Correspondence
Health Care in Canada
N Engl J Med 1990; 322:1674-1675June 7, 1990
- Article
To the Editor:
Iglehart's Health Policy Report in the December 21 issue1 was basically accurate from the viewpoint of a physician who has practiced in both the United States and Canada. There is, however, an error in the second paragraph, which states that physicians' incomes "make them the highest earners among professional groups in Canada." This is not correct. Data published annually2 by the Canadian federal government indicate that since 1970, the top earners have been lawyers, dentists, and accountants.
2 ReferencesHugh R. Brodie, M.D.
600 Lansdowne Ave., Montreal, PQ H3Y 2V8, Canada1
Iglehart
Full Text | Web of Science | Medline2
Statistics Canada. Ottawa, Ont.: Queen's Printer.
To the Editor:
Iglehart's recent treatise on Canadian health care was a well-documented, objective, and convincing counterargument to Canadians who look to the various American nonsystems of care for inspiration. I would quibble with one word. In discussing differences between Canadian and American society, Iglehart describes the Canadian parliamentary system as representing a more "authoritative" form of government than its U.S. counterpart. In my dictionary this word is defined as "possessing or proceeding from proper authority" or "duly sanctioned." Even the most acerbic critics would hardly characterize successive American governments as not proceeding from legitimate authority, at least as much as their Canadian counterparts.
I believe that the more appropriate word would have been "authoritarian," defined as "favouring subjection to authority as opposed to individual freedom." Although most Canadians clearly value and protect their political rights almost as much as our American neighbors do theirs, we do allow and encourage government to involve itself appropriately in certain spheres — the provision of universal, publicly funded and administered health care being one of them.
A. Mark Clarfield, M.D.
Sir Mortimer B. Davis—Jewish General Hospital, Montreal, PQ H3T 1E2, CanadaTo the Editor:
The Health Policy Report by Iglehart summarizes many articles in American journals by authors who cast longing looks at Canada's health care system. I am astounded that these articles all overlook two fundamental differences in our systems that make it very difficult to compare them.
The first regards the cost of health care. It is true that the observed health care costs are 20 to 40 percent lower in Canada as a percentage of the gross domestic product. But the cost of the American system also includes the horrendous costs of litigation. It is not uncommon for American specialists to pay $50,000 to $150,000 a year for malpractice insurance. That is equal to the gross cash flow in my practice. All of this is built into the cost of the American health system, but it does not really represent the cost of health care. Without the expenses related to malpractice litigation, the cost of medical care in the United States would probably drop below that in Canada.
The second difference is that Canada's medical manpower is very homogeneous, whereas that of the United States is very heterogeneous. A Canadian specialist is someone who has satisfied all the training requirements of the Royal College of Canada and has successfully passed all of its examinations. No one else is allowed to use the word "specialist" in advertising. An American specialist may be anyone from the most highly trained specialist who has passed numerous examinations to the self-declared "board-eligible" specialist. In addition, U.S. health care includes hoards of fringe practitioners, ranging all the way from osteopaths to herbalists. Whose services should the American government insure?
I am in favor of some form of universal medical coverage, and I wish America luck in setting it up. The U.S. government will not find it as easy as the Canadian government did.
Arnold Voth, M.D., L.M.C.C., F.R.C.P.(C.)
231B 10106–111 Ave., Edmonton, AB T5G 0B4, CanadaThe above letters were referred to Mr. Iglehart, who offers the following reply:
To the Editor: I do not know to what data Dr. Brodie is making reference, but I believe his assertion is incorrect. The data in Table 1 were obtained from L.W. Rehmer, director of the Health Information Division of Health and Welfare Canada. These data document the point that Brodie disputes — that Canada's physicians have been and remain the country's highest-paid professionals.
Dr. Clarfield's point is well taken. I would only add that although Americans have almost always been more skeptical than Canadians of a strong central government, the degree to which that is true may be even greater today than in previous periods when it comes to the issue of financing medical care. Ever since President Carter's failed efforts in the late 1970s to enact hospital cost-containment legislation that would have applied to both private and public third-party payers, the policies of the Reagan and Bush administrations in relation to government's ongoing concerns about rising costs have addressed only the public programs that finance medical care —Medicare and Medicaid. Of course, there have been indirect and rather substantial effects on private insurers and employers of the cost shifting that has occurred as rates of Medicare and Medicaid payment are squeezed and providers are forced to recoup their expenses from other sources of payment. These policies represent a contraction of what the federal government views as its responsibility, as compared with the policies of previous Republican presidents Ford and Nixon, who sponsored approaches that called for covering most Americans. The current posture of President Bush in this regard could complicate the already difficult challenge the United States faces in crafting a policy to provide millions of uninsured Americans with access to medical care.
Dr. Voth is right on both counts: the costs of professional-liability insurance are indeed far higher in the United States than in Canada, and the population of physicians in the United States is weighted far more heavily to medical specialists and subspecialists. Indeed, Canada could do, if anything, with more specialists and perhaps fewer family physicians in the larger cities, where the market for their services seems in many cases to be saturated.
John K. Iglehart
12008 River Rd., Potomac, MD 20854- Letters
