Monday, October 17, 2005

Blame Canada!

Last week a little post of mine on frustration with US health care made some noise here and here. I have to admit I was taken by suprise that my bitching got so much attention.

Much of that attention demanded that I give proof for my accusations! Well, if you read the post closely you'd see I wasn't making any claims except the simple fact that our health system has its problems, waiting being one of them. But today I'm going to give all those naysayers some satisfaction by debunking another huge myth about the perils of Canadian medicine: that many thousands of desperate Canadians cross the border every year seeking medical care because of unsatisfactory care at home, be it long waits, lack of new technology, or [insert appropriate false claim about Canadian care here.]

Three years ago, long before this blog came into existence, Health Affairs ran an article on Canadians seeking care in the US. The authors used some nifty methodology, including surveying numerous US hospitals along the border, as well as institutions generally regarded as "America's Best Hospitals". On the Canadian side, they used the National Population Health Survey (which literally asks, "In the past twelve months did you receive any health care services in the United States?" and "Did you go there primarily to get these services?"), as well as querying insurance companies on the Canadian side about the popularity of policies that cover US institutions.

Before I pull back the curtain to reveal their astounding findings, let's make a couple things clear. Many Canadians travel in the US every year. It is expected that this fact will show up in statistics. Further, I assume there are some very wealthy Canadians who will always say "No thanks" to waiting lists, and hop over to the US. I believe that is a reasonable assumption, and a fact of life that I'm comfortable with.

So what did the authors find?

In terms of hospitals along the border offering advanced treatments or special diagnostic technology (i.e. CT scans and MRIs), about 640 Canadians were seen, along with 270 for procedures like cataract surgery. They compare this to about 375,000 and 44,000 similar procedures in the region of Quebec alone during the same period. If you divide the total number of Canadians seeking those treatments in the US, divided by the number in Quebec alone that's about 0.09%. Not even a tenth of a percent.

But the most striking stats come from the Canadian National Population Health Survey (NPHS). From the article:
Only 90 of 18,000 respondents to the 1996 Canadian NPHS indicated that they had received care in the United States during the previous twelve months, and only twenty had indicated that they had gone to the United States expressly for the purpose of getting that care.

Only 20 of 18,000 sought care in the United States. I can't believe how many people are coming over here! Their system but be truly awful.

But let's give this number some context. We've all heard about seniors getting their prescriptions from Canada. (Hell, even driving to visit my sister at college in rural Kansas, I saw a billboard for "Canada Drug of Topeka!") But how many seniors really do that? Is it exaggerated, like the claims of Canadians coming stateside?

Polling data from 2003 (approximately a year after the Health Affairs article) indicates that 8% answered YES to the following question:

"Have you ever bought prescription drugs from Canada or other countries outside the United States in order to pay a lower price?"

If 8% of the 18,000 Canadians polled in NPHS had expressly sought care in the United States, that would be 1,440. Not 20, as the survey showed.

In other words, we have 72 times the number of Canadians seeking care in the US going to Canada (or at least calling there) to get prescriptions.

Honestly, what's really wrong with this picture?

[Source: Katz, Steven J et al. "Phantoms in the Snow: Canadians' Use Of Health Care Services In The United States." Health Affairs May/June 2002.


At 10/17/2005 11:58 AM, Blogger Robert McClelland said...

Here's something that you might be interested in. The Fraser Institute, a Canadian right wing think tank, publishes a report on waiting times in our health care system every year.

According to their data (pdf: page 19, table 11) only 1.2% of patients are receiving treatment outside of Canada.

At 10/17/2005 8:17 PM, Blogger Geoff Egan said...

That's not even the best comparison. To be truly valid one would have to ask how many Americans come north for medical care. Writing from Edmonton, I know that Alberta Health estimates that several thousand residents of northern Montana, Idaho, and Washington State have Alberta health care cards and come to Lethbridge or Calgary for all their health care needs. I also understand that OHIP has at any moment more than that of citizens of Michigan and up-state New York coming to Ontario for their care.

At 10/18/2005 7:18 AM, Blogger Steve Robinson said...


Thanks for calling attention to the NPHS results and making an attempt to provide some comparative analysis of the results. I'll start looking at some earlier StatCan reports on the provincial healthcare systems to get a better understanding of this issue before I make any broad responses.

I comment on one claim in your post. Re: the significance of US residents coming across the border (literally or figuratively) to obtain Canadian prescription medication. You seem to be drawing upon this as a vindication of the overall attractiveness of the Canadian healthcare system.

I differ. Given the strict price controls imposed upon US drug manufacturers who sell their products to Canada, it's purely this market distortion, not any quality of care difference, that is drawing these Americans to buy Canadian drugs.

A point of note: Americans rarely purchase drugs from other countries with nationalised healthcare systems, such as EU countries. This undercuts the assumption that they're responding to quality concerns, since US manufacturers sell the same drugs to Canada that they sell to a number of EU countries.

Now your larger thesis may be that these price controls are an embedded part of the Canadian notion of governance, in which case the outcome [lowered drug prices] should be seen as an inherent characteristic of Canadian health care. If so, then I concede the matter. But surely a reasonable person would have good cause to dispute your conclusion on this point.

Re: Geoff Egan's comments on Americans going north to obtain actual healthcare. I can't dispute this directly, but of the two families I know who've told me they've done this, both are Canadian families living in the US. One in Kalispell, MT (who visits Calgary) and one in Lake Champlain, NY (who goes to Montreal).

How would American citizens legally obtain a provincial health registry card? I remember asking OHIP about this when I visited T.O. a few years ago, and was told in no uncertain terms that it would be against the law to do this. Of course, if you are talking about improperly obtaining a card, then the discussion moves from healthcare choice to healthcare fraud. A topic about which I'm sure there are hundreds of studies waiting for us to digest before further pontification.

At 10/18/2005 8:12 AM, Anonymous Harley D said...

Geoff egan speaks of "market distortion" brought about by Canadian regulation of health care prices - by the way, a very good post. I wish to bring to his attention certain US laws prohibiting importation of drugs, granting US based drug companies de facto monopoly. This particular kind of market distortion results in unusually high drug prices here. Canada's is a distorition that faovrs consumers, and therefore draws American ire.

At 10/18/2005 8:45 PM, Blogger Kate said...


I agree, drug prices are not a chief indicator of quality of care. They are, however, a chief indicator of price controls. Americans are certainly (at least in my opinion) not buying Canadian drugs because their system is better. They buy Canadian drugs because they are cheaper.

Now, I happen to believe cheaper pharmaceuticals are, in fact, indicative of the overall attraction of Canadian health care. But comparing health systems purely in terms of drug prices is a false comparison. In the last couple posts on Canada my only aim is to debunk claims of the US system's perfection, being that we do have to wait, and the idea that literally hundreds of thousands of Canadians come to the US every year to get care that their system cannot offer, is false.

I added the statistic of pharmaceuticals to illustrate how many Americans are taking advantage of the Canadian system.

At 10/19/2005 8:29 AM, Anonymous Harley D said...

Kate - could you cite some direct sources for the stats you provided regarding the number of Candaians coming down here for care? They'd be useful. Health Affairs is a subscription journal, and I'm not about to subscribe. It woudl be good to have this info - any way of getting around the subscription price to get the information to us?

At 10/19/2005 1:04 PM, Blogger Kate said...

harley --

what exactly do you have in mind? do you want me to quote the numbers literally, in terms of everything they cite in the article?

At 10/20/2005 8:22 PM, Anonymous Harley D said...

Ah -- get a hold of the article without paying for it. Otherwise, we're kind of at your mercy.

At 11/27/2006 7:53 PM, Blogger Prasad said...

The original blog is right about low Canada to US medical crossings. This article is very specific about the figures:

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