Child Health in Canada

These data, coupled with the description of what is really an elegantly simple system of health services, provide a compelling argument for legislators to consider seriously some form of national health insurance for the US. This seems to be the conclusion of many Americans based on recent polls. Other arguments in support of comprehensive health insurance, at least for children, have been heard from some unusual quarters. Many of those advocating reconsideration of this issue, apart from some politicians, include economists, some branches of `organized medicine,' and even business (The Financial Post. November 3, 1989). For example, Lee Iacocca has written: "We've had a war on health care costs in this country for over 10 years, and we've lost it. Those costs have gone up year after year at almost double the rate of inflation, and they now account for about $550 billion a year or over 11% of our GNP." (Inside Guide. 1989:25) He goes on to call attention to the fact that the per capita health bill in the US is 41% higher than Canada's, 61% higher than Sweden's, 85% higher than France's, 131% more than Japan's, and 171% above Great Britain. As Iaccoca points out, if it was the case that the US was getting more for its investment than the others, the higher prices would make sense. But, he adds, "There is little such evidence. Life expectancy in the US is no better than the rest of the Western world, and infant mortality rates are one of the worst. There are nearly 40 million people without any health insurance coverage." He notes that an appendectomy or hysterectomy costs 3.5 times as much in California as in Ontario, and the ratio of costs is 5 times greater for a coronary artery bypass, and 7 times greater for an electrocardiogram. Iacocca's concern arises in large part because American business pays a large part of the costs of what he views as an `overpriced system.' Those costs go directly into the price of goods, and this amounts to an export tax when those goods are sold abroad. He estimates that over $700 of the cost of producing a car in the US goes to pay for health care for employees, compared with $223 in Canada. Between 1978 and 1980, General Motors reportedly spent three times as much on health insurance as it did on the steel used to manufacture its cars! Apart from these hard core economic issues, other differences are more subtle. Once concerns about paying for conventional medical care are set aside, serious consideration can be given to broader questions related to health and health care. In Canada there now appears to be a rapidly growing acceptance of the view that the main factors responsible for the health of populations are clean water, good food, education, employment, housing and, perhaps, good genes. This view has been articulated by the Population Health Group of the Canadian Institute for Advanced Research. Nonetheless, the view that equitable access to medical care is essential to the integrity of a fair and just society remains firmly entrenched. As a consequence Canadians maintain a firm desire to accept even the high costs associated with elaborate hospital care and physician services to be confident that they will continue to be free for all. Many have observed that the major improvements in the health of most Western societies during the last 200 years predated advances in medical diagnosis and therapy by many years. Accordingly, some experts are convinced that the main determinants of health lie beyond traditional medical care. They note that the persistent discrepancies in the health status of different sectors of the population, particularly those divided by income or social class, may reflect complex social and environmental phenomena. Those in higher social class groups may have been quicker to adopt better lifestyles with respect to matters like smoking and diet. Similarly, social relationships, the control one has over one's own life, security of employment, and a sense of self-worth, all appear to be strongly related to health in the aggregate From this perspective it might appear that the arguments of critics of health insurance have some merit. The opponents suggest that it is not the absence of insurance per se that accounts for the embarrassing differences in health statistics when children in the US are compared with those in other nations, but rather differences in population composition. The argument is made that the American population has more poor, more blacks, and generally more heterogeneity than those of countries being compared. Even if that were true (although each point is debatable, and it seems a strange argument coming from what many consider to be one of the richest nations in the world), even if conceded, it seems to make the case for health insurance all the more compelling. This is so because there can be no doubt that one main effect of such insurance is to narrow the gap in access to and the use of services between the rich and the poor. Hence the more poor a nation has, the stronger the case for health insurance. Successive ministers of Health and Welfare in Canada, beginning with Lalonde in 1974 to Epp in 1987, have emphasized the importance of environment and lifestyle, as opposed to physicians and hospitals in obtaining further improvements in the health of Canadians. A cynic might suggest that these calls are motivated largely by the pressure to control spiralling health care costs, but the evidence appears to suggest that regardless of motive, they are on the right track. Contrary to views propagated in the US during the Reagan era, there is no evidence from Canada's experience that deregulation and competition either improves the public's health or reduces costs. In fact, the Canadian example suggests just the opposite, that the more care is made free to the patient at the time of receipt of service, and the more the system is planned and regulated by the state in the public interest, the better is the quality of service, the better the health of the people, and the less it costs. Despite the evidence, spokespersons for "the loyal opposition" persist: "Universal health insurance is not a good idea. . . [it] would fly in the face of the American way of doing things. . . .The United States is unique, and our pluralistic approach is unique. There is no reason to think that an imported system would be successful here or that American citizens would accept its implicit restrictions. . . . Other countries ignore appropriateness and effectiveness; they ignore the many complex elements of high-quality care that we in America demand; and they largely ignore the citizen's right to free choice, a concept we hold very dear." That dissenting opinion, written, perhaps not surprisingly by James S. Todd, of the American Medical Association, is certainly not one shared by most Canadians. It would seem that many Americans would gladly change places with their Canadian cousins or those of any of the other nations who long ago accepted that universal health insurance is a requisite for national self-respect.