Towards Universal healthcare coverage: Viability of Canadian Medicare as a model for Affordable Care Act expansion
June 2015
Glaring disparities in care delivery, intensified by uncontrollably mounting costs of care, necessitate revolutionary reform in the U.S. healthcare system. The predicament holds our nation back from the forefront of medicine and demands a redefinition of the American concept of healthcare away from the “commodity” model.
Until now the only industrialized nation that does not guarantee access to healthcare for all its citizens, health care for the most part is only consistently available to those who can afford the highest out-of-pocket costs in the world (Bodenheimer, Understanding Health Policy, 2012). This clashes with the fact that the indispensability of coverage and healthcare security transcends socioeconomic status—because you never know when you will get sick, and costs of care can be unpredictable. Simply, people cannot live without health care and the nation can no longer afford the hidden system costs of uninsurance.
Healthcare is a basic human need rather than a privilege, and ethically prevailing over American attitudes of individual responsibility, there should exist to some degree the right to basic access and availability of standard care.
Universal health care, long mislabeled “socialized medicine” still sits as a concept of controversy, with looming uncertainties if the Affordable Care Act on paper will hold up in the long haul. It should be noted, the ACA lacks the elements of the single-payer Canadian Health Reform grounded in public administration, comprehensiveness, universality, portability, and accessibility to be truly considered universal health coverage (Dorland 2014).
Examining the inexorably tied aspects of access, equity, costs, quality, and outcomes reveals the superiority of the single-payer system—objectively, before we consider its viability in the cultural and sociopolitical climate that can only be described as uniquely American.
GIF by Robert Ek
In one sense, with the most high-tech innovations and scientific knowledge available at our disposal, the United States offers some of the best care in the world; those who can afford the expense retain the right to the most technologically advanced & expensive procedures. We would in fact have one of the best healthcare systems in the world if we were able to allow everyone to access and afford that high-quality care.
The ACA’s remedy to the disparate distribution of healthcare access includes the individual health insurance mandate, Medicaid eligibility expansion, and insurance market regulation (Weiner 2014). People with pre-existing conditions can no longer be denied coverage by private health insurance. Expanded coverage now includes one of the most critically uninsured groups, young adults under age 26, as dependents of their parents’ private insurance. Income-based sliding-scale subsidies are available for households below 400% of the federal poverty line (Bodenheimer 2012).
Certainly far behind full coverage of medically-necessary hospital and physician services by the Canadian government, elimination of certain categorical qualification requirements expands U.S. Medicaid eligibility only to households earning up to 133% of the federal poverty line. Theoretically, 32 million of the 51 million uninsured Americans would qualify for coverage, subject to the ratification by their state of residence. Medicaid expansion will be fully federally-funded through 2016, along with setup of health insurance exchanges, in states which voluntarily elect to cooperate (Bodenheimer 2012).
In an unfortunate twist for many Americans, we observe a coverage gap in the six states that have opted out of Medicaid expansion and others that have stalled in division over the issue. Neither the benefits of Medicaid coverage, nor the tax credit for households of income up to 400% of the federal poverty line, will extend to the childless, poorest residents of states which choose not to implement expansion (AMSA, 2013).
Blocked by political interests and poor management by federal administration (i.e. government shutdown, deficit of information and promotion, bad publicity), the transition to universal healthcare has not been organized and marketed well to get as much of the public on board as possible. Political ideology trumps the common good, as the states prove far less cooperative than the provinces of Canada (the reform has remained politically untouched since national adoption of the Saskatchewan Plan, with portability throughout the country).
Neither the benefits of Medicaid coverage, nor the tax credit for households of income up to 400% of the federal poverty line, will extend to the childless, poorest residents of states which choose not to implement expansion (AMSA, 2013).
Progressively increasing financial penalties (up to the greater of either an annual $695/person or 2.5% of the household income) attempt to enforce the individual mandate, requiring everyone who does not qualify for Medicaid to purchase at least the baseline-standard health insurance plan or bronze model (Bodenheimer 2012). Of course, with the commodity approach, equity in coverage could never exist; a bewildering full spectrum of plans exist with prices determined by coverage type.
Alas, the individual mandate has not eliminated the for-profit corporatization of health insurance but reinforced it instead. High out-of-pocket costs result from the prevalence of the baseline minimum benefit, high cost-sharing plans. Simply having insurance does not necessarily correlate to health care access; co-pays and high deductibles often deter people from seeking treatment, especially essential primary care, until the illness escalates and they resort to the ER, driving up system-wide costs (Barr 2011).
A first step towards the primary care priority effectively implemented in Canada, the Affordable Care Act’s provision fully covers those crucial preventive services for the expanded group of Medicaid-qualifying patients, banning barriers of co-payments and deductibles (Weiner 2014). Free preventive services via the coordinated care of “medical homes” under Medicaid removes a major financial barrier and smoothes out socioeconomic-driven healthcare disparities, as these patients will be more likely to seek out care, and earlier, to better outcomes (Barr 2011).
As 20% of the American population generate 80% of the healthcare system’s costs (Escape Fire 2012), the Affordable Care attempts at cost-effectiveness by promoting prevention in the most critical populations, but this alone does not appear able to offset the overall net increase in healthcare expenditures. Goal coverage of an additional 32 million people and individual mandate subsidies inevitably adds costs to the health care system, predictably escalating to an estimated $938 billion and 19.6% of the national GDP by 2019 (Barr 2011). Somehow this is to be funded by new taxes, fees, and cost savings in the Medicare and Medicaid programs.
High out-of-pocket costs result from the prevalence of the baseline minimum benefit, high cost-sharing plans.
Simply having insurance does not necessarily correlate to health care access; co-pays and high deductibles often deter people from seeking treatment, especially essential primary care, until the illness escalates and they resort to the ER, driving up system-wide costs.
For private insurance purchasers, even with some degree of subsidy, out-of-pocket expenses remain a barrier to true comprehensive access, as seen with the Massachusetts Individual Plan: 18% of residents reported unmet health care needs due to these costs (Bodenheimer 2012).
Under the Canada Health Act’s standard of healthcare access, such user charges and extra billing are prohibited; the single-payer system assures no discrimination based on ability to pay, strictly regulates supplemental health insurance plans, and even negotiates with pharmaceutical corporations to maintain affordable branded drugs to lower system costs (Dorland 2014).
Detractors of the single-payer system cite inefficiencies pertaining to waiting times and queues for specialty service; comparatively, need-based rationing based on urgency is justifiably more ethical than rationing based on socioeconomic status and the ability to pay. In Canada, urgent care is expeditiously delivered, whereas elective or less urgent cases have months-long wait times and less funding options if deemed medically unnecessary (Phillips 2014). People with less urgent problems seek elective designation and resort to niche private insurance supplement, because Canadians do not have the financial entitlement or right to pay out-of-pocket for services to queue-jump (Phillips 2014).
Nonetheless, the Canadian system has historically faced significant shortage of physicians, particularly with limited providers in rural areas. Select family physicians operate closed practices at capacity and a lack of access to specialist services persists because specialists remain concentrated in urban centers with already-equipped facilities. Since 2004, when the proportion of Canadian medical students entering family medicine at an all-time low of 24%, primary care reforms have revamped the system with family physicians at the center (Philips 2014).
Primary care at the focal point, patients seek treatment from their family doctor first and as the access point to specialist referrals, unless in the event of an emergency. Built-in provisions for continuity of care include patient enrollment rosters for capitation (limited in switching family physician enrollment to less than twice yearly), networked practices of family health teams or multidisciplinary and multi-location providers, and IT infrastructure link rural practices with the switch to the paperless EMR system. While coverage is portable within Canada and similarly administered provincially, inconsistencies do exist. For example provincial plans might vary in drug formularies. Match funding and startup funding promote a high degree of similarity in the primary care reforms.
Public payment and accountability but private provision of care translates into quite a bit more physician autonomy, relative to the American managed care model dictated by corporate administrative overhead. The move away from fee-for-service in Canada has favored a blended model featuring capitation, lump sum, and special premiums—all resulting in a significant pay raise for family physicians providing broad-based comprehensive care (~80% of the specialist income). Nowadays, primary care reform has shifted the proportion to 39% of new doctors becoming family physicians (Phillips 2014).
Perhaps pointing to an inequity of information and communication access, we observe more primary care contact yet less utilization of available specialist services by the less educated of lower socioeconomic status (Glazier 2009). Yet, the inverse income-health gradient observed in Canada demonstrates the system’s overall equalizing effect, as the wealthier willingly contribute more for the same coverage to receive less care or net benefits (Dorland 2014).
In Canada, universal coverage applies to all residents and includes refugees (Phillips 2014). Unfortunately for those seeking refuge in the United States, prevailing American attitudes and policy exclude undocumented immigrants to fend for themselves in chaotic ERs, and consequently, all of society to shoulder the absurdly expensive and inefficient costs. While these immigrants put into the system in the form of payroll tax, they receive no benefits, protections, or primary care services (AMSA 2013). Free healthcare is a myth, as inevitably when they are forced to use emergency rooms, the cost-sharing for uncompensated care raises costs for everyone system-wide.
The concept of individual responsibility does not apply, as we are only as healthy as the society around us, so it is in the common interest to keep people healthy and only needing most effective, low-cost interventions. Health care access as a basic human right should not be affected by one’s citizenship status.
While the ACA does a great job at establishing “the core principle that everybody should have some basic [healthcare] security,” to quote the president’s eponymous policy, Obamacare has not changed the underlying cost structure of American health care and leaves the implicated cost containment up to states and local medical professionals to determine. The for-profit structure of the third-party player remains very much intact, if not fortified by the individual mandate.
Publically funded, privately delivered Canadian health care remains a high cost system, second to the U.S.; the key distinction: its large public sector component, under which costs are more controllable with set budget negotiations, in contrast with America’s fragmented financing system (Dorland 2014). Historically, the cost of the Canadian single-payer system has maintained in the neighborhood of 10% of the national GDP, in contrast to the dangerously escalating costs of American health care. The successfully implemented primary care focus model has excelled at preventative services; maximal cost-benefit evaluation for the individual defines “medically necessary” as deliberated by a family physician (Phillips 2014).
Under primary care structure’s built-in cost-saving strategy, overtreatment is rare—few cases of superfluous surgeries or administration of injections have been documented. Canada is WHO-ranked 11th in life expectancy, versus U.S. at 37th (Dorland 2014). Canadians enjoy a lower infant mortality, no overtreatment, no cost-influenced life-or-death decisions, and consequently their healthcare system is characterized by high patient satisfaction, ubiquitous public support, and an untouchable political policy.
Obamacare has not changed the underlying cost structure of American health care and leaves the implicated cost containment up to states and local medical professionals to determine. The for-profit structure of the third-party player remains very much intact, if not fortified by the individual mandate.
Confronting the broader issues of medical culture instilled in physician education requires recognition of the in-sustainability of intervention and the technological imperative, plus most importantly, a shift towards preventative, patient-focused medicine, which Canada has long realized. Referring to Bodenheimer’s model of quality (“care that assists healthy people to stay healthy, cures acute illness, and allows chronically ill people to live as long and fulfilling life as possible”), reorientation of our health care system towards keeping patients out of the hospital lowers costs and improves care.
Seventy-five percent of healthcare expenditures are drained treating preventable diseases (Center of Disease Control, as cited by Escape Fire 2012), problematic as we observe a decline in the healthcare system’s backbone of primary care. Especially necessary is fostering interest in primary care versus specialization through loan forgiveness programs. Aspiring doctors serve community health centers get in touch with the altruistic incentives and rewards of cultivating longstanding patient connections.
These community health centers and health homes also serve to remedy the underuse connected to poor healthcare quality, providing low-cost access to the underinsured and free preventive services under the expansion of Medicaid. Strengthening primary care enhances physician-patient relationships. More likely to fulfill the quality definition of the American Medical Association “care that consistently contributes to improvement and maintenance of the quality and/or duration of life”, primary care facilitates guidance- cooperation interactions which treat the individual as a whole person.
Long-standing connections and continuity of care enhances compliance and patient education; in this arena, physicians have the opportunity to answer key questions and facilitate crucial discussions, such as introducing the topic of palliative care. When weighing aggressive interventions in the intensive care unit with palliative hospice care, it’s important for physicians to discuss the not so clear- cut options with patients. To provide quality care, doctors must be able to articulate the costs, risks, and side effects versus the marginal benefits; they must listen and into take account the context of each patient’s lifestyle, history, and personal factors. All physicians will need to employ humanism and empathy to counteract the ingrained institutions of emotional detachment and the mechanistic model.
Coordinated family health teams designed for continuity of care may not be necessarily cost effective, but they are quality-effective. The American tenet of physician sovereignty has become a relic with third party for-profit privatization, and lost practicality. The average time spent with a patient is already considered unduly short; half of patients are not receiving optimal care from doctor’s visits (Escape Fire 2012). Mid-level providers earn less and spend more time with patients, to overall greater patient satisfaction. We can conceive potential improvement of care quality in employing these nurse case managers, nurse practitioners, and physician assistants, who effectively proceed through clear-cut steps of a checklist to check-in and communicate with a physician supervisor (á la Gawande’s Checklist Manifesto). This shift circumvents the quality issues which arise out of the institutional status quo, for instance, how hospital structure promulgates churning, for-profit care, as well as physician burnout.
Entrenched U.S. cultural and political factors suggest Canadian-style reform unviable, unless we can shift longstanding attitudes and institutions. Most likely, little can be done about powerful political interests, which spent $1.1 billion, not on health care but lobbying Washington on the issue in 2009 (Escape Fire 2012). We could never count on states to adopt a one-size-fits-all plan; because America’s political system runs on ideological factionalism to represent all regions and groups; a plan successful in Massachusetts may never fly in Texas. Dependent on health care reform’s success is each state’s full cooperation by customizing the program to their populational needs.
The impact of expanded access on available resources and healthcare rationing will force physicians to confront the underlying profit-driven motives in their care delivery. This is essential if we hope to foster efficient, accountable providers and patients as conscious, informed consumers.
Oft-cited is America’s standing as an individualistic and capitalistic society, which would never stand for the implications of universal healthcare. Already, the U.S. healthcare system rations care on the basis of ability to pay—opposed to proposed measures of need-based prioritization, which has worked effectively in the rationing of vaccines during the 2004 shortage and the 2009 H1N1 outbreak (Barr 2011).
Even implementing comparative strategies to balance costs with clinical outcomes, brings us up against the larger cultural stumbling block of American medical consumerism. Exemplified in the national outcry in response the new, scaled-back mammography guidelines, the public experiences withdrawal due the misconception that more is better (Barr 2011).
Medical culture equates high-tech, costly care with better care, without considering marginal benefits or accompanied risks and side effects. The impact of expanded access on available resources and healthcare rationing will force physicians to confront the underlying profit-driven motives in their care delivery. This is essential if we hope to foster efficient, accountable providers and patients as conscious, informed consumers. With the implications of cost and quality in perspective, the Affordable Care Act seems less like the comprehensive long term solution to all the system’s woes, than an interim access solution, pending fundamental changes in social culture.
R E F E R E N C E S
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Bodenheimer, Thomas. Kevin Grumbach, Understanding U.S. Health Policy: A Clinical Approach, Sixth edition, New York: McGraw Hill Lange, 2013
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Escape Fire. Dir. Matthey Heineman and Susan Froemke. Roadside Attractions, 2012. DVD.
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