A conversation with Howard Dean

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On Monday, a group of prominent American and Canadian physicians will debate, in Toronto, the question: "Be it resolved that I would rather get sick in the U.S. than in Canada." One of the panelists is Howard Dean, the former governor of Vermont, chairman of the Democratic Party and a one-time presidential candidate. He is also author of the new book Howard Dean's Prescription for Real Health Care. During the health-care reform debate, Dr. Dean was one of the most outspoken proponents of the "public option" - offering state-financed insurance similar to what exists in Canada. He spoke to The Globe and Mail about the views he will be putting forward in the debate.

You were a strong proponent of the public health-care option in the U.S. Why?

A public plan allows people more choices. The truth is we have a social system for veterans, we have a single-payer system like Canada's for people over 65 and we have a private enterprise system. I think the best way to get reform [is]to give people more choices and let them do the reform.

But one of the principal criticisms of a public system, a single-payer system like Canada's, is that it robs consumers of choice.

Well, the U.S. system is not the same as Canada's. What I was proposing is a choice: a socialist system, a single-payer system or a private enterprise system.

Would a Canadian-style system work in the U.S.?

It would certainly work in terms of delivering good health care for less money - because that's what Canada does now. But from a political point of view, it would be very difficult to implement a single-payer system.

People tend to forget that you already have some socialized medicine in the U.S., as well as a large single-payer system.

Medicare is not socialized, not in the U.S. and not in Canada. It's a single-payer system. Despite what is often said, your system is not socialized, it's a single-payer insurance system. The Veterans Health Administration, however, which has 25 million people in it, is a truly socialized system - it's government-owned and government-operated and it's worked very well. In fact, the VHA is the No. 1 rated system in the country, according to patients.

What are Americans afraid of - why are they reluctant to expand those models?

I think they have been told a number of things that were not so, a number of very alarming things, and the Democrats were slow on the uptake in counteracting those lies.

Health-care reform dominated the headlines for a long time. Was it successful?

We didn't pass reform. All we did pass was putting more money into what we already have. It's successful in a sense that 1) we got a major bill passed, which is something for a new administration; 2) we created a system that's going to force reform because of the financial realities; 3) a great many more people are going to have coverage. But this system is still not nearly as effective and efficient as the Canadian system.

The big knock against the Canadian system is wait times. Is that a deal breaker?

Wait times is an issue that is greatly exaggerated by American politicians. The truth is that there are wait times in the Canadian system, but with emergencies and urgent situations, the wait times disappear and that's as it should be.

Can you have a universal system without undue wait times?

It depends on your definition of undue waits. From a medical point of view, the answer is absolutely yes, of course you can. But most things we do in the medical system are not required at all, let alone required immediately. From a political point of view, people want what they want right away. Consumers are difficult: They want everything, they want it right away, but they don't want to pay for it. There's a trade-off.

You're a physician. There is an assumption physicians don't like a universal system because, with less competition, they come out losers.

I know a lot of American physicians who would much rather practise under a Canadian model. There is less malpractice, more actual health care, and a lot less bureaucracy like insurance forms to fill out. I think it depends on why you went into medicine. If you want to make a lot of money, the Canadian system is not for you; if you really like to take care of patients, the Canadian system is well suited.

What's the single most important lesson that Americans can take from the Canadian system?

It covers everybody with a relative lack of bureaucracy. I know Canadians think there is bureaucracy, but you haven't seen anything until you work in a system with several hundred insurance companies that all do something different. American hospitals have a whole floor occupied by a billing office. You don't have that in Canada.

Conversely, what's the most important lesson Canadians can take from the U.S. health-care system?

I'm afraid I'm not sure there is one. There is more cutting-edge innovative technology, but the cost of that is to pay 70 per cent more than Canadians do for health insurance. Canadians will have to decide if that's a lesson they want to learn.

Bottom line, which system is better for the patient?

I've spent a lot of time in both countries and there is no doubt that you're better off getting sick in Canada.

But don't you have the best health care in the world? We hear that mantra constantly.

We have the best health care in the world for people who can afford it. But Canada has very, very good health care for everybody.