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opinion

Michael Moore has a habit of exaggerating differences in Canadian and American culture as a device for persuading U.S. audiences to examine their values. In a scene from his anti-gun movie Bowling for Columbine, for example, Mr. Moore walks unannounced into an unlocked Windsor household. Following some chatter, he thanks the homeowner for not shooting him for the intrusion. We would all agree that there is less gun violence in Canada than in the United States - but not many of us feel secure enough to leave our doors unlocked.

Mr. Moore's new film, Sicko, emulates this approach by presenting an unbalanced comparison of the U.S. and Canadian health systems that ignores real problems in Canadian health care. Notwithstanding the exaggerated rhetoric that Mr. Moore uses to make his point, however, there is clear evidence that Canadians do, indeed, have a better system than our neighbours.

Canadian health care is often attacked by invoking anecdotes about patients who have experienced long waits in achieving access to services. But there are similar anecdotes describing the problems in accessing care experienced by the 44 million Americans who lack health insurance. In making a rational comparison of the Canadian and U.S. health systems, it is appropriate to contrast costs and patient outcomes of the systems rather than trading anecdotal sniper attacks.

Canadians pay about 9 per cent of GDP to insure 100 per cent of citizens; Americans expend more than 14 per cent of GDP to insure 85 per cent of the population. The Kaiser Family Foundation reports that the average compound annual growth rate in U.S. health-insurance costs has been 11.6 per cent over the past five years. It is, therefore, not surprising that polling by Kaiser found that 75 per cent of Americans were worried about the amount they would need to pay for health insurance in the future and that 63 per cent were worried about not being able to afford health-care services.

This remarkable growth in health-insurance costs also suggests that the U.S. insurance industry will protect their revenues by attacking Sicko and the movie's positive depiction of Canada's publicly funded health care. (Check out "What Michael Moore Left Out of His Movie" at for Health Care America's response.)

The Commonwealth Fund is a private American foundation that aims to promote a high-performing health-care system. In 2005, the fund evaluated access and continuity of care for adults with chronic illness across five countries. Comparing results in Canada and the United States, they found that 97 per cent of Canadians had a primary doctor and that 78 per cent had visited the same doctor for more than five years. In the U.S., only 84 per cent had a doctor and barely 50 per cent had the same one for more than five years. They also found that 26 per cent of Canadians and 51 per cent of Americans reported an unmet health need within the past two years due to cost. Finally, 29 per cent of Canadians, versus 39 per cent of Americans, reported difficulty in achieving access to care at off hours.

That is not to say that Canada's health-care system is flawless. There is no question that suboptimal access to tightly controlled health services has contributed to the lower costs of health care in Canada. But targeting new funding in our system to improve access, combined with transparent reporting of results and a pay-for-performance approach, is resulting in Canadian patients getting more timely access to higher quality care.

Those of us who have worked in hospitals north and south of the border admire the top performers in the American system for their innovation and relentless pursuit of excellence. But it is often difficult to understand the lack of an evidence-based approach to resource utilization and the tendency of U.S. centres to invest in expensive new technology based on marketing strategy. Prudent adoption of expensive technology does not result in worse patient outcomes in our system. For example, comparisons of five-year cancer survival or cardiac-surgery mortality show that Canadians have equivalent or better outcomes than Americans in these areas. Dr. Elliot Fisher of Dartmouth University has evaluated regional differences in costs of health care and patient outcomes across the United States. In an editorial in The New England Journal of Medicine in 2003, he said states with higher per capita health spending actually have worse outcomes.

Canadian health care is an economic as well as a social asset. Auto makers produce cars $1,500 cheaper in Ontario than in Michigan because of cost-effective health insurance. The scientific talent present in the University of Toronto research hospitals has recently attracted Alexandria Real Estate Equities Inc. to invest $350-million (U.S.) in new biology laboratories in this city. The publicly funded health system is an asset for today's manufacturing jobs as well as for the scientific jobs of the future.

Canadians spend about 55 per cent of what Americans spend on health care and have longer life expectancy and lower infant mortality rates. Many Americans have access to quality health care. But all Canadians have access to similar care at a considerably lower cost. Michael Moore exaggerates the excellence of Canada's health-care system. But his hyperbolic approach should not prevent us from concluding that the Canadian system is much better than the American one.