Canadian and American health care systems compared



Government and private health and public policy analysts have compared the health care systems of Canada and the United States.  In 2004, per-capita spending for health care in the U.S. was more than double that in Canada: in the U.S., it totaled US$6,096; in Canada, US$3,038. Studies have come to different conclusions about the result of this disparity in spending. A 2007 review of all studies comparing health outcomes in Canada and the U.S., in a Canadian peer-reviewed medical journal, found that "health outcomes may be superior in patients cared for in Canada versus the United States, but differences are not consistent." Life expectancy is longer in Canada, and its infant mortality rate is lower than that of the U.S., but there is debate about the underlying causes of these differences. The World Health Organization's ratings of health care system performance among 191 member nations, published in 2000, ranked Canada 30th and the U.S. 37th, and the overall health of Canadians 35th and Americans 72nd.

The health care system in Canada is largely government-funded, with most services provided by private enterprises. Waiting times for major non-emergency surgery have been longer in Canada, and Canada has been slightly slower to adopt expensive technology and medicines. Consequently, Canada has had higher mortality rates for some conditions, such as heart attacks. Canadian health administrators say that these problems are improving.

Through all entities in its public-private system, the U.S. spends more per capita than any other nation in the world, but is the only wealthy industrialized country in the world that lacks some form of universal health care. Health insurance in the U.S. is expensive, rapidly rising costs are affecting employers and consumers as well as the government, and a study in Health Affairs concluded that half of personal bankruptcies involved medical bills. [But see Zywicki ]

As both countries consider changes to their systems, there is debate over whether resources should be added to the public or private sector. Although Canadians and Americans have each looked to the other for ways to improve their respective health care systems, there exists a substantial amount of conflicting information regarding the relative merits of the two systems. In Canada, the United States is used as a model and as a warning against increasing private sector involvement in health care. In the U.S., meanwhile, Canada's mostly monopsonistic health system is seen by different sides of the ideological spectrum as either a model to be followed or avoided.

Government involvement
Canada and the United States had similar health care systems in the early 1960s, but now have different funding mechanisms. Canada's single-payer health care system is universal, while in the United States, with its mixed public-private system, 16% are uninsured at any one time. The U.S. is one of three OECD countries not to have some form of universal health coverage; the other two being Turkey and Mexico.

The governments of both nations are closely involved in the delivery of health care. The central structural difference between the two is in health insurance. In Canada, the federal government is committed to providing funding support to its provincial governments for health care expenditures as long as the province in question abides by accessibility guarantees as set out in the Canada Health Act, which explicitly prohibits billing end users for procedures that are covered by Medicare. While some label Canada's system as "socialized medicine," the term is controversial. Princeton University health economist Uwe E. Reinhardt says that single-payer systems are not "socialized medicine" but "social insurance" systems, because doctors are in the private sector.

In the U.S., direct federal and state government funding of health care needs of its citizens is limited to Medicare, Medicaid, the VA (Veterans Administration) hospital system, and the State Children's Health Insurance Program (SCHIP) insurance programs for eligible senior citizens, very poor, veterans, disabled persons, and children. One study estimates that about 25 percent of the uninsured in the U.S. are eligible for these programs but unenrolled, but extending coverage to all who are eligible remains a fiscal and political challenge. The federal government also runs the Veterans Administration, which provides care to veterans, their families, and survivors through medical centers and clinics. For everyone else, health insurance must be paid for privately. Just under 60% of U.S. residents have access to health care insurance through employers, although this figure is decreasing, and the workers' expected contribution to such plans varies widely. Those whose employer does not offer health insurance, as well as those who are self-employed or unemployed, must purchase it on their own. More than 27 million of the 47 million U.S. uninsured worked at least part-time in 2006, and more than a third are in households that earned more than $50,000/year. Despite the greater role of private business in the U.S., federal and state agencies are increasingly involved in U.S. health care spending, paying about 45% of the $2.2 trillion the nation spent on medical care in 2004. Beyond its direct spending, the U.S. government is also highly involved in health care through regulation and legislation. For example, the Health Maintenance Organization Act of 1973 provided grants and loans to subsidize Health Maintenance Organizations and contained provisions to stimulate their popularity. HMOs had been declining before the law; by 2002 there were 500 such plans enrolling 76 million people.

The Canadian system has been 69-75% publicly funded, though a substantial portion of services are provided by private corporations, namely the privately incorporated medical practices of most physicians (although they may derive their revenue primarily from government billings). Although some doctors work on a purely fee-for-service basis (usually family physicians), some family physicians and most specialists are paid through a combination of fee-for-service and fixed contracts with hospitals or health service management organizations.

Canada's universal health plan does not cover certain services. Non-cosmetic dental care is covered for children up to age 14 in some provinces. Prescription drugs are not covered, but some provinces have drug cost programs that cover most drug costs over a certain portion of a family's income. Drug prices are also regulated, so brand-name prescription drugs are often significantly cheaper than in the U.S. Optometry is only covered in some provinces and is sometimes only covered for children under a certain age. Visits to many specialists may require an additional fee. Also, some procedures are only covered under certain circumstances. For example, circumcision is not covered, and a fee is usually charged when a parent requests the procedure; however, if an infection or medical necessity arises, the procedure would be covered.

According to Dr. Albert Schumacher, former president of the Canadian Medical Association, an estimated 75 percent of Canadian health care services are delivered privately, but funded publicly. "'Frontline practitioners whether they're GPs or specialists by and large are not salaried. They're small hardware stores. Same thing with labs and radiology clinics …The situation we are seeing now are more services around not being funded publicly but people having to pay for them, or their insurance companies. We have sort of a passive privatization.'"

Why these two countries' health systems diverged over the last 40 years is subject to historical debate. One explanation is that, during the period when Canada and most other developed nations introduced a publicly funded health system, the American government was investing a large portion of its GDP (roughly 7.5% ) into the military due to the Cold War and thus simply couldn't afford to fund public health care. By the time the Cold War had eased, consensus on government involvement in the economy had broken down, so it was all but impossible to introduce new spending programs on the scale of a national health plan. As it is, the U.S. government spends more on health care than on Social Security and national defense combined, according to the Brookings Institute.

Another explanation is that Canada's parliamentary system makes the passage of legislation easier. Bill Clinton did have a plan for universal coverage, but his plan did not come to a vote in either house of Congress, let alone win a majority or survive a filibuster. It is difficult to imagine parliament similarly dismissing the centerpiece of a prime minister's agenda because the government would otherwise fall due to the principle of responsible government; in a majority government, that would mean party members voting against its own Cabinet, in contrast to the rarer minority government where failure to gain support of other parties would fell the government. The appointed Senate very rarely vetoes a bill, serving as a "house of sober second thought" and simply tables amendments if needed. Additionally, most bills come from the government itself, in contrast to the American Presidential system. The Canada Health Act was passed under a majority government in 1984.

Coverage and access
In Canada, every citizen has coverage, but access can still be a problem. Based on 2003 data from the Canadian Community Health Survey, an estimated 1.2 million Canadians do not have a regular doctor because they "cannot find" one, and just over twice that number do not have one because they "haven't looked". Those without a regular doctor are 3.5 times more likely to visit an emergency room for treatment.

In the U.S., the federal government does not guarantee universal health care to all its citizens, but publicly funded health care programs help to provide for the elderly, disabled, the poor, and children. The Emergency Medical Treatment and Active Labor Act also ensures public access to emergency services regardless of ability to pay.

According to the United States Census Bureau, just under 60% of U.S. citizens have health insurance related to employment, 27% have government-provided health-insurance; another 9% purchase health insurance directly (there is some overlap in these figures), and 15.8% (47 million) were uninsured in 2006. An estimated 25 percent of the uninsured are eligible for government programs but unenrolled. About a third of the uninsured are in households earning more than $50,000 annually, who presumably could afford insurance. A 2003 report by the Congressional Budget office found that many people lack health insurance only temporarily, such as between job changes. The number of chronically uninsured (uninsured all year) was estimated at between 21 and 31 million in 1998. Another study, by the Kaiser Commission on Medicaid and the Uninsured, estimated that 59 percent of uninsured adults have been uninsured for at least two years.

A number of free clinics provide free or low-cost non-emergency care to poor, uninsured patients. The National Association of Free Clinics claims that its member clinics provide $3 billion in services to some 3.5 million patients annually.

A peer-reviewed comparison study of health care access in the two countries published in 2006 concluded that U.S. residents are one third less likely to have a regular medical doctor, one fourth more likely to have unmet health care needs, and are more than twice as likely to forgo needed medicines. The study noted that access problems "were particularly dire for the US uninsured." Those who lack insurance in the U.S. were much less satisfied, less likely to have seen a doctor, and more likely to have been unable to receive desired care than both Canadians and insured Americans.

According to President George W. Bush, "people have access to health care in America. After all, you just go to an emergency room. The question is, will we be wise about how we pay for health care. I believe the best way to do so is to enable more people to have private insurance. And the reason I emphasize private insurance, the best health care plan -- the best health care policy is one that emphasizes private health. In other words, the opposite of that would be government control of health care."

Wait times
One of the major complaints about the Canadian health care system is waiting times, whether for a specialist, major elective surgery, such as hip replacement, or specialized treatments, such as radiation for breast cancer. Studies by the Commonwealth Fund found that 24% of Canadians waited 4 hours or more in the emergency room, vs. 12% in the U.S.; 57% waited 4 weeks or more to see a specialist, vs. 23% in the U.S.

In a 2003 survey of hospital administrators conducted in Canada, the U.S., and three other countries, 21% of Canadian hospital administrators, but less than 1% of American administrators, said that it would take over three weeks to do a biopsy for possible breast cancer on a 50-year-old woman; 50% of Canadian administrators versus none of their American counterparts said that it would take over six months for a 65-year-old to undergo a routine hip replacement surgery. Yet U.S. administrators were the most negative about their country's health care system. Hospital executives in all five countries expressed concerns about staffing shortages and emergency department waiting times and quality.

In the Canadian Supreme Court case of Chaoulli v.  Quebec, Chaoulli argued that the long waits were life-threatening and violated human rights, and that doctors and patients had a right to contract for private health care, despite the prohibitions on those medical services.

Canadians concede that waiting time is a problem that stems from the country's lower costs and commitment to universal coverage. In a letter to the Wall Street Journal, Robert S. Bell, M.D., President and CEO of University Health Network, Toronto, said that Michael Moore's film Sicko "exaggerated the performance of the Canadian health system &mdash; there is no doubt that too many patients still stay in our emergency departments waiting for admission to scarce hospital beds." However, "Canadians spend about 55% of what Americans spend on health care and have longer life expectancy, and lower infant mortality rates. Many Americans have access to quality health care. All Canadians have access to similar care at a considerably lower cost." Canadians pay 9% of GDP to insure 100% of citizens, compared with 14% of GDP to insure 85% of Americans. The Kaiser Family Foundation found that 63% of Americans were worried about not being able to afford health-care services. There is "no question" that the lower cost has come at the cost of "restriction of supply with sub-optimal access to services," said Bell. A new approach is targeting waiting times, which are reported on public web sites

In the U.S., patients on Medicaid, the low-income government programs, can wait three months or more to see specialists. Because Medicaid payments are so low, doctors don't want to see Medicaid patients. In Benton Harbor, Michigan, specialists agreed to spend one afternoon every week or two at a Medicaid clinic, which meant that Medicaid patients had to make appointments not at the doctor's office, but at the clinic, where appointments had to be booked months in advance.

Price of health care
Health care is one of the most expensive items of both nations’ budgets. The U.S. government spends more per capita on health care than the government does in Canada. In 2004, the government of Canada spent $2,120 (in US dollars) per person on health care, while the United States government spent $2,724.

However, U.S. government spending covers less than half of all health care costs. Private spending for health care is also far greater in the U.S. than in Canada. In Canada, an average of $917 was spent annually by individuals or private insurance companies for health care, including dental, eye care, and drugs. In the U.S., this number is $3,372. In 2004, health care consumed 15.4% of U.S. annual GDP. In Canada, only 9.8% of GDP was spent on health care. This difference is a relatively recent development. In 1971 the nations were much closer, with Canada spending 7.1% of GDP on health while the U.S. spent 7.6%.

The health share of gross domestic product (GDP) in America is expected to hold steady in 2006 before resuming its historical upward trend, reaching 19.6 percent of GDP by 2016.

Some advocating against socialized health care have asserted that the difference in health care costs between the two nations is partially explained by the differences in their demographics. Police-reported drug abuse and violence are more common in the United States than in Canada; both place a burden on the health care system. Illegal immigrants, who are more prevalent in the U.S. than in Canada, also add a burden to the health care system, as many of them do not carry health insurance and rely on emergency rooms &mdash; which are legally required to treat them &mdash; as a principal source of care. In Colorado, for example, 80% of illegal immigrants do not have health insurance. Illegal immigrants' relative lack of preventative care also incurs higher overall costs. In addition, recent history has meant that the U.S. has far more veterans and war wounded, also somewhat increasing cost.

The mixed system in the United States has become more similar to the Canadian system. In recent decades, managed care has become prevalent in the United States, with some 90% of privately insured Americans belonging to plans with some form of managed care. Managed care is when the insurance company controls patients' health care to reduce costs, for instance by demanding a second opinion prior to any expensive treatment or by denying coverage for expensive treatments not considered worth their cost.

Administrative costs for health care are also higher in the United States than in Canada.

Medical professionals
Some of the extra money spent in the United States goes to doctors, nurses, and other medical professionals, all of whom receive higher compensation than their counterparts north of the border. According to health data collected by the OECD, average income for physicians in the United States in 1996 was nearly twice that for physicians in Canada.

The causes of these differences are complex. Factors such as higher cost of living in the United States, lower private cost of medical training in Canada, and high costs of medical malpractice insurance in the United States, contribute to the differences. Which entities exercise market power in each country also influences the differences in compensation. Canadian billing rates for each procedure are set through negotiations between the provincial governments and the physicians' organizations. In the U.S., physicians have greater freedom to set rates according to the local market. Anti-trust regulations prohibit the formation of uniform rates for procedures. Actual compensation to medical professionals in the U.S. is also highly influenced by the discounted rates that publicly funded insurance programs, Medicaid and Medicare, and major health insurance companies, are able to negotiate through the exercise of their market power. Private insurance companies often set their own reimbursement rates as a percentage of the Medicare reimbursement rate for all procedures though details are kept secret via confidentiality agreements that are a condition for participating in their panels of physicians.

Some economists have argued that, in highly technical matters like health care, the free market fails due to the problem of asymmetric information. According to this argument, one group, the doctors, have much greater knowledge about the true value of their services, and, therefore, are at an advantage vis-a-vis health care consumers when it comes to setting rates. In Canada, professionals working for the government are also experts in the field and thus, the argument goes, fairer rates are set. This argument also does not fully account for the disparity in pay for medical professionals in the two countries.

Canada has fewer doctors per capita than the United States. In the U.S, there were 2.4 doctors per 1,000 people in 2005; in Canada, there were 2.2. Some doctors leave Canada to pursue career goals or higher pay in the U.S. Many Canadian physicians and new medical graduates also go to the U.S. for post-graduate training in medical residencies. Often new and cutting-edge sub-specialties are more widely available in the U.S. as opposed to Canada. However, statistics published in 2005 by the Canadian Institute for Health Information (CIHI), show that, for the first time since 1969 (the period for which data are available), more physicians returned to Canada than moved abroad.

Drugs
Both Canada and the United States have limited programs to provide prescription drugs to those in need. In the U.S., the introduction of Medicare Part D has extended partial coverage for pharmaceuticals to Medicare beneficiaries. In Canada all drugs given in hospitals fall under Medicare, but other prescriptions do not. The provinces all have some programs to help the poor and seniors have access to drugs, but while there have been calls to create one, no national program exists. About two thirds of Canadians have private prescription drug coverage, mostly through their employers. In both countries, there is a significant population not fully covered by these programs. A 2005 study found that 20% of Canada's and 40% of America's sicker adults did not fulfill a prescription because of cost.

One of the most important differences between the two countries is the much higher cost of drugs in the United States. In the U.S., $728 per capita is spent each year on drugs, while in Canada it is $509. At the same time, consumption is higher in Canada, with about 12 prescriptions being filled per person each year in Canada and 10.6 in the United States. The main difference is that patented drug prices in Canada average between 35% and 45% lower than in the United States. The price differential for brand-name drugs between the two countries has led Americans to purchase upward of US$1 billion in drugs per year from Canadian pharmacies.

There are several reasons for the disparity. The Canadian system takes advantage of centralized buying by the provincial governments that have more market heft and buy in bulk, lowering prices. By contrast, the U.S. has explicit laws that prohibit Medicare or Medicaid from negotiating drug prices. In addition, price negotiations by Canadian health insurers are based on evaluations of the clinical effectiveness of prescription drugs, allowing the relative prices of therapeutically-similar drugs to be considered in context. The Canadian Patented Medicine Prices Review Board also has the authority to set a fair and reasonable price on patented products, either comparing it to similar drugs already on the market, or by taking the average price in seven developed nations. Prices are also lowered through more limited patent protection in Canada. In the U.S., a drug patent may be extended five years to make up for time lost in development. Some generic drugs are thus available on Canadian shelves sooner.

The pharmaceutical industry is important in both countries, though both are net importers of drugs. Both countries spend about the same amount of their GDP on pharmaceutical research, about 0.1% annually

Technology
The United States spends more on technology than Canada. The study Medical Imaging in Canada, 2004 reported that in 2004, Canada had 4.6 MRI scanners per million population while the U.S. had 19.5 per million. Canada's 10.3 CT scanners per million also ranked behind the U.S., which had 29.5 per million. The study did not attempt to assess whether the difference in the number of MRI and CT scanners had any effect on the medical outcomes.

Malpractice litigation
The extra cost of malpractice lawsuits accounts for some of the difference in health spending in the two countries. In Canada the total cost of settlements, legal fees, and insurance comes to $4 per person each year, but in the United States it is $16. Average payouts to American plaintiffs were $265,103, while payouts to Canadian plaintiffs were somewhat higher, averaging $309,417. However, malpractice suits are far more common in the U.S., with 350% more suits filed each year per person. While malpractice costs are significantly higher in the U.S., they make up only a small proportion of total medical spending. The total cost of defending and settling malpractice lawsuits in the U.S. in 2001 was approximately $6.5bn, or 0.46% of total health spending. Critics say that defensive medicine consumes up to 9% of American healthcare expenses. In the same year in Canada, the total burden of malpractice suits was $237 million, or 0.27% of total health spending.

Ancillary expenses
There are a number of ancillary costs that are higher in the U.S. Administrative costs are significantly higher in the U.S.; government mandates on record keeping and the diversity of insurers, plans and administrative layers involved in every transaction result in greater administrative effort. One recent study comparing administrative costs in the two countries found that these costs in the U.S. are roughly double what they are in Canada. Another ancillary cost is marketing both by insurance companies and health care providers. These costs are relatively higher in the U.S., contributing to higher overall costs in that nation.

Health care outcomes
In 2007, Gordon H. Guyatt et al. conducted a meta-analysis, or systematic review, of all studies that compared health outcomes for similar conditions in Canada and the U.S., in Open Medicine, an open-access peer-reviewed Canadian medical journal. They concluded, "Available studies suggest that health outcomes may be superior in patients cared for in Canada versus the United States, but differences are not consistent." Guyatt identified 38 studies addressing conditions including cancer, coronary artery disease, chronic medical illnesses and surgical procedures. Of 10 studies with the strongest statistical validity, 5 favoured Canada, 2 favoured the United States, and 3 were equivalent or mixed. Of 28 weaker studies, 9 favoured Canada, 3 favoured the United States, and 16 were equivalent or mixed. Overall, results for mortality favoured Canada with a 5% advantage, but the results were weak and varied. The only consistent pattern was that Canadian patients fared better in kidney failure.

Canadians are, overall, statistically healthier than Americans and show lower rates of many diseases such as various forms of cancer. On the other hand, evidence suggests that with respect to some illnesses (such as breast cancer), those who do get sick have a higher rate of cure in the U.S. than in Canada.

In terms of population health, life expectancy in 2006 was about two and a half years longer in Canada, with Canadians living to an average of 79.9 years and Americans 77.5 years. Infant and child mortality rates are also higher in the U.S. . Some comparisons suggest that the American system underperforms Canada's system as well as those of other industrialized nations with universal coverage. For example, a ranking by the World Health Organization of health care system performance among 191 member nations, published in 2000, ranked Canada 30th and the U.S. 37th, and the overall health of Canada 35th to the American 72nd. The WHO did not merely consider health care outcomes, but also placed heavy emphasis on the health disparities between rich and poor, funding for the health care needs of the poor, and the extent to which a country was reaching the potential health care outcomes they believed were possible for that nation. In an international comparison of 21 more specific quality indicators conducted by the Commonwealth Fund International Working Group on Quality Indicators, the results were more divided. One of the indicators was a tie, and in 3 others, data was unavailable from one country or the other. Canada performed better on 11 indicators; such as survival rates for colorectal cancer, childhood leukemia, and kidney and liver transplants. The U.S. performed better on 6 indicators, including survival rates for breast and cervical cancer, and avoidance of childhood diseases such as pertussis and measles. It should be noted that the 21 indicators were distilled from a starting list of 1000. The authors state that, "It is an opportunistic list, rather than a comprehensive list."

Some of the difference in outcomes may also be related to lifestyle choices. The OECD found that Americans have slightly higher rates of smoking and alcohol consumption than do Canadians as well as significantly higher rates of obesity. Though a joint US-Canadian study found slightly higher smoking rates among Canadians. Another study found that Americans have higher rates not only of obesity, but also of other health risk factors and chronic conditions, including physical inactivity, diabetes, hypertension, arthritis, and chronic obstructive pulmonary disease.

A Canadian systematic review concluded that differences in the health care systems of Canada and the United States could not alone explain differences in health care outcomes.

Heart attacks in the 1990s
A study in the journal Circulation found that Canadian patients whose histories were followed from 1990 to 1993 had a 17% higher risk of dying from heart attacks than did U.S. patients. The five-year mortality rate was 21.4% among the Canadian study participants and 19.6% among U.S. participants. The authors attributed this to the greater use of invasive procedures in the U.S., and in the organization of the Canadian health care system, in which specialized procedures are only available in central hospitals. Almost a third (30%) of American heart attack patients received an angioplasty, versus 11% of Canadians, and more than 13% of Americans had bypass surgery, compared with 4% in Canada. However, this study was done to determine whether invasive treatment had a beneficial outcome. At the time of the study, doctors didn't know whether invasive treatment would be beneficial.

In Canada between 1992 and 2001, there was a decline in death rates from coronary artery balloon angioplasty of 2.7% to 0.9% (67%) and of coronary artery bypass surgery from 3.5% to 2.0%

Cancer
Numerous studies have attempted to compare the rates of cancer incidence and mortality in Canada and the U.S., with varying results. Doctors who study cancer epidemiology warn that the diagnosis of cancer is subjective, and the reported incidence of a cancer will rise if screening is more aggressive, even if the real cancer incidence is the same. Statistics from different sources may not be compatible if they were collected in different ways. The proper interpretation of cancer statistics has been an important issue for many years. Dr. Barry Kramer of the National Institutes of Health points to the fact that cancer incidence rose sharply over the past few decades as screening became more common. He attributes the rise to increased detection of benign early stage cancers that pose little risk of metastasizing. Furthermore, though patients who were treated for these benign cancers were at little risk, they often have trouble finding health insurance after the fact.

Cancer survival time increases with later years of diagnosis, because cancer treatment improves, so cancer survival statistics can only be compared for cohorts in the same diagnosis year. For example, as doctors in British Columbia adopted new treatments, survival time for patients with metastatic breast cancer increased from 438 days for those diagnosed in 1991-1992, to 667 days for those diagnosed in 1999-2001.

An assessment by Health Canada found that cancer mortality rates are almost identical in the two countries. Another international comparison by the National Cancer Institute of Canada indicated that incidence rates for most, but not all, cancers were higher in the U.S. than in Canada during the period studied (1993-1997). Incidence rates for certain types, such as colorectal and stomach cancer, were actually higher in Canada than in the U.S. In 2004, researchers published a study comparing health outcomes in the Anglo countries. Their analysis indicates that Canada has greater survival rates for both colorectal cancer and childhood leukemia, while the United States has greater survival rates for Non-Hodgkin's lymphoma as well as breast and cervical cancer.

A study based on data from 1993 through 1997 found lower cancer survival rates among Canadians than among Americans. However, an earlier study based on data from 1978 through 1986 found very similar survival rates in both countries.

A few comparative studies have found that cancer survival rates vary more widely among different populations in the U.S. than they do in Canada. Mackillop and colleagues compared cancer survival rates in Ontario and the U.S. They found that cancer survival was more strongly correlated with socio-economic class in the U.S. than in Ontario. Furthermore, they found that the American survival advantage in the four highest quintiles was statistically significant. They strongly suspected that the difference due to prostate cancer was a result of greater detection of asymptomatic cases in the U.S. Their data indicates that neglecting the prostate cancer data reduces the American advantage in the four highest quintiles and gives Canada a statistically significant advantage in the lowest quintile. Similarly, they believe differences in screening mammography may explain part of the American advantage in breast cancer. Exclusion of breast and prostate cancer data results in very similar survival rates for both countries.

Hsing et al. found that prostate cancer mortality-incidence rate ratios were lower among U.S. whites than among any of the nationalities included in their study, including Canadians. U.S. blacks in the study had lower rates than any group except for Canadians and U.S. whites. Echoing the concerns of Dr. Kramer and Professor Mackillop, Hsing later wrote that reported prostate cancer incidence depends on screening. Among whites in the U.S., the death rate for prostate cancer remained constant, even though the incidence increased, so the additional reported prostate cancers did not represent an increase in real prostate cancers, said Hsing. Similarly, the death rates from prostate cancer in the U.S. increased during the 1980s and peaked in early 1990. This is at least partially due to "attribution bias" on death certificates, where doctors are more likely to ascribe a death to prostate cancer than to other diseases that affected the patient, because of greater awareness of prostate cancer or other reasons.

Below are the figures for number of cancers diagnosed per 100,000 persons and number of deaths attributed to cancer per 100,000 persons in 2003. The Canadian and American data were collected separately and may not be compatible. However, all data for both studies was collected from registries that are members of the North American Association of Central Cancer Registries, an organization dedicated to developing and promoting uniform data standards for cancer registration in North America.

Females

Males

Sources: U.S. Cancer Statistics Working Group and Canadian Cancer Society

Racial and ethnic differences
The U.S. and Canada differ substantially in their demographics, and these differences may contribute to differences in health outcomes between the two nations. Although both countries have white majorities, the United States has a significantly larger minority population. Furthermore, the relative size of different ethnic and racial groups vary widely in each country. Hispanics and peoples of African descent constitute a much larger proportion of the American population. Aboriginal peoples constitute a much larger proportion of the Canadian population. Canada also has a relatively larger East Asian population. Also, the proportion of each population that is native born vs. immigrant is often different in each nation.

A study comparing aboriginal mortality rates in Canada, the U.S. and New Zealand found that aboriginals in all three countries had greater mortality rates and shorter life expectancies than the white majorities. That study also found that aboriginals in Canada had both shorter life expectancies and greater infant mortality rates than aboriginals in the United States and New Zealand. The health outcome differences between aboriginals and whites in Canada was also larger than in the United States.

Though relatively few studies have been published concerning the health of Black Canadians, health disparities between whites and blacks in the U.S. have received intense scrutiny. Blacks in the U.S. have significantly greater rates of cancer incidence and mortality. Drs. Singh and Yu found that neonatal and postnatal mortality rates for Americans blacks are more than double the non-Hispanic white rate. This difference persisted even after controlling for household income and was actually greatest in the highest income quintile. A Canadian study also found differences in neonatal mortality between different racial and ethnic groups. Although Canadians of African descent had a greater mortality rate than whites in that study, the rate was somewhat less than double the white rate.

The racially heterogeneous Hispanic population in the U.S. has also been the subject of several studies. Although members of this group are significantly more likely to live in poverty than are non-Hispanic whites, they often have disease rates that are comparable to or better than the non-Hispanic white majority. Hispanics have lower cancer incidence and mortality, lower infant mortality, and lower rates of neural tube defects. Singh and Yu found that infant mortality among Hispanic sub-groups varied with the racial composition of that group. The mostly white Cuban population had a neonatal mortality rate (NMR) nearly identical to that found in non-Hispanic whites and a postnatal mortality rate (PMR) that was somewhat lower. The largely Mestizo, Mexican, Central, and South American Hispanic populations had somewhat lower NMR and PMR. Puerto Ricans who often have a mix of white and African ancestry had higher NMR and PMR rates.

Impact on economy
In 2002, automotive companies claimed universal health care system in Canada saved labour costs. In 2004, health care cost General Motors $5.8 billion, and would increase to $7 billion. The UAW also claimed the resulted escalating health care premiums reduced workers' bargaining powers. While such arguments certainly demonstrate that employer provided care impacts corporate bottom lines more than health care that is socialized and thus does not appear on the balance sheet, tracing out the net effect is more difficult.

Flexibility
In Canada, increasing demands for health care, due to the aging population, must be met by either increasing taxes or reducing other government programs. In the United States, under the current system, more of the burden for health care will be taken up by the private sector and individuals.

Canada's multi-billion dollar budget surpluses, however, have allowed a significant injection of new funding to the healthcare system, with the stated goal of reducing waiting times for treatment.

One historical problem with the U.S. system was known as job lock, in which people become tied to their jobs for fear of losing their health insurance. This reduces the flexibility of the labor market. Federal legislation passed since the mid-1980s, particularly COBRA and HIPAA, has been aimed at reducing job lock.

Politics of health
In Canada, the right-wing and now defunct Reform Party and its successor, the Conservative Party of Canada considered increasing the role of the private sector in the Canadian health care system. Public backlash caused these plans to be abandoned, and the current minority Conservative government has re-affirmed its commitment to universal public medicine.

The Democratic President Bill Clinton attempted a significant restructuring of health care, but the effort collapsed under public pressure against it. The 2000 U.S. election saw prescription drugs become a central issue, although the system did not fundamentally change. In the 2004 U.S. election health care proved to be an important issue to some voters, though not a primary one.

More radical solutions in both countries have come from the sub-national level. In 2006, Massachusetts adopted a plan that intends to vastly reduce the number of uninsured. It requires everyone to buy insurance and subsidizes insurance costs for lower income people on a sliding scale. In Canada, it is oil-rich Alberta under the conservative government of Ralph Klein that is seen to experiment most with increasing the role of the private sector in health care. Measures have included the introduction of private clinics that are allowed to bill patients for some of the cost of a procedure. After the 2005 Supreme Court of Canada ruling that the Quebec government cannot prevent people from paying for private insurance for healthcare procedures covered under medicare, private healthcare in Quebec began to grow rapidly. Quebec now has the highest number of private clinics delivering publicly funded care as well as whole hospitals and emergency wards that have opted out of the public system.

Monopsony
The Canadian government has outlawed private medical care for services covered by the public health plan. This results as governments attempt to control costs by gaining or enforcing monopsony power. Those with non-emergency illnesses such as cancer cannot pay out of pocket for time-sensitive surgeries and must wait their turn on waiting lists. According to the Canadian Supreme Court in its 2005 ruling in  Chaoulli v. Quebec, waiting list delays "increase the patient’s risk of mortality or the risk that his or her injuries will become irreparable." The ruling, which found that a Quebec provincial ban on private health insurance was unconstitutional when patients were suffering and even dying on waiting lists, has been called a turning point for the country's health system and is expected to lead to greater privatization.

Consumer driven health care
Republicans in the U.S. have recently enacted laws to promote consumer driven health care. By that they mean Health Savings Accounts (HSAs), which were created by the Medicare bill signed by President Bush on December 8, 2003. HSAs are designed to provide tax incentives for individuals to save for future qualified medical and retiree health expenses; the money placed in such accounts is tax-free. To qualify for these tax-deferred accounts, individuals must carry a High Deductible Health Plan (HDHP). The higher deductible shifts some of the financial responsibility for health care from insurance providers to the individual consumer. This shift towards a market-based system with greater individual responsibility may increase the differences between the U.S. and Canadian systems. Some economists who have studied various proposals for universal health care are concerned that the main effect of the consumer driven healthcare movement will be to reduce the social redistributive effects of insurance that pools high-risk and low-risk people together.