Despite spending half what the U.S. does on health care, Canada doesn’t appear to be any worse at looking after the health of its citizens

By Christopher Mims
Scientific American
May 03, 2007

Whether it is American senior citizens driving into Canada in order to buy cheap prescription drugs or Canadians coming to the U.S. for surgery in order to avoid long wait times, the relative merits of these two nations’ health care systems are often cast in terms of anecdotes. Both systems are beset by ballooning costs and, especially with a presidential election on the horizon, calls for reform, but a recent study could put ammunition in the hands of people who believe it is time the U.S. ceased to be the only developed nation without universal health coverage.

Gordon H. Guyatt, a professor of epidemiology and biostatistics at McMaster University in Hamilton, Ontario, who coined the term “evidence-based medicine,” collaborated with 16 of his colleagues in an exhaustive survey of existing studies on the outcomes of various medical procedures in both the U.S. and Canada. Their work appears in the inaugural issue of the new Canadian journal Open Medicine, and comes at a time when many in Canada are debating whether or not to move that country’s single-payer system toward for-profit delivery of care. The ultimate conclusion of the study is that the Canadian medical system is as good as the U.S. version, at least when measured by a single metric–the rate at which patients in either system died.

“Other people knew that Canadians live two to two and a half years longer than Americans,” says Steffie Woolhandler, an author on the paper and an associate professor of medicine at Harvard Medical School, citing a phenomenon that many attribute to differences in lifestyle between the two countries. “But what was not known was once you got sick, was the quality of care equivalent in the two countries.”

Americans Less Likely to Survive Treatment

According to Woolhandler, by looking at already ill patients, the researchers eliminated any Canadian lifestyle advantage and just examined the degree to which the two systems affected patient deaths. (Mortality was the one kind of data they could extract from a disparate pool of 38 papers examining everything from kidney failure to rheumatoid arthritis.)

Overall, the results favored Canadians, who were 5 percent less likely than Americans to die in the course of treatment. Some disorders, such as kidney failure, favored Canadians more strongly than Americans, whereas others, such as hip fracture, had slightly better outcomes in the U.S. than in Canada. Of the 38 studies the authors surveyed, which were winnowed down from a pool of thousands, 14 favored Canada, five the U.S., and 19 yielded mixed results.

Mortality Isn’t the Only Measure That Matters

Not all experts agree with the implication that the Canadian system is better than the U.S. system, however, or with the researchers’ methodology. Vivian Ho, who is the James A. Baker III Institute for Public Policy chair in health economics at Rice University in Houston and has spent time living and conducting research in both the U.S. and Canada, argues that the study’s focus on mortality could be misleading.

“When we look at health systems we look at other things than death,” Ho explains. In her own research on hip fracture, which was cited in Guyatt’s study, she found that the time a patient had to wait before surgery–which was significantly longer in Canada than the U.S. because of a shortage of operating rooms–made only a 1 percent difference in terms of mortality.

“But certainly if you ask people waiting in the hospital,” Ho notes, “They’re going to say I’d rather have the U.S. system…. Waiting means there’s a significant amount of distress for an elderly patient, and also higher complications for pneumonia because you have the patient immobile for so long.”

Patti Groome, an epidemiologist at Queens University Cancer Research Institute in Kingston, Ontario, said she believes that overall the paper was balanced. “But when you get into [the] meat of [the] paper they can’t sort out what’s going on…. There’s way too much heterogeneity in these studies to come to a conclusion about these systems.” In meta-analyses such as this one, “heterogeneity” in results corresponds to variations in the size of an effect across the studies being reviewed.

In other words, of the studies surveyed, some showed slightly better outcomes for the Canadian system and some showed slightly better outcomes for the U.S. approach, making it hard to draw any conclusion other than that, on balance, the two systems seem to yield only slightly different outcomes.

Money Doesn’t Necessarily Buy Health

The study’s authors highlight the fact that per capita spending on health care is 89 percent higher in the U.S. than in Canada. “One thing that people generally know is that the administration costs are much higher in the U.S.,” Groome notes. Indeed, one study by Woolhandler published in The New England Journal of Medicine in 2003 found that 31 percent of spending on health care in the U.S. went to administrative costs, whereas Canada spent only 17 percent on the same functions.

Ho believes, however, that there are also inefficiencies in the Canadian system. In her own work on hip fracture, she found that Canadian hospitals held patients for longer periods because there was no incentive to discharge them. “These patients are easier to take care of,” she explains, “and that helps [hospital administrators] justify their budget…. I think there is room for economic incentives [in the Canadian system].”

“Personally,” Ho adds, “my view is that the Canadian system is good for Canada and the American system is good for America. Neither side should switch, because the systems are a function of the population–the Canadian population believes much more in maintaining social safety nets.”

This research may already be having an impact on policy debate: According to Woolhandler, Ohio democratic congressman and presidential candidate Dennis Kucinich has plans to circulate the results of this study to Congress. Woolhandler herself would like to see this study play a part in a slightly different debate–one over whether it it is better to be sick and insured in the U.S. or in Canada. “I’d like to see politicians giving up on this mythology that the quality of care for sick people in the U.S. is unique.”

Michael Moore’s new film about the US healthcare system must be seen in Europe as well as the US

Agnès Poirier
The Guardian
Monday May 21, 2007

In four tidy acts, Michael Moore spells out the facts. Act one: 50 million Americans have no health cover, and 250 million who think they do, through costly health insurance schemes ($2,000 per person a year), are often denied treatment when they need it. A guy without cover who chopped off two of his fingers in a bout of DIY was presented with an invoice for $12,000 to reattach his ring-finger and $60,000 for his forefinger. Being a romantic, and skint, he chose to get his ring-finger back.

Act two: when did it all start going wrong, asks Moore. The answer: in August 1971. President Richard Nixon and his adviser Edgar Kaiser plot to break the system. “The less care they give, the more money they make,” says Nixon, caught on tape. They? Their friends, the health industry moguls, the same ones who fund the political campaigns of US congressmen. Moore shows us the price tag on every single one of them. One in particular, Billy Tauzin, leaves Congress to become CEO of the drug industry’s top lobbying group, PhRMA, with a $2m a year salary.

Meanwhile astute national publicity campaigns have demonised the concept of universal healthcare by associating it with “socialised medicine”, which in American English translates as “Soviet medicine” – the kind such oppressive regimes as Canada, Britain and France have adopted for their citizens.

Act three: Moore pays these regimes a visit. Britain’s NHS is paid a well deserved tribute, with Tony Benn appearing as the country’s conscience. Then off to France. A mother of three explains that her state nanny does the family’s laundry while the creche down the street, with professionally trained staff, costs her 50p per hour. Moore concludes his French tour by asking: “Is there a reason why they want to make us hate the French? Are they afraid we might want to live like them?”

Act four, the most powerful: Moore decides to test the US administration’s claim that Guantanamo Bay prisoners get the best free healthcare in the world. He takes 9/11 volunteer rescue workers, whose health problems were not covered by the state because they weren’t on its payroll when they ran to help, to Guantánamo Bay in Cuba. At least he tries to. Arriving at the gates, Moore shouts through a loudspeaker: “I have 9/11 sick rescue workers, can you please open the gates?” A siren begins to wail. Moore and his troops make off as fast as they can – to Havana. Where they are treated immediately.

I know what you’re thinking, I know what you’re going to say. And so what? Yes, Michael Moore has an agenda. No, he isn’t among the giants of documentary film-making. No, he isn’t an ordinary journalist. He is, as he says, the op-ed variety, the kind who is constantly angry. He has issues with the way of the world and wants to set records straight. His goal is simply to put universal healthcare back at the centre of the American debate. And while Moore’s main objective is to reach his fellow Americans, his film should also make Europeans ponder on the system they too often take for granted. George Orwell would hate it. But forget about him for a minute. There may sometimes be such a thing as good propaganda.

Agnès Poirier, a journalist and film critic, is an independent adviser on British films for the Cannes film festival

agnescatherinepoirier@hotmail.com

Michael Moore’s scathing, important look at the U.S. healthcare system has plenty to rile the far right — and a lot more to enrage the larger American public.

By Andrew O’Hehir
Salon.com

May. 20, 2007 | “I know the storm awaits me back in the United States,” Michael Moore told a wall-to-wall throng of reporters here after the Saturday morning press premiere of his new film, “Sicko.” Then he heaved a deep breath and added, “But this is just so pleasant.”

It was indeed another gorgeous, summery morning on the French Riviera, but the real heat was indoors. There wasn’t a single empty seat inside the Grand Théâtre Lumière — which holds more than 2,000 people — for “Sicko,” and dozens of stragglers were locked out on the sidewalk. Moore’s screed against the outrageous state of American healthcare was received with uproarious affection, but one might argue that Cannes provided the softest possible crowd. An American left-wing populist, attacking America’s profit-motive, private-sector ideology before a roomful of international intellectuals, at least half of them Europeans. May I introduce a new phrase into the Franglais dictionary? C’était un slam-dunk.

“Sicko” does not display Moore at his most cinematically inventive or imaginative. It presents a TV-documentary-style parade of episodes, characters and settings, bouncing from various American cities to Canada, Britain, France and Cuba (and yes, don’t worry, we’ll get to that). Moore plays a far smaller personal role in this film, appearing only occasionally in his comic-relief role as the clueless buffoon who can’t seem to grasp that healthcare in all those other countries is free, or virtually so. When he’s eating dinner with a group of Americans living in Paris who begin to list all the things they can have as free or nearly free entitlements — not just healthcare but an emergency doctor who makes house calls; not just childcare but a part-time in-home nanny — Moore puts his hands over his ears and begins singing “La la la la la.” (If you have kids or any kind of chronic family health problems, your reactions might include weeping in despair, slitting your wrists or booking a one-way ticket.)

Still, there is no mistaking the passion and political intelligence at work in “Sicko.” It’s both a more finely calibrated film and one with more far-reaching consequences than any he’s made before. Moore is trying to rouse Americans to action on an issue most of us agree about, at least superficially. You may know people who will still defend the Iraq war (although they’re less and less eager to talk about it). But who do you know who will defend the current method of healthcare delivery, administered by insurance companies whose central task is to minimize cost and maximize shareholder return? Americans of many different political stripes would probably share Moore’s conclusions at the press conference: “It’s wrong and it’s immoral. We have to take the profit motive out of healthcare. It’s as simple as that.”

“Sicko” purposefully does not focus on the 50 million or so Americans who don’t have health insurance, as scandalous as that is, but on the horror stories of middle-class working folks who believed they were adequately covered. There are so many of these they begin to blur into each other: the woman in Los Angeles whose baby was denied treatment at an emergency room outside her HMO network, and died as it was being transferred hours later; the woman in Kansas City whose husband was repeatedly denied various drugs his physician prescribed for kidney cancer, and who in the last stage of life was denied a bone-marrow transplant that could have saved his life; the woman who was told her brain tumor was not a life-threatening illness, and died; the woman who was told her cancer must have been a preexisting condition, and died.

One might respond that anecdotes like these have tremendous emotional power but little analytical rigor, but in this case I think we all know (and fear) that these worst-case outcomes exemplify the system perfectly. Moore interviews two healthcare whistle-blowers, both now plagued with guilt, who explain what should be obvious: The point of the system is to treat as few people as possible as cheaply as possible, and those who get ahead in the healthcare industry are those who find ever more devious ways to deny coverage. (For example, you can now be denied for certain preexisting conditions you didn’t know about, on the premise that you should have known about them.)

OK, let’s get to the headlines: Yes, in the film Moore travels with a group of ill and injured 9/11 rescue workers (along with several other of his film’s protagonists) to Cuba, where they receive free and apparently excellent medical treatment. It’s unquestionably another button-pushing Michael Moore stunt, designed to provoke controversy. It’s cheap but funny, dubious as evidence but affecting anyway. Moore does not even seem aware of the possibility that the Cubans were shrewd enough to see the propaganda value in this exercise, and put on a dog-and-pony show for his and our benefit. (For that matter, we don’t know how much of the visit was planned in advance with Cuban authorities.) All that aside, within the context of the film and the argument Moore is building, Cuba makes as much sense as anywhere else.

Moore begins his foreign odyssey in the film after meeting a 22-year-old Michigan woman who has moved across the Ontario border (not entirely on the up-and-up) because she’s been denied treatment for cervical cancer. He wanders around emergency rooms in London, Ontario, and London, England (where he discovers that the cashier’s window is for paying patients their travel expenses, not for settling the bill). He zips from one Parisian arrondissement to another with an on-call physician on the night shift. He dines with the aforementioned Americans abroad, who seem dazed and a little guilty about their escape from healthcare hell.

Much of this is played as comedy; Moore corners a young Afro-British couple with a wiggling bundle in the hallway of a London hospital and says cheerfully, “So — how much they charge you for that baby?” But Moore is trying to push us beyond the universally shared idea that something must be done to the slightly more controversial idea that something has been done, and that all we have to do is appropriate it. Americans have of course been conditioned for generations to believe that socialized medicine is first of all a disaster in its own terms, and secondly, the pathway to totalitarianism.

His portrayal of the Canadian, British and French systems is undoubtedly simplistic , and several Canadian reporters took that up with him at the press conference — although all of them admitted they wouldn’t trade their system for ours. But Moore’s overall point is, I think, inarguable: Flawed as they may be, those systems are a hell of a lot more humane and civilized than anything we’ve got. (Life expectancy is significantly higher, and infant mortality lower, in all of those countries than the United States. Whatever outdated stereotypes you may hold, these days poor people in Britain are statistically healthier than rich people in America.)

Addressing a series of questions from foreign reporters at the press conference, Moore said: “We should do what we always do as Americans, steal the best things you’re doing and make them our own. The Canadians do certain things very well. The Brits do certain things very well. The French have the best system in the world, and that’s not my opinion. That’s how the World Health Organization rates them. None of them is perfect, but it’s not my role to make criticisms. It’s my role as an American to say, why don’t we take the best elements you’re doing and blend them together, and call it the American system?”

Moore decided to go to Cuba, as he explains in the film, after learning the peculiar irony that detainees at Guantánamo Bay are entitled to something American citizens are not: free healthcare. In a brief and awkward scene, he tries to bring a fishing boat with his 9/11 refugees aboard into U.S. waters just off the naval base. They are refused entry (Moore is evasive about the details) and then seek treatment at the best hospital in Havana.

“The point of this was not to go to Cuba,” Moore said at the press conference. “The point was to go to Guantánamo Bay, to get the 9/11 workers the same medical care we’re giving to members of al-Qaida.” If the detainees had been at a U.S. base in Spain or Italy or Australia — all countries with universal healthcare — he’d have taken his 9/11 workers there instead. In fact, when Moore drops the jokes and political attitudinizing during the Cuba sequence, the pathos of the story makes his point for him: A poor Caribbean island, whatever its ideology, can afford healthcare for everyone while we do not. The only possible conclusion is that our society has chosen not to.

When asked about his potential prosecution for violating U.S. Treasury sanctions against trade with or travel to Cuba, Moore was uncharacteristically sober. “I know a lot of you have written things like, ‘How dumb are they?'” he said, “but I don’t take this lightly. The Bush administration may try to claim that my footage was obtained illegally. We haven’t discussed this possibility yet, but actions could be taken to prevent this film from opening on June 29. I know that sounds crazy to the Americans in the room. I guess it is crazy.”

When Americans do get to see “Sicko,” Moore says, “They will understand that this was about helping 9/11 rescue workers who’ve been abandoned by the government. They’re not going to focus on Cuba or Fidel Castro or any other nonsense coming out of the Bush White House. They’re going to say: ‘You’re telling me that al-Qaida prisoners get better medical treatment than the people who tried to recover bodies from the wreckage at ground zero?'”

When Moore interviews Tony Benn, a leading figure on the British left, his larger concerns come into focus. Benn argues that for-profit healthcare and the other instruments of the corporate state, like student loans and bottomless credit-card debt, perform a crucial function for that state. They undermine democracy by creating a docile and hardworking population that is addicted to constant debt and an essentially unsustainable lifestyle, that literally cannot afford to quit jobs or take time off, that is more interested in maintaining high incomes than in social or political change. Moore seizes on this insight and makes it a kind of central theme; both in the film and aloud, at the press conference, he wondered whether some essential and unrecognized change has occurred in the American character.

“I hope this film engenders discussion, not just about healthcare, but about why we are the way we are these days,” Moore told us. “Where is our soul? Why would we allow 50 million Americans, 9 million of them children, not to have health insurance? Maybe my role as a filmmaker is to go down a road we might be afraid to go down, because it might lead to a dark place.”

Moore’s last revelation in “Sicko” is sure to be endlessly debated in the right-wing blogosphere that is so obsessed with him (and may be of little interest to ordinary viewers). Some time ago, Jim Kenefick, proprietor of the especially bilious anti-Moore site Moorewatch, almost shut down his site to focus on his wife’s worsening illness and escalating healthcare costs. An anonymous donor then sent him $12,000 to cover his wife’s bills and keep the site running. (She has apparently recovered.) Now that donor has been revealed and, as Kenefick now says he suspected all along, it turns out to be Michael Moore.

“I want him to know that it was done with all the best intentions,” said Moore, adding that he planned to phone Kenefick personally after the press conference. (According to Kenefick’s blog, Moore left him a voice-mail message later on Saturday.) “I went back and forth about whether to use that material,” Moore went on. “I asked myself, would you be doing this if it weren’t in the film? I decided that I would, and I should, and that that’s the way I think we should live.”

Moore says he began exercising and lost 25 pounds while working on his healthcare film; “I’m actually a fairly skinny person for the Midwest,” he quipped. He says he’s tried to maintain a lower public profile since “Fahrenheit 9/11” and would like Kenefick and his many other critics to cut him some slack. “You know, I begin to hope that as I enter the discourse with this film, I might get some kind of a break. As far as the accuracy of my movies goes, I think the record speaks for itself. Maybe people will say: He warned us about General Motors, he warned us about school shootings and he warned us about Bush.”