Image: Dr. Christopher Thompson, Albert Hammill
Darryl Dyck  /  AP
Dr. Christopher Thompson, left, examines 81-year-old Albert Hammill, who has heart disease, diabetes and kidney problems, at St. Paul's Hospital in Vancouver, B.C. A new clinic at the hospital is allowing health care specialists to coordinate the treatment of patients with complex chronic illnesses to improve the quality of care and reduce costs.
updated 8/31/2009 9:50:27 AM ET 2009-08-31T13:50:27

From screaming babies to frail seniors, Canadian-born or recent immigrants, the patients flow continuously through the waiting room of Dr. Kamini Kambli's clinic. Most have made their appointments that day. None will receive a bill.

The receptionist swipes their ID to verify their eligibility as Ontario residents for coverage under Canada's universal health care system. Kambli's family medical practice will be reimbursed by the government.

Canada's system is called Medicare, and is much like Medicare in the U.S. for over-65-year-olds, except that this one treats virtually the entire Canadian population of 33 million.

"It's one of the best systems in the world. Everyone is guaranteed health care and it does not matter if you're rich or poor or what your medical condition is — you will be seen and provided health care. How can you argue with that?" says Kambli, who used to practice medicine in her native India.

To be sure, Canadians have their complaints about their health care system — about long waits for elective care, including appointments with specialists and selected surgical procedures; shortages of doctors and nurses, particularly in rural areas; and the growing costs of covering an aging population.

The Canadian Medical Association wants to mix private insurance into the government monopoly. There have been lawsuits demanding the right to buy private health insurance. David Sebald, a Toronto-based health care consultant who has lived in the U.S., calls for a co-payment system to "eliminate the hypochondriacs."

But right now, Canadians are setting aside their criticisms of Medicare and rallying to its defense. The reason: Their system has been dragged into the debate over President Barack Obama's health care reform proposals by opponents who say Canada proves Obama is wrong — that Canadians endure long waits for critical procedures, medical rationing, scant resources and heavy-handed government interference.

A TV ad sponsored by the conservative Americans For Prosperity Foundation spotlighted a Canadian woman, Shona Holmes, who has challenged the system in court. She spoke of suffering from a brain tumor and declared she would "be dead" had she relied on her government. She said she had to mortgage her home to pay more than $97,000 to get timely treatment at the Mayo Clinic in Arizona.

In Canada, groups quickly sprouted up on Facebook accusing Holmes of betraying her country and exaggerating her illness.

In a report on its Web site, the Mayo Clinic said Holmes was suffering from a Rathke's cleft cyst near her pituitary gland. The Web sites of several reputable medical groups list the cyst as non-cancerous.

'A lot the U.S. could learn'
"We've heard talk in the U.S. that you may die here because of long wait times, you can't choose the doctors or the care you want and that the government makes your health decisions for you, but none of that is really true," said Dr. Michael M. Rachlis, a leading Canadian health policy analyst who has written three books about Canada's system. "I think there's a lot that the U.S. could learn from Canada."

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Rachlis believes the most significant lesson is the Canadian system's egalitarianism: health care regardless of income, age and health status. No one is left without critical care and consequently, Canadians live three years longer on average than Americans, according to the World Health Organization.

"The flaw in the American system," Ontario Health Minister David Caplan said recently, "is that first they check the size of your wallet, not the size of your need."

Obama has stepped in to defend his neighbors' system.

"I don't find Canadians particularly scary, but I guess some of the opponents of reform think they make a good bogeyman. I think that's a mistake," he said.

In seeking to spread affordable coverage, including to the nearly 50 million uninsured Americans, Obama has said he isn't looking to copy the Canadian model, but wants to build on the existing U.S. system with a mix of private and government-funded insurance.

For all the rhetoric, both Canadians and Americans appear in opinion polls to be broadly content with the care they have.

A Harris-Decima poll published last month found that 82 percent of Canadians believe their system outdoes America's, and 70 percent felt it was working very well or well. The telephone poll of 1,000 Canadians was conducted from June 4 to 8 with a margin of error of 3.1 percentage points.

A survey released this month by the nonpartisan Robert Wood Johnson Foundation said more than 86 percent of Americans rated their care as good to excellent. But 52 percent were very or somewhat worried they wouldn't be able to afford future care, and nearly 30 percent said they were very or somewhat worried it would bankrupt them. The telephone poll of 500 Americans had a margin of error of 4.4 percentage points.

Canada's system provides its citizens with coverage at a much lower per capita cost than the U.S. largely because its single-payer system, in which the government picks up the tab, greatly reduces administrative costs.

According to the Organization for Economic Cooperation and Development, per-capita spending for health care in the U.S. was $6,714 in 2006; in Canada, $3,678. The U.S. spent 16 percent of its GDP on health care that year; Canada spent 10 percent.

Canadians pay half income in taxes
Canadians do pay higher taxes than Americans — the average family pays about 48 percent of its annual income in taxes — partly to fund the health care system.

"It's a trade-off — we pay more in taxes, but no Canadian ever goes bankrupt because of medical bills. You will always get looked after without worrying about costs," said Kambli, the doctor.

Some disagree.

"It is in fact a very poor health care system that regularly fails Canadians," Nadeem Esmail of the Fraser Institute, a conservative Canadian think tank, wrote in a newspaper opinion piece published this month.

He said Canada has the developed world's second most expensive universal health care system after Iceland, yet lags behind other industrialized countries in access to medical technologies and physician-to-population ratios. He noted that Canadians on average had to wait longer to see a specialist or receive elective surgery than in other developed countries with universal health care such as Australia and Britain.

Four month wait time to see specialist
A Fraser Institute study found that the average wait time from general practitioner referral to treatment by a specialist was 17.3 weeks in 2008, compared to 11.9 weeks back in 1997.

The federal government is aware of the criticisms. In 2004, it instituted a multi-billion-dollar plan aimed at reducing wait times in priority areas such as cancer care and cardiac treatment.

The Canadian Institute for Health Information, an independent nonprofit group, reported that as of April at least 75 percent of patients receive non-emergency surgeries — radiation treatments, coronary artery bypass, hip and knee replacements, cataract surgery — in acceptable time.

David Johnson, 28, of Toronto, said he received immediate treatment after dislocating a shoulder playing ice hockey, but had to wait six months to have surgery to reattach torn cartilage.

"It wasn't a life or death issue and I wasn't in pain while I waited," said Johnson, a finance company employee. "I had the care I needed without worrying about anything like bills."

The 1984 Canada Health Act guarantees mostly free health care to all citizens and sets overall guidelines for systems in each of Canada's 10 provinces and three territories. Canadians are barred from purchasing private medical insurance for services covered by the government, and doctors cannot charge patients extra fees.

In Canada's largest province, the Ontario Health Insurance Plan (OHIP) covers all medically necessary doctor and hospital care, with fees negotiated between the Ontario Ministry of Health and the provincial medical association.

OHIP excludes some services — optometry, dentistry and outpatient prescription drugs — but many Canadians are covered in those areas by supplemental private insurance, often provided through their employers. Prescription drugs are much cheaper than in the U.S. because the government negotiates prices directly with the drug companies.

Given its popularity, Canadian Medicare enjoys support across the political spectrum. Prime Minister Stephen Harper, whose Conservative Party is closest politically to U.S. Republicans, has not moved to privatize the system since taking office in 2006.

But right-of-center foundations that support a greater private-sector role in medicine have supported lawsuits on behalf of patients who claim that lengthy waiting lists violate basic rights guaranteed under the Canadian Charter of Rights and Freedoms.

In 2005, Canada's Supreme Court struck down a Quebec law banning private medical insurance, but the decision had no immediate impact on the system outside Quebec.

After lively debate at its annual convention this month, the Canadian Medical Association approved a resolution urging provincial governments to "examine internal market mechanisms, which could include a role for the private sector" in Canada's publicly funded health care system.

Outgoing CMA president Robert Ouellet told a news conference that most doctors "believe there is an urgent need to fix Canada's health care system," learning from European countries that offer a mixed public-private universal health care system.

"We need to stop deceiving ourselves into believing that we have the best health care system in the world," he said.

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