Professor Antonia Maioni PHOTO: MICHAEL QUAN

Health care's divergent paths

HÉLÈNA KATZ | On the first day of her "Political Process and Behaviour" class, Professor Antonia Maioni asks her students what makes Canada different from the United States. Universal health care, the majority reply. "It shows that Canadians are profoundly attached to the system because it works, but that they're concerned about it," says Maioni, author of the recent book, Parting at the Crossroads: The Emergence of Health Insurance in the United States and Canada (Princeton University Press). That concern is evident in a study put together by Robert Blendon at the Harvard School of Public Health. In 1988, five per cent of respondents said there were problems with Canada's health care system. That figure shot up to 23 per cent in 1998. In comparison, Americans' dissatisfaction with their own health care system only marginally increased from 29 per cent to 33 per cent over the same period of time. With the recent painful budget cuts to Canada's health care system and with widespread dissatisfaction south of the border with the proliferation of penny-pinching Health Maintenance Organizations, people in both countries look to their neighbour's system for answers. Canadian health care was a hot topic during the 1992 U.S. elections, as proponents of universal health care pointed to Canada as a successful model. "Today, the Canadian model is much less in vogue," says Maioni, in part because American critics of health care reform portrayed the Canadian system as less than ideal -- Canadians were said to have to wait long months for critically needed surgeries, for instance. These days, says Maioni, it's Canadians who are turning increasingly to the U.S. for ideas about reforming health care. "The biggest change in the health care debate in Canada over the past 10 years has been the increase in discussion of U.S.-style innovations, like managed care and market incentives. Although it is still politically unpopular to talk about changing the health care system in Canada, there is now a lot more discussion of its problems and possible alternatives." While universal health care has become a national symbol of sorts in Canada, the idea was first hatched in the United States in the 1930s and '40s, Maioni points out. U.S. president Harry Truman tried unsuccessfully, on two occasions, to have a national health insurance plan passed. "We forget that there were attempts to have national health care passed in the United States," Maioni says. "Even though legislation did not pass through Congress, it doesn't mean that health insurance was not part of political debate." Even passing Medicare (for elderly or disabled Americans) and Medicaid for the poor, met some opposition when passed in the 1960s. Ultimately, health insurance was left to be handled on the open market. As Maioni points out, "It's one thing to have an idea and another one to make it work." In Canada it was left to the CCF -- forerunner to the New Democratic Party -- to bring in hospital insurance in Saskatchewan in 1947 and then medical insurance in 1962. Other provinces began adopting the system and the federal government agreed to share the cost of hospital insurance in 1957. Nine years later, it added cost-sharing of medical insurance with the provinces. Under the terms of these cost-sharing agreements, health care had to be universal; comprehensive, in that all services were covered; portable so that Canadians were covered between provinces; and it had to be publicly funded. Ten years later, with the 1984 Canada Health Act, the federal government outlawed extra billing and user fees. Although Canada and the United States are similar in many ways, they diverged on the question of health insurance because of differences in their political systems, Maioni says. Parliament's multi-party system offers more room for the dissenting voice of the left to be heard. The American two-party system means more compromises need to be made to allow politicians to work within the broad coalitions that comprise each party. That made it easier for doctors and insurance companies to lobby against universal health care in the United States, leaving 44 million Americans without health insurance. Nonetheless, 14 per cent of the U.S. gross domestic product goes to health care costs, compared with nine per cent in Canada. The increase in profit-driven HMOs has highlighted public concerns about access to quality health care in the U.S. "The proliferation of managed care has made the differences (between the two health care systems) sharper," Maioni says. Meanwhile, Canadians worry about budget cuts that translate into waiting lists for some services and the end to coverage for others. That has given rise to public and political debate about future directions for the health insurance system in each country. Democratic candidates for the 2000 elections have indicated the issue will be on the agenda; both vice president Al Gore and former senator Bill Bradley have pledged that every child in the U.S. will have access to affordable health care. In Canada, talk of a shift to a two-tiered system is gaining momentum. An attempt at creating private clinics in Alberta sparked a recent battle between the province and the federal government; Ottawa threatened to withhold funding over the issue. Are there lessons for the two systems to learn from each other? Maioni says the U.S. might be surprised to realize that there is plenty of evidence that the "single payer," publicly administered health care system "saves money because of dramatically lower administrative overhead costs and also because governments can set hospital budgets and negotiate fees with doctors." Canada should be wary about adopting elements of the U.S. system, says Maioni. "Health care is not an ordinary market commodity." When it's left unregulated, "one does not get optimal outcomes either in terms of people's health or in terms of economic efficiency." In the U.S., "the uninsured are not only a problem in health terms, but also in economic terms." When government is involved in health care, as is the case in Canada, it "often becomes a political football," states Maioni. "That may not necessarily be a bad thing, since it means debates about allocation of resources are in the public domain. "Part of the message in my book is that just because we're on different (health care) paths doesn't mean we can't veer off," Maioni says. Although neither country has a cure for health care insurance envy, it's certain to provoke plenty of debate on both sides of the Canada - U.S. border.