The problem with a single-payer system is that it is just that—a single-payer system. The government is the sole source for the financing of the entire healthcare system. Since there is a tendency for governments to trim budgets in tough economic times, rising healthcare costs and inflation tend to outpace the allocated revenues. Over time, it is inevitable that this will result in reductions in the level of care. This may not have been as much of an issue in the earliest days of the Canadian experiment, when technology was in its infancy, drug charges were modest, and hospitalization expenditures could be controlled. However, over time these costs have exploded. Access to timely and appropriate care in Canada began to lag behind other industrialized nations because the governments (federal and provincial) were unwilling to recognize the need for investment in these new technologies. For example, during the 1990s and the first decade of this century, there had been an unofficial moratorium on the integration of magnetic resonance imaging (MRI) technology into the healthcare system. This resulted in a situation where a single Boston teaching hospital owned more MRI machines than the entire province of Quebec (population 7 million). Today, the wait time for most outpatient MRI imaging is measured in months. The slots for elective surgical procedures are rationed. In most provinces, total joint replacement wait times average six to 12 months or longer. Referrals to specialists can take six months or longer to book. The perverse consolation in all this waiting is that patients rarely miss appointments! There are few, if any, “no shows,” because if you miss your turn, you must start all over again, at the back of a very long line.
Keep in mind that there is no such thing as a perfect healthcare system anywhere. We have the high-capacity and costly U.S. system, where an anxious patient of mine…can get an abdominal ultrasound, computed tomography, and MRI of the liver, all within 48 hours. Or there is the Canadian system, where such speed is nonexistent. Is there a way to incorporate universal coverage without bankrupting the whole system? This is a daunting challenge.
Cost Control Is Key
In some ways, the delivery of healthcare is like a superhighway; in the United States, it might consist of four lanes of traffic moving at various speeds. In Canada, the traffic is narrowed to a single lane. It moves slowly. Sometimes it crawls. There are tie-ups everywhere. Governments are keenly aware that this is the way to control costs. By limiting access, you limit costs. Since few doctors take call at night or weekends, most patients are told to go the local emergency rooms, where admitted patients must lay and wait for days for an available inpatient bed. The inpatient beds turn over slowly because rehabilitation and long-term placement beds for patients awaiting discharge are also in short supply. Hospital budgets are centralized; they are closely regulated by each provincial healthcare authority. To stay within budget, administrators try to keep their census numbers high with patients who are not consuming too many medical resources. This creates a relative disincentive for getting patients discharged quickly. This appears to be the complete opposite of the U.S. system, where the Diagnostic Related Group (DRG) drives discharges.
