The Globe and Mail                                              Monday,
May 15, 2000

An American diagnosis: If it ain't broke, don't fix it

        By Theodore Marmor

        As an academic observer of Canadian and American medical care
for a quarter of a century, I want to say to Canadians: Despite the
strains
of the past decade, you don't know how lucky you are. It is precisely
because Canada has good value for money through medicare that it
represents an ideological threat to U.S. medical and pharmaceutical
interest groups. This is playing out in Canadian medicare's image in the

North American media.
        Crisis and crowding in the emergency room has been a familiar
story
in Canada and the United States over the past decade. The media took
special notice when this past winter's flu season aggravated
overcrowding in the ER. Between mid-December and early February,
ABC News, The New York Times and The Washington Post did stories
on the quality of Canada's ERs. Steven Pearlstein of the Post asserted
that "most experts" agree that Canada's medicare is doomed. He wrote:
"While 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."
        During the same period, USA Today and Time magazine published
substantial reports on U.S. emergency rooms -- with this difference:
While the reports on Canada used the overcrowding problem to suggest
that your medicare is critically flawed, by contrast, parallel reports
on
U.S. overcrowding did not indict my country's health-insurance
arrangements.
        The image of a troubled medicare program is being amplified in
the
Canadian media, too. Yet this fearful portrait is strikingly at variance
with
the research. A 1992 study (Roos et. al.) found that three-year
mortality
rates following surgery were better in Canada than in the States for
eight
out of 10 types of surgery (including bypass surgery). A 1997 U.S.
General Accounting Office study found that Canadians are 5-per-cent
more likely to survive lung cancer than Americans, 4-per-cent less
likely
to survive breast cancer, and do equally well with colon cancer,
Hodgkinson's disease and hip fractures -- at far less cost to the
patient.
        Now we have a new and rigorous report of the Canadian Institute
for
Health Information. In providing a synthesis of research on medicare,
the
report is the enemy of anecdote (and in that sense is explicitly
critical of
the media). The CIHI found that medicare is a structurally sound program

of universal health insurance that largely satisfies those who use it
(but,
like all programs, requires managerial adjustment over time).
        However, the report noted a sharp distinction between the
satisfaction of Canadian users of medicare and the fears of the public
at
large. In l998, 54 per cent of Canadian users reported that the care
their
family had received in the previous 12 months was "excellent" or "very
good" -- and yet the public felt anxieties about the system's viability.
The
discrepancy between user satisfaction and perceived systemic trouble,
the CIHI's research suggests, is in part because "individuals' ratings
of
the health-care system seem most influenced by the media when their
own experience provides little guidance."
        The CIHI portrays Canadian medical care as institutionally
stable but
financially pressured, with pockets of strain and distress. It found
sharp
increases in hospital workload and constrained budgets through most of
the l990s. Tight budgets necessarily mean limits on the incomes of
doctors, nurses, and other medical personnel.
        But why do such specific problems turn into medicare crises? The

answer lies with the habits and stakes of the media, of medical pressure

groups, and of political elites.
        For most of its history, medicare has been the jewel of the
postwar
Canadian crown. Polls from the l970s through to l990 regularly reported
that you Canadians gave your system overwhelming approval and had
no interest whatsoever in following America's health-insurance example.
But with the recession of the early 1990s, your country's journalists
turned their attention to the belt-tightening, and the way frozen
budgets
meant real strain, disappointed nurses and doctors, and in the hospital
world, downsizing, closure, and merging. In short, there was much to be
concerned about, and reporters pursued the complaints that
straightened economic circumstances inevitably generate.
        But in doing so, they amplified the demands of stakeholders much

more than they systematically portrayed Canadian medicare. The truth
about a medical-care system is complicated. Pressure groups have no or
little interest in truth-telling as such, and journalists have a very
difficult
time evaluating complex, major programs through particular stories.
That's why the authority of the CIHI report is so important. It is both
a
voice to counterbalance vocal pressure groups with a stake in crisis
talk,
and a reliable source that every journalist covering medicare needs to
master.
        American journalistic interest in Canadian medicare reflects the
place
of health-insurance issues in our national agenda. The attention is
episodic and largely reflects preoccupations of U.S. interest groups.
Recently, we've had a flurry of articles (and ads) in the United States
about the "dangers" of Canadian-style "price controls" on
pharmaceuticals. Significantly, these stories emerged in March -- just
as
the U.S. Congress debated adding outpatient drug coverage to the
(U.S.) medicare program. A group called Citizens for Better Medicare
launched a multimedia campaign "urging American seniors to reject the
Canadian model of health insurance and coverage of prescription
drugs."
        The "citizens" turn out to include the U.S. Chamber of Commerce,

The National Association of Manufacturers, and the pharmaceutical
trade association. Together they claimed that Canadians suffer from a
"big, government-run system that rations health care, delays access to
treatments, including new technology and medicines, and harms too
many patients."
        Since few American reporters know enough about Canada to
question any of these caricatures, the claims are amplified, not
analyzed.
And, given the way the North American media market works, the U.S.
claims are transmitted north -- that is, Canadians see the Citizens for
Better Medicare campaign -- while Canadian stories don't flow south. I
can predict confidently that no New York Times story will analyze the
CIHI report.
        A portrait of Canada's medicare will never be painted properly
by
episodic, dramatic representations of particular trouble spots.
Moreover,
the very structure of medicare brings with it conflicts. Paying for
medical
care from a single provincial budget -- where other competitors for
public
funds help restrain medical demands -- means debate about how much
to spend, on what, for whom, and under what conception of fairness.
This brings accountability, but it also brings constant media attention,

constant claims of need, and considerable exaggeration of the state of
medicare.
        And as long as anecdotal and political stories are the way we
get our
coverage of medicare, we'll see distortion of the program's true
performance. Evaluating a system requires systematic evidence, which
is what the CIHI has provided -- a portrait of a medical system that is
not
critically flawed, but simply in need of targeted adjustments.
        For all the criticism of Canada's medicare program, I for one
would
be delighted to have its manageable problems in place of those in the
United States.


Theodore R. Marmor is a professor of public policy, Yale School of
Management. He is a Fellow of the Institute of Medicine and of the
National Academy of Sciences and a Fellow of the Canadian Institute for
Advanced Research 1987-95. He is the author of Understanding Health
Care Reform.