The myths surrounding the Canadian health care system and how they take care of their patients continue to mount – so here are a few hard statistics that will give you some pause. But we need to place the statistics in context.

Basic Statistics

The Canadian Drain- Coming to America for Health Care
Canadians do come to the US for health care  – but let us compare apples to apples here. If a province does not have the specific health care  service, the province pays for the person to come to the US and get that service. And in rural provinces, the population is often too small to support medical specialists. Compare that to the rural United States, if there is not a specialist in a small town a patient is (and there are not in most of the rural states) referred to the major cities for specialty health care. Here is the difference- if they are referred from the United States there is no payment involved – just directions on where to go. If the Canadian government refers you for specialized health care it comes with the assurance that the health care is paid for.

If you need specialized health care, for some rare diseases or specialized treatments, and have the means, you can go to Arizona Heart, for example, to have your thoracic aortic aneurysm taken care of with a stent, instead of having major, high risk chest surgery. If you have a brain tumor you, and insurance or means, you can go to Duke University that has the best experience with brain tumors (as a friend of mine did from Alaska, and Ted Kennedy did when he had his brain tumor). At my own center, we are the only ones in Arizona offering the gastric plication for obesity, and one of the few in the nation, so we get patients from other states and Canada. Specialized health care centers have waiting lists, we do not get people in right away, but most wait to get in and be treated by the specialists.  Even here there are exceptions – a good friend of mine had a brain tumor and wanted to get into Barrows Neurologic Institute (one of the premier neurosurgery centers in the world) – and was unable to get an appointment for several months, but needed to have brain surgery.  Ultimately he had surgery in San Francisco, and then went to Duke for his chemotherapy.

Specialized medical facilities are not available in every city, or every state and no one claims this is a failure of the US health care system. If you live in a small town, which is most of Canada, chances are you don’t have many specialists in your town.  To a point, there is a severe shortage of surgeons in the United States – many small towns that use to have surgeons no longer do, and there is no reason to expect this to change.  Are surgeons moving from Canada to the United States — nope. To put some numbers on this: data from the 18,000 Canadians who participated in the National Population Health Survey. In the previous year, 90 of those 18,000 Canadians had received care in the United States; only 20 of them, however, reported going to the United States expressively for the purpose of obtaining care. I had three of those patients, who came to me for weight loss surgery.

In the US we have established a trauma system, and for a hospital to have a level 1 trauma center it has to meet certain qualifications. In the state of Washington there is one level 1 trauma center, and it serves  the entire state of Washington plus Idaho and Montana. Is that a failure when people are transported to a specialized care center? No, that is good medicine. In the state of Arizona there is one burn unit – is that a failure when people are referred to Maricopa County Hospital burn center? No, it makes good sense, it is a good use of resources, but the difference is this: if a US citizen is referred because of trauma or a burn to a specialized center there is no guarantee of payment, if the patient is referred from Canada payment is guaranteed. Somehow, when someone in Canada is referred to a medical center, be it in Canada or in the United States- that is considered “waiting” for care – where in the US it is called “referral.”

In the 1980’s there was a nurses strike at the major heart hospital in Vancouver. The strike was anticipated, and the province made arrangements that those who needed heart surgery would go to Virginia Mason, in Seattle, to have their operations. Is that a failure of a Canadian system? No, it is great planning. First, not one of those patients who received a cardiac bypass had to pay for their surgery, or their transportation to the US. It prevented a dangerous backlog of heart cases, and provided an outlet.

The US Outsources Health Care Also
Medical tourism, people from the United States going outside the US for healthcare, is one of the largest imports to Asia these days.  While in China, I was shown the hospitals dedicated to patients coming to China for hip replacements, heart operations, plastic surgery, and a host of other operations and treatment.  The stroke center in China has a better record for rehabilitation from strokes than any center in the United States, and many US citizens are going there.

In Mexico, many patients have gone there for health care including prescriptions, surgery, and dental care. Those numbers  decreased recently because of the recent border violence in Mexico. Still a number of individuals travel to Mexico because of the  decreased costs for surgery, plastic surgery, cosmetic dentistry, and prescriptions.

So what are some of the real numbers? Is this a flood of Canadians coming to the US for healthcare? No- is the simple answer. The best statistics show that the numbers are much less than 1 percent (which, by the way, is lower than rates of transfer from rural America to tertiary care hospitals in the US).  Here are a few of the statistics:

Tertiary Care Facilities- the Best of the US:
When tertiary care centers were checked, the authors of the study surveyed America’s 20 “best” hospitals — as identified by U.S. News & World Report — on the assumption that if Canadians were going to travel for health care, they would be more likely to go to the best-known and highest-quality facilities. Only one of the 11 hospitals that responded saw more than 60 Canadians in a year. And, again, that included both emergencies and elective care.

Less than 0.5% for elective health care and 0.11% for emergency health care.  Of that 0.11% the majority were patients who were in the states and had an emergency. Any hospital will tell you that if a Canadian has an emergency, the government will do their best to have the patient transported back to Canada as soon as they are stable (at no expense to the patient).

Physician Satisfaction
As a physician, when asked what things I am bothered by in the US healthcare system, there are several: first the insurance companies. I have a staff member dedicated to just dealing with insurance companies.  Do I need a staff member for Medicare? No. So what about physician satisfaction around the world– well, here is a great graph to display that:

Odd that physicians in Canada are more satisfied than in the US isn’t it? Not at all.  There will always be a “brain drain” between Canada and the United States.  That happens with comedians, doctors, actors, engineers, and etc. By the way, Canada does cap the earnings a physician can make — at $700,000 per year (in the US, most family physicians make around 100K per year).

Wait Times
No one likes to wait to see a doctor, to get an x-ray or an MRI.  The idea that we can see a physician on demand is appealing.  So appealing that in the United States a new phenomenon called “concierge” medicine has developed, where some primary care physicians charge patients an annual fee to see them, giving them their phone numbers, and making it fast and easy. This is not, however the “normal” way that medicine is practiced. Most of the time people have to wait for a physician, and if they need a referral to specialists, they have to wait to see the specialist. Canada has more primary care physicians per capita than the United States.

When someone talks about socialized medicine, people will cite that in Canada there are wait times, and people have to wait months to get an operation, or an MRI.

This is a political issue as well, and as with most political issues the statistics are exaggerated.  Most often quoted is the Fraser Institute. The Fraser Institute is highly partisan and bias and annually publishes waiting times for Canadians. Fraser Institute’s data does not take into account the diagnosis and whether it is a referral from a rural area to a specialist in a large city.  The Fraser Institute sends a survey to a select group of Canadian physicians. Of those who receive the inquiry only 16% respond. But its data is used by right-wing bloggers constantly.  For those who wonder, it is the right wing Koch brothers who are among those who fund the Fraser Institute. The issue isn’t that the Fraser Institute is right wing, and has wanted to dismantle the Canadian system, which very few Canadians wish to get rid of.  The issue is that their statistics are simply incorrect.

A survey done between equivalent major metropolitan cities for wait times to see specialists in Canada vs. the United States shows that for some specialists the wait times are longer in the United States than in Canada. If you needed to see a specialist in gastroenterology, rheumatology, dermatology, and neurosurgery you would see them faster in Toronto, Canada than in Phoenix, Arizona.

Wait times are not a function of spending – and the US there is almost twice as much spent per capita on health care as any other society.  In Japan, wait times are less than the United States, and in France they are less than the United States.

In the United States where 20% of the population has no insurance, the wait time is the money you have to pay for the medical service. But why pick on a rural country, such as Canada, where wait times are influenced by supply, but also by the ability of a person to get to a specialist, and whether they have an urgent or emergent issue (none of those are taken into account with most wait time studies).

Again put this in context: if you ask someone from Red Deer, Alberta (Alberta’s third largest city at 90,000) to see a specialist in Edmonton – a two hour drive – chances are it would take some scheduling between your schedule, and the physicians. That extra scheduling time is figured into wait times.

I read a blog by someone who stated, “There are no wait times in the United States” Sadly, there are wait times in the United States.  If you take the next available opening to see a gastroenterologist in Phoenix for a non-emergency, the wait time is about six weeks. Patients who come to see our office from around the country wait to see us more for their schedule than for ours.

Lets look at sick people:
 

So yes, we beat Canada- we spend twice as much as they do per person, and don’t cover 20% of the population, but we beat Canada.  We didn’t beat France, or Germany (which has had socialized medicine since 1880).  The increased health care spending does not buy you less wait times.

The US also beat Canada with getting patients to see physicians for elective surgeries.  Of course an economist has to speak out of both sides with this statistic: if you want to decrease the cost of health care then you increase waiting times for elective operations.

The US has More MRI machines
People often cite how MRI’s are in low supply in Canada, but in any major city in the US there is an MRI that you can get an examination if you have insurance, or cash to pay.  MRI machines are expensive- so who pays- the user through insurance or with cash. If you ask the radiologists we order way too many MRI examinations.  One does not need an MRI for every joint pain or injury – a physical examination is just as diagnostic and costs less. So we pay for those machines by ordering more MRI’s and then think that ordering an MRI is a standard of care and waiting is horrible.

But waiting for the MRI exam is a great way to reduce the cost of medical care.  For those examinations that require an MRI for urgent diagnosis, they are available in Canada- but for joint pain, that is mainly going to be treated by medication and rest, an MRI is unnecessary. Reduce the number of MRI machines in the US and you will reduce the health care cost. The bottom line is we have too many MRI machines in the United States for the number of examinations we need, thus we are paying and receiving more MRI machines than needed.

 Hips, Prostates, Knees and Hearts
Somewhere in Canada someone waited to have his hip replaced. Since they waited, this story is now forever on the internet and has become famous “I know someone who waited for their hip to be fixed.” Ask any orthopedic surgeon that does joint replacement surgery and they will tell you that the longer you can keep your own hip or knee the better. Artificial joints wear out – and while they are better now than ten years ago, and continue to improve, chances are the hips of tomorrow will be better and last longer. It is rare that hips and knees are fine one day and wear out the next – just as it is rare that you walk into an orthopedic surgeon’s office with a sore knee and are scheduled for surgery the following week for a knee replacement. But, most people are told that they will need an artificial hip.  My good friend, a gastroenterologist, was 40 when she had her first hip replaced.  She knew it needed replacing, and was walking with a cane until she finally consented to have it replaced. It was scheduled. From the time she was told it would need replacement until she had it replaced was about ten months. Her second hip was replaced two years later, but she didn’t wait as long. The point is: some people think because they are told their hip needs replacement that it should be scheduled that week– that does not happen in the United States, and it does not happen in Canada. Same with knees.

The other is the prostate.  Someone had an elevated PSA level, and “finally” was scheduled for a prostate biopsy. Canada knows what we in the United States know: (a) most prostate cancers, if confined to the prostate, do not need to be operated on and (b) PSA exams will over-diagnose prostate issues and cause a lot of unnecessary biopsies. For someone who thinks they might have prostate cancer, they want it now. It isn’t needed.

People with heart disease die waiting for surgery in the United States and the rest of the world. Perhaps the most famous recent is Tim Russert- who needed heart surgery, but was working out when he suffered his fatal heart attack. I’ve had patients who have been “cleared” for weight loss surgery by cardiologists, and have died of heart disease. It is not a problem in Canada.

Private Insurance Policies in Canada
In Canada you can purchase a private insurance policy for traveling emergencies outside the United States. In fact, the number of those policies sold has increased. What has not happened was this: there has been no demand for elective care policies outside Canada, and no market (although it was tested) for policies that would provide for care in the US if there was a longer than 30 day wait for services in Canada.

What about disease and care?

In Canada, the main reason for an unmet need was because the wait was too long or the treatment was unavailable. In the U.S., most people who do not receive treatment fail to do so because of cost considerations. However, Canada has more family physicians per 1000 people than the United States does, and their needs continue to be met.

Greatest Canadian?
When the Canadian Broadcast Company polled its viewers to see who was their favorite Canadian, the answer was not William Shatner (of Star Trek Fame) or Wayne Gretsky, but it was Tommy Douglass – the father of the Canadian Health Care System.

The Canadian System
The system in Canada is not a perfect system.  It costs Canadians less per person for the health care system and 100 percent of the people within its borders are covered. The United States pays twice as much per person for health care and twenty percent of them are not covered. There will always be people with horror stories, both in the United States and Canada- but when the statistics are looked at, Canadians enjoy longer lives, have lower infant mortality, have better care for cancer and live longer with chronic diseases than the higher priced, bloated health care system in the United States.

References:
Health Aff May 2002 vol. 21 no. 3 19-31

Image taken from – and a great article by:
http://theincidentaleconomist.com/wordpress/enough-with-the-wait-times-already/

Physician satisfaction graph taken from The Washington Post:
http://www.washingtonpost.com/blogs/ezra-klein/post/meme-busting-doctors-are-all-leaving-canada-to-practice-in-the-us/2011/06/03/AGVdAuHH_blog.html

June E. O’Neill and Dave M. O’Neill (2008) “Health Status, Health Care and Inequality: Canada vs. the U.S.,” Forum for Health Economics & Policy: Vol. 10: Iss. 1 (Frontiers in Health Policy Research), Article 3.
O’Neill JE; O’Neill DM (2007) “Health Status, Health Care and Inequality: Canada vs. the U.S.” NBER working paper #13429.