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I find it amusing that whenever anyone suggests a single-payer healthcare system for the US, one of the most common arguments against it is to mention Canada as "proof" that all single-payer systems are a Bad Idea.

Whether or not Canada's system is flawed, where does the assumption come from that the only option for a single-payer system is one exactly like Canada's? Why the assumption that one could not devise an innovative and perhaps more effective health care system?



There's something more at work there . . . there's more to it than a "distribution" schematic. Something dynamic is taking place.

Peter Reiter

The major problems with our health care system today all come from the pay-once, then all expenses are covered style of health insurance today.

This removes all cost-benefit analysis from the consumer of health care. Heath Care providers need not compete on the basis of price, the cost of the doctor is irrelevant to the consumer, the cost of the medication is irrelevant to the consumer, the cost of varying courses of treatment are irrelevant to the person making the decisions about what source of health care they consume. Is it any wonder health care costs are out of control?

We need to find a way to restore aspects of a free market system to health care to solve the current crisis. Trying to find a way to extend the current system as-is, so that it covers everyone just makes things worse.

Charlie (Colorado)

Aha, I see, you let us insert links but not html for the links. okay ....

(1) I'm less than completely convinced about the notion that we have "low to middle quality" health care. I suspect this is a function of the selection of quality measures. OECD has done a study that shows people in the US get much quicker, better access to health care. (Disucssed here: http://cafehayek.typepad.com/hayek/2006/02/waiting_here_an.html)

Anecdotally, having lived in Canada and Germany, my impression is that the Canadian system has really poor quality, the German somewhat better, but neither matches the US.

(2) mivox, Canada isn't "proof" that single-payer systems are bad. On the other hand, I'm hard pressed to think of a single-payer system that I'd count as "good". After a while, the accumulation of negative experiments, while not proof, has to be considered evidence.

In this context, for example, I'd include in my metrics the waiting time for "elective" surgery, as well as what's considered "elective". (I had a friend in Canada who moved to the US to get "elective" surgery on his eyes when it would actually save his eyesight, because it would only become mandatory surgery in Canada when his eyesight had degraded enough to make him legally blind.) In both Canada and the UK, certain carcinomas are effectively not treated, where treatments common in the US can at least extend life by months or years. I lost a girlfriend to glioblastoma multiformae; the difference between the 90 days she would have gotten in the UK, and the nearly two years she got in the US, meant she saw her son graduate from high school.)


Australia has a private and public healthcare system - everyone pays 1.5% of their income (with exceptions for low income and a few others) for Medicare, which provides defined rebates for various defined medical services (going to your GP, getting prescriptions etc.) For things like a GP you are free to choose whoever you want, you might just have to pay extra if their fees are higher - often doctors in low-income areas and at universities etc. will bulk-bill for healthcare card holders (which basically means you're unemployed/low income/on a disability pension) and for students, which means they don't have to pay at the time of consultation and get their rebate back later. However if you attend a hospital you'll have to take whichever doctor is assinged to you (generally a fresh out of medical school resident).

You can then optionally take out private medical insurance which as well as providing cover for more elective surgery, dental (which has no cover under Medicare, which is bad), optics etc. The big gain is at hospitals is that you can choose your doctor (and generally get a private room), however this comes at the cost of paying whatever gap between the rate your insurance is allowed to pay and what is actually charged, as well as having to pay up-front. As a public patient your stay would generally be free, but in a shared room, and subject to waiting lists for surgery (some surgeries only happen two days a week in order to reduce the yearly cost to the government, and even on those days, if a surgery is about to start at 3, but has been pushed back, it'll probably be rescheduled as government work stops at 5pm). Private patients aren't subject to these waiting lists, and going overtime isn't such an issue as it's a private practice. Most large hospitals are funded by the state government (which leads to some fun state/federal interaction), but also have allowance (rooms, scheduling) for private patients as well, and there are also smaller purely private hospitals.

As a system, it seems to work fairly well, with the better bits of both US and Canadian systems, without the worse bits - a certain level of care is guaranteed (although mental healthcare sucks atm), but if you want/need a surgery done now you can pay for it. People always complain about healthcare systems, but nowhere near as much as I hear people complain about the US in particular.

The main problems are it's mostly reactive, and that funding proactive (exercise more, early screening, etc.) healthcare is hard to do under the current system. Also the state/federal split, but this might be an advantage as the several beauracracies are smaller combined than one large one would be.

Tom (Vancouver)

The reason you're looking to Canada as a model for health care is proximity. In reality, Canada doesn't fare that much better in WHO rankings than the US. I'd suggest looking at places like Japan, France, Sweden & Australia if you're looking for a model that the US should adopt.

Additionally, an American public health care system would have problems that the rest of the world doesn't face. The governments of other countries artificially cap the prices of prescription drugs. We rely on Americans to finance the R&D necessary to create new drugs. As a result we can have far cheaper healthcare. Would a part of changing your system involve capping prescription drug prices? If so, are you willing to accept having fewer new drugs?

Tom (Vancouver)

The reason you're looking to Canada as a model for health care is proximity. In reality, Canada doesn't fare that much better in WHO rankings than the US. I'd suggest looking at places like Japan, France, Sweden & Australia if you're looking for a model that the US should adopt.

Additionally, an American public health care system would have problems that the rest of the world doesn't face. The governments of other countries artificially cap the prices of prescription drugs. We rely on Americans to finance the R&D necessary to create new drugs. As a result we can have far cheaper healthcare. Would a part of changing your system involve capping prescription drug prices? If so, are you willing to accept having fewer new drugs?


I didn't read a lot of these comments, so my apologies if I'm repeating anything, but I think the time of universal healthcare hasn't come of age yet for a variety of reasons.

1. employer based healthcare and insurance companies are run as businesses and hence are often subject to newer managerment techniques and a strong need to drive the cost of healthcare down. As has been pointed out many government and non-profit businesses are run ineffecienly compared to their private sector counter parts. This isn't to say government or NGOs aren't fixable (if anything NGOs have been catching up recently), but when 20 - 30% of the taxed subsided healthcare programs in the U.S. funds are wasted if hardly seems like a good idea to create a bigger potential waste with more centralization.

2. Healthcare is fairly new. Right now we don't have cures for many common maladies ranging from cancer to alzheimers. Why take the cost of developing cures for these drugs onto the government when you can wait for the private sector to cure them and then reap the benefits once the drug becomes public domain when the patent is up? Which brings me to issue 3.

3. Instead of a subway (and btw it's been shown that providing the unemployed with cars reduces unemployment a lot in the u.s.) let's say it's movies. A film costs around 200 million or so to produce. A drug costs around 200 million or so to research and develop. The industries are similar in that they're both high risk areas. There's no guarantee that your 200 million drug or movie will actually make it to hospitals or theaters and that it will even make profits when it has to compete with the 200 million product being offered in the same place. The result is a lot of fluff (romantic comedies and impotence cures), but it's these safe bets that let studios and phamacetuicl firms bank roll the next possible break through. Additionally let's imagine a world where we can all go see movies for free becuase the government pays the studios to make them. This creates a fixed system in which several major playors all compete for the government's limited funding. Right now we live in a golden age where entrepeuners and the wealthy are losing billions trying to develop drugs, if the whole system was government funded we lose a lot of the source of funding and the incentive to make new drugs. Basically government funded HC would ensure only a few key players can survive in the market while limiting the number of people developing drugs. Who knows what start-up will become the new glaxo-smith-klien etc?

Tom's comments at the bottom was going to be my last point. Americans pay a higher price for healthcare and put more money into R&D than most places in the world. With out the U.S. it's possible that there wouldn't be as many medicines as most of the world enjoys.

I think what's better is to focus copyright reforms that allow firms to recoup the millions in R&D while allowing the public to reap the benefits once the drug is easy to produce as aspirin.

Kind Regards,

p.s. nice blog

L Newman

What I find interesting is that the public in the US and in Canada are so afraid of each other's medical systems that we won't consider any move to a middle way. Even the hardest right wing politicians in Canada suport the National Health Act, as it is suicide not to. However I feel both countries are avoiding the elephant in the room; we both have a huge population of people who are overweight, eat poorly, and don't exercise, and these people are getting older. I don't see how either system can support the needs of this population; up here in Canada we will tax ourselves to death trying, and down your way the price of insurance will rise beyond what the majority can afford. The answer, it seems, would be preventitive care, but it is a little late for that now, eh? (Sorry, couldn't resist the eh)

Trapier K. Michael

Evian has a lot to say about this over on "Free Canada," a blog devoted purely to Canadian health reform...



jeff angus

RE Tom (Vancouver)'s comment: "The reason you're looking to Canada as a model for health care is proximity. In reality, Canada doesn't fare that much better in WHO rankings than the US."

Yes, proximity, true. But remember, Canada's similar quality is delivered for 45% less $$ per person. For 55% as much as we spend, Canada's imperfect system delivers outcomes slightly better or perhaps only equal to ours. In business, if we have a competitor who is able to design and deliver products of equal or better quality for 15% less, we look to tweak processes, suppliers, marketing or human organization. If that differential gets up to 30% or so, it's time to rip apart the entire structure and re-design. This is way past that at 45% more. I think that costs much less, delivers same or better, in addition to your proximity thesis, is a major allure.

RE andrew's "3. Instead of a subway (and btw it's been shown that providing the unemployed with cars reduces unemployment a lot in the u.s.) let's say it's movies."

I think this analogy fails the Adam Smith test. You make a good argument, *IF* we share your assumption that the deliverable of health care -- health/wellness/quality of life/whatever you'd like to call it, is as roughly as necessary as the deliverable of seeing a good flick. In Wealth of Nations, Smith describes differences in market structures between optional items of value (he uses Gold as the commodity) and essential life components (he uses Water as the commodity).

Speaking for myself, and perhaps others, while I love even middling movies, I view adequate health care for my family and fellow taxpayers/citizens as being more essential than a great movie. Appropriate forms dictate that the optimum design for a health care system be different from the optimum design for the movie business.

RE Tom (vancouver)'s suggestion that Japan, France, Sweden & Oz were interesting alternatives.

Oz we already had elaborated. France's system costs only 51% per patient what ours does, 49% less than ours, with outcomes roughly similar, perhaps a little better.

My daughter was working in France for the last five years. She got to choose her own docs, once when she woke up with a sore throat she thought might be strep, she got their norm in urban areas, a house call from a doctor (a GP) within four hours -- her own doc wasn't available that morning. That's episodic info (like almost all the complaints about Canada's system -- cherry picking an affordance or a blemish to make a point pro or con). But she hates France and she thinks the French are absurd -- but would trade health care systems any day of the week, no questions asked, even if she had to pay blubbericious, overhead-larded American system rates to get French system care. And France is one of the leading funders of Pharm research, probably the 5th or 6th biggest exporter of patented drugs in the world, so it's not like they're pimping research.

jean z

pwb, my mother lives in southern ontario - she fell and broke her hip last year, and had it replaced the next day. 12-16 week wait to see a gp? never happened to me or anyone i know of. although waiting for specialists *does* take a while, but these other wait times you're talking about i've never experienced. not saying it can't happen in canada, just that i've never seen it.

Will C.

When thinking about a healthcare system why not just use auto insurance as an example? People here manage to find an insurer, shop rate, choose whom to have fix the car, etc. The auto insurers even cover the uninsurable.

Mike H.

Six years ago or so, Matt Miller sat down with two US politicians - a conservative Republican and a liberal Democrat - and they banged out an amazing start to the issues being raised here. The link is here:


The bottom line is that through tax credits, mandatory signup, voluntary purchasing groups, better information made widely available about health and health coverage, and personal responsibility can achieve the liberal dream of covering everyone and the conservative dream of avoiding "single payer" health care.

When this idea came out, of course, partisans from both parties absolutely hated it. It would have robbed the coverage and tax deduction goodies that the partisans love so much.

Roger L

To pwb---on hoping I dont move back to Canada in case I break my hip....

I am tired of all the gloom and doom that many in the US pronounce about the Canadian system--long waits, people coming to the US for surgery, etc etc. Most of this drivle is put upon us by right wing lobbyists and the insurance industry. Most are anecdotal in nature and stray far from reality. All of my family (I am the only one living in the US) are in Canada (my Mom is 85) and not once have they experienced any of the gloom and doom that pwb mentions. My mom had a hip replacement done in a very timely fashion, was not kicked out of the hospital hours after the surgery, and received top-notch physical therapy.

So pwb, get your facts straight and stop believing the fairy tales that insurance companies and wing nuts spew out to you....

A reminder...45 million people in this country have no health insurance and are denied even basic health care (including many who have good jobs); we have a lower death at birth rate than almost any western nation, a male living in Shanghai has a longer life span then a male living in NY City, I could go on and on...face it, we have a third rate health system that might not even make it in a third world country. It is our Achilles Heel, and every politician running for office should be forced to answer the question as to what are they going to do about it.


I am so glad you are blogging!! I work in hospital administration and like you, think our current health insurance system (and much of the rest of the US healthcare system) is...well, wrong. just wrong. There is zero connection between transportation and employment. Also zero connection between medical care and employment. Medical Care should be available and affordable for everyone. I find it sad that, as a country, our innertia keeps us from mandating a change. I also believe it's because, sadly, the poor and near-poor are the ones most hurt by the current system and as in most areas, they don't get heard by those in power.


I wonder if you would take a moment to comment on the bay area's public transit commuter checks, which discount public transportation for people who are employed.

laurie kalmanson

here's an analogy:

employer based auto insurance

sounds silly, right?

we're all required to have it if we drive a car; and somehow we do.

John Richardson

A blog as interesting as your books. Great Job. The health care crisis will be solved by a "Starbucks" of the medical community. When somebody can offer the ambiance and great service of a Starbucks along with a limited but interesting menu of options to all of us who have minor ailments, the tipping point will happen and you'll have one on every corner. Instead of going to the emergency ward you'll drink two Medibucks and call them in the morning.

Look for somebody wearing Hush Puppy shoes to launch this one!

Dan Tudor

God help us if we ever have a national healthcare system. Here's just one of dozens of comments I've read or heard of from former Canadian citizens about the healthcare system there...this one is from a student at the University of Oklahoma:

I lived in Canada for 11 years and can tell you that Canadian health care is a far cry from what is depicted in (a recent pro-nationalized healthcare) article.

For example, the author mentions wait times.

According to the Fraser Institute, a Canadian think-tank, the average wait time between seeing a general practitioner and seeking treatment was about 17.7 weeks.

Saskatchewan had the highest average wait time of about 30 weeks while Ontario, the province I was born in, had the lowest wait time of about 14 weeks.

Hip-replacement patients often end up non-ambulatory after waiting an average of 20 weeks. That is after waiting about 13 weeks just to see a specialist. There have been many cases of patients dying while waiting for a procedure.

With a socialized health care system, demand for services exceeds supply. In an attempt to alleviate this problem, health care has rationed the government.

The government also decides who is eligible for certain procedures. In Canada, renal dialysis, a life-saving procedure, is denied to those over the age of 70.

We have the best health care system in the world because we have the best doctors in the world. There is a reason why thousands of the best doctors have made an exodus from Canada to the United States.

A socialized health care system is a great idea in theory, but in reality, it is a failure.

— Hasan Masood, history sophomore

Ben Sommer

MG: "I woke up one day and realized what much smarter people than me (Adam Gopnik) realized a long time ago, which is that the idea of employer-based health care is just plain stupid"

No, in fact it is a natural, and one might say ingenious, outcome of past events. A history lesson for all here, including Mr. Gladwell:

Employer-provided health care in the US dates from the 1940s and war-time federal wage controls - laws forbidding paying "too much" to workers. In an effort to circumvent these laws, employers enticed workers by pairing wages with health care, which was then tax-free.

And now a lesson in political economy for all here, including Mr. Gladwell:

Government intervention (in the labor market) leads to unintended consequences (employers bending over backward to pay workers their worth) that then lead to further interventions (some states now requiring employers to cover workers). Ludwig von Mises (http://www.mises.org) proved the logic of this over 60 years ago and still, few understand it. And those who do (beaurocrats, _muckrackers_) don't care.

If you still think socialist health care is great idea, look in the mirror and tell yourself this is what you want:

"The essential feature of government is the enforcement of its decrees by beating, killing, and imprisoning. Those who are asking for more government interference are asking ultimately for more compulsion and less freedom". ~L. Mises

I believe Canada is now in the first stage, imprisoning anyone offering private health care. More to come.

navjyoti sharma

my beef with the analogy above is that medical insurance is being viewed as a liability instead of being an asset... not an asset in traditional terms but in preventive terms ... now that orgs are changing to leaner meaner types ... it is in the interest of the corp to make sure each employee is healthy and is tied to max productivity. Provided the incentives are fair enough the interest lies in favor of the employee as well ..i.e. not missing many paydays..besides quality of life arguments that can be messaged in a skewed manner.
the example that you have given takes the argument from an economic context to a social context in which case unless the employers are actively involved in governance and policy making , the scope of the argument is not valid..( a question of larger scope is required..not just a focus on whether one party is responsible for healthcare and a yes and no answer to that suffices )
to the earlier point ,if productive employees are being let go then there are bigger problems that need to be solved than med insurance
--- an employee


Canada's health care system is, indeed, in peril. There is a lot of money and lobbying going on now to increase privatization in all the provinces. And along with that there is much dessemination of disinformation. The Fraser Intitute, by the way, is a right wing 'think tank' ,which, as many people are becoming aware of, is just another name for 'lobbyist group'... in their case, for privatization and deregulation of all sorts. The sad thing is that many people still take them seriously.


I agree with you that employer based health care is a bad idea but the best alternative isn't national health care. First the laws favoring employer based health care should be removed. Also buying interstate insurance should be legal. The major problem is that there are no incentives for employers to buy the health care which is best for our system overall, Catastrophic insurance, the reason is that the employee is paying for the health care through his paycheck. Individuals would be more inclined to get the catastrophic insurance. You see this in home insurance. This insurance doesn't pay for the gas and electricity there is no reason health care should be like that.


Brad, you can insure yourself at "pretty reasonable cost"? Let me assure that it varies by state. My COBRA as a single woman was $600/month, and to self-insure when I was consulting through a group that got me a discount was $320/month. Not really so reasonable for most people.

In another state that doesn't require that all people who apply for insurance get some option, it's much cheaper--but that leaves open another entire population that cannot get insurance because they are already sick

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