From Portside <[email protected]>
Subject What Medicare for All Really Looks Like
Date March 28, 2020 3:48 AM
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[We dont have to debate whether Medicare for All is possible. It
exists. The Canadian system, also called Medicare, guarantees coverage
to every resident north of the U.S. border.] [[link removed]]

WHAT MEDICARE FOR ALL REALLY LOOKS LIKE  
[[link removed]]

 

Caitlin Kelly
January 8, 2020
The American Prospect
[[link removed]]


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_ We don't have to debate whether Medicare for All is possible. It
exists. The Canadian system, also called Medicare, guarantees coverage
to every resident north of the U.S. border. _

David Dennnis, 28, pays nothing for his health insurance. Simply
being a tax-paying Canadian is enough , Jose R. Lopez

 

He spends long days navigating Toronto’s miserable traffic, finding
whatever’s needed for his work as a freelance production designer
for film and commercials. It’s demanding physical labor, with injury
a daily possibility.

Like so many these days, David Dennis, 28, is an independent worker.
But he pays nothing for his health insurance. Simply being a
tax-paying Canadian is enough. As an Ontario resident, Dennis’ OHIP
[[link removed]] (Ontario
Health Insurance Plan) card entitles him to see a physician, visit an
urgent-care clinic or any hospital, and receive whatever
services—including multiple surgeries and weeks or months of
inpatient care—are deemed medically necessary, with no fear of ever
paying for these out of pocket.

Government-funded health care, from cradle to grave, is Dennis’s
Canadian birthright. It’s something he takes for granted, as do all
Canadians, comforted by knowing that whatever their age, health, or
employment status, they’re entitled to comprehensive medical care,
most of it at no additional cost beyond their taxes.

Canadian health care is publicly funded and privately delivered,
approximately the same vision that single-payer enthusiasts have for
the American system. It even shares the same name as our largest
government-run insurance provider: Medicare. But contrary to
persistent American partisan mythmaking, no government officials sit
in doctors’ offices or haunt hospital hallways with a checklist of
all the services they’ll question and deny. They don’t dictate
hands-on care. Canadians face little government interference or
oversight of their health care, although, for historical reasons,
their doctors retain much more power than patients.

The familiar and dreaded words “co-pay,” “deductible,”
“pre-existing condition,” and “out of network” are meaningless
here, in English or French, Canada’s two official languages.
Patients don’t waste time chasing pre-authorizations or fighting
medical bills, while physicians save thousands of administrative
hours.

As Americans’ life expectancy is dropping and maternal mortality
is ranked shockingly high
[[link removed]] among
other wealthy nations, Canadian health outcomes fare better
[[link removed]];
Canadian women live two more years
[[link removed]] than
their American counterparts, men three.

But the system is far from perfect. Outpatient care, like physical and
occupational therapy or prescription medicine, is paid for out of
pocket. In some places, there’s no mandate to use electronic
records, so patient information can be difficult to access. And
medical care of impoverished and remote First Nation and Inuit
communities is openly acknowledged as abysmal.

Like Americans, many Canadians with full-time jobs receive
supplemental coverage as a benefit through their employers, while
independent workers like David Dennis can buy a policy on their own.

Canada provides coverage for about 35 million, one-tenth the
population of the United States. But how they’ve set up their health
care system, and how it evolved over the decades, is instructive,
especially given the robust debate during the presidential primary
about overhauling our current system. It can inform how U.S.
policymakers—and Canadians, for that matter—approach cost control,
physician payment, and services for vulnerable communities. Rather
than scaring Americans with well-structured narratives about the
alleged horrors of Canadian Medicare, we could take the opportunity to
learn from it.

HOW IT’S FUNDED

Limited Time! A Matching Gift Doubles Your Donation. Please Sign Up
Today! SUPPORT THE PROSPECT
[[link removed]]

The health care Canadians receive flows through a hybrid federal and
provincial system. The federal government supplies about $36 billion
(Canadian) in health care funding annually, distributed among each
province and territory’s Ministry of Health (MOH). Federal dollars
cover roughly 20 percent of total health care costs, with each
province and territory responsible for the remaining 80
percent. Poorer provinces, and those with smaller populations
[[link removed]]—like
Newfoundland and Labrador (528,817), Prince Edward Island (153,244),
and the Northwest Territories (44,541)—receive higher federal
amounts in compensation.

The provincial ministries make decisions about how best to apply that
funding, further decentralized in some provinces through regional
agencies. If a Canadian needs care while out of their home province,
most reciprocal inter-provincial and territorial agreements ensure
that they won’t receive bills for it.

Many of Canada’s most senior physicians and policymakers simply
consider health care a human right. 

At no point do government bureaucrats direct patient care—aka
“death panels.” Canadian physicians essentially run their own
businesses, and enjoy tremendous autonomy. Their fees are negotiated
annually with each provincial or territorial MOH through a provincial
medical association, setting specific fees for each service and
specialty. The Canadian government operates mostly as insurance
payers, while doctors focus on serving patients.

Each doctor bills the MOH, paid in Ontario twice a month by direct
deposit. Many physicians are paid well, even for part-time work. Some
easily earn $300,000 or more a year, while paying much less for
malpractice insurance than their American counterparts. And without
multiple insurers to wrangle, Canadian doctors need fewer employees.
“I have a pal in Sausalito,” says John Hickie, a former family
physician in Calgary, Alberta, “who has more billing staff than
medical staff. In contrast, I could do my billing in one hour on a
Sunday evening at the computer.”

Nor do Canadians and their employers fear annual double-digit
increases in the cost of their health insurance, which is paid for
through a broad mix of taxes. So David Dennis lives free of daily
financial anxiety over potential injury, a personal and professional
freedom many Americans only dream of. He plays baseball several times
a week and, when he slid into second base and banged himself up badly,
went to an urgent-care clinic, also covered through OHIP. Throughout
his teen years, skateboarding (broken left elbow), hockey (broken
right collarbone, separated shoulder), and baseball (broken left hand)
sent Dennis to the local emergency room so frequently he jokes he had
an E-ZPass.

He’s never needed an ambulance; in Ontario they cost $240, with OHIP
paying $195 of that. (Contrary to the vision of Senator Bernie Sanders
(I-VT) and many U.S. single-payer supporters, some Canadian provinces
require varying levels of cost-sharing.) If an Ontario resident is
hurt far away from a hospital, there’s Ornge
[[link removed]], with 12 bases across Ontario, eight
staffed helicopters, four staffed airplanes, and four critical-care
land ambulance crews. More than 60 percent of its work takes place in
Northern Ontario, including service to many fly-in only communities.
All of this at no extra cost to patients.

Limited Time! A Matching Gift Doubles Your Donation. Please Sign Up
Today! SUPPORT THE PROSPECT

Broke and desperate Americans increasingly are choosing to call an
Uber
[[link removed]] over
an ambulance, as an ambulance ride can add the potential shock of an
unaffordable four-figure bill, even with health insurance
[[link removed]].
Dennis works in the gig economy, but he never has to fear the
potential cost of an ambulance.

[JF20-Kelly4.jpg]

JOSE R. LOPEZ

Ontario author Ann Douglas at her home near Bancroft, Ontario

WAIT TIMES FOR LESS-URGENT CASES MEAN FRUSTRATION

When they need to see a doctor, Canadians must first visit their
family physician_. _The family physician decides if the matter
requires a referral to a specialist and how quickly to ask for one.
This gatekeeper role is one way that Canada controls health care
spending. Currently Canadian health care costs 10.4 percent of GDP,
versus 17.2 percent for the United States.

There are downsides to this approach—waiting for diagnosis,
treatment, and relief from pain and anxiety can be frustrating. “The
Canadian system is characterized by waiting,” says André Picard,
health reporter since 1987 for _The Globe and Mail_, Canada’s
national newspaper. “We wait to see a GP, wait for a referral to a
specialist, for elective surgery, for home care and longer for
long-term care. There is little to no accountability and little
incentive for solving these problems.”

The Canadian Institute for Health Information offers detailed data
[[link removed]] on wait times for some specific
procedures, including hip and knee replacement. Access to specialty
services can vary widely, even in major cities like Toronto,
Vancouver, and Montreal. For Ontario parenting author Ann Douglas
[[link removed]], it meant waiting eight months to see an
ear, nose, and throat specialist to finally diagnose and treat her
repeated spells of vertigo. She quickly saw her GP and had an MRI, but
only a specialist diagnosed Ménière’s disease
[[link removed]]; eight months
of weekly physiotherapy ended her symptoms.

Waiting for diagnosis and treatment can feel neglectful and
frightening. But surveys
[[link removed]] show
[[link removed]] repeatedly
[[link removed]] that
the system still remains a source of deep national pride and shared
identity. Canadians like knowing that, under federal law,
[[link removed]] everyone
is entitled to equal access. Unlike in the U.S., the wealthy and
powerful can’t pay extra or pull strings to jump to the front of the
line. This lessens the sting of waiting and contributes to a sense of
solidarity.

No one wants to wait, but Canadians also live without fear of medical
bankruptcy, a trade-off they deeply value. Inundated by American media
reports, some having lived and studied in the U.S., Canadians know how
bad it can get.

“Canada makes you wait because everybody’s included,” says Dr.
Tom Noseworthy, a professor of health policy and management at the
University of Calgary, and a former hospital CEO, ICU specialist, and
rural GP. “But _every_ nation rations its health care. No one can
get everything, everywhere, all the time. One system is explicit in
its rationing, Canada, where we howl at our wait times—and the other
is implicit, because Americans can only get it if they can afford
it.”

Alberta researcher Tamara McCarron has just finished her Ph.D.
examining how Canadian patients experience health care, including
prostate cancer patients. “When I asked them if they were happy with
wait times, they said: ‘Hell, no!’” she tells me. “The common
theme I heard was ‘I had to wait a completely unacceptable amount of
time to get the diagnosis from my urologist. This was ridiculous!’
But the positives I heard were: ‘I’m healthy. I’m good. The
surgeon was amazing, pre-op was amazing. I can be really critical of
the system, but I’m still here.’”

“It’s not that Canadians don’t want stuff now,” she adds,”
but knowing they may have to wait three or six months to see a
physician is the worst of it. Never seeing a bill is a huge comfort,
so people are more forgiving of the challenges and inconsistencies
because of that.”

For Ann Douglas, wait times also meant frustration when seeking mental
health care for her four children. “The wait time to see a
psychiatrist can be zero days to 18 months,” she says. “There has
always been a shortage of child psychiatrists, leading to the hashtag
#kidscantwait. They have been underfunded for years. Long waits for
care exacerbate a minor issue to a major issue, so a kid with mental
health issues becomes suicidal or a drug-using teen.”

“This is a very Canadian thing that health is a collective
responsibility because any one of us can be hit by a car at any
moment. We _should _pay into a common system so that everyone can
get care.”

Paying for outpatient medical services presents another major
challenge for Canadians. Any service offered outside of a hospital or
doctor’s office must be paid for out of pocket. Luckily for Douglas,
her husband had a good benefit plan through his job, saving her $100
per week until the final few weeks for her physical therapy. At one
point, Douglas needed $900 worth of medication each month, also
covered through her husband’s plan. But those without such benefits,
like David Dennis, face the same financial anxiety as Americans if
they can’t afford such services.

Canada is also the world’s only country offering government-paid
hospital and physician care that doesn’t pay for medication. This
has led to a growing push for national pharmacare, as even some
Canadians can’t afford their insulin, invented by Canadians
Frederick Banting and Charles Best and celebrated on the Canadian $100
bill. Americans pay the world’s highest drug costs, but Canadians,
with a small population and strong drug lobby, pay the world’s
second-highest.

RACISM AND CANADIAN HEALTH CARE

The Canadians most frustrated with their health care are the
nation’s 1,637,785 Inuit, Métis (mixed European and indigenous
descent), and indigenous peoples. Prime Minister Justin Trudeau
has promised a radical overhaul
[[link removed]] and
improvements by 2030. But he now leads a minority government, giving
him less power.

Improvements can’t come quickly enough for physicians like Dr. Mike
Kirlew
[[link removed]],
practicing medicine in northern Ontario for ten years. Born and raised
in Ottawa, he’s an outspoken critic of First Nations’ health care,
which he calls “unbelievable systematic oppression.”

Kirlew is based in Sioux Lookout, 1,090 miles northwest of Toronto, at
its 100-bed hospital. From there, he flies in or drives up to 18 hours
by ice road to one of 30 remote nursing stations to see patients from
32 communities, in an area the size of Germany and France combined.
The nursing stations have no X-ray machine, MRI, or ambulance service.
Even the Sioux Lookout hospital has no MRI, which means patients must
fly south or west to neighboring Manitoba.

In October 2018, addressing fellow family physicians at his alma
mater, the University of Ottawa, Kirlew gave a searing indictment of
this system [[link removed]], describing
a patient screaming in pain for 9.5 hours while awaiting a helicopter
to fly him to an orthopedic surgeon—as the station had no
painkillers on hand.

“We need 54 to 60 full-time physicians,” he said. “We have 18.
We have very limited access to specialists of any type. We have very
high rates of MRSA, strep, and rheumatic fever,” he told colleagues.

“When you contrast that with what’s in the provincial system
it’s night and day,” he told a CBC reporter in March 2018
[[link removed]].
“It’s far inferior. We have a system that triages people, based on
their race, to inferior care. That’s the height of
un-Canadian-ness.” It’s even worse for the Inuit, indigenous
peoples who live in the Arctic. Suicide rates in Nunavut, a territory
in this region, are ten times that of the rest of Canada
[[link removed]].

Canadians expect their health care system to offer everyone—rich or
poor, employed or not, of every race and ethnic background—fair and
equal treatment. And Canadians are proud of their nation’s openness
to refugees and immigrants, with many fewer illegal entrants than the
United States
[[link removed]] to
foster resentment of those abusing the system in a country already
more welcoming to immigrants than the U.S. Yet in health
care, there _is_ definitely racism and bias
[[link removed]].
“The status quo is perpetuating inequities, misery and associated
higher health care costs,” wrote Josée Lavoie, professor in the
Department of Community Health Sciences at the University of Manitoba,
and director of Ongomiizwin Research, in a 2018 paper
[[link removed]] on
First Nations health disparities.

[JF20-Kelly3.jpg]

JOSE R. LOPEZ

‘I don’t think Americans will ever do it,’ says Dr. Margaret
Tromp, president of the Society of Rural Physicians of Canada, of
nationalized heath care. ‘America is much more right-wing and based
on the American dream.’

A SERIES OF DIFFERENT SYSTEMS, WITH PATIENT EXPERIENCES MADE SECONDARY

The national expectation of fairness and equity lessens the sting of
paying taxes for health care. “I don’t resent paying one cent of
our taxes,” says Vancouver-based patient advocate and author Sue
Robins [[link removed]]. “This is a very Canadian thing that
health is a collective responsibility because any one of us can be hit
by a car at any moment. We _should_ pay into a common system so that
everyone can get care. We _do_ get value over the years, especially
as we get older.”

However, that expectation of equity breaks down across provincial
lines. Robins worked in Alberta for nine years, enjoying excellent
services for her son, Aaron, 16, who has Down syndrome. When the
family moved to British Columbia, none were offered. “Care is not
consistent between the provinces, even though the Canada Health Act
[[link removed]] says
it’s portable,” she says. “A broken leg is a broken leg, but
there are no consistent standards. There’s no national plan or
strategy.”

As Vik Adhopia, national health television reporter for the Canadian
Broadcasting Corporation, explains, “The Canadian system is a series
of systems and they are all different. There are significant
disparities from province to province.” Adhopia has lived in
Toronto, northern British Columbia, Alberta, and St. John’s,
Newfoundland. “CPAPs (a device used to relieve obstructive sleep
apnea), are covered in Ontario, but not in Manitoba,” he says.
“You hear of people who move from one province to another for
coverage.”

Another fragmented element of the system is electronic medical
records. Canadian hospitals and physicians use them, but the data is
often siloed in multiple separate systems, and less immediately shared
or accessible.

Residents who complain about these issues find little sympathy.
“Canada does not have a patient-centered health care system,”
wrote _The Globe and Mail_’s André Picard in May 2018.
“Communication with patients is abysmal, customer care is virtually
non-existent and the opportunities for feedback are minimal.”

Robins agrees with this assessment. “I found my treatment very
impersonal,” she says. “They could do so much better when it comes
to patient care, kindness, respect, and dignity. People don’t
collect data on patient experience as they do in the U.S.,” she
adds. “What about the waiting room experience? Is the care
patient-centered? Are they making decisions together? They don’t see
patients as experts.”

When Ontario psychiatrist Dr. Javeed Sukhera needed emergency care at
a local hospital, he, too, was deeply disappointed. “From my own
health care experiences, I would say patients are often treated like
problems and not like people. I felt like I was treated like a piece
of trash. I was discharged into the cold without any concern for
whether I had a ride or not, wearing an undershirt in the winter. I
had expected more compassion than I received. My experience as a
patient in the U.S. system [where Sukhera did his residency] was
vastly different than how I was treated in Canada.”

One key reason for this frustration is that hospitals in Canada
receive global budgets annually from the MOH. They must figure out how
to serve patients within that budget. This can create efficiency and
limit unnecessary treatments. But in addition, patients in Canada are
not seen as sources of revenue but as costs, explains Sukhera, who is
president of the Ontario Psychiatric Association and an activist for
health care improvement. “That transforms how we treat patients and
provide care. The way we organize payments makes it hard to improve
quality,” he says.

“The patient is not just a consumer, but also a citizen, taxpayer,
and user all wrapped into one,” says Gregory Marchildon
[[link removed]], a faculty
member at the University of Toronto and an expert on health care
policy. “Patients don’t have much power and they accept this, and
they shouldn’t. Canadian patients need to become much more
demanding. The systems are weak, and Canadians are quite passive,
which has not been a good thing. There needs to be a lot more effort
made to hold doctors accountable.” To create much greater
accountability, Marchildon suggests creating a written agreement
between each patient and their physician, “and if the patient exits
[that practice] is penalized financially, which creates a hard landing
for the physicians.”

The flip side to this is that doctors don’t see Canadian patients
(with a few miscreant outliers
[[link removed]])
as a source of personal profit. Rounds of tests that fatten a
doctor’s wallet mostly don’t exist in Canada. The way the nation
finances medical education also eases the financial pressures on
doctors. While public and private American medical schools charge a
median tuition of more than $200,000 for a four-year program, “when
I went to medical school, tuition was $6,000 a year,” says Dr. John
Hickie. “Now it’s $16,000 to $20,000 a year. It’s still hugely
subsidized and that’s the same everywhere in Canada. Compared to the
States, it’s nothing.”

A DIFFERENCE IN BEDROCK PHILOSOPHIES

A fundamental conceptual difference also divides how Canadians and
Americans view their relationship to using government-financed or -run
services. Classic American insistence on the bedrock values of
individualism, self-reliance, and shunning government aid as a sign of
moral failure differs radically from that of Canadians, who are more
committed politically and economically to health care equity as a
collective good. Consistently receiving free health care and heavily
subsidized university and college tuition fees means that Canadians of
all ages and income levels experience firsthand a consistent,
quantifiable return on their tax dollars.

“One thing I wish Americans would understand is that ‘who’s
going to pay?’ is actually a distraction,” says Dr. Danielle
Martin, executive vice president and chief medical executive of
Women’s College Hospital in Toronto. “It’s ‘how will you
organize delivery of it?’ Payment is just the first step on a worthy
and interesting journey. The conflation of single-payer and wait times
is false. We have wait times because of a million other issues, like
we can’t get physicians to work in rural areas.”

Consistently receiving free health care and heavily subsidized
university and college tuition fees means that Canadians of all ages
and income levels experience firsthand a consistent, quantifiable
return on their tax dollars.

Canadian taxpayers put up with a lot to maintain their health care
system, but so do Americans, such as the tremendous cost of gun
violence. A comprehensive state-by-state report released in September
2019 by the Joint Economic Committee found that in 2017, 40,000
Americans were killed by guns. The health care costs for California
alone were $348 million, borne by both individuals and taxpayers
through uncompensated care. By contrast, 311 Canadians were
hospitalized for firearm injuries in 2017–2018, according to
the Canadian Institute for Health Information;
[[link removed]] 249
died in 2018 as a result, according to Statistics Canada.
[[link removed]]

HOW DID THESE SYSTEMS EVOLVE?

It became nationally obvious that health care improvements were badly
needed in Canada when residents signed up to fight World War I and
World War II, many of them in poor physical condition thanks to
unaffordable medical care. An astounding 56 percent of WWII volunteers
failed their initial physical examination. The Depression also hit
hard; broke patients needed care, and doctors and hospitals had to get
paid promptly for it.

Tommy Douglas [[link removed]],
grandfather of actor Kiefer Sutherland, is considered the father of
Canadian health care, as revered and well known as Martin Luther King
to Americans. Born in Scotland, Douglas grew up in Glasgow and
Winnipeg, Manitoba. He attended theology school and became an ordained
Baptist minister. While studying sociology in 1931 at the University
of Chicago, he also witnessed the desperation of Americans in the
Depression. He became leader of the Co-Operative Commonwealth
Federation,
[[link removed]] a
democratic socialist party. In 1961, it was renamed the New Democratic
Party, and is currently headed by Jagmeet Singh.

Douglas led the party to five successive wins in Saskatchewan, pushing
to create a provincial medical insurance program. The province’s
doctors fought the effort hard, even going on strike in 1962, but the
plan went through that year anyway. Throughout the 1960s, successive
provincial and territorial governments adopted the “Saskatchewan
model,” and in 1972, Yukon Territory was the last subnational
jurisdiction to adopt it.

In 1966, the Liberal minority government of Lester B. Pearson
[[link removed]] committed the
federal government to paying 50 percent of health care costs, with the
provinces paying the other half. The federal burden has shrunk over
time.

The memories of crippling medical costs are still very real for some
Canadians, like labor economist Armine Yalnizyan, the inaugural
Atkinson Fellow on the Future of Workers. Her father, Puzant
Yalnizyan, an electrical and mechanical engineer and inventor, started
suffering several medical conditions within months of moving to Canada
in 1951, until his death in 1964.

“I have kept some of the bills,” she says. “It was a lot of
money as a share of income,” even for a salaried professional with a
full-time job. “We did not get public health insurance in Ontario
until 1966, after his death.” Yalnizyan’s mother, with little
formal education, had to scrape together whatever work she could find
to help support the family, like tutoring French, and the family took
in a boarder. “Being Armenian, and the child of children who lost
their parents to the Turkish massacre and were treated as easily
exploitable and a lower-tier citizen informed my understanding of the
importance of societies that value and support equality,” she adds.
“Health care is one of the most material ways of expressing that
commitment to equality.”

The Canadian system evolved through decades of political debate,
battles, and negotiations with physicians and insurance companies. The
debate continues even today, says Yalnizyan. “It’s the zombie
conversation. We have the same conversation every 25 years. Health
care is both a market failure and a market magnet because there’s
money to be made. That conflict of public and private interests will
never go away!”

VOTING WITH THEIR FEET: “I COULDN’T WORK THERE”

Many of Canada’s most senior physicians and policymakers simply
consider health care a human right. Dr. Bob Bell
[[link removed]], a former deputy minister of health
for Ontario from 2014 to 2019, then responsible for a $50 billion
budget, half of all provincial spending, is an orthopedic surgeon
specializing in bone cancer who trained at Harvard, and at
Massachusetts General Hospital, before running several Toronto
hospitals.

“I was going to work in the U.S. but what concerned me was the kids
we saw with osteosarcoma
[[link removed]],” he says, “a horrific
disease that demands intense chemotherapy, inpatient treatment for
months, and really aggressive surgery.” Bell ultimately had a
reckoning. “I couldn’t work there,” he explains. “There was
such a differential with patients with good insurance and those that
didn’t have it. I could not imagine working in that environment.
People who present with disease need to be treated with equity and
equality. It is a human right.”

Dr. Emily Queenan [[link removed]], who is American, also voted
with her feet; after studying biology at Williams College, working for
Americorps in Peekskill, New York, in community health, and attending
medical school at the University of Pennsylvania, she did her
residency in Rochester, New York. She opened a family medicine
practice there in June 2009, closing it in May 2014—and moving to
Canada.

[JF20-Kelly2.jpg]

JOSE R. LOPEZ

Dr. Emily Queenan, who is American, standing on the front porch of a
1920s-era red-brick house in small-town Ontario whose main floor is
now her office.

After being recruited by an agency of the MOH, Queenan visited four
cities selected from a list of rural communities needing a doctor, She
chose Penetanguishene
[[link removed]], a middle-class town
of 8,962 in northern Ontario on Georgian Bay, a beautiful area that
welcomes many summer-home visitors.

“It was a wrought decision to close my practice,” Queenan says,
sitting in the 1920s-era red-brick house in small-town Ontario whose
main floor is now her office. “I envisioned having my [U.S.]
practice for decades. But I was really burned out by the burden of
being someone’s family doctor and the moral injury of denying care
versus the lack of payment versus dealing with your own medical bills.
This is not asked of other professions.”

Still in New York, Queenan attended a local meeting of Physicians for
a National Health Plan, [[link removed]] an American advocacy
group founded in 1985 by Dr. Steffie Woolhandler and Dr. David
Himmelstein, “trying to decide what was next. I was on the cusp of
turning 40 and saw a career of fighting stupid fights. Doctors across
the country were going through exactly what I was going through. I am
not unique.”

Her children, then 5, 7, and 9, were “easily transportable,” and
her husband left a corporate job with Nabisco to become a stay-at-home
father. Yet as much as Queenan loves her life, Canadian rural medical
practice—chronically and woefully short of doctors—offers its own
challenges. She has 1,000 patients, seeing 20 to 25 a day. She’s the
only obstetrician for many miles and hates the “obscene” waits her
patients endure to see a specialist.

COULD THIS WORK IN THE U.S.?

Will Americans ever choose Medicare for All? Will they agree to a
facsimile of the Canadian system? Experts in Canada have varying
opinions.

“I don’t think Americans will ever do it,” says Dr. Margaret
Tromp, president of the Society of Rural Physicians of Canada.
“America is much more right-wing and based on the American
dream—if you’re not getting ahead, you’re not working hard
enough.”

“You have to believe it’s possible, and it’s iterative,” says
Dr. Jane Philpott, former federal minister of health. “It’s
something that took half a century here, and extraordinary leadership.
And medical educators have to be on board.”

“Americans need the choice to also go private, so you would have to
regulate that,” says Colleen Flood, a health policy analyst at the
University of Ottawa.

“The bigger the population, the more healthy people you have to
offset the sickest. Scale is a bonus,” says Dr. Danielle Martin,
author of a 2017 book suggesting six ways to improve Canadian health
care.
[[link removed]]

“Yes, because there are so many people being hurt by the current
system and if those folks can be mobilized because this system will
forever do it to them,” says health policy analyst Greg Marchildon.
“It’s a huge battle,” he adds, “and will polarize the American
public, but it was the same here in Canada at first. But within four
or five years Canadians came around. This will always polarize people
and there will always be interest groups fighting it. But if you
don’t make radical change, you’re just fiddling.”

 Tom Noseworthy is less optimistic, especially in a time of such deep
political division. “On paper, economists and sociologists can do
this, but _will_ it get done? I’m not sure there’s any single
force to get it done. It would take another world war to create that
same sense of solidarity.” But the matter is urgent, he adds. “The
U.S. economy will fail if this isn’t fixed. No one knows how to
control the costs. It’s going to break the bank.”

“Americans don’t want to be told what to do,” says Bob Bell.
“The U.S. should have a public and a private option. But Americans
are so smart with market innovation. This is just market innovation.
In the States, you’re already way above us because Medicare is run
federally. That’s perfect.”

“The Canadian system is good, but underfunded,” says Steffie
Woolhandler. “The American system is shitty but over-funded.”

And what of all those health insurance employees who’d lose their
jobs? “Sixty million Americans a year are separated from their jobs,
of which 20 million is involuntary,” she replies. “So it’s not a
huge issue if you put aside billions of dollars to deal with this.
Within a medical practice or hospital, you could retrain them on the
spot.”

When serving as executive director of the Royal Commission on the
Future of Health Care in Canada
[[link removed]],
delivered in 2002 with 47 recommendations, Marchildon and Roy Romanow,
former premier of Saskatchewan, sought out Hillary Clinton, then a
senator, to hear her thoughts.

“She tried to get us to think about the possibility of a ‘release
valve’ (i.e., a private option), even though it does create an
inequity. We found her far more expert on the Canadian system than I
could ever have expected,” Marchildon says.

The constant fight with those insisting on a private option, which
some argue is inherently elitist and unfair, means constant vigilance
to retain a fair and equitable system.

Clinton predicted “that a very wealthy and powerful minority would
make our system unworkable,” says Marchildon. “She warned us:
‘Don’t let them destroy your system. You got it right.’”

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