Hearing: “Access and Cost: What the U.S. Health Care System Can Learn from Other Countries”
Testimony of Sally C. Pipes, President and CEO, Pacific Research Institute
U.S. Senate Committee on Health, Education, Labor and Pensions, Subcommittee on Primary Health and Aging, March 11, 2014
Those Canadians who can afford to do so have simply opted out of their healthcare system. An enormous number jump the queue for care in their native land and travel to the United States to receive medical attention. In 2012, over 42,000 Canadians crossed the border to get treated.
Frasier Institute Reports:
Leaving Canada for Medical Care 2010
Estimated number of patients receiving treatment outside Canada, 2010: 44,794
Leaving Canada for Medical Care 2011
Estimated number of patients receiving treatment outside Canada, 2011: 46,159
Leaving Canada for Medical Care 2012
Estimated number of patients receiving treatment outside Canada, 2012: 42,173
Waiting Your Turn: Wait Times for Health Care in Canada 2011
Average Percentage of Patients Receiving Treatment Outside of Canada, 2011: 1.0%
(See Page 58, Table 11)
Waiting Your Turn: Wait Times for Health Care in Canada 2012
Average Percentage of Patients Receiving Treatment Outside of Canada, 2012: 0.9%
(See Page 62, Table 11)
Waiting Your Turn: Wait Times for Health Care in Canada 2013
Average Percentage of Patients Receiving Treatment Outside of Canada, 2013: 0.9%
(See Page 64, Table 11)
Phantoms In The Snow: Canadians’ Use Of Health Care Services In The United States
By Steven J. Katz, Karen Cardiff, Marina Pascali, Morris L. Barer and Robert G. Evans
Health Affairs, May 2002
To examine the extent to which Canadian residents seek medical care across the border, we collected data about Canadians’ use of services from ambulatory care facilities and hospitals located in Michigan, New York State, and Washington State during 1994–1998. We also collected information from several Canadian sources, including the 1996 National Population Health Survey, the provincial Ministries of Health, and the Canadian Life and Health Insurance Association. Results from these sources do not support the widespread perception that Canadian residents seek care extensively in the United States. Indeed, the numbers found are so small as to be barely detectible relative to the use of care by Canadians at home.
Phantoms in the snow.
Despite the evidence presented in our study, the Canadian border-crossing claims will probably persist. The tension between payers and providers is real, inevitable, and permanent, and claims that serve the interests of either party will continue to be independent of the evidentiary base. Debates over health policy furnish a number of examples of these “zombies”—ideas that, on logic or evidence, are intellectually dead—that can never be laid to rest because they are useful to some powerful interests. The phantom hordes of Canadian medical refugees are likely to remain among them.
Each year the Fraser Institute of Canada issues a report claiming that over 40,000 patients leave Canada for medical care. Yet a highly credible study done over a decade ago revealed that many of these supposed patients were merely “phantoms in the snow” and that this is another “zombie idea” that, on logic or evidence, is “intellectually dead” but “can never be laid to rest because (the concept is) useful to some powerful interests.” So it is important to understand the source of the Fraser numbers.
Warning: The following is wonkish
As part of their annual survey of specialists to determine waiting times in Canada, the Fraser Institute asks the following question (the last question of their survey):
12. Approximately what percentage of your patients received non-emergency medical treatment in the past 12 months:
In another province? ______ % Outside of Canada? ______ %
Then, within each of twelve specialties in each of the ten provinces, they average the percent of patients who reportedly obtain care outside of Canada, as estimated by the practitioners of those specialities. If you look at Table 11 in any of the “Waiting Your Turn” reports listed above (choose 2013 as the latest example), you will see that this creates a grid of 120 percentages. Averages are obtained for each province (bottom line) and for each specialty (column on the right). These are then averaged to get the final percentage for all of Canada – 0.9% for 2013.
Stop here and think about that. Each practitioner was asked to estimate a percentage of his or her patients who left Canada for care (not specifically for care in the United States as Canada has a very large immigrant population – about one-fifth were born outside of Canada). If they had been asked for specific numbers, each may have been able to make a fairly reasonable guesstimate. But they were asked for a percentage. If there were not very many then the lowest full integer might come to mind – one percent (“Oh, it can’t be more than one percent”). In fact, 37% of the 120 sections of the grid reported zero percentages of patients leaving the country for care – probably a more realistic assessment since those specialists likely couldn’t remember any patients who left. Nevertheless, the majority estimated percentages well below one percent, i.e., there weren’t very many.
But look at Table 11 for 2013. There is quite a wide variation in the 120 results listed. For 2013 that ranged from 0.0% (the most common response) to 5.0%. The responses of 1.0% and higher were the outliers. With the outliers, it is difficult to imagine why a given specialty in a given province would have such a high number of patients leaving the country for health care. When we hear about delays in care in Canada, the most common one is orthopedics – joint replacement, etc. Yet in all of Canada, orthopedics is listed at 0.7%, below the 0.9% average for all specialties combined. It is suspicious that some physicians, intentionally or unintentionally, may be making high estimates which would skew the numbers upwards.
Let’s look at Table 11 for 2011 and 2012 as well as 2013. Urology in British Columbia was 1.3% in 2011, 2.0% in 2012, and 3.8% in 2013. Plastic surgery in British Columbia was 7.8%, 1.3%, and 0.4% in those same years. Cardiovascular survey in New Brunswick was 0.0%, 3.0%, and 0.5%. Internal Medicine in Manitoba was 3.4%, 0.5%, and 0.3%. Radiation oncology in New Brunswick was 0.5%, 7.0%, and zero. Obviously there is a large scatter in the high outliers that changes from year to year. Further, the entire population of specialists surveyed in 2013 totaled only 2,160 physicians scattered amongst 120 categories in the grid. It is quite obvious that only a few individual outliers, who either guessed high or wanted to make a political point, were able to skew the percentages upward. Eliminating the outliers likely would reduce the net percentage in half and maybe more.
For the next step, the Fraser Institute “(combined) these percentages with the number of procedures performed in each province and in each medical specialty (to give) an estimate of the number of Canadians who actually received treatment outside the country.” The results are in Table 1 of each of the three reports, “Leaving Canada for Medical Care.” If their percentages were correct (which they likely are not) and the tally of the procedures were correct (uncertain) then this calculation might give a very rough approximation of the number of procedures performed outside of Canada for each of the 120 categories of the grid. But talk about soft numbers.
They then add a “residual” number of procedures for which people are waiting. “To estimate this residual number, the number of non-emergency operations not contained in the survey that are done in each province annually must be used” – using CIHI and other data which they “pro-rated.” This “residual” for 2012 was 18,265 of the 42,173 total estimated to have exited Canada for health care. It’s a convenient number to boost the figures, even if they are “operations not contained in the survey.”
Talk about phantoms in the snow. This data is almost useless for estimating the number of Canadians who leave Canada for health care, much less whether or not they received it in the United States.
More importantly, the premise of those who use these unreliable numbers of patients exiting Canada for care is that single payer financing results in excessive queues which then triggers this exit. That should not necessarily follow since queues can be tamed if the stewards of the system are attentive to system capacity and queue management. Many nations with comprehensive systems do not have problems with queues.
In contrast, in the United States, the financial barriers to care (that do not exist in Canada) are so great that tens of millions who need care do not even gain a place in the queue – rationing based on ability to pay. Only a fool would recommend our callous system over Canada’s egalitarian single payer system.
For those who read this far, it might be worth your time to look at one more item. The “Waiting Your Turn” reports are the same reports that are used each year to claim that Canadians have intolerable delays in accessing their health care. For the 2013 Waiting Your Turn report, look at Chart 6 on page 10. Except for plastic surgery, orthopedics and internal medicine (not primary care), the actual median time between an appointment with a specialist and treatment is quite close to the median time that the specialists deemed to be a reasonable wait. And where there are problems, they are working on it.
More reliable data on wait times in Canada is available through the Canadian Institute for Health Information: