Economist Sandra J. Peart is dean of the Jepson School of Leadership Studies at the University of Richmond. One of her research interests is ethics and economics.
It's been some time since I lived in Canada. Much of what I know of the health-care system there comes from that experience and the ongoing conversations I have with relatives and friends who are now of an age to place demands on the system. As a graduate student, I needed very little in the way of medical services. Wisdom-teeth extractions weren't covered by the system. I had to have those done at reduced rates by a dental student at the University of Toronto.
In Canada, we revel in the universality of the system. Rightly so: It's wonderful to know that all have access to affordable basic medical services. The simplicity of the system is breathtaking — especially for one who has for some time had to deal with the American version. I never saw a bill for any service covered by OHIP, the Ontario Health Insurance Plan. Since there is sometimes a misconception about this, I should say as well that I did have some choices for my health: I wasn't forced to take on a specific doctor. Other choices, however, are more circumscribed.
These are, perhaps, the best features of the Canadian system: universal access, simplicity and choice.
They are also its weaknesses. In a system that is increasingly stressed for resources as the population ages, it seems unreasonable to expect that the provinces can continue to offer "free" services to all Canadians irrespective of income or wealth levels. By this I don't mean to suggest that services should be restricted to those who can afford to pay for service. On the contrary, it may make sense for those at the higher end of the income distribution to pay a larger amount for the services they demand. This is what has apparently happened as wealthier Canadians increasingly add private-insurance supplements to the publicly provided plan. As for simplicity and choice, though I enjoyed the lack of medical bills or statements when I lived in Canada, I had no idea what anything cost there. That just wasn't sensible. More than this, some items (my wisdom teeth) are simply off the table, unavailable through the public plan — as a result of tough choices that OHIP makes for all in order to maintain fiscal viability.
Any system that offers services that are free of monetary payment needs to come up with a rationing scheme. Waiting times might do it: They are longer in the Canadian system than they might otherwise be. But it may be that Canadians would be willing instead to pay money (as opposed to time) for services. Co-payments might help preserve the integrity of the system, and they have the added benefit of making those who use the system think seriously about whether the visit to the doctor is really needed.
It's important to recognize, as well, that extended waiting times and overstressing a system have real consequences. A relative, now deceased, was recently hospitalized for chemotherapy treatments. He suffered a series of strokes while there; no one noticed until it was entirely too late to treat him adequately.
What of the health-care system in the United States? One might argue that its best features are decentralization, diversity and choice. It offers more options than in Canada, and this generally works out to be a good thing. But we have long recognized that the system fails on one key metric: access. It fails to ensure that all of us have access to affordable health insurance. There are some 47 million uninsured Americans. Many of these are children who don't choose to be uninsured. In my view, the national debate regarding health care in America should focus on this one crucial issue: access. Most other issues are window dressing.
If we agree that whatever the final arrangements are for our health-care system, it should be characterized by accessibility and affordability, the question that follows is how best to deliver on that promise? Do we need a wholesale switch to a centralized single-payer system such as that in Canada? Here, the debate at the national level has sometimes been lacking in imagination: presenting the two systems as if one precludes the other. But just as the Canadian system has and will continue to move closer to the American version, mixing private and public funding options, it seems reasonable that a series of reforms might be implemented in the United States that preserves much of what we have while offering affordable options to those who are uninsured.
The leadership question, then, is how to ensure that the discussion that ensues in the next months doesn't get shunted onto the side rails of calls to centralize, to create a huge new bureaucracy, to redesign the entire system. Instead, we should recognize that much of what we have here is fine. We need to find ways to preserve its good features while we broaden accessibility.
The first question to address is why the uninsured are uninsured. As we consider reforms, we should also pay attention to significant incentive and free-rider effects and think about (and discuss) the costs associated with alternative policy regimes. We have taken on trillions of dollars of new debt in the United States, and we will need to make some tough choices going forward about how to contain costs.
Neither the Canadian nor the U.S. health-care system is perfect (no surprise there). As we cast about for solutions to the problem of the uninsured in the United States, we need to realize that the Canadian system, too, faces challenges. Some sort of hybrid of private and public provision of services may well be the best we can hope for in both countries.
