Almost a year after President Lyndon B. Johnson signed Medicare into law, Prime Minister Lester B. Pearson followed suit. Despite being similar in name, the Canadian bill covered all persons. It’s what we’ve come to know as universal health coverage, and it has been a principal difference between our two countries ever since.
You may also know of the narrative that has saddled American health care: yawning disparities in access, plenty of administrative “waste,” as well as gross overpayments for routine health services. Add last-place finishes in the Commonwealth Fund’s global rankings, and on the surface, the case for drawing lessons from America could seem fatuous.
This time, however, we find our neighbours four years into the Affordable Care Act (ACA). Some hail it as the “civil rights bill of a lifetime,” others don’t think it went nearly far enough, and when called by its nickname, Obamacare, it might as well be a Rorschach test for your feelings on the U.S. President himself. In fact, it’s a bill that recognizes markets alone won’t cure health care, while setting the stage for local policy experiments across the country. And as the ACA is widely being scored in its tally of the insured – over 20 million to date – extending health insurance is only one of its provisions. The rest of it aims to deliver care that is less expensive, more effective, and squarely patient-centred.
This is a challenge that should sound familiar. It’s one most countries are grappling with, including ours. And as we string together lessons from higher-performing systems, such as in Europe, it might also be worth taking a humble look at this legislative leviathan.
Focusing on payment reform: holding providers accountable
A centrepiece of the ACA is the formation of accountable care organizations (ACOs). These are essentially networks of providers responsible for the whole spectrum of care through lump-sum payments. As an example, if a patient is managed in a cost-effective fashion, any savings are shared among providers. In contrast to LHINS (Local Health Integration Networks) in Ontario, the concept here is to do away with the bureaucratic layers and get right to what is really known to drive costs: the physician’s pen. To make sure this doesn’t lead to systematic rationing, providers can’t keep the savings unless they reach measurable quality improvements. Surely, not all ACOs will be equal either; and only time will tell how successful they are in bringing costs down. But if they can eliminate unnecessary tests or procedures, there lies an upside both for patients and the public purse.
While a fee-for-service model alarmed Bernard Shaw more than a century ago, much of Canada still runs on one. Experimenting with how to better align incentives with the needs of the patient should continue at home, while also finding the right mix of bundled payments to improve the co-ordination of care. There are certainly trade-offs with different payment schemes – and questions over which quality measures work best – but the United States is moving the way of rewarding value over volume. We should, too.
Moving upstream: solving a health-care paradox
The ACA asks whether America has been spending all that money in the right places. Washington, a capital mired in gridlock, has long burdened the health-care system with deep social inequalities. Now, in a seemingly roundabout approach, the ACA is tasking hospitals to come up with solutions. In tying payments to outcomes that involve social factors, such as how often a patient returns to the hospital, it’s nudging providers to move more care into the community. And to build healthier neighbourhoods, the ACA rolled out the Prevention and Public Health Fund – a near $15-billion (U.S.) response to the fact that most health-care costs are for preventable conditions. With such moves upstream and out of the hospital, we may be watching a serious departure from the medical fortresses that have long defined the American health system.
On the matter of a healthy society, Canada blazed a trail with the Lalonde Report more than 40 years ago. The premise was not to conflate health with health care alone. That meant reducing infections from hospital stays, but also protecting citizens from the pathologies of poverty. Fast-forward to today and we now stand last in early childhood education spending among our OECD peers, an area known to have some of the best returns for health and our economy. Perhaps then, the lesson here from America serves as more of a warning: Relatively skimping on social services can stack the deck against good health outcomes for future generations. That’s a costly game no government wants to play.
Focusing on transparency: Big data and value
One of the biggest knocks on America’s health-care system is that it operates under a shroud of secrecy. For all the free-market talk, it’s been hard to figure out what anything costs, which technologies work or who’s paying whom. As part of the Obama administration’s effort to improve transparency, the U.S. Centers for Medicare and Medicaid Services released a landmark dataset on payments to physicians earlier this year. This data deluge took decades of litigation, and – while it’s far from perfect – the hope is to detect some forms of fraud and shed light on practice patterns across the country. To better inform patients, the Physician Payment Sunshine Act will also require drug companies to publicly report virtually every transfer of value to doctors and hospitals. Moreover, for a country that has a deep disdain for limits (see death panels), the ACA ended up introducing the Patient-Centered Outcomes Research Institute
Much of this could be done in Canada. Our single-payer system offers a big data platform that can help drive innovation. And in committing to greater transparency, patients will know how often surgeons are doing certain procedures, or how much their family doctor is receiving from pharma before filling a prescription. More research comparing different treatment options can also help assure patients that they are making the best possible care decisions. All this is important because it gets Canada closer to a crucial question: Where should we allocate our resources to get the best possible impact on people’s health?
The audacity of hope in health reform
U.S. President Barack Obama’s health reform can be a source of inspiration for Canadians. Especially when the obstacle is ultimately one of political leadership: Where a federal government is being faulted for doing too much, ours seems content in simply writing cheques. Where health-care providers are bunching together in the United States, we have failed to leverage the true efficiencies of a single-payer system. And so the saga continues.
This just can’t afford to happen any more – not when we’re sleeping next to an elephant fed up with being last.
Andrew S. Boozary is a resident physician at the University of Toronto and visiting scientist at the Harvard School of Public Health. Follow him on Twitter at @DrAndrewB. Pierre-Gerlier Forest is the director of the Institute for Health and Social Policy at the Johns Hopkins Bloomberg School of Public Health. He can be followed on Twitter at @pgfor.
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