What Medicare for All Really Looks Like

What Medicare for All Really Looks Like

The Canadian system, also called Medicare, guarantees coverage to every resident north of the U.S. border.

By Caitlin Kelly for The American Prospect

He spends long days navigating Toronto’s miserable traffic, finding whatever’s needed for his work as a freelance production designer for film and commercials. It’s demanding physical labor, with injury a daily possibility.

Like so many these days, David Dennis, 28, is an independent worker. But he pays nothing for his health insurance. Simply being a tax-paying Canadian is enough. As an Ontario resident, Dennis’ OHIP (Ontario Health Insurance Plan) card entitles him to see a physician, visit an urgent-care clinic or any hospital, and receive whatever services—including multiple surgeries and weeks or months of inpatient care—are deemed medically necessary, with no fear of ever paying for these out of pocket.

Government-funded health care, from cradle to grave, is Dennis’s Canadian birthright. It’s something he takes for granted, as do all Canadians, comforted by knowing that whatever their age, health, or employment status, they’re entitled to comprehensive medical care, most of it at no additional cost beyond their taxes.

Canadian health care is publicly funded and privately delivered, approximately the same vision that single-payer enthusiasts have for the American system. It even shares the same name as our largest government-run insurance provider: Medicare. But contrary to persistent American partisan mythmaking, no government officials sit in doctors’ offices or haunt hospital hallways with a checklist of all the services they’ll question and deny. They don’t dictate hands-on care. Canadians face little government interference or oversight of their health care, although, for historical reasons, their doctors retain much more power than patients.

The familiar and dreaded words “co-pay,” “deductible,” “pre-existing condition,” and “out of network” are meaningless here, in English or French, Canada’s two official languages. Patients don’t waste time chasing pre-authorizations or fighting medical bills, while physicians save thousands of administrative hours.

As Americans’ life expectancy is dropping and maternal mortality is ranked shockingly high among other wealthy nations, Canadian health outcomes fare better; Canadian women live two more years than their American counterparts, men three.

But the system is far from perfect. Outpatient care, like physical and occupational therapy or prescription medicine, is paid for out of pocket. In some places, there’s no mandate to use electronic records, so patient information can be difficult to access. And medical care of impoverished and remote First Nation and Inuit communities is openly acknowledged as abysmal.

Like Americans, many Canadians with full-time jobs receive supplemental coverage as a benefit through their employers, while independent workers like David Dennis can buy a policy on their own.

Canada provides coverage for about 35 million, one-tenth the population of the United States. But how they’ve set up their health care system, and how it evolved over the decades, is instructive, especially given the robust debate during the presidential primary about overhauling our current system. It can inform how U.S. policymakers—and Canadians, for that matter—approach cost control, physician payment, and services for vulnerable communities. Rather than scaring Americans with well-structured narratives about the alleged horrors of Canadian Medicare, we could take the opportunity to learn from it.

How It’s Funded

The health care Canadians receive flows through a hybrid federal and provincial system. The federal government supplies about $36 billion (Canadian) in health care funding annually, distributed among each province and territory’s Ministry of Health (MOH). Federal dollars cover roughly 20 percent of total health care costs, with each province and territory responsible for the remaining 80 percent. Poorer provinces, and those with smaller populations—like Newfoundland and Labrador (528,817), Prince Edward Island (153,244), and the Northwest Territories (44,541)—receive higher federal amounts in compensation.

The provincial ministries make decisions about how best to apply that funding, further decentralized in some provinces through regional agencies. If a Canadian needs care while out of their home province, most reciprocal inter-provincial and territorial agreements ensure that they won’t receive bills for it.

Many of Canada’s most senior physicians and policymakers simply consider health care a human right. 

At no point do government bureaucrats direct patient care—aka “death panels.” Canadian physicians essentially run their own businesses, and enjoy tremendous autonomy. Their fees are negotiated annually with each provincial or territorial MOH through a provincial medical association, setting specific fees for each service and specialty. The Canadian government operates mostly as insurance payers, while doctors focus on serving patients.

Each doctor bills the MOH, paid in Ontario twice a month by direct deposit. Many physicians are paid well, even for part-time work. Some easily earn $300,000 or more a year, while paying much less for malpractice insurance than their American counterparts. And without multiple insurers to wrangle, Canadian doctors need fewer employees. “I have a pal in Sausalito,” says John Hickie, a former family physician in Calgary, Alberta, “who has more billing staff than medical staff. In contrast, I could do my billing in one hour on a Sunday evening at the computer.”

Nor do Canadians and their employers fear annual double-digit increases in the cost of their health insurance, which is paid for through a broad mix of taxes. So David Dennis lives free of daily financial anxiety over potential injury, a personal and professional freedom many Americans only dream of. He plays baseball several times a week and, when he slid into second base and banged himself up badly, went to an urgent-care clinic, also covered through OHIP. Throughout his teen years, skateboarding (broken left elbow), hockey (broken right collarbone, separated shoulder), and baseball (broken left hand) sent Dennis to the local emergency room so frequently he jokes he had an E-ZPass.

He’s never needed an ambulance; in Ontario they cost $240, with OHIP paying $195 of that. (Contrary to the vision of Senator Bernie Sanders (I-VT) and many U.S. single-payer supporters, some Canadian provinces require varying levels of cost-sharing.) If an Ontario resident is hurt far away from a hospital, there’s Ornge, with 12 bases across Ontario, eight staffed helicopters, four staffed airplanes, and four critical-care land ambulance crews. More than 60 percent of its work takes place in Northern Ontario, including service to many fly-in only communities. All of this at no extra cost to patients.

Broke and desperate Americans increasingly are choosing to call an Uber over an ambulance, as an ambulance ride can add the potential shock of an unaffordable four-figure bill, even with health insurance. Dennis works in the gig economy, but he never has to fear the potential cost of an ambulance.Expand

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Ontario author Ann Douglas at her home near Bancroft, Ontario by Jose R. Lopez

Wait Times for Less-Urgent Cases Mean Frustration

When they need to see a doctor, Canadians must first visit their family physician. The family physician decides if the matter requires a referral to a specialist and how quickly to ask for one. This gatekeeper role is one way that Canada controls health care spending. Currently Canadian health care costs 10.4 percent of GDP, versus 17.2 percent for the United States.

There are downsides to this approach—waiting for diagnosis, treatment, and relief from pain and anxiety can be frustrating. “The Canadian system is characterized by waiting,” says André Picard, health reporter since 1987 for The Globe and Mail, Canada’s national newspaper. “We wait to see a GP, wait for a referral to a specialist, for elective surgery, for home care and longer for long-term care. There is little to no accountability and little incentive for solving these problems.”

The Canadian Institute for Health Information offers detailed data on wait times for some specific procedures, including hip and knee replacement. Access to specialty services can vary widely, even in major cities like Toronto, Vancouver, and Montreal. For Ontario parenting author Ann Douglas, it meant waiting eight months to see an ear, nose, and throat specialist to finally diagnose and treat her repeated spells of vertigo. She quickly saw her GP and had an MRI, but only a specialist diagnosed Ménière’s disease; eight months of weekly physiotherapy ended her symptoms.

Waiting for diagnosis and treatment can feel neglectful and frightening. But surveys show repeatedly that the system still remains a source of deep national pride and shared identity. Canadians like knowing that, under federal law, everyone is entitled to equal access. Unlike in the U.S., the wealthy and powerful can’t pay extra or pull strings to jump to the front of the line. This lessens the sting of waiting and contributes to a sense of solidarity.

No one wants to wait, but Canadians also live without fear of medical bankruptcy, a trade-off they deeply value. Inundated by American media reports, some having lived and studied in the U.S., Canadians know how bad it can get.

“Canada makes you wait because everybody’s included,” says Dr. Tom Noseworthy, a professor of health policy and management at the University of Calgary, and a former hospital CEO, ICU specialist, and rural GP. “But every nation rations its health care. No one can get everything, everywhere, all the time. One system is explicit in its rationing, Canada, where we howl at our wait times—and the other is implicit, because Americans can only get it if they can afford it.”

Alberta researcher Tamara McCarron has just finished her Ph.D. examining how Canadian patients experience health care, including prostate cancer patients. “When I asked them if they were happy with wait times, they said: ‘Hell, no!’” she tells me. “The common theme I heard was ‘I had to wait a completely unacceptable amount of time to get the diagnosis from my urologist. This was ridiculous!’ But the positives I heard were: ‘I’m healthy. I’m good. The surgeon was amazing, pre-op was amazing. I can be really critical of the system, but I’m still here.’”

“It’s not that Canadians don’t want stuff now,” she adds,” but knowing they may have to wait three or six months to see a physician is the worst of it. Never seeing a bill is a huge comfort, so people are more forgiving of the challenges and inconsistencies because of that.”

For Ann Douglas, wait times also meant frustration when seeking mental health care for her four children. “The wait time to see a psychiatrist can be zero days to 18 months,” she says. “There has always been a shortage of child psychiatrists, leading to the hashtag #kidscantwait. They have been underfunded for years. Long waits for care exacerbate a minor issue to a major issue, so a kid with mental health issues becomes suicidal or a drug-using teen.”

“This is a very Canadian thing that health is a collective responsibility because any one of us can be hit by a car at any moment. We should pay into a common system so that everyone can get care.”

Paying for outpatient medical services presents another major challenge for Canadians. Any service offered outside of a hospital or doctor’s office must be paid for out of pocket. Luckily for Douglas, her husband had a good benefit plan through his job, saving her $100 per week until the final few weeks for her physical therapy. At one point, Douglas needed $900 worth of medication each month, also covered through her husband’s plan. But those without such benefits, like David Dennis, face the same financial anxiety as Americans if they can’t afford such services.

Canada is also the world’s only country offering government-paid hospital and physician care that doesn’t pay for medication. This has led to a growing push for national pharmacare, as even some Canadians can’t afford their insulin, invented by Canadians Frederick Banting and Charles Best and celebrated on the Canadian $100 bill. Americans pay the world’s highest drug costs, but Canadians, with a small population and strong drug lobby, pay the world’s second-highest.

Racism and Canadian Health Care

The Canadians most frustrated with their health care are the nation’s 1,637,785 Inuit, Métis (mixed European and indigenous descent), and indigenous peoples. Prime Minister Justin Trudeau has promised a radical overhaul and improvements by 2030. But he now leads a minority government, giving him less power.

Improvements can’t come quickly enough for physicians like Dr. Mike Kirlew, practicing medicine in northern Ontario for ten years. Born and raised in Ottawa, he’s an outspoken critic of First Nations’ health care, which he calls “unbelievable systematic oppression.”

Kirlew is based in Sioux Lookout, 1,090 miles northwest of Toronto, at its 100-bed hospital. From there, he flies in or drives up to 18 hours by ice road to one of 30 remote nursing stations to see patients from 32 communities, in an area the size of Germany and France combined. The nursing stations have no X-ray machine, MRI, or ambulance service. Even the Sioux Lookout hospital has no MRI, which means patients must fly south or west to neighboring Manitoba.

In October 2018, addressing fellow family physicians at his alma mater, the University of Ottawa, Kirlew gave a searing indictment of this system, describing a patient screaming in pain for 9.5 hours while awaiting a helicopter to fly him to an orthopedic surgeon—as the station had no painkillers on hand.

“We need 54 to 60 full-time physicians,” he said. “We have 18. We have very limited access to specialists of any type. We have very high rates of MRSA, strep, and rheumatic fever,” he told colleagues.

“When you contrast that with what’s in the provincial system it’s night and day,” he told a CBC reporter in March 2018. “It’s far inferior. We have a system that triages people, based on their race, to inferior care. That’s the height of un-Canadian-ness.” It’s even worse for the Inuit, indigenous peoples who live in the Arctic. Suicide rates in Nunavut, a territory in this region, are ten times that of the rest of Canada.

Canadians expect their health care system to offer everyone—rich or poor, employed or not, of every race and ethnic background—fair and equal treatment. And Canadians are proud of their nation’s openness to refugees and immigrants, with many fewer illegal entrants than the United States to foster resentment of those abusing the system in a country already more welcoming to immigrants than the U.S. Yet in health care, there is definitely racism and bias. “The status quo is perpetuating inequities, misery and associated higher health care costs,” wrote Josée Lavoie, professor in the Department of Community Health Sciences at the University of Manitoba, and director of Ongomiizwin Research, in a 2018 paper on First Nations health disparities.Expand

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‘I don’t think Americans will ever do it,’ says Dr. Margaret Tromp, president of the Society of Rural Physicians of Canada, of nationalized heath care. ‘America is much more right-wing and based on the American dream.’ by Jose R Lopez

A Series of Different Systems, With Patient Experiences Made Secondary

The national expectation of fairness and equity lessens the sting of paying taxes for health care. “I don’t resent paying one cent of our taxes,” says Vancouver-based patient advocate and author Sue Robins. “This is a very Canadian thing that health is a collective responsibility because any one of us can be hit by a car at any moment. We should pay into a common system so that everyone can get care. We do get value over the years, especially as we get older.”

However, that expectation of equity breaks down across provincial lines. Robins worked in Alberta for nine years, enjoying excellent services for her son, Aaron, 16, who has Down syndrome. When the family moved to British Columbia, none were offered. “Care is not consistent between the provinces, even though the Canada Health Act says it’s portable,” she says. “A broken leg is a broken leg, but there are no consistent standards. There’s no national plan or strategy.”

As Vik Adhopia, national health television reporter for the Canadian Broadcasting Corporation, explains, “The Canadian system is a series of systems and they are all different. There are significant disparities from province to province.” Adhopia has lived in Toronto, northern British Columbia, Alberta, and St. John’s, Newfoundland. “CPAPs (a device used to relieve obstructive sleep apnea), are covered in Ontario, but not in Manitoba,” he says. “You hear of people who move from one province to another for coverage.”

Another fragmented element of the system is electronic medical records. Canadian hospitals and physicians use them, but the data is often siloed in multiple separate systems, and less immediately shared or accessible.

Residents who complain about these issues find little sympathy. “Canada does not have a patient-centered health care system,” wrote The Globe and Mail’s André Picard in May 2018. “Communication with patients is abysmal, customer care is virtually non-existent and the opportunities for feedback are minimal.”

Robins agrees with this assessment. “I found my treatment very impersonal,” she says. “They could do so much better when it comes to patient care, kindness, respect, and dignity. People don’t collect data on patient experience as they do in the U.S.,” she adds. “What about the waiting room experience? Is the care patient-centered? Are they making decisions together? They don’t see patients as experts.”

When Ontario psychiatrist Dr. Javeed Sukhera needed emergency care at a local hospital, he, too, was deeply disappointed. “From my own health care experiences, I would say patients are often treated like problems and not like people. I felt like I was treated like a piece of trash. I was discharged into the cold without any concern for whether I had a ride or not, wearing an undershirt in the winter. I had expected more compassion than I received. My experience as a patient in the U.S. system [where Sukhera did his residency] was vastly different than how I was treated in Canada.”

One key reason for this frustration is that hospitals in Canada receive global budgets annually from the MOH. They must figure out how to serve patients within that budget. This can create efficiency and limit unnecessary treatments. But in addition, patients in Canada are not seen as sources of revenue but as costs, explains Sukhera, who is president of the Ontario Psychiatric Association and an activist for health care improvement. “That transforms how we treat patients and provide care. The way we organize payments makes it hard to improve quality,” he says.

“The patient is not just a consumer, but also a citizen, taxpayer, and user all wrapped into one,” says Gregory Marchildon, a faculty member at the University of Toronto and an expert on health care policy. “Patients don’t have much power and they accept this, and they shouldn’t. Canadian patients need to become much more demanding. The systems are weak, and Canadians are quite passive, which has not been a good thing. There needs to be a lot more effort made to hold doctors accountable.” To create much greater accountability, Marchildon suggests creating a written agreement between each patient and their physician, “and if the patient exits [that practice] is penalized financially, which creates a hard landing for the physicians.”

The flip side to this is that doctors don’t see Canadian patients (with a few miscreant outliers) as a source of personal profit. Rounds of tests that fatten a doctor’s wallet mostly don’t exist in Canada. The way the nation finances medical education also eases the financial pressures on doctors. While public and private American medical schools charge a median tuition of more than $200,000 for a four-year program, “when I went to medical school, tuition was $6,000 a year,” says Dr. John Hickie. “Now it’s $16,000 to $20,000 a year. It’s still hugely subsidized and that’s the same everywhere in Canada. Compared to the States, it’s nothing.”

A Difference in Bedrock Philosophies

A fundamental conceptual difference also divides how Canadians and Americans view their relationship to using government-financed or -run services. Classic American insistence on the bedrock values of individualism, self-reliance, and shunning government aid as a sign of moral failure differs radically from that of Canadians, who are more committed politically and economically to health care equity as a collective good. Consistently receiving free health care and heavily subsidized university and college tuition fees means that Canadians of all ages and income levels experience firsthand a consistent, quantifiable return on their tax dollars.

“One thing I wish Americans would understand is that ‘who’s going to pay?’ is actually a distraction,” says Dr. Danielle Martin, executive vice president and chief medical executive of Women’s College Hospital in Toronto. “It’s ‘how will you organize delivery of it?’ Payment is just the first step on a worthy and interesting journey. The conflation of single-payer and wait times is false. We have wait times because of a million other issues, like we can’t get physicians to work in rural areas.”

Consistently receiving free health care and heavily subsidized university and college tuition fees means that Canadians of all ages and income levels experience firsthand a consistent, quantifiable return on their tax dollars.

Canadian taxpayers put up with a lot to maintain their health care system, but so do Americans, such as the tremendous cost of gun violence. A comprehensive state-by-state report released in September 2019 by the Joint Economic Committee found that in 2017, 40,000 Americans were killed by guns. The health care costs for California alone were $348 million, borne by both individuals and taxpayers through uncompensated care. By contrast, 311 Canadians were hospitalized for firearm injuries in 2017–2018, according to the Canadian Institute for Health Information; 249 died in 2018 as a result, according to Statistics Canada.

How Did These Systems Evolve?

It became nationally obvious that health care improvements were badly needed in Canada when residents signed up to fight World War I and World War II, many of them in poor physical condition thanks to unaffordable medical care. An astounding 56 percent of WWII volunteers failed their initial physical examination. The Depression also hit hard; broke patients needed care, and doctors and hospitals had to get paid promptly for it.

Tommy Douglas, grandfather of actor Kiefer Sutherland, is considered the father of Canadian health care, as revered and well known as Martin Luther King to Americans. Born in Scotland, Douglas grew up in Glasgow and Winnipeg, Manitoba. He attended theology school and became an ordained Baptist minister. While studying sociology in 1931 at the University of Chicago, he also witnessed the desperation of Americans in the Depression. He became leader of the Co-Operative Commonwealth Federation, a democratic socialist party. In 1961, it was renamed the New Democratic Party, and is currently headed by Jagmeet Singh.

Douglas led the party to five successive wins in Saskatchewan, pushing to create a provincial medical insurance program. The province’s doctors fought the effort hard, even going on strike in 1962, but the plan went through that year anyway. Throughout the 1960s, successive provincial and territorial governments adopted the “Saskatchewan model,” and in 1972, Yukon Territory was the last subnational jurisdiction to adopt it.

In 1966, the Liberal minority government of Lester B. Pearson committed the federal government to paying 50 percent of health care costs, with the provinces paying the other half. The federal burden has shrunk over time.

The memories of crippling medical costs are still very real for some Canadians, like labor economist Armine Yalnizyan, the inaugural Atkinson Fellow on the Future of Workers. Her father, Puzant Yalnizyan, an electrical and mechanical engineer and inventor, started suffering several medical conditions within months of moving to Canada in 1951, until his death in 1964.

“I have kept some of the bills,” she says. “It was a lot of money as a share of income,” even for a salaried professional with a full-time job. “We did not get public health insurance in Ontario until 1966, after his death.” Yalnizyan’s mother, with little formal education, had to scrape together whatever work she could find to help support the family, like tutoring French, and the family took in a boarder. “Being Armenian, and the child of children who lost their parents to the Turkish massacre and were treated as easily exploitable and a lower-tier citizen informed my understanding of the importance of societies that value and support equality,” she adds. “Health care is one of the most material ways of expressing that commitment to equality.”

The Canadian system evolved through decades of political debate, battles, and negotiations with physicians and insurance companies. The debate continues even today, says Yalnizyan. “It’s the zombie conversation. We have the same conversation every 25 years. Health care is both a market failure and a market magnet because there’s money to be made. That conflict of public and private interests will never go away!”

Voting With Their Feet: “I Couldn’t Work There”

Many of Canada’s most senior physicians and policymakers simply consider health care a human right. Dr. Bob Bell, a former deputy minister of health for Ontario from 2014 to 2019, then responsible for a $50 billion budget, half of all provincial spending, is an orthopedic surgeon specializing in bone cancer who trained at Harvard, and at Massachusetts General Hospital, before running several Toronto hospitals.

“I was going to work in the U.S. but what concerned me was the kids we saw with osteosarcoma,” he says, “a horrific disease that demands intense chemotherapy, inpatient treatment for months, and really aggressive surgery.” Bell ultimately had a reckoning. “I couldn’t work there,” he explains. “There was such a differential with patients with good insurance and those that didn’t have it. I could not imagine working in that environment. People who present with disease need to be treated with equity and equality. It is a human right.”

Dr. Emily Queenan, who is American, also voted with her feet; after studying biology at Williams College, working for Americorps in Peekskill, New York, in community health, and attending medical school at the University of Pennsylvania, she did her residency in Rochester, New York. She opened a family medicine practice there in June 2009, closing it in May 2014—and moving to Canada.Expand

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Dr. Emily Queenan, who is American, standing on the front porch of a 1920s-era red-brick house in small-town Ontario whose main floor is now her office. by Jose R. Lopez

After being recruited by an agency of the MOH, Queenan visited four cities selected from a list of rural communities needing a doctor, She chose Penetanguishene, a middle-class town of 8,962 in northern Ontario on Georgian Bay, a beautiful area that welcomes many summer-home visitors.

“It was a wrought decision to close my practice,” Queenan says, sitting in the 1920s-era red-brick house in small-town Ontario whose main floor is now her office. “I envisioned having my [U.S.] practice for decades. But I was really burned out by the burden of being someone’s family doctor and the moral injury of denying care versus the lack of payment versus dealing with your own medical bills. This is not asked of other professions.”

Still in New York, Queenan attended a local meeting of Physicians for a National Health Plan, an American advocacy group founded in 1985 by Dr. Steffie Woolhandler and Dr. David Himmelstein, “trying to decide what was next. I was on the cusp of turning 40 and saw a career of fighting stupid fights. Doctors across the country were going through exactly what I was going through. I am not unique.”

Her children, then 5, 7, and 9, were “easily transportable,” and her husband left a corporate job with Nabisco to become a stay-at-home father. Yet as much as Queenan loves her life, Canadian rural medical practice—chronically and woefully short of doctors—offers its own challenges. She has 1,000 patients, seeing 20 to 25 a day. She’s the only obstetrician for many miles and hates the “obscene” waits her patients endure to see a specialist.

Could This Work in the U.S.?

Will Americans ever choose Medicare for All? Will they agree to a facsimile of the Canadian system? Experts in Canada have varying opinions.

“I don’t think Americans will ever do it,” says Dr. Margaret Tromp, president of the Society of Rural Physicians of Canada. “America is much more right-wing and based on the American dream—if you’re not getting ahead, you’re not working hard enough.”

“You have to believe it’s possible, and it’s iterative,” says Dr. Jane Philpott, former federal minister of health. “It’s something that took half a century here, and extraordinary leadership. And medical educators have to be on board.”

“Americans need the choice to also go private, so you would have to regulate that,” says Colleen Flood, a health policy analyst at the University of Ottawa.

“The bigger the population, the more healthy people you have to offset the sickest. Scale is a bonus,” says Dr. Danielle Martin, author of a 2017 book suggesting six ways to improve Canadian health care.

“Yes, because there are so many people being hurt by the current system and if those folks can be mobilized because this system will forever do it to them,” says health policy analyst Greg Marchildon. “It’s a huge battle,” he adds, “and will polarize the American public, but it was the same here in Canada at first. But within four or five years Canadians came around. This will always polarize people and there will always be interest groups fighting it. But if you don’t make radical change, you’re just fiddling.”

 Tom Noseworthy is less optimistic, especially in a time of such deep political division. “On paper, economists and sociologists can do this, but will it get done? I’m not sure there’s any single force to get it done. It would take another world war to create that same sense of solidarity.” But the matter is urgent, he adds. “The U.S. economy will fail if this isn’t fixed. No one knows how to control the costs. It’s going to break the bank.”

“Americans don’t want to be told what to do,” says Bob Bell. “The U.S. should have a public and a private option. But Americans are so smart with market innovation. This is just market innovation. In the States, you’re already way above us because Medicare is run federally. That’s perfect.”

“The Canadian system is good, but underfunded,” says Steffie Woolhandler. “The American system is shitty but over-funded.”

And what of all those health insurance employees who’d lose their jobs? “Sixty million Americans a year are separated from their jobs, of which 20 million is involuntary,” she replies. “So it’s not a huge issue if you put aside billions of dollars to deal with this. Within a medical practice or hospital, you could retrain them on the spot.”

When serving as executive director of the Royal Commission on the Future of Health Care in Canada, delivered in 2002 with 47 recommendations, Marchildon and Roy Romanow, former premier of Saskatchewan, sought out Hillary Clinton, then a senator, to hear her thoughts.

“She tried to get us to think about the possibility of a ‘release valve’ (i.e., a private option), even though it does create an inequity. We found her far more expert on the Canadian system than I could ever have expected,” Marchildon says.

The constant fight with those insisting on a private option, which some argue is inherently elitist and unfair, means constant vigilance to retain a fair and equitable system.

Clinton predicted “that a very wealthy and powerful minority would make our system unworkable,” says Marchildon. “She warned us: ‘Don’t let them destroy your system. You got it right.’”

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