The Myth of Universal Health Care
The Walrus|January/February 2021
Two physicians on what it would take for Canada’s health care system to deliver on its promises
NADINE CARON AND DANIELLE MARTIN

ERYN DIXON had enough to manage as it was. At the age of forty-five, with profound disabilities related to multiple sclerosis, Dixon was living in Almonte Country Haven, a long-term care facility on a grassy hill in eastern Ontario. Then, in March, she contracted coviD-19. As she lay unconscious and unresponsive, struggling on oxygen, her father, Rick, was told to say his final goodbyes. Against the odds, Dixon pulled through, but more than a third of her facility’s residents weren’t so lucky.

Hers is just one of so many stories that we have been reading and watching and hearing for months — a catalog of media reports every day, documenting coviD-19’s progression through our communities and the various ways it takes its toll.

On May 4, Karam Singh Punian, age fifty-nine, did die of coviD-19. He was one of an estimated twenty Toronto airport taxi drivers who contracted the virus that month alone. Most of the 1,500 people who make their living driving passengers to and from Toronto Pearson International Airport are self-employed men who are newcomers to Canada. They work long hours in sedentary jobs and eat on the go, without access to health benefits or paid sick days.

In early August, Patrice Bernadel, a much-loved Montreal pastry chef, suffered from coviD-19 in a different way. Like so many people in the restaurant industry, Bernadel had seen his business devastated by the pandemic. And, like so many self-employed Canadians, he had no guaranteed access to mental health services outside his doctor’s office or the emergency department.

“The economic, social and psychological impacts of the coviD-19 pandemic have destabilized his life to the point of diving him into a deep depression, preventing him from seeing the light at the end of the tunnel,” his brother wrote in a Facebook post soon after Bernadel died by suicide.

As coviD-19 took hold around the world in the spring, Canada prepared for one very specific kind of tragedy: the kind we saw unfold in Italy and in New York, one where hospitals were overwhelmed and ventilators in short supply. Thanks to good timing, hard work, and an economic shutdown that will have ripple effects for years, we have so far avoided that particular calamity. But, as Dixon’s, Punian’s, and Bernadel’s stories reveal, there are many kinds of tragedies: as a country, we were too slow to realize that there were — and are — other pandemic disasters happening all around us. The stories of coviD-19-affected Canadians are also stories about Canada and our health care systems — about which kinds of tragedies we go to great lengths to avoid and which we allow persisting.

By comparison with the death count unfolding south of our border, many Canadians have felt very proud of how our country and its health systems —  thirteen provincial and territorial systems, with some areas of federal responsibility as well — rose to meet the initial crisis of the pandemic. Canadian medicare has always meant more than a set of public insurance programs: we are prouder of it than we are of ice hockey or the maple leaf. The notion that access to health care should be based on need, not ability to pay, is a defining Canadian value, surviving along the longest shared border in the world with the country that hosts the most expensive, inequitable, profit-driven alternative imaginable. That difference in values is often emphasized in our political rhetoric, as when Jean Chrétien would say, “Down there, they check your wallet before they check your pulse.”

We are two doctors working in very different environments and very different medical disciplines, and we have been seeing coviD-19 reinforce some basic lessons about Canada’s health care. First, our systems’ preexisting cracks become chasms when subjected to major shocks. Second, a conversation about health care that is divorced from the social factors that help determine how healthy you are is not really a meaningful conversation at all. And, third, perhaps the only lesson that should qualify as news: when they feel they have no alternative and the need is sufficiently great, governments, private-sector players, and individual people can make tremendous changes in very short order.

HEALTH CARE SYSTEMS exist to prevent and treat illness. What this means, as a matter of medical practice and health policy, is a matter of enormous ongoing debate. When Tommy Douglas implemented public health insurance in 1947, his Saskatchewan government focused first on covering hospitals and later on medical care — at that time mainly defined as physician services. This model spread across the country in the decades that followed, with the support of the federal government and its spending power.

Canada does a reasonably good job on these basics. Despite unevenness and variability, our national performance on a wide range of health indicators is generally strong. A person diagnosed with leukemia, for example, is less likely to die in Canada than in Ireland, Sweden, or France, the 2016 Global Burden of Disease Study found. Similarly, someone who experiences a stroke in Canada is likely to have a better outcome than is someone in the US, South Korea, or Singapore.

Just about any Canadian will tell you that the Achilles heel of our health care system — what is sometimes characterized as the price of these basics — is the wait time to get access to non-urgent care. It isn’t the kind of delay imagined by some American conservatives, in which

“socialized health care” leaves people to exsanguinate on the sidewalk while they’re told to take a number. Rather, it’s the senior who, in line for a hip replacement, loses the chance to dance at her granddaughter’s wedding; the smalltown teacher with chronic headaches waiting months for an outpatient neurology appointment; the parents, worried about their daughter’s shift in eating habits, recognizing that it will take months to get an eating disorder assessment.

In the “new normal” of coviD-19, that problem is worse. Public health efforts to quell the spread of the coronavirus have been admirable and necessary, and the sacrifices within the health care system — delayed operations, canceled clinic visits, postponed diagnostic testing — to prepare for a potential onslaught of cases were likely unavoidable. But the toll is steep and ongoing. Tens of thousands of canceled procedures need to be rescheduled while hospitals grapple with a new reality that is much less efficient than the pre-coviD-19 world was. It is no longer prudent to have four patients in a single hospital room, let alone people on gurneys in the hallways; PPE must be conserved, so cases continue to be prioritized based on clinical factors; physical distancing must be respected. The high-volume churn of operating rooms for surgical cases is a thing of the past; everything just takes longer.

There are other layers of service, unattended to during the first wave, that may declare their impacts in the coming months and years. In primary care, immunizations were delayed, diabetes management put on hold, and routine visits for diseases like schizophrenia or high blood pressure forgone. In Manitoba, there was a 25 percent drop in administered measles, mumps, and rubella vaccines between March and April for children two and under, the National Post reported. Meanwhile, BC Cancer, a wing of the province’s health authority, estimates that in the first six weeks after the pandemic was declared, almost 250 British Columbians unknowingly had silent cancers go undiagnosed as their screening mammograms, colonoscopies, and pap smears were cancelled.

And all that is still just the basics. Douglas dreamed of moving to the second stage of medicare, in which coverage would be much broader and the prevention of disease a bigger focus. That dream was never realized, and there are whole swaths of health care that are not included in our universal system at all. Instead, an ongoing emphasis on doctors and hospitals has led many observers to characterize Canada’s so-called universal health care coverage as “narrow and deep.” What we do provide (services like primary and specialty medical care, diagnostics, surgery) tends to be high quality; our health care system strives for equal access to care particularly by ensuring there are no financial charges for these services. If you are seen by a doctor or admitted to the hospital, if you need a CT scan or a blood test, if you require a biopsy or a specialist assessment, you will be well taken care of and never see a bill. But, if you are among the 20 percent of Canadians lacking adequate drug coverage and you walk out of your doctor’s office with a prescription for medication to treat your diabetes or high blood pressure or infection, or depression, you may be on your own. If you require therapy with a psychologist for anxiety, or physiotherapy for your sports injury, or a root canal, your access will depend on your ability to pay.

THE COST OF CUTTING CORNERS

DEBATES ABOUT expanding our public health care plans to include medications, mental health care, home care, and a host of other medical services — and to move beyond treatment into true prevention — are as old as the plans themselves. Out-of-pocket health care spending (what you reach into your wallet to pay for, whether the full cost of a service or the co-payment or deductible) accounts for roughly 14 percent of total health care expenditures. Private insurance often provided through our workplaces, accounts for another 12 percent. Of course, some of this is discretionary health spending (the massage you enjoy but that isn’t medically necessary, or that second pair of eyeglasses you get because they look cooler than your old ones do), but reliance on private spending and employment- dependent insurance is still higher in Canada than in most high-income nations.

When one includes both public and private spending, health care amounts to 10.7 percent of our GDP, which is in the top third of OECD nations. But our government spending is actually lower than most of our comparator nations’. While 70 percent of health care spending is public in Canada, that number is 82 percent in the Netherlands, 77 percent in the UK, and 79 percent in New Zealand. Each of those countries’ universal health care systems includes both coverages of prescription medications with just nominal user fees and some degree of mental health care.

Canada has long had the dubious distinction of being the only country in the world with universal health care that doesn’t include prescription drugs. We also have less public coverage of home care, dental care, and nonphysician care outside hospitals — which includes services provided by everyone from social workers to psychologists and physiotherapists — than most comparator nations. For example, New Zealand’s publicly funded system includes long-term care, mental health care, physical therapy, and prescription drugs in addition to hospital and physician care. In Germany, mental health care, dental care, optometry, and prescription drugs are all covered by mandatory universal health insurance.

While some public coverage for these services exists for some people in Canada, the amount differs by province and territory, and many people fall through the cracks. The result is that, in our purportedly universal system, many Canadians go without necessary services if they don’t have private insurance coverage, usually through their employers. And Douglas’s vision of a social-democratic society that would take the broadest approach to alleviate the root causes of ill health — which include poverty, racism, and lack of education — has not dominated the political discourse for generations. Canada has moved so slowly on the journey to expand and improve medicare that it has been accused of a “paradigm freeze” — stuck in a system just good enough to prevent any major change or improvement from ever occurring.

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