The star-spangled straw man
A recent testimony before a U.S. Senate subcommittee by Dr. Danielle Martin, former head of the Canadian Doctors for Medicare, has given Canadians the chance to indulge in what may be a favourite pastime - criticizing the American health care system.
Unfortunately, rather than sparking a discussion about how to improve both the Canadian and U.S. health care systems to better serve their populations - pundits, online commenters, and tweeters have simply resorted to nationalistic chest pounding, accompanied by the usual overly simplistic arguments about why each system should be considered a model for the other.
Easily forgotten is the fact that both the Canadian and American health care systems are widely considered to be expensive and inefficient.
To be fair, Dr. Martin did mention that she does "not presume to claim today that the Canadian system is perfect or that we do not face significant challenges." However, in the polarized environment following her speech, it is important to set the record straight on some key figures she chose to cite, as well as some of the important information she conveniently left out.
Lets start with the big one her claim 'that there are 45,000 in America who die waiting because they don't have insurance at all.' It's pretty safe to surmise that she's referring to a 2009 study by Wilper et al., who piggybacked their research on a previous study by the Institute of Medicine in 2002 (which pegged the number at 18,000).
Of course, promoting health care insurance coverage for the population is not a bad thing. But to propose that a lack of insurance coverage in and of itself leads to death is absurd. People don't die simply because they lack health insurance.
In fact, the sensationalistic conclusions drawn from these two studies have been criticized by several economists. John Goodman points out that both studies fail to account for changes in insurance status during the periods examined, while Jenny Kim and Jeffery Milyo demonstrate the pitfalls of such observational studies by replicating Wilper et al.'s methodology to conclude that Medicaid (governmental health insurance for lower income Americans) coverage is also associated with higher mortality. Further, June O'Neill (former director of the Congressional Budget office) and Dave O'Neill concluded that health-care insurance itself is not the primary reason for higher mortality rates among populations that are uninsured (who may face multiple disadvantages), while Richard Kronick found no difference in mortality between the uninsured and those with employer-sponsored insurance once demographic factors, health status, and health behavior characteristics were controlled for.
There's even some evidence (again, from June and Dave O'Neill) to suggest that, for some health services (e.g. screening for cancer), uninsured Americans may actually be better off than "insured" Canadians.
Dr. Martin's second major claim - and one that Canadian defenders of the status-quo have latched onto - presumably relies upon a study by Stephen Duckett (former head of Alberta Health Services) which suggests that 'increased private sector activity [in health care] is associated with increased public sector waiting times' in Australia. First, this statement says nothing about overall wait times, only those in public hospitals. Second, it doesn't inform us about the line of causation, or directionality. In fact, Duckett entertains the possibility that increased private sector activity may have actually been a response to inadequate public sector services rather than the cause of longer public wait times. And there's still the complex matter of how governments respond to expansions in private sector activity (including, sometimes, deliberate reductions in public activity), as well as the question of why waits occurred in the first place.
Finally, the entire argument breaks down when one is confronted by data from the Commonwealth Fund which indicates that fewer Australians than Canadians waited two months or more for specialist appointments and four months or more for elective surgery.
In fact, all of the best performers on the Commonwealth Fund's list (Switzerland, the Netherlands, and Germany) have universal health care systems with private parallel options. Further, their performance is in stark contrast to Canada's, where over-reliance on government planning, lack of competition, and lack of cost-sharing have resulted in some of the longest wait times in the developed world.
These are the countries, and policies, we should be talking about if we are truly interested in delivering timely access to quality health care for our citizens.
While the American health care system has some important shortcomings, the same holds true for Canada's. Inordinately long wait times, medical resource shortages, and ballooning healthcare costs have become defining characteristics of healthcare in our country - and denigrating the American approach will not fix those problems.
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