Health care has gotten a lot media coverage in the last few weeks. Prime Minister Stephen Harper announced a new funding formula and most provincial leaders are opposed to his plans. Covering health policy is tough for any general assignment reporter; it’s complex and confusing. In the launch of J-Source's Health & Medical Journalism section, Dr. Gordon Guyatt, co-developer of evidence-based medicine and an advocate of public health care, offers journalists some evidence-based arguments on five key issues.
Health care has gotten a lot media coverage in the last few weeks. Prime Minister Stephen Harper announced a new funding formula and most provincial leaders are opposed to his plans. Covering health policy is tough for any general assignment reporter; it’s complex and confusing. In the launch of J-Source's Health & Medical Journalism section, Dr. Gordon Guyatt, co-developer of evidence-based medicine and an advocate of public health care, offers journalists some evidence-based arguments on five key issues.
J-Source is pleased to re-launch its health and medical journalism section with a piece commissioned from Dr. Gordon Guyatt (pictured right), the internationally renowned medical researcher and co-developer of evidence-based medicine. Dr. Guyatt’s research has made important contributions to debates about health care policy in Canada, the US and beyond. In 2010, the British Medical Journal short-listed Dr. Guyatt for its life-time achievement award. Dr. Guyatt pays close attention to media coverage of health and medical issues and has been a columnist for both the Hamilton Spectator and the Winnipeg Free Press. In 2011, Dr. Guyatt was appointed an Officer of the Order of Canada.
1. Canada has universal, publicly funded health care…well, partly.
We have universal care for only part of our health system. Public payment covers well over 90 per cent of physician and hospital services, but only a relatively small proportion of other services. For drugs (over 60% private), dental care (over 90% private), home care, and eye care, private payment is large or dominant. Canada (in contrast to European countries) has adopted an oddly inconsistent payment system: universal, single payer, public payment for physician and hospital services, US-style mixed payment, dominated by private payment, for all else. Further, what is publicly funded is often privately delivered. Doctors offices, funded publicly, are small private business. Hospitals, publicly funded, are private non-for-profit institutions.
2. Rising health care costs do NOT explain why health spending keeps claiming a larger portion of provincial budgets.
It is true that health care has accounted for an increasing porportion of public expenditures: 30% of the Ontario provincial budget in 1980, 42% in 2009. But over the last 20 years, the proportion of the GDP allocated to public health care expenditures has risen only modestly – 7% in 1992, just under 8% in 2010. So how can we explain health care gobbling up the provincial budget? While we have spent only a small additional proportion of our wealth on public health care, we have cut public income substantially. In 1992 we spent 45% of our GDP on public expenditures; it's now well under 40%. So with less of our national income to spend, and health care spending as a proportion of that income remaining essentially stable, spending on everything else – education, social services, environmental protection, infrastructure maintenance – must constrict.
3. The US health care system doesn’t get better results than the Canadian system. It’s just more expensive.
The US system is far more costly than the Canadian – in U.S. dollars, $7,960 per citizen per year to Canada's $4,363. Our research group at McMaster conducted a systematic review in which we examined all the studies comparing American and Canadian outcomes for heart attacks, cancer, surgical procedures, and chronic medical conditions. Of the 10 best studies in terms of quality of their research, 5 favoured Canada, 2 favoured the United States, and 3 showed equivalent or mixed results. An additional 28 studies were reviewed, all acceptable in terms of quality of research, but not as impeccable as the first group. In this group we found the following results: 9 favoured Canada, 3 favoured the United States, and 16 showed equivalent or mixed results. Conclusion: Canada does at least as well in health outcomes, at little more than half the cost.
4. Rising health care costs—don’t blame it all on seniors.
It's true that older people use, on average, more health care than younger. The health care spending tsunami that many fear will result from an aging population will, however, be little more than a slightly higher tide. One reason is that a large proportion of health care costs are spent on the last year of life: up to 10 times as much as in any other year. As a result, those who die young still cost the system a lot of money in their last year, and those who die later put off the big expenditure. A second reason is that our older population is getting progressively healthier. Europe and Japan, which are over a decade ahead of us on the aging population curve, have demonstrated that costs are likely to rise only 10% as a result of aging. So – as in every other country – we do have to address increasing costs of health care, but the reason is not the aging population. Rather, the reason is that we keep developing effective new treatments that benefit both the elderly and the younger. Many cancers are now curable. Chemo- and radiotherapy and more aggressive surgery have made many other cancers into chronic diseases. Joint replacements return those disabled by chronic pain to prior states of activity and function. Invasive cardiac procedures prolong life and prevent disability. Intensive care units prevent otherwise certain deaths, including in the elderly. Drugs and surgical procedures prevent otherwise certain blindness. And on and on. All this is good news, but it is expensive.
5. Private isn’t always more efficient than public – indeed, in health care, it's less efficient.
The prevailing wisdom suggests that public is always less efficient than private. This may be true in the airline industry, but not in health care. Public payment and administration is hugely more efficient than private because private insurance companies have to compete for customers, create insurance packages, process (and often try to deny) claims, pay their executives high salaries, and make profits. The result is administrative costs are far higher with private health care than with a public system. On the delivery side, for-profit providers have to allocate a substantial amount of their income to profit. Not-for-profit providers can devote the entire income to care. The result is, for example, lower death rates in not-for-profit hospitals versus their for-profit competitors.
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