By Aaron E. Carroll, M.D., M.S.
AARP Newsletter, April 16, 2012
How does the U.S. health care system stack up against Canada’s? You’ve probably heard allegedly true horror stories about the Canadian system — like 340-day waits for knee replacement surgery, for example.
To separate fact from fiction, Aaron E. Carroll, M.D., the director of the Center for Health Policy and Professionalism Research in Indianapolis, identified the top myths about the two health care systems.
Myth #1: Canadians are flocking to the United States to get medical care.
How many times have you heard that Canadians, frustrated by long wait times and rationing where they live, come to the United States for medical care?
I don’t deny that some well-off people might come to the United States for medical care. If I needed a heart or lung transplant, there’s no place I’d rather have it done. But for the vast, vast majority of people, that’s not happening.
The most comprehensive study I’ve seen on this topic — it employed three different methodologies, all with solid rationales behind them — was published in the peer-reviewed journal Health Affairs.
Source: “Phantoms in the Snow: Canadians’ Use of Health Care Services in the United States,” Health Affairs, May 2002.
The authors of the study started by surveying 136 ambulatory care facilities near the U.S.-Canada border in Michigan, New York and Washington. It makes sense that Canadians crossing the border for care would favor places close by, right? It turns out, however, that about 80 percent of such facilities saw, on average, fewer than one Canadian per month; about 40 percent had seen none in the preceding year.
Then, the researchers looked at how many Canadians were discharged over a five-year period from acute-care hospitals in the same three states. They found that more than 80 percent of these hospital visits were for emergency or urgent care (that is, tourists who had to go to the emergency room). Only about 20 percent of the visits were for elective procedures or care.
Next, 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.
Finally, the study’s authors examined 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.
Myth #2: Doctors in Canada are flocking to the United States to practice.
Every time I talk about health care policy with physicians, one inevitably tells me of the doctor he or she knows who ran away from Canada to practice in the United States. Evidently, there’s a general perception that practicing medicine in the United States is much more satisfying than in Canada.
Problem is, it’s just not so. Consider this chart:
Source: “2009 International Health Policy Survey of Primary Care Physicians in Eleven Countries,” The Commonwealth Fund, November 2009.
The Canadian Institute for Health Information has been tracking doctors’ destinations since 1992. Since then, 60 percent to 70 percent of the physicians who emigrate have headed south of the border. In the mid-1990s, the number of Canadian doctors leaving for the United States spiked at about 400 to 500 a year. But in recent years this number has declined, with only 169 physicians leaving for the States in 2003, 138 in 2004 and 122 both in 2005 and 2006. These numbers represent less than 0.5 percent of all doctors working in Canada.
So when emigration “spiked,” 400 to 500 doctors were leaving Canada for the United States. There are more than 800,000 physicians in the United States right now, so I’m skeptical that every doctor knows one of those émigrés. But look closely at the tan line in the following chart, which represents the net loss of doctors to Canada.
Source: Canadian Institute for Health Information
In 2004, net emigration became net immigration. Let me say that again. More doctors were moving into Canada than were moving out.
Myth #3: Canada rations health care; that’s why hip replacements and cataract surgeries happen faster in the United States.
When people want to demonize Canada’s health care system — and other single-payer systems, for that matter — they always end up going after rationing, and often hip replacements in particular.
Take Republican Rep. Todd Akin of Missouri, for example. A couple of years ago he took to the House floor to tell his colleagues:
“I just hit 62, and I was just reading that in Canada [if] I got a bad hip I wouldn’t be able to get that hip replacement that [Rep. Dan Lungren] got, because I’m too old! I’m an old geezer now and it’s not worth a government bureaucrat to pay me to get my hip fixed.”
This has been debunked so often, it’s tiring. The St. Louis Post-Dispatch, for example, concluded: “At least 63 percent of hip replacements performed in Canada last year  … were on patients age 65 or older.” And more than 1,500 of those, it turned out, were on patients over 85.
The bottom line: Canada doesn’t deny hip replacements to older people.
But there’s more.
Know who gets most of the hip replacements in the United States? Older people.
Know who pays for care for older people in the United States? Medicare.
Know what Medicare is? A single-payer system.
Myth #4: Canada has long wait times because it has a single-payer system.
The wait times that Canada might experience are not caused by its being a single-payer system.
Wait times aren’t like cancer. We know what causes wait times; we know how to fix them. Spend more money.
Our single-payer system, which is called Medicare (see above), manages not to have the “wait times” issue that Canada’s does. There must, therefore, be some other reason for the wait times. There is, of course. It’s this:
Source: Organisation for Economic Co-operation and Development (OECD)
In 1966, Canada implemented a single-payer health care system, which is also known as Medicare. Since then, as a country, Canadians have made a conscious decision to hold down costs. One of the ways they do that is by limiting supply, mostly for elective things, which can create wait times. Their outcomes are otherwise comparable to ours.
Please understand, the wait times could be overcome. Canadians could spend more. They don’t want to. We can choose to dislike wait times in principle, but they are a byproduct of Canada’s choice to be fiscally conservative.
Yes, they chose this. In a rational world, those who are concerned about health care costs and what they mean to the economy might respect that course of action. But instead, they attack the system.
Myth #5: Canada rations health care; the United States doesn’t.
This one’s a little bit tricky. The truth is, Canada may “ration” by making people wait for some things, but here in the United States we also “ration” — by cost.
An 11-country survey carried out in 2010 by the Commonwealth Fund, a Washington-based health policy foundation, found that adults in the United States are by far the most likely to go without care because of cost. In fact, 42 percent of the Americans surveyed did not express confidence that they would be able to afford health care if seriously ill.
Source: “How Health Insurance Design Affects Access to Care and Costs, by Income, in Eleven Countries,” Health Affairs, November 2010.
Further, about a third of the Americans surveyed reported that, in the preceding year, they didn’t go to the doctor when sick, didn’t get recommended care when needed, didn’t fill a prescription or skipped doses of medications because of cost.
Finally, about one in five of the Americans surveyed had struggled to pay or were unable to pay their medical bills in the preceding year. That was more than twice the percentage found in any of the other 10 countries.
So feel free to have a discussion about the relative merits of the U.S. and Canadian health care systems. Just stick to the facts.
Aaron E. Carroll frequently blogs about this topic for The Incidental Economist and is the coauthor of Don’t Swallow Your Gum: Myths, Half-Truths, and Outright Lies About Your Body and Health.