Conclusiones del Capítulo

Are comparisons to Canada relevant? Do they offer any value to policy makers or to the American public? The frequency of these comparisons might suggest that the answer is obvious. Yet there are substantial reasons to pause and consider when and how comparisons to Canada are truly relevant for the United States.²

1 Dean and Professor of Law, University of British Columbia Faculty of Law. This Essay is based on a presentation originally given in January 2007 at the AALS Conference in Washington, D.C. The Essay was substantially revised, updated and submitted for publication in February 2008. The Essay’s consideration of cross-border health law is paired with separate piece on the relevance of U.S. health law and policy for Canada. See Judicial Responses to Government Restrictions on Health Care Markets in the US and Canada, presented at the Visions National Health Law Conference in Banff, Alberta (November 10, 2007). The author wishes to thank commentators at the AALS Section on Insurance program in January 2007 for their questions and suggestions as well as Betsy Segal (UBC Law ’07) and Brenda Osmond (UBC Law class ’09) for research assistance.

2 For a general discussion of the benefits and risks of comparative health policy analyses, see Timothy Stoltzfus Jost, Comparative and International Health Law, 14 HEALTH MATRIX 141 (2004). See also American College of Physicians, Achieving a High-Performance Health Care System with Universal Access: What the United States Can Learn from Other Countries, 148 ANNALS INTERN.MED. 55, 62-63 (2008) (noting difficulties of using comparative data but arguing that “the United States has much to learn by closely examining how other countries’ health care systems tried to solve the problems that underlie

For many in the U.S., Canada is a cold country to the north, perhaps best known for maple syrup, ice hockey, natural beauty, and polite citizenry. Canada’s proximity to the U.S. and the substantial economic ties between the two countries tend to promote the comparison industry.

Canada seems familiar enough to create a natural quasi-empirical research study for U.S. policy makers interested in trying to predict the impact of changes in health care policy in the U.S. Advocates on both sides of the debate seem to believe that we can determine, for example, whether or not a single payer system would address the ills of the U.S. health care system by looking to the Canadian experience.

There are of course substantial differences between the two countries.

Canada has roughly a tenth the population of the United States even though it is slightly larger in size.³ Despite Canada’s vast geography, ninety percent of Canadians live within a few hours’ drive of the U.S. border⁴ and a significant portion of Canada’s economy is based on exports to the U.S.⁵ Canada has nonetheless retained its distinctive character, readily seen in areas ranging from the coexistence of English and French traditions and languages to a political and social climate generally viewed as significantly more “liberal” and less dominated by social conservatives than the United States. An illustrative list of the differences between the two countries would probably include Canada’s failure to support the war in Iraq, the relatively swift legalization of same sex marriage, and Canada’s pride in adopting a largely government-funded health care system.⁶

Over and above these significant differences in history, politics, and culture, so much of the debate about Canada seems to reveal more about the U.S. than it does about Canada itself. The U.S.-Canadian border – frequently referred to as “the longest undefended border in the world”⁷ – may not provide a clear window into an alternate reality so much as it

the United States’ low-ranking performance ….”); Editor’s Note, Comparative Health Policy, 26 J.H.POLITICS POL’Y &L.675.

3 The Central Intelligence Agency, “Canada,” in The World Factbook, https://www.cia.gov/library/publications/the-world-factbook/geos/ca.html (updated regularly with new data).

4 Id. (“Geography-note . . ..approximately 90% of the population is concentrated within 160 km of the US border”).

5 Id. (Economy-overview section)

6 For a recent view on Canada’s slight shift to the center or right, see Clifford Krauss, Conservative Win in Canada Could Help Repair Ties to the U.S., N.Y.TIMES, Jan.

23, 2006, at A4.

7 See, e.g., Susan Catto, Tighter Border Security Slows Canadian Traffic, N.Y.

TIMES, Apr. 6, 2003, sec. 5, at 3 (noting new post-9/11 security measures).

serves as a fun house mirror: reflecting back American concerns in exaggerated form rather than revealing relevant data about the impact of different systems of organizing and delivering health care.⁸ Is it accurate, relevant or useful to characterize the Canadian system as “socialized medicine” with health care providers fleeing to better paid jobs in the U.S.

and Canadian citizens waiting in dangerously long lines for emergency or specialized care while government bureaucrats decide who will receive what types of care?⁹ Is it any more accurate, relevant or useful to describe the Canadian system as a nirvana in which society has accepted responsibility for providing basic health care for all and has developed an efficient, effective, and stable system of delivering on that commitment?¹⁰ The very terms of the debate – “socialized medicine” and “government bureaucrats” -- reveal more about the signposts of American political discourse than they do about the reality of the system they seek to describe.¹¹

Filmmaker Michael Moore’s indictment of the U.S. health care system, Sicko¸ provides a useful illustration of this problem.¹² The movie attempts to puncture the myths about Canada’s health care system through vignettes involving U.S. citizens seeking to qualify for coverage under the public system in Canada and Canadians who have received prompt care for their health conditions in Canada. The film thus includes an undoubtedly a humorous debunking of the negative stereotypes about the Canadian health care system often heard in political debates. Yet the Canadian reaction to the movie is somewhat complex. Canadians view their health care system as a source of national pride and identity and many Canadians undoubtedly

8 For a slightly different use of the mirror image, see KAREN DAVIS, ET AL., MIRROR, MIRROR ON THE WALL: AN INTERNATIONAL UPDATE ON THE COMPARATIVE

PERFORMANCE OF AMERICAN HEALTH CARE 1 (2007) (“Like the queen in the ‘Snow White’fairy tale, Americans often look only at their own reflection in the mirror – failing to include international experience in assessments of the health care system.”), http://www.commonwealthfund.org/usr_doc/1027_Davis_mirror_mirror_international_upda te_final.pdf?section=4039.

9 The answer is “no,” of course. Among other things, medicine is Canada is not socialized: Canada has a single-payer system but most health care is provided by non-governmental institutions and private physicians. See William Lahey, Medicare and the Law: Contours of an Evolving Relationship, in CANADIAN HEALTH LAW AND POLICY 1, 13 (Jocelyn Downie, Timothy Caulfield, and Colleen Flood, eds., 3d ed. 2007).

10 The answer here is “no” as well. See text accompanying notes 70-71.

11 For similar observations, see Peter S. Hussey, Review, Health Systems in Transition: Canada, 297 JAMA 647 (2007).

12 See Michael Moore, Sicko, http://www.michaelmoore.com/sicko/index.html (last visited Nov. 23, 2008).

enjoyed the humorous comparisons between the two systems. But, at the same time, the movie’s rosy glow created more than a few moments of discomfort for Canadian audiences given broad concerns about the sustainability of the current system and an intense debate about how to address lengthy waiting times for certain procedures.¹³

Given the risks of cross-border comparisons, this Essay therefore takes a skeptical, limited view of the relevance of the Canadian experience for the insurance debate in the United States. The next section of this Essay provides a basic outline of the Canadian system and then analyzes some recent data comparing Canada to the U.S. using data on health care expenditures, access and outcomes.

III. THE CANADIAN EXPERIENCE