When Danny Williams, the Premier of Newfoundland and Labrador, mysteriously disappeared to the United States for heart surgery, it was a scandal in Canada.  Why, asked many Canadians, would a government official abandon the Canadian health care system in his own time of need?

The secrecy surrounding where he went and why only added to the sense that he knew the was doing something bad for his political health.

Now he’s talking, and he’s saying things that I suspect sound pretty radical for Canadians.  Politically, he’s almost forced to say it.  But I wonder if he really needed to be in the fix he is in.

The problem was that Williams needed a heart valve replacement.  He decided he wanted it done in a way that involved a small incision in his arm-pit instead of using the more traditional, sternum-cracking technique.  They don’t do the minimally-invasive approach in Newfoundland and Labrador, so he knew would have to leave his home province one way or the other.  After talking to a doctor in New Jersey, he decided that the right place to go was Mt. Sinai Hospital in Miami, Florida.  There is a doctor there who has apparently performed thousands of these surgeries.

As Williams put it:

“This was my heart, my choice and my health,” Williams said late Monday from his condominium in Sarasota, Fla.”I did not sign away my right to get the best possible health care for myself when I entered politics.

Well, ok.  But what about the fact that the same surgery actually was available in Canada?

“I would’ve been criticized if I had stayed in Canada and had been perceived as jumping a line or a wait list. … I accept that. That’s public life,” he said.  “(But) this is not a unique phenomenon to me. This is something that happens with lots of families throughout this country, so I make no apologies for that.”

Here’s where I wonder if the Premier actually knew that the same surgery could have been done in Canada.  For example, there is a major hospital in Vancouver which does these procedures.  How much better would it have been for him to go there?  He could have had his surgery and been released from the hospital just in time to go to the Olympics.

You know, there are a lot of TV cameras at the Olympics.  The Premier could have used this as a chance to talk about how the Canadian health care system had served him.  It would have been a political gold mine for him, and not just in Canada.   Instead, he announced he’s going from Florida to Vancouver tomorrow, where he will be hounded by controversy.

How could this happen?

Well, the problem of figuring out what to do when you’re sick is hard, no matter who you are, or what health care system you live under.  You suddenly have to try to become an expert in your condition.  Of course, you really can’t.  There’s no way you can replicate all the years of education and training and experience that a doctor has.  And so there will be big gaps in your knowledge about your condition.  Do you have the right diagnosis?  Are you looking at the right treatment options?  Are you with the right doctors?  Do you really understand the risks and benefits of the treatment?

In our work at Best Doctors we have collected a great deal of data from the several million people we cover in North America.  More than half of those who call us are people, like Danny Williams, who are facing surgery and aren’t sure what to do.  It’s a serious problem, and one for which there are very few solutions.

So in this sense, Premier Williams is right.  His problem – how to make sure you are getting the right diagnosis and treatment – is not unique.  It’s something that families thought the country and throughout the world deal with every day.

How different are Canada and the United States?

Depending on who you ask, they’re neighbours, or neighbors.  So they’re pretty similar.  But if you ask your Canadian neighbour to bring over a case of beer so you can watch a hockey game together, he’ll be very happy to bring over a two-four.  So they’re pretty different.

Still, this is all superficial.  What Americans don’t realize is how different our countries really are (I know Canadians don’t like it when Americans co-opt the word “American” like that.  I’m sorry, I just can’t help it).

You can see this difference most clearly when it comes to health care.  Today’s news supplies a good example.

Yesterday, it was announced that the premier of Newfoundland and Labrador needed heart surgery.  After consulting with his doctors, he decided to have it done at a hospital somewhere in the U.S.

To an American eye, this is a perfectly mundane story.  A person is sick, can afford it, and so decides to get care someplace he thinks is the best. If it weren’t for the health care reform debate, we wouldn’t hear much about this story in the States.  Pundits wouldn’t be using it to make bad implications about the Canadian system, or suggesting this is what U.S. reform promises to create.

But it’s very different from a Canadian perspective.  The story is something of a scandal.  It’s not because a government official has suddenly left office for health reasons.  It’s got to do with the way Canadians feel about their health care system.

Canadians feel very proud of their system of universal health care.  Like every health care system, it is beset by problems, but in a diverse and often fractious country, it is a unifying presence and one of the things most certain to stir patriotic passions.  Unlike the United States, where health care is just another part of the economy, Canadians regard health care as more like a civil right.  I think many consider it part of their civic duty to support it, and they certainly expect that from their politicians.  And so when a leading politician decides not to use the Canadian system for his own health care, it’s treated like something of a betrayal.

To get a sense of this all you have to do is watch the media interviews with the leaders of the provincial government this morning (videos are here).  At least half of a six-minute interview with the acting premier was spent parrying questions like this one:

What can you say about what kind of message it might send to people in this province and elsewhere that [the premier] felt he needed to go not just out of the province but out of the country for this treatment?

And later, the leader of the opposition party spoke about the premier’s decision to go to the U.S. for his care:

So although I know health care is a very private piece [sic] for all of us I think when we’re in a position of public office like he is . . . I think at the very minimum we deserve an explanation for the people of this province and would expect that from him.

From an American perspective, this looks like the usual old political scandal: catching a politician in some hypocrisy in which he makes everyone else live by rules that don’t apply to him.  But I don’t think this is really how this appears in Canada.  The resentment in these comments is about something else:  the idea that the premier is seen as having abandoned a system he is duty-bound to uphold.

So remember, when it comes to health care the differences between the U.S. and Canada run far deeper than just the way each country pays for it.

Many Americans look to Canada, as an example of a government-run health care system that works.

But is that really what it is?

Health care in Canada is funded mostly publicly, but is provided mostly privately.  That is, most care is delivered by privately run hospitals and medical clinics, with fees paid for by the various provincial governments.

Americans often call this system “single payer,” but it’s really not true.  There are many other payers.

For example, if you’re injured on the job, your care is paid by a workers compensation insurance plan funded by employer premiums.  Millions of  Canadians also have supplementary health insurance policies, typically called “extended health care” coverage, which cover things not paid for by the government, like prescription drugs and other medical services.  There is also a growing market for full medical insurance plans, and critical illness plans to provide cash to offset the out of pocket burdens of medical cost.  As much as 30% of Canadian health care expenses are funded through these non-government payers.

However paid for, supply (and funding) for health care has not been able to keep up with increasing demand.  The result has been well-documented: long waits for health care services.  Waiting is a normal part of the Canadian health care experience, with provincial governments publishing  information on wait times and working to fix them.  The Canadian Supreme Court admonished the provincial governments in 2005, saying “access to a wait list is not access to health care.”

And so an interesting dynamic has emerged.

Canadians are justifiably proud of their extraordinary health care system, and care deeply about preserving its core principles.  But they also care deeply about looking after each other, and are as creative and innovative as any people on the planet.  As wait times have grown, so has a burgeoning private market.

Hospitals running diagnostic imaging equipment like MRIs are only paid by the government to run during certain hours of the day.  So creative hospitals decided to run the same machines during the overnight hours, charging patients (rather than the government) a fee for the service, which could be provided on an expedited basis.  While politically controversial, it made it possible to serve more patients without the need for additional government funding.

These types of ideas have grown, extending now to stand-alone diagnostic centers.  A couple of days ago, I visited one, Mayfair Diagnostics, in Calgary.  This center was created by a group of physicians, who, like others I have met, knew they couldn’t change the system, but could improve the part in which they work.  So they bought leading imaging equipment and opened up centers that cater to self-pay patients, as well as those funded through other sources.  They actively promote themselves as a way to get needed medical insight only a couple of days – as opposed to the 6-8 week average wait patients would otherwise face.  Doctors working in this center also work in hospitals serving government-sponsored patients, making the Mayfair center and others like it a supplement to the government system.  And at a price of $650 for an MRI, it’s inexpensive by U.S. standards.

Other kinds of private centers have opened up as well.  Some operate almost as membership-only medical practices, offering much of what might be considered primary care.  Others provide even more comprehensive services, making most aspects of ambulatory care available on a privately-paid basis.  For certain specialties like orthopedics, some even offer complete hospital surgical services.

The Canadian system remains very different from the American one.  Canadians do not want their system transformed into anything that reflects American “rugged individualism.”  And yet the natural human desire to look after oneself and ones family poses dilemmas.  When a loved one is sick, all the abstract ideas melt away, and you think – how can I do everything I can to get help, now.

We’re all entitled to that kind of help — Americans, Canadians, whatever.

The ways Canadians are trying to make sure everyone gets that help are slowly changing the face of Canadian health care.

Why paying for health care is so difficult:

a gigantic, complex raft of billing codes which are seemingly designed to haunt you in your sleep. With thousands of codes, and with frequent revisions to the fee schedule, it’s difficult to imagine a bureaucratic system. . . more challenging to decipher.

American health care?  No, Canadian.

Some problems are inherent to health care, regardless of who pays for it.