The current political conversation regarding U.S. health care reform does not reflect the complexity and diversity of the American medical care system, argued Theodore Marmor of Yale University's School of Management. Marmor and co-author Antonia Maioni of McGill University were on hand for the publication launch of the Canada Institute's ninth One Issue, Two Voices series on April 16, 2008. Drawing on expertise from both sides of the Canada-U.S. border, the One Issue, Two Voices series is designed to stimulate dialogue on policy issues that have a significant impact on the bilateral relationship. In this issue, the authors provided a comparative analysis on the medical care systems in Canada and the United States and outlined the disputes over reform. The launch was held in collaboration with the Woodrow Wilson Center's Global Health Initiative.

A Current Assessment of the U.S. Medical Care System

Marmor began his presentation by breaking down the various ways Americans receive health care into five categories. The first is via the U.S. Department of Veterans Affairs, which Marmor noted is structured similarly to the National Health Service in the United Kingdom. The second is found within the U.S. Medicare Program's Part A arrangement that, according to Marmor, resembles a system similar to Germany's that reflects a "continental style social insurance" program. Medicaid, a need-based program intended to help the United States' poorest citizens, represents a third access point to health coverage in the United States. The fourth, and primary way working Americans receive health care, is through private insurance, which Marmor noted, has increasingly become a legally profit-making sector over the last 30 years. The final way that Americans receive care is through "charity medicine," described by Marmor as care that is administered to patients without the means to afford or pay for the care.

The point of outlining the various ways Americans receive care, said Marmor, was to emphasize the complexity and diverse avenues to access to care that encompasses the U.S. health care system. All too often, foreign analysts mischaracterize the U.S. system as simply market-based, which fails to take into account the variety of public programs that co-exist with private insurance programs, he said.

Nevertheless, U.S. policymakers have also demonstrated a lack of understanding of what it will take to successfully reform the country's health care system, said Marmor. He noted that each health care plan proposed by presidential candidates Hillary Rodham Clinton, Barak Obama, and John McCain have proposed to use the same models of reform to improve health care that have failed in the past. According to Marmor, this reflects the fact that the political conversation regarding health reform in the United States lacks sufficient historical knowledge with respect to what policy tools have been tried in the past to improve the health care system, and what degree of success they enjoyed.

While the problems facing the U.S. health system have largely remained the same for decades, explained Marmor, new ideas and solutions to address health care access and costs have yet to materialize.

A Looming Crisis North of the Border?

Unlike the United States, the political conversation regarding health reform has evolved in Canada, said Maioni. On the issue of health care spending, for instance, Maioni noted that there is growing recognition within Canada that there is not enough public funding available to sufficiently fund the Canadian health care system. Consequently, the debate has now evolved into one assessing the best options available to fund Canadian health care from sources outside the public realm. According to Maioni, such an approach fails to ask critical questions such as whether or not Canadians are receiving sufficient value for their tax dollars spent on health care. Cost effectiveness in health care, said Maioni, remains an issue that has inexplicably failed to enter into the political conversation in Canada: "Every other industrialized country is trying to figure out how to spend less in health care, in Canada, we're trying to figure out how to spend more."

Canada faces challenges other than spending to maintain its lauded health care system. Similar to the United States, said Maioni, Canada faces demographic issues, human resource issues, rising expectations, and diminishing confidence among Canadians in the system to provide necessary care. Like spending, maintained Maioni, it will be critical to ensure that the right questions are considered before attempting reform. In the realm of human resources, for instance, the debate continues to center on how to train more physicians, while failing to ask how best to distribute trained physicians across Canada, and how to accredit foreign physicians. It is imperative to take the time to understand the complexity of the problems at hand before trying to solve them, she stressed.

Moving Forward

Both authors agreed that despite having two very different health care systems, Canada and the United States could learn from each other's attempts to address national issues in the health sector. Marmor suggested that if officials on both sides of the border paused to consider the challenges in the health sector both countries face, it may "illuminate" the problems within their respective health sectors and lead to promising reforms that may not have otherwise been considered.

He also maintained that if the United States was ever ready to seriously consider implementing universal health coverage, U.S. officials should look toward its northern neighbor to learn how Canada proceeded in implementing its system. Marmor noted that prior to developing a public health care system in the post World War II era, Canada's health sector was financed and administered similarly to that of the United States' current system. This fact, combined with the cultural and ideological similarities between the two countries, could allow Canada's system to be a useful model for the United States to build its own version of universal health care.

Maioni maintained that Canadians would also profit by contrasting the problems of their own health care system with those of the United States' and other industrialized countries. Canadians, she said, often fail to recognize that they are not the only industrialized country that suffers from long waiting times for specific treatments or rising costs of care. Comparing Canada's problems against some of the United States', particularly the 47 million Americans without any health insurance, should remind Canadians of the relative strength of their health care system, argued Maioni. Marmor echoed Maioni's sentiment, stating that while both Canada and the United States face challenges within their respective health care systems, he believes that Americans would "overwhelmingly opt for the difficulties" facing the Canadian system rather than their own.

Drafted by Ken Crist, Program Associate
David Biette, Director, Canada Institute