This year, the Canadian health-care system will be a contentious issue in both the Canadian and U.S. election campaigns.
In Canada, health care is a perennial top-of-mind issue, but the nature of the conversation has changed over the years.
In the 1960s, the focus was on getting it done; on implementing universal health insurance across the country, following the example of Saskatchewan. Spurred by the NDP, Liberals and Progressive Conservatives alike -- at both the federal and provincial levels -- embraced the idea of a system of publicly funded insurance that would cover all basic health needs. At that time, basic needs included doctors' visits, surgery and hospitalization, but not medical drugs, eyeglasses, hearing aids or dentistry.
In the decades after the implementation of the notionally universal system, the battle for health care took on a defensive posture. The main fight was to preserve what we had, not expand the system.
By the 1980s, many provinces had allowed the system to erode. They permitted practices that undermined the principle of universality and accessibility. One of those was extra billing, which meant doctors would collect the fees paid by the public insurance and then turn around and send patients a bill for additional charges.
When I went under the knife for an emergency appendectomy at Ottawa General Hospital in the early 1980s, a friend who worked as an anesthesiologist there told me their team at Ottawa General ran a closed shop. They systematically blocked access to any anesthesiologist who refused to extra bill.
That meant that I could expect to pay a fairly hefty charge for the anesthetic part of my life-saving surgery. I was in excruciating agony, and did not protest.
Not too long after that day, Prime Minister Pierre Trudeau's health minister, Monique Bégin, brought in the Canada Health Act, which used the federal financial contribution as a lever to push the provinces to end practices that eroded the system. Extra billing was one of those practices.
Since that time, the prevailing political discourse on health care in Canada has been almost exclusively about maintaining, protecting -- and paying for -- the system as it is.
Head-to-toe coverage -- NDP
This year, however, the party that championed health care in the original instance is pushing not just to defend the status quo but to significantly expand it.
The NDP wants to grow the concept of universal coverage to include eye care, dental care, audiology, pharma care, physiotherapy, foot care and psychotherapy -- in short, what it calls head-to-toe coverage.
The Liberals, too, have jumped on the health-care expansion bandwagon. They focus mostly on bringing in some form of pharma care, over time, taking a more step-by-step and gradualist approach than the NDP.
Prime Minister Justin Trudeau's minions say NDP Leader Jagmeet Singh is being unrealistic, selling pie-in-the-sky to the voters. In the past, mainstream parties routinely leveled that accusation at every proposal to expand Canada's welfare state, from public pensions to unemployment insurance to supports for families with children.
Even Andrew Scheer's Conservatives have gotten into the "we-support-universal-health-care" act. Earlier this summer, Scheer wrote all provincial premiers to promise that, if elected, he would increase the federal health and social transfer by at least three per cent per year, every year he was in power.
For the Conservatives this is, in fact, playing defence. They can expect the parties to their left to accuse them of having an agenda of cuts to health transfers, which would open the door to more privately provided health services and a two-tier system. The example of the Ford government in Ontario is not helpful to Scheer.
More important, however, is that fact that even Canada's party of overt anti-environmentalism, restrictions on refugees, lower taxes and overall fiscal restraint believes it has no choice, politically, but to affirm some sort of commitment to the "socialistic" principle of universal health care. Health care as we know it seems to have become something approaching a political sacred cow in Canada.
Others join Bernie in pushing for Canadian system for the U.S.
While the Canadian conversation on health has moved from protection to enhancement, in the U.S. support for the Canadian system -- or something that appears to resemble it -- has become more politically mainstream than ever before. The majority of candidates vying for the Democratic party's presidential nomination say they support what they call "Medicare for all" -- which has many features of the Canadian system.
Vermont Senator Bernie Sanders -- an avowed democratic socialist -- has been advocating this idea for decades and frequently cites the Canadian model, but, until recently, his was a lonely voice.
Now Sanders has been joined by Massachusetts Senator Elizabeth Warren, New York Senator Kirsten Gillibrand, New Jersey Senator Cory Booker, California Senator Kamala Harris, New York Mayor Bill de Blasio, and a number of other, lesser-known candidates.
There is no unanimity among Democrats, of course.
The current leader in the opinion polls, former vice-president Joe Biden, opposes "Medicare for all," as do a number of other supposedly centrist Democrats, such as Minnesota Senator Amy Klobuchar.
Canadians should note that in the U.S. the term Medicare -- which is what we in Canada used to call our system as a whole -- denotes the publicly funded federal health insurance plan for seniors, which president Lyndon Johnson instituted in the 1960s, as part of the vast expansion of social programs he called the Great Society.
Unlike Canadian Conservatives, U.S. Republicans do not even pay lip service to the goal of providing universal coverage. They want to move in the opposite direction and undo the gains for the millions of uninsured achieved by president Obama's Affordable Care Act.
Hardly anyone portrays Canadian system accurately
In the U.S., and to some extent even here in Canada, everybody who evokes the Canadian system tends to exaggerate the extent to which it is public. In fact, the way Canada delivers health care is a blend of public and private. The same is true in comparable countries such as Germany, France, Sweden, Australia and the Netherlands.
Seventy per cent of that was public money; 30 per cent private.
This ratio is very similar to that of other countries such as Australia and Israel. In fact, Canada's private sector in health care is larger, in proportional terms, than that of most other countries with comparable systems.
In France, the public portion of spending is over 75 per cent, as it is in Finland. In the U.K., Japan, and Germany the public share is over 80 per cent.
Many in Canada perceive our system to be more socialized than it actually is, because they think of health care only as doctors' visits and hospitalization.
Most other health-care systems similar to Canada's cast a far wider net for their coverage. They include health-care goods and services, such as the key ones of pharmaceutical drugs and dentistry, that Canada mostly excludes.
The truth is that, in Canada, as in almost all similar developed countries, health care is a mixed system. Countries that aim for something close to universal coverage might choose different ways to mix their systems, but all have vigorous private sectors, including private insurance.
U.S. politicians who refer to the Canadian system -- whether negatively or positively -- would do well to recognize its true nature as a mixed, public-private enterprise.
In fact, even the U.S., which prides itself as the bastion of private enterprise in all fields, has a mixed system. That is because of the huge public sector presence via Medicare, Medicaid (the similar program for low-income people) and publicly funded health services for the military.
In the U.S., in 2016, per capita public spending on health care was US$4,860. Private spending, per capita, was only slightly more: US$5,032.
The glaring statistic for the U.S. is not the public-private split. It is for total spending, which is considerably in excess of that for all other countries -- while achieving only fair to middling results.
Average life expectancy in the U.S. -- to cite just one important health measurement -- is one of the lowest among developed countries.
The U.S. ranks number 31 in the world for average life expectancy, more than four years less than Japan, Switzerland and Singapore, and more than three years less than France, Sweden, Italy, South Korea and Canada.
Clearly Americans are not getting their money's worth for health care.
Presidential candidates who propose moving the U.S. in a more public direction might want to emphasize not just how doing so would cover the millions of uninsured. They could add that a larger public presence in the health sector would mean better health outcomes for all, at a far lower cost.
Karl Nerenberg has been a journalist and filmmaker for more than 25 years. He is rabble's politics reporter.
Photo: Obert Madondo/Flickr
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