The Cost of Instant Access to Health Care

IN THIS ISSUE of THE JOURNAL, Bell and colleagues¹ report a comparison of waiting times and charges for several well-defined and commonly used health care services in acute care hospitals in Canada and the United States. The authors conducted a telephone survey of 18 Canadian and 48 US hospitals in cities having a population of more than 500000 and inquired about the availability and cost to consumers for 7 diagnostic and therapeutic procedures (prothrombin time measurement, 12-lead electrocardiography, screening mammography, screening colonoscopy, magnetic resonance imaging of the head, a session of hemodialysis, and total knee replacement surgery), assuming that patients in both countries would be willing and able to pay out-of-pocket for such services. The authors found that compared with Canadian hospitals, US hospitals had significantly shorter median waiting times to obtain 4 of these services and had significantly higher median charges for 6 services.

Although the study by Bell et al¹ demonstrates fairly dramatic differences in prices and waiting times for some hospital services, the authors do not account for the major difference between the health care systems in Canada and the United States. Canada has a comprehensive, national health insurance program that covers all of its population and provides publicly mandated insurance coverage for all inpatient hospital care. The United States has a pluralistic system of public and private health insurance coverage that leaves scores of millions uninsured and underinsured.² In 1995, the rate of publicly mandated coverage in the United States, mainly in the form of Medicare and Medicaid, was 46%. Recent studies have reported that, on any given day, 44.8 million persons (17% of the US population) are not covered by any health insurance, private or public,³ and 29 million more are seriously underinsured.²

Bell et al¹ also "take the perspective of an individual consumer who is seeking medical care in the 1990s and willing to pay out-of-pocket." Except for some minor copayments in Canada, paying out-of-pocket for most health care is not necessary and is relatively uncommon, and the majority of Canadians are willing to wait for most medical services. Anecdotal reports indicate that some people who are willing to pay to obtain instant health services may cross the border from Canada to the United States, but this occurrence probably is relatively uncommon. In the United States, patients and the public pay a high premium for receiving medical services quickly, but the cost to the nation for such rapid access is considerable. In contrast, those who are unable to pay out-of-pocket may receive care, but many have to wait for provision of health services.

The findings on charges reported by Bell et al¹ document for a few selected hospital services what has been fairly well known in the aggregate for some time, especially with regard to the costs of medical care in the United States compared with Canada and other industrialized countries. For example, per capita spending on health care in 1996 was 85% higher in the United States than in Canada, $3708 compared with $2002 (in US dollars).⁴ Likewise, among the 29 countries with data reported by the Organization for Economic Cooperation and Development,⁴ per capita health care spending was $2412 in Switzerland, $2222 in Germany, $1978 in France, and $1304 in the United Kingdom. The United States also spends the highest percentage of gross domestic product on health care. In 1996, the United States spent 14.2% of its gross domestic product on health care, followed by Germany (10.5%), Switzerland (9.8%), France (9.6%), and Canada (9.2%).⁴

Even though the United States spends more than Canada on health care, both in the aggregate and for specific services, as documented in the study by Bell et al,¹ certain commonly used indicators suggest that the United States fares worse on some health outcomes than Canada and several other industrialized nations. For instance, in 1995, the infant mortality rate in the United States was 8.0 per 1000 live births compared with 6.0 per 1000 live births in Canada, and the United States ranked 23rd among 29 industrialized countries.⁴ In 1995, life expectancy at birth in the United States was 72.5 years for men and 79.2 years for women; in Canada, it was 75.3 years for men and 81.3 years for women. Among the 29 Organization for Economic Cooperation and Development countries, life expectancy for women in the United States was tied with New Zealand for 20th; for men, life expectancy⁴ ranked 21st.

Access to medical care for those who are unable to pay for such services continues to be one of the most important health system problems in the United States today, and must be considered when comparing charges and waiting times for medical services between the United States and Canada. The Canadian health care system, with universal coverage, longer waiting times, and lower costs for health services, should not be equated with the shorter waiting periods and more costly care in the US health care system that falls short of providing universal health insurance coverage. A willingness for the US health care system to trade off shorter waiting periods for the opportunity to increase coverage for those unable to pay may be worth consideration as one aspect in a national strategy to provide needed medical services for the uninsured and underinsured population.