The MacNeil/Lehrer Report; Canadian Health Insurance

ROBERT MacNEIL: Good evening. National health insurance has become the symbolic issue dividing the Democratic Party. Senator Edward Kennedy is demanding that the party keep its commitment now to a comprehensive national health care system; President Carter is urging delay and gradualism because of strains on the federal budget. To strengthen his case, Senator Kennedy is holding hearings around the country comparing the experiences of Americans and Canadians with their different health care sys tems. His witnesses are chosen to make the comparison unfavorable to the American system, and the effect has been to focus fresh attention on the Canadian way of doing it. We attended one of these hearings last Friday in California, and tonight we`ll hear a selection of the witnesses. Then, with three doctors in Ottawa, the Canadian capital, we`ll discuss what they see as the strengths and weaknesses of Canadian medicine and how it`s paid for.

The Kennedy hearings last Friday were held in Garden Grove, California. The witnesses testified in pairs, each carefully chosen for their parallel medical experiences -- an American story matched by a Canadian story. The first witness was Mrs. Dan Neal of Bakersfield, California.

Mrs. DAN NEAL, United States: I`m forty-three years old, and twelve years ago I was coming home from a class at school and was hit head-on by a drunk driver who was driving without a license and who was in a car with $2,000 worth of insurance on it. My insurance at the time was the maximum medical coverage allowed, which was $5,000 medical. Because of this I had three years, approximately, in the hospitals, twenty major surgeries, reconstructive surgeries, and astronomical medical bills which we are still paying and which I feel in a way will never ever be paid off. What stands out most in my mind, aside from any of the pain and the problems involved, was the fact that even though some surgeries were lifesaving, I couldn`t get into hospitals because I didn`t have enough money to get into hospitals; and also, my medical insurance was canceled right after this happened because the bills would have been too much to pay. There were times when my husband had to leave a job he was on because they would take me into a hospital if I had an unemployed spouse, but they wouldn`t take me into a hospital if my husband was working.

Sen. EDWARD KENNEDY: What was the total amount of your bills?

NEAL: I would say $50,000 at that time.

Mrs. RUBY BOYCHUK, Canada: My name is Ruby Boychuk, I come from Williams Lake, I`m a public health nurse there, and I`m thirty-seven years old. In 1973 1 was on my way to Vancouver to take a course at UBC, which is the university, and approximately 200 miles from Vancouver I hit a semitruck on the highway, and that was my fault; my car went out of control, slid into this truck, and it was a United States transport truck taking mail to Alaska. I sustained eleven broken bones, I had lung and heart damage, I had facial fractures, nose fractures, I had extensive dental work done and was hospitalized for three weeks. I had five surgeries, two on my arm; I had a cast on this arm, I had another cast on my leg and had a pin put into my leg.

KENNEDY: It seems to me that in terms of the types of injuries, as Mrs. Neal had ribs, arms, legs, collapsed lung, facial and other medical difficulties, they`re very similar to yours. And you were in the hospital a number of different times, had a series of operations. Now, can you tell us what kind of expenses you had, or how you met them?

BOYCHUK: The expenses to myself?

KENNEDY: The medical expenses that you had. BOYCHUK: My expenses were nil.

MacNEIL: Next was James Williams of Banning, California, who described an operation performed on his wife.

JAMES T. WILLIAMS, United States: First she had surgery, heart bypass, the 27th day of August this year, and she did not survive.

KENNEDY: I`m sorry to hear that. Could you tell us what the bills were that you experienced?

WILLIAMS: Yes, sir. To begin with this total time involved, the time preceding the surgery was approximately a week -- five days actually in the hospital. The counseling prior to the operation, the office visit, there was one day devoted to EKG and treadmill testing. The length of the stay in the hospital was $17,389.73. This is for less than a week. The surgeon`s fee the day of the operation, $6,000. The surgeon`s assistant, $1,125 the day of the surgery. The anesthetist alone, $3,000. I`m talking about one day. The total for the week run more than $30,000.

KENNEDY: Now, you had a group policy with Riverside County, is that correct?

WILLIAMS: Yes, sir.

KENNEDY: And in spite of the coverage, did you owe any money?

WILLIAMS: I will have to pay approximately $6,000.

KENNEDY: Did you have to use up your savings?

WILLIAMS: I sure did.

KENNEDY: Did you use all Jour savings?

WILLIAMS: Yes, sir. What I managed to put aside, it went in one day.

KENNEDY: One day for thirty years of work. Mr. Stata from Prince Albert, Saskatchewan, as I understand, you had a serious operation for an aneurism, is that correct?

CLIFFORD STATA, Canada: That`s right.

KENNEDY: And when was that done?

STATA: That was in July of 1970.

KENNEDY: I see. And you`ve had other medical expenses besides your aneurism, is that correct?

STATA: Yes, I have.

KENNEDY: And how long were you in the hospital then, for the aneurism?

STATA: For the aneurism?

KENNEDY: Yes.

STATA: I was there seventeen days.

KENNEDY: Seventeen days. So you were in there three times as long as Mr. Williams` wife was in there. She was in for just about a week, is that correct?

WILLIAMS: Yes, sir.

KENNEDY: Now, did you require surgery when you were in there for three weeks? Did you receive surgery?

STATA: Yes, the aneurism was removed.

KENNEDY: Right.

STATA: And the aorta where the aneurism was was bypassed with plastic arteries.

KENNEDY: And what were your medical bills for this in particular, for the bypass for the aneurism?

STATA: My medical bills for that treatment? KENNEDY: Yes.

STATA: Were nothing. I paid nothing at all.

KENNEDY: Mr. Thompson.

GARY THOMPSON, United States: Yes, sir..

KENNEDY: Could you tell us how old you are and where you work.

THOMPSON: Senator, I`m forty-one years old, I was forty-one on October 25th, which was the day I filed bankruptcy because of my medical bills. I work at a radio station as an engineer. And what brought about the bankruptcy was my wife and I had a little girl who was born near the end of March of `76 and died near the end of June. And in those three months she spent more than half of that time in intensive care in the hospital, and the medical insurance that I have at the company where I work is very good and was paying eighty percent in the major medical field. However, even after this was paid the doctor bills and the hospital bill, what was left over came to over $10,000. I never did get a handle on exactly how much it was. She was in and out of the hospital two or three times in that period, and each time they started a new series of bills; and I was never sure exactly how much I owed, but I knew it was a large amount. And then earlier this year they were finally coming to the point where they were going to sue me and garnish my salary, and that was the time that I finally decided it was time to go bankrupt.

DONALD PATTERSON, Canada: My name is Donald Patterson, I`m an associate professor of economic history at the University of British Columbia. My wife, in May 1974, gave birth to our first child two months prematurely. It was a case of placenta abruptia. A Caesarian section was of course necessary. The child was then in intensive care for four and a half weeks. My wife was released from the hospital within seven days. The cost at that time was seven dollars, the dollar a day charge for my wife. No charge levied for the child, on the argument that since he was born in hospital he had no option and (unintelligible) fees therefore didn`t apply.

KENNEDY: Could you run that one by me....

(Laughter from audience.)

MacNEIL: The lone dissenting voice at this hearing came from the president of the Orange County Medical Association, Dr. William Thompson. He read a prepared statement calling on the government to play more of an educational role in preventive health care and less of a role in regulating medical care.

Dr. WILLIAM THOMPSON, Orange County Medical Association: Let us start with the premise that the health care delivery system in this country is the best that has been developed in any country in all of history. Other...

(Booing and dissent from audience.)

KENNEDY: Now, we`ll really have to insist on order on this.

THOMPSON: Other countries send their physicians, their medical students and their patients to this country for treatment and for training. We are the central training ground for medical students and physicians all over the world and have been for a number of years. It is only because the overall level of access and quality is so high that certain defects are magnified. It seems axiomatic in such a highly developed system that the defects should be cured by selection and evaluation and solution rather than by redesigning the entire package. It is the premise of a relatively small group in this country that too much of the gross national product is expended for health care. How does one determine what is too much? Perhaps too much of the GNP is expended for transportation, for recreation, for education. Every study I have seen indicates that people want more and better medical care.

Secondly, governmental programs have been developed to improve access into the health care system delivery by the elderly -- Medicare; by the poor -- Medicaid; more recently with women and children in the Maternicare and Pedicare type of program. In view of the foregoing, it would seem obvious that the most significant remaining aspect of medical care which is relatively uncovered and which is of extraordinary concern to many individuals is catastrophic health coverage. This type of medical coverage is long overdue. It would be appropriate for Senator Kennedy to alter his long-standing opposition to catastrophic health insurance coverage, especially in view of the current precarious economic situation in this country and President Carter`s announced step-by-step health care program.

MacNEIL: The three Canadians who testified, as you heard, all said that the care they or their families had received cost them nothing, or in one case a dollar a day. The Canadian health insurance system has been running for about ten years. It is mandatory for nearly all citizens, and it pays for just about every medical charge in hospital and outside. The Canadian federal government sets the basic guidelines, but each of Canada`s ten provinces and two territories runs its own system. Some provinces collect nominal insurance premiums, but most Canadians pay nothing directly. Private insurance companies, like Blue Cross, are not part of the system. The cost is shared by federal and provincial governments; by common measurements like infant mortality and life expectancy, Canadians are healthier than Americans and pay less for it. Also, opinion polls show that most Canadians are happy with the way it works.

But there is no shortage of critics. Dr. Raymond Robillard is a neurologist working in Montreal in the Province of Quebec. Dr. Robillard founded the Quebec Federation of Medical Specialists, which represents 6,000 doctors in fee negotiations with the provincial government. Dr. Robillard is also a member of the Quebec Health Insurance Board, which administers the system in that province. Dr. Robillard, in the Kennedy hearings -- and you took part in one of them recently in Chicago, so you are familiar with them -- Canadian witnesses, by comparison with Americans, sound very happy with their medical system. What is your reaction to the way they sound?

RAYMOND ROBILLARD: Indeed they should be; they have full catastrophic illness coverage, and as I`ve said in the hearings, there`s absolutely nothing wrong with the Canadian system as an insurance plan. What we`re talking about is not the fact that we are running a good insurance plan but the fact that it is wholly government-run and that this particular fact has brought us to a takeover of the system by the state and is leading us into a series of problems.

MacNEIL: What are those problems, as you see them?

ROBILLARD: Those problems are political, essentially. The fact that you have cut down on competition and given the government, for all ends and purposes, a monopoly of medical services in Canada leaves you a shortage of funds for teaching, research, and even the ordinary dispensation of services. We have not yet come to a situation of catastrophe; we are certainly able, from the medical profession`s point of view, to see that the warning lights are up.

MacNEIL: What in particular is wrong? Is the quality of care not the way we`re led to believe in these interviews we`ve been hearing in the hearings?

ROBILLARD: You know, quality of care is a very difficult thing to appreciate, and one must be careful when you talk about this, of looking at Canada as not a single state, as in the United States, but as a series of provinces. You have geographical situations in Canada where the system at this point functions fairly well. You have conservative governments in Canada, especially in Ontario; you have more money in Ontario than in other provinces, as the GNP goes; and then you have Quebec, which is about middle of the road, and then you have other provinces which are more sociallist. I`m from Quebec, so I can really have a good idea what`s going at home, and we have a series of parameters. The main hospitals in Montreal, as an example, are four, five, six million dollars in debt and there is no way in which the government is going to carry that debt; they have to solve the problem themselves. The only way there is to solve the problem is to close beds. The only way to run the system fairly well in Montreal is in the summertime when you close beds. We can`t admit patients in Montreal. Oh, we admit catastrophic emergencies; people don`t die on the streets by any stretch of the imagination, but if you want one example, a mild example, take medical cases -- and I`m not talking about surgical cases; we`ll come to that if you want to -- but medical cases that need to be admitted for investigation purposes. For 1,000 of population in Quebec we only admit half the number that they admit in Ontario. Then you have to say that Ontario admits twice too many, which is hard to believe, or that we admit half less than we should, which is, I think, the truth.

MacNEIL: What would you advise Americans watching those Kennedy hearings and perhaps finding the Canadian system very attractive, to think about it? Is it a good model for the United States?

ROBILLARD: Well, I think there`s a profound dishonesty --I`m sorry about the word, but I feel strongly about this -- in presenting the problem to the American citizen as purely and simply an insurance program, a better insurance policy that has to be run by the government to be more efficient. That it is not. It is a political issue fundamentally, and in a nutshell what Dr. Walters here said when he was with the Ontario Medical Association and what I have said five, ten years ago is that you don`t want to mix politics with medicine too closely.

MacNEIL: Well, we`ll come back, Dr. Robillard. Thank you. As Dr. Robillard indicated, because each Canadian province shapes its own system, there are differences. Next to Quebec is Ontario, the richest and most industrialized province. It spends about $430 per person a year on medical care, as compared with an average American cost of about $530 a head. One doctor who`s worked in both the American and Canadian systems is Jack Walters, who practices obstetrics and gynecology and teaches at Ottawa University. Dr. Walters, what do you say to Dr. Robillard`s criticisms? Is the Canadian system on the way to catastrophe?

JACK WALTERS: No, I don`t think so. I think in some provinces -probably Ontario is not a good example to quote as one that is not going in a catastrophic way -- I think they have been running it very well. I think they were running it very well before the federal government stepped in and brought us all into Medicare, and perhaps that was one of the areas that there could have been some changes made to allow the Ontario government to choose its own method. I know Premier Robards tried to make that point at the time, but they were forced into Medicare under the federal regulations, which really were not very suitable for Ontario but were suitable and needed in other provinces. So there is this variation, as Raymond has said.

MacNEIL: As a doctor working in the Canadian system, are you happy with the way it works? Is it a good system for delivering care to people?

WALTERS: Yes, I think it is. I think there are some cost problems, again, as Raymond has said. We`re trying to control these; but I think having worked in the Canadian system and in the American system it`s a relief to get back where I can make medical decisions for my patients rather than economic decisions for my patients as I had to in the States.

MacNEIL: What weaknesses do you see in the Canadian system?

WALTERS: I think one of the problems is just straight costs, and I think the priorities having been set for health and education in this province they`re mixed in together, and I think we don`t have enough money for research, we probably are wasting money in certain areas and not spending it in others; the hospitals are in financial straits right now. They are given global budgets and they have to live within them, and I think it`s difficult for some of them to do so. They are struggling with it. Here in Ottawa, for instance, we need more beds for our new health science center and university hospital, and we`ve been limited; we`re going to be moving from our old unit into a new one with less beds, and we need more beds because we`re serving a re tonal area. Those are the kind of conflicts that are coming up, and were trying to solve them but they are problems.

MacNEIL: Is it a system which could provide a model for Americans looking to improve the distribution and delivery of health care?

WALTERS: Yes, I think it could, and I`ve been interested in this, along with Raymond and Dr. Law, for a number of years. And I think if you look at some of the hearings -- and I was a little upset when I heard the Kennedy group were going to England to look at their system; I don`t think that`s a good model for North America. The British health system was different long before they had a national health insurance, and it isn`t applicable on this continent. I think the Canadian system is a good model; perhaps they won`t make the mistakes we made in some of the areas, and if they had it to do over again I think the Canadian planners probably would not have done it exactly the same here.

MacNEIL: Well, thanks; we`ll come back. It was the Canadian Federal Government in Ottawa which fought for the principle of national health insurance until it was finally accepted by all of the provinces at the end of the `60s. Dr. Maureen Law, a community health specialist, is Assistant Deputy Minister of Health in the federal government. Dr. Law, how do you answer Dr. Robillard`s criticisms?

Dr. MAUREEN LAW: First of all I would like to just clarify one point, and that is that in fact our hospital insurance program has been in effect for twenty years and what we call Medicare, which is the insurance for physicians` services, for ten years. And I would also like to point out that some provinces, for example Saskatchewan, had pioneered in both these fields before the federal government got into the act in 1957 for hospital insurance, in 1968 for physicians` services. One of the points that Dr. Robillard made and also Dr. Walters I would really like to emphasize, and that is the fact that these are provincial plans, interlocking plans with federal financial assistance. The variation from one province to another is extremely important to understand. I think that the situation which Dr. Robillard describes in Quebec is one which is a bit different from many other provinces, perhaps most other provinces in the country, in that I think it would be true to say that that is one of the provinces where the greatest effort has been made to modify the delivery system along with providing an insurance system.

MacNEIL: Going into the business of health care centers to replace some of the direct physician-patient relationships.

LAW: That`s the sort of thing I`m referring to.

MacNEIL: Has it been possible under the Canadian system to do those things which so bedevil the American system, and that is to distribute services more rationally so that you don`t have concentrations in one place and less in another, and to control the rising costs? Is that possible?

LAW: It`s very difficult, clearly, and we`ve been concerned about the distribution and we continue to b e concerned about the distribution of services, particularly physicians` services. I could say, however, that following the development of the health insurance program for physicians` services we did see some improvement in the distribution of physicians; it became economically feasible for physicians to practice in less affluent areas. We still face the problems about whether physicians want to practice in those areas, and we haven`t taken any specific actions to try to coerce physicians into underdoctored areas or whatever. But at least it has become economically feasible for them to do it, and some provinces also have developed incentive programs to try to encourage physicians into those areas.

With respect to the costs of health services, again, it`s a very complex issue and certainly we have not been as successful as we would like to be in the control of costs. Nevertheless, I think it is interesting to note that in the last, say, six or seven years we have been able to keep the costs of health services at relatively the same proportion of gross national product. That is, around seven percent, which is lower...

MacNEIL: Which is lower than in this country

LAW: Right, than in the United States.

MacNEIL: One final question. Why does the Canadian system not use private insurance companies, which is often talked about here as the next step towards a national health insurance system?

LAW: There was a decision made not to -- well, first of all, private insurance companies could be used, theoretically, by a province as the carriers for insurance, and that has been done in some provinces at some points in time. However, they have to be administered on a non-profit basis; the program generally does, and also on a publicly accountable basis. And provinces which have experimented with that have generally found it to be more expensive than running the program themselves. The decision to keep private insurance companies out of the business of insuring the basic services which are covered by the insurance program is to avoid a situation where there could be two classes of medicine, one for those covered by the insurance program and one for those who could afford extra premiums for special treatment. They are in the business, I should say, of providing for non-insured services such as drugs, eyeglasses and things that are not generally covered by the insurance programs.

MacNEIL: We just have a minute or so left; I just want to ask each of you very quickly: Dr. Robillard, what is the lesson for Americans in the Canadian system, as you see it?

ROBILLARD: Well, don`t destroy what you have. Don`t think that the doctors are the culprits of this system right away, that you have to destroy the system, and don`t talk with them for fear that they will not cooperate; I think that`s untrue. And that`s the single most important lesson that I have -- you don`t give lessons to the United States, but I mean piece of advice that I have if we had to start over again. I think Jack alluded to that. He worked with me very closely at the time we tried to establish a meaningful relation with the government. We had a meeting here in Toronto about a month ago with representatives of the American Medical Association in a seminar trying to tell them about the system here, and representatives of all provinces, including Ontario, told us the same thing: physicians are demoralized and they don`t feel they are bits and parts of it, and they don`t contribute to the elaboration of the system and they are facing difficulties.

MacNEIL: I`m sorry, and I apologize to the other two of you. We have to leave it there; I`m awfully sorry. But thank you very much for joining us this evening. And good night to all of you in Ottawa. That`s all for this evening. We`ll be back tomorrow night. I`m Robert MacNeil. Good night.