As an academic observer of Canadian and American medical care for a quarter of a century, I want to say to Canadians: Despite the strains of the past decade, you don't know how lucky you are. It is precisely because Canada has good value for money through medicare that it represents an ideological threat to U.S. medical and pharmaceutical interest groups. This is playing out in Canadian medicare's image in the North American media.
Crisis and crowding in the emergency room has been a familiar story in Canada and the United States over the past decade. The media took special notice when this past winter's flu season aggravated overcrowding in the ER. Between mid-December and early February, ABC News, The New York Times and The Washington Post did stories on the quality of Canada's ERs. Steven Pearlstein of the Post asserted that "most experts" agree that Canada's medicare is doomed. He wrote: "While money might alleviate the shortage of advanced machinery, hospital beds, and medical school slots, it will only be a matter of time before the demand for medical services once again overtakes the willingness of voters to pay for it."
During the same period, USA Today and Time magazine published substantial reports on U.S. emergency rooms -- with this difference: While the reports on Canada used the overcrowding problem to suggest that your medicare is critically flawed, by contrast, parallel reports on U.S. overcrowding did not indict my country's health-insurance arrangements.
The image of a troubled medicare program is being amplified in the Canadian media, too. Yet this fearful portrait is strikingly at variance with the research. A 1992 study (Roos et. al.) found that three-year mortality rates following surgery were better in Canada than in the States for eight out of 10 types of surgery (including bypass surgery). A 1997 U.S. General Accounting Office study found that Canadians are 5-per-cent more likely to survive lung cancer than Americans, 4-per-cent less likely to survive breast cancer, and do equally well with colon cancer, Hodgkinson's disease and hip fractures -- at far less cost to the patient.
Now we have a new and rigorous report of the Canadian Institute for Health Information. In providing a synthesis of research on medicare, the report is the enemy of anecdote (and in that sense is explicitly critical of the media). The CIHI found that medicare is a structurally sound program of universal health insurance that largely satisfies those who use it (but, like all programs, requires managerial adjustment over time).
However, the report noted a sharp distinction between the satisfaction of Canadian users of medicare and the fears of the public at large. In l998, 54 per cent of Canadian users reported that the care their family had received in the previous 12 months was "excellent" or "very good" -- and yet the public felt anxieties about the system's viability. The discrepancy between user satisfaction and perceived systemic trouble, the CIHI's research suggests, is in part because "individuals' ratings of the health-care system seem most influenced by the media when their own experience provides little guidance."
The CIHI portrays Canadian medical care as institutionally stable but financially pressured, with pockets of strain and distress. It found sharp increases in hospital workload and constrained budgets through most of the l990s. Tight budgets necessarily mean limits on the incomes of doctors, nurses, and other medical personnel.
But why do such specific problems turn into medicare crises? The answer lies with the habits and stakes of the media, of medical pressure groups, and of political elites.
For most of its history, medicare has been the jewel of the postwar Canadian crown. Polls from the l970s through to l990 regularly reported that you Canadians gave your system overwhelming approval and had no interest whatsoever in following America's health-insurance example. But with the recession of the early 1990s, your country's journalists turned their attention to the belt-tightening, and the way frozen budgets meant real strain, disappointed nurses and doctors, and in the hospital world, downsizing, closure, and merging. In short, there was much to be concerned about, and reporters pursued the complaints that straightened economic circumstances inevitably generate.
But in doing so, they amplified the demands of stakeholders much more than they systematically portrayed Canadian medicare. The truth about a medical-care system is complicated. Pressure groups have no or little interest in truth-telling as such, and journalists have a very difficult time evaluating complex, major programs through particular stories. That's why the authority of the CIHI report is so important. It is both a voice to counterbalance vocal pressure groups with a stake in crisis talk, and a reliable source that every journalist covering medicare needs to master.
American journalistic interest in Canadian medicare reflects the place of health-insurance issues in our national agenda. The attention is episodic and largely reflects preoccupations of U.S. interest groups. Recently, we've had a flurry of articles (and ads) in the United States about the "dangers" of Canadian-style "price controls" on pharmaceuticals. Significantly, these stories emerged in March -- just as the U.S. Congress debated adding outpatient drug coverage to the (U.S.) medicare program. A group called Citizens for Better Medicare launched a multimedia campaign "urging American seniors to reject the Canadian model of health insurance and coverage of prescription drugs."
The "citizens" turn out to include the U.S. Chamber of Commerce, The National Association of Manufacturers, and the pharmaceutical trade association. Together they claimed that Canadians suffer from a "big, government-run system that rations health care, delays access to treatments, including new technology and medicines, and harms too many patients."
Since few American reporters know enough about Canada to question any of these caricatures, the claims are amplified, not analyzed. And, given the way the North American media market works, the U.S. claims are transmitted north -- that is, Canadians see the Citizens for Better Medicare campaign -- while Canadian stories don't flow south. I can predict confidently that no New York Times story will analyze the CIHI report.
A portrait of Canada's medicare will never be painted properly by episodic, dramatic representations of particular trouble spots. Moreover, the very structure of medicare brings with it conflicts. Paying for medical care from a single provincial budget -- where other competitors for public funds help restrain medical demands -- means debate about how much to spend, on what, for whom, and under what conception of fairness. This brings accountability, but it also brings constant media attention, constant claims of need, and considerable exaggeration of the state of medicare.
And as long as anecdotal and political stories are the way we get our coverage of medicare, we'll see distortion of the program's true performance. Evaluating a system requires systematic evidence, which is what the CIHI has provided -- a portrait of a medical system that is not critically flawed, but simply in need of targeted adjustments.
For all the criticism of Canada's medicare program, I for one would be delighted to have its manageable problems in place of those in the United States.
Theodore R. Marmor is a professor of public policy, Yale School of Management. He is a Fellow of the Institute of Medicine and of the National Academy of Sciences and a Fellow of the Canadian Institute for Advanced Research 1987-95. He is the author of Understanding Health Care Reform.
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