All is not quiet on the Canadian health system front

Debates about health system reform in the United States are heating up, stimulated by activity in Congress to reauthorize the State Children's Health Insurance Program, state actions and proposals (especially the new law in Massachusetts) that aim to achieve universal health insurance coverage, reform proposals offered by presidential candidates, and Michael Moore's movie, "Sicko."

Advocates on opposite sides of these debates often point to Canada to bolster their arguments.

Those favoring a single-payer system tout Canada's public health care system, which promises access to health care for everyone, and which is purported to achieve health outcomes as good as (or better than) those in the United States, while using a smaller slice of the nation's GDP for health care.

Opponents argue that rationing and long queues for modern diagnostic tests and elective surgery undermine and contradict the Canadian government's guarantees of universal access.

Last month I attended the annual meeting of the Canadian Medical Assn. in Vancouver. And although "Sicko" portrayed Canada's public health care system as being problem-free, I heard a different story from Canadian physicians.

CMA delegates received the 7th Annual National Report Card on Health Care, which is based on a June survey of 1,000 Canadian adults. When asked to grade the overall quality of health care services (A, B, C, or F), three of five respondents gave the system an A (21%) or B (41%).

However, the percentage choosing C (28%) or F (9%) was higher than in 2006 (33%). When asked to assess their most recent experience dealing with the health care system in their community, three in 10 gave a grade of C (20%) or F (9%).

Grades were worse for access to health care services. Almost half gave a C (23%) or F (22%) for access to a family doctor in their community, and 50% or more gave a C or F for access to medical specialists (37% and 21%, respectively), access to modern diagnostic equipment such as MRI and CT scanners (35%, 19%), access to emergency department services (32%, 18%), and access to health care services on evenings and weekends (39%, 21%).

The report highlighted four areas for which the percentage of respondents choosing F exceeded the percentage of those choosing A -- access to medical specialists, access to modern diagnostic equipment, access to services on evenings and weekends, and access to mental health care services in their community.

Annual survey data for the past four years indicate that these perceived access problems have worsened or remained about the same, with no significant improvement for any single service. Moreover, about half of the respondents believe that health care services will get somewhat worse (34%) or much worse (15%) during the next two to three years.

The CMA has adopted several policies to address access deficits. In a July policy statement entitled "It's still about access," the CMA called on federal and provincial governments to work with it and other health groups "to establish clinically appropriate wait-time benchmarks for all major diagnostic, therapeutic, surgical and emergency services."

If national benchmarks are not met, the CMA recommends that Canadians be entitled to obtain government-funded treatment outside their home jurisdiction or within the private sector. CMA argues that when the publicly funded system cannot provide access to timely care, Canadians should be able to use private health insurance, as is allowed in Quebec for hip replacement and cataract surgery.

More than 1,300 Canadian physicians shared their opinions and concerns with CMA's 2006-2007 president, Dr. Colin McMillan, at face-to-face events and through online "conversations" held from February to June in a "Members' Outreach Initiative."

Many participants attributed access problems to physician workforce shortages (especially in primary care), infrastructure weaknesses (such as insufficient ED capacity and OR time), and undue wait times (for example, to see a specialist).

Among the 800 physicians participating online, 39% said that Canada's health care system should allow for an increased role for private financing and delivery of health care services. A rather low 63% said they would recommend medicine as a rewarding career to aspiring young people.

Many Canadian physicians believe that current efforts to remedy the problems in their public health care system are not working. At its meeting in Vancouver, the CMA general council (its large policymaking body) adopted a resolution directing the CMA to "communicate to the federal government that present federal wait- list strategies have failed to provide Canadians with timely access to quality medical care."

Dr. Brian Day, an orthopedic surgeon, was inaugurated as CMA president in Vancouver (where he practices). His election as president-elect one year ago was publicized widely, in large part because of his involvement in private medicine. In 1995 he founded the Cambie Surgery Centre, a private surgical facility, and he's the founder and a past president of the Canadian Independent Medical Clinics Assn.

Delegates in Vancouver elected Dr. Robert Ouellet, a radiologist, as president-elect. Dr. Ouellet runs five private radiology clinics in Quebec, prompting the Canadian Medical Association Journal to highlight in a news article that a "for-profit private clinic owner/operator" has been elected as CMA president-elect for two consecutive years.

Dr. Day emphasized in his inaugural address that "Canadians should have the right to private medical insurance when timely access is not available in the public system." He added, however, that Canadians do not want American-style health care. His bottom line was that "it is not about private or public, it is about patient care."

In my brief remarks to the CMA general council, I noted that most Americans do not want Canadian-style health care if it means limited choice of physicians and waiting lists for nonemergency treatment.

Each of our countries has a mix of health care services that is funded and administered to varying degrees by the public and private sectors. Each system of care has strengths and weaknesses.

Although we can learn a great deal from one another, solutions to the major structural problems in our health care systems are likely to come from within each of our own countries, not from countries with different traditions, cultures, economies, government structures, and political environments.