By MARGOT SANGER-KATZ
New York Times, November 3, 2017
TORONTO — As he tells it, Senator Bernie Sanders of Vermont fell in love with the Canadian health system 20 years ago when he brought a busload of his constituents across the border to buy cheaper prescription drugs. Now he wants to make Americans fall in love with his proposal to make the United States system a lot more like Canada’s.
That’s one reason he took the equivalent of a busload of staffers, American health care providers and journalists to Toronto last weekend, in a two-day trip that was part immersion, part publicity tour. Canadian government officials and hospital executives showed him high-tech care, compassionate providers and satisfied patients, all as videographers recorded.
He ended the trip with a speech at the University of Toronto titled, “What the U.S. Can Learn From Canadian Health Care.”
But our question is this: What did Bernie Sanders learn from his weekend in Canada?
Lesson 1: He’s a ‘rock star’
Mr. Sanders — after wedging himself into Row 21 and taking extensive notes on a legal pad during the flight — had barely gotten off the plane in Toronto when an airport security guard chased him down the hallway, telling him, “You’re like a hero to me.”
A team of cardiac nurses at Toronto General Hospital asked to take pictures after he toured their unit. At a full 1,600-seat university auditorium on Sunday, he received repeated and sustained standing ovations. College students waited for hours to get into the auditorium and see him speak.
Mr. Sanders, who drew huge crowds as a presidential candidate in the United States last year, learned firsthand that he is also a household name in Toronto. His policy vision, decidedly from the left in the United States, matches mainstream Canadian views.
“You received the welcome here that is normally reserved for celebrity rock stars,” said Greg Marchildon, the director of the North American Observatory on Health Systems and Policies at the University of Toronto.
Ed Broadbent, the chairman of the progressive Broadbent Institute, called Mr. Sanders the most important social democrat in North America — even though Mr. Sanders is not a Canadian social democrat, and is not even a particularly powerful member of the Senate.
Lesson 2: Doctors like the system as much as patients do
Many developed countries have achieved universal health coverage, but Canada is relatively distinct in its insistence that individuals should not have to pay any money at the point of care. When Canadians go to the doctor or hospital, they just show their Canadian “Medicare” card.
At Women’s College Hospital, executives showed Mr. Sanders an empty billing window. The hospital, they told him, has one employee who manages bills. “For the entire hospital?” Mr. Sanders said, in mock disbelief.
Several patients told him about the comfort that comes from not having to pay for their care directly. And doctors, too, said they felt more comfortable recommending their patients get an operation or see a specialist than they might if those treatments weren’t free.
“I didn’t have to fill out any forms; I didn’t have to worry about how I was going to pay for the simple job of staying alive,” said Lilac Chow, a kidney transplant patient at Toronto General Hospital, who had been brought in to share her experience with the senator.
Whenever Mr. Sanders was asked what he learned about the Canadian system, the value of free care came up.
“What I think stuck out to me was from both the patients and the physicians, the importance of not having to worry about money in terms of the doctor-patient relationship,” he said in an interview after his trip on Tuesday.
His Medicare-for-All bill includes free care as a central feature. If the legislation became law, no American would pay directly for a doctor, dentist or hospital visit, and co-payments for prescription drugs would be limited. (Taxpayers would, of course, finance the system.)
Lesson 3: Sometimes, you have to wait
At a round-table discussion at Women’s College Hospital, the chief of surgery noted that Canadian patients can’t always get all the care they want right away. “Wait times, you could argue are a problem for certain procedures,” said Dr. David Urbach, before discussing the ways the province and hospital were working to shorten the lines. Mr. Sanders quickly turned to the glass-half-full interpretation. “What you are arguing — correct me if I’m wrong — is that waiting times are not a problem, and it’s an issue you are dealing with,” he said.
In Canada, where government finances health insurance and the private sector delivers a lot of the care, patients with life-threatening emergencies are treated right away. But patients with cataracts or arthritis often have to wait for operations the Canadian system considers elective. A governmental review of the Ontario system recently found that wait times were getting worse in some cases, like knee replacements.
The Canadian system puts hospitals on a budget and limits the number of specialists it trains, both factors that can lead to lines for complex care that’s not life-threatening. The system also limits access to services, like M.R.I. scans, that are much more abundant south of the border.
On his weekend tour, Mr. Sanders didn’t see the places where patients might wait. Hospital executives instead showed him a refugee primary care clinic, a neonatal intensive care unit and a cardiac surgery unit.
But he points out that many Americans who are uninsured — or who have limited savings and insurance with high deductibles — may wait even longer than Canadians for elective, or even urgent, care.
“If you’re very, very rich, you’ll get the highest-quality care immediately in the United States,” Mr. Sanders said, in the interview. “If you’re working class, if you’re middle class, it is a very, very different story.”
The Commonwealth Fund, a health research group, ranked the United States health system at the bottom of its most recent 11-country rankings, published in July. But Canada did only a little better, at No. 9. Of all the measures in the study, Canada ranked the worst on the “timeliness” of care. (A team of Upshot experts eliminated Canada in the first round in an eight-country virtual bracket tournament of international health system performance.)
Any single-payer system will need to grapple with how much it should spend over all, and where it will save money. Mr. Sanders’s Medicare-for-All bill currently includes few details about how the government would set budgets and allocate resources once all Americans were brought into the government system.
Lesson 4: Even Canada’s system has holes
Mr. Sanders wants to bring big, sweeping change to the American health care system. Unlike the Affordable Care Act, which filled in holes in an existing system, his Medicare-for-All plan would take away the health coverage that most Americans hold now, replacing it with a single, very generous government system. It would do away with the premiums, deductibles and co-payments that individuals and businesses pay for health care, and instead impose large tax increases.
That is not the kind of change that would be politically trivial. In his speech, he noted that the creation of a single-payer system in Canada and Britain followed grass-roots movements, and political landslides by the parties that favored the change. “Real change always happens from the bottom up,” he said, to big applause. “You’ve got to struggle for it. You’ve got to fight for it. You’ve got to take it. And that is the history of all real change in this world.”
Yet even in Canada, he learned, changes to the health care system have been difficult. The Canadian system, with insurance run at the province level, covers doctors and hospitals. But decades after the 1984 Canada Health Act, many Canadians pay for supplemental private insurance through their jobs for prescription drugs, dentistry and optometry — despite a growing recognition that medications are essential to care.
“Any one of us around the table is just a job loss away from having access to prescription medications, and that’s a problem,” said Danielle Martin, a vice president at Women’s College Hospital and policy researcher, who helped organize the trip, at a round-table discussion.
“I’m on my own going to the dentist,” said Naomi Duguid, a patient, sitting across the table. “It’s the only time I get to experience what it must be like to be an uninsured American.”
Ontario has recently started a program that will provide coverage for medications to residents under 25. And there is a patchwork of drug coverage programs for older people, the poor and those who get insurance from work. But even in Canada, it’s tough to find the resources to expand coverage.
“We have to find the money to fund the program up front,” said Kathleen Wynne, the premier of Ontario, who helped establish the youth drug coverage program.
Lesson 5: Canadians seem to value fairness more than Americans do
Equity. Fairness. Throughout the weekend, Mr. Sanders kept asking Canadians what they thought about the higher taxes they’d paid to finance their system. Every one among the patients and doctors selected to meet him said the trade-off was worth it because it made the system fair.
“I think it’s a really fair way to do it,” said Frederick Brownridge, 67, of Etobicoke, Ontario, as he sat by the window in his Toronto General Hospital room, with IV lines in his arms. Mr. Brownridge had had two heart valves repaired and a double bypass three days earlier. “It also means if you’re in a lower economic status or higher economic status, you’ll get the treatment you need.”
On Tuesday, Mr. Sanders said the uniformity of this message really stuck out to him: “There really is, I think, a deep-seated belief in Canada that health care is a right, and whether you’re rich or whether you’re poor or whether you’re middle class, you are entitled to health care.”
In the United States, though, Republicans control the presidency and the Congress, and many candidates last year ran on a promise to roll back government support for health care coverage.
Several recent public opinion surveys show majority support for a government guarantee of health coverage, but support declines substantially when pollsters mention that government coverage would mean higher taxes.
Mr. Sanders said he knows his bill isn’t going to become law anytime soon, but he thinks discussing the idea will help make its underlying values more broadly acceptable.
“When you talk about health care, you’re not just talking about health care,” he said in his Toronto speech. “You’re talking about values, because how a society deals with health care is more than medicine. It’s more than technology. It is about the values that those societies hold dear.”