Arguments against health care reform in the United States show some of the most unpleasant aspects of current political debate. Currently, the Canadian health care system is being demonized in the US health care debates.

I lived in Canada for four years. Nothing said matches my experience of the Canadian health care system. I loved it - but I could have been lucky. Let’s look at some more objective evidence.

Here's a comparison of basic health stats from the 2009 WHO statistical division. If Canadian health care is so inadequate, why are the stats so much better despite the US spending so much more on health care? Basic health indices in bold...

United States

Statistics:
Total population: 302,841,000

Gross national income per capita (PPP international $): 44,070
Life expectancy at birth m/f (years): 75/80
Healthy life expectancy at birth m/f (years, 2003): 67/71
Probability of dying under five (per 1 000 live births): 8
Probability of dying between 15 and 60 years m/f (per 1 000 population): 137/80
Total expenditure on health per capita (Intl $, 2006): 6,714
Total expenditure on health as % of GDP (2006): 15.3
Figures are for 2006 unless indicated. Source: World Health Statistics 2008

Canada

Statistics:
Total population: 32,577,000
Gross national income per capita (PPP international $): 36,280
Life expectancy at birth m/f (years): 78/83
Healthy life expectancy at birth m/f (years, 2003): 70/74
Probability of dying under five (per 1 000 live births): 6
Probability of dying between 15 and 60 years m/f (per 1 000 population): 89/55
Total expenditure on health per capita (Intl $, 2006): 3,672
Total expenditure on health as % of GDP (2006): 10.0
Figures are for 2006 unless indicated. Source: World Health Statistics 2008

Statistics are the basic tool of the epidemiologist. You look at populations. If you want to compare how healthy two populations are, life expectancy and infant mortality rates are the standard quick way of doing so. Then you look at the factors affecting illness and health. How do the populations differ? You measure the difference using statistics. You then look at common and different factors between the populations. What explains it?

Any comparison of the US and Canada in terms of basic population to be served by the health care system needs to begin with considering how the populations differ:

Climate: Canada’s severe cold, in the far north, is not healthy. It's not as bad as the tropics, but it's a lot more challenging to human health than the temperate zones.

Transportation infrastructure: In the Canadian far north, access to medical care is difficult. (A further breakdown of Canadian health stats on infant mortality reflects this.) Too few people over too much land, lack of transportation...

Sources of Wealth, Occupations: Some industries are high risk in terms of health: agriculture, mining and construction are three. A lot of Canada's wealth comes from agriculture and mining.

One factor in Canada’s favor is relative poverty. Canada, like the US, has pockets of poverty in its major cities. They also have poverty on some on the Reserves [Canadian for 'reservation] controlled by indigenous peoples.  Canada has a basic safety net in place for the very poor. If you're poor, you're not as poor. This, by itself, contributes to higher levels of health in Canada. I don’t think this is enough to explain the differences in infant mortality and life expectancy.

Canadian health figures should be worse than those of the US. Why aren't they? A major reason, I think, is access to medical care that is free at the point of delivery.

Health care free at the point of delivery means people go earlier in an illness when it's cheaper and easier to treat. A case of flu does not develop into pneumonia. If you've got high blood pressure, you can actually (1) get it diagnosed (2) afford the meds. Thus postponing, if not preventing, heart attacks and strokes. People live longer as a result. An infant with a cold is taken to the doctor - before he/she develops meningitis. If you have a large segment of the population without access to health care, you also have a large reservoir where infectious disease is maintained - TB is a good example. Diarrheal` disease is another. It spreads and it kills the very young and the old. Deaths from diarrheal disease are usually preventable in the early stages. Cholera is a good example. (The US has clean water and efficient waste disposal systems - the result, incidentally, of public health policies backed by John Snow, statistics and fact based analysis of water supplies in London. Your clean water and waste disposal protect you from a lot.)

Opponents of Obama's health care plan ignore statistics and supply horror stories about Canada: mainly,  anecdotal evidence concerning health care rationing and waiting lists.

Every health system in the world uses some form of rationing. The US form of rationing is ability to pay. In the UK, health authorities sometimes refuse to pay for certain drugs, arguing that their usefulness has not been demonstrated. The patient is always at liberty to pay for the drug themselves. They can also challenge the health authority ruling. They sometimes win. There are waiting lists for some kinds of surgery. Hip replacements, for example, typically have a waiting time of about six months. That's in the UK - and the UK is not the best example of a national medical system. Japan, France, the Scandinavian countries, the Netherlands - all better than the UK. (The UK really does run its system on the cheap... you get what you pay for, except in the US... interesting.)

Every system also has its horror stories. A man took his seven year old son with a broken arm to a doctor in Alabama. After the doctor set the arm and put on the cast, he asked for his money. Man didn't have it, and had no insurance. The doctor sawed off the cast and told him to take the boy to the nearest emergency room, 40 miles away. Is this typical of the US health system? Absolutely not. It was in all the papers, people were horrified and I think the doctor lost his license. You use statistics because stories like that don't tell you very much about the health care system.

Canadian waiting lists are offered as reasons to avoid any changes to the US system. Kao-Ping Chua, AMSA [American Medical Student Association] Jack Rutledge Fellow 2005-2006, analyzed American and Canadian experiences in getting medical treatment. The full report in pdf format is available here: 

http://www.amsa.org/studytours/WaitingTimes_primer.pdf


Here are some quotes and his conclusions:

“On average, U.S. citizens experience some of the shortest wait times for non-emergency surgeries among industrialized countries, although the waiting times vary considerably by procedure[11]. Furthermore, the short waiting times apply mainly to those who have insurance;
for those who do not, the waiting line is arguably infinite.[emphasis added. wll] Finally, the short waiting lists in the U.S. should be tempered with the realization that the lack of universal healthcare in the U.S. means less demand for the system. If there were universal healthcare without an expansion of capacity, one might see how waiting lines in the U.S. could increase.”

Chua’s Summary, quoted in full:
What is clear from this analysis is that Canadian waiting lists are undoubtedly a problem for many Canadians on certain elective procedures. What is not clear, however, is the magnitude
of the problem, and it is certainly not necessarily true that there is a Canadian "waiting list crisis."

1. •The lack of quality data on waiting lists from the Canadian government, coupled with the limitations of surveys (e.g. differing methodologies), makes it very difficult to conclude with any certainty the size of the true waiting list problem.
   

2. •
   • The Canadian experience with waiting times will necessarily be uneven, as waiting times vary by specialty, procedure, province, and region. That is, any given individual Canadian will have different experiences with waiting times. This may partly explain the
   existence of anecdotal reports of intolerable waits from certain individual Canadians (such stories often are dramatized in the media), juxtaposed with the denial of the problem from other Canadians.
   

3. •
   • The U.S. does not experience problems with waiting lists as much as Canada does, although the problem does exist for some Americans.
   

4. •
   • There is a small minority of Canadians who receive care in the U.S., and even a smaller minority who specifically come to the U.S. to receive care. The idea that hordes of Canadians cross the border to avoid waiting lists is a myth.
   

I started this blog by mentioning the standard of debate in Congress: in the cellar, I think. These people lie. The health plan itself is misrepresented and the misrepresentations are gross enough to be considered straightforward  lies. How can you have a successful modern democracy when lying about an opponent's position is considered another rhetorical tool?

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Here's an addendum, a colmn cut and pasted from the Washington Post, giving some examples of lies over the health care plan:

Republicans Propagating Falsehoods in Attacks on Health-Care Reform

By Steven Pearlstein
Friday, August 7, 2009, Washington Post

As a columnist who regularly dishes out sharp criticism, I try not to question the motives of people with whom I don't agree. Today, I'm going to step over that line.

The recent attacks by Republican leaders and their ideological fellow-travelers on the effort to reform the health-care system have been so misleading, so disingenuous, that they could only spring from a cynical effort to gain partisan political advantage. By poisoning the political well, they've given up any pretense of being the loyal opposition. They've become political terrorists, willing to say or do anything to prevent the country from reaching a consensus on one of its most serious domestic problems.

There are lots of valid criticisms that can be made against the health reform plans moving through Congress -- I've made a few myself. But there is no credible way to look at what has been proposed by the president or any congressional committee and conclude that these will result in a government takeover of the health-care system. That is a flat-out lie whose only purpose is to scare the public and stop political conversation.

Under any plan likely to emerge from Congress, the vast majority of Americans who are not old or poor will continue to buy health insurance from private companies, continue to get their health care from doctors in private practice and continue to be treated at privately owned hospitals.

The centerpiece of all the plans is a new health insurance exchange set up by the government where individuals, small businesses and eventually larger businesses will be able to purchase insurance from private insurers at lower rates than are now generally available under rules that require insurers to offer coverage to anyone regardless of health condition. Low-income workers buying insurance through the exchange -- along with their employers -- would be eligible for government subsidies. While the government will take a more active role in regulating the insurance market and increase its spending for health care, that hardly amounts to the kind of government-run system that critics conjure up when they trot out that oh-so-clever line about the Department of Motor Vehicles being in charge of your colonoscopy.

There is still a vigorous debate as to whether one of the insurance options offered through those exchanges would be a government-run insurance company of some sort. There are now less-than-even odds that such a public option will survive in the Senate, while even House leaders have agreed that the public plan won't be able to piggy-back on Medicare. So the probability that a public-run insurance plan is about to drive every private insurer out of business -- the Republican nightmare scenario -- is approximately zero.

By now, you've probably also heard that health reform will cost taxpayers at least a trillion dollars. Another lie.

First of all, that's not a trillion every year, as most people assume -- it's a trillion over 10 years, which is the silly way that people in Washington talk about federal budgets. On an annual basis, that translates to about $140 billion, when things are up and running.

Even that, however, grossly overstates the net cost to the government of providing universal coverage. Other parts of the reform plan would result in offsetting savings for Medicare: reductions in unnecessary subsidies to private insurers, in annual increases in payments rates for doctors and in payments to hospitals for providing free care to the uninsured. The net increase in government spending for health care would likely be about $100 billion a year, a one-time increase equal to less than 1 percent of a national income that grows at an average rate of 2.5 percent every year.

The Republican lies about the economics of health reform are also heavily laced with hypocrisy.

While holding themselves out as paragons of fiscal rectitude, Republicans grandstand against just about every idea to reduce the amount of health care people consume or the prices paid to health-care providers -- the only two ways I can think of to credibly bring health spending under control.

When Democrats, for example, propose to fund research to give doctors, patients and health plans better information on what works and what doesn't, Republicans sense a sinister plot to have the government decide what treatments you will get. By the same wacko-logic, a proposal that Medicare pay for counseling on end-of-life care is transformed into a secret plan for mass euthanasia of the elderly.

Government negotiation on drug prices? The end of medical innovation as we know it, according to the GOP's Dr. No. Reduce Medicare payments to overpriced specialists and inefficient hospitals? The first step on the slippery slope toward rationing.

Can there be anyone more two-faced than the Republican leaders who in one breath rail against the evils of government-run health care and in another propose a government-subsidized high-risk pool for people with chronic illness, government-subsidized community health centers for the uninsured, and opening up Medicare to people at age 55?

Health reform is a test of whether this country can function once again as a civil society -- whether we can trust ourselves to embrace the big, important changes that require everyone to give up something in order to make everyone better off. Republican leaders are eager to see us fail that test. We need to show them that no matter how many lies they tell or how many scare tactics they concoct, Americans will come together and get this done.

If health reform is to be anyone's Waterloo, let it be theirs.