Occasionally, articles appear comparing health care in the United States with health care in Canada or other wealthy western countries in terms of health outcomes. Yesterday, Nicholas Kristof, in an op-ed piece in the New York Times, compared the two countries’ health care system through the filter of the experience of a 59 year-old American Attorney named Diane Tucker who moved to Vancouver in 2006. I urge you to read Kristof’s article to get the full flavor of her contrasting recent experiences with the two health care systems. But the bottom line is that Ms. Tucker, who’s job in Canada ended, now finds herself constrained to remain there because if she came back to the United States her medical history which includes a stroke would prevent her from getting insurance in the United States at anything but a prohibitive cost. Kristof tells this story to make the larger point that Americans ought not to get scared by current health industry advertising campaigns offering horror stories about Canadian health care, and he also points out that even though America spends nearly twice as much per person on health care as Canada, the “infant mortality rate is 40 percent higher than Canada’s, and American mothers are 57 percent more likely to die in childbirth than Canadian ones.” He also might have added that life expectancy in Canada is now at 81, while it is only 78 for Americans.
At the Oxdown Gazette, Scarecrow discusses the results of a careful Canadian study comparing health care outcomes in Canada and the United States and after citing the study’s finding that Canadian health outcomes “may be superior . . . but differences are not consistent, Scarecrow also points out, correctly, I think, that the Canadian study focuses on patients who make it into the system only, and doesn’t take into account health care outcomes for people without insurance who do not get medical care. He then concludes that if these are taken into account, it’s pretty obvious that the Canadian system is clearly superior in “overall health outcomes” to the American system.
And this brings us to the larger question. You don’t really get an unbiased comparison between the US and alternative systems, if all you do is to focus on health outcomes among patients treated in the alternative systems. To really compare health care systems, we have to view them as implementations of national policies and ask what the full impact of those policies are in terms of both health and non-health outcomes.
Articles like Kristof’s and the very careful Canadian Study are fine as far as they go, but they look at impact in terms of aggregate costs vs. health care outcomes, while other impacts of national health care aren’t included in the discussion. Too bad, because it’s pretty clear that the fact that no one in Canada goes bankrupt, or is foreclosed upon, or loses their health care because they lose their job, is a pretty important impact of contrasting national health care policies. The fact that no Canadian business has to worry about expenses for health care also improves its competitiveness relative to US competitors. People in Canada don’t have to feel tied to a Company because it provides specific health care benefits they must have. No one has to worry about pre-existing conditions making them uninsurable. Nor do they have to worry about whether a hospital near an accident will serve them, because they have insurance that works with a hospital that’s further away.
In short, there’s a lot more to a comparison between the US and Canadian systems than just health care outcomes and aggregate or average costs. And these other comparative impacts boil down to a favorite American idea, and that idea is “freedom.” Defenders of the American private insurance system always make the case that their preferred system is about freedom of choice for the insured, and they say that a single payer system will restrict individual freedom. But when we look at the full impact of the Canadian system vs. the American system, we see that the American system is much more about the economic freedom of the insurers to become wealthier at the expense of the insured, while the Canadian system is about Freedom from Want, and Freedom from Fear, two of Franklin Delano Roosevelt’s four freedoms. It’s time that Americans had a greater amount of those freedoms, whatever the cost to those who’ve been on the health care gravy train.
3 responses so far ↓
1 Henk Hadders // Jun 20, 2009 at 4:03 pm
Dear Joe,
What a joy to read your blog; some of your posts about politics are jewels. It makes one even hesitate to react. Personally I would be very sad, if you are going to like this so much, that you stop blogging about KM altogether.
There’s something peculiar about our western word “healthcare”. Our western healthcare is about many things, it’s about diseases, about hospitals, about doctors and nurses, about cure, mostly about money, but strangely it’s hardly ever what it should be about: the care for health. In cultures like Japan people talk far more about health and about food as a medicine. In China healthy people visit doctors for advice about the care for their health and how to find the right balance adjusting food and exercise. Doctors deal with the art of a good and thus healthy life. Cultural views, social and cultural values determine the way how we look at health and disease and how we create social systems and artifacts to deal with these issues, like a health delivery system, insurance system etc. Language is also a cultural artifact, with linguistic expressions of facts and values, and linguistic expressions of beliefs and knowledge claims. Language really matters ! In the Western world the word “healthcare” is about disease care, and as we use this word for the treatment of diseases, we are not talking about true healthcare, but mainly about diseases and everything associated with that.
The word and concept “care” is also problematic, as the doctor doesn’t take care of us, but he or she treats us; it’s “disease treatment”. True healthcare is something else, it’s about the care for health. But using the notion of healthcare for disease treatment leads us to a rather twisted image and to the fixation of policies on the treatment of diseases, rather than on true healthcare. Regarding the health-illness dichotomy we are considered to be sick once we enter the healthcare system. Our western cultural linguistic expressions confirms the orthodox or conventional view of health within healthcare (with medicine as its primary process), dealing almost entirely with the physical organism using physical interventions: surgery, drugs, medication etc.
Looking at parts and wholes, I agree with you that healthcare comparisons shouldn’t be partial, as healthcare shouldn’t be partial itself. The health outcomes of healthcare systems are poor all over the developed world and plagued with low quality, medical errors (IOM) etc. And their non-health outcomes (like energy-use, wastes such as dumping medicines in our water systems etc) are poor as well; one might even say that the well-being and health of the population is even threatened by this unsustainable behavior of healthcare. All this is also true in The Netherlands. But the quality of a population’s health is not equal to the quality of its national healthcare delivery system. And paraphrasing the “quotient” approach of our mutual friend Mark W. McElroy: treating cases of illness (the numerator) is not the same as contributing to population health (the denominator). We really need more denominator-medicine & healthcare, creating health for patients, workers, society and the environment.
What a paradox in the US ! It has the best healthcare system in the world, but the US population becomes unhealthier by the minute, with obesity, mental problems etc. You will find them waggling about their favored health-setting: Wall Mart. It becomes increasingly clear that changes in the existing healthcare system will not be sufficient to maintain and improve our health.
The fact that the health status in other nations is better than the US, seems to me also due to better health promotion, public and population health (and I might add environmental health) interventions. And “Health in all Policies”, meaning that all Government Agencies take health issues into account while developing their policies and programs regarding housing, transportation, agriculture etc.
There really is no need for the US to look down on Canada, as we in the Netherlands actually look up to them for what they’ve achieved in these fields. “Freedom” is a great cultural value and an important part of well-being, but I’m glad that I live in a country where the healthcare delivery system is still shaped by the value of “solidarity” (BTW this is not the same as Socialism). It simply means helping one another, as health care is a right of each citizen and not a privilege (of the wealthy).
The Netherlands,
Henk Hadders
2 Joe // Jun 20, 2009 at 10:19 pm
Dear Henk,
What a joy to read to read your comment. Any blogger would feel encouraged to receive a comment like this one, and, it goes without saying that I won’t stop blogging on KM.
Of course, I agree wholeheartedly with everything you’ve said about health care. I would only add that we in the United States need to get over the idea that we currently provide the best health care on earth and face the reality that our system does not deliver good care for the majority of our population under 65 when we take into account the uninsured, the many insured who are driven into bankruptcy, or who have inadequate and costly policies. Our system is the worst performing of any advanced nation, and, in truth, we need to be looking up to every other advanced nation, rather than down at anyone.
3 Henk Hadders // Jun 21, 2009 at 9:12 am
Dear Joe,
I fully agree with your final remarks. When I stated that the Unitede States has the best healthcare system in the world, I meant its knowledge, technology, artifacts and machines etc. But it has the worst system in the world for its people (access, funding etc). The system seems to be driven by perverse incentives as it is all about the financial bottom line. I really hope your president Obama delivers his promise…… to deliver a good and payable healthcare system for all Americans. In the meantime ….be well.
Henk