Brian Lee Crowley is the founding president of the Atlantic Institute for Market Studies, Atlantic Canada’s public policy think tank. He has written extensively on the centrally planned, government monopoly model of health care in Canada.
Carolina Journal interviewed Crowley during his recent visit to Raleigh.
CJ: Health care and health coverage are the subjects of continual and growing conversation here in the United States, and a frequent refrain from so-called reformers is that the United States should really dump the system that we are using and adopt the Canadian single-payer system. Now you are an analyst, a researcher, and you know that system inside and out. What do you think when you hear the Canadian system presented as such a panacea?
Crowley: It makes me think of a famous historian who once said that the history of the 20th century was of the abandonment of what works in favor of what sounds good. And when I hear many American advocates of the Canadian system describe it, I have to admit it sounds really good. I don’t think the reality is quite as bright as it is often painted. And I don’t mean to suggest that there aren’t strengths of the Canadian system, but I think you would want to be very careful that you understood what the Canadian system was before you decided that you wanted to import it wholus bolus.
CJ: Well, do you have any sense then of if there are downsides to the Canadian system—and we will talk about that in a moment. Why is there so much romance, almost, about the Canadian system here in the United States as this debate continues?
Crowley: I think one of the reasons is because there is something that appeals to people’s altruism about the Canadian system. It is a system in which people say, “Well, profit doesn’t matter. Money’s not the issue. We make sure that people who need health care get it.” And indeed, all of these things have their virtues. But people forget that there are consequences to the Canadian system. Like for instance, it’s a public-sector monopoly provider. There’s one place you can go for most health care, and if they don’t give you the health care that you want or you think you need, unlike the American system, you cannot go somewhere else and say, “I wasn’t getting satisfactory service where I was before. I brought my money. I want you to look after me.” You don’t have that choice in Canada. You are not allowed to buy health care.
CJ: And in fact, isn’t that illegal, to do that?
Crowley: It is illegal to sell health care and it is illegal to sell insurance for health care, where whatever health-care service we’re talking about is insured by the public system. You may not buy it and you may not buy insurance to cover it.
CJ: You know, there seems to be a belief that somehow Canadian health care is free to Canadian citizens. Is it free?
Crowley: Well, as we say in the technical language, it’s free at the point of service. You don’t pay when you go to see the doctor. On the other hand. . .
CJ: You pay, though.
Crowley …You do pay. There is no free lunch. It takes about seven percent of the Canadian GDP. In other words, seven percent of the national wealth, in order to pay for the public health care system in Canada, and that’s an amount that’s been rising faster than GDP growth. It’s rising faster than tax revenues. It’s rising faster than all other forms of public spending, so it’s really become quite unsustainable, and clearly it’s going to get worse.
CJ: Now how long can that go on, if costs are continuing to rise?
Crowley: The average Canadian province—which provides most of the health care services, it’s like an American state—used to spend 30 percent of its budget on health care. It now spends 50 percent of its budget on it. That’s up over the last 30 years.
CJ: Half of its budget in health care?
Crowley: Half of every dollar spent by the provinces in Canada. The provinces are much bigger than states. Their budgets are much bigger. They have much bigger responsibilities. Fifty percent of the average province’s spending now goes on health care. It’s growing faster than their economy. It’s growing faster then their tax revenues. They’re just falling behind all the time.
CJ: Now, I find that fascinating, because one of the myths that you hear about the Canadian system is that it’s able to keep costs under control, while the criticism of the U.S. system is that it really encourages over-consumption, because there’s no relationship between, for most of us, what we pay for a service and what the actual cost is for that health care, so it sounds to me like you’re saying the Canadian system is not more efficient.
Crowley: Well, my view is that it’s not a great system for keeping costs under control. It’s very good at making sure that bureaucrats decide who gets what health service. You know, if they decide that you should be queuing up for an MRI or if it’s going to take eight months to get a hip replacement, or whatever, they can do that. But they’re not very successful at reducing costs, and indeed, if Canada hadn’t enjoyed very significant faster economic growth than the United States in the ’70s and ’80s, we would’ve had the most expensive health care system in the world. It was our faster economic growth that was keeping us afloat.
CJ: One vexing question that we deal with here in this country is the question of the uninsured. Now, the Canadian system covers every citizen as I understand it. But there’s a tremendous wait for services, is there not?
Crowley: Well, we have to be a little bit careful, but it’s certainly true that for many services there are significant waits. The worst I’ve heard is for an MRI scan in Saskatchewan is 22 months. Recently the province of Ontario had to send cancer care patients to New York state because the cancer treatment waits were simply too long in Ontario.
CJ: Now one of the common beliefs about the Canadian system is that somehow it empowers poor people, while the criticism of the U.S. system is that our system either ignores the poor or it provides them with sometimes substandard or untimely care. Is the Canadian system really better at providing service for the poor?
Crowley: Well, the poor don’t think so. If you look at polling results, what the poor actually say, more poor people are interested in being able to buy private coverage and pay for health-care services than people who are better off and better-educated. People under $25,000 a year, about half of them want to be able to buy private insurance for their own health care, whereas people over $75,000, it’s less than 40 percent of them are interested in that. And in my view, and I think this has been borne out by the research that has been done on the Canadian system, is that medical care in the Canadian system is distributed in middle- class networks; you know, the articulate, the smart, get around the obstacles in the system, they get in the face of providers, they get what they need. But if you’re not able to — you know, payment makes you powerful. I think one of the things that we’ve learned from the Canadian system is that when you deprive people of the ability to pay for health care if they think it’s important to them, that you really do disempower them.
CJ: That’s interesting, because, again, one of the things that I think is common to hear or read about the Canadian system, the single-payer system, is that it’s really fair to all people, that there’s no prejudice based on your wealth or who you know, if you’re a family member of a doctor, etc. But it sounds as if that is really more of a myth. Am I misinterpreting, or is that correct?
Crowley: No, I think that is correct. The research very clearly shows that the articulate, the well-connected, are able to get health care faster, and as I’ve already said, if you have enough money to be able to drive 100 miles to the U.S. border and go to a U.S. clinic, you can jump the queue completely.
CJ: We in the U.S. are told that Canadians really love this system. We should look to Canadians because they’re using it and they’re saying it’s the way to go. Do they love this system?
Crowley: I think Canadians love the system in theory, but I think the evidence is growing that they are very, very concerned about its sustainability and I think, according to the polls, they are very willing to look at new reform options that would put the system on a sustainable basis. We need to know what the facts are.