”Quand on se regarde, on se désole; quand on se compare, on se console.”
That French proverb has no pithy English equivalent but essentially says: “When we look at ourselves, we despair; when we compare ourselves to others, we take comfort.”
If there is a guiding dictum in Canadian health care, that has to be it.
We bellyache relentlessly about the failings of Canada’s health system – the waits, the shortages, the costs. But we can always look to the train wreck of a non-system in the United States – with millions of uninsured, perverse prices and partisan political machinations, and think “it could be worse.”
A new study, published in the Journal of the American Medical Association, sets out to answer the question: “Why is health-care spending in the U.S. so much greater than other high-income countries?”
The JAMA paper also provides a rare opportunity to compare health performance among 11 peer countries, including the United States and Canada.
U.S. health spending is almost double that of other countries because they pay more for everything: drugs, equipment, salaries and so on. As the late, great health economist Uwe Reinhardt said: “It’s the prices, stupid.”
The new research, however, challenges several other assumptions, showing that health-care utilization is not much higher in the United States (with one exception – diagnostic imaging), that the country does not grossly under-spend on social programs, and that the preponderance of specialist physicians is what is driving up cost.
There is much to give pause to politicians and policy-makers here in Canada, too.
The United States spends US$9,403 per capita on health, or 17.8 per cent of GDP. Median per-capita spending in other countries is far less, US$5,419, or 11.5 per cent of GDP.
Canada spends US$4,641 per capita on health, or 10.3 per cent of gross domestic product. That ranks 7 among 11 countries. If you look at public spending alone, it’s 7.4 per cent of GDP; even the United States spends more on health from public coffers, 8.3 per cent of GDP.
The notion that health spending is out of control and gobbling up too much of our tax dollars simply does not hold up to international scrutiny.
What is more shocking, though, is how comparatively little Canada spends on social programs – 13 per cent of GDP, dead last. Denmark, by contrast, spends 27 per cent on social programs; even the hard-hearted U.S spends more, 16.7 per cent.
This underscores the findings of a recent paper in the Canadian Medical Association Journal that showed Canada has systematically under-invested in social programs over the past three decades.
The new JAMA paper also provides illuminating data on a number of topical issues.
Canada spends only 14 per cent of its health dollars on long-term care for the aging population, compared to 26 per cent by Sweden. Canada spends the least on in-patient hospital care, at 17 per cent, compared to 32 per cent for the Netherlands. Canada also has among the lowest number of hospital beds, 2.7 per 1,000 population, compared to 13.2 per 1,000 in Japan. It follows that this country has among the shortest length of hospital stays.
On the politically charged issues of staffing and remuneration, the data tell a mixed tale. With 2.6 physicians per 1,000 population, Canada has one of the lowest ratios of doctors, ranking 9 among 11 countries. But the data show that, more than anything, there is a maldistribution problem: Canada ranks third in physicians in urban areas, but dead last in rural and remote areas.
Canadian physicians, on an international scale, are well-paid, with average income of US$146,286 for general practitioners (3 of 11) and US$188,260 for specialists (4 of 11). By comparison, U.S. GPs earn on average US$218,173, and those in Sweden US$86,607; U.S. specialists make US$316,000 on average, compared to $US98,452 for those in Sweden. (These figures are U.S. dollars adapted for purchasing parity, so they are directly comparable.)
Finally, as the pharmacare debate rages, it’s worth looking at prescription-drug spending. Canadians spend US$613 per capita on drugs, eighth among 11 countries. But only 36 per cent of drug costs are covered publicly; in France, it’s 80 per cent; only the United States spends fewer public dollars on prescription drugs. Canada also has the second-highest rate of private insurance for drugs, 30 per cent, compared to 0 per cent in Sweden.
In these comparisons, we can find reasons for both despair and relief, but mostly food for thought to inform more sound and nuanced public policies.