Canadian vs. American Medical Systems

I’ve been asked to provide my view of (and experience with) the differences between the Canadian and American medical systems. A lot of opinions get thrown around about this topic in various places, and most of them leave me cold. I suspect that’s because reality is a lot more complicated than a simple black & white view of things allows for.

To get started, I must admit at least the following limitations:

• This is a complex topic. No one understands it all, least of all me.
• I am not a subject matter expert in any sense of the word, even as a healthcare consumer. While I lived with the American system for more than 50 years, I have only about five years of experience with the Canadian system. There’s a lot I still don’t know.
• I don’t spend a lot of virtual ink discussing the details of Medicare or Obamacare. That’s because I’m young enough that I can’t yet apply for the former, and at least one of Anne and I have always been employed and thus we’ve had insurance. If you are looking for details about those programs, this is not the place to get your information. Sorry.
• I have my own biases, both known to me and otherwise. I’m human, after all.

I’ll do my best to keep this factual, fair and cover all the angles I can think of, but remember that this is my personal take on things, and my opinions and beliefs make an appearance. You are encouraged to do your own research if any of my claims or numbers seem out of line.

First, let’s consider how each country’s healthcare systems are described and perceived.

America

Americans often hear that their medical system is “the best in the world,” and many believe it. After all:

• America’s medical system provides lots of choice to consumers. You can pick your doctor(s) and switch between them as you desire, at least in theory. That may be less possible in other systems.
• The American system creates a lot of innovation in the medical industry, and a lot of high tech interventions are developed in the USA. That new technology may improve treatment.

On the other hand:

• The US has a lower life expectancy than many other developed nations. Statistically, Canadians live about three years longer than Americans despite similar lifestyles and consumption patterns.
• America has a unique problem of bankruptcies due to medical bills. China’s system can push people into severe medical debt, but I have been unable to determine how many bankruptcies result. In the rest of the world, bankruptcy related to medical bills seems to be basically non-existent.
• The medical innovations mentioned above can also drive up prices in addition to improving care outcomes. However, new technology can change treatment without actually improving anything. That seems pointless, but it can also be accompanied by new patents which keep prices up and protect long term profits for drug and tech companies.
• The United States spends more on medical care as a percentage of GDP than other countries, and that discrepancy has grown considerably since 1980. In theory that money could be used for other purposes.
• Americans often think they don’t ration health care, but that’s simply not true. Those who lack adequate insurance and the money to pay out of pocket may not be able to get the care they need. That’s just rationing based on the ability to pay.

In addition, insurance — a cornerstone of the American medical system — comes with a number of sticking points:

• The American system generally counts on employers to provide medical insurance to employees, but that leaves out the unemployed and makes it harder to change jobs, particularly for those with ongoing illnesses. In addition many work in jobs that provide no medical benefits. For those without jobs insurance may be prohibitively expensive, but Obamacare attempts to make it affordable for more people.
• I have yet to find a single way in which insurance companies are a net good when compared with a universal coverage system. Insurance companies generally seek a profit. Any money they take out of the system to create that profit is not going toward the care of patients. That’s an obvious net drain on the system, and a reduction in resources available for patient care.
• Insurance coverage varies widely. The specifics about the coverage you have matter quite a bit.
• Some things about insurance and the US medical system may seem strange to outsiders. Copays (co-payments) come to mind. For those who don’t know, when you visit a doctor in the US your insurance may require you to pay some amount per visit, generally $15 to $50.

An interesting question: is the US medical system actually a free market, as most Americans assume? Competition, capitalism, and the “free market” are practically sacred words in the US, and I know many who feel those forces are the only “efficient” way to distribute resources.

In addition, Americans largely hate the idea of “socialised medicine.” When asked about it they react as if Lenin is reaching out from the grave to attack the bedrock principles of the country. But what does “socialised medicine” really mean? Quite simply it’s when public funds (taxes collected by the government) are used to pay for medical treatment, rather than private funds (as from an employer, a private insurance company, or an individual). The key distinction in the eyes of many Americans is whose taxes are paying for someone else’s care. If my taxes pay for your treatment, that’s “socialised medicine” and (in my experience) a lot of Americans think that’s intrinsically evil. Note, however, that many don’t realise their insurance premiums do the same thing. That’s how insurance works: everyone pays a little to cover the expenses of the few who need it. Pooled risk. Socialised medicine is the same using taxes instead of insurance premiums. But taxes have a special place in the mind of Americans and they are particularly loathed when they benefit someone else.

But about 64 million Americans get Medicare (federally funded medical coverage for seniors) and 75 million are enrolled in Medicaid (state and federally funded medical care for those with disabilities or who cannot otherwise afford it). About 11 million are eligible for both Medicare and Medicaid, which means about 128 million Americans already get their medical care paid for with tax dollars. And that is just those two programs. Care for veterans, government employees, and many state programs adds to that total. I don’t have exact numbers, but with the US population at about 330 million simple math shows that at least 38% of the US population is covered by “socialised medicine” right now.

I conclude that despite what Americans may think, the US has a mixed medical system, encompassing both private (free market) and socialised (paid for by government entities) aspects. Keep this in mind when you encounter claims that the US’s system works better or worse than the socialised system in some other country. In large part, the US has a socialised medical system already.

Canada

The Canadian medical system is also complex, and it differs a bit between the provinces and territories. I can only address the system in British Columbia where I live, so don’t take this as general truth for the entire country.

BC has a tax funded insurance program — called MSP — that pays for most traditional medical care. In general, if you see a doctor for an illness or injury there are no bills associated with it and the government covers the cost. But there are some situations where medical care is not paid for by MSP. Examples include:

• Dental care, though there is a program to provide basic dental care to those with financial need or disabilities.
• Vision correction — glasses or contacts, etc. Note that eye disease is covered by MSP, and there is some assistance with vision correction for those with financial need or disabilities.
• Hearing care (and hearing aids) unless something is specifically prescribed by a doctor and tests are performed at a hospital. Coverage for diseases that might cause hearing loss is also available through MSP as far as I know.
• In general, prescription drugs are not covered, though there is a program called Pharmacare that pays for prescriptions for some people, generally those with financial need or for very specific medical conditions or circumstances.
• Ambulance service.
• Some medical procedures and treatments. An example: IVF (in vitro fertilisation) is not covered as of this writing, so a couple needing it would have to pay for it themselves. Experimental treatments fall into the same category.

In short, MSP has a long list of things it covers, and what it doesn’t cover, you wind up paying for yourself. Because those coverage gaps exist, there is a market for supplementary insurance. Employers sometimes provide that insurance to employees and their families, but not always.

Going even farther afield, there is a rare and legally sketchy approach to medical care in which a clinic will collect a relatively large monthly fee from members. From a legal perspective that fee is only allowed to pay for things that MSP doesn’t cover, but such clinics appear to keep a low patient to provider ratio to make their doctors readily available, which seems to mean those fees actually go to paying doctors. These clinics appear to target wealthy individuals (who can afford the monthly fees), but in at least one case I read about this kind of “service” resulted in legal action from the province.

I conclude that the Canadian system is more complicated than the simplistic label “socialised medicine” suggests. However, for most routine medical care here in BC, it’s basically correct to use that term. (Interestingly, I’ve never heard a Canadian use the phrase “socialised medicine.” Only Americans seem to call it that.)

As for how Canadians view their system, that’s harder to assess, and it varies quite a bit. In the western provinces and more rural areas, where conservative politicians tend to hold sway, people seem to be more in favour of private medical care. In the coastal and urban areas things generally swing the other way. Here in BC, some chafe at the lack of private care options while others take it as a point of pride that everyone is covered. Like all humans, Canadians love to complain about whatever they have, but in my experience such complaints about the medical system aren’t all that serious, though there are exceptions.

Looked at another way, it is sometimes claimed that Canadians often go to the US for medical care, but this has been studied and it is simply not true. Of course Canadians visiting or travelling through the US sometimes get sick or injured and seek care, but the number who seek routine care in the US is vanishingly small.

Wait Times

I regularly hear it stated that there are long waits for care in the Canadian system. Some Americans think this is the Canadian system’s fatal flaw, as if they don’t have to wait for treatment on their side of the border. However, I have personally encountered long waits in the American system, and I know others who’ve had similar issues.

In my experience, on the US side wait times can vary widely, and there are many circumstances that drive them. Medical groups typically refer internally, and that can cause delays when staffing issues and patient loads mean some specialty is particularly busy. I was once referred to a dermatologist in my medical group, but the wait to get an appointment was several months. We were about to move and I didn’t have the time, so I looked elsewhere. I was able to see a different dermatologist outside the medical group and avoid the long wait, but I was lucky in that our insurance covered the doctor outside my regular medical group. Others might not have that option depending on their circumstances.

To be sure, there are wait times here in BC for some non-emergency care. When we arrived in Canada I needed to see a dermatologist and that proved challenging. Eventually I got a referral to one who was seeing new patients and didn’t have a backlog, but I suspect I got lucky.

A number of conditions exacerbate the wait time issue. One is a shortage of medical professionals. Many students complete medical school and then go to the US where they are paid substantially more than they would be paid here. As a result even specialist positions have staffing shortages. In addition, there is a problem with the way GPs are compensated here in BC, causing them to leave the practice. Another issue is that there are fewer pieces of diagnostic equipment (like CT machines) here than in the US. More of those might reduce the wait times for some routine care.

I don’t pretend to have complete insight into the profession or its problems, but there are definitely issues that need to be resolved. I suspect many of them could be handled given money and political will.

Of course COVID has played havoc with the entire medical system in both countries. Medical staff on both sides of the border are stressed and leaving the profession at alarming rates, which will add to wait times. It will be a long while before either system has managed to work through that issue.

Coverage

In the US, if you lack insurance and money, your only option for care may be the emergency room. This is both inefficient and expensive. About 31 million Americans are uninsured, and that strains emergency rooms and their budgets.

In comparison, Canada covers all citizens and permanent residents. There are some oddities, like exemptions for the first three months after you move into a province (which supplementary insurance will cover). But in general all Canadians are supposed to be able to see their doctor free of charge.

Sadly, the shortage of doctors has meant that many Canadians don’t have a GP, and so use walk-in clinics and emergency rooms for primary care. Finding a GP seems to be the sticking point, and it takes effort and research. In smaller communities there may actually be no doctors available, particularly now that COVID has done such damage to the profession.

Here I discuss my personal experiences. These are only anecdotes, but they may provide some insight.

Diagnosing the Odd

In my mid 40s I changed doctors in California for various reasons. My new doctor was a big step up, and on seeing my first round of routine blood work she asked why I had pancytopenia. I didn’t even know what she was talking about. Turns out all of my various blood cell counts were low.

Thus began an 18 month journey of referrals and tests as we tried to figure out what was wrong with me. In addition to my GP I had appointments with a gastroenterologist and a haematologist. All three ordered various tests — some of which looked to be repeats at the time. Words like leukaemia and lymphoma were floating around, but in the end I was finally diagnosed with hereditary spherocytosis. It’s an odd genetic disorder that causes your red blood cells to be misshaped, and there are follow on effects from that. It can vary in severity and my case is mild. The haematologist described getting the diagnosis as almost an accident; it required getting a “good” blood smear on a microscope slide. She said that the usual way slides are prepared can cause the cells to ball up. It was only when she made a slide more gently and didn’t ball up the cells that she noted their abnormal shape.

I mention this because doctors in Canada have appeared surprised at how long the diagnosis took. At the time I also wondered about all that diagnostic effort. Those tests and referrals resulted in charges billed to our insurance company, and in copays as well. I’m not accusing anyone of fraud, but it felt like we were being milked just a bit. And the reaction of doctors up here — while not saying anything specific — has led me to wonder about it all over again.

Thinking About Private Insurance

After the Affordable Care Act — Obamacare — passed, Anne and I looked into private insurance. We didn’t actually need it yet — Anne was still working and we had insurance through her employer — but we wondered what the impact of early retirement would be on our budget. We were below the age at which we’d become eligible for Medicare, so it made sense to research what medical insurance would cost. This is exactly what Obamacare was designed for: Americans without health insurance either because their jobs don’t provide it, they are between jobs, or they’ve retired before they are eligible for Medicare.

It’s been quite a while, but at the time I think the premium was something like $1500 a month for the two of us to be covered. $18,000 a year. That didn’t seem particularly affordable but Obamacare includes payment assistance which varies with income. That could greatly reduce the cost, but the insurance exchange website available at the time didn’t highlight that as well as it does now. As part of writing this I looked up the cost of health insurance for a hypothetical couple our age, living in our old home, with $50,000 in annual income. It could be as little as $225 a month depending on the policy selected, or about $2,700 a year. Much better, and the price should continue to drop with lower incomes.

I also seem to recall that insurance cost varies with location and how much healthcare infrastructure is present where you live. Our home was in a county with relatively limited healthcare services and a rural population. As a result, costs there were higher. However, just one mile to the north you changed counties to one of the most populated in the state, where costs dropped.

In summary, if your state has implemented Obamacare well — not all states do so — it should be possible to purchase health insurance without incurring excessive costs.

Colonoscopies and Insurance

Being of “a certain age” I’ve had two colonoscopies, one in the US and one in Canada. Neither was an emergency or the result of any diagnosis. Instead both were screening exams.

In the US case, it was prescribed because I turned 50. There wasn’t a long wait to schedule the procedure, and it went just fine. A couple of minor polyps were removed and biopsied, and there were no complications. Shortly after my procedure, my wife went through the same thing with exactly the same medical results, using the same insurance coverage and medical group.

My procedure resulted in a bill of about $1,000, but Anne’s procedure was fully covered.

I spent over a year fighting that result. When questioned, the insurance company said of course they would cover it — in fact they were required to do so by law — but the medical group had not properly coded the procedure and they could not pay for it until that was corrected. The medical group claimed their coding was just fine — of course — and pointed the finger back at the insurance company.

I honestly don’t know how many hours I spent, how many emails and letters I sent, and how many phone calls I made while dealing with this. In the end I did manage to get the money back, but exactly how it was resolved was never made clear to me. Multiple people told me they would have given up, but for me it was the principle of the thing. In addition I was relatively well off and had the time and ability to keep at it. If I’d been working full time at a minimum wage job I probably wouldn’t have been able to continue.

Compare that with my colonoscopy in Canada.

I consulted with my GP and told him that after my previous colonoscopy I’d been put on a five year recall. As those five years had passed he referred me to a surgeon. There was a wait of a few months (this was early on during COVID) and then I was scheduled into the hospital for the event. This time there was a complication and my procedure could not be finished. I was told my colon is longer and more twisty than normal, so they couldn’t get to it all without too much risk. They did find and remove a couple of polyps, and then referred me to the hospital imaging department for a colonograph. There was another wait of a few months — again, exacerbated by COVID — before I was scheduled in for that. Nothing else was found and I was done, with another five year recall.

There was no charge for any of that. I did have to buy some inexpensive over the counter purgatives used to prepare for the procedures, but that’s it. Everything else was covered.

Gallstone City

More recently, I had my gallbladder removed. I’d spent about a year trying to track down some sort of dietary issue that was causing occasional digestive pain and pressure, but I’d found no patterns. This was during COVID, while BC was opening back up as the first Omicron wave was ending, there were (and are) still large backlogs in many medical clinics and hospitals. I got an appointment with my GP to discuss this with only a two week wait, and he suggested that the problem was my gallbladder. (I already knew I had a very large gallstone and a family history of these issues, so in hindsight this was likely and I should have approached him well before I did.)

Again I was referred to a surgeon, but there was a mix up in the doctor’s office and the referral didn’t go through. As it happens though, it was the same surgeon that did my colonoscopy, so I knew who to contact when I’d heard nothing after a few weeks. I expected a long wait due to the COVID backlog, but when contacted the surgeon’s office told me that my issue was high enough priority that I would get an open slot relatively quickly. They triage patients based on medical need. Cancer patients go first, but those like me, with more severe conditions, move up the list. I was asked to contact my GP’s office immediately to get them to resend the referral, and was scheduled in for the surgery surprisingly quickly.

Before that could happen I had to have a consultation with the surgeon, who then referred me to an internist to discuss my spherocytosis and see if there were any surgical complications we needed to worry about. (There weren’t.)

The surgery was outpatient and successful, and I was scheduled for a follow up exam with the surgeon four weeks after the surgery itself.

As with my recent colonoscopy, there were no out of pocket costs for this. And while I know there is still a large, COVID induced backlog of surgeries, it is clear the medical system here in BC is catching up in at least some areas. My visit to the internist was scheduled and happened within a single week, for example.

Thoughts and Opinions

Now we’re getting to what I personally think. Opinions abound. Beware.

First, my experience with the insurance side of the American medical system makes me very wary of such things. In my view, insurance was a significant hindrance in one situation, and might have led to excessive diagnostic testing in another. In neither case can I prove that, but I am sure the system is out of whack as a result of insurance companies being in the middle of things.

If you ever see a medical bill before insurance has “reduced the costs” you might be astonished. Supposedly insurance companies and medical groups negotiate the costs of procedures in some way, so an insurance bill submitted from a medical group might be multiple times what insurance (or Medicare) will actually pay. But if you don’t have insurance you will probably be billed those huge, original costs, and you may have no way to negotiate them down to something reasonable. I find that reprehensible.

Similarly, I find the opaque billing and cost structures awful. For a free market to work, consumers need information — like the cost of a procedure — and the ability to go to a competitor offering the same procedure for a lower price. But medicine rarely works that way. If you’re sick you go to your doctor and pay what they charge. If you need a hospital stay you probably can’t compare prices at three different hospitals in advance. And even if you wanted to, no medical group or hospital I have ever encountered has a list of prices in the waiting room. The entire idea that medical care can operate properly in a capitalist marketplace is lunacy, and the American system shows that at every turn.

Beyond that, in my opinion the American system fails on inclusivity. Far too many people are uncovered (again, about 31 million in 2021) or inadequately covered (12.3% of adults in 2020, according to this site) and thus at risk of untreated health issues and/or bankruptcy if they seek treatment. And these days — after COVID killed over one million Americans — it should be obvious that preventive medicine — like vaccines — saves the lives of far more people than just those who are treated. In addition, a healthy population means a healthier economy, which is good for everyone. These points alone justify ensuring healthcare is available to everyone, even without going so far as asserting that healthcare is a human right or making some kind of moral argument. That said, I think healthcare actually is a human right, and on that ground the US system fails spectacularly.

But is Canada’s system perfect? Of course not.

First, let me admit that I know I pay for my healthcare — and that of others — through my taxes. I am happy about that. We live in a society after all, and the libertarian ideal of complete independence is a childish fantasy. Even Neanderthals took care of their sick and injured. We can do at least as well, which means we all must contribute — both money and effort — to make our society function. Healthcare is one important aspect of that, and my taxes should definitely go towards paying for it.

That said, there are ways in which the Canadian system isn’t working well. We need more doctors and nurses, and we probably need to pay them more to retain them. I’m also not 100% convinced that our GP based system is ideal. If I want to see a dermatologist for my annual skin exam — being far too pale for my own good — why do I have to see my GP first? That’s a waste of resources, though I do understand that a GP acting as a gatekeeper can avoid certain kinds of misuse or abuse of the system.

I also suspect there is a need for additional medical equipment to optimise patient throughput. We don’t need a CT machine on every corner — the US probably has the opposite problem of having too much equipment available, driving up costs — but we would see lower wait times for non-emergency care if we had more diagnostic equipment available for doctors to use. Happily, it’s my understanding that such equipment is generally available for emergency care when needed.

If the wait times and doctor shortages here were less severe, the Canadian system would be the obvious winner. As it stands, while I still think it is better, it suffers from those problems, and they are not insignificant.

A fellow American living here once told me how odd she felt walking out of a doctor’s office without discussing insurance, the bill, or payment. She’s right, it does feel odd. Good, but odd. And speaking for myself, I am pleased that everyone around me experiences the same thing.

Another friend told me that a big difference between the American and Canadian medical systems is that up here you need to manage your own treatment more actively. That is, you need to make more phone calls, send more emails, and generally keep on top of things. If you don’t, the systems here are less well automated and you are more likely to fall through the cracks. I have followed that advice and it has worked well for me.

Thus far the quality of my care here in Canada has been excellent, but I suppose if I took a less active hand or simply didn’t pay attention, the opposite could be true. But that same active role helps you get better care in the US as well, so perhaps we should all do that.

Conclusion

As I hope I have made clear, neither the US or Canadian medical system is perfect. But in my mind the Canadian system is fairer and supports the population better. Given the Canadian system also tends to produce better medical outcomes and costs less, I think the choice is clear. The wildcard is COVID and the staffing issues that we’re facing. Those problems might worsen in the near term, putting the Canadian system under even more strain. That’s probably my biggest worry on this topic.

Late Breaking News

As I finished writing this piece one of my reviewers sent me this article in the Proceedings of the National Academy of Sciences, which says of the US:

[…] a single-payer universal healthcare system would have saved 212,000 lives in 2020 alone. We also calculated that US$105.6 billion of medical expenses associated with COVID-19 hospitalization could have been averted by a Medicare for All system.

Those numbers speak for themselves.

Notes

• I apologise for the spelling mess in this document. Canada uses a mix of British and American spellings, and there is no consistency (that I can find) as to when one or the other applies. To make matters worse, my spelling checkers have American and British English dictionaries, but not a Canadian one. So is it “socialized medicine” or “socialised medicine”? Even now I am not sure, but I have elected to use the British spelling. If I have guessed wrong about any Canadian spellings, please know that Google let me down.
• Many of the numbers cited here are hard to pin down with any certainty. I’ve included links for the things I cite but I don’t claim they are definitive. Even something as simple as the population of the US varies depending on which source you use, and with more complex questions everything gets much murkier. Add political motivations, the potential biases of any given researcher or organisation, and natural changes over time, and you will find multiple answers for any question. This difficulty explains why some numbers are percentages of the population instead of counts of people, and why some are for different years. I’ve had to choose from the available statistics as best I can. As I said at the beginning, please do your own research if anything here feels off.
• Many thanks to my reviewers: Jim, Ducky, and Sue. Their comments helped me clarify a number of points and made this document substantially better. Any errors are my own, not theirs.