Respond to this Article July/August 2000

Canada's Burning!

Media myths about universal health coverage

By Theodore Marmor & Kip Sullivan

Last winter's flu epidemic overwhelmed emergency rooms across North America. Patients trapped in uncomfortable conditions were forced to wait for long periods of time before finally getting treatment. It was an ugly situation and the American press dutifully reported the winding lines, the cold drafts, and the screaming drug addicts adjacent to the people suffering from the flu. But their reporting of the situation in Canada and the situation in the United States was dramatically different.

The three major reports on Canada, by The Washington Post, The New York Times, and ABC News, used the overcrowding problem as evidence that Canada's universal health insurance program was critically flawed. The problems of Canadian emergency rooms, in short, indicted Canada's medicare. The two major reports on the problem in the United States, by USA Today and Time magazine, did not, however, turn overcrowding in American ERs into an indictment of America's non-universal health insurance system.

This contrast in press coverage cannot be attributed to obviously better conditions in American emergency rooms. Emergency rooms in both the United States and Canada have come under increasing stress over the last decade and, although there's no rigorous data on ER overcrowding, the data we do have suggest conditions are as bad, if not worse, in the United States. What the disparity does reflect is a tendency among American reporters to state or imply that Canada's increasingly intense debate about its universal health insurance program is evidence that its program is in "crisis" and that universal, government-financed health insurance programs are bound to fail.

Breaking the News

The USA Today and Time articles presented vivid evidence that in parts of the United States the condition of the ER is already putting Americans at risk. Time reported that patients entering the Thunderbird Samaritan Medical Center near Phoenix last December waited "for up to six hours to see a doctor." In Los Angeles, "for nearly 10 days in December," according to USA Today, "60 of the [city's] 81 ERs were so full that hospital administrators asked to send ambulances elsewhere." The USA Today story quoted a Boston paramedic saying: "When we get to a hospital, we either have to wait with the patient on a stretcher or we are told on the radio, 'No, you can't come to this hospital.'" The articles explicitly attributed some of the overcrowding directly to the flu epidemic.

The journalistic portrait of Canadian ERs was similarly and deservedly dire. But the conclusion drawn wasn't simply that some Canadian ERs could be overwhelmed by events like the flu epidemic. The three reports on Canadian ERs either ignored the flu or dismissed it as an excuse used by Canadian public officials trying to minimize "the crisis." The problem was really our northern neighbor's universal health insurance program.

Steven Pearlstein of The Washington Post quoted unnamed "experts" to the effect that Canada's system is doomed. "Most academic experts," wrote Pearlstein, "say that while more money might alleviate the shortage of advanced machinery, hospital beds, and medical school slots, it will only be a matter of time before the demand for medical services once again overtakes the willingness of voters to pay for it." Pearlstein then quoted a Canadian "professor of health administration" who claimed "the big problem" is that "Canada has un-managed care," implying that Canada could avoid the apocalypse predicted by Pearlstein if it would import the techniques of managed care from the United States.

What Pearlstein did not say is that Canada is spending far less of its national income on health care than the United States is, that polls indicate Canadian voters want to spend more money on health care, and that in all countries with national health-insurance programs, doctors and other health-care professionals justify their demands for medical care with claims of critical shortages--a tactic known as "orchestrated outrage." Under these circumstances it is easy to find an "expert" who claims to foresee catastrophe; pending disaster is a great way to justify increased funding.

James Brooke, covering the flu outbreak for The New York Times, asserted that "few Canadians would recommend their system as a model for export," citing a tangential poll that actually only suggested that Canadians wanted the government to make health care a "top priority," and ignoring other polls that show that the vast majority of Canadians support their national health-insurance program. Brooke seemed to argue that Canada's whole "system" stands indicted by the reported problems its ERs were having during a bad flu season, at a holiday period where staff falls as much as 30 percent according to studies cited by the Canadian Institute for Health Information.

Although Pearlstein and Brooke based their indictments of Canada's universal health insurance on "expert" and "popular" opinion, Deborah Amos of ABC News was not so cautious. In her Feb. 3 report from Toronto for ABC's evening news, Amos averred that the "problem [of ER overcrowding in Canada] goes back a decade to when the Canadian government... recognized that universal care was inefficient and expensive" and drastically cut the Ontario health-care budget. Amos offered no study and quoted no expert in support of this statement. This is not surprising because the portion of her statement in quotes is palpably false. Canadian "universal care" is not, by any reasonable comparative standard, "inefficient" and the "Canadian government" has never said or implied it was.

Like Pearlstein and Brooke, Amos forgot to place American and Canadian performance in a comparative context. She failed to tell her audience (or did not know) that Canada insured 100 percent of its citizens for $2,250 per person in l998 while the United States expended $4,270 per person insuring only 84 percent of our citizens. This oversight was convenient. One would look rather foolish asserting that Canada's medical care costs half what ours does and insures everyone, but is, nonetheless, "inefficient."

The Pattern of Distortion

These three reports weren't the first time that American reporters gave slanted coverage of the Canadian health-care system. In fact, American media coverage of Canada has suffered from two defects for a long time: it is infrequent, and it is often biased. These two problems also, of course, overlap since infrequent coverage is frequently ill-informed.

Canadian medicare has from time to time popped into the American media consciousness, but with precious little background or continuity of coverage. In the early 1970s, for instance, Sen. Edward Kennedy led a posse of politicians and press north to observe the successes of universal health insurance. In l975, a serious and sustained comparative book was published with the accurate and promising title: Canadian National Health Insurance: Lessons for the United States. An academic bestseller in Canada, the book never reached the American journalistic community. The brief upswing in coverage of Canada was followed by a harsh backlash and then, with the stagflation of the l970s, the domestic policy frustrations of the Carter years, and the conservatism of the Reagan administrations, a long silence ensued. Americans might, by a majority, favor universal insurance and, as the polls showed in the late l980s, overwhelmingly favor what they thought Canada had. But their preferences forced no action in Congress and consequently stirred little media interest.

In l989, during a period of economic growth and amidst the new ideas that always come in with a change in presidential administration, there was the typical flurry of inquiring (and occasionally appreciative) television programs, newspaper features, and radio interviews about Canada's medicare. As before, these were soon followed by counter-stories fueled by the same interest groups that would scuttle the debate over President Clinton's health-care plan in 1993. Coverage slacked off after the counterattacks in both 1989 and 1992 and, by 1999, when the failings of the American health-care system began to reappear on our national political agenda, the journalistic community had again fallen out of touch with the Canadian situation. Thus, once again, they became easy prey for the special interest groups aligned against the Canadian system.

Bias

Foreign experience thoughtfully portrayed would help Americans participate intelligently in the great debate about how to reform our medical care arrangements that still leave over 44 million Americans uninsured. Readers would turn to such stories for the same reason they buy Consumer Reports: to read about cars, prescription drugs, or other complex consumer items. They are looking for clear-headed and well-informed assessments, not ideological ones. They expect to find in Consumer Reports not merely a list of horror stories about car A or car B, antidepressant X or antidepressant Y, but discussion of the available and reliable data, presented in a truly balanced fashion.

Why don't our journalists practice such careful reporting more consistently? What explains their penchant for using a single story to suggest system-wide problems without providing comprehensive supporting evidence? Part of the answer is that they are generalists, not specialists in Canadian (or international) medical care. And there's a well-documented tendency for journalists to look for one hot scandal and then expand it into what they think is a universal point. Reporters tend to ignore scientific or polling data in favor of anecdotes and quotations, and, with rare exceptions (see Ron Winslow's May 9, 1990 article in The Wall Street Journal), U.S. reporters do not provide Americans with the comparative data that would help them fairly evaluate the situation. Any reporter writing about Canada needs to understand the context and history of the debate if he wants to be able to offer a level-headed and informative analysis. But American reporters, for the most part, are trained to jump from story to story and speciality to speciality. Just in May, 2000, the New York Times' reporter who wrote about Canada's system during the flu epidemic has also written about gun control, immigrants from Kosovo, the history of Montreal, and the impact of a beer commercial on Canadian national identity.

The problem is compounded because the American media are not terribly interested in foreign experience with public policy and, when they turn to such a subject, it is often because American actors are using such experience to praise or blame some domestic U.S. initiative, program, or point of view. Domestic interest groups provide the spur to such stories, and the richest of such groups overwhelmingly want to attack the Canadian model. To the extent American journalists interpret balance and objectivity as quoting the views of contending parties, the imbalance in what they hear distorts the story they tell.

Precisely because Canada has achieved comparatively good value for money through a government program, it represents an ideological threat to a number of interest groups in the United States. Private health insurance firms play a relatively minor role in Canada, insuring only those services and goods not covered by their medicare. Second, Canadian medicare relies largely on price controls to keep physician fees and drug prices far below those that prevail in the United States. Canada thus poses a threat to the American health insurance industry, to the pharmaceutical industry, and to a substantial portion of the American medical profession. At one time or another, all three groups have conducted lobbying campaigns to discredit Canada's medicare.

In response to proposals by state and federal legislators to limit U.S. drug prices to those that prevail in Canada, the U.S. drug industry recently uncorked the latest anti-Canada disinformation campaign. On March 29, 2000, a drug-industry front group, described without a hint of irony as "Citizens for Better Medicare," launched a multimedia campaign "urging American seniors to reject the Canadian model of health insurance and coverage of prescription drugs." Here is how they pose the issue: "In a system of government price controls, you can't get the price without the government controls," according to Timothy Ryan, the executive director of this campaign. The price Canadians pay, according to Ryan, is enormous and includes controls in a "big government-run system that rations health care, delays access to treatments including new technology and medicines, and harms too many patients." The ad omitted data, such as the statistic reported in the sidebar indicating that "rationing" is far worse in the U.S., and concluded, "if American politicians are going to advocate Canadian-style solutions, then they must be prepared to accept Canadian-style consequences." The ad campaign apparently reflects the judgment of 40 national associations, including such traditional universal health-insurance supporters as the U.S. Chamber of Commerce, the National Association of Manufacturers, and the Pharmaceutical trade association. Most journalists aren't going to believe every word that these industry groups say, but there's no organized support on the other side. And when you've got millions of dollars in advertisements telling you something, and no one is rebutting the information, biases start to sneak in.

Myths

American journalists are subjected to more than just anti-Canada mythology from big business and right-wing organizations. These groups also inundate reporters with mythology that is simply anti-government.

The most generic myth is that any government program is by nature more complex and less administratively efficient than its private-sector counterpart. That's true in some cases, but in the case of Canada's medicare program, the reverse is true. Medicare--Canada's great concordat--is simple, but powerful. Canada's health-care system has an overhead of approximately one percent, far below the 15 to 30 percent levels of the private-sector insurance companies that rule the roost in the United States. Canadian provincial governments determine the budget available for medical care (albeit under pressure) and they leave patients and physicians largely to their choices. Hospital beds are tight, but no official from a managed-care firm hundreds of miles away makes judgments about who should and who should not have admission to, or stay in, a hospital. Likewise, the fights over what doctors and nurses should be paid are intense, as they are in every national health-insurance system. But unlike the lonely, invisible struggles of U.S. doctors with their HMO supervisors, Canadian health care professionals do battle with health-care ministries in a highly public, highly organized, and, therefore, highly influential manner.

Patient bills of rights are not on the Canadian political agenda. Why? Because they don't need to be in a system of universal coverage that does not rely on HMOs to control costs. And where legal challenges are being heard in Canadian medicine, they have to do with the regulatory power of government to limit where doctors can practice under full insurance reimbursement, not with micro-management of physician practices.

Universal health insurance is for most Canadians the country's post-war public triumph. It has brought a decent level of care to most citizens and at a price that consumes 40 percent less of Canada's national income than America's. The necessary consequence of Canada's method of cost control--paying for medical care from a single provincial budget, setting budgets for hospitals, and limiting what doctors and drug companies can charge--is regular controversy. That controversy is about how much to spend, on what, for whom, and under what rules of fairness. There is a democratic accountability that is truly astonishing when compared to the impotence of the U.S. Congress and state legislatures to respond to the health-care crisis in the United States. But a necessary condition for accountability of any government program, in any country, is constant media attention, and that's what Canada's medicare gets, and with it the constant claims by Canada's doctors and others that "crises" are imminent or in full bloom. The intense media coverage and the "crisis" talk in turn provides grist for distorted stories by American media.

Just this spring the Canadian Institute for Health Information issued a comprehensive examination of the problems and performance of Canada's health-care system, a document which, if read by reporters, could greatly improve American (and Canadian) understanding of the program. Unfortunately, there doesn't appear to be a lot of interest in it. It doesn't have spicy anecdotes, and it's certainly not going to be sent around to newsroom after newsroom by a well-funded special interest group.

That's too bad. There is a real health-care crisis in this country and if America is going to solve it, citizens must understand the differences between democratically controlled and corporate-controlled health-care systems. And if Americans are to understand those differences, reporters must consistently report the whole truth--not little truths, semi-truths, and falsehoods. They must give us a full and fair comparison between Canada's system of universal health insurance and our own. If they did that, the average American would finally be able to understand what we really can learn from Canada.

Theodore Marmor is the author of The Politics of Medicare and a professor at the Yale school of management. Kip Sullivan writes frequently about health policy.


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