The COVID-19 crisis has cast a shadow over the 2020 election and will virtually guarantee a renewed debate over healthcare policy in the United States. Even the current protests against systemic racism in America have as their backdrop the reality that African-Americans have been disproportionately affected by the novel coronavirus, in large part because the Black community on average tends to be poorer, and as such has less access to healthcare.
It doesn’t mean reform is inevitable. Healthcare policy is a notoriously knotty problem, with countless interlocking trade-offs making any compromise a hard sell. Add to that the reality that the debate has gotten polarized along party lines in the United States, and it makes arguing for one set of reforms versus another feel a little like screaming in a hurricane. Still, you have to start somewhere, and paradoxically, COVID-19 provides an opportunity. A glance across our northern border, for example, lets us compare how Canada’s single-payer model fared against America’s current hybrid system of public and private healthcare. It may not ultimately move the needle politically, but as an exercise, the comparison is worth making.
The United States and Canada both have world-class facilities, personnel, treatments, and medicines. Both have similar living standards, lifestyles, health outcomes, and demographics. Both were hard hit in densely populated urban areas while sparsely populated or rural areas remained relatively unscathed. As of today, the number of dead in the United States is 116,000 (or 353 per million) and plateauing, while Canada’s is 8,048 (or 214 per million) and tapering off. A comparison of how New York State and the Province of Ontario met the challenge is instructive.
The two share a lengthy border, and have densely populated cities with high volumes of international visitors. New York has a population of 19.5 million and Ontario has 14.5 million. By June 11, New York had 24,495 COVID19 deaths, or roughly 1,259 for every million residents, and Ontario had 2,487 deaths or 171 per million. This disparity was due to many non-healthcare factors, notably higher poverty rates in New York and less access to medical care. But the way their respective healthcare cultures managed the crisis also affected outcomes.
In Ontario, all residents have access to basic care (paid for out of taxes) and are issued a fraud-proof green medical card. All hospitals and other medical facilities are owned by the provincial government and operations are overseen by 14 Health Authorities or Regions with boards comprised of appointed representatives from the medical community and the public at large. In essence, Canada’s gigantic health care sector is a publicly owned not-for-profit entity whose shareholders are the taxpayers. The provinces spend half their revenues on their healthcare systems, which, if privatized, would be worth hundreds of billions of dollars. The federal government’s role is mostly to top up poorer provinces so they can provide equivalent basic care.
But beyond the well-known benefit of providing access to healthcare to the entire society, a more centralized system allows for better capacity for coordination. Ontario created a pandemic plan following the 2003 SARS outbreak which killed 44 residents. In January, these were dusted off and implemented after the first COVID-19 patient was diagnosed in Toronto. By contrast, New York was taken by surprise with an outbreak in early March in New Rochelle, then flailed around for weeks until competing government bureaucracies, agencies, suppliers, the private sector, the public sector, the military, and others were able to coordinate efforts. It’s unknown to what extent Ontario’s greater preparedness saved lives, but emerging studies suggest that delays and missteps were the biggest death-multipliers in New York.
“The kind of system we have in Canada allows the public health authorities to essentially commandeer the hospital system. It’s a command and control thing,” explained health economist Peter Berman, who once worked at Harvard University but is now at the University of British Columbia. By contrast, American hospitals are mostly private institutions without any overall control and are burdened with an added mandate to maximize profits.
Ontario elective surgeries were postponed, and designated hospitals began to restructure to handle COVID-19. Beds were freed up by discharging patients for home care, or by transferring them to other facilities. Hotels or dormitories were lined up to handle any overflows. All the province’s doctors and nurses were contacted and recruited to bolster staffing levels at hospitals, to establish testing centers, or to screen “essential” workers at power plants or food or security-related facilities as they entered their workplaces in order to ensure services ran smoothly. They were redeployed where the need arose.
Another measure mitigated the spread: Doctors’ offices were shuttered because physicians were allowed, for the first time, to bill the government for telephone consultations. Information hotlines were established and publicized. They referred patients with serious symptoms to emergency rooms, or to COVID-19-designated hospitals, where they were tested immediately and admitted if infected. The policy prevented people from being corralled in overcrowded doctors’ offices or hospital waiting rooms where the virus spread exponentially.
Before Ontario’s official overall lockdown began, public health officials were tracking cases and alerting affected residences or workplaces where possible. For instance, authorities notified the management of my condo building that an owner, who had returned from Florida, had tested positive with the virus. We were informed that the owner was isolating himself and his family in his unit for two weeks. Precautions were taken, the building was locked down to visitors, common areas were sanitized, the gym and pool shut down, and masks were made available to staff and residents. Similar notices were sent to other workplaces and organizations. Eventually, the province was totally locked down, and compliance was strictly enforced with fines. In essence, the province and others snapped to attention and became medical corps at war with a virus.
Dr. Kevin Smith, CEO of the University Health Center in Toronto (a cluster of hospitals and research centers cited by Newsweek as the world’s fourth-best hospital complex), described the cultural transition: “Our entire focus is completely shifted wherever possible on preparing for the growth of COVID-19 cases. The entire health care system has mobilized to address what we anticipate to be a very challenging time.”
Needless to say, Canadian healthcare is far from perfect, but it is valued by Canadians and ranked highly internationally. An added advantage is that it is significantly more cost-effective than America’s or most of Europe’s systems, according to the OECD. In 2018, U.S. healthcare costs tallied $10,586 per person while Canada’s totaled $4,974 per person. Much, though not all, of these savings are due to the elimination of insurance company profits and the attendant administrative costs imposed on healthcare providers. It’s also because centralized administration reduces hospital bureaucracies. A recent study showed that Canadian administrative costs are one-quarter of American costs.
A final benefit is that public ownership of the healthcare system and access-to-all de-politicizes the issue. No one would argue that the Canadian system is the Platonic ideal—there are mishaps and critics—but during the crisis, all of Canada’s provinces moved in lockstep to impose mitigation measures that have lowered death rates. The United States is culturally more rambunctious than Canada, and fights over how a national system should operate would not die down with far-reaching healthcare reforms nudging America’s system towards more centralization. Still, deciding the bigger issue in favor of universal access once and for all—deflating it as a political football—sounds really good in these hyper-polarized times. The debates certainly won’t go away, but perhaps they will be in a lower register.