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United States vs. Canadian Healthcare Notes on a presentation by Dr. Laura Chalfin & John Heinegg Healthcare Work Group November 20, 2006 Dr. Laura Chalfin and nurse John Heinegg spoke to an open meeting of the Coalition for Democracy of Central New York Healthcare Committee on Monday evening, November 20, 2006, at the First United Methodist Church in Oneonta. They spoke about their experiences practicing medicine for the past year or so on Hornby Island in British Columbia, Canada -- and compared this experience to their private practice in Delhi in Delaware County, New York, for the previous 15 years. About 35 people attended from around Delaware and Otsego Counties. The clinic on Hornby Island serves a permanent population of 900 and a summer population of 6000. They started their talk by showing a PowerPoint slide show of the beautiful scenery on the island, which was clearly part of the reason that they moved. Dr. Chalfin receives a $24,000 premium from British Columbia for practicing in an area that would otherwise be underserved by healthcare practitioners. In Delhi, where she was in private practice, there were no such incentives -- although our area is underserved. She explained that British Columbia pays a premium to doctors who practice a long distance from a hospital or where there are fewer than four doctors in the area. She pointed out how that was the effective opposite of her experience of practicing in Delhi (where as a rural doctor she was paid less). After nine months of practice, Dr. Chalfin also began receiving a retention incentive and some funds for continuing education -- and she gets some money back on her malpractice insurance. In the US she was paid by ailment using complicated rate codes which varied by insurer. But in Canada she is paid per person regardless of the number of ailments. In Delhi she paid $8,000 a year for malpractice. She now pays $1200 a year but doesn't do obstetrics. In Delhi she had a private practice and worked full-time. On Hornby Island she is on call 24 hours a day seven days a week but works in shifts of three weeks on and three weeks off. The second doctor works the alternating shift. She earns roughly twice what she earned in the similarly rural community of Delhi. Unlike in Delhi, there is no hospital on Hornby Island. In an emergency, volunteer first responders, like John Heinegg, take patients by helicopter for a one-hour flight to a hospital on the mainland. In non-life-threatening situations the 911 system organizes a special ferry ride to the mainland. Dr. Chalfin seemed most passionate about Canada's universal health insurance system. She pulled out her "Care Card" and showed it to the audience. Every Canadian has one and it entitles each to doctor and hospital care. Canadians get the card at birth and new residents fill out a one-page form to apply for one after residing in Canada for three months. In British Columbia (which is currently led by a conservative premier), the card also covers physical therapy, optometry, and podiatry. Medicines are provided free to those who can't afford them, but most people pay for medications. Dr. Chalfin claimed that medicines in Canada generally cost far less than in the United States. Each province in Canada has its citizens pay a monthly medical insurance fee. In British Columbia the highest bracket premium is $96 per month for an individual (like herself). There are no co-pays or deductibles for doctor visits. She thought that a family with one child paid $106 per month. The Care Card is recognized in all provinces. The federal government pays half and each province pays half the cost of healthcare. There is far less bureaucracy and it costs far less to administer the health system per capita than in the United States. According to John Heinegg, in 1999 the U.S. spent 14% of GDP on health care and Canada spent 9%. Now the US spends 16% of GDP. In her Delhi practice, Dr. Chalfin paid three full-time workers and a billing service to handle the ever-changing sets of requirements from a multitude of insurance companies. On Hornby Island one person works for her. She mentioned that just one network of insurance companies in the United States, Blue Cross Blue Shield, has 2.5 million employees -- more than all employees for the Canadian health care system. Dr. Chalfin said that Canada spent 1.5% on administrative overhead expenses. Though very enthusiastic about how much better the Canadian health care system was than the American one, she acknowledged some problems. She explained that because the Canadian system was publicly owned they were able to address the problems and were trying to do so. The largest problem was long waiting times, primarily for elective surgery. As a doctor, she said she can juggle waiting times and in fact can get some things done faster than in Delhi. As an example she explained that in Delhi she had been on the Board of MVP, where they had discussed a bone marrow transplant for months -- something that would be acted on much faster in Canada. But some things, like hip replacements, take longer in Canada. Another example of how a public system is able to address shortcomings more effectively than a private system, said Dr. Chalfin, is how Canada addresses the problem of doctor shortages in rural areas. In addition to the incentive pay (which a private system wouldn't provide), British Columbia also decided to start putting more money into training family doctors -- so there would be a larger supply of people to work in underserved areas. Dental care is not covered by the Canadian system. But Dr. Chalfin noted that the Norwegian system not only covers dental care, but sends out friendly reminders every six months to remind people to come in for preventive care. She said there were doctors in private practice in Canada, though she didn't favor a two-tier system. Almost all doctors are paid primarily by the government health insurance system. Dr. Chalfin said Canada does not have enough expensive MRI machines. The Québec system is particularly underfunded, and so many people are leaving it. Quebec and British Columbia do not have reciprocity. She was asked if she knew of doctors who had moved to the United States for better pay. Chalfin told the story of a doctor she knew who did move to the US, but was so disgusted with the insurance system here that he moved back to Canada to practice. She also challenged the concept that doctors weren't paid enough in Canada, saying that a full-time doctor earns roughly $200,000 per year. An OB/Gyn earns $400,000 + per year in Canada. Rolling her eyes, she said that was more than enough. The medical associations negotiate with the provincial health care system over payment. In general the unions are much stronger in Canada than in the United States -- and that goes for doctors as well, who have struck in the past over reimbursement rates. When asked if Canadians abused their system by using it too much and wasting her time, she said no. There are very few people wandering in for social visits. But Dr. Chalfin said she does have more face-to-face time in Canada than she had in Delhi, and that allowed her not only to be more thorough but to do preventive care. She noted that Canadians can go in directly for a mammogram without having to first get a referral from a primary care physician. Chalfin's experience in Delhi was that patients tended to come in with a saved up list of ailments so they could save on their copayments. But in Canada, patients come in when they need to and thus can be treated before problems get out of hand and become more expensive. In Canada, people have more freedom than in the United States, because they aren't stuck in an unpleasant job simply because it offers health insurance. The Canadian system started in 1948 but went into full effect as it now exists in 1969. Canadians feel that healthcare is their right. John Heinegg said the Canadians view government differently than Americans. They see government as an expression of the community's will. Their health care system has three components: the government, the doctors, and people. The government exists to serve the people.
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