When Bill Clinton attempted to reform US healthcare in 1994, his administration often touted Canada's publicly funded, universal access system as a model to be emulated. As it turns out, the Canadian system may be crumbling under its own weight.
Despite spending nearly C$100 billion (US$64 billion) per year on healthcare the most per capita among countries that run a similar system a study released last week by the Fraser Institute, a public-policy think tank in Vancouver, shows that Canada ranks only slightly higher than Hungary, Poland, and Turkey in the quality of service its citizens receive.
Canada is the last industrialized nation to rely solely on government funds for its core healthcare system. There's an emerging view that it, too, may abandon a system that has long been a symbol of its national identity.
"We are no longer the model," says Michael Walker, executive director of the Fraser Institute. "When you consider that equal access in a country as spread out as Canada would require a greater number of physicians and diagnostic equipment, we're clearly headed in the wrong direction."
Two issues in particular plague the Canadian system, which forbids any form of user payment or private care for core services: the number of doctors and access to high technology.
Canada fields 1.8 doctors per 1,000 inhabitants, which places it 17th on a list of 20 countries with universal access (the list does not include the US). To leap into first place, Canada would need to add 48,000 doctors to its current roster of 57,000.
Canada lags even further behind in access to high-tech equipment, including machines used for magnetic resonance imaging (MRI) and computed axial tomography (CAT) scans. This shortage affects wait time for diagnostic assessments, which in provinces such as Saskatchewan can run well over three months.
According to Dr. Walker, hospitals absorb 55 percent of the total annual healthcare budget. The Fraser study found that nonmedical staff including painters, electricians, and cooks tend to be paid 50 percent higher than their counterparts in nonmedical industries. "We are not controlling our costs," he says.
Exacerbating Canada's poor performance among industrialized countries is its proximity to the US, notes Princeton University health economist Uwe Reinhardt. "Since Canada is part of the American job market, Canadian nurses and doctors must be compensated at levels that compete against US jobs," he says. "That means that even with the same level of care, Canadians will pay more than Europeans for core services."
Another survey, released last week by the Canadian Medical Association (CMA), shows growing dissatisfaction with the current system. The findings reveal that six in 10 Canadians expect the quality of healthcare to worsen over the next five years. And with 58 percent of respondents acknowledging that their confidence in the system is falling, versus 51 percent in 2000, Canadians are seriously contemplating a user-pay system. While 56 percent of survey respondents say they would pay more in taxes to maintain current service levels, 49 percent say they would welcome an approach that blends public and private care.
Canada's provincial leaders pledged C$1 billion (US$640 million) to purchase high-tech equipment starting this year. But any shortening of the typical two-month wait for patients to receive MRI tests and CAT scans isn't likely soon.
"It will take a decade to get speed of access and modern healthcare back in Canada," says Michael Decter, chair of the national board of the Canadian Institute for Health Information, and former deputy minister of health in Ontario.
Although Mr. Decter agrees that the system is shaken, he still says that modernized public healthcare is the solution.
"We do well on life expectancy and immunization of children compared to the US," he says, noting that the US spends about 40 percent more on healthcare in total than Canada. "But we see the drug ads on US television and worry that we're not as shiny and new as the Americans."
Fixing the deficiencies of the healthcare system is now the mandate of a royal commission, headed by former Saskatchewan premier Roy Romanow. Over the next few months, Mr. Romanow will head to London, Paris, and Washington to gather insights that could help remedy Canada's ailing system.
Solutions would likely include greater home care, user fees for patients who can afford them, and private or semiprivate hospitals, all of which top-ranked countries such as France, Sweden, and Australia feature.
The strains on the system are already forcing local shifts to alternative models. Some communities are allowing nurses to treat minor cases without referring patients to a doctor. Seventy-seven percent of nurses and 60 percent of doctors support this approach.
One of the CMA's recommendations is setting national standards for wait times.
"Canadians are divided over the establishment of user fees," says CMA president Dana Hanson. Although Dr. Hanson believes in a publicly funded system, he doesn't discount private-public partnerships. Some provinces already hire private labs, he points out.
Should Romanow's commission fail to deliver a workable solution, Canada's 10 provinces might be forced to take matters into their own hands.
"Some provinces could independently impose user fees or copayments," suggests Walker. Ontario and Alberta are the two provinces who, he says, might be able to give up federal Medicare aid in favor of a provincially run system. Both provinces are wealthier and less dependent on federal outlays to balance their medical costs.
But Mr. Reinhardt says introducing some features of the US healthcare system might be fraught with difficulties. "[The US] system has left 40 million people uninsured," he says, "and medical bills have become the second leading cause of personal bankruptcy in the US."