Tuesday, September 22, 2009

One Canadian's perspective

In a recent edition of LFCA, Joy wrote:
"This is a request for non-U.S. bloggers - we need your healthcare stories! Yesterday in my gym I heard a woman tell another woman that in the U.K., once you get to be over 60, you're 'put on a list' so that you can be denied joint replacements and other health care measures for which you are now 'too old.' Please set the record straight about whether you like your health care, how long you wait, and how your older friends and loved ones have fared. The misinformation here is incredible and insulting to you, our UK / Canadian / Aussie / South African / friends. We can link to these blog entries and try to inject some real experiences into the conversation." dispel some of the myths and fear-mongering being tossed around south of the border about "socialized" medicine in other countries.

I hesitated about whether I should post anything on this subject. The debate over health care reform in the States has gotten so ridiculously (over)heated, and I am not a person who enjoys or invites conflict of any kind.

But as a Canadian, I can't believe some of the stories being tossed around south of the border about our healthcare system. It would be funny, except there are too many people who actually believe this stuff -- and too many people who are being denied basic health care because too many people believe this stuff. So I decided to share a few thoughts with you from my own perspective. Other Canadians may share my opinions or disagree with me.

First, you should probably know that my mother is American, & that I have lots of American relatives, and so I am familiar with some of their experiences with the American health care system.

Of course, we pay for our "free" universal health care in Canada through our taxes. They are somewhat higher than what Americans pay, although I've seen studies that show the difference is not all that great, depending on how you slice things. Everyone is entitled to a basic level of health care, regardless of income.

Some provinces, including the provincial government of Ontario, also charge health care premiums. Here in Ontario, the premium is calculated as part of your annual income tax payment. It's based on a sliding income scale and costs up to $900 per person. (My dh & I pay less than that.) People with incomes of $20,000 or less are exempt.

Most workplaces of any size offer employes additional medical and dental coverage. My dh & I work for the same company and co-ordinate our benefits. Our company offers "flex credits" that we can spend as we choose, & anything above & beyond a very basic level of coverage, we pay for through payroll deductions. Almost all of our medical & dental coverage is paid for through credits. Depending on the kind of plan you choose, this additional medical coverage pays for some, most or all the cost of things like prescription drugs, medical devices, ambulance services, etc. (sometimes to certain plan maximums, which are spelled out in your policy information).

Annual vision checkups at the optometrist, once free of charge, were de-listed by the provincial government a few years ago -- but our workplace medical insurance covers the cost of one standard visit every two years.

Terms like co-payments, deductibles and billing are foreign to Canadians' health care vocabularies. The only times in my life I can ever remember being billed by a doctor (outside of fertility treatments):

  • dh has a PSA exam done every year (to detect prostate cancer) which costs about $35. I would need to dig through my files to confirm this, but I believe I've had the cost reimbursed through our workplace medical plan.
  • likewise, I paid for a CA125 test suggested by my dr at my checkup two years ago -- can't remember the cost -- it was slightly more expensive than dh's PSA test.
  • and when we went to hospital to deliver Katie in 1998, the admissions clerk insisted that if I wanted a private room, I had to pay for it -- even though my dr had told me I was GETTING a private room & didn't mention anything about cost. Dh forked over the credit card & we were charged ($150 for one night, I think). I brought it up with my OB, sent him a copy of the bill & the charges were reversed. Even if they hadn't, my workplace insurance likely would have covered most if not all of the cost.
The only thing we have to do to access care is to show our provincial health card at each visit to a dr's office, clinic or hospital. There is no insurance coverage to sort out or credit cards to hand over before anyone agrees to see you, and no paperwork to deal with afterwards. The dr bills the province for each visit/procedure & is reimbursed by the government.

The only paperwork I ever have to deal with is the claims I submit for the "extras" that my workplace medical insurance covers. Much of that is being automated, too -- our dentist's office submits our claims electronically and we're reimbursed with a deposit to our bank account almost immediately. For prescription drugs, we have electronic swipe cards. When we first got our cards, I took them to the pharmacy where I regularly have my prescriptions filled, & they put us into their system. When I get a prescription filled there, their system automatically files the claim & calculates the discount. I most cases, I pay only a small fraction of the actual cost of the prescription. The pills I take for my thyroid condition, for example, cost me under $4 out of pocket for 100 pills. My Epi-pen has a price tag of $100, but I did not pay a cent -- the entire cost was covered.

When I was going through infertility treatment (clomid, injectable drugs & IUIs), my workplace plan covered some of the drug costs -- up to a lifetime maximum of $2,500 (it's $3,000 now). As you can imagine, it didn't take very long to blow through $2,500 in fertility drugs. All of my diagnostic tests, bloodwork, ultrasounds and the IUI itself were covered by the provincial government's plan -- but the sperm wash cost $350 (go figure). In-vitro fertilization is not covered in Ontario, except in cases where both fallopian tubes are blocked -- then the province will pay for up to three IVF attempts. Last year, the provincial government assembled an expert panel on infertility & adoption, and its recent report recommended that the province should fund up to three cycles of IVF for women under 42 years old, with single-embryo transfers mandated in most cases. Whether these recommendations will ever become policy/law is anyone's guess...

What else?

I have never, ever heard of people being deemed "too old" for a hip replacement or other such surgery. This reminds me of a few years ago, when my extremely athletic & healthy 50-something boss broke her hip while on a skiing vacation. She eventually had to have a total hip replacement. (She did have some trouble finding an orthopedic surgeon in the city to see her right away, but was able to access one outside the city, in a smaller centre where she & her partner own a second home.) She told us how happy she was one day to walk into the waiting room & see someone else around her own age waiting, because just about everybody else was a senior citizen. She got talking to this other 50-something -- & found out she was just there, waiting for her 86-year old mother, lol.

We chose our own family doctors (a friend referred us to him -- although he no longer takes new patients). The government does not choose for me, or for anyone else. Obviously, in a large urban area like Toronto, there is more choice than in a small town with few larger centres in the area. I'm sure it's the same in the States.

My family dr refers me to any specialists I need to see. If I don't like them or am not satisfied, I can ask for another referral. (I'm puzzled when I hear that Americans think universal/single-payer coverage or even a public option means the government will make decisions about their health care for them, which drs they can see, etc. First, in Canada, anyway, it's simply not true, and second, don't the insurance companies do that for you in the States anyway, under the current system -- telling you which hospitals and drs you can see within their plans and denying claims because of "pre-existing conditions," etc.?).

Being young & relatively healthy, I have not had any health problems that were too serious. Aside from having my wisdom teeth out at age 28, I have never had surgery (knock wood). But throughout my life, I've been referred to various specialists for various issues that came up. The time I've waited to see a specialist has ranged from a few days to a few months.

For example, when my ob-gyn referred me to an RE to begin fertility treatments, I had to wait six weeks for my first appointment. Another example: when I had my annual checkup with my family dr last year (in mid-September), he gave me a referral for my annual routine mammogram & my first bone density scan. I called to arrange the appointment myself, at a breast clinic at one of the city's top hospitals. The earliest I could get in was mid-December. However, had there been a reason for concern, I know I would have been seen much earlier.

Equal access to care is the goal, but unfortunately not always the reality, in both rural areas & some cities. Hospitals, especially in the cities, have bed shortages, and there are staff shortages -- of family drs in particular. Sometimes, your ability to "choose" your healthcare provider is limited by what's available -- and certainly, if you live in a small rural community, you will need to travel to a larger centre to access specialists and more acute care. I doubt the situation is much different in comparable areas of the States.

My own family dr, whom I've seen for the past 24 years, is 71 and plans to retire when he's 75. I don't know if he plans to turn the practice over to someone else, and if he doesn't, I'm not sure what dh & I will do then. He doesn't make house calls (who does, these days?) but he does have an answering service & is great about returning calls. He's even called me at home to check up on me if I've been having a hard time with something.

Besides family drs, the system in Ontario (& most other provinces) includes a free telehealth service, which you can call 24 hours a day to speak to a registered nurse or pharmacist with questions about symptoms you may be having or medications you are taking. If you don't want to wait on the line, you can leave a message & someone will call you back. I've never had to wait more than about 40 minutes for a callback. Most larger communities have walk-in urgent care clinics, and then of course, there is always the hospital emergency room -- which does tend to get overused/abused at times when the dr's offices & walk-in clinics are closed, or by people who don't have a family dr in the first place.

My family dr is in the city, close to where dh & I had our first apartment, & a 15-minute subway ride from my office. If I've been feeling crappy when I'm at work & he can't see me that day, there's a walk-in clinic a short walk from my office, where I've never waited more than an hour to see someone. I used the walk-in urgent care in the community where I live once, when I was feeling too sick to make the trip downtown to my family dr. And I've used the emergency room at the local suburban hospital several times. Naturally, incoming patients are triaged and the most urgent/serious cases get seen first. Most of my visits to the ER have been for prolonged bouts of vomiting, suspected allergic reactions &/or ailments that were eventually chalked up to anxiety attacks. I've waited as little as 10 minutes and as long as 10 hours (ugh), with about two hours being common.

Yes, some Canadians do seek treatment in the States, because they think they can get it faster, because they have a rare condition that few drs here have handled, because there's an experimental treatment available in the States that they want to try, or just because they want to consult with someone there (even if they ultimately wind up being treated at home). Sometimes the provincial government will pay; sometimes it's out of pocket. I grew up in Manitoba, in the Canadian Prairies. The world-famous Mayo Clinic in Rochester, MN, is just a day's drive away, & I know several people (particularly cancer patients) who chose to go there for consultations &/or treatment.

But for the most part, care in Canada is on par with that offered anywhere else in the world. And you just don't hear of people in Canada being bankrupted and losing their homes because they got sick and couldn't afford the huge medical bills. It just doesn't happen.

I know that American members of my own extended family have been touched by the lack of affordable health care south of the border. In my own family, I know of:
  • one retired couple, who were paying $1,100 a month for health insurance -- & that was several years ago (I'm sure it's more now).
  • a couple in their 40s who recently lost their house, staggering under the debt of medical bills.
  • someone who needs surgery but whose insurance company will not authorize it because money is still owed from a previous surgery.
  • a woman in her 40s with a chronic medical condition who is covered by her husband's workplace insurance, but even so cannot afford to take all the medications she needs as regularly as she needs them.
  • several relatives who are well over 65 but continue to work, because they fear losing their medical benefits.
Few if any of these scenarios would ever exist in Canada. The closest situation I can think of is I have heard that some expensive, relatively new cancer treatment drugs are not covered under provincial or private drug plans -- but people are fighting back and, in some cases, winning a significant reduction in the cost of the drugs they need for their treatment. These cases make the news precisely because they are exceptional -- they are not the norm.

When my American grandparents were still alive, Medicare paid for most of the care they needed, but the paperwork involved just about drove my mother around the bend. My mother has lived in Canada since her marriage almost 50 years ago; she is a proud, flag-waving Republican, but even she thinks the U.S. healthcare system is insane & ours much preferable.

I am not saying the Canadian system is perfect. Every system has its pros & cons.

I'm not saying the Canadian system should necessarily be adopted wholesale in the U.S. If you don't want our system, fine. There are many different ways that different countries deliver & pay for their citizens' health care. You have lots of models to look at.

But I am saying that the status quo in the U.S. is completely unfathomable to those of us who live in countries where some form of universal healthcare is available to all. It's hard for us to believe that so many people lack basic healthcare -- and, because of it, get sick, go deeply into debt, lose their homes, line up by the tens of thousands outside of sports arenas to be seen by teams that normally deliver health care to Third World countries (I saw a story on "60 Minutes" along these lines that had me in tears), and, yes, die -- all in the richest and most powerful nation on the face of the earth.

And I am saying that I'd never trade what we have for the U.S. system, and the vast majority Canadians wouldn't either.

As I stated early on, I don't care for conflict. I will be happy to answer any thoughtful questions about my/my family's healthcare experiences, but I will delete any comments that are less than civil.

For some further perspectives on Canadian vs U.S. health care systems, from Canadians as well as Americans who are now living in Canada, here are some links I've found recently that I thought were interesting:

The New York Times has an ongoing series in its Economix blog about regulation in Canada, including several articles explaining various aspects of our health care system, which provides a pretty good overview. There are many Canadians commenting on each article as well. I would recommend these if you're really interested in learning more about how Canada's health care system works.


  1. It's such a muddled mess, the whole healthcare debate. Ugh. Living in CA I can tell you that for me, and the vast majority of people here the issue is the enormous burden the illegal immigrants have put on our health care system. The ER's are flooded with people who can not pay, have no insurance, and use the hospital as a doctors office. They require special services because most don't speak english and have no medical 'history' that the docs can work from. And the children, no vaccination records, no birth records etc...then of course they need the additional help filling out all of the paperwork that will get them the healthcare for free(healthcare I have to pay for and I pay, through my premiums and taxes, for theirs as well) Quite honestly, I don't want to pay for their care. And that is what you will here from many here. I don't support illeagal immigration at all and have long hoped that our government would do a better job of protecting our borders and ensuring a fair and simple but LEGAL process for immigrating here. I don't want to get into the whole immigration/economic impact debate, so I will leave it at that.
    I like the idea of a national healthcare program but I have little if any confidence in my governments ability to manage such a system. Just look at our IRS and the way our tax code has been manipulated...
    Finally, I have serious doubts as to whether a real 'confidentiality' will remain between me and my caregiver(s) if there are micromangers overseeing and approving what care I get and from whom. It is one of the many reasons we(my family) continue to pay so much for the plan we do have. No one tells us who to see or when, my docs never have to refer me, they never have to get approval for anyhting when treating me and I have never, ever had to wait 6 weeks to see any doctor.
    I'd like to think that my government could effect a system that works as well as you describe yours but reality tells me it will never happen.

  2. Thanks for this thorough overview. Sadly, I think the reaction to the health care debate isn't really about fixing or even just discussing our f'ed up system and its continuing slide into non-viability, but about people being afraid on a very visceral level of something they don't understand: "the government." Unfortunately, most folks don't really understand our system, other countries' systems, or how governments function--forget the history and nature of things like "socialism." That's in part the failure of our education system.

    Just for comparison, I'm a grad student. I have had to pay around $750 for coverage this semester as I can't teach or work and there is no family leave option that the university can offer me. That coverage does not include Rx AT ALL. Nothing. Nada. My generic thyroid meds, when they were covered, cost $10 US per month.

  3. Thanks for sharing your perspective. The tying of health insurance to employment in the US makes things very precarious, especially given current unemployment rates. D's company is circling the drain, and if he loses his job and cannot find another one soon, we would blow through our savings very, very quickly with COBRA payments. And we have always prided ourselves on having such a good savings safety net. We have a high-deductible policy through D.'s employer and have spent $7300 out of pocket this year, including $1900 on "out of network" anesthesia for my emergency C-section (I tried to fight this claim and it was rejected). This is in addition to $195 pretax per pay period for coverage.

    My dearest wish is for eventual Canadian citizenship for I & N. Seriously.

    BTW, I had to wait 3 months to get an RE appointment. We paid $13,000 out of pocket for one IVF/ICSI cycle and meds.

  4. Thanks for sharing this - fear of provoke people's passionate ire!
    the unknown as Shinejil said can truly provoke some passionate sentiments!

    I know that something truly needs to be done. My concerns stem from how poorly managed many other "programs" have been and a lack of faith that they could manage something like this any better. Medical costs are ridiculous - $8 or more for one aspirin?! The hours long wait in the ER while you are behind people with non-emergent issues like a cold and you have a bleeding kid who needs stitches.

    The problem is - its the horror stories that people hear the most about on both sides of the border. I appreciate you sharing the not so sensational side. :0)

  5. I'm Canadian, but I went to grad school in the US for two years and had some interesting experiences with the healthcare system there.

    The bottom line, our Cdn system is not perfect. Far from it. That said, I wouldn't change it for the world. I really, really cannot imagine going through something medically traumatic and having to worry about the COST of it. With the exception of a private hospital room (which my health insurance covers anyway) and a small portion of my prescriptions, I have never had to pay for anything. When I had HELLP and pre-e last year I never paid a cent and my care was first-rate. This pregnancy, they're bending over backwards to keep me and baby safe, even sending nurses to my home almost daily. I pay for none of it. Neither does my insurance- it's all through the gov't.

    I can't imagine getting a BILL for any of this. IMO, these are basic human rights, for me, and for anyone in this country regardless of their income or social status.

  6. Part of what is causing anger toward our government over health care reform in the U.S. is that our country and our Constitution are based on freedom, and the more the government gets involved with our lives, the less freedom we have. The federal government is a government of limited, enumerated powers, with the states retaining broad regulatory authority. Congress cannot regulate simply because it sees a problem to be fixed. Federal law must be grounded in one of the specific grants of authority found in the Constitution, and the Constitution would never allow for federal regulation of health care (not that this has stopped our government since the 1930s).

    I think most people want some sort of reform so that health care is not tied to employment and we have more of a choice (I can't imagine our employers offering auto insurance - it makes about as much sense), but most Americans are generally happy with their health insurance. I know that as a cancer survivor who hardly had to pay a thing for numerous surgeries, chemotherapy, and tests (including some very new and innovative drugs and tests), I certainly have no room to complain about my health care.

  7. Thanks for such a thorough and interesting description of the Canadian health care system. How I wish all the people in the U.S. who are so terrified of changing our health care system could be even a fraction as educated about other countries' systems as you are about ours.

  8. Thank you for posting this. Your comments are right in line with others posts I've read by Canadians. . . which all just leave me so confused by 1) what Americans are so terrified of/ angry about, and 2) how people can continue to believe all the misinformation out there.

    It's really heartbreaking. I mean, my DH and I are both professionals, have decent paying jobs, and have health care through our jobs. My insurance plan (I pay $100 premiums a month) has a $5000/ year deductible for me, and it goes to $10,000 for a family. So, between having HELLP last year, continuing to treat/ be pregnant this year, and maybe deliving a live baby next year - we're looking at $20,000 in medical expenses (not to mention the $7,000 oop we paid for fertility treatments).

    That is *nothing* compared to what many in America have to pay. But its certainly enough to break us. Will it render us homeless? No. But between the bills and the time off work, we'll be out of savings and will likely have to sell our house. Its insane, and it pains to think about what those without the decent-paying jobs and etc. deal with.

  9. I find it disheartening that people only seem to care about themselves - if they can pay for their comprehensive health insurance, then too bad for other people. If they get sick, too bad for them. And yet Americans can be incredibly generous and compassionate - all the years of foreign aid, supporting human rights and democracy. Yet some people tend to think that the right to proper health care is a privilege for those who can afford it.

    Even my own sister used to crow about how they had all the great experts down there, yet now she is miserable because she has been laid off (she's a special ed teacher), her husband can't find enough work near home, so it's incredibly difficult to sustain their health coverage, her son is frequently ill, and she's had more than her share of battles with insurance companies. Even her own health has suffered greatly because of all the stress of not being able to pay her medical bills (even though she HAS insurance)- I had to send her money to get a CAT scan! So guess who wants to come home now?

    No one should have to choose between paying for food and paying for medicine. In North America - we are rich compared to most of all the world - we CAN afford to be compassionate to our neighbours, whether we like them or not.

  10. I am from Canada, as well, and I hear many complaints about our health care system, but I find it works very well. Especially compared to our American friends and family.

    My parents always lived hand-to-mouth and never saved a thing for retirement. I have just gone through years of helping look after my mother, with lots of doctor appointments, hospital visits, her inability to walk, admission to a nursing home, and death. Through this all, she got amazing care, although penniless. My father is looked after, as well.

    My daughter (now 16) is very healthy (thank God - no really, I thank Her daily) but had 3 hospital trips before she turned 2, and we were looked after very well.

    Yes, there are things that are not perfect, but we have a working compassionate system.