CHICAGO - October 7 - Canada's publicly funded health insurance program known as medicare "is one of the best health care systems in the world," a leading U.S. health policy expert says, but is being threatened by government underfunding and by those who would partially privatize it under the guise of reducing wait times for elective medical procedures.

Dr. Marcia Angell, a senior lecturer at Harvard Medical School, writes in the Oct. 21 issue of the Canadian Medical Association Journal (CMAJ) that Canada's health expenditures are half those in the United States - US$3,326 per person versus US$6,697. Yet, in sharp contrast to the U.S., Canada's health system guarantees essential medical care to all of the country's residents.

In addition, Angell says, since the full implementation of medicare in 1972, Canada's medical outcomes have surpassed those of the U.S. "The life expectancy of Americans is now 2.5 years shorter than that of Canadians," she writes. "Infant mortality rates are higher in the U.S., as is preventable mortality (death before the age of 75 from diseases that are amenable to treatment)." Americans also visit their doctors much less often than their Canadian counterparts.

Saying the only plausible explanation for the U.S. spending more and getting less than Canada is that the U.S. system is "enormously inefficient," an inefficiency that stems from relying "primarily on private, largely investor-owned corporations to provide health care."

These for-profit health insurance companies, hospitals, and "satellite businesses that have sprung up around the health care industry" like drug-management companies, utilization review companies and billing agencies siphon off about 31 percent of all health care spending in the U.S. for administrative costs, marketing and profits, she says.

By contrast, she writes, Canada's public system and the U.S. Medicare system incur administrative costs of 2 percent or less.

The main charge leveled against Canada's system is that it requires excessive wait times, particularly for elective procedures, Angell says.

Waiting times are a concern, she says. Some waits were lengthened when Canada adopted a 1984 law that essentially abolished user fees and extra charges. To compensate, system administrators tried to contain costs by controlling the supply of services like imaging and the use of surgical facilities, leading to longer waits.

Wait times also increased in the 1990s, when the Canadian system was badly underfunded. The funding became a political issue, and while subsequent funding improved the situation, today "waiting times are still too long for certain elective procedures, such as hip and knee replacements, and it takes time for increased funding to be translated into more facilities and specialists."

But waiting lists for these procedures are no reason to abandon what clearly amounts to a superior overall system of delivering health care, a system that provides essential health care to all based on medical need, not ability to pay, Angell says. Canadian medicare still remains popular with the public, she notes.

Those who say that privatizing part of Canada's system will reduce wait times have produced little evidence to back up their claim, she says. In fact, Angell believes the pressure to partially privatize the Canadian system has more to do with "the desire of businesses and some specialists to profit from the system, just as they do in the U.S.," combined with a desire on the part of federal and provincial governments to shift more health care costs onto individual patients.

Such steps toward privatization would backfire, she says, since "for-profit care is nearly always more expensive and often of lower quality."

Instead, she urges better funding for Canada's medicare. "The wisest course for Canada is to expand and reinforce its public system, not undermine it," Angell says.

Angell, the former editor-in-chief of The New England Journal of Medicine, notes that many Americans also appreciate the merits of a national health insurance system: "Polls have shown that about two-thirds of Americans would prefer a Canadian-style system, as would three-fifths of doctors."