Universality of health care delivery and proposals for a single-payer system have become issues of great concern to Americans; financing and managing medical care are no less an issue in Canada which has had a single-payer system for 40 years. During 2001 and 2002, the Commission on the Future of Health Care in Canada, also known as the Romanow Commission (named after Roy Romanow, former premier of Saskatchewan who chaired the commission), examined all aspects of health care in Canada, and presented a report with findings and recommendations late last year. Gregory Marchildon, who served as Executive Director of the Romanow Commission, and Pierre-Gerlier Forest, who served as its Director of Research, discussed the evolution of the Canadian plan and its applicability as a model for the United States.

Marchildon and Forest said that any model is incremental and built on past efforts but noted that neither Canada nor the United States must be prisoners of history. Canada's model, though not entirely transferrable to the United States, merits examination by Americans, some of whom hold it up as an ideal while others criticize it vehemently. Marchildon and Forest noted that Canada has better health outcomes than the United States as measured by the UN human development index, in particular that infant mortality is 25% lower in Canada than the United States; these results are curious given that Canadian medical services are generally the same and Canadian doctors are trained in essentially the same way.

In describing the development of Canada's universal single-payer system, Marchildon pointed out that Canadian hospitals are independently—not publicly—owned and that there is a guarantee of professional autonomy for physicians; they do not work for the state. The Canadian system is a collection of 13 provincial and territorial systems, largely paid for by the provinces and territories which receive some federal contributions but for smaller and smaller shares of cost. Co-payments are not required. Coverage is narrow but deep, and parallel private tier plans are all but prohibited for provincially-covered services. However, when asked about ways to improve medicare funding, either by increased taxes, institution of co-payments, opening up parallel private services, or "rostering" patients, Canadian were overwhelmingly willing to pay more taxes to improve the system.

Marchildon and Forest acknowledged some inefficiencies in equity of access to primary care in the Canadian system, mostly from locational disadvantages, which affect rural and especially aboriginal populations in greater numbers. Referrals to specialists in Canada are generally more difficult than in the United States, with higher income, better educated Canadians obtaining access to more specialists.

They acknowledged a cultural difference in attitudes towards health care, with Americans more likely to see health care as an "industry" with Canadians perceiving it as a "service." Forest suggested that Canada has become more communitarian in nature than the United States because of the country's universal health care, not in spite of it. They added that eye care, dental care, and pharmacy are not considered part of Canadian "medicare" and are insured and paid for privately. To the surprise of the audience, there has not been a public movement to incorporate those medical services into the single-payer public medicare plan. Incidentally, medical malpractice insurance is kept down in Canada, largely because damage awards are more often determined by judges in Canada and by juries in the United States.

While accountability has become a value in both Canada and the United States, Americans appear willing to pay more for their health care to keep choice. Canadians are beginning to have declining tolerance for variations between what is available in Canada and what is available in the United States.

David N. Biette
Director, Canada Institute