Affordable Care Act compared to Canadian Health Care

Since this is nearly upon us, and all you hear in the news is hyperbole, can anyone acurately answer the following questions:

  1. Exactly what is included in the Affordable Care Act?
  2. How does this compare to Canadian Health Care system?
  3. How good is the Canadian system, anyhow?

Thanks in advance,
John from Raleigh

Seriously? just wiki it, it is all there. Read the legislation for yourself.

very poorly, you are still going to get financially clobbered at point of use and just reading the wiki entry made my headspin. How can it be so long-winded and complicated?

Cheaper and far more comprehensive whilst maintaining a very high quality of healthcare rating.
(and they aren’t looking to ape the USA system any time)

And just to get it out in the open you are best to let people know how you approaching this and whether you have an agenda. Do you think it is a good thing or not? for or against?

The Affordable Care Act is a legalistic mess - a compromise between having private healthcare providers, being as little disruptive to existing health care plans, while allowing the worst problems to be corrected (allegedly) and providing healthcare for the uninsured.

Canadian Health Care is real simple. Each province has its own health care provider. they pay all bills (sort of) for all covered residents of that province. When you move into a province, IIRC once you’ve been there 90 days, and are a legal Canadian resident (citizen, landed immigrant, etc.) you are covered. You get a card, and a number, and the doctor who sees you bills the provincial provider.

It works great if you are in need of emergency service. If the procedure can be put off, there are waiting lists. They can get long. My wife’s grandfather fell, broke his hip (at 87 years old) and had a new hip that same night. My boss had chronic hip pain due to mismatched leg length (a snowmobile accident 30 years before - how Canadian cliche can you get?). He waited 16 months. First they scheduled him for the consultation, 4 months. the consult found he had screws in his leg. (Duh!) Then he went off the hip list, and onto the “remove the screws” waiting list. 8 months later, the screws were out of his thigh, ow they can put him back on the hip list, and 6 months later, tada! New hip. Sounds annoying, but guess how much it cost him? (Hint -zero!)

It’s hard to find a doctor here. It’s hard to get an appointment. To see a specialist, you must be referred by a GP. Surgery tends to have wait lists. Things that are not covered, electives like plastic surgery, are quicker and probably cheaper than the USA. Drugs are not covered unless administered in a hospital setting.

For doctors - they are paid according to the fee schedule. it i low. Not too many filthy rich doctors here compared to the USA. If you want to charge more than the fee schedule (“extra billing”), you opt out completely and try to find people who can pay your fees out of their pocket. The Plans will not pay a portion of your fee - it’s all or nothing, and virtually nobody has private health care plans, so your only option is to be a doctor to the very very rich.

The plan is not tied to employment, or income, or anything, it’s funded out of taxes. So, employers do not count it as an expense, people are not tied to jobs with these golden handcuffs. (Those tend to be prescription drug pans and such benefits). Our taxes are higher (somewhat) but then, we don’t pay $5000 to $15000 in health insurance…

But doctors generally bill one system, they know what is covered by that one plan, they simply need to see your health card, there is no complex billing administration to deal with a hundred insurance compaies and a hundred different criteria for each procedure.

I know if I walk into a hospital (or are carried in) I stand to lose wages, but not much more. they won’t turn me away because of money, they won’t give me second class treatment, I won’t get a bill (except maybe for the TV rental in the room if I want a TV).

Also, there are very few of these convoluted things in Canada like you find in the USA. In the USA, you have problems like “pre-existing conditions”, lifetime maximums, or the newest one - if your employer plan is too high, you can join the government plans; but that’s only if the personal, not the family plan is too high. So the incentive is to make the employee plan cheap, and the family plan exorbitant, and the family man is screwed. In another case, the “Pre existing Condition Plans” are way over budget and stopped signing up new patients.

(According to one op-ed piece - normally, this sort of problem with legislation would be tidied up by congress over the next few years; the Obamacare thing is going to blow up in peoples faces because teh Republicans REFUSE to make any changes to it except to demand it be repealed. The house keeps trying to repeal it and rfuses to make changes from Democratic senate bills that would tidy up the mess; each side hopes the other will be blamed when things finally mess up completely.)

I have a question-if prescription medications are not covered, how in the world do people afford them? Some of my patients are on 20 medications and even at 30 dollars each a months that’s over 600 dollars monthly. What if you have a transplant and need antirejection drugs that can cost over 100K yearly? Do transplants just get rejected because nobody can afford the medications?

For one thing Canadian drugs tend to be cheaper, probably in part because in the US it’s usually the insurance companies paying.

As a note, the health insurance company I work for is not sad to see pre-existing conditions, student dependency requirements, and lifetime maximums eliminated. Those were a labor intensive, error prone nightmares to administer, (for lifetime we would order microfilms from our archives and add them up on an Excel spreadsheet!) most of these personal were transferred to other departments.

The provinces have individual prescription drug insurance programs which you can sign up for. Back when I was using one 10 years ago in Ontario they had a fairly high deductible, up to about 5% of your income, but after that everything was covered.

I am an Albertan. I pay C$190.50 every 3 months for optional Blue Cross coverage. That is supplementary insurance to cover some things that Alberta Health Insurance (the universal coverage provided by the province) does not cover. There are lots of other supplementary plans (very common for employers to provide some plan or other, but I’m retired) covering various things, but they are all supplementary to Alberta Health Insurance. What I have is fairly minimal coverage; it covers a few other things but what I got it primarily for is the fact that it covers 70% of my prescription costs. Pretty sure there is a maximum cost per prescription as well, but I’m not in the mood to dig up the plan description to check that (bit of a pain to find the info if you don’t have it bookmarked, which I don’t). It has no deductible for prescriptions (it does for the other things it covers that I’m not particularly concerned about).

In Quebec drugs are covered more or less. There is a copay, but it is capped at something like $100/month; after that drugs are free. And the provinces negotiate prices with the drug companies.

Yes, you can wait a long time for certain operations. It took about four months to schedule a cataract operation, but when I had a detached retina, it took 6 days and when the repair didn’t quite hold, it took five days for a repeat. And the first operation took place during a semi-holiday when the hospital was in only partial operation (e.g the outpatient surgery wing was closed and I had to go to the post-op ward for the prep, but they opened the outpatient eye surgery for my operation).

There is a real problem with enough GPs. And the system is always short of money, but we pay, in total, only about 60% of what the US is paying for medical services. And even if you go private it is grossly cheaper. The NY Times reported last week that a colonoscopy cost between $7K and $19K in some US hospitals and most refused to estimate. If you feel it is urgent (I had to wait about 4 months for one) you can get it done at a private clinic for about $500.

When my MIL died in Florida, she spent her last three days in a hospital (paid for by insurance, to be sure), but we got the final bill, which ran to about 7 pages. An aspirin, for example, was billed at something like $10. When I went to a hospital here with a broken ankle 9 years ago, I went in, showed my medicare card, was operated on 4 days later (swelling had to subside) and simply walked out two days after that. No bill, nothing. It just happened.

Just in case it isn’t obvious to folk south of the border, this discussion of drug costs applies to out-patient and going-to-a-drugstore drug costs. Drugs received as a hospital in-patient are covered by provincial health insurance.

Provinces have (free or mostly free) drug benefit plans that cover certain folks, for example, in Ontario people who face high drug costs relative to income, or are seniors, or are in long term care, or are in home care, or are on provincial disability or on social assistance (welfare).

This adds up to a bit less than half of prescription drug purchases in Ontario being paid for by the government, which in turn gives the government a lot of purchasing power by way of limiting the rates it will pay for prescriptions. The government has also tightened up on kickbacks from the pharmaceutical companies to the pharmacists, and tightened up on pharmacists’ prescription fees. Even now there is a way to go in further reducing drug prices, for Canadian drug prices are higher than some other nations, such as England.

When comparing Canada with the USA, Canadians live longer, life in a healthier state longer, pay less out of their own pockets, and pay less out of the government pockets than Americans.

I agree with all of md2000’s post # 3, except this bit:

  • I have never had any trouble finding a family doctor.

  • If the matter isn’t urgent, the appointment with my family doctor will usually be within a week to 10 days.

  • If the matter is urgent and I can’t get in to see my own doctor, the clinic has “walk-ins”, where you see whichever doctor in the clinic is handling the walk-ins that day.

  • the wait lists for surgery can vary tremendously, as some of the others have commented, depending on how urgent the need for surgery is. If a condition is life-threatening, or possibly would cause long-term damage (e.g. - blindness from a detached retina, as Hari Seldon mentions), surgery will happen quickly. If it is a chronic condition that does not require immediate attention, the wait might be longer.

Note that I’m not saying md2000 is wrong; that’s his experience, which is different from mine. You have to remember that there is no single “Canadian Health Care System.” The feds set the general rules and contribute a honking big chunk of cash to each province, but each province has sole jurisdiction over how to set up its own health care system. There can be major variations from province to province, and even regionally within provinces.

I started a thread on my own experience with the health care system in Saskatchewan last summer, just as a comparison piece for US Dopers to see how it works up north. The OP might find it interesting: “Get this thing off my back!” A Canuck Doper Universal Health Care case study.

I discuss the drug issue in the “Get this Thing off my Back” thread, giving some practical experiences.

The applicable federal legislation is the Canada Health Act, which authorises the federal government to make payments to each province to support the provincial health care system. The Act also sets out five key conditions which the provincial system must meet, as well a sorta sixth condition, not related to health care delivery, but to political accountability.

If a province does not comply with those conditions, it may find its federal funding cut proportionately:

1 Public administration: the provincial health care system must be publicly administered, not privately for profit. Note that does not mean that the Provincial government must directly run the health care system. I think all of the provinces delegate the administration to regional public health boards, set up under provincial law. Nor are doctors public employees. They are in private practice, responsible for their own business, partnerships, hours of work, etc. It is just that they bill to the single biller to be compensated for seeing each patient, based on the cost chart.

2 Comprehensiveness: the provincial plan must cover every medical service offered by medical physicians and hospitals. Notably, that includes abortion.

3 Universality: with a few exceptions (e.g. federal military personnel; serving federal prisoners) every Canadian citizen and permanent resident must be covered by the provincial plan, on uniform terms.

4 Portability: there is no lapse of coverage if you move from one province to another. During the qualification period in the new province, you’re covered by the health care plan from your previous province.

5 Accessibility: the provinces must provide reasonable access to health care throughout the province, not just centred in a few major centres. Of course, there has to be some flexibiity; in areas of extremely low population density in a province (e.g. many of the northern parts of the provinces) the local hospital won’t be as elaborate as the hospitals in the south. But, there will be some local health care stations, and things like air ambulance to get patients to bigger hospitals down south.

6 Additional conditions: the province must provide regular administrative reports to the federal Department of Health, and also routinely credit the federal government for its contribution to the health care system.

And we complain about the NHS…?

Note that the Canadian Health Act (which sets standards) is specifically aimed to avoid some of the shortcomings of the NHS in Britain.

The key one is “no extra billing”. A doctor is either in the plan and charges only the fee schedule (to the province) every time an insured procedure is done, or is completely outside the plan, nothing from the province. No such thing as “Friday I see private patients”. If the doctor is not in the plan, the patient does not get the fee schedule amount reimbursed. So, the patient has to be willing to pay cash out of pocket and there must be a big enough market. Employers refuse to offer any equivalent to US health plans, so that avenue is out. Typically the very few private doctors do things like medicine for a pro sports team, very specialized clinics for the filthy rich, etc. A doctor can do plan work and also do procedures like plastic surgery at their own fee schedule provided those procedure would not be covered by the provincial health plan. One plastic surgeon I know of splits his time between burn victims etc. (covered) and rich fat ladies (not covered).

If the plan started to allow extra charges, then quickly health costs would end up being just a supplement, doctors would charge much much more, and employers would have to offer health care supplement plans, and poor people would not be able to afford doctor visits extra fees - and we’d be back to where the USA is.

Yes, a lot of the provinces offer prescription drug plans for those who can’t afford it - i.e. on welfare, seniors, low income workers, etc. My Blue Cross plan pays a fixed fee schedule; I switched to Costco pharmacy when I realized the Shoppers Drug Mart was costing me a few dollars more per prescription because they decided to charge more than the BC fee schedule, for example. The provinces buy a lot of the medications under their plans, and twist arms to keep prices down. Those internet pharmacies are usually not selling you crap, they are (were?) selling Americans the same drugs at the Canadian price and making a profit. Why do you think Big Pharma twisted congress’ arm to make that stuff illegal? Heck, you can’t even go and pick up your own drugs and bring them back there… Money, money…

Not sure the exact situation - it varies by province. Doctors tend to like to live in big cities, so the smaller the town and more remote, the less likely the doctors will have time for you unless it is an emergency. You can wait hours in the walk-in emergency room - but isn’t that the same in the USA? However, as mentioned - if it is a real emergency, you will get the same care as everyone else and quickly. In fact some of the queue problem comes from people being bumped by emergencies. Kind of silly - you can wait for the heart bypass, you wait. While waiting, you have a massive attack - oops, got do the work NOW! To some extent, rationing provides its own emergencies.

Still, with all the problems, I would NEVER trade this for what I see in the USA, with or without Obamacare.

The only thing most serious medical emergencies - heart attack, broken leg, cancer - really cost is lost wages. Nobody loses their house or goes bankrupt over medical bills.

There has not really been a doctor or hospital shortage, but there have been allocation problems, for the resources we have today were more or less determined years ago, such that at any given time a particular patient might not be treated as quickly as he or she would like due to a physician or a facility being at capacity already.

For example, at this time folks where I live who want hip replacements can wait a couple of months or they can travel a few hours down the road and get the surgery done now by the same physicians because our hospital’s operating rooms are operating at capacity whereas the ones down the road are not. Another example is that it used to be difficult to find a GP around here (folks used walk-in clinics instead) until incentives were provided by the government to encourage doctors to train as GPs, such that now there is not longer any difficulty in finding a GP here. Similarly, folks up my way used to have to travel south for angioplasties, whereas now such operations are being performed here due to a needs based reallocation of resources.

The further from cities one goes, the more difficult it is to attract physicians, and here in the northern part of Ontario there are communities that are so small that they could never justify a physician. To address this, the government has started a medical school up here, offers incentives for doctors to practice in the boonies, is promoting nurse-practitioners, and is developing telemedicine.

All in all, in Ontario wait time is not a problem, although for any given procedure on any given patient in any given location there may be a wait.

I expect that the next big challenge will be having the appropriate resources in place to meet the needs of our aging boomers. A lot of medical professionals will be retiring in the next few years, at the same time that a lot of the general population will be retiring. Fortunately we have universal health care in an integrated health care system, so we are well positioned to deal with this challenge.

Two other points -

The most common service outside plan is provincial Worker’s Comp. AFAIK in each province, they have a Workers’ Compensation Board. All employers should be enrolled. Rates are by industry, so there is no massive pressure on each employer to deny claims and hide injuries or face a premium rise. (If your workplace is unsafe, you will get investigated, charges could be laid - but rates are typically by industry not employer.) If you tell the doctor it happened at work, they report and bill the WCB instead. In return for lost wage support and disability pensions, you lose the right to sue your employer. (The old joke was"If I have a heart attack, drive me to work and throw me over the fence")

Additionally, since there are no medical bills for most incidents, there are a lot less lawsuits. Real Canadian lawyers will weigh in here I hope, but the rules in Canada are loaded against pain and suffering awards, and tend toward loser pays legal fees - so a lot less incentive to try for those stupid “I scalded myself with your coffee so it’s your fault” lawsuits.

Because the federal government pays an amount toward provincial health care plans, they get to set some standards to ensure the plans are all about the same. the amount paid to health Care (and post-secondary education support) are the major issues around federal-provincial politics. health care is one of the biggest government expenditures, rivalled only by education. OTOH, we don’t have the level of government infrastructure like Interstate Highways, etc. to match the USA - no surprise in a country that’s bigger but 1/10 the population.


The Nipigon bridge that is the only road that connects eastern and western Canada is being replaced. Now there’s infrastructure for you. :smiley:

Since this is GQ, here is the what citing the WHO, albeit a bit dated since I first posted it.

What really stands out is that Americans pay more per capita out of the public purse, but they are not all covered, then they pay nearly twice as much as we do out of their personal pockets, but still don’t out live us. If we had those sort of results in Canada, I very much expect that the government would fall in short order. My take on it is that the Canadian health care system is results driven, whereas the American health care system is ideologically driven – all about personal freedom from the government (especially in the red/southern states), such that the middle man (private health insurers) has been able to take control of the field to fill the void in the USA that the government occupies in Canada. Since private health insurers are profit driven rather than health driven, the health results are poor when compared to other first world nations that have greater government control over their own health care systems.

With respect to Obamacare, it is a huge step forward, for although it does not cover everyone, it does extend coverage significantly. Kudos for that, and keep moving forward with it. That being said, it is still a private insurer based system significantly dependant upon employer based premiums, so I do not expect it to be as efficient or to produce as good health results as Canada’s public based system, for private insurers and employers are not in the business of promoting optimal health.

Very brief analysis for any Canadian reader wondering about ACA:

The ACA’s main goal was to provide insurance coverage to Americans who lack it, without creating a single-payer system where the government just takes over most insurance functions, because many Americans fear government control of just about anything. So instead, it will buy people private insurance, or more or less. But to keep costs down, it requires everyone to have insurance (to keep the healthy or rich from opting out and leaving insurance costs to the rest of us). Most Americans have insurance through their employer; those who don’t must get it or pay a penalty.