Canadian and American health care systems compared

basis ($2724 and $2121 on a non-adjusted basis); total U.S. spending was US$6096 vs. US$3137 (PPP) ($6096 and $3038 on a non-adjusted basis).]

Studies have come to different conclusions about the result of this disparity in spending. A 2007 review of all studies comparing health outcomes in Canada and the U.S., in a Canadian peer-reviewed medical journal, found that "health outcomes may be superior in patients cared for in Canada versus the United States, but differences are not consistent."Guyatt, G.H. "et al." 2007. [http://www.openmedicine.ca/article/view/8/1 A systematic review of studies comparing health outcomes in Canada and the United States.] "Open Medicine", Vol 1, No 1.] Life expectancy is longer in Canada, and its infant mortality rate is lower than that of the U.S., but there is debate about the underlying causes of these differences. One commonly cited comparison, the World Health Organization's ratings of health care system performance among 191 member nations published in 2000, ranked Canada 30th and the U.S. 37th, and the overall health of Canadians 35th and Americans 72nd. [http://www.who.int/whr/2000/en/annex01_en.pdf Health system attainment and performance in all Member States, ranked by eight measures, estimates for 1997] ] However, the WHO's study methods were criticized by some analyses. Some argue that Canada has had higher mortality rates for some conditions, such as heart attacks. [ [http://circ.ahajournals.org/cgi/content/full/110/13/1754 Long-term mortality of patients with acute myocardial infarction in the United States and Canada: comparison of patients enrolled in Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries (GUSTO)-I.] Kaul P, et al., Circulation. 2004 Sep 28;110(13):1754-60. PMID15381645] A recent report by the Congressional Research Service carefully summarizes some recent data and notes the "difficult research issues" facing international comparisons. [Congressional Research Service, [http://assets.opencrs.com/rpts/RL34175_20070917.pdf "U.S. Health Care Spending: Comparison with Other OECD Countries"] , September 17, 2007. Order Code RL34175] The health care system in Canada is funded by a mix of public (70%) and private (30%) funding, with most services delivered by private (both for-profit and not-for-profit) providers. Waiting times for major non-emergency surgery have been longer in Canada, and Canada has been slightly slower to adopt expensive technology and medicines.

Through all entities in its public-private system, the U.S. spends more per capita than any other nation in the world, but is the only wealthy industrialized country in the world that lacks some form of universal health care. [http://www.iom.edu/?id=17848 Insuring America's Health: Principles and Recommendations] , Institute of Medicine at the National Academies, 2004-01-14, accessed 2007-10-22]

Health care costs in both countries are rising faster than inflation. [cite press release |title=Health care spending to reach $160 billion this year |publisher=Canadian Institute for Health Information |date=2007-11-13 |url=http://www.icis.ca/cihiweb/dispPage.jsp?cw_page=media_13nov2007_e |accessdate=2008-03-27] [cite press release |title=Growth In National Health Expenditures Projected To Remain Steady Through 2017; Health Spending Growth |publisher=Centers for Medicare and Medicaid Services Office of Public Affairs |date=2008-02-26|url=http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=2935 |format= |language= |accessdate=2007-03-27 ] As both countries consider changes to their systems, there is debate over whether resources should be added to the public or private sector. Although Canadians and Americans have each looked to the other for ways to improve their respective health care systems, there exists a substantial amount of conflicting information regarding the relative merits of the two systems. [ [http://dsp-psd.communication.gc.ca/Collection-R/LoPBdP/BP/bp300-e.htm The Canadian and American Health Care Systems] ] In Canada, the United States is used as a model and as a warning against increasing private sector involvement in financing health care. In the U.S., meanwhile, Canada's mostly monopsonistic health system is seen by different sides of the ideological spectrum as either a model to be followed or avoided.cite journal | coauthors=Karen E. Lasser, David U. Himmelstein, and Steffie Woolhandler | year=2006 |month=07 | title=Access to Care, Health Status, and Health Disparities in the United States and Canada: Results of a Cross-National Population-Based Survey | journal=American Journal of Public Health | volume=96 | issue=7 |url=http://www.pnhp.org/canadastudy/CanadaUSStudy.pdf |accessdate=2007-07-02 |quote=In multivariate analyses, US respondents (compared with Canadians) were less likely to have a regular doctor, more likely to have unmet health needs, and more likely to forgo needed medicines...United States residents are less able to access care than are Canadians. ] [cite web | url=http://www.freemarketcure.com/singlepayermyths.php | title=The Myths of Single Payer Health Care | accessdate=2007-07-02 | last=David |first=Hogberg | publisher=Free Market Cure | quote=Single-payer is popular among the political left in the United States. Leftists have emitted tons of propaganda in favor of a single-payer system, much of which has fossilized into myth. ]

Government involvement

Canada and the United States had similar health care systems in the early 1960s, but now have a different mix of funding mechanisms. Canada's universal single-payer health care system covers about 70% of expenditures, and the Canada Health Act requires that all insured persons be fully insured, without co-payments or user fees, for all medically necessary hospital and physician care. In the United States, with its mixed public-private system, 16% are uninsured at any one time. [ [http://www.nchc.org/facts/coverage.shtml The National Coalition on Health Care, Facts About Healthcare - Health Insurance Coverage.] ] The U.S. is one of three OECD countries not to have some form of universal health coverage; the other two being Turkey and Mexico. [cite web |url=http://www.oecdwash.org/PDFILES/health2003_wash.pdf |title = Reforming Health Systems in OECD Countries |accessdate=2007-07-11 |last=Docteur |first=Elizabeth |date=2003-06-23 |format=PDF |work=Presentation, OECD Breakfast Series in Partnership with NABE. |publisher=OECD |pages = page 20]

The governments of both nations are closely involved in health care. The central structural difference between the two is in health insurance. In Canada, the federal government is committed to providing funding support to its provincial governments for health care expenditures as long as the province in question abides by accessibility guarantees as set out in the Canada Health Act, which explicitly prohibits billing end users for procedures that are covered by Medicare. While some label Canada's system as "socialized medicine," the term is inaccurate. Unlike systems with public delivery, such as the UK, the Canadian system provides public coverage for private delivery. As Princeton University health economist Uwe E. Reinhardt notes, single-payer systems are not "socialized medicine" but "social insurance" systems, because doctors are in the private sector. [Reinhardt, U.E. "et al." [http://online.wsj.com/article/SB118411829790962883.html Letters: For Children's Sake, This 'Schip' Needs to Be Relaunched.] "Wall Street Journal", July 11, 2007.] Similarly, Canadian hospitals are controlled by private boards and/or regional health authorities, rather than being part of government.

In the U.S., direct federal and state government funding of health care needs of its citizens is limited to Medicare, Medicaid, and the State Children's Health Insurance Program (SCHIP), which cover eligible senior citizens, the very poor, disabled persons, and children. The federal government also runs the Veterans Administration, which provides care to veterans, their families, and survivors through medical centers and clinics. One study estimates that about 25 percent of the uninsured in the U.S. are eligible for these programs but remain unenrolled; however, extending coverage to all who are eligible remains a fiscal and political challenge.cite web |url=http://www.kff.org/uninsured/upload/7613.pdf |title=Characteristics of the Uninsured: Who is Eligible for Public Coverage and Who Needs Help Affording Coverage? |accessdate=2007-07-19 |format=PDF |work=Kaiser Commission on Medicaid and the Uninsured ]

For everyone else, health insurance must be paid for privately. Some 59% of U.S. residents have access to health care insurance through employers, although this figure is decreasing, and coverages as well as workers' expected contributions vary widely.cite web |url=http://www.census.gov/prod/2008pubs/p60-235.pdf| title=Income, Poverty, and Health Insurance Coverage in the United States: 2007 |accessdate=2008-08-26 | format=PDF |work=U.S. Census Bureau] Those whose employers do not offer health insurance, as well as those who are self-employed or unemployed, must purchase it on their own. Nearly 27 million of the 45 million uninsured U.S. residents worked at least part-time in 2007, and more than a third were in households that earned $50,000 or more per year.

Despite the greater role of private business in the U.S., federal and state agencies are increasingly involved in U.S. health care spending, paying about 45% of the $2.2 trillion the nation spent on medical care in 2004. [cite news |first=Julie |last=Appleby |title=Universal care appeals to USA |url=http://www.usatoday.com/money/industries/health/2006-10-15-universal-usat_x.htm |work= |publisher=USA Today |date=2006-10-16 |accessdate=2007-05-22 ] The U.S. government spends more on health care than on Social Security and national defense combined, according to the Brookings Institute. [cite web |url=http://www.opportunity08.org/Files/FD.ashx?guid=98a417e5-5972-4031-b361-e11e00981f55 |title=Meeting the Dilemma of Health Care Access |accessdate=2007-06-21 |format=PDF |work=Opportunity 08: A Project of the Brookings Institution ]

Beyond its direct spending, the U.S. government is also highly involved in health care through regulation and legislation. For example, the Health Maintenance Organization Act of 1973 provided grants and loans to subsidize Health Maintenance Organizations and contained provisions to stimulate their popularity. HMOs had been declining before the law; by 2002 there were 500 such plans enrolling 76 million people. [cite web |url=http://www.medicalnewstoday.com/articles/6225.php |title=Health Care Expenditures in the USA |accessdate=2007-07-18 |work=National Center for Health Statistics | publisher=Medical News Today]

The Canadian system has been 69-75% publicly funded, [cite web |url=http://www.oecd.org/dataoecd/46/36/38979632.xls |title=OECD Health Data 2007 - Frequently Requested Data |accessdate=2007-08-27 |format=Excel |work=OECD ] though most services are delivered by private providers, including physicians (although they may derive their revenue primarily from government billings). Although some doctors work on a purely fee-for-service basis (usually family physicians), some family physicians and most specialists are paid through a combination of fee-for-service and fixed contracts with hospitals or health service management organizations.

Canada's universal health plan does not cover certain services. Non-cosmetic dental care is covered for children up to age 14 in some provinces. Outpatient prescription drugs are not required to be covered, but some provinces have drug cost programs that cover most drug costs for certain populations. In every province, seniors receiving the Guaranteed Income Supplement have significant additional coverage; some provinces expand forms of drug coverage to all seniors, [ [http://www.coverme.com/LH/CoverMe/miniWhy/English/NotCovered/A_NS.html CoverMe Government Health Insurance Coverage ] ] low-income families, [ [http://www.coverme.com/LH/CoverMe/miniWhy/English/NotCovered/A_SK.html CoverMe Government Health Insurance Coverage ] ] those on social assistance, [ [http://www.coverme.com/LH/CoverMe/miniWhy/English/NotCovered/A_NF.html CoverMe Government Health Insurance Coverage ] ] or those with certain medical conditions. [ [http://www.gnb.ca/0212/intro-e.asp Health - Prescription Drug Program ] ] Some provinces cover all drug prescriptions over a certain portion of a family's income. [cite web |url=http://www.gov.mb.ca/health/pharmacare/index.html |title=Manitoba Pharmacare Program Information: 2007-2008 |accessdate=2007-08-27 |work=Province of Manitoba ] Drug prices are also regulated, so brand-name prescription drugs are often significantly cheaper than in the U.S. [cite web |url=http://www.aarp.org/bulletin/prescription/Articles/a2003-08-12-whydrugs.html |title=Why Drugs Cost Less Up North: Important Differences in American, Canadian Systems Produce Big Price Disparities |year=2003 | month=June | accessdate=2007-07-02 |work=AARP Bulletin ] Optometry is only covered in some provinces and is sometimes only covered for children under a certain age. [ [http://www.gov.mb.ca/health/mhsip/index.html#insuredmedicalbenefits Manitoba Health Benefits.] ] Visits to non-physician specialists may require an additional fee. Also, some procedures are only covered under certain circumstances. For example, circumcision is not covered, and a fee is usually charged when a parent requests the procedure; however, if an infection or medical necessity arises, the procedure would be covered.

According to Dr. Albert Schumacher, former president of the Canadian Medical Association, an estimated 75 percent of Canadian health care services are delivered privately, but funded publicly.

"Frontline practitioners whether they're GPs or specialists by and large are not salaried. They're small hardware stores. Same thing with labs and radiology clinics …The situation we are seeing now are more services around not being funded publicly but people having to pay for them, or their insurance companies. We have sort of a passive privatization." [ [http://www.cbc.ca/news/background/healthcare/public_vs_private.html Public vs. private health care.] "CBC", December 1, 2006.]

Coverage and access

In Canada, every citizen has coverage, but access can still be a problem. Based on 2003 data from the Canadian Community Health Survey, [http://www.statcan.ca/Daily/English/040615/d040615b.htm Canadian Community Health Survey] , 04-06-15] an estimated 1.2 million Canadians do not have a regular doctor because they "cannot find" one, and just over twice that number do not have one because they "haven't looked". Those without a regular doctor are 3.5 times more likely to visit an emergency room for treatment.

In the U.S., the federal government does not guarantee universal health care to all its citizens, but publicly funded health care programs help to provide for the elderly, disabled, the poor, and children. [cite web |url=http://www.cms.hhs.gov |title=U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services |accessdate=2007-06-20 ] The Emergency Medical Treatment and Active Labor Act also ensures public access to emergency services regardless of ability to pay. [ [http://www.cms.hhs.gov/EMTALA/ Centers for Medicare & Medicaid Services: Emergency Medical Treatment & Labor Act] ]

According to the United States Census Bureau, 59.3% of U.S. citizens have health insurance related to employment, 27.8% have government-provided health-insurance; nearly 9% purchase health insurance directly (there is some overlap in these figures), and 15.3% (45.7 million) were uninsured in 2007. An estimated 25 percent of the uninsured are eligible for government programs but unenrolled. About a third of the uninsured are in households earning more than $50,000 annually. [Seymour, J.A. [http://www.businessandmedia.org/articles/2007/20070718153509.aspx Health Care Lie: '47 Million Uninsured Americans'. Michael Moore, politicians and the media use inflated numbers of those without health insurance to promote universal coverage.] Business and Media Institute, July 18, 2007.] A 2003 report by the Congressional Budget office found that many people lack health insurance only temporarily, such as after leaving one employer and before a new job. The number of chronically uninsured (uninsured all year) was estimated at between 21 and 31 million in 1998. [cite web |url=http://www.cbo.gov/showdoc.cfm?index=4211&sequence=0 |title=How Many People Lack Health Insurance and For How Long? |accessdate=2007-06-20 |format= |work=Congressional Budget Office Report, 2003 ] Another study, by the Kaiser Commission on Medicaid and the Uninsured, estimated that 59 percent of uninsured adults have been uninsured for at least two years. [cite web |url=http://www.kff.org/uninsured/upload/7451-021.pdf |title=The Uninsured: A Primer |accessdate=2007-07-19 |format=PDF |work=Kaiser Commission on Medicaid and the Uninsured] One indicator of the consequences of Americans' inconsistent health care coverage is a study in "Health Affairs" that concluded that half of personal bankruptcies involved medical bills, [ [http://content.healthaffairs.org/cgi/content/full/hlthaff.w5.63/DC1 "Illness And Injury As Contributors To Bankruptcy"] , by David U. Himmelstein, Elizabeth Warren, Deborah Thorne, and Steffie Woolhandler, Health Aff (Millwood). 2005 Jan-Jun;Suppl Web Exclusives:W5-63-W5-73. [PMID15689369] ] although other sources dispute this. [Todd Zywicki, [http://papers.ssrn.com/sol3/papers.cfm?abstract_id=587901 "An Economic Analysis of the Consumer Bankruptcy Crisis"] , 99 NWU L. Rev. 1463 (2005)]

A number of free clinics provide free or low-cost non-emergency care to poor, uninsured patients. The National Association of Free Clinics claims that its member clinics provide $3 billion in services to some 3.5 million patients annually. [cite web |url=http://www.freeclinics.us/AboutUs/tabid/54/Default.aspx |title=National Association of Free Clinics: About Us |accessdate=2007-06-20 |format= |work= ]

A peer-reviewed comparison study of health care access in the two countries published in 2006 concluded that U.S. residents are one third less likely to have a regular medical doctor, one fourth more likely to have unmet health care needs, and are more than twice as likely to forgo needed medicines. The study noted that access problems "were particularly dire for the US uninsured." Those who lack insurance in the U.S. were much less satisfied, less likely to have seen a doctor, and more likely to have been unable to receive desired care than both Canadians and insured Americans.

According to President George W. Bush, "people have access to health care in America. After all, you just go to an emergency room. The question is, will we be wise about how we pay for health care. I believe the best way to do so is to enable more people to have private insurance. And the reason I emphasize private insurance, the best health care plan -- the best health care policy is one that emphasizes private health. In other words, the opposite of that would be government control of health care." [ [http://www.whitehouse.gov/news/releases/2007/07/20070710-6.html Office of the Press Secretary, July 10, 2007,] President Bush Visits Cleveland, Ohio, Intercontinental Hotel Cleveland, Cleveland, Ohio]

Cato Institute has expressed concerns that the U.S. government has restricted the freedom of Medicare patients to spend their own money on health care, and has contrasted these developments with the situation in Canada, where in 2005 the Supreme Court of Canada ruled that the province of Quebec could not prohibit its citizens from purchasing covered services through private health insurance. The institute has urged the Congress to restore the right of American seniors to spend their own money on medical care. [Kent Masterson Brown, [http://www.cato.org/pub_display.php?pub_id=8737 "The Freedom to Spend Your Own Money on Medical Care: A Common Casualty of Universal Coverage"] , CATO Institute Policy Analysis no. 601, October 15, 2007 ]

Wait times

One of the major complaints about the Canadian health care system is waiting times, whether for a specialist, major elective surgery, such as hip replacement, or specialized treatments, such as radiation for breast cancer. Studies by the Commonwealth Fund found that 24% of Canadians waited 4 hours or more in the emergency room, vs. 12% in the U.S.; 57% waited 4 weeks or more to see a specialist, vs. 23% in the U.S. [Commonwealth Fund, Mirror, Mirror on the Wall: An International update on the comparative performance of American health care, Karen Davis et al., May 15, 2007.]

In a 2003 survey of hospital administrators conducted in Canada, the U.S., and three other countries, 21% of Canadian hospital administrators, but less than 1% of American administrators, said that it would take over three weeks to do a biopsy for possible breast cancer on a 50-year-old woman; 50% of Canadian administrators versus none of their American counterparts said that it would take over six months for a 65-year-old to undergo a routine hip replacement surgery. Yet U.S. administrators were the most negative about their country's health care system. Hospital executives in all five countries expressed concerns about staffing shortages and emergency department waiting times and quality. [ [http://seattletimes.nwsource.com/html/opinion/2001977834_cihak13.html Guest columnist: The truth about Canada's ailing health-care system,] By Robert J. Cihak, Seattle Times, July 13, 2004] [ [http://content.healthaffairs.org/cgi/content/full/22/3/106 Confronting competing demands to improve quality: a five-country hospital survey. Blendon RJ, et al. Health Aff (Millwood). 2004 May-Jun;23(3):119-35. [PMID15160810] ]

In the Canadian Supreme Court case of Chaoulli v. Quebec, Chaoulli argued that the long waits were life-threatening and violated human rights, and that doctors and patients had a right to contract for private health care, despite the prohibitions on those medical services.

Canadians concede that waiting time is a problem that stems from the country's lower costs and commitment to universal coverage. In a letter to the Wall Street Journal, Robert S. Bell, M.D., President and CEO of University Health Network, Toronto, said that Michael Moore's film "Sicko" "exaggerated the performance of the Canadian health system — there is no doubt that too many patients still stay in our emergency departments waiting for admission to scarce hospital beds." However, "Canadians spend about 55% of what Americans spend on health care and have longer life expectancy, and lower infant mortality rates. Many Americans have access to quality health care. All Canadians have access to similar care at a considerably lower cost." The Kaiser Family Foundation found that 63% of Americans were worried about not being able to afford health-care services. There is "no question" that the lower cost has come at the cost of "restriction of supply with sub-optimal access to services," said Bell. A new approach is targeting waiting times, which are reported on public websites. [ [http://www.health.gov.on.ca/transformation/wait_times/wait_mn.html Ontario Wait Times.] From: health.gov.on.ca.] [ [http://www.cancercare.on.ca Cancer Care Ontario.] ] [ [http://online.wsj.com/article/SB118394504633260585.html "Canadian and U.S. Health Services -- Let's Compare the Two,"] Letters, Wall Street Journal, July 9, 2007; Page A13]

In the U.S., patients on Medicaid, the low-income government programs, can wait three months or more to see specialists. Because Medicaid payments are so low, doctors don't want to see Medicaid patients. In Benton Harbor, Michigan, specialists agreed to spend one afternoon every week or two at a Medicaid clinic, which meant that Medicaid patients had to make appointments not at the doctor's office, but at the clinic, where appointments had to be booked months in advance. [Fuhrmans, V. [http://online.wsj.com/article/SB118480165648770935.html?mod=todays_us_page_one Locked Out: Note to Medicaid Patients: The Doctor Won't See You; As Program Cuts Fees, MDs Drop Out; Hurdle For Expansion of Care.] "Wall Street Journal", July 19, 2007.]

Price of health care

Health care is one of the most expensive items of both nations’ budgets. The U.S. government spends more per capita on health care than the government does in Canada. In 2004, the government of Canada spent $2,120 (in US dollars) per person on health care, while the United States government spent $2,724.cite web |url=http://www.who.int/whosis/database/core/core_select_process.cfm?countries=all&indicators=nha |title=World Health Organization: Core Health Indicators |accessdate=2007-06-20 |format= |work= ]

However, U.S. government spending covers less than half of all health care costs. Private spending for health care is also far greater in the U.S. than in Canada. In Canada, an average of $917 was spent annually by individuals or private insurance companies for health care, including dental, eye care, and drugs. In the U.S., this sum is $3,372. In 2005, health care consumed 15.3% of U.S. annual GDP. In Canada, only 9.8% of GDP was spent on health care. This difference is a relatively recent development. In 1971 the nations were much closer, with Canada spending 7.1% of GDP on health while the U.S. spent 7.6%.

Some who advocate against greater government involvement in health care have asserted that the difference in health care costs between the two nations is partially explained by the differences in their demographics. [Sheldon L. Richman. [http://www.amatecon.com/etext/dosm/dosm-ch03.html "A Free Market for Health Care."] From "The Dangers of Socialized Medicine", edited by Jacob G. Hornberger and Richard M. Ebeling. Future of Freedom Foundation (February 1994). ISBN 0-9640447-0-6. Retrieved September 8, 2006.] Police-reported drug abuse and violence are more common in the United States than in Canada; [cite web |url=http://www.statcan.ca/Daily/English/011218/d011218b.htm |title=Crime comparisons between Canada and the United States | date=2001-12-18 |accessdate=2007-08-27 |work=Statistics Canada: The Daily ] both place a burden on the health care system. Illegal immigrants, more prevalent in the U.S. than in Canada, also add a burden to the health care system, as many of them do not carry health insurance and rely on emergency rooms — which are legally required to treat them — as a principal source of care.Brand, R. and R. Ramirez. [http://www.rockymountainnews.com/drmn/local/article/0,1299,DRMN_15_4950391,00.html "Hospital, Medicaid numbers tell immigration tale"] , "Rocky Mountain News", August 28, 2006.] In Colorado, for example, an estimated 80% of illegal immigrants do not have health insurance. Illegal immigrants' relative lack of preventative care also incurs higher overall costs. In addition, the U.S. has far more veterans and war wounded, also somewhat increasing cost.

The mixed system in the United States has become more similar to the Canadian system. In recent decades, managed care has become prevalent in the United States, with some 90% of privately insured Americans belonging to plans with some form of managed care. [cite web |url=http://www.healthdecisions.org/LearningCenter/Facts.aspx |title=Fast Facts |accessdate=2007-07-18 |work=HealthDecisions.org | publisher=America's Health Insurance Plans] In "managed care", insurance companies control patients' health care to reduce costs, for instance by demanding a second opinion prior to some expensive treatments or by denying coverage for treatments not considered worth their cost.

Administrative costs for health care are also higher in the United States than in Canada. [Woolhandler S, Campbell T, Himmelstein DU. "Costs of health care administration in the United States and Canada." "N Engl J Med." 2003 August 21;349(8):768-75. PMID 12930930.]

Medical professionals

Some of the extra money spent in the United States goes to doctors, nurses, and other medical professionals, all of whom receive higher compensation than their counterparts north of the border. According to health data collected by the OECD, average income for physicians in the United States in 1996 was nearly twice that for physicians in Canada. [ [http://www.pnrec.org/2001papers/DaigneaultLajoie.pdf Health Care Systems: An International Comparison.] Strategic Policy and Research Intergovernmental Affairs, May 2001.]

The causes of these differences are complex. Factors such as higher cost of living in the United States, lower private cost of medical training in Canada, and high costs of medical malpractice insurance in the United States, contribute to the differences.Fact|date=February 2008 Which entities exercise market power in each country also influences the differences in compensation. Canadian billing rates for each procedure are set through negotiations between the provincial governments and the physicians' organizations.Fact|date=February 2008 In the U.S., physicians have greater freedom to set rates according to the local market. Anti-trust regulations prohibit the formation of uniform rates for procedures. Actual compensation to medical professionals in the U.S. is also highly influenced by the discounted rates that publicly funded insurance programs, Medicaid and Medicare, and major health insurance companies, are able to negotiate through the exercise of their market power.Fact|date=February 2008 Private insurance companies often set their own reimbursement rates as a percentage of the Medicare reimbursement rate for all procedures though details are kept secret via confidentiality agreements that are a condition for participating in their panels of physicians.Fact|date=February 2008

Canada has fewer doctors per capita than the United States. In the U.S, there were 2.4 doctors per 1,000 people in 2005; in Canada, there were 2.2. [cite web |url=http://www.oecd.org/document/16/0,3343,en_2825_495642_2085200_1_1_1_1,00.html |title=OECD Health Data 2007: Frequently Requested Data |accessdate=2007-07-19 |format=Excel spreadsheet |work=Organisation for Economic Co-operation and Development] Some doctors leave Canada to pursue career goals or higher pay in the U.S. Many Canadian physicians and new medical graduates also go to the U.S. for post-graduate training in medical residencies. Often new and cutting-edge sub-specialties are more widely available in the U.S. as opposed to Canada. However, statistics published in 2005 by the Canadian Institute for Health Information (CIHI), show that, for the first time since 1969 (the period for which data are available), more physicians returned to Canada than moved abroad. [cite web |url=http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=PG_587_E&cw_topic=587&cw_rel=AR_14_E |title=Supply, Distribution and Migration of Canadian Physicians, 2005 |accessdate=2007-07-11 | date=2006-10-12 |format=PDF |publisher=Canadian Institute for Health Information |pages=page 40, figure 10 |quote=...in the past two years, the number of physicians returning from abroad has exceeded the number of physicians moving abroad.]

Drugs

Both Canada and the United States have limited programs to provide prescription drugs to the needy. In the U.S., the introduction of Medicare Part D has extended partial coverage for pharmaceuticals to Medicare beneficiaries. In Canada all drugs given in hospitals fall under Medicare, but other prescriptions do not. The provinces all have some programs to help the poor and seniors have access to drugs, but while there have been calls to create one, no national program exists. [ [http://www.cbc.ca/canada/story/2004/07/30/pharma_040730.html CBC.ca - Premiers propose drug plan paid for by Ottawa] ] About two thirds of Canadians have private prescription drug coverage, mostly through their employers.Valérie Paris and Elizabeth Docteur. [http://www.oecd.org/dataoecd/21/40/37868186.pdf Pharmaceutical Pricing and Reimbursement Policies in Canada] OECD Health Working Papers] In both countries, there is a significant population not fully covered by these programs. A 2005 study found that 20% of Canada's and 40% of America's sicker adults did not fill a prescription because of cost. ["Taking The Pulse Of Health Care Systems: Experiences Of Patients With Health Problems In Six Countries" Cathy Schoen, "Health Affairs." Chevy Chase: Jul-Dec 2005. Vol. 24 pg. 509, 17 pgs]

One of the most important differences between the two countries is the much higher cost of drugs in the United States. In the U.S., $728 per capita is spent each year on drugs, while in Canada it is $509. At the same time, consumption is higher in Canada, with about 12 prescriptions being filled per person each year in Canada and 10.6 in the United States. [Valérie Paris and Elizabeth Docteur. [http://www.oecd.org/dataoecd/21/40/37868186.pdf Pharmaceutical Pricing and Reimbursement Policies in Canada] OECD Health Working Papers pg. 49] The main difference is that patented drug prices in Canada average between 35% and 45% lower than in the United States. [Valérie Paris and Elizabeth Docteur. [http://www.oecd.org/dataoecd/21/40/37868186.pdf Pharmaceutical Pricing and Reimbursement Policies in Canada] OECD Health Working Papers pg. 52] The price differential for brand-name drugs between the two countries has led Americans to purchase upward of US$1 billion in drugs per year from Canadian pharmacies. [cite journal |author = Morgan, Steven; Hurley, Jeremiah |date=2004-03-16 |title=Internet pharmacy: prices on the up-and-up |journal=CMAJ |volume=170 |issue=6 |pages=945–946 |pmid=15023915 |doi=10.1503/cmaj.104001 |url=http://www.cmaj.ca/cgi/content/full/170/6/945?etoc |accessdate= 2007-07-11 ]

There are several reasons for the disparity. The Canadian system takes advantage of centralized buying by the provincial governments that have more market heft and buy in bulk, lowering prices. By contrast, the U.S. has explicit laws that prohibit Medicare or Medicaid from negotiating drug prices. In addition, price negotiations by Canadian health insurers are based on evaluations of the clinical effectiveness of prescription drugs,Gross, David. " [http://www.aarp.org/research/international/perspectives/jul_03_rxprices_canada.html Prescription Drug Prices in Canada: What Are the Lessons for the U.S.?] " "AARP." July 2003. Retrieved on February 3, 2008.] allowing the relative prices of therapeutically-similar drugs to be considered in context. The Canadian Patented Medicine Prices Review Board also has the authority to set a fair and reasonable price on patented products, either comparing it to similar drugs already on the market, or by taking the average price in seven developed nations. [ [http://www.pmprb-cepmb.gc.ca/english/view.asp?x=654&mid=589 Compendium of Guidelines, Policies and Procedures. Schedule 2 - Therapeutic Class Comparison Test.] ] [ [http://www.pmprb-cepmb.gc.ca/english/view.asp?x=654&mid=590 Compendium of Guidelines, Policies and Procedures. Schedule 3 - International Price Comparison.] ] Prices are also lowered through more limited patent protection in Canada. In the U.S., a drug patent may be extended five years to make up for time lost in development. [ [http://www.essentialdrugs.org/edrug/archive/199703/msg00036.php Re: E-DRUG: Patent rights on Ciprofloxacin] From: essentialdrugs.org.] Some generic drugs are thus available on Canadian shelves sooner. [cite web |url=http://www.fraserinstitute.ca/admin/books/files/PriceCtrlsXborderPharm2.pdf |title=Price Controls, Patents, and Cross-Border Internet Pharmacies |accessdate=2007-07-12 |last=Skinner |first=Brett J. |year=2006 |format=PDF |work=Critical Issues Bulletin |publisher=Fraser Institute |pages=page 6 |quote="Nearly half the value of sales (47%) in generic products sold through cross-border Internet pharmacies was accounted for by drugs that were not yet genericized in the United States. Most of these drugs were likely still under active patent protection in the United States.]

The pharmaceutical industry is important in both countries, though both are net importers of drugs. Both countries spend about the same amount of their GDP on pharmaceutical research, about 0.1% annually [Valérie Paris and Elizabeth Docteur. [http://www.oecd.org/dataoecd/21/40/37868186.pdf Pharmaceutical Pricing and Reimbursement Policies in Canada] OECD Health Working Papers pg. 57]


=Technology=

The United States spends more on technology than Canada. In a 2004 study on medical imaging in Canada, [ [http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=media_13jan2005_e "CIHI report shows increase in MRI and CT scanners, up more than 75% in the last decade."] "Medical Imaging in Canada, 2004."] it was found that Canada had 4.6 MRI scanners per million population while the U.S. had 19.5 per million. Canada's 10.3 CT scanners per million also ranked behind the U.S., which had 29.5 per million. [ [http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=media_13jan2005_e Press release: CIHI Report shows increase in MRI and CT scanners, up more than 75% in the last decade] ] The study did not attempt to assess whether the difference in the number of MRI and CT scanners had any effect on the medical outcomes. [ [http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=PG_328_E&cw_topic=328&cw_rel=AR_1043_E#full Medical Imaging in Canada, 2004] . ISBN 1-55392-515-7.]

Malpractice litigation

The extra cost of malpractice lawsuits accounts for some of the difference in health spending in the two countries. In Canada the total cost of settlements, legal fees, and insurance comes to $4 per person each year, but in the United States it is $16."Health Spending In The United States And The Rest Of The Industrialized World." Gerard F Anderson, Peter S Hussey, Bianca K Frogner, Hugh R Waters. "Health Affairs." Chevy Chase: Jul/Aug 2005. Vol. 24, Iss. 4; pg. 903, 12 pgs] Average payouts to American plaintiffs were $265,103, while payouts to Canadian plaintiffs were somewhat higher, averaging $309,417. [ [http://www.medicalnewstoday.com/medicalnews.php?newsid=27348 USA Spends More Per Capita on Health Care Than Other Nations, Study Finds ] ] However, malpractice suits are far more common in the U.S., with 350% more suits filed each year per person. While malpractice costs are significantly higher in the U.S., they make up only a small proportion of total medical spending. The total cost of defending and settling malpractice lawsuits in the U.S. in 2001 was approximately $6.5 billion, or 0.46% of total health spending. [ [http://content.healthaffairs.org/cgi/content/abstract/24/4/903 Health Spending In The United States And The Rest Of The Industrialized World - Anderson et al. 24 (4): 903 - Health Affairs ] ] Critics say that defensive medicine consumes up to 9% of American healthcare expenses. [ [http://jec.senate.gov/Documents/Hearings/mcclellantestimony28april2005.pdf Testimony of Mark McClellan, MD, Ph.D., Administrator, Centers for Medicare & Medicaid Services,] before the Joint Economic Committee Hearing on Malpractice Liability Reform, April 28, 2005] [ [http://ideas.repec.org/p/nbr/nberwo/5466.html Kessler, Daniel and Mark McClellan. "Do Doctors Practice Defense Medicine?," Quarterly Journal of Economics, 1996, v111(2,May), 353-390. Towards a More Effective Monetary Policy, Kuroda, Twao, ed.,: Macmillan, 1997, pp. 137-164.] ] In the same year in Canada, the total burden of malpractice suits was $237 million, or 0.27% of total health spending.

Ancillary expenses

There are a number of ancillary costs that are higher in the U.S. Administrative costs are significantly higher in the U.S.; government mandates on record keeping and the diversity of insurers, plans and administrative layers involved in every transaction result in greater administrative effort. One recent study comparing administrative costs in the two countries found that these costs in the U.S. are roughly double what they are in Canada. [cite journal |coauthors=Steffie Woolhandler, M.D., M.P.H., Terry Campbell, M.H.A., and David U. Himmelstein, M.D. |year=2003 |month=August |title=Costs of Health Care Administration in the United States and Canada
journal=New England Journal of Medicine |volume=349 |issue=8 |pages= 768|id= | url= http://content.nejm.org/cgi/content/full/349/8/768?ijkey=717e74affa656dce6c9502e8fb9621bbd373345d | format= HTML: full text | doi= 10.1056/NEJMsa022033 |accessdate=2007-06-20 |author=Woolhandler, S. |pmid=12930930
] Another ancillary cost is marketing, both by insurance companies and health care providers. These costs are relatively higher in the U.S., contributing to higher overall costs in that nation.

Health care outcomes

In the World Health Organization's ratings of health care system performance among 191 member nations published in 2000, Canada ranked 30th and the U.S. 37th, while the overall health of Canadians was ranked 35th and Americans 72nd. However, the WHO's methodologies, which attempted to measure how efficiently health systems translate expenditure into health, generated broad debate and criticism. [Deber, Raisa, [http://www.longwoods.com/product.php?productid=17238&cat=367&page=1 "Why Did the World Health Organization Rate Canada's Health System as 30th? Some Thoughts on League Tables"] , Longwoods Review 2 (1). Retrieved on 2008-01-09.]

Researchers caution against inferring health care quality from some health statistics. June O'Neill and Dave O'Neill point out that "...life expectancy and infant mortality are both poor measures of the efficacy of a health care system because they are influenced by many factors that are unrelated to the quality and accessibility of medical care". [O'Neill, J., O'Neill, D. M., [http://www.nber.org/papers/w13429 "Health Status, Health Care and Inequality: Canada vs. the U.S."] , National Bureau of Economic Research, NBER Working Paper 13429, September 2007.]

In 2007, Gordon H. Guyatt et al. conducted a meta-analysis, or systematic review, of all studies that compared health outcomes for similar conditions in Canada and the U.S., in "Open Medicine", an open-access peer-reviewed Canadian medical journal. They concluded, "Available studies suggest that health outcomes may be superior in patients cared for in Canada versus the United States, but differences are not consistent." Guyatt identified 38 studies addressing conditions including cancer, coronary artery disease, chronic medical illnesses and surgical procedures. Of 10 studies with the strongest statistical validity, 5 favoured Canada, 2 favoured the United States, and 3 were equivalent or mixed. Of 28 weaker studies, 9 favoured Canada, 3 favoured the United States, and 16 were equivalent or mixed. Overall, results for mortality favoured Canada with a 5% advantage, but the results were weak and varied. The only consistent pattern was that Canadian patients fared better in kidney failure.

Canadians are, overall, statistically healthier than Americans and show lower rates of many diseases such as various forms of cancer. On the other hand, evidence suggests that with respect to some illnesses (such as breast cancer), those who do get sick have a higher rate of cure in the U.S. than in Canada.

In terms of population health, life expectancy in 2006 was about two and a half years longer in Canada, with Canadians living to an average of 79.9 years and Americans 77.5 years.cite web |url=http://www.oecdobserver.org/news/get_file.php3/id/25/file/OECDInFigures2006-2007.pdf |title=OECD in Figures 2006-2007 |accessdate=2007-06-21 |format=PDF |work=Organisation for Economic Co-operation and Development ] Infant and child mortality rates are also higher in the U.S.. Some comparisons suggest that the American system underperforms Canada's system as well as those of other industrialized nations with universal coverage. [ [http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=482678 Commonwealth Fund Study] ] For example, a ranking by the World Health Organization of health care system performance among 191 member nations, published in 2000, ranked Canada 30th and the U.S. 37th, and the overall health of Canada 35th to the American 72nd. The WHO did not merely consider health care outcomes, but also placed heavy emphasis on the health disparities between rich and poor, funding for the health care needs of the poor, and the extent to which a country was reaching the potential health care outcomes they believed were possible for that nation. In an international comparison of 21 more specific quality indicators conducted by the Commonwealth Fund International Working Group on Quality Indicators, the results were more divided. One of the indicators was a tie, and in 3 others, data was unavailable from one country or the other. Canada performed better on 11 indicators; such as survival rates for colorectal cancer, childhood leukemia, and kidney and liver transplants. The U.S. performed better on 6 indicators, including survival rates for breast and cervical cancer, and avoidance of childhood diseases such as pertussis and measles. It should be noted that the 21 indicators were distilled from a starting list of 1000. The authors state that, "It is an opportunistic list, rather than a comprehensive list." [http://content.healthaffairs.org/cgi/content/full/23/3/89 How Does the Quality of Care Compare in Five Countries?] Peter S. Hussey, Gerard F. Anderson, Robin Osborn, Colin Feek, Vivienne McLaughlin, John Millar and Arnold Epstein, Health Affairs, 23, no. 3 (2004): 89-99]

Some of the difference in outcomes may also be related to lifestyle choices. The OECD found that Americans have slightly higher rates of smoking and alcohol consumption than do Canadians as well as significantly higher rates of obesity. [ [http://www.statcan.ca/english/research/82-620-MIE/2005001/articles/adults/aobesity.htm#5 Adult obesity in Canada: Measured height and weight] ] A joint US-Canadian study found slightly higher smoking rates among Canadians. [ [http://www.cdc.gov/nchs/about/major/nhis/jcush_mainpage.htm The Joint Canada/United States Survey of Health (JCUSH).] CDC - National Center for Health Statistics.] Another study found that Americans have higher rates not only of obesity, but also of other health risk factors and chronic conditions, including physical inactivity, diabetes, hypertension, arthritis, and chronic obstructive pulmonary disease.

A Canadian systematic review concluded that differences in the health care systems of Canada and the United States could not alone explain differences in health care outcomes.

Heart attacks in the 1990s

A study in the journal "Circulation" found that Canadian patients whose histories were followed from 1990 to 1993 had a 17% higher risk of dying from heart attacks than did U.S. patients. The five-year mortality rate was 21.4% among the Canadian study participants and 19.6% among U.S. participants. The authors attributed this to the greater use of invasive procedures in the U.S., and in the organization of the Canadian health care system, in which specialized procedures are only available in central hospitals. Almost a third (30%) of American heart attack patients received an angioplasty, versus 11% of Canadians, and more than 13% of Americans had bypass surgery, compared with 4% in Canada. However, this study was done to determine whether invasive treatment had a beneficial outcome. At the time of the study, doctors didn't know whether invasive treatment would be beneficial. [ [http://www.webmd.com/heart-disease/news/20040920/us-tops-canada-in-post-heart-attack-care U.S. Tops Canada in Post-Heart Attack Care; More Aggressive Care May Explain Americans Survival Edge] , WebMD Medical News, Sept. 20, 2004] [ [http://circ.ahajournals.org/cgi/content/full/110/13/1754 Long-term mortality of patients with acute myocardial infarction in the United States and Canada: comparison of patients enrolled in Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries (GUSTO)-I.] Kaul P, et al., Circulation. 2004 Sep 28;110(13):1754-60. [PMID15381645] ]

In Canada between 1992 and 2001, there was a decline in death rates from coronary artery balloon angioplasty of 2.7% to 0.9% (67%) [ [http://www.ncbi.nlm.nih.gov/sites/entrez?Db=PubMed&Cmd=ShowDetailView&TermToSearch=12813611 Can J Cardiol. 2003 Jun;19(7):782-9. In-hospital outcomes after percutaneous coronary intervention in Canada: 1992/93 to 2000/01.] Jamal SM, Shrive FM, Ghali WA, Knudtson ML, Eisenberg MJ; Canadian Cardiovascular Outcomes Research Team (CCORT). [PMID12813611] ] and of coronary artery bypass surgery from 3.5% to 2.0% [ [http://www.ncbi.nlm.nih.gov/sites/entrez?Db=PubMed&Cmd=ShowDetailView&TermToSearch=12813610 Can J Cardiol. 2003 Jun;19(7):774-81. Outcomes after coronary artery bypass graft surgery in Canada: 1992/93 to 2000/01.] Ghali WA, Quan H, Shrive FM, Hirsch GM; Canadian Cardiovascular Outcomes Research Team. [PMID12813610] ]

Cancer

Numerous studies have attempted to compare the rates of cancer incidence and mortality in Canada and the U.S., with varying results. Doctors who study cancer epidemiology warn that the diagnosis of cancer is subjective, and the "reported" incidence of a cancer will rise if screening is more aggressive, even if the "real" cancer incidence is the same. Statistics from different sources may not be compatible if they were collected in different ways. The proper interpretation of cancer statistics has been an important issue for many years. [Dickman P. W., Adami H.-O., Interpreting trends in cancer patient survival, J. Int. Med. 2006; 260; 103-117.] Dr. Barry Kramer of the National Institutes of Health points to the fact that cancer incidence rose sharply over the past few decades as screening became more common. He attributes the rise to increased detection of benign early stage cancers that pose little risk of metastasizing. [ [http://www.nytimes.com/2007/07/10/health/10skin.html Doctors Balk at Cancer Ad, Citing Lack of Evidence] By CHRISTIE ASCHWANDEN, New York Times, July 10, 2007] Furthermore, though patients who were treated for these benign cancers were at little risk, they often have trouble finding health insurance after the fact.

Cancer survival time increases with later years of diagnosis, because cancer treatment improves, so cancer survival statistics can only be compared for cohorts in the same diagnosis year. For example, as doctors in British Columbia adopted new treatments, survival time for patients with metastatic breast cancer increased from 438 days for those diagnosed in 1991-1992, to 667 days for those diagnosed in 1999-2001. [ [http://www3.interscience.wiley.com/cgi-bin/abstract/114295142/ABSTRACT The impact of new chemotherapeutic and hormone agents on survival in a population-based cohort of women with metastatic breast cancer,] Stephen K. Chia, et al., Cancer, Published Online: 23 Jul 2007, DOI 10.1002/cncr.22867]

An assessment by Health Canada found that cancer mortality rates are almost identical in the two countries. ["Progress Report on Cancer Control in Canada." "Centre for Chronic Disease Prevention and Control", 2004 pg. 11] Another international comparison by the National Cancer Institute of Canada indicated that incidence rates for most, but not all, cancers were higher in the U.S. than in Canada during the period studied (1993-1997). Incidence rates for certain types, such as colorectal and stomach cancer, were actually higher in Canada than in the U.S. [cite web |url=http://www.ncic.cancer.ca/ncic/internet/standard/0,3621,84658243_85787780_379601028_langId-en,00.html |title=International variation in cancer incidence |accessdate=2007-07-02 |format= |work=National Cancer Institute of Canada ] In 2004, researchers published a study comparing health outcomes in the Anglo countries. Their analysis indicates that Canada has greater survival rates for both colorectal cancer and childhood leukemia, while the United States has greater survival rates for Non-Hodgkin's lymphoma as well as breast and cervical cancer. [Health Affairs, 23, no. 3 (2004): 89-99Quality: How Does The Quality Of Care Compare In Five Countries? PMID 15160806]

A study based on data from 1993 through 1997 found lower cancer survival rates among Canadians than among Americans. [Chen VW, Howe HL, Wu XC, Hotes JL, Correa CN (eds). Cancer in North America, 1993-1997. Volume Two: Mortality. Springfield, IL: North American Association of Central Cancer Registries, April 2000] However, an earlier study based on data from 1978 through 1986 found very similar survival rates in both countries. [cite journal | last = Keller | first = D M | coauthors = E A Peterson, G Silberman | year = 1997 | month = July | title = Survival rates for four forms of cancer in the United States and Ontario | journal = Am J Public Health | volume = 87 | issue = 7 | pages = 1164–1167 | publisher = | location = | issn = | pmid = 9240107 | doi = | url = | format = | accessdate = | quote = ] A few comparative studies have found that cancer survival rates vary more widely among different populations in the U.S. than they do in Canada. Mackillop and colleagues compared cancer survival rates in Ontario and the U.S. They found that cancer survival was more strongly correlated with socio-economic class in the U.S. than in Ontario. Furthermore, they found that the American survival advantage in the four highest quintiles was statistically significant. They strongly suspected that the difference due to prostate cancer was a result of greater detection of asymptomatic cases in the U.S. Their data indicates that neglecting the prostate cancer data reduces the American advantage in the four highest quintiles and gives Canada a statistically significant advantage in the lowest quintile. Similarly, they believe differences in screening mammography may explain part of the American advantage in breast cancer. Exclusion of breast and prostate cancer data results in very similar survival rates for both countries. [ Boyd C., Zhang-Salomons J. Y., Groome P. A., Mackillop W. J., Associations between community income and cancer survival in Ontario, Canada, and the United States, J. Clin. Oncol., vol. 17, no 7 (July), 1999; 2244-2255.]

Hsing et al. found that prostate cancer mortality-incidence rate ratios were lower among U.S. whites than among any of the nationalities included in their study, including Canadians. U.S. blacks in the study had lower rates than any group except for Canadians and U.S. whites. [Hsing A. W., Tsao L., Devesa S. S., International trends and patterns of prostate cancer incidence and mortality, Int. J. Cancer, 85, 60-67, (2000).] Echoing the concerns of Dr. Kramer and Professor Mackillop, Hsing later wrote that reported prostate cancer incidence depends on screening. Among whites in the U.S., the death rate for prostate cancer remained constant, even though the incidence increased, so the additional reported prostate cancers did not represent an increase in real prostate cancers, said Hsing. Similarly, the death rates from prostate cancer in the U.S. increased during the 1980s and peaked in early 1990. This is at least partially due to "attribution bias" on death certificates, where doctors are more likely to ascribe a death to prostate cancer than to other diseases that affected the patient, because of greater awareness of prostate cancer or other reasons. [ [http://epirev.oxfordjournals.org/cgi/reprint/23/1/3.pdf Trends and Patterns of Prostate Cancer: What Do They Suggest?] Epidemiologic Reviews, 23(1):3 (2001), Ann W. Hsing and Susan S. Devesa]

Below are the figures for number of cancers diagnosed per 100,000 persons and number of deaths attributed to cancer per 100,000 persons in 2003. Because health status is "considerably affected" by socioeconomic and demographic characteristics, such as level of education and income, "the value of comparisons in isolating the impact of the health care system on outcomes is limited," according to health care analysts. [ [http://jama.ama-assn.org/cgi/content/full/292/10/1213 Consumer-Driven Health Care: Lessons From Switzerland, Herzlinger and Parsa-Parsi, JAMA.2004; 292: 1213-1220.] ] Experts say that the incidence and mortality rates of cancer cannot be combined to calculate survival from cancer. [Mooney, B.C. [http://www.boston.com/news/nation/articles/2007/11/03/giulianis_healthcare_figure_outdated Giuliani's healthcare figure outdated; He says system in US superior to that in Britain.] "Boston Globe" November 3, 2007.] Nevertheless, researchers have used the ratio of mortality to incidence rates as one measure of the effectiveness of health care. [ [http://www.nber.org/papers/w13429 O'Neill, J. O'Neill, D. M. "Health Status, Health Care and Inequality: Canada vs. the U.S.," National Bureau of Economic Research, NBER Working Paper 13429, September 2007.] ] Data for both studies was collected from registries that are members of the North American Association of Central Cancer Registries, an organization dedicated to developing and promoting uniform data standards for cancer registration in North America. [ [http://www.naaccr.org North American Association of Central Cancer Registries] ]

Females

Males

Sources: [http://www.cdc.gov/uscs U.S. Cancer Statistics Working Group] and [http://129.33.170.32/vgn/images/portal/cit_86751114/36/15/1816216925cw_2007stats_en.pdf Canadian Cancer Society]

Racial and ethnic differences

The U.S. and Canada differ substantially in their demographics, and these differences may contribute to differences in health outcomes between the two nations.Singh, G. K., Yu, S. M., Infant Mortality in the United States: Trends, Differentials, and Projections, 1950 through 2010. Am. J. Public Health. 1995; 85; 957-964.] Although both countries have white majorities, the United States has a significantly larger minority population. Furthermore, the relative size of different ethnic and racial groups vary widely in each country. Hispanics and peoples of African descent constitute a much larger proportion of the American population. Aboriginal peoples constitute a much larger proportion of the Canadian population. Canada also has a relatively larger East Asian population. Also, the proportion of each population that is native born vs. immigrant is often different in each nation.

A study comparing aboriginal mortality rates in Canada, the U.S. and New Zealand found that aboriginals in all three countries had greater mortality rates and shorter life expectancies than the white majorities. [ Travato, F. Aboriginal Mortality in Canada, The United States and New Zealand. J. Biosoc. Sci. (2001), 33, 67-86.] That study also found that aboriginals in Canada had both shorter life expectancies and greater infant mortality rates than aboriginals in the United States and New Zealand. The health outcome differences between aboriginals and whites in Canada was also larger than in the United States.

Though relatively few studies have been published concerning the health of Black Canadians, health disparities between whites and blacks in the U.S. have received intense scrutiny. [Collins, C.A., Williams, D.R., Segregation and Mortality: The Deadly Effects of Racism? Sociological Forum, 14, 3, 1999 ] Blacks in the U.S. have significantly greater rates of cancer incidence and mortality. Drs. Singh and Yu found that neonatal and postnatal mortality rates for Americans blacks are more than double the non-Hispanic white rate. This difference persisted even after controlling for household income and was actually greatest in the highest income quintile. A Canadian study also found differences in neonatal mortality between different racial and ethnic groups. [Claydon, J.E., Mitton,, C., Sankaran, K., Lee, S. K., Canadian Neonatal Network, Ethnic Differences in Risk Factors for Neonatal Morality and Morbidity in the Neonatal Intensive Care Unit, J. Perin., 2007, 27, 448-452.] Although Canadians of African descent had a greater mortality rate than whites in that study, the rate was somewhat less than double the white rate.

The racially heterogeneous Hispanic population in the U.S. has also been the subject of several studies. Although members of this group are significantly more likely to live in poverty than are non-Hispanic whites, they often have disease rates that are comparable to or better than the non-Hispanic white majority. Hispanics have lower cancer incidence and mortality, lower infant mortality, and lower rates of neural tube defects. [ [http://www.cdc.gov/uscs U.S. Cancer Statistics Working Group] ] [Fetchbaum, L. B., Currier, R. J., Riggle, S., Roberson, M., Lorey, F. W., Cunningham, G. C., Neural Tube Defect Prevalence in California (1990-1994): Eliciting Patterns by Type of Defect and Maternal Race/Ethnicity, Genetic Testing, 3, 3, 1999.] Singh and Yu found that infant mortality among Hispanic sub-groups varied with the racial composition of that group. The mostly white Cuban population had a neonatal mortality rate (NMR) nearly identical to that found in non-Hispanic whites and a postnatal mortality rate (PMR) that was somewhat lower. The largely Mestizo, Mexican, Central, and South American Hispanic populations had somewhat lower NMR and PMR. Puerto Ricans who often have a mix of white and African ancestry had higher NMR and PMR rates.

Impact on economy

In 2002, automotive companies claimed that the universal health care system in Canada saved labour costs. [ [http://www.house.gov/mcdermott/sp051215a.shtml U.S. Auto Industry Supports Universial Healthcare... in Canada.] House of Representatives - December 15, 2005.] In 2004, health care cost General Motors $5.8 billion, and increased to $7 billion. [Garsten, E. [http://www.detnews.com/2005/autosinsider/0502/10/A01-85815.htm GM: Repair health care. CEO urges U.S. to help ease skyrocketing tab: Automaker lobbies up to 16 states to cut costs.] "The Detroit News", February 10, 2005.] The UAW also claimed that the resulting escalating health care premiums reduced workers' bargaining powers. [ [http://www.uaw.org/barg/03/barg04.cfm UAW 2003 Bargaining for America.] ] While such arguments certainly demonstrate that employer provided insurance impacts corporate bottom lines more than health insurance that is socialized and thus does not appear on the balance sheet, tracing out the net effect is more difficult.

Flexibility

In Canada, increasing demands for health care, due to the aging population, must be met by either increasing taxes or reducing other government programs. In the United States, under the current system, more of the burden for health care will be taken up by the private sector and individuals.

Canada's multi-billion dollar budget surpluses, however, have allowed a significant injection of new funding to the healthcare system, with the stated goal of reducing waiting times for treatment.Fact|date=November 2007

One historical problem with the U.S. system was known as job lock, in which people become tied to their jobs for fear of losing their health insurance. This reduces the flexibility of the labor market. [Blomqvist, Åke. [http://www.cdhowe.org/pdf/benefactors_lecture_2002.pdf Canadian Health Care in a Global Context: Diagnoses and Prescriptions] . Toronto: C.D. Howe Institute, 2002. pg. 17 ] Federal legislation passed since the mid-1980s, particularly COBRA and HIPAA, has been aimed at reducing job lock.

Politics of health

In Canada, the right-wing and now defunct Reform Party and its successor, the Conservative Party of Canada considered increasing the role of the private sector in the Canadian health care system. Public backlash caused these plans to be abandoned, and the current minority Conservative government has re-affirmed its commitment to universal public medicine.

In the US, President Bill Clinton attempted a significant restructuring of health care, but the effort collapsed under public pressure against it. The 2000 U.S. election saw prescription drugs become a central issue, although the system did not fundamentally change. In the 2004 U.S. election health care proved to be an important issue to some voters, though not a primary one.

More radical solutions in both countries have come from the sub-national level. In 2006, Massachusetts adopted a plan that intends to vastly reduce the number of uninsured. It requires everyone to buy insurance and subsidizes insurance costs for lower income people on a sliding scale. In Canada, it is oil-rich Alberta under the conservative government of Ralph Klein that is seen to experiment most with increasing the role of the private sector in health care. Measures have included the introduction of private clinics that are allowed to bill patients for some of the cost of a procedure. After the 2005 Supreme Court of Canada ruling that the Quebec government cannot prevent people from paying for private insurance for healthcare procedures covered under medicare, private healthcare in Quebec began to grow rapidly. Quebec now has the highest number of private clinics delivering publicly funded care as well as whole hospitals and emergency wards that have opted out of the public system.Fact|date=August 2007

Private care

The Canada Health Act of 1984 "does not directly bar private delivery or private insurance for publicly insured services," but provides financial disincentives for doing so. "Although there are laws prohibiting or curtailing private health care in some provinces, they can be changed," according to a report in the New England Journal of Medicine. [ [http://content.nejm.org/cgi/content/full/354/16/1661 Private Health Care in Canada, Robert Steinbrook, N Engl J Med, 354:1661-1664, April 20, 2006] ] Governments attempt to control health care costs by being the sole purchasers and thus they do not allow private patients to bid up prices. Fact|date=January 2008 Those with non-emergency illnesses such as cancer cannot pay out of pocket for time-sensitive surgeries and must wait their turn on waiting lists. According to the Canadian Supreme Court in its 2005 ruling in " Chaoulli v. Quebec", waiting list delays "increase the patient’s risk of mortality or the risk that his or her injuries will become irreparable." [ [http://scc.lexum.umontreal.ca/en/2005/2005scc35/2005scc35.html Chaoulli v. Quebec (Attorney General), (2005). S.C.R. 791, 2005 SCC 35] ] The ruling found that a Quebec provincial ban on private health insurance was unlawful, because it was contrary to Quebec's own legislative act, the 1975 Charter of Human Rights and Freedoms.cite news |first=Clifford |last=Kraus |title=As Canada's Slow-Motion Public Health System Falters, Private Medical Care Is Surging. |url=http://www.nytimes.com/2006/02/26/international/americas/26canada.html?ex=1184644800&en=44cca772dc339429&ei=5070 |work= |publisher=New York Times |date=2006-02-26 |accessdate=2007-07-16] [Chaoulli, J. [http://www.cato.org/pub_display.php?pub_id=6378 A Seismic Shift: How Canada's Supreme Court Sparked a Patients' Rights Revolution.] Cato Institute. Policy Analysis no. 568. May 8, 2006.]

Consumer driven health care

Republicans in the U.S. have recently enacted laws to promote consumer driven health care. By that they mean Health Savings Accounts (HSAs), which were created by the Medicare bill signed by President Bush on December 8, 2003. HSAs are designed to provide tax incentives for individuals to save for future qualified medical and retiree health expenses; the money placed in such accounts is tax-free. To qualify for these tax-deferred accounts, individuals must carry a High Deductible Health Plan (HDHP). The higher deductible shifts some of the financial responsibility for health care from insurance providers to the individual consumer. This shift towards a market-based system with greater individual responsibility may increase the differences between the U.S. and Canadian systems. Some economists who have studied various proposals for universal health care are concerned that the main effect of the consumer driven healthcare movement will be to reduce the social redistributive effects of insurance that pools high-risk and low-risk people together. [Citation| last=Gladwell| first=Malcolm | author-link=Malcolm Gladwell | year=2005 |date=2005-08-29 | title=The Moral Hazard Myth | periodical=The New Yorker | url=http://www.gladwell.com/2005/2005_08_29_a_hazard.html | accessdate=2007-06-28]

ee also

*Health care in Canada
*Health care in the United States
*Universal health care

References


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