Tuesday, October 7, 2008

Privatizing health care is not the answer: lessons from the United States -- Marcia Angell -- Canadian Medical Association Journal

There are strong moves within Canada to make the Canadian health care system more like the US system by partially privatizing it. Those who favour this approach claim that the US system offers more choice and better quality of care and spares the public purse. Some proponents even go so far as to claim that it is more efficient.  My purpose here is to disabuse Canadians of these myths by taking a close look at how the US system works and comparing it with the Canadian system.

In 1972 the Yukon Territory became the last jurisdiction in Canada to adopt the Medical Care Act, which set up a system to provide hospital and physician care to all Canadians.  Before then, the Canadian and US health care systems were similar. Both were partly public, partly private, partly for profit and partly nonprofit. Both also left a great many citizens uninsured. The costs were also about the same — a little over $300 per person in 1970 — as were outcomes. At that time, life expectancy was about a year longer in the United States.

But with the implementation of Canadian medicare, the 2 systems rapidly began to diverge in all respects. The US system became more and more costly, leaving increasing numbers of Americans — now about 46 million people —uninsured. In 2005, expenditures were twice as high in the US as in Canada — US$6697 per person v. US$3326 in Canada. And although Canada insures all its population for necessary doctor and hospital care, the US leaves 15% without any insurance whatsoever. Those who are insured often need to pay a substantial fraction of the bill out-of-pocket, and some necessary services may not be covered.  In a recent survey, 37% of Americans reported that they went without needed care because of cost, compared with 12% of Canadians.

Outcomes also now favour Canada. Instead of living a year longer, the life expectancy of Americans is now 2.5 years shorter than that of Canadians.2 Infant mortality rates are higher in the US, as is preventable mortality (death before the age of 75 years from diseases that are amenable to treatment). Furthermore, contrary to popular belief, people in the US do not receive more health care services. They visit their doctors much less often and spend less time in hospital than Canadians do (Table 1). Per population, there are also fewer nurses and hospital beds in the US, although there are slightly more doctors and many more magnetic resonance imaging (MRI) units.

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Key points

• Health care costs per person are twice as high in the
United States as in Canada.

• The US health care system has worse outcomes, is less efficient
and provides fewer of many basic services than the
Canadian system.

• The United States is the only industrialized country that
treats health care as a market commodity, not a social service,
and leaves uninsured those who cannot pay.

• In the United States, for-profit health care is more expensive
and often of lower quality than not-for-profit or government
care, with much higher overhead costs.

• The notion that partial privatization in Canada will shorten
waiting times for elective procedures is misguided.

• Partial privatization would draw off resources from the
public system, increase costs overall and introduce the inequities
of the US system.

• The best way to improve the Canadian health care system
is to put more resources into it.