"Us Canadians, we're kind of understated by nature," Marcus Davies told me in his soft-spoken way. "We don't go around chanting 'We're No. 1!' But you know, there are two areas where we feel superior to the U.S.: hockey and health care."
Davies is an official of the Saskatchewan Medical Society, so it's not surprising that he would want to extol Canadian medicine. But that feeling of patriotic pride in the nation's health-care system is something that just about all Canadians share. They love to point out that Canada provides coverage for everybody, usually with no copay and no deductible—while the U.S. leaves tens of millions of its citizens uninsured. They love to remind us that, while the U.S. lets some 700,000 people go bankrupt due to medical bills each year, the number of medical bankruptcies in Canada is precisely zero.
Yet I wasn't inclined to let Davies go unchallenged. I agreed that Canada does an admirable job of providing free and prompt care to anybody with an acute medical condition. But for nonemergency cases, the system often provides nothing but a long wait. Last summer I tried to get an appointment with an orthopedist in Canada to treat my aching right shoulder; the waiting time, just for an initial consultation, was 10 months. How could you be proud of that?
"You're right," Davies said frankly. "We keep people waiting, to limit costs. But you have to understand something basic about Canadians. Canadians don't mind waiting for elective care all that much, so long as the rich Canadian and the poor Canadian have to wait about the same amount of time."
In that last sentence, Davies set forth the national ethic of health care in his country: medicine is not a commodity to be sold to the highest bidder, but a right that must be distributed equitably to one and all. In short, the Canadians have built a health-care system that neatly fits the Canadian character: ferociously egalitarian, but thrifty at the same time.
I found that same pattern—a health-care system that reflects a nation's basic cultural values—everywhere I went when I traveled the world for a PBS documentary and a book about how other wealthy countries provide health care. "The fundamental truth about health care in every country," notes Princeton professor Uwe Reinhardt, one of the world's preeminent health-care economists, "is that national values, national character, determine how each system works."
The design of any country's health-care system involves political, medical, and economic decisions. But the primary issue for any health-care system is, as President Obama made clear last week, a moral question: should a rich society provide health care to everyone who needs it? If a nation answers yes to that moral question, it will build a health-care system like the ones in Britain, Germany, Canada, France, and Japan, where everybody is covered. If a nation doesn't decide to provide universal coverage, then you're likely to end up with a system where some people get the finest medical care on earth in the finest hospitals, and tens of thousands of others are left to die for lack of care. Without the moral commitment, in other words, you end up with a system like America's.
Around the world, cultural influences govern much of the nitty-gritty of daily medical practice. In the Confucian nations of East Asia, doctors were traditionally expected to treat people for free; they earned a living by selling medicine to be taken once the patient went home. To this day, doctors in Japan and China do both the prescribing and the selling of medicine. And guess what? Those doctors tend to prescribe far more drugs than their Western counterparts, who don't share in the pharmacy's profit.
British women tend to have their babies at home; American women tend to deliver in the hospital, but go home a day or two after the birth; Japanese women remain in the hospital with the baby an average of 10 days after delivery. In Britain, Spain, and Italy, the basic rule of medicine is that people never get a doctor's bill; health care is funded through general taxation. But just across the border, in France, patients are expected to make a cash payment for any encounter with the health-care system, even though the insurance plan will reimburse most of that copay within a week or so. The French have decided that people should be reminded on every visit that health care costs money—even if it's the insurance company's money.
In Germany and Austria, health insurance pays for a week at a spa, if a doctor prescribes it to deal with stress. In Britain, when I asked whether the National Health Service would provide the same benefit, my doctor laughed at the very thought of it.
But the most important influence of national culture can be seen in the most basic question facing any country's health-care system: who is covered?
On this fundamental issue, the United States is the odd man out among the world's advanced, free-market democracies. All the other industrialized democracies guarantee health care for everybody—young or old, sick or well, rich or poor, native or immigrant. The U.S.A., the world's richest and most powerful nation, is the only advanced country that has never made a commitment to provide medical care to everyone who needs it.
Our lack of universal coverage has consequences. According to government and private studies, about 22,000 of our fellow Americans die each year of treatable diseases because they lack insurance and can't afford a doctor. This generally happens to people with a chronic illness who have too much money to qualify for Medicaid, but too little to pay for the drugs and treatment they need to stay alive. Among the rich nations, this happens only in America. Likewise, the U.S. is the only developed country where medical bankruptcies can happen.
Those Americans who die or go broke because they happened to get sick represent a basic moral decision our country has made. All the other rich countries have made a different decision: they cover everybody. A French physician, Dr. Valerie Newman, explained it this way: "You Americans say that everybody is equal," she said. "But this is not so. Some are beautiful, some aren't. Some are brilliant, some aren't. But when we get sick—then, yes: everybody is equal. That is something we can deal with on an equal basis. This rule seems so basic to the French: we should all have the same access to care when it comes to life and death."
Other nations adhere to the same principle, with slightly different explanations. For Switzerland—a rich, capitalist country that didn't create a universal health-care system until 1994—the underlying rationale is the concept of solidarité. That's a crucial word in the Swiss vocabulary, freighted with meanings that include "community," "equal treatment," and "despite our differences, we're all in this together."
"To have a great sense of solidarité among the people," former Swiss president Pascal Couchepin told me, "all must have an equal right—and particularly, a right to medical care. Because it is a profound need for people to be sure, if they are struck by the stroke of destiny, they can have a good health system."
That principle seems so obvious to people in Europe, Canada, and the East Asian democracies that health officials asked me over and over to explain why it isn't obvious to Americans as well. "The formula is so simple: health care for everybody, paid for by everybody," a deputy health minister in Sweden told me. "You Americans are so clever. Why haven't you figured that out?"
This formula is so basic in the other industrialized democracies that virtually all of them have included some version of a "right to medical care" in the national constitution. Nearly all European countries (the striking exception is Russia) have signed on to the European Union's Charter of Fundamental Rights, which serves as a sort of continentwide Bill of Rights, enforceable by the courts. "Everyone has the right of access to preventive health care and the right to benefit from medical treatment," the charter says.
The new democracies that have emerged in the two decades since the fall of the Soviet Union generally include a "right to health care" in their constitutions. The Czech Constitution, written in 1992, is typical. "The state is obliged to guarantee the right to life and the right to protection of health, and health care for all," the document declares.
In the U.S., in contrast, neither the federal Constitution nor any state guarantees "health care for all." Some Americans have gone to court claiming a right to care. The legal theory is that our Declaration of Independence says we all have "inalienable rights," including a right to life, and you can't have life without medical care to keep you alive. No U.S. court has ever bought this argument.
In the other advanced democracies, though, there's no debate. All of them recognize a right to "health care for all" as a moral obligation. But they don't all agree on the way to assure that right.
Some nations—Britain, Spain, Italy, and New Zealand, among others—have decided that providing health care is a job for government, just like building roads or putting out fires. In those countries, government owns the hospitals, employs many or most of the doctors, and pays the bills. That seems pretty close to what Americans think of as "socialized medicine."
But many rich democracies—Germany, France, Switzerland, the Netherlands, Japan—provide universal coverage with private doctors, private hospitals, and mainly private insurance plans. Unlike Americans, who switch to government-run insurance (Medicare) at age 65, Germans stick with private insurance from cradle to grave. Japan has more for-profit hospitals than the U.S., and far fewer doctors on the government payroll than we do. This is universal coverage, but it's not socialism.
Some countries—Canada, Taiwan, Australia—have a blended system, with private-sector doctors and hospitals, but a government payment system. The Canadian model—private providers, but public insurance to pay them—is the system Lyndon Johnson copied when he created Medicare in 1965. The difference is that Canada, Taiwan, and Australia provide the public insurance for everybody, while the U.S. restricts it to seniors and the disabled.
In our current debate on health care, many have warned that universal coverage will inevitably lead to "rationing" of health care. The argument overlooks a basic fact: the United States already rations health care. Indeed, every country rations health care, because no system can afford to pay for everything. The key distinction is the way rationing happens.
In the other developed democracies, there's a basic floor of coverage that everybody is entitled to; that's why nobody dies in those nations for lack of care. But there are limits on which procedures and which medications the system will pay for. That's where the rationing kicks in. "We cover everybody, but we don't cover everything," the former British health minister John Reid explained.
In the U.S., in contrast, some people have access to just about everything doctors and hospitals can provide. But others can't even get in the door (until they are sick enough to need emergency care). That amounts to rationing care by wealth. This seems natural to Americans; to the rest of the developed world, it looks immoral.
"Canadians don't mind waiting for elective care all that much, so long as the rich Canadian and the poor Canadian have to wait about the same amount of time." In that one sentence, Marcus Davies laid out the ethical basis of Canada's health-care system. The question facing Americans this fall is: what should be the ethical basis of America's health-care system?