The Single-Payer Myth

Like many nations, we Canadians have many favourite pastimes. Hockey, uninvited apologies, basking in the glow of foreign praise of our healthcare system…

It’s ingrained in us from a young age. Unlike those heartless, corporate Americans, we take care of everyone, rich or poor. After all, it’s the right thing to do. No argument there.

If only it were that simple.

Not long ago, none other than Bernie Sanders made the trip north of the 49th parallel on a ‘fact-finding’ mission whose reported premise was to take notes on what can be learned from the Canadian experience. At face value that seems like a perfectly logical endeavour; a politician doing their own research. How refreshing. The fact that tens of millions of Americans can’t afford basic medical care and in many cases are forced to choose between bankruptcy and staying alive is quite frankly pathetic, disgusting, horrifying, baffling, <insert adjective here>. Even among the most conservative Canadians, I’d wager that you’d struggle to find any serious number of people who resent the fact that a child born with a congenital heart defect isn’t going to die because his parents don’t have $100,000 for surgery (full disclosure, I was one of those children). Which brings us back to Bernie.

I like Bernie. I despise most of his supporters, but I like Bernie. He’s a pretty smart guy who knows how to tell people what they want to hear. Bernie, like most reasonable people, believes that access to healthcare ought to be a universal individual right. In the rest of the developed world it already effectively is. Ok Bernie, I’m with you so far.

Now, if you’ve heard him speak on the subject at any length, you know that Bernie is not just after universal health-care, but specifically a single-payer healthcare system. Like Canada. (Dammit Bernie, I’m feeling all warm and fuzzy). To help him accomplish this, he’s enlisted an entourage of Canadian physicians to help him push his proposed legislation through the court of public opinion as well as both houses on Capitol Hill. So what’s the big deal?

Well let’s start with the obvious. Canada’s healthcare infrastructure is crumbling. Years, maybe decades, of chronic under-funding have left major parts of the system basically broken, where seemingly routine procedures like a hip-replacement can have wait-lists lasting up to a year and beyond. Hospitals across the country suffer from shortages of everything from doctors to beds to test equipment. All the while, patients whose condition is deemed not to be life-threatening are faced with a choice between sucking it up or heading overseas. That’s not the hallmark of a system that ought to be emulated.

On the other hand, for the vast majority of patients, this broken system is still far superior to the one that would figuratively cost them an arm and a leg. And herein lies the problem. It’s easy to stop the comparison there and say “at least it’s better than financial ruin.” But that’s an incredibly lazy argument if I’ve ever heard one.

So then what’s the alternative? Two-tiers, obviously.

If you’ve heard this argument before and still don’t buy it, this is the part where you say that a two-tier system is unfair because it means that people who can afford it, get better quality care while the rest of us suckers still have to deal with the less-than-efficiently run public system.

Yes. That is the price of sustainability.

Let’s get something straight here. Universal healthcare as an individual right does not mean access to the exact same level of care, any more than the Liberal government’s recent declaration of access to housing as a universal right means that everyone gets to live in a mansion. The reality is this: the public system is overburdened. Allowing people with the means more freedom to choose how their care is delivered could go a long way to clearing some of the backlog in the public system. We know this because as much as the US is an anomaly among the first-world in terms of its healthcare system, so too is Canada in its staunchly and strictly centralized single-payer system. As much as Bernie and his Canadians-for-hire would like you to believe that many other wealthy countries also have single-payer systems which don’t suffer from the same chronic problems that Canada has, the truth is that that suggestion is incredibly misleading, if not an outright lie.

This past summer, The Commonwealth Fund published a study ranking 11 wealthy nations on the strength of their healthcare systems based on factors including access, administrative efficiency, equity and health care outcomes. Canada ranked 3rd last, ahead of only the US and France. So what’s so special about jurisdictions like the UK and Australia (ranked 1st and 2nd respectively)? Well for starters, both offer a far greater amount of freedom in terms of how healthcare is delivered. Yes both provide universal primary care funded through general taxation, but under the hood, a broader and cleverer use of private healthcare providers and insurance means that both of those systems are far more flexible than the centrally planned Canadian boondoggle.

Both the NHS and Aussie Medicare legislation have provisions allowing for private health insurance for primary care. Neither has a direct impact on the level of funding available to the public system. In Australia for example, all residents pay a 2% levy (income tax) that is directly earmarked to fund the public Medicare system. In addition, high-income earners are encouraged to buy private insurance via an additional 1-2% levy if they choose not to. In Canada, such a system is effectively illegal under the federal Canada Health Act. Canada is the only country of the 11 ranked by the Commonwealth Fund study where the provision of private health insurance for hospital and physician services is actually illegal.

Let’s be clear: the notion that allowing private healthcare will inevitably lead to the death of the public system is a myth. A simple look at Europe makes this readily apparent. Differences in architecture and bureaucratic hurdles aside, there is no logical argument to be made that Canada is a special case where only a government monopoly can work. Indeed, many ancillary services such as dental, physio, prescriptions, eye care, etc. are already almost exclusively the domain of private insurance and out-of-pocket expenses. Why are we allowed – sometimes even obliged – to buy private insurance for those services but not for surgery and doctors’ visits? Why can the UK and Australia cover many of those other services via their public system while still allowing their citizens to choose private care if they feel so inclined (after being taxed out the rear-end)? Somewhere along the way, the logic behind Canadian primary care has been lost.

Some nay-sayers will argue that private care doesn’t guarantee better care. Others will argue that the quality of public care will suffer as the profit-driven private industry will be able to attract all of the best doctors. Besides the fact that these two arguments are contradictory, they are both straw-men at best. Obviously when someone chooses to subject themselves to the rules of supply and demand, their level of choice (demand) will be limited by the availability of the service they wish to buy (supply). That is the trade-off that comes with the freedom to choose. But that freedom is the core issue. There is a very important ethical difference between imposing a minimum standard, and forcing the same minimum quality on the entire population. That’s not “fairness”. It is hostage-taking. As for all of those specialists that would supposedly flood out of the public system if given the option, tell that to the hundreds of medical students graduating from Canadian universities each year who are unable to find work in the country that subsidized their education. Besides, with a few notable exceptions (such as those at the Munk cardiac centre in Toronto), the vast majority of those distinguished specialists are already going south of the border.

You can argue the technical validity of rankings like those quoted here until the cows come home. For their part, the World Health Organization ranked France (which has a similar public/private hybrid model) tops the last time they published a similar study in 2000 (the UK was 18th, Canada 30th, Australia 32nd). Other studies in the intervening years each come up with slightly different results. But that’s not the point. Instead, the purpose of this self-criticism ought to be to bring Canadians to terms with the failings of our coveted “free” healthcare. “Better than the US” is not good enough.

I’m not going to pretend that a European-inspired hybrid model is a magic pill that will automatically cure long wait times and GP shortages, but it’s no coincidence that when we look at places with better healthcare outcomes than our own, they all have mixed public-private systems.

There is much that the US can learn about healthcare from Canada, but if you want to see what a truly functional patient-focused system looks like Bernie, you should head across the pond.