Why Canadian medicare should neither ‘go Dutch’ or ‘to the dogs’

Canada’s health care system faced some provocative comparisons recently.

First was Sarah Boston’s new book, Lucky Dog, in which she details her personal experience with thyroid cancer and navigating the Canadian health system. Boston, a veterinary oncologist, claims that Canadian dogs often have better access to health care than their human counterparts.

The next round of comparisons came from the Commonwealth Fund’s annual report analyzing 11 national health care systems. In line with their previous rankings, Canada appears to have underperformed, and the Netherlands comes out on top. This report cued the oft-repeated calls for Canada to embrace the free-market reforms that the Dutch and other European healthy systems have undertaken.

So should Canadian health care go Dutch or to the dogs? Neither.

Here’s the problem with Boston’s veterinary comparison and those who would convince us that private, for-profit care is the answer to all that ails medicare: All dogs may go to heaven, but they certainly don’t all see the vet first. Veterinary care may be high quality and quickly accessed by those who can afford it, but it’s far from universal. In interviews, Boston acknowledges that she has witnessed clients re-mortgaging their houses to pay for their dogs’ cancer treatments.

When care gets too difficult or expensive for a cat or dog, many pet owners are faced with the option of having the animal put down. In Canada, we are fortunate that our universal health insurance means people don’t have to make choices between their homes or livelihoods and their lives.

While the problems with comparing Canadian health care to veterinary services are rather apparent, understanding why we cannot simply copy and paste a European health care system requires more careful consideration. Health care systems don’t exist in a vacuum: their structures, funding models, and usages are all informed by the nation they serve and other policies these countries adopt.

European countries that spend more money on social programs such as affordable housing, education, and senior care consistently have better health outcomes than countries that are slashing these budgets. Why? Research estimates that access to health care accounts for only 25% of health outcomes: the rest is largely determined by income, employment, education, housing, food security and other social and economic factors.

We can’t talk about the success of national health care systems, in other words, without first considering the social programs that also influence health.

In any case, it’s not all a bed of roses in Europe where health care is concerned. Market reforms in recent years have driven up costs in several European countries. Switzerland, Germany, and the Netherlands all outspend Canada on health care costs per capita. A lack of price controls for services in Switzerland means that an abdominal CT scan that would cost $97 in Canada costs, on average, $432 there. Since the Dutch government implemented market reforms in 2006, there has been some improvement in cost control. This has come, however, at the expense of patient choice and equitable access.

The Dutch have also introduced “co-pays” – a euphemism for user fees that ostensibly allow patients and the system to “go Dutch” by sharing the costs and discouraging excessive use. However, extensive research has shown that these types of fees simply discourage those most in need from accessing care in a timely fashion, thus causing them to present later in their illness, when they are sicker and their care actually costs more.

So instead of falling for false comparators, how can we have a broader, proactive conversation on the future of Canadian health care?

Boston’s book highlights how isolated and frustrating the experience of a patient seeking treatment for a life-altering disease can be. She describes much of her frustration as stemming from rushed appointments that left little time for asking questions. What improvements in system efficiency or changes to compensation models would enable physicians to spend more time providing quality, patient-focused care?

Or, on the European front, why shouldn’t Canada take advantage of the buying power of universal health coverage to expand access to pharmaceuticals, dental and eye care – which is a positive example we can borrow from European systems, and one many Canadians would welcome.

Canadian health care can’t be simply equated to either veterinary services or European models. There are always lessons to learn by comparison, but we can’t import elements wholesale without considering the context.

Dr. Ryan Meili is an expert advisor with EvidenceNetwork.ca, a medical doctor, and the author of A Healthy Society.