover the costs because the patient had not had a routine dental visit in the past year. The agent on the phone had no formal medical training. After sev- eral hours via multiple chains of command, the physi- cian finally spoke with another physician who granted approval for the transplant pending a dentist’s examina- tion of the patient in the intensive care unit.
It is estimated that one-quarter of health care costs in the multipayer system are administrative, creating a tremendous burden on both physicians and patients in the United States.
Myth 3: No access to specialists
According to the American Academy of Family Physicians, in the past 10 years 90% of medical school graduates in the United States have opted to enter into subspecialties. Only 10% have chosen primary care.5 These figures are in comparison with the nearly 40% of medical graduates in Canada who were matched to fam- ily medicine in 2009 by the Canadian Resident Matching Service.6 It is no surprise, therefore, that Americans see 40% more doctors, most likely owing to increased spe- cialist referrals and self-referrals.7
My experience as a medical student in North Carolina attests to such figures. Even at a public medical school with a very strong family medicine department, there was tremendous pressure to choose subspecialty resi- dency programs over primary care. In my class of 160 students, 14 went into family medicine, and we all heard comments from our staff physicians such as “what a waste of a good doctor” and “you will be bored in fam- ily medicine.”
The shortage of primary care physicians in the United States means many patients do not have primary care providers organizing multiple medical diagnoses or tak- ing responsibility for preventive care. It is like a foot- ball team not having a quarterback. President Obama’s Health Care Reform Act seeks to give more than 40 mil- lion Americans better access to health care; however, should it be enacted, it will likely be very difficult for those Americans to actually access health care because of the lack of primary care physicians.
This prediction regarding limited access to health care owing to lack of primary care physicians is based on the events following the passing of a 2006 health care reform law in Massachusetts that required all medi- cal residents to have health insurance. The influx of more than a quarter of a million newly insured residents
led to overcrowded waiting rooms and overworked pri- mary care physicians who were already in short supply in Massachusetts.8,9
Health care reform is a contentious and divisive issue in my home town this year. Even at neighbourhood potlucks, it replaces talk of traditionally divisive issues such as war, abortion, and gay marriage. Unfortunately, rather than focusing on the need to change the US sys- tem, the debate vilifies the Canadian single-payer struc- ture and offers a distorted view of health care across the border. As Canadian family physicians, we should use the attention garnered from the American debate as an opportunity to increase public awareness of successful elements of our system and to highlight failing areas, rather than allowing a wide net of negativity to be cast over the entire Canadian health care system.
Dr Varner is a second-year resident in the Department of Family and Community Medicine at the University of Toronto in Ontario.
Competing interests None declared References
1. Amick J. Health-care reform peaks and valleys. Washington Post 2009 Jul 12.
Available from: http://voices.washingtonpost.com/44/2009/07/
senators-unload-views-as-sotom.html. Accessed 2010 May 4.
2. DeNavas-Walt C, Proctor BD, Smith J. Income, poverty, and health insurance coverage in the United States: 2006. Washington, DC: US Census Bureau; 2007.
Available from: www.census.gov/prod/2007pubs/p60-233.pdf. Accessed 2010 May 4.
3. Summary of HR 3200. America’s Affordable Health Choices Act of 2009.
Washington, DC: US Library of Congress; 2009. Available from:
http://fifthfreedom.org/elections/pdf/health_care_bill_summary.pdf.
Accessed 2010 May 4.
4. CNN Newsroom. President makes hard push for health care reform;
President Obama’s American citizenship questioned by some; questions swirl around capture of Bowe Berghdal [Transcripts]. CNN International 2009 Jul 21. Available from: http://transcripts.cnn.com/TRANSCRIPTS/0907/21/
cnr.07.html. Accessed 2010 May 4.
5. American Academy of Family Physicians. 2009 match summary and analy- sis. Leawood, KS: American Academy of Family Physicians; 2009. Available from: www.aafp.org/online/en/home/residents/match/summary.
html#Parsys60571. Accessed 2010 May 4.
6. Canadian Resident Matching Service. Discipline choice of Canadian appli- cants. 2009 first iteration R-1 match. Ottawa, ON: Canadian Resident Matching Service; 2009. Available from: www.carms.ca/pdfs/2009R1_
MatchResults/9MatchReport_E.pdf. Accessed 2010 May 4.
7. The OECD Health Project. Towards high-performing health systems. Paris, Fr:
Organisation for Economic Co-operation and Development; 2004. p. 100.
Available from: www.oecd.org/document/58/0,3343,en_2649_33929_
31786874_1_1_1_1,00.html. Accessed 2010 May 4.
8. General Court of the Commonwealth of Massachusetts. Summary of the Massachusetts Health Reform Law. Westborough, MA: General Court of the Commonwealth of Massachusetts; 2006. Available from: www.mass.gov/
legis/summary.pdf. Accessed 2010 May 4.
9. Lowry F. Massachusetts’ universal healthcare coverage reveals serious short- age of primary care physicians. Medscape Today 2009 Oct 8. Available from:
www.medscape.com/viewarticle/710200. Accessed 2010 May 4.
Want to be published?
Canadian Family Physician is looking for thoughtful
