reform pressure in US puts spotlight on Canada

System provides health care to all Canadians and at lower cost than in US

WHEN a serious accident occurs in central or northern Ontario, chances are the phone will ring at this small, windowless office in Toronto.This is the Integrated Trauma Program, a two-year-old service that handles emergency calls and determines which Toronto-area trauma unit can accept the patient. A bulletin board tracks which trauma units are filled and which are open. Simple idea. Simple technology. Yet revolutionary from an American perspective. When coordinator Alastair Dempster described how the hospitals cooperated (instead of competing) at a recent Philadelphia conference, his American counterparts were amazed. "They just didn't get it," he says. The more the United States disparages its own health-care system, the more attention it pays to foreign ones. Canada is especially intriguing because of its health-care system's similarities to that of the US. It has private-sector doctors and uses insurance to distribute benefits. Yet the system provides care to all its people. At lower cost. Does the system hold lessons for Americans? Yes, a number of Canadian health professionals say, but the lessons aren't medical or economic. They're ethical. High above Toronto, in the mauve and gray surroundings that mark KPMG Peat Marwick offices around the world, Martin Barkin ponders the cross-border differences. He knows Canada's system inside out - as a physician, former chief executive officer of a hospital, Ontario's deputy minister of health, and now consultant and health administration professor. "Health care is a value, not a commodity," he says. "The Canadian belief is that health care is an essential public service and everyone should have access.... In the United States, no such principle exists." His advice to Americans? "Sit down and try to articulate what your value system is vis-a-vis health care. Everything flows from there." Many Canadians appear baffled by the continuing US debate over the issue. "It's surprising in a country as wealthy as the US that there are so many that are going wanting," says Eric Meslin, bioethicist at Sunnybrook Health Science Centre and assistant director of the University of Toronto's Centre for Bioethics. "And it need not be."

Less paperwork with a single insurer Universal access at lower cost? The solution sounds so simple. Beguilingly so. In the US, about 33 million Americans have no health insurance, most of them because they can't afford the private insurance. In Canada, everyone is insured because the government pays all the bills. Moreover, Canadians spend substantially less on health care: an estimated $1,683 annually per person versus $2,345 in the US. One reason is lower administrative overhead. Because Canada has a single payer (the provincial government), there are far fewer forms to fill out than in the US, where more than 1,500 insurance companies foot the bill. The Massachusetts operations of Blue Cross/Blue Shield alone have a larger administrative staff than Canada's entire health-care system. A study earlier this year by Harvard Medical School researchers found that 24 cents of every US health-care dollar is spent on administrative costs. In Canada, it's 11 cents. If the US could streamline administrative costs to Canada's levels, the savings could be enormous. Congress's General Accounting Office pegs the savings at $67 billion. The Harvard researchers estimated savings of $115 billion to $136 billion a year. Another study, commissioned by the Robert Wood Johnson Foundation, estimated that if the US fully adopted a Canadian-style system and spent no more than 8.7 percent of national output on health care, $4.2 trillion would be saved during this decade. Such comparisons do not account for the cultural, political, and demographic differences between the two countries. The American Medical Association argues that the rising costs of US medical malpractice suits, among other things, would make a Canadian-style system as expensive as the present one. Other critics point out that while Canada has lower costs than the US, it still ranks among the most costly systems in the world. Per person, Britain spends about half what Canada spends on health care. Neither Canadian nor American health-care experts say the US could or should adopt its northern neighbor's system wholesale. "I think this searching for the health-care holy grail in foreign lands is crazy," says Peter Ellis, Sunnybrook's chief executive. "As long as it [the US] believes in survival of the fittest ... no one is going to buy into a universal health-care system." Canada, in any case, is moving to grapple with a new and more difficult set of ethical questions related to health care. How much health care is appropriate? How should it be parceled out? How central is medicine to better health? When Canada enacted the National Medical Insurance Act in 1966, it had the luxury of avoiding these questions. The economy was strong. Personal income was growing rapidly. The federal government could be generous in offering a new level of hospital care to its populace. The federal government offered to shoulder half the costs of a universal health-care system for any province that agreed to administer it. By 1971, all 10 provinces had signed on. Canadians adapted quickly, writes Monique Begin, Canada's former federal health minister, in her recent book on the subject. "Practically overnight, health care changed from a privilege to a right." But the economic roller-coaster of the 1980s, soaring health-care costs, and federal and provincial deficits have forced policymakers and analysts to take a harder look at their system. There's no immediate sense of crisis, but many experts see an almost inevitable squeeze. Ontario, for example, already spends 34 cents of each dollar in its provincial budget on health care - up from 10 cents in 1960. And the federal government, once so generous, is slowly backing off its commitment to pay 50 percent of Ontario's costs.

Ontario moves to control costs So, the province has begun to take action. Six years ago, Ontario started a premier's council on health care, including medical and nonmedical professionals. The council is looking at issues such as the cost-effectiveness of drugs and whether some surgical procedures, such as Caesarean sections, are overused. The province has also negotiated with the Ontario Medical Association a cap on payments to physicians that is expected to keep medical costs from rising much faster than the inflation rate. Although these policies were started when the Liberal Party was in power, Ontario's ruling New Democratic Party has taken up the same mantle. "There really is a sea change in Canadian thinking about the determinants of health," says Michael Decter, Ontario's deputy minister of health. "What we've discovered is that of the determinants of health, health care is only one of four and probably the least important. We need to put our emphasis on decent housing, nutrition, because these things are more important to health than the latest imaging machine in a hospital." So the province is looking carefully at programs that encourage people to make healthy choices (such as not smoking), at policies that prevent disease and accidents (such as safe highways and clean water and air), and at income distribution policies. "Health is not simply the absence of disease and infirmity," says Dr. Meslin. "It's something more full than that." To pay for these improvements, Canada will have to address two other prickly issues. Can it innovate quickly enough? And will it parcel out health care rationally as technology allows doctors to do more and more exotic things? "New procedures - expensive procedures - are coming along every day," says Ake Blomqvist, professor of economics at the University of Western Ontario. "As the technology spreads, this is going to be a question that's faced more and more frequently."

Standing in line for care Although Canadians don't like to admit it, the system does ration health care by limiting access to certain expensive procedures. Here at Sunnybrook, for example, a heart-disease patient categorized as an emergency case gets an operation within 48 hours. The wait lasts up to a week for urgent patients, up to six weeks for semi-urgent patients, and up to four months for elective patients. Hospital officials are quick to point out that the system does accommodate patients who suddenly become emergency cases. In a few cases, though, the delay has proved fatal. To avoid the wait, some Canadians cross the border and have the operation in a US hospital, where no such waiting lines exist.