Physician and health policy analyst based in Toronto, Canada. He is also an adjunct professor in health policy studies at the University of Toronto. His latest book is Prescription for Excellence: How Innovation is Saving Canada’s Health Care System.
As premier of Saskatchewan, Tommy Douglas pioneered a number of progressive policies there, including the expansion of public utilities, unionization and public auto insurance. But his biggest achievement was the creation of universal health insurance, called Medicare. It passed in Saskatchewan in 1962, guaranteeing hospital care for all residents. The rest of Canada soon followed, province by province. After his death, Douglas earned the title of "The Greatest Canadian" in a poll by the CBC. We speak with Canadian doctor Michael Rachlis. [includes rush transcript]
SHARIF ABDEL KOUDDOUS: We continue our look at healthcare in foreign countries. We’re going to turn now to Canada. In a moment, we’ll go to Toronto to hear from physician and health policy analyst Dr. Michael Rachlis. But first, we turn to the words of Tommy Douglas, a Canadian politician who helped usher in Canada’s single-payer system.
As premier of Saskatchewan, Douglas pioneered a number of progressive policies there, including the expansion of public utilities, unionization and public auto insurance. But his biggest achievement was the creation of universal health insurance, called Medicare. It passed in Saskatchewan in 1962, guaranteeing hospital care for all residents. The rest of Canada soon followed, province by province.
In 1983, three years before his death, Tommy Douglas spoke about healthcare at the fiftieth anniversary of the founding of the Co-operative Commonwealth Federation, his longtime political party.
TOMMY DOUGLAS: When you go back to your constituency and you run into somebody who says, “Oh, it’s a good idea for you soft-hearted humanitarians, but we can’t afford it,” let me give you a simple statistic, which you can put down on a piece of paper and carry in your hand. And that is that our friends in the United States are spending nine percent of their gross national product — and they get a higher per capita gross national product than we do — they spend nine percent of their gross national product on healthcare, and 34 million of their people have no healthcare coverage. And in Canada, we spend seven percent of our gross national product, and every man, woman and child in Canada is covered under Medicare.
If you want a two-tiered health program, then just continue the way we’re going. And I remind you that in this movement, we pledged ourselves fifty years ago that we would provide healthcare for every man, woman and child, irrespective of their color, their race or their potential status, and, by God, we’re going to do it!
AMY GOODMAN: That was Canadian politician Tommy Douglas speaking in 1983. Eleven years later, a nationwide poll conducted by the CBC earned Tommy Douglas the title of "The Greatest Canadian."
Well, let’s look at this country, the United States, America, 2009. Eighteen thousand people have died in one year, an average of almost fifty a day. Who’s killing them? To investigate, President Obama might be tempted to call on Jack Bauer, the fictional rogue intelligence agent from the hit TV series 24, who’s invariably employing torture and a host of other illegal tactics to help the President fight terrorism. But terrorism is not the culprit here; it’s lack of adequate healthcare. So maybe the President’s solution isn’t Jack Bauer, but rather the actor who plays him.
Yes, that’s right. The star of 24 is played by Kiefer Sutherland, whose family has very deep connections in healthcare reform. That is, in Canada. Take a listen to Kiefer Sutherland.
KIEFER SUTHERLAND: Hi, my name is Kiefer Sutherland. Many of you may know me [inaudible], but there’s something in my background that you may not know, something which I am very proud of. I am also a grandson of the late Tommy Douglas, a premier who brought enormous change to Saskatchewan and the rest of Canada.
AMY GOODMAN: Yes, that’s Kiefer Sutherland, the grandson of the late Tommy Douglas, the pioneering Canadian politician, the premier of Saskatchewan who helped usher in the modern Canadian healthcare system.
We turn right now in Toronto to a doctor who is very important in this system, Dr. Michael Rachlis, physician and health policy analyst, also adjunct professor in health policy studies at the University of Toronto. His latest book, Prescription for Excellence: How Innovation is Saving Canada’s Health Care System.
We welcome you to Democracy Now! What does our debate look like on your side of the border up north, Dr. Rachlis?
DR. MICHAEL RACHLIS: I think I can say that across the political spectrum in Canada, almost across the political spectrum, we’re quite appalled at the level of the debate in the United States and, in particular, what’s being said about our country’s healthcare system.
AMY GOODMAN: You know, when Tommy Douglas pushed through universal healthcare, single payer, in Saskatchewan, he had a major opponent: the US American Medical Association, who led a strike of Canadian doctors in Saskatchewan. Despite this more than three-week strike, universal healthcare, single-payer system in Canada, was instituted, first in Saskatchewan, then adopted all over. Explain the system as you have it today.
DR. MICHAEL RACHLIS: Yes, and I think that there are many misunderstandings, unfortunately, about our system. And I should make it clear that my intention certainly isn’t to push our system on your country. You’ll have to make your own choices. But I am trying to clear up some of the misconceptions.
Our system evolved over the same time as you were making decisions about your system in the ’40s, ’50s and ’60s. We initially had hospital insurance in Saskatchewan under Douglas in the 1940s. Then, in 1957, the federal government brought in a hospital insurance program, which led the way for other programs after it, in that our federal government is not responsible for healthcare. It is the provinces, by our constitution. But the federal government provided money to the provinces, if they met certain terms and conditions for their insurance programs. And one of them was universality. All the provinces bought into the federal hospital program in ’57. And then that — because Saskatchewan then had some money from the federal government for their hospital program, they were able to push ahead to medical insurance in 1962, which wasn’t as popular with physicians as the hospital insurance program, which is why, as you mentioned, physicians did go on strike. But the strike was settled. And a federal government royal commission in 1964 recommended a Saskatchewan style of medical insurance for the whole country, and the federal government passed their medical insurance legislation in ’66, enacted it in ’68, and then all provinces had bought in by ’71.
In parallel, in your country, Truman almost launched a national health insurance program in the late ’40s, defeated by a concentrated AMA lobby. And then, in the 1960s, you grappled with whether to go to a universal program, but ended up with two programs for those populations that the private insurance system wouldn’t cover — the elderly and the very poor — your Medicare and Medicaid programs.
So, in Canada, our national health insurance program, again, is a mandate from the federal government that if the provinces want the federal money, they have to meet certain terms and conditions. But as opposed to being so-called socialized medicine like in Britain — excuse me — where the government employs the doctors directly and owns the hospitals through the National Health Service, in Canada almost all doctors are in private practice. And although it varies from province to province, in the largest province, Ontario, with almost 40 percent of the population, all our 160 hospitals are private, although not for-profit, entities.
And the government program pays for care for whatever physician or hospital you choose. And that’s another myth in the US debate these days, that we can’t choose our doctors or hospitals. In fact, we have completely free choice of physicians in this country. And wherever you go, you take your Medicare card with you, and then the government will pay the bill.
SHARIF ABDEL KOUDDOUS: And Dr. Michael Rachlis, you recently penned an op-ed in the Los Angeles Times, where you outlined five lessons of the Canadian system for the US system. Can you go through them?
DR. MICHAEL RACHLIS: Yes, that the first couple of lessons have to do with the — simply, it’s economics 101. That is, that if you have a single-payer system, like Canada has — and virtually every other wealthy country, as well, has some variation of either a national health system like the UK or, more commonly, a national health insurance program like France and the Nordic countries, etc. — that if you have a single-payer system, when you don’t have to have thousands of actuaries to set premiums or thousands of lawyers in your country to deny care, there’s huge savings on administration, both within the insurance system but also in doctors’ offices.
A recent report in the US said over six percent of all doctors’ revenues are spent on billing and reconciliation. The Massachusetts General Hospital has more people working in their billings and reconciliation department than we have at the Ontario Health Insurance Plan head office to administer health insurance for 13 million people. So, all through the system, there is increased administration.
And so, Canada spends ten percent of its gross domestic product of our national economy now on healthcare. You folks are spending 16 percent. Half of the difference is due to the increased administration of insurance, and the other half is due to the fact that a single-payer system can negotiate much lower prices than multiple payers in your system. And so, about half of the rest of the difference is due to higher prices.
In fact, Canadians get more of some services than Americans. We get fewer of some high-tech services, but even in the high-tech end, like for lung transplants, Toronto is an international center. We do more lung transplant surgery per capita than the US.
So, the first couple of lessons would be that single payer or a national health insurance program is going to be cheaper, because it will have lower administrative overhead and, secondly, because we’ll have lower prices. And then, that, too, that a national health insurance program, or single payer, also means that everybody is covered.
And even the problems with Canada’s health system — and we do have them. We do have longer wait lists than you folks have for a lot of elective care. Notwithstanding some of the high-profile cases in your country of Canadians who apparently couldn’t get care for urgent conditions, they’re just not true. Canadians who have urgent conditions do get care right away, but we wait longer for elective care than Americans. But on the other hand, Americans wait longer for an appointment with a specialist or elective surgery than do the French or the Germans. And so, even the problems in Canada’s system, I think, are illustrative to you folks, because a lot of our problems, like the wait times that we have, have nothing to do with our national health insurance system.
And, in fact, using a process, improvement techniques that have been pioneered by Americans, largely, through the National Institute of Medicine and the Boston-based Institute for Healthcare Improvement, in some parts of Canada the last few years, wait times have plummeted. In Toronto, for example, it was common for people to wait up to a year for cataract surgery or joint replacement surgery, up until four or five years ago. Now there are assessment centers that people can refer themselves to. They can see a specialist quickly. And from the first phone call to getting their eye surgery or joint replacement surgery, now is only taking something like four to six weeks in Toronto, without much more money, but simply with process improvement in healthcare.
So our good points, I think, are certainly illustrative for you that they demonstrate what any economist teaching a first-year class could tell you, which is that single payer will reduce administration, administrative costs. And then, even our problems, like waits for care, are illustrative, because they show that they’re not really due to the fact that we have national health insurance; they’re much more due to problems within the system and the way that administrators and doctors, in particular, have organized their practices.
SHARIF ABDEL KOUDDOUS: And Dr. Rachlis, we just have about a minute left. But you raised this very interesting point about the issue of choice. We hear a lot in this country about how we want to have free choice of doctors, but it’s actually Americans who are restricted by these — having to choose within your plan for a doctor.
DR. MICHAEL RACHLIS: Yes, that’s right. I mean, I’ll give you an example. A cousin of mine in Toronto a few years ago was told that he needed a gastroscopy examination, examination of his stomach through an endoscopic tube. He was originally told by his family doctor that the usual specialist she referred people to would take fifteen weeks. But he used a public website for the College of Physicians and Surgeons in Ontario and found a gastroneurologist who could do his procedure the following week. His family doctor made the referral, and he had his procedure. So you can choose any doctor you wish in Canada. They might not always be able to see you, but we have completely free choice of care. And as you mention, many Americans do not these days.
AMY GOODMAN: Dr. Michael Rachlis, finally, the answer to the question that is continually posed by those who oppose any kind of public plan, and that is, having a bureaucrat between the doctor and the patient. Your response to that?
DR. MICHAEL RACHLIS: That there certainly isn’t the kind of formal rationing that people have been describing in your country. Or we don’t have death panels in this country, for example. That the decision about treatment is made actually just between the doctor and the patient. The insurance plan is virtually never involved. And ironically, in your country, it’s the private insurers that often stand between patients and physicians.
You have to finance healthcare some way. And then there have to be some decisions made about what’s covered and how you’re going to organize those services. In our country, we made the choice to have it as a public insurance plan and to make those decisions democratically. And somewhat ironically, in your country, those decisions, they’re left to somebody, but in this case they’re left to private insurers who appear to be a whole lot less accountable than our elected politicians are in this country.
AMY GOODMAN: Dr. Michael Rachlis, we want to thank you for being with us. His latest book, Prescription for Excellence: How Innovation is Saving Canada’s Health Care System.