It's nice to be included. In Canada we usually sit on the sidelines and observe American angst about large issues such as Vietnam, drugs, and urban decay. It's not that we don't have problems of our own, it's just that (in the absence of intensive media hype) our problems never seem as large or as dramatic. But in health care we finally have found a common concern.
Best of all, America has taken a real interest in our health-care system, an interest we are well aware of because Canadians are exposed to essentially the same media as Americans. The Canadian media have drawn further attention to the American news coverage by running stories about it. One local television station tracked down a number of the Canadians interviewed for the Walter Cronkite documentary Cross Border Medicine and stopped just short of asking them about the thrill of being interviewed by an American network news teams.
The attention has been flattering, but unfortunately we were unprepared. Because the Canadian medical system is not a business, statistics on cost, price, and service were not available.
Consider waiting lists, one quirk of the Canadian medical system that attracted a lot of attention but was not well documented. Waiting lists exist in hospital mainframe computers and on surgeon's ledgers, but these data are rarely gathered and studied. Prior to 1989, the last attempt to document the waiting lists for specialists was by the Ontario Medical Association in 1982. Despite public concern, we found evidence of only three other papers studying the waiting-list phenomenon in Canada. One was written in 1967, which gives you an idea of how old the problem is; a second covered only three operations; and the last was a short American study.
Since 1989, the Fraser Institute, an independent Canadian think tank, has been attempting to fill this information void. In 1991 we published a report on the findings of a pilot study in British Columbia. In this pilot project we developed a mail survey that we sent to specialists in 10 areas of practice. We asked them about the average wait and the number of patients waiting for 58 common procedures. Based on their responses, we determined the average wait for each specialist and for each procedure. Then President George Bush used our estimate of the average wait for coronary-bypass surgery in his speech outlining healthcare policy.
The following year we mailed an improved version of this survey to physicians in five provinces (see "Cold Reality," March 1992), and in 1992 we surveyed all 10 Canadian provinces. Our research shows that waiting for treatments and appointments is a significant problem in the Canadian medical system. Waits for medical services differ by region, and these differences are closely associated with per-capita health-care spending. We also found that strikes temporarily increase the length of waits for most surgery.
The Fraser Institute estimates that 177,000 people in Canada waited for hospital admissions in 1992, a lower number than the 234,000 estimated in a 1991 patient survey by the research organization Statistics Canada. But even our conservative figure suggests that almost 0.7 percent of the Canadian population had to wait for hospital services last year. If a similar percentage of the U.S. population were delayed, it would mean that nearly 1.5 million people had to queue up for hospital services. In addition to delays in hospital admission, there are delays at all levels of the Canadian health-care system: for G.P. and specialist appointments, for both basic and sophisticated diagnostic tests, and for admission to nursing homes.
Statistics Canada estimates that more than 1 million Canadians over the age of 15 experienced delays in receiving health-care services in 1991. Our survey, which asked specialists about some 50 operations and which measured waits for hospital admissions and appointments with specialists, indicates that people are waiting a significant amount of time. The longest treatment wait (time from booking an appointment to treatment) was two years for mammoplasty and rhinoplasty surgery in Newfoundland. Most (52 percent) of the procedures we asked about had treatment waits of less than two months; 41 percent had waits between two and six months; 6.2 percent had waits between six months and a year; and less than 1 percent had waits over a year.
The table gives the average wait for an appointment with a specialist and for common procedures (measured from the time the specialist scheduled the procedure). Adding the wait for the specialist appointment to the wait for hospital procedures shows that the shortest average wait totaled six weeks. Waits of three to four months were not uncommon. In emergencies, patients may be admitted to the hospital directly, rather than seeing a specialist first. Anecdotal evidence from physicians suggests that patients are sometimes admitted to the hospital as "emergency" cases in an attempt to bypass the queue.
Waits for treatment were not evenly distributed around the country. Since each province is responsible for organizing its own medical system, differences in efficiency may produce differences in waits for treatment. But longer waits in eastern Canada, which is a less economically successful area, suggest that the differences may be tied to funding. Average waits are inversely related to per capita provincial spending on health care. Ontario, which had the shortest average wait for treatment, spent $313.70 per capita more on health care than the rest of Canada. Provinces such as New Brunswick and Newfoundland, which have lengthy waits, spent much less per capita.
Regional discrepancies are likely to get worse. Since 1987, the federal government has been paying for a consistently smaller share of provincial health-care spending. Eventually health care may be the sole responsibility of provincial governments. The result could be extreme regional differences.
Many Americans have been attracted to the Canadian system of health care because a one-payer system supposedly cuts administrative costs. While it is actually not clear how much the Canadian system spends on administration, what is evident is that a one-payer system is vulnerable to strikes. When the government is a monopoly provider of healthcare services, it is also a monopoly employer. Since there is no market to determine the wages of health-care workers, wages are negotiated collectively. The result can be strikes that cause extended shutdowns in the healthcare system.
We did our 1990 study less than a month after a province-wide nursing strike in British Columbia. The average times waited per person in this study were one-third higher than those found in the 1991 study. In the second survey, we surveyed Manitoba six months after a province-wide nursing strike. Treatment waits were about 11-percent higher than they were the following year.
These findings indicate that province-wide strikes create backlogs that may take months to dissipate. An August 1991 article in JAMA, the journal of the American Medical Association, offered further evidence of this phenomenon. The authors found that waiting lists for cardiovascular surgery in British Columbia doubled during the 1990 nursing strike. This substantial backlog was compounded by a shortage of cardiac-surgery assistants, making the situation critical. The provincial government eventually contracted out for the needed services, and over the next 16 months some 200 patients were sent to Seattle hospitals for cardiovascular surgery. The government was forced into this recourse due to a public outcry, including a man who threatened to sue the government when his wife died while waiting for heart surgery. Americans might want to think twice about a one-payer system in which they have no legal recourse against the one payer.
Lately the American news media have turned their attention away from the Canadian medical system and toward existing U.S. alternatives. True to form, a major Canadian newspaper recently ran an editorial suggesting that HMOs are the solution to Canada's health-care woes.
Joanna Miyake is a research economist at the Fraser Institute in Vancouver. Michael Walker is executive director of the Fraser Institute.