At sporting matches, it is customary for fans of the home team to chant unflattering jabs at their opponents, and the Sunday night soccer "friendly" game between Canada and the U.S., played at Toronto's BMO Field, was no exception.
What was unusual though was one of the taunts chosen by the Canadian faithful: "Free health care, free health care."
If there is one thing that distinguishes the two neighbouring countries, it is their health care systems.
Canada's state-funded insurance program, informally known as medicare, ensures a measure of universality and equity in health-care delivery. It is, for better or worse, often held out as this country's defining feature, our pride and joy. This despite the fact that medicare coverage is far less comprehensive than any other universal health system.
The U.S., as we all know, has a non-system that is far more polarized and less equitable. Those who are insured privately tend to have extensive coverage and great care, while tens of millions of citizens who are uninsured or underinsured pay heavily for their care (to the point where health expenses are a leading cause of bankruptcy) and must sometimes depend on charity.
These distinctions are well known, if frequently exaggerated for political effect.
It is not surprising, then, that the taunts of soccer fans would spark an interesting polemic on Twitter.
Are soccer fans more politically astute and clever than hockey fans, who tend to limit themselves to profundities like "Go Leafs Go" and "Crosby sucks"?
Or, more to the point, do Canadians really think health care is free?
Last year in Canada, we spent an estimated $200.5-billion on health services. About 70 per cent of the total, $141-billon, was paid from public coffers and the other $59.5-billion with private insurance and out-of-pocket.
The "free" part, presumably, is the public piece of the pie.
While they don't get doctor and hospital bills, Canadians are all-too-aware that these services are paid for through taxes just as they are aware that the "benefits" deductions from their paycheques pay for things like drug insurance.
Health spending now gobbles up more than 38 per cent of most provincial budgets – ranging from 30 per cent in Quebec to 47 per cent in Nova Scotia.
The public policy question is whether or not paying for health-care services fairly amorphously through taxation – both income taxes and sales taxes – leaves individuals oblivious to their own health-care costs. In other words, do they overuse care, going to the emergency room for a tummy ache or a hangnail, for example, because it's "free"?
There are a lot of inefficiencies but there is actually little evidence that Canadians overuse the system. The long waits for care, both in emergency rooms and in booking physician visits, actually discourage abuse. And let's not forget that problems like overuse of emergency rooms are a symptom of bad structure and management, not a proof that Canadians are health-care spendthrifts.
One of the defining characteristics of the U.S. system is, in fact, overtreatment. Paying directly for care actually fuels demand because a) people want to get their money's worth for their insurance premiums and b) the private-driven system needs volume to be profitable.
When you have people paying for care directly – not indirectly, through taxation – the only ones actively discouraged from seeking treatment are those who can't afford it. Paradoxically, they are often those most in need.
Because of the widespread belief that Canadians abuse medicare, it is often proposed that they be sent statements (or, if you prefer, shadow bills) that enumerate the costs of their care.
This has actually been tried but did not have the desired results. First, the Canadian system does a poor job of tracking costs of specific interventions and procedures. Doing so would require a significant investment in better data collection – which would not, in itself, be a bad thing.
The problem is that when people were sent shadow bills – as was done in a large-scale experiment in Alberta many years back – they often reacted angrily, feeling they were being judged and blamed for getting care. After all, the reasoning goes, we pay our taxes and one of the principal benefits of that is "free" health care.
So, no, Canadians don't think their health care is free per se. But they do see access to health services as a right, one they have paid for collectively and can use as they see fit.
This sense of entitlement may well be an impediment to reforming health care, to getting a smarter mix of private and public coverage of health services (as is done in most European countries, which tend to be cheaper and more cost-effective overall).
But that's how the discussion needs to be framed. We shouldn't be angry or disgusted that Canadians are going around chanting that their health care is "free," at sporting venues and otherwise – as some in the Twitteverse appeared to be.
Rather, we should be stressing that there are limits to the care that can (and should) be provided by the state in a universal system.
What we saw at the Canada-U.S. friendly match was a prideful display in medicare. What we must not do is allow pride to give way to vanity and the naive belief that, because our system is more equitable than the American one (at least on the surface), we can rest on our laurels.
Universal health coverage provided, in part, through a state-funded insurance program is a good foundation, one that's cost-effective.
That statement doesn't roll off the tongue like a chant of "free health care, free health care," but the message is essentially the same. Let's not make the mistake of thinking the public is too stupid to know it.