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Can the US Learn From Canadian Healthcare? · CareTalk: Healthcare. Unfiltered.

• 0:00
  In Canada, they spend half as much on health care as the U .S., but their outcomes are at least as good and lifespans are longer.
• 0:07
  Americans, including most recently the state of Florida, are keen to import cheaper drugs from our northern neighbor.
• 0:13
  Or should we import any of their other health care ideas while we're at it?
• 0:17
  Oh Canada, what can we learn from thee?
• 0:23
  you Welcome to Care Talk, America's home for incisive debate about healthcare business and policy.
• 0:32
  I'm David Williams, president of Health Business Group.
• 0:35
  And I'm John Driscoll, the president of Walgreens Health.
• 0:37
  David, come on, really?
• 0:38
  Oh, Canada, come on.
• 0:40
  John, I would sing it for you.
• 0:41
  You know, they have V in there a few times.
• 0:43
  So I had to throw it into the intro, John.
• 0:46
  I expect a standing ovation at the bare minimum, a play ball, you know?
• 0:51
  Well, I spend a lot of time...
• 0:53
  playing hockey and some of that time even as a junior was up in Canada.
• 1:00
  So I am well acquainted with at least watching great hockey and hearing that song.
• 1:04
  But David, what about this whole, I thought that Canada was the desert of healthcare based on what the Republicans are talking about, not the promised land.
• 1:15
  How can you suggest we're gonna learn anything from Canada?
• 1:19
  I mean, it's interesting, John, you can say that, but the very un -woke, state of Florida is one that's been pushing for, you know, imports of drugs from Canada.
• 1:29
  So at a pragmatic level, they're not saying it's a desert.
• 1:32
  They'd like to turn it into a desert and just take all the medications out of there.
• 1:36
  Let's back up and talk about the Canadian health system overall and, you know, what it is.
• 1:42
  It is a public health care system.
• 1:43
  Isn't it just like ours?
• 1:45
  Like, how can, I mean, describe a little bit of what the differences are.
• 1:50
  John, the main thing that people from Canada say is, you know, in Canada, healthcare is free.
• 1:54
  And it is actually free at the point of care.
• 1:56
  There's actually five pillars of the Canadian health system under the Canada Health Act.
• 2:01
  Universal coverage, it's publicly administered, there's comprehensive coverage, it's portable across provinces, and it's accessible to the population.
• 2:09
  That's what it's like, John.
• 2:10
  They call their whole system Medicare.
• 2:12
  That's a little confusing for a US audience, but that's Canadian healthcare.
• 2:16
  Well, and I think the most important thing, well, first of all, provinces are the same as states.
• 2:22
  And you have a little bit of an advantage here because you're married to a Canadian native.
• 2:27
  So I'm going to try to pick apart your arguments carefully because you have a knowledge advantage here.
• 2:35
  But I think that the big difference is that Canada, like most industrialized countries, industrialized being like the industrial, Europe, modern Europe and Japan, have a federal system that basically gives some form of cradle to grave coverage that is not private.
• 2:55
  It's largely but not exclusively publicly funded, which does at a minimum mean that everybody's got coverage and that it is portable.
• 3:06
  They don't have a lot of the idiosyncrasies and frankly, gaps that we have in the US where our system is largely or starts as largely.
• 3:15
  private because of a quirk in what happened during the Second World War where the public private companies found that at a time of the Second World War that they were the only way they could compete for employees was to enhance or create new forms of health care coverage.
• 3:36
  And that created the private health care system that we have that in addition to our Medicare, which is our the federal program for the elderly.
• 3:45
  and Medicaid, the federal state program for the poor, which really emerged only in the sixties, left us with a primarily dominant private sector system with health insurance, where health insurance companies competing with one another.
• 3:57
  And I think that the interesting thing about this conversation is that, you for years, people have conservatives have railed against the ills of a Canadian health care system and threatened socialism.
• 4:13
  as the bogeyman when actually there's some reasonably good outcomes on the Canadian system.
• 4:22
  Do you want to just talk a little bit about what this, whatever you call it, but most importantly, what it is, the Canadian healthcare system with national coverage, what does that translate into in terms of system and then outcomes?
• 4:38
  So John, you know, the Canadian healthcare system is similar to most healthcare systems in the developed world, you know, in the OECD countries.
• 4:46
  And the US is the one that really stands out.
• 4:49
  So they're actually more similar to other countries like the UK, parts of Europe, even Asia, than what we have in the US.
• 4:58
  When you talk about outcomes, well, first of all, you know, life expectancy in Canada is about 82 years.
• 5:06
  where it's about 77 in the US, which is the lowest in the OECD.
• 5:10
  If you look at infant mortality, it's about four and a half out of a thousand in Canada, which is actually the second worst in the OECD, although I'll let you take a wild guess to who the worst one is.
• 5:21
  Correct, the US is the worst one, 5 .4.
• 5:25
  And actually what stands out the most to me is if you look at deaths from assaults in Canada, it's about one out of a hundred thousand population, in the US, 7 .4.
• 5:35
  out of 100 ,000.
• 5:37
  And the Canadian is actually much closer to the mean.
• 5:39
  So one of the things, and the last one I'll mention, John, is on the death rate from COVID, which would be another way to measure the system's performance recently, 1 ,300 out of a million population in Canada compared to 3 ,250 out of a million population in the US, which again, the worst one.
• 5:57
  So what's interesting there, John, is that there's some of these things are the health care system and some are just like public health or society at large.
• 6:05
  Well, I think – but let's not conflate the two because I think that confuses it.
• 6:10
  I do think it's important to call out the fact that our private sector system on an international standard has probably – has some of the best statistics around quality of service and access to, you know, particularly – what are considered optional surgeries, even though they're not so optional for someone who needs a new knee or needs a new hip.
• 6:37
  But there's no question that on the standard measures of population, whether it's cardiovascular health or just to your point, like people live longer and fewer people die young in Canada, that while the system, the Canadian system does a great job, a superior job, by any measure on delivering outcomes across the population in any individual circumstance, there are some challenges.
• 7:10
  And so I think it's worth calling out those challenges, David, in terms of access and sort of managing the system that create some of that friction that people talk about.
• 7:21
  Yeah.
• 7:21
  Because as you've often said, No one loves their healthcare system because you experience what goes wrong.
• 7:29
  You don't necessarily understand what's going right.
• 7:34
  Maybe we could talk a little bit about some of the quirks in the system that create access problems.
• 7:39
  So for example, maybe just talk a little bit about primary care.
• 7:42
  I mean, one of the interesting things from a Walgreens perspective is some of the most innovative work is being done with pharmacists replacing or augmenting or extending primary care.
• 7:54
  through Schropper's, Drug Mart, and others as part of an extension of the health care system because there's a really pretty significant lack of internal medicine, of general practitioners, of your kind of garden variety primary care doc.
• 8:09
  Yeah, John, and I think it is worth looking at, you know, what do the Canadians say that they don't like about the system as opposed to what do Republicans in the US are using it as a foil for the US system say?
• 8:21
  And the primary care is really a key part of it.
• 8:23
  So they...
• 8:23
  The number of doctors in Canada is limited.
• 8:26
  They limit the med school enrollment and they limit what physicians essentially can make.
• 8:33
  Doctors don't actually - Well, they definitely control what physicians are going to make because all of these budgets are based on kind of a federal budget that's given to the states and the states are trying to manage to a number.
• 8:46
  Yeah.
• 8:46
  So that's right.
• 8:48
  So the provinces manage to a number, but also specifically, so the hospitals would have like a fixed budget.
• 8:52
  And then the individual physicians, they may work for themselves, but they have a cap on what their earnings can be.
• 8:58
  So they actually don't necessarily make themselves so available.
• 9:02
  What's weird is if you think about how in the US or other places you try to actually keep costs down, it's by having primary care, right?
• 9:10
  More primary care and less specialty or less hospital care.
• 9:13
  In Canada, oddly, my own personal experience has been that it's hard to get a primary care physician.
• 9:18
  We tried to get one for an elderly relative who had a lot of a lot of chronic conditions and a lot of acute conditions.
• 9:24
  And we actually talked to the specialist and they said, like, why can't they get a primary care physician?
• 9:29
  And this specialist said, he can't get a primary care physician himself.
• 9:32
  They're just extremely limited.
• 9:33
  So that is definitely a drawback.
• 9:35
  And as you say, you know, leading on pharmacy is one of the ways to actually address that.
• 9:40
  Another area, John, of concern are these sort of intermediate things.
• 9:43
  You could call them elective, although they may not feel elective to you at the time when you have trouble walking, like a hip replacement, knee replacement.
• 9:49
  advanced imaging like MRI.
• 9:52
  And they actually complain about lack of care coordination, John, just because it's all paid for by the government doesn't mean that there's care coordination.
• 9:58
  There's not that much incentive to do it.
• 10:01
  And then you have some rationing because the hospitals in particular are on fixed budgets.
• 10:06
  My experience has been that actually for the most expensive kind of care, people that are really sick, they actually don't hold back.
• 10:13
  And there's a surprising amount of resources dedicated to somebody who.
• 10:17
  is even like an end of life person that you'd think, well, maybe there's rationing and they're going to say goodbye to grandma.
• 10:22
  But that's not what I see.
• 10:23
  But let's pause there because I think that that's another really important thing is people take the examples of the electives, those one that are non -life threatening is I think a way of thinking about elective versus non -elective.
• 10:36
  Elective is sort of one of those generic terms that it's elective for somebody else, but it doesn't feel that way for you to your point.
• 10:42
  But for life threatening access, it sounds like the Canadian system kind of works.
• 10:48
  Yeah.
• 10:49
  And you know, we talk sometimes here about medical bankruptcy and the abstract.
• 10:52
  That concept doesn't exist elsewhere.
• 10:53
  Let's talk about what it feels like as a Canadian coming into the U .S.
• 10:56
  I'll give the example of my wife when we were actually in graduate school together and she was not yet my wife and she was still Canadian.
• 11:05
  And she had she got a cut on her hand.
• 11:08
  She had surgery.
• 11:09
  And then next thing you knew, she had this huge bill because.
• 11:14
  She got this bill and they said, you owe$15 ,000.
• 11:17
  And the reason was she'd had prior authorization for physical therapy, but somehow she received occupational therapy and she was crying and very upset.
• 11:26
  And then what she didn't realize yet, I said, oh, you don't have to pay that, you know, just cause they sent you a bill.
• 11:31
  But this is like the shocking thing.
• 11:33
  You're going to come, you know, people may say you're going to come to the U S and because of all the guns, you're going to get shot.
• 11:37
  True.
• 11:38
  But.
• 11:39
  The more of the concern is like, you're going to come and you're going to be like medically bankrupted.
• 11:43
  And that's a real thing.
• 11:44
  You know, Canadians can see how crazy that is.
• 11:46
  You know, the medical debt is still one of the leading causes of bankruptcy in the US.
• 11:53
  Usually it's combined with other stuff.
• 11:55
  And by the way, I want to point out that your wife, regardless of whether she's married to you, is still a Canadian.
• 11:59
  She to a Canadian American, but your marital status did not change her national origin.
• 12:06
  But just to put, again, to return to a finer point here, The costs per person in Canada are roughly 50 % less.
• 12:15
  I mean, our costs in the US are 50 % more than the per person cost in Canada.
• 12:19
  That's a tax on every American.
• 12:21
  There is no form of medical bankruptcy.
• 12:24
  There is rationing.
• 12:25
  And I think we ought to be honest about that, that they do ration care.
• 12:29
  But to your point, not life threatening care, which is why the outcomes in terms of lifespan, public health outcomes like COVID, Things like infant mortality are so substantially better in Canada, but it's still not a perfect system.
• 12:51
  And one of the things that people don't realize is that 67 % of Canadians have some form of supplemental private insurance to cover other stuff.
• 13:01
  Do you want to talk a little bit about what's not covered in the national budget?
• 13:05
  So one of the things that makes Canada an outlier actually is that they don't cover prescription drugs like outpatient prescription drugs equivalent of our Medicare Part D here.
• 13:14
  It is covered for inpatient care.
• 13:17
  So that's not covered.
• 13:18
  Also dental insurance, vision, some rehab is not covered.
• 13:24
  And then the other thing where you can buy up a little bit is actually you can get insurance to have a private hospital room.
• 13:29
  So when you are in the hospital, the medical care is the same, but...
• 13:33
  you can actually upgrade your room.
• 13:35
  So as you say, about two thirds of Canadians have some private coverage and it covers about 30 % of expenses are actually privately covered.
• 13:44
  So it's not as though, you know, it's all paid by the federal or the provincial governments.
• 13:51
  Prescription drugs is an interesting one because we talk about importing cheap drugs from Canada.
• 13:56
  They actually have one of the higher...
• 13:59
  drug prices in the world and people do feel it a bit more directly because they actually are paying for the prescriptions directly or they're paying for insurance.
• 14:09
  Now, no one's going without because if you're low income, it will be subsidized or paid for.
• 14:14
  But that is actually an area of difference.
• 14:16
  And ironically, we look at Canadian drugs as being cheap and they look at it as being expensive.
• 14:20
  Well, I think that's, you know, you've got, again, just the most important thing is that none, all of these national healthcare systems and the OECD by the way is all the developed countries in the West plus Japan.
• 14:36
  All of those countries have some form of more extensive national health coverage but each of them has their own quirks.
• 14:44
  I think it's interesting that Canada gets called out as a outlier in terms of the rationing but people who criticize it aren't honest about its outcomes.
• 14:57
  And I think that the Swiss system and the German system have different forms of a combination of broad, almost complete, rather national healthcare coverage, but they deal a private sector system in so that there's some element of competition around pricing and service.
• 15:15
  In the Canadian system, certain chunks of things are well covered, but dental, eye care, and prescription drugs are supplemental.
• 15:26
  But still the cost for drugs in Canada, because the federal government participates directly in negotiating drug pricing, is still substantially lower, so substantially lower that red and blue states, to your point, are saying, hell, let's import that same drug from Pfizer or Lilly or whatever into our states to kind of bring the cost down, because it just offends everyone that the US doesn't negotiate drug pricing.
• 15:54
  And pharma certainly you know, earns a disproportionate share of its income off of every vulnerable American who needs expensive or non-expensive drugs.
• 16:05
  But I think that the most important thing is that the criticism really comes down to, are you willing to accept a budget for healthcare that's invested in the most important things in terms of healthcare outcomes?
• 16:19
  Or do you want to over -rotate or focus on...
• 16:23
  you know, access and service where I think actually the US does a superior job.
• 16:28
  Another place where the US I think does a really good job is in cancer screening because we cover, we have broad coverage of that.
• 16:36
  There's broad access to scans.
• 16:39
  I mean, as you know, David in Canada, it can take a little bit of time to get an MRI as opposed to an x -ray.
• 16:46
  Again, they will prioritize lower cost scans over more expensive ones.
• 16:51
  And that does result in more cancer being identified, even if the total life expectancy is actually greater in Canada.
• 16:59
  Yeah.
• 16:59
  Well, I mean, one way to look at it is going back to these these five pillars and see, you know, what are things people would embrace?
• 17:05
  I think of those five, you know, universal coverage makes sense.
• 17:10
  Comprehensive coverage, portability and accessibility are all good.
• 17:16
  The one that I think you'd have.
• 17:17
  So I think actually most Americans would agree with all of those.
• 17:20
  And the one where you struggle is the second one, which is the publicly administered.
• 17:24
  You don't want the government to do it.
• 17:26
  Now there's that side.
• 17:28
  That means they really don't have private health insurance companies the way that we have here.
• 17:32
  And they don't have the equivalent of Medicare Advantage or anything like that.
• 17:35
  That is really probably the very biggest difference.
• 17:39
  If you look at what Canadians are trying to do, they are allowing, because they are allowing more in some provinces, more privately paid care.
• 17:49
  And they're allowing, you know, in Ontario, they're trying to expand.
• 17:53
  So like a hip and knee replacements, we talked about bringing some of the private sector in and allowing coverage there under Medicare.
• 18:01
  But there's some concern that if you go too far this way, they're worried, hey, okay, it's great.
• 18:05
  We've got these sort of mom and pops that are acting, but what if a big US company like let's say Optum, you know, is gonna come in and seek to optimize profits in Ontario.
• 18:14
  They're actually worried about that.
• 18:16
  And perhaps rightfully so.
• 18:18
  Well, I think it's just a different approach to the obligation of a country to its citizens to provide national health care.
• 18:28
  You know, we've had this kind of rocky, imperfect road to get to national health care.
• 18:33
  And to some degree, we've made a lot of progress in terms of coverage through Obamacare extending and really bringing down the number of people who are uncovered to a very, a relatively small amount, but it's still not perfect.
• 18:46
  But what's interesting and I think what shows the reason why a country like Canada will have such better outcomes in a public health emergency and so clearly an advantage in terms of life expectancy and lower increases in life expectancy and lower infant mortality is because the consistency of the coverage and access is just so broad.
• 19:11
  I think it's just a, I'm not suggesting it's a perfect system, but that it's a system that because it rotates, because it focuses, prioritizes that over rapid access and high service, it actually, you know, it's a more comprehensive safety net, which we all might gain from.
• 19:33
  I think the critical thing when you look at these different differences between nations isn't to mirror the all of the aspects of the system.
• 19:42
  Because to your point, no one really loves their healthcare system, but to figure out like what can we learn?
• 19:47
  So David, if we were to wrap this up, you with your near all your experience in the Canadian healthcare system and your expertise as a strategy, healthcare strategy consultant, what are the top two or three things that you think Americans can learn from the Canadian system?
• 20:05
  And is there anything the Canadians can learn from ours?
• 20:08
  Well, John, I was going to say, I think the best is if we come to like a Bruins-Canadians game, we can all rise for the singing of both national anthems.
• 20:14
  That would be a starting point to recognize there are things to learn.
• 20:17
  Yeah, the Bruins are going to crush the Canadians, you know.
• 20:19
  That's true.
• 20:20
  I think they're just, they're having a great year.
• 20:22
  Actually blew them out the other day.
• 20:24
  But in terms of the healthcare, yeah, I mean, I think understanding that, you know, sort of stepping back from the specifics and looking at some of the principles and saying about, you know, like, universal coverage, not having medical bankruptcy is a thing, not having such a big emphasis on co -pays and so on, is a positive.
• 20:43
  And also that how important public health is in the whole system and that we shouldn't just accept the idea that we have to spend twice as much, at least as everybody else, in order to get the same or better outcomes.
• 20:59
  That's what I would say, John.
• 21:00
  And what can they learn from us?
• 21:03
  Well, There's your answer, David.
• 21:09
  Yeah, they may come.
• 21:12
  I would say, I think you're pretty good on the principles.
• 21:14
  I think you dodged the question.
• 21:16
  I think you eventually got there.
• 21:17
  I think the three most important things we can learn are the cost of not having comprehensive coverage is a broken health care access, certainly in a public health emergency with those kinds of differences in numbers.
• 21:31
  I think we definitely have a different risk profile in the US because you've got much more of a multicultural background, much more of a mix.
• 21:37
  It's less homogenous and less homogenous system.
• 21:40
  You're going to have real differences in how people present to the healthcare system and we need to tune a healthcare system to support that.
• 21:47
  And the other is to your point about medical bankruptcy.
• 21:50
  That's just, it's crazy that people are going, literally going bankrupt because they can't afford the healthcare bills that they need to pay in order to survive and thrive.
• 22:00
  But I think the one thing that the Canadian healthcare system can really learn from ours is investing in primary care and coordination of care.
• 22:07
  I think as you see life expectancy grow and chronic conditions inevitably grow as a population gets older, as the Canadian population gets older, they're going to need to think through how they invest in coordinated care if they're going to continue to keep those costs down and provide access.
• 22:22
  I think that's something where I think the US has shown some real success, particularly in integrated systems.
• 22:27
  And I think there is a lesson there.
• 22:30
  Well, that's it for yet another episode of Care Talk.
• 22:33
  We've been talking today about our neighbor to the north in Canada and their health care system.
• 22:37
  I'm David Williams, president of Health Business Group.
• 22:40
  And I'm John Driscoll, the president of Walgreens South.
• 22:42
  If you liked what you heard or you didn't, please subscribe on your favorite service.
• 22:46
  And we love a review.