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Universal Health Care:

What the United States Can Learn from the Canadian Experience

1998, The New Press, NY (distributed by W W Norton & Company, NY)
by Pat and Hugh Armstrong with Claudia Fegan, M.D.

Reviewed by Art Myatt

This slim volume (176 pages) delivers what its subtitle promises with an easy-to-read narrative. The issue of health care insurance is unavoidably a complex one, tied up as it is with history, politics, economics, ideologies, and values. The inevitable development of science and technology affecting the possibilities and costs of health care means that the issues will never be finally and absolutely settled. However, there are some principles and general rules that last. All the essential elements are addressed in a plain-spoken and straightforward manner in this book.

The authors believe that a single-payer system of universal coverage like Canada's is distinctly preferable to the mix of private, corporate, government and charitable health care found in the United States. They have come to this conclusion partly through their own experiences - incidents of the authors' family medical history on occasion have been used as illustration of a point in the text - and partly by comparative study of how the systems work on both sides of the border. Their approach is not strident or ideological. The tone of the book is one of reasoned explanation.

There are some statistical and economic tables in the book, twelve tables in all. These have been kept as simple as possible, but are detailed enough to allow the reader to see how the countries match up in terms of where the money comes from, how it is spent, and who benefits. References are given so the reader can check the original sources and find more detailed statistics if that is desired. The statistical approach has been kept to a minimum.

In principle, Canadian law requires that "core medical services be universal, portable, accessible, comprehensive, and publicly administered." (page 2) The book describes the introduction of universal hospital insurance in Saskatchewan in 1947, the federal Hospital Insurance Act of 1957 (only 6 pages long!), the Medical Care Act of 1966 (8 pages) and other significant legal steps. However, the book is not about the political history so much as it is about how the system works and how it compares to medical care and coverage in the United States.

There is no good and generally accepted method to compare the quality of care from one institution to another. Methods to measure this kind of quality are just now being developed and tried, and they are certain to be controversial for some time to come. Measured by outcome (infant and maternal mortality, life expectancy, survival rates for major illness), the Canadian system is approximately equal to the one in the States, and maybe slightly better. (page 79) In the US, there is more high-tech medical equipment per population and there are more specialist doctors; in Canada, more nurses are available, and equivalent patients will get more hours of nursing care and probably more time in the hospital (pp. 36-38). On average, Canadians are far more satisfied with their medical coverage (page 1) and they have a slightly better life expectancy. Most importantly, in Canada everyone is covered. In the US, there are more than 41 million uninsured people (preface).

On cost, the Canadians win, hands down. In 1995, the total cost of health care was $2,049 per Canadian citizen, compared to $3,701 in the US. (page 104) Remember, this is for approximately equal results. In the debates over health care in the United States, there is often an assumption that for-profit, competitive health insurance will necessarily be cheaper, less bureaucratic, and more effective than any possible government program. The evidence indicates this assumption is false. This evidence, both statistical and anecdotal, is well-covered in this book. Anybody who is sincere about reducing or controlling the costs of health care would have to give the Canadian approach some serious consideration.

There is no pretense that the Canadian system is a perfect one. The final chapter of the book deals explicitly with some of the flaws evident in it and some recent developments that seem to be moving away from the principles stated in the initial laws. The book has no political advice for US citizens on how to organize to get universal health care. It certainly has no partisan position , and in fact does not mention US political parties. It does show that universal health insurance, both cheaper and more humane than the US practice, is a reality north of the border and therefore is possible to the south of Canada.

It is not common to find writing on a hot political issue that is reasonable rather than argumentative, with conclusions that are based on facts and experience, not ideology. This book is a useful resource for anyone who is actually trying to make American health care better for American patients and doctors. It speaks in opposition to the rhetoric generated by those who are merely trying to make it more profitable for hospitals, HMOs, and insurance companies.

This review also appears on the Amazon.com web site.