A trip to Toronto reveals a hard truth about bringing single-payer to America.
TORONTO — In late October, Sen. Bernie Sanders (I-VT) took a flight from Washington, DC, to Toronto. He sat in a cramped seat in the 21st row of the small plane.
“I’m here to learn about your health care system,” Sanders told a woman behind him who asked for a selfie, shortly after the plane touched down in Canada. The woman informed Sanders that she was American but was still pleased to grab a photo.
Sanders was flying to Toronto for an event his staff dubbed “The Cross-Border Learning Tour: Single Payer Healthcare in Canada.” Sanders recently introduced a bill in the Senate that would create a system much like Canada’s in the United States, with one government plan that covers all citizens.
It was time, the senator decided, to see what the Canadian system looked like in action. So he shuttled from conference rooms to exam rooms, meeting with doctors, patients, and hospital executives. He brought four reporters and many more photographers and videographers in tow.
Sanders went into the visit an avid support of the Canadian health care system. The trip only deepened his ardor. Many of his questions were those he already knew the answer to, like when Sanders asked if it was true that Canadians can’t choose their own doctors.
An audience of doctors murmured back, no, that was not true.
“Not true!” the senator exclaimed in mock surprise. “I’m shocked!”
But there was one observation — at the very end of the learning tour, in a big hospital atrium — that seemed to inadvertently point to the biggest challenge of importing Canada’s system to the United States.
It was after a reporter asked Sanders what he found most interesting about the visit.
“It was interesting to talk to patients who said, ‘We believe health care is a right,’” Sanders responded. “I think if you walked out in the street and you talked to people, they would find it inconceivable that somebody would not be able to get the health care they need because they don’t have that money.”
Sanders is pointing toward a genuine chasm in the values that separates America from Canada. Recent Gallup polling finds that 52 percent of Americans believe the government should guarantee access to health care and 45 percent disagree.
There are massive policy obstacles to bringing a single-payer system to the United States. But there is also a more fundamentally philosophical obstacle: Americans haven’t decided whether health insurance is a right. We haven’t made up our minds that the government ought to guarantee coverage for all citizens to begin with.
The Canadian system is all about equity
“We looked all over the world and we asked the hard question: What can we do to make our health care system better?” Sanders says. “Our job in the US is to learn from Canada and learn from other countries in the world.”
As he suggests, a survey of international systems reveals a plethora of possible models. Britain, for example, not only runs a national insurance plan but also employs its doctors as public workers. In Germany, dozens of private “sickness plans” compete with one another in a tightly regulated market. In Australia, there is one big, public plan — but wealthier citizens can buy a private plan that may guarantee faster access or nicer facilities.
But the “Medicare-for-all” bill Sanders released last month looks the most like Canada’s universal coverage plan — and Canada’s is a system that prizes equity above all else.
At the core of Canadian health care is an absolute belief in the right of each citizen to receive the same care regardless of their income. As one scholar described the system to journalist T.R. Reid, “Canadians don’t mind waiting lines, as long as the rich Canadian and the poor Canadian have to wait about the same amount of time.”
Canada’s single-payer system is unique in that it bans private health plans from competing with government coverage.
In Australia and Britain, for example, insurers can offer coverage at doctors’ offices and hospitals. These countries have decided that it is okay — even preferable — to allow those who can afford it to spend more and get easier access to the health care system.
But in Canada, this behavior is illegal.
“Canada has tried so hard to avoid a two-tier system,” says Robin Osborn, the director of the Commonwealth Fund’s International Health Policy program. “The belief in equity is the overriding thing in Canada, and they really hold to that. It’s a very strong principle.”
Another sign of the equity of the Canadian health care system is the fact it has no copayments when patients do go to the doctor. Other countries with socialized medicine, such as Australia and Taiwan, charge a fee at the doctor’s office (although these are typically waived for low-income citizens). Sanders argues that Canada has gotten this feature of a health care system right. He says he’s considered copayments for an American universal coverage system, but “the logic comes down on the way of what the Canadians are doing.”
The senator who rails regularly against “millionaires and billionaires” doesn’t see value in asking those people to pay when they show up at the doctor. They’ll pay more in taxes, but when they go to the doctor, he argues, they ought to be treated the same as the poor. They can’t skip the line, but they won’t be charged fees either.
“It’s a pretty deep-seated value that [health care] is a human right that should accrue to everyone,” says Ontario Premier Kathleen Wynne of health care in her province. “I get that sometimes i’s hard to wait if you’re not in an urgent situation, but how lucky are you that you’re not on the verge of death? That is how we think about it.”
“How a country chooses to provide health care is about its core values as a nation”
On Sunday morning, an audience of 1,600 Torontonians — mostly students — gathered at a large college lecture hall to hear Sanders speak. Some students lined up as early as 5 am to get a ticket. (Sanders is a celebrity in Canada; an airport gate agent who snapped a selfie with him in Toronto described it as “the best Saturday of [my] life.”)
A string quartet played music until Sanders took the stage to a standing ovation. He spoke to a foreign audience as if he were holding a campaign rally.
“The most important point I want to make is that how a country chooses to provide health care for its citizens is not simply about the practice of medicine,” Sanders boomed. “It is about its core values as a nation.”
As Sanders is fond of pointing out, America is the only industrialized country that has no guaranteed access to health care. There are 28 million Americans who currently lack health insurance, and that number may rise as the Trump administration continues to undermine the Affordable Care Act.
Sanders often frames this as a violation of American values, but it may instead be a reflection of them. Most polls find that only a small majority believe the government ought to ensure coverage for all citizens. Gallup finds 52 percent support this idea, and Pew estimates it is 57 percent. The Kaiser Family Foundation found that 53 percent support a government-run health plan, but that support falls sharply when respondents are asked about the possibility that taxes might rise.
Polling experts recently told my colleague Dylan Scott that even though more Americans are becoming comfortable with a larger government role in health care, they don’t necessarily line up behind the system Sanders has proposed.
“Lots of the country may be very ready for … single-payer as an idea, as a slogan. They may embrace the goals that go with it: universal coverage, health care as a right,” Drew Altman, president of the Kaiser Family Foundation, told Scott. “That doesn’t tell us much at all about where the country will be if you get to a debate about real legislation, with real details, with real winners and losers.”
Earlier this year, New Yorker write Atul Gawande went to the Appalachian area of Ohio, where he grew up, to ask people this question.
One of the things he ran into again and again was an opposition to health care as a right for people who don’t seem to deserve it. One woman he interviewed, a librarian named Monna, told him, “If you’re disabled, if you’re mentally ill, fine, I get it. But I know so many folks on Medicaid that just don’t work. They’re lazy.”
Another man, Joe, put it this way: “I see people on the same road I live on who have never worked a lick in their life. They’re living on disability incomes, and they’re healthier than I am.”
As Gawande notes in his piece, “A right makes no distinction between the deserving and undeserving.” But he often found this to be the key dividing line when he asked people whether everyone should have health coverage. Often, it came down to whether that person was perceived to be the type who merited such help.
In his speech at the University of Toronto, Sanders argued that a universal health care system would only come as the result of political revolution.
He told the story of Tommy Douglas, who created Canada’s first universal health care system in Saskatchewan. (Douglas is a household name in Canada, who receiving roaring cheers in the lecture hall when Sanders mentioned him. A CBC poll recently found that people consider Douglas the most important Canadian of the past century.)
“It wasn’t as if Tommy Douglas said, ‘I had a dream and this is a pretty good idea,’” Sanders argued. “He was able to implement his program because his political party won 47 out of 52 seats in 1944.”
This theme felt at home in Sanders’s 2016 presidential run, where he often discussed the idea of a political uprising on the left. But in 2017, it feels more pessimistic.
American voters did not elect a party that campaigned on expanding coverage to all Americans. There was no political revolution to level the playing field. Instead, American voters elected a party that wants to dismantle the Affordable Care Act to control the White House and Congress.
On his Canada trip, Sanders seemed to recognize that core to a system like Canada’s is a belief, by the people, that all other people ought to have equitable access to health insurance. Sanders is bullish that this belief exists to a wide extent in the United States too.
“Frankly, in the United States, I think most people do believe it is a right and it doesn’t matter if you’re rich or if you’re poor,” Sanders says.
But polling and reporting suggest otherwise. They show that belief doesn’t seem to exist in the United States right now. The question is whether Sanders can change that, whether he can persuade Americans to see health care the way he does — and the way Canadians do too.