Beth Gamulka: View from the Great White North

Last month I had the pleasure of reconnecting with many classmates at the same reunion that Jonathan Miller enjoyed. I went to a panel discussion about health care reform. As a physician who is interested in health policy, I was eager to hear what the panelists had to say. My former classmates were now health services researchers, physicians, and health policy experts. Other audience members were now health insurance executives, policy makers, and health care users with diverse political affiliations. It didn’t take long before I felt as if I had mistakenly walked into a foreign language film without English subtitles. While Canadians may spell and pronounce words differently, understanding American English is usually not a hardship. The language used in public discourse on the Affordable Care Act, however, simply does not resonate with Canadians.

While I have lived in the US, I have never practiced medicine there, nor have I ever been a consistent user of US health care services (unless you count sporadic interactions with the University Health Service in college– but let’s not). I have spent over 20 years as a health care provider and a lifetime as a health care user in Canada. I am not a comparative expert on US vs. Canadian health care models. I have simply experienced the Canadian system both as a physician and a patient/ advocate.

There are three key components of the Canadian universal health care system that are integral to its success and might illustrate the true differences between citizens of both countries (aside from the Canadian propensity to be polite and apologetic). The first is the way in which Canadians view their right to health care. It is an expectation but not one that is felt to necessarily be an immediate one. Canadians are very patient people (unless they are watching an NHL playoff game on TV and the cable goes out). I think it is similar to garbage collection. I pay taxes to the city of Toronto and in return I get my garbage collected on a regular basis. While I might want the garbage collectors to come every day, instead I have to wait patiently to have it removed according to the schedule.

What if there is a chemical spill or a major hazard that would require removal of toxic waste urgently? There is a way to initiate an emergency system to get that garbage removed. Access to health care is seen in much the same way.

Another component of Canadian Medicare that supports its success is the belief of most Canadians that every citizen has the right to access the system. While there may be geographic variations with respect to the services that are offered, those differences are not unique to this country. It is similar to public primary and secondary education. This belief is part of the fabric of the country.

The last characteristic of Canadian Medicare might sound odd. I actually believe that we have less government and third-party intervention in the doctor-patient relationship in Canada when compared to the US. While government involvement in instituting Obamacare has met with resistance from insurance companies and individuals on many levels because of the fear of losing free choice, the recent Supreme Court Hobby Lobby decision suggests that there is a long road ahead. As a physician, I see patients and bill the province’s Ministry of Health, who then pays me for the services that I have provided. Neither the patient nor the physician has to get approval from a third party for the care that is needed. The role of health insurance companies is for extended benefits only, such as dental and psychological services, medical device costs, medication costs, and use of private hospital rooms. While there are government controls on overall costs and resource allocation, there are certainly no government or third parties interfering with moral decision-making for the patient.

Canada has usually been a little behind the times when compared to the US. In a reference to the ‘80s fashions worn by Robin Sparkles in 1994 in an episode of How I Met Your Mother, Cobie Smulders’ character says, “The ‘80s didn’t come to Canada ‘til like ’93.” While that may be the case for access to stores like Target (which finally opened in Canada in 2013), access to health care in Canada is the exception. While uninsured rates for those without health insurance are followed closely south of the border, and are thankfully dropping, they are negligible in Canada and have been for 50 years.

In 2004, the Canadian Broadcasting Corporation (CBC) launched a TV series called The Greatest Canadian. It was a reality show/documentary, of sorts, that encouraged viewers across the nation to nominate the greatest Canadian. The winner was not Mike Myers, Wayne Gretzky, Alexander Graham Bell, William Shatner or Jim Carrey. It was Tommy Douglas, the politician who is rightfully considered the father of universal health care in Canada. This year, the federal government ran an on-line survey asking Canadians which of the country’s accomplishments “make you most proud to be a Canadian?” The answer, not surprisingly, was Medicare. So this Canada Day (yes, July 1 is a real holiday here with beer and fireworks and everything), I will pick up a bottle of Molson Canadian and toast Mr.Douglas.