One of the key arguments by opponents of Gov. Peter Shumlin’s single payer health reform initiative is that it mirrors the single payer system in Canada, which they say has serious problems. The opponents have a point about Canada’s problems, but they are entirely wrong about Canada’s relevance to Vermont. You could fairly call the Vermont design the “un-Canada.”
The reason is that the center of gravity of the Vermont initiative is finding a way to reliably contain costs. Since its formation two years ago, the Green Mountain Care Board has focused on slowing down the growth of hospital budgets through regulation and then following that up with a complete rebuild of the infrastructure and payment methodologies.
Cost Control First
That effort is supported by a $45 million federal grant, which is being managed by Anya RaderWallack, now a consultant, who was the lead designer of Shumlin’s proposed system. There is no way to tell yet how successful that effort will be, but the intention couldn’t be clearer: Ask the governor, or Wallack, or Al Gobeille (chair of the Green Mountain Care Board) or Michael Costa (who Shumlin has tasked with financing the system) and they will tell you that if you can’t reliably contain costs then you can forget about single payer.
To that end, a good 85 to 90 percent of the Shumlin single payer initiative is aimed at wresting costs under control.
And if anyone doubts the resolve of the Shumlin team, he or she can look at Act 48, the legal foundation for the whole enterprise, which says explicitly that no single payer plan can be put into operation until a series of conditions has been met; those conditions add up to the stricture that costs must be sustainable over time.
When Canada adopted its single payer system in the 1980s, it gave governments — both federal and provincial — the responsibility for paying for it. However, they did not change the fee-for-service system, which is a notorious driver of overuse in a medical system.
All this stands in stark contrast to Canada, which has the worst access to care in the developed world. The reason is that the central problem in Canada is cost containment. The Canadians contain cost not by regulation, although there is some of that, but by queuing – making people wait for care, even when they clearly need it.
Queuing For Care
When Canada adopted its single payer system in the 1980s, it gave governments – both federal and provincial – the responsibility for paying for it. However, they did not change the fee-for-service system, which is a notorious driver of overuse in a medical system, nor did they change the basic structure of the delivery system in a way that would shift the risk of excessive cost increases annually from government to the medical providers.
Both of those steps lie at the center of the reform effort in Vermont. Canada’s failure to confront these structural difficulties directly forced them to deal with rapidly rising costs by just paying into the system what their governments could afford, and since what they could afford was often not enough to meet the demand, they had no choice but to go to queuing.
Despite these clear differences, the implacable Shumlin opponents, like John McClaughry of the Ethan Allan Institute and Darcie Johnston, who runs an anti-Shumlin-reform organization, want very badly to persuade Vermonters that if Shumlin’s reform prevails they will suffer the same difficulty of access that plagues the Canadian system.
Screen Shots
The latest maneuver in the Johnston campaign is a movie that Johnston has scheduled for viewing by the public in several locations in Vermont over the coming weeks. The title of this film is Vermont Experiments, which she said will allow viewers to “learn about how single payer health care will threaten Vermont’s economy, lead to rationing of care and will force doctors to leave Vermont.”
If you don’t catch the movie yourself, you might consider some of the reasons that the Vermont designers, rather than following Canada, are avoiding it assiduously:
- On Jan. 8, 2000, the Toronto Globe and Mail (the New York Times of Canada) reported that the Princess Margaret hospital, the largest cancer care facility in Canada, was considering requiring patients to sign “waivers recognizing what doctors have known all along: Waiting for treatment in Canada’s overcrowded medical system can be hazardous to your health.”
Dr. Alan Hudson, the president of the hospital network that included Princess Margaret, was quoted as saying that the organization was “terribly worried” that their patients would be endangered by the delays in the system at the time. “The fact is, while they are waiting their cancer is spreading,” he said. “We don’t want them to have a false sense of security.”
- In June of 2005 the Supreme Court of Canada struck down a Quebec law prohibiting private insurance for most acute health care. The court ruled that long delays in seeking care in effect deprived Quebec residents of their rights under a provincial charter.
The case was brought by a Montreal surgeon, Jacques Chaoulli, and his prospective patient, George Zeliotis, a businessman who had waited a year for a hip replacement. A report in the Los Angeles Times quoted from the decision of the court’s majority:
“In the case of certain surgical procedures, the delays that are the necessary result of waiting lists increase the patient’s risk of mortality or the risk that his or her injuries will become irreparable,” the decision said. “Many patients on non-urgent waiting lists are in pain and cannot enjoy any real quality of life. The right to life and personal inviolability is therefore affected by waiting times.”
- In November of last year, the Commonwealth Fund published a study of ease of access to medical care in 11 developed countries (Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom and the United States.
- The U.S. tends to show up badly in such studies, owing mainly to the very high cost of our system, combined with the difficulty of access generated by the presence of so many uninsured people here. For the sake of this discussion, however, the results were striking in that they showed that the only country with more difficulty of access was Canada.
The study measured four basic parameters: the percentage of adults who (1) got to see a doctor or nurse the same day or the next day; (2) waited six days or more to see a doctor or nurse; (3) waited four weeks or less to see a specialist; and (4) waited two months or more to see a specialist.
On all four, Canada has the worst access of the 11 countries. The U.S. is the next to worst on the first criteria, second to worst on number 2; the U.S. shines on item 4 – access to specialists, where it ranks third, behind the Netherlands and Switzerland. Medical specialists are, of course, where the big money is. In the U.S., 6 percent of adults have to wait more than two months to see a specialist. By comparison, it’s 3 percent in the Netherlands and Switzerland.
Canada is last, with 29 percent of adults who wait that long to see a specialist.
An interesting footnote: Several years ago, the Rutland Regional Medical Center provided large volumes of radiological cancer care to patients from the towns lying along the St. Lawrence River east of Montreal. Busloads of these cancer patients would arrive on Monday; they would get treatment all week, and then return home on Friday.
Why does Canada matter here? Mainly for political reasons. The actual engineering of the Shumlin project is going well, but in the wake of the exchange rollout problems, the political environment, especially in the Legislature, is becoming toxic.
None of this means that Canada has a bad system. The queuing is a major flaw, but the system has major advantages, and the Canadians generally like it. In fact, while polling in Canada shows considerable sentiment for reform, it also testifies to very widespread support for the basic structure. And the Canadian government does reform the country’s health system incrementally.
When public pressure builds up uncomfortably, the Canadian governments put in more money. That’s what happened to the waiver that patients at the Toronto cancer hospital were supposed to sign saying that they knew a delay was hazardous to their health. The waiver was so scary that the Canadians added additional money to ease the problem and the waiver went away, without actually being implemented.
The Political Label
So, why does Canada matter here? Mainly for political reasons. The actual engineering of the Shumlin project is going well, but in the wake of the exchange rollout problems, the political environment, especially in the Legislature, is becoming toxic. If the opponents can persuade legislators and a meaningful part of the public that “Shumlin single payer” is no different from “Canadian single payer” they might succeed in derailing it.
An exquisite irony in all of this is that there is considerable support for a Canadian style single payer system among the left in Vermont. The 1991-92 session of the Vermont Legislature saw Vermont’s first big health care reform push. At the time, then-Senator Cheryl Rivers proposed a bill modeled directly on Canada.
Rivers couldn’t get that bill out of her own committee. But she and Sen. Sally Conrad, the chairwoman of the Health and Welfare Committee, persuaded House Speaker Ralph Wright to modify a health care reform bill to require that a reform study include a single payer as well as a non-single payer option.
Then-Lt. Gov. Howard Dean supported the Canadian structure in testimony before Conrad’s committee, and Bernie Sanders weighed in support of the Rivers bill also. The single payer advocates based their efforts on the work of two American academics, David Himmelstein and Steffi Woolhandler, who continue to press U.S. policy makers to base new reform efforts on Canada. But Vermont lawmakers didn’t have the appetite to emulate the north-of-the-border policy. The single payer option was ignored in the subsequent session, and the non-single payer alternative died also.
Nevertheless, the left in both the U.S. and Vermont continue to pine for a Canadian model. They love it because of its simple guarantee that everybody gets the health care he or she needs irrespective of the cost. The huge complexity of the American private health insurance industry goes away at a stroke. The American left downplays the queuing issue in the Canadian system, but, in fact, the evidence for its deleterious effect is extensive.
And the opponents know that while queuing is at least reasonably acceptable in Canada, it would be entirely unacceptable here. That is why the real subtitle of the Darcie Johnston film should be, “Caveat Spectator.”
