Pains of Canada's waiting room

TORONTO -- A letter from the Moncton Hospital to a New Brunswick heart patient in need of an electrocardiogram said the appointment would be in three months. It added: "If the person named on this computer-generated letter is deceased, please accept our sincere apologies."

The patient wasn't dead, according to the doctor who showed the letter to The Associated Press on condition of anonymity. But there are many Canadians who claim the long wait for the test and the frigid formality of the letter are indicative of a health system badly in need of emergency care.

Americans who flock to Canada for cheap flu shots often come away impressed at the free and first-class medical care available to Canadians, rich or poor. But tell that to hospital administrators constantly having to cut staff for lack of funds, or to the mother whose teenager was advised she would have to wait up to three years for surgery to repair a torn knee ligament.

"It's like somebody's telling you that you can buy this car, and you've paid for the car, but you can't have it right now," said Jane Pelton. Rather than leave daughter Emily in pain and a knee brace, the Ottawa family opted to pay $3,300 for arthroscopic surgery at a private clinic in Vancouver, with no help from the government.

"Every day we're paying for health care, yet when we go to access it, it's just not there," said Pelton.

The average Canadian family pays about 48 percent of its income in taxes each year, partly to fund the health care system. Rates vary from province to province, but Ontario, the most populous, spends roughly 40 percent of every tax dollar on health care, according to the Canadian Taxpayers Federation.

Going for broke

The system is going broke, says the federation, which campaigns for tax reform and private enterprise in health care.

It calculates that at present rates, Ontario will be spending 85 percent of its budget on health care by 2035. "We can't afford a state monopoly on health care anymore," says Tasha Kheiriddin, Ontario director of the federation. "We have to examine private alternatives as well."

The federal government and virtually every province acknowledge there's a crisis: a lack of physicians and nurses, state-of-the-art equipment and funding. In Ontario, more than 10,000 nurses and hospital workers are facing layoffs over the next two years unless the provincial government boosts funding, says the Ontario Hospital Association, which represents health-care providers in the province.

In 1984 Parliament passed the Canada Health Act, which affirmed the federal government's commitment to provide mostly free health care to all, including the 200,000 immigrants arriving each year. The system is called Medicare -- no relation to Medicare in the United States.

Despite the financial burden, Canadians value their Medicare as a marker of egalitarianism and independent identity that sets their country apart from the United States, where some 45 million Americans lack health insurance.

Raisa Deber, a professor of health policy at the University of Toronto, believes Canada's system is one of the world's fairest.

"Canadians are very proud of the fact that if they need care, they will get care," she said. Of the United States, she said: "I don't understand how they got to this worship of markets, to the extent that they're perfectly happy that some people don't get the health care that they need."

Canada does not have fully nationalized health care; its doctors are in private practice and send their bills to the government for reimbursement.

"That doctor doesn't have to worry about how you're going to pay the bill," said Deber. "He knows that his bill will be paid, so there's absolutely nothing to stop any doctor from treating anyone."

Care they need

Deber acknowledges problems in the system, but believes most Canadians get the care they need. She said the federal government should attach more strings to its annual lump-sum allocations to the provinces so that tax dollars are better spent on preventive care and improvements in working conditions for health-care professionals.

In Alberta, a conservative province where pressure for private clinics and insurance is strong, a not-for-profit organization called Friends of Medicare has sprung to the system's defense. It points up the inequities in U.S. health care and calls the Canada's "the most moral and the most cost-effective health care system there is in the world." "Is your sick grandchild more deserving of help than your neighbor's grandchild?" It asks.

Yes, says Dr. Brian Day, if that grandchild needs urgent care and can't get it at a government-funded hospital.

Day, an English-born arthroscopic surgeon, founded Cambie Surgery Center in Vancouver, British Columbia -- another province where private surgeries are making inroads. He is also former president of the Arthroscopy Association of North America in Orlando, Fla.

He says he got so frustrated at the long delays to book surgeries at the public hospitals in Vancouver that he built his own private clinic. A leading advocate for reform, he testified last June before the Supreme Court in a landmark appeal against a Quebec ruling upholding limits on private care and insurance.

George Zeliotis told the court he suffered pain and became addicted to painkillers during a yearlong wait for hip replacement surgery, and should have been allowed to pay for faster service. His physician, Dr. Jacques Chaoulli, said his patient's constitutional rights were violated because Quebec couldn't provide the care he needed, but didn't offer him the option of getting it privately.

A ruling on the case is expected any time.

If Zeliotis had been from the United States, China or neighboring Ontario-- anywhere, in fact, except Quebec -- he could have bought treatment in a private Quebec clinic. That's one way the system discourages the spread of private medicine -- by limiting it to nonresidents. But it can have curious results, says Day.

He tells of a patient who was informed by Ontario officials that since Ontario couldn't help him, they would spend $35,000 to send him to the United States for surgery.

Day said his Vancouver clinic could have done it for $12,000 but the Ontario officials "do not philosophically support sending an individual to a nongovernment clinic in Canada."

Banned insurance

Canadians can buy insurance for dental and eye care, physical and chiropractic therapy, long-term nursing and prescriptions, among other services. But according to experts on both sides of the debate, Canada and North Korea are the only countries with laws banning the purchase of insurance for hospitalization or surgery.

Meanwhile, the average wait for surgical or specialist treatment is nearly 18 weeks, up from 9.3 weeks in 1993, according to the Fraser Institute, a right-wing public policy think tank in Vancouver. A Fraser study last year said the average wait for an orthopedic surgeon was more than nine months.

Prime Minister Paul Martin's Liberal government has pledged $33.3 billion in new funding to improve health in all provinces and territories over the next 10 years. Critics aren't impressed.

"It won't make a difference," said Sally C. Pipes, a Canadian who heads the conservative Pacific Research Institute in San Francisco. "They need to break the system down, or open the system up to competition."

Pipes is a big supporter of the Bush administration proposal to allow Americans to divert some of their payroll taxes into medical savings accounts. She claims the two-tiered system feared by Canadian liberals already exists because those with connections jump to the head of the medical queue and those who can afford it can get treated in the United States.

"These are not wealthy people; these are people who are in pain," Pipes said.

Another watershed lawsuit was filed last year against 12 Quebec hospitals on behalf of 10,000 breast-cancer patients in Quebec who had to wait more than eight weeks for radiation therapy during a period dating to October 1997.

One woman went to Turkey for treatment. Another, Johanne Lavoie, was among several sent to the United States. Diagnosed with invasive breast cancer in 1999, she traveled every week with her 5-year-old son to Vermont, a four-hour bus ride.

"It was an inhuman thing to live through," Lavoie told Toronto's Globe and Mail.

"This is the first time someone has decided to attack the source of problems -- the waiting list," said Montreal attorney Michel Savonitto, who is representing the cancer victims. "We're lucky to have the system we do in Canada," he told the court. "But if we want to supply proper care and commit to doing it, then we can't do it halfway."

An estimated 4 million of Canada's 33 million people don't have family physicians and more than 1 million are on waiting lists for treatment, according to the Canadian Medical Association. Meanwhile, some 200 physicians head to the United States each year, attracted by lower taxes and better working conditions. Canada has 2.1 physicians per 1,000 people, while Belgium has 3.9, according to the Organization for Economic Cooperation and Development.

The World Health Organization in 2000 ranked France's health system as the best, followed by Italy, Spain, Oman and Australia. Canada came in 30th and the United States 37th.

Alberta Premier Ralph Klein is pushing what he calls "the third way" -- a fusion of Canadian Medicare and the system in France and many other nations, where residents can supplement their government-funded health care with private insurance and services.

But some Canadians worry even partial privatization would be damaging.

"My concern is that the private clinics would only serve to further drain the scarce physician resources that we already have," said Dr. Saralaine Johnstone, a 31-year-old family physician in Geraldton, a papermill hamlet in northern Ontario.

"We first need to guarantee that everybody has access to quality health care," she said, "and we just don't have that."