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By Shannon Brownlee and Ezekiel Emanuel

The Washington Post newspaper, Sunday, November 23, 2008; Page B03

With Congress ready to spend $700 billion to prop up the U.S. economy, enacting health-care reform may seem about as likely as the Dow hitting 10,000 again before the end of the year. But it may be more doable than you think, provided we dispel a few myths about how health care works and how much reform Americans are willing to stomach.

1. America has the best health care in the world.

Let’s bury this one once and for all. The United States is No. 1 in only one sense: the amount we shell out for health care. We have the most expensive system in the world per capita, but we lag behind many developed countries on virtually every health statistic you can name. Life expectancy at birth? We rank near the bottom of countries in the Organization for Economic Cooperation and Development, just ahead of Cuba and way behind Japan, France, Italy, Sweden and Canada, countries whose governments (gasp!) pay for the lion’s share of health care. Infant mortality in the United States is 6.8 per 1,000 births, more than twice as high as in Japan, Norway and Sweden and worse than in Poland and Hungary. We’re doing a better job than most on reducing smoking rates, but our obesity epidemic is out of control, our death rate from prostate cancer is only slightly lower than the United Kingdom’s, and in at least one study, American heart attack patients did no better than Swedish patients, even though the Americans got twice as many high-tech treatments.

Moreover, the quality of health care is different in different parts of the country. The Centers for Medicare and Medicaid Services have issued a list of 26 measures of quality, such as making sure that heart-attack patients being discharged from the hospital get a prescription for a beta blocker or aspirin to help reduce the risk of a second attack. It turns out that quality is all over the map, and it isn’t necessarily better in the places we might expect, such as academic medical centers. Worse still, according to the Congressional Budget Office (CBO), there appears to be no connection between how much Medicare and other payers spend on patients in different parts of the country and the quality of the care the patients receive. You are no more likely to get that beta blocker or aspirin in Los Angeles than in Portland, even though Medicare spends twice as much per beneficiary in Los Angeles.

2. Somebody else is paying for your health insurance.

Nope. Even when your employer offers coverage, he isn’t reaching into his own pocket to cover you and your fellow employees; he’s reaching into your pocket, paying you lower wages than he would if he didn’t have to pay for your health insurance.

Rising health-care costs are partly to blame for stagnant wages. Over the past five years, health insurance premiums have risen 5.5 times faster on average than inflation, 2.3 times faster than business income and four times faster than workers’ earnings. Four times. That’s why wages have been nearly flat since the 1980s, even as U.S. productivity has been going up. In effect, about half the money you should be earning for being more productive is being sucked up by ever more expensive health-insurance premiums.

If you pay taxes, you’re also paying for the health care provided through state and federal programs such as Medicare, Medicaid, the Veterans Administration and the military. All told, the average family of four is coughing up $29,000 a year for health care through taxes, lower wages and out-of-pocket medical expenses.

3. We would save a lot if we could cut the administrative waste of private insurance.

The idea that we could wring billions of dollars in savings this way is seductive, but it wouldn’t really accomplish that much. For one thing, some administrative costs are not only necessary but beneficial. Following heart-attack or cancer patients to see which interventions work best is an administrative cost, but it’s also invaluable if you want to improve care. Tracking the rate of heart attacks from drugs such as Avandia is key to ensuring safe pharmaceuticals.

Let’s just say that we could wave a magic wand and cut private insurers’ overhead by half, to what the Canadian government spends on administering its health-care system — 15 percent. How much would we save? Not as much as you may think. Private insurers pay a little more than a third of what we spend on health care, which means that we’d cut a little more than 5 percent from our total budget, or about $124 billion. That’s not peanuts, but it’s not even enough to cover everybody who’s currently uninsured.

More to the point, we only get to save it once. That’s because administrative waste isn’t what’s driving health-care costs up faster than inflation. Most of the relentless rise can be attributed to the expansion of hospitals and other health-care sectors and the rapid adoption of expensive new technologies — new drugs, devices, tests and procedures. Unfortunately, only a fraction of all that new stuff offers dramatically better outcomes. If we’re worried about costs, we have to ask whether a $55,000 drug that prolongs the lives of lung cancer patients for an average of a few weeks is really worth it. Unless we find a cure for our addiction to the new but not necessarily improved, our national medical bill will continue to skyrocket, regardless of how efficient insurance companies become.

4. Health-care reform is going to cost a bundle.

Only if you think that covering the uninsured is our only priority. Yes, making health care available to all citizens is the right thing to do. But it isn’t the only thing to do. We also have to fix the spectacularly wasteful and expensive way doctors and hospitals deliver care.

Our physicians are working within a truly dysfunctional, often chaotic system that prevents them from caring for us properly. Between 50,000 and 100,000 patients die each year from preventable medical errors. According to the Centers for Disease Control, 1.7 million Americans acquire an infection while in the hospital and nearly 100,000 of them die from it. Laboratory imaging tests are routinely repeated because the originals can’t be found. Patients with such chronic illnesses as heart failure and diabetes land in the hospital because their physicians fail to monitor their condition. When patients have multiple doctors, there’s often nobody keeping track of the different medications, tests and treatments each one prescribes.

Our doctors and hospitals are failing to provide us with care we need while delivering a staggering amount that we don’t need. Current estimates suggest that as much as 20 to 30 percent of what we spend, or about $500 billion, goes toward useless, potentially harmful care.

There are two bright spots. One: We can improve the quality of care and cut costs without rationing. There are models out there for how to do it right — the Mayo Clinic, the Geisinger Clinic in Pennsylvania, the Cleveland Clinic and California’s Kaiser Permanente are just a few of the organized group practices that are doing a better job for less. Their doctors are better than average at using the best medical evidence available. They’re more likely to be using electronic medical records, which can help keep track of patients who have multiple physicians and need complex care. And they’re less likely to provide unnecessary care.

Two: Even moderate reform of the delivery system would improve care and save money. The Lewin Group’s analysis shows that a bill proposed by Sen. Ron Wyden, an Oregon Democrat, calling for a more comprehensive overhaul of the health-care system than either McCain’s plan or Obama’s could actually insure everyone and save $1.4 trillion over 10 years. More reform is cheaper.

5. Americans aren’t ready for a major overhaul of the health-care system.

We may be readier than you think. A recent study published in the New England Journal of Medicine found that only 7 percent of Americans rate our health-care system excellent. Nearly 40 percent consider it poor. A whopping 70 percent believe it needs major changes, if not a complete overhaul.

Now is not the time to think small, to cover a few million Americans and leave the bigger job of controlling costs and improving quality for another day. We can’t afford not to reform the delivery system as soon as possible. At 17 percent of gross domestic product, health care is the biggest single sector of the economy, and it’s consuming a larger and larger proportion every year. According to CBO projections, health care will account for 25 percent of GDP by 2025 and 49 percent by 2082. That’s simply unsustainable. Any plan that reforms health care has to do more than simply cover the uninsured. The nation’s health and wealth depend on it.

Shannon Brownlee, a visiting scholar at the National Institutes of Health Clinical Center, is the author of “Overtreated.” Ezekiel Emanuel, an oncologist and author of “Healthcare, Guaranteed,” is chairman of the center’s Department of Bioethics. The views expressed here are the authors’ own.



The article FIVE MYTHS ABOUT OUR AILING HEALTH CARE SYSTEM (Washington Post Newspaper, Sunday, November 23, 2008; Page B03) is a masterpiece of obfuscation and a shameful example of what is wrong with print journalism today. Let’s quickly look at the “five myths” to see if we can figure out what the authors are doing here — and what they are doing wrong.

Myth #1: America has the best health care in the world.

Excellent introduction. Except, the truth as spelled out by the authors could hardly be called a myth. No one–except possibly the highly-paid executives of America’s health care conglomerates — has said anything different for decades. The failings Of America’s health care system are widely recognized, if the causes are not. The costly inefficiency of administration by HMOs and insurance companies (what I call private bureaucracy-for-profit) is universally regarded as the single most important factor in the high cost of America’s health care system, which is by far the most expensive, inefficient, and ineffective health care system in the world.

If anyone still believes that America has the best–or even a good — health care system, then they are out of touch with reality. This myth has been thoroughly debunked in countless books and articles.

Myth #2: Somebody else is paying for your health insurance.

First, we must question the author’s contention that rising health care premiums are the reason why US wages have remained flat. While it is true that rising health care premiums is ONE reason why US wages have not kept pace with inflation, it is only one of many factors including globalization, over-productivity, and especially financial manipulation by the corporatists and the financial sector. It is important not to overstate the case here.

With regard to health care premiums rising faster than wages, Washington Post’s economic adviser Robert J. Samuelson has pondered why productivity gains have historically benefitted the wealthy more than the poor. The rising cost of health insurance is obviously one reason — but hardly the only, or even the primary, reason.
Of rising concern are these and other unseen costs of the nation’s dysfunctional health care system, the costs paid by society as a whole. This includes the impact on the US economy and is a major reason for the nation’s lack of competitiveness in today’s global economy. These costs also include emergency care that is written off as “charity” care by hospitals, as well as unpaid care at community clinics and volunteer organizations. And what about the pain and suffering of those with inadequate health care — what we might call quality of life issues. These costs are distributed disproportionately, with those paying the highest price being those who have no health care coverage at all. Yet, because health insurance is tax deductible for employers (but not for most individuals) the working poor who have no health coverage are actually subsidizing health care for those who do! These cost factors are borne by society as a whole, and cannot readily be measured in terms of dollars.

Myth #3: We would save a lot if we could cut the administrative waste of private insurance.

Finally, we get to the heart of the matter — or so we think. Discussion of the third myth starts with a bland — and meaningless, observation:

     “For one thing, some administrative costs are not only necessary but beneficial.”

No one disputes this. But what is the point?

If the reader is next expecting a discussion of the unnecessary costs or wasteful aspects of private insurance companies administering our health care (as opposed to the different approaches taken by the various nations of the world) he will be disappointed. Before any discussion of the waste and inefficiency inherent in insurance-based health care systems, or any attempt at quantifying such unnecessary costs is made, the authors move on to a startling (and false) example of why this aspect of health care costs need not concern us. This is where the authors really drop the ball:

    “Let’s just say that we could wave a magic wand and cut private insurers’ overhead by half, to what the Canadian government spends on administering its health-care system — 15 percent. How much would we save? Not as much as you may think.”

First of all, the numbers are questionable. Most estimates put the cost of administration of Canadian’s single-payer health care system at 11-13%, while the overhead of America’s health care system is generally estimated to be between 37-40%. That’s not double, but nearly triple.

By some estimates, it would be possible to pay for health care for all Americans who currently have no health coverage from the savings in administrative costs alone were we to adopt the Canadian single-payer system here in America. But I am getting ahead of myself here . . . .

Next comes a math test of sorts:

     “Private insurers pay a little more than a third of what we spend on health care, which means that we’d cut a little more than 5 percent from our total budget, or about $124 billion.”

First of all, the sentence would make more sense if it read, “overhead and administrative costs account for a little more than a third of [health care costs].” Correcting the authors’ confusing wording might help them to keep the math straight. For a 50% savings of “a little more than a third” is way more than 5%. The authors have already said we were working on the premise of cutting administrative costs in half to achieve a savings of roughly 15% I think this might be conservative, but let’s give them the benefit of the doubt, and go with the 15% figure, representing half (?) of 37% overall administrative costs. While I am getting up in years, my memory is not so bad that I cannot recall what was said in the previous sentence. By what stroke of the pen can the authors convert 15% to 5%? Presumably they’ll claim that it was a typographical error. The way the sentence is written, however, it sounds like someone flunked math, coming up with the 5% figure by some thoughtful calculation. Whether an accidental typographical error, or deliberate attempt to confuse, the result is the same. Whether it be sloppy journalism or sloppy math, this glaring error has undermined their argument.

Then the authors lament,

     “While it’s not peanuts, it’s not even enough to cover everybody who’s currently uninsured.”

It’s not enough to pay off the national debt, either . . . but, like the author’s observation here, that really is irrelevant. No one framed the discussion in terms of accepting a high level of waste and inefficiency versus providing health care coverage for all Americans (but maybe we should.) The authors would dismiss as inconsequential a 15% or more reduction in overall health care costs because this isn’t enough to provide coverage for everyone? There is simply no way to make sense of the author’s comment, so that sentence should be stricken, replaced with something like,

     “A 15% savings in overall health care costs would go a long way toward paying for coverage for the more than 40 million Americans who presently have no health care coverage.”

But it gets worse. In the next paragraph under Myth #3 the authors say something so stupid as to be beyond comprehension:

     “More to the point, we only get to save it once. That’s because administrative waste isn’t what’s driving health-care costs up faster than inflation.”

Here we have proof that the author’s logic is actually worse than their faulty arithmetic. It is completely untrue that the cost savings in reducing administrative overhead is only to be recouped one time, as they claim. What an absurd thing to say! The cost savings from reduced overhead will apply to every dollar spend on health care, forever and ever, amen. If you reduce your overhead by 15% you save 15% every time you go to the doctor. Period.

     “. . . because administrative waste isn’t what’s driving health-care costs up faster than inflation.”

Now the authors, who apparently cannot do even simple math, are going to factor in inflation? Thankfully, no. What happens here is a sudden change in direction. Halfway through this miserable exercise in logic, we are told that the problem is not administrative waste at all, but unnecessary procedures on the part of health care providers.

     “Most of the relentless rise can be attributed to the expansion of hospitals and other health-care sectors and the rapid adoption of expensive new technologies — new drugs, devices, tests and procedures.”

Now, this is where the authors’ logic–bad as it is so far — falls flat on its face. In a literary sleight-of-hand, the authors have changed the game on us. First, we were talking about the high cost of overhead, specifically the administrative waste inherent in health care administration by insurance companies — private bureaucracy for profit. But now we are talking about something else entirely — the high cost of health care itself, as delivered by the providers. There are many reasons for the high cost of health care as provided, including perhaps an over reliance on expensive tests and procedures (the authors do not point out — are they even aware of the fact — that the outside facilities that provide these expensive tests are often owned by the doctors and health-care administrators and their coterie of investor friends?) The authors have switched from a discussion of the cost of health care overhead to the different issue of the extravagant cost of health care itself. Both are important factors in the high cost of US health care.

Discussion related to some of the things that are driving up health care costs conclude the section on Myth #3. Note that the authors missed the opportunity to list some of the more significant cost factors, such as doctors’ salaries, hospital chains’ profits, shareholders’ dividends, predatory pricing practices, and obscene salaries for hospital administrators. The fact that the CEOs of America’s two largest hospital chains pay themselves almost $1,000,000,000.00 (that’s one billion dollars) per year in combined salaries probably contributes somewhat to the rising cost of health care in America.

In fact, I bet that if we took only these two mens’ salaries, and added the 15% savings from administrative waste (which is what this article purported to be about in the beginning) we could cover the cost of health insurance for all uninsured Americans, using a single-payer model.

Myth #4: Health-care reform is going to cost a bundle.

In Myth #4, the authors first tell us what everyone already knows — that the American health care system is dysfunctional. The litany of problems they give us is well known, and is not all-inclusive. But irrelevant as all this is (to the discussion of administrative waste) it is even more disconnected, logically, to what follows: an advertisement for HMOs. Finally, we see what this article is all about: an endorsement of HMOs as the real solution for America’s out-of-control health care costs. Just follow the examples of the HMOs (the authors cite a few) in deciding what procedures, and what care, patients are to receive, and America’s health care crisis will be over!

At this point the reader thinks to himself, “I am reading an advertisement for a book about HMOs as a solution to America’s health care crisis?”

This is when anger causes many readers to go blind with rage. Such a cheap shot–blatant and shameless hucksterism for a book glorifying HMOs? HMOs are EVIL. Is there anything on God’s earth that is more satanic than HMOs? (Not in the eyes of 99% of Americans.)

I’ll say one thing. This book better be a whole lot better than this poor excuse for an opinion piece. The authors’ expectation that they are going to change the public’s opinion of HMOs is one more example of failed logic. They are truly beating a dead horse.

5. Americans aren’t ready for a major overhaul of the health-care system.

The authors introduced this advertisement for their book on cost containment via HMO by proposing to “dispel a few myths about how health care works . . . .” But rather than advocating the controversial idea of increased reliance on HMOs, why not consider an alternative that will actually work: the Canadian single-payer plan, referred to earlier in the essay? An excellent article written by a woman who has direct experience of both American and Canadian health care systems, entitled “Ten Myths About the Canadian Health Care Program”, would be a good place to start. I suggest the authors read it so they will at least have some idea of what they are talking about, for most readers are likely to have strong opinions about HMOs, and probably know more about the subject than the authors seem to.

Honesty is the best policy, especially in journalism. Had the authors told us the truth from the beginning — that they have written a book on this aspect of the US health care system, in support of the proposition that HMOs are especially well suited to address this particular problem, then they wouldn’t have gotten in so much trouble, figuratively speaking. But the essay as written shows them to be in way over their heads, beginning with the pretentious title and ending with the advertising hook.
The debunking of myths really should be left to mythbusters. The following essay is a good example of how it is done, when it is done right.

(C) 2008, 2009 Charles H. Sulka


10 Myths About Canadian Health Care, Busted

By Sara Robinson

ICH [informationclearinghouse]


“TomPaine <>”

2008 is shaping up to be the election year that we finally get to have the Great American Healthcare Debate again. Harry and Louise are back with a vengeance. Conservatives are rumbling around the talk show circuit bellowing about the socialist threat to the (literal) American body politic. And, as usual, Canada is once again getting dragged into the fracas, shoved around by both sides as either an exemplar or a warning — and, along the way, getting coated with the obfuscating dust of so many willful misconceptions that the actual facts about How Canada Does It are completely lost in the melee.

I’m both a health-care-card-carrying Canadian resident and an uninsured American citizen who regularly sees doctors on both sides of the border. As such, I’m in a unique position to address the pros and cons of both systems first-hand. If we’re going to have this conversation, it would be great if we could start out (for once) with actual facts, instead of ideological posturing, wishful thinking, hearsay, and random guessing about how things get done up here.

To that end, here’s the first of a two-part series aimed at busting the common myths Americans routinely tell each other about Canadian health care. When the right-wing hysterics drag out these hoary old bogeymen, this time, we need to be armed and ready to blast them into straw. Because, mostly, straw is all they’re made of.


FALSE. In socialized medical systems, the doctors work directly for the state. In Canada (and many other countries with universal care), doctors run their own private practices, just like they do in the US. The only difference is that every doctor deals with one insurer, instead of 150. And that insurer is the provincial government, which is accountable to the legislature and the voters if the quality of coverage is allowed to slide.

The proper term for this is “single-payer insurance.” In talking to Americans about it, the better phrase is “Medicare for all.”


TRUE and FALSE. Doctors in Canada do make less than their US counterparts. But they also have lower overhead, and usually much better working conditions. A few reasons for this:

First, as noted, they don’t have to charge higher fees to cover the salary of a full-time staffer to deal with over a hundred different insurers, all of whom are bent on denying care whenever possible. In fact, most Canadian doctors get by quite nicely with just one assistant, who cheerfully handles the phones, mail, scheduling, patient reception, stocking, filing, and billing all by herself in the course of a standard workday.

Second, they don’t have to spend several hours every day on the phone cajoling insurance company bean counters into doing the right thing by their patients. My doctor in California worked a 70-hour week: 35 hours seeing patients, and another 35 hours on the phone arguing with insurance companies. My Canadian doctor, on the other hand, works a 35-hour week, period. She files her invoices online, and the vast majority are simply paid — quietly, quickly, and without hassle. There is no runaround. There are no fights. Appointments aren’t interrupted by vexing phone calls. Care is seldom denied (because everybody knows the rules). She gets her checks on time, sees her patients on schedule, takes Thursdays off, and gets home in time for dinner.

One unsurprising side effect of all this is that the doctors I see here are, to a person, more focused, more relaxed, more generous with their time, more up-to-date in their specialties, and overall much less distracted from the real work of doctoring. You don’t realize how much stress the American doctor-insurer fights put on the day-to-day quality of care until you see doctors who don’t operate under that stress, because they never have to fight those battles at all. Amazingly: they seem to enjoy their jobs.

Third: The average American medical student graduates $140,000 in hock. The average Canadian doctor’s debt is roughly half that.

Finally, Canadian doctors pay lower malpractice insurance fees. When paying for health care constitutes a one of a family’s major expenses, expectations tend to run very high. A doctor’s mistake not only damages the body; it may very well throw a middle-class family permanently into the ranks of the working poor, and render the victim uninsurable for life. With so much at stake, it’s no wonder people are quick to rush to court for redress.

Canadians are far less likely to sue in the first place, since they’re not having to absorb devastating financial losses in addition to any physical losses when something goes awry. The cost of the damaging treatment will be covered. So will the cost of fixing it. And, no matter what happens, the victim will remain insured for life. When lawsuits do occur, the awards don’t have to include coverage for future medical costs, which reduces the insurance company’s liability.


TRUE and FALSE again — it depends on which province you live in, and what’s wrong with you. Canada’s health care system runs on federal guidelines that ensure uniform standards of care, but each territory and province administers its own program. Some provinces don’t plan their facilities well enough; in those, you can have waits. Some do better. As a general rule, the farther north you live, the harder it is to get to care, simply because the doctors and hospitals are concentrated in the south. But that’s just as true in any rural county in the U.S.

You can hear the bitching about it no matter where you live, though. The percentage of Canadians who’d consider giving up their beloved system consistently languishes in the single digits. A few years ago, a TV show asked Canadians to name the Greatest Canadian in history; and in a broad national consensus, they gave the honor to Tommy Douglas, the Saskatchewan premier who is considered the father of the country’s health care system. (And no, it had nothing to do with the fact that he was also Kiefer Sutherland’s grandfather.) In spite of that, though, grousing about health care is still unofficially Canada’s third national sport after curling and hockey.

And for the country’s newspapers, it’s a prime watchdogging opportunity. Any little thing goes sideways at the local hospital, and it’s on the front pages the next day. Those kinds of stories sell papers, because everyone is invested in that system and has a personal stake in how well it functions. The American system might benefit from this kind of constant scrutiny, because it’s certainly one of the things that keeps the quality high. But it also makes people think it’s far worse than it is.

Critics should be reminded that the American system is not exactly instant-on, either. When I lived in California, I had excellent insurance, and got my care through one of the best university-based systems in the nation. Yet I routinely had to wait anywhere from six to twelve weeks to get in to see a specialist. Non-emergency surgical waits could be anywhere from four weeks to four months. After two years in the BC system, I’m finding the experience to be pretty much comparable, and often better. The notable exception is MRIs, which were easy in California, but can take many months to get here. (It’s the number one thing people go over the border for.) Other than that, urban Canadians get care about as fast as urban Americans do.


FALSE for the vast majority of Canadians, but TRUE for a few. Again, it all depends on where you live. I live in suburban Vancouver, and there are any number of first-rate GPs in my neighborhood who are taking new patients. If you don’t have a working relationship with one, but need to see a doctor now, there are 24-hour urgent care clinics in most neighborhoods that will usually get you in and out on the minor stuff in under an hour.

It is, absolutely, harder to get to a doctor if you live out in a small town, or up in the territories. But that’s just as true in the U.S. — and in America, the government won’t cover the airfare for rural folk to come down to the city for needed treatment, which all the provincial plans do.


Scurrilously FALSE. Somebody, somewhere, is getting paid a lot of money to make this kind of stuff up. The cons love to scare the kids with stories about the government picking your doctor for you, and you don’t get a choice. Be afraid! Be very afraid!

For the record: Canadians pick their own doctors, just like Americans do. And not only that: since it all pays the same, poor Canadians have exactly the same access to the country’s top specialists that rich ones do.


TRUE — but not as big an issue as you might think. The province does charge a small monthly premium (ours is $108/month for a family of four) for the basic coverage. However, most people never even have to write that check: almost all employers pick up the tab for their employees’ premiums as part of the standard benefits package; and the province covers it for people on public assistance or disability.

“The basics” covered by this plan include 100% of all doctor’s fees, ambulance fares, tests, and everything that happens in a hospital — in other words, the really big-ticket items that routinely drive American families into bankruptcy. In BC, it doesn’t include “extras” like medical equipment, prescriptions, physical therapy or chiropractic care, dental, vision, and so on; and if you want a private or semi-private room with TV and phone, that costs extra (about what you’d pay for a room in a middling hotel). That other stuff does add up; but it’s far easier to afford if you’re not having to cover the big expenses, too. Furthermore: you can deduct any out-of-pocket health expenses you do have to pay off your income taxes. And, as every American knows by now, drugs aren’t nearly as expensive here, either.

Filling the gap between the basics and the extras is the job of the country’s remaining private health insurers. Since they’re off the hook for the ruinously expensive big-ticket items that can put their own profits at risk, the insurance companies make a tidy business out of offering inexpensive policies that cover all those smaller, more predictable expenses. Top-quality add-on policies typically run in the ballpark of $75 per person in a family per month — about $300 for a family of four — if you’re stuck buying an individual plan. Group plans are cheap enough that even small employers can afford to offer them as a routine benefit. An average working Canadian with employer-paid basic care and supplemental insurance gets free coverage equal to the best policies now only offered at a few of America’s largest corporations. And that employer is probably only paying a couple hundred dollars a month to provide that benefit.


More preposterous bogosity. They are exactly the same drugs, made by the same pharmaceutical companies, often in the same factories. The Canadian drug distribution system, however, has much tighter oversight; and pharmacies and pharmacists are more closely regulated. If there is a difference in Canadian drugs at all, they’re actually likely to be safer.

Also: pharmacists here dispense what the doctors tell them to dispense, the first time, without moralizing. I know. It’s amazing.


FALSE. And mind-bogglingly so. The papers would have a field day if there was the barest hint that this might be true.

One of the things that constantly amazes me here is how well-cared-for the elderly and disabled you see on the streets here are. No, these people are not being thrown out on the curb. In fact, they live longer, healthier, and more productive lives because they’re getting a constant level of care that ensures small things get treated before they become big problems.

The health care system also makes it easier on their caregiving adult children, who have more time to look in on Mom and take her on outings because they aren’t working 60-hour weeks trying to hold onto a job that gives them insurance.


FALSE. The philosophical basis of America’s privatized health care system might best be characterized as medical Calvinism. It’s fascinating to watch well-educated secularists who recoil at the Protestant obsession with personal virtue, prosperity as a cardinal sign of election by God, and total responsibility for one’s own salvation turn into fire-eyed, moralizing True Believers when it comes to the subject of Taking Responsibility For One’s Own Health.

They’ll insist that health, like salvation, is entirely in our own hands. If you just have the character and self-discipline to stick to an abstemious regime of careful diet, clean living, and frequent sweat offerings to the Great Treadmill God, you’ll never get sick. (Like all good theologies, there’s even an unspoken promise of immortality: f you do it really really right, they imply, you might even live forever.) The virtuous Elect can be discerned by their svelte figures and low cholesterol numbers. From here, it’s a short leap to the conviction that those who suffer from chronic conditions are victims of their own weaknesses, and simply getting what they deserve. Part of their punishment is being forced to pay for the expensive, heavily marketed pharmaceuticals needed to alleviate these avoidable illnesses. They can’t complain. It was their own damned fault; and it’s not our responsibility to pay for their sins. In fact, it’s recently been suggested that they be shunned, lest they lead the virtuous into sin <>.

Of course, this is bad theology whether you’re applying it to the state of one’s soul or one’s arteries. The fact is that bad genes, bad luck, and the ravages of age eventually take their toll on all of us — even the most careful of us. The economics of the Canadian system reflect this very different philosophy: it’s built on the belief that maintaining health is not an individual responsibility, but a collective one. Since none of us controls fate, the least we can do is be there for each other as our numbers come up.

This difference is expressed in a few different ways. First: Canadians tend to think of tending to one’s health as one of your duties as a citizen. You do what’s right because you don’t want to take up space in the system, or put that burden on your fellow taxpayers. Second, “taking care of yourself” has a slightly expanded definition here, which includes a greater emphasis on public health. Canadians are serious about not coming to work if you’re contagious, and seeing a doctor ASAP if you need to. Staying healthy includes not only diet and exercise; but also taking care to keep your germs to yourself, avoiding stress, and getting things treated while they’re still small and cheap to fix.

Third, there’s a somewhat larger awareness that stress leads to big-ticket illnesses — and a somewhat lower cultural tolerance for employers who put people in high-stress situations. Nobody wants to pick up the tab for their greed. And finally, there’s a generally greater acceptance on the part of both the elderly and their families that end-of-life heroics may be drawing resources away from people who might put them to better use. You can have them if you want them; but reasonable and compassionate people should be able to take the larger view.

The bottom line: When it comes to getting people to make healthy choices, appealing to their sense of the common good seems to work at least as well as Calvinist moralizing.


FALSE. On one hand, our annual Canadian tax bite runs about 10% higher than our U.S. taxes did. On the other, we’re not paying out the equivalent of two new car payments every month to keep the family insured here. When you balance out the difference, we’re actually money ahead. When you factor in the greatly increased social stability that follows when everybody’s getting their necessary health care, the impact on our quality of life becomes even more significant.

And, TRUE — but only because this is a universal truth that we need to make our peace with. Yes, the provincial plans are always struggling. So is every single publicly-funded health care system in the world, including the VA and Medicare. There’s always tension between what the users of the system want, and what the taxpayers are willing to pay. The balance of power ebbs and flows between them; but no matter where it lies at any given moment, at least one of the pair is always going to be at least somewhat unhappy.

But, as many of us know all too well, there’s also constant tension between what patients want and what private insurers are willing to pay. At least when it’s in government hands, we can demand some accountability. And my experience in Canada has convinced me that this accountability is what makes all the difference between the two systems.

It is true that Canada’s system is not the same as the U.S. system. It’s designed to deliver a somewhat different product, to a population that has somewhat different expectations. But the end result is that the vast majority of Canadians get the vast majority of what they need the vast majority of the time. It’ll be a good day when Americans can hold their heads high and proudly make that same declaration.

V 1.3.1 (WIN) UPDATED 09/21/2012 12:37 -0500