Should the United States implement a more inclusive, publicly funded health care system? That's a big debate throughout the country. But even as it rages, most Americans are unaware that the United States is the only country in the developed world that doesn't already have a fundamentally public--that is, tax-supported--health care system.
That means that the United States has been the unwitting control subject in a 30-year, worldwide experiment comparing the merits of private versus public health care funding. For the people living in the United States, the results of this experiment with privately funded health care have been grim. The United States now has the most expensive health care system on earth and, despite remarkable technology, the general health of the U.S. population is lower than in most industrialized countries. Worse, Americans' mortality rates--both general and infant--are shockingly high.
Beginning in the 1930s, both the Americans and the Canadians tried to alleviate health care gaps by increasing use of employment-based insurance plans. Both countries encouraged nonprofit private insurance plans like Blue Cross, as well as for-profit insurance plans. The difference between the United States and Canada is that Americans are still doing this, ignoring decades of international statistics that show that this type of funding inevitably leads to poorer public health.
Meanwhile, according to author Terry Boychuk, the rest of the industrialized world, including many developing countries like Mexico, Korea, and India, viscerally understood that "private insurance would [never be able to] cover all necessary hospital procedures and services; and that even minimal protection [is] beyond the reach of the poor, the working poor, and those with the most serious health problems." 1 Today, over half the family bankruptcies filed every year in the United States are directly related to medical expenses, and a recent study shows that 75 percent of those are filed by people with health insurance.2
The United States spends far more per capita on health care than any comparable country. In fact, the gap is so enormous that a recent University of California, San Francisco, study estimates that the United States would save over $161 billion every year in paperwork alone if it switched to a singlepayer system like Canada's.3 These billions of dollars are not abstract amounts deducted from government budgets; they come directly out of the pockets of people who are sick.
The year 2000 marked the beginning of a crucial period, when international trade rules, economic theory, and political action had begun to fully reflect the belief in the superiority of private, as opposed to public, management, especially in the United States. By that year the U.S. health care system had undergone what has been called "the health management organization revolution." U.S. government figures show that medical care costs have spiked since 2000, with total spending on prescriptions nearly doubling. 4
Cutting costs, cutting care
There are two criteria used to judge a country's health care system: the overall success of creating and sustaining health in the population, and the ability to control costs while doing so. One recent study published in the Canadian Medical Association Journal compares mortality rates in private forprofit and nonprofit hospitals in the United States. Research on 38 million adult patients in 26,000 U.S. hospitals revealed that death rates in for-profit hospitals are significantly higher than in nonprofit hospitals: for-profit patients have a 2 percent higher chance of dying in the hospital or within 30 days of discharge. The increased death rates were clearly linked to "the corners that for-profit hospitals must cut in order to achieve a profit margin for investors, as well as to pay high salaries for administrators."5
“To ease cost pressures, administrators tend to hire less highly skilled personnel, including doctors, nurses, and pharmacists…,” wrote P. J. Devereaux, a cardiologist at McMaster University and the lead researcher. “The U.S. statistics clearly show that when the need for profits drives hospital decisionmaking, more patients die.”
The value of care for all
Historically, one of the cruelest aspects of unequal income distribution is that poor people not only experience material want all their lives, they also suffer more illness and die younger. But in Canada there is no association between income inequality and mortality rates—none whatsoever.
In a massive study undertaken by Statistics Canada in the early 1990s, income and mortality census data were analyzed from all Canadian provinces and all U.S. states, as well as 53 Canadian and 282 American metropolitan areas.6 The study concluded that “the relationship between income inequality and mortality is not universal, but instead depends on social and political characteristics specific to place.” In other words, government health policies have an effect.
“Income inequality is strongly associated with mortality in the United States and in North America as a whole,” the study found, “but there is no relation within Canada at either the province or metropolitan area level -- between income inequality and mortality.”
The same study revealed that among the poorest people in the United States, even a one percent increase inincome resulted in a mortality decline of nearly 22 out of 100,000.
What makes this study so interesting is that Canada used to have statistics that mirrored those in the United States. In 1970, U.S. and Canadian mortality rates calculated along income lines were virtually identical. But 1970 also marked the introduction of Medicare in Canada -- universal, singlepayer coverage. The simple explanation for how Canadians have all become equally healthy, regardless of income, most likely lies in the fact that they have a publicly funded, single-payer health system and the control group, the United States, does not.
Infant mortality rates, which refl ect the health of the mother and her access to prenatal and postnatal care, are considered one of the most reliable measures of the general health of a population. Today, U.S. government statistics rank Canada's infant mortality rate of 4.7 per thousand 23rd out of 225 countries, in the company of the Netherlands, Luxembourg, Australia, and Denmark. The U.S. is 43rd--in the company of Croatia and Lithuania, below Taiwan and Cuba.
All the countries surrounding Canada or above it in the rankings have tax-supported health care systems. The countries surrounding the United States and below have mixed systems or are, in general, extremely poor in comparison to the United States and the other G8 industrial powerhouses.
There are no major industrialized countries near the United States in the rankings. The closest is Italy, at 5.83 infants dying per thousand, but it is still ranked five places higher.7
In the United States, infant mortality rates are 7.1 per 1,000, the highest in the industrialized world -- much higher than some of the poorer states in India, for example, which have public health systems in place, at least for mothers and infants. Among the inner-city poor in the United States, more than 8 percent of mothers receive no prenatal care at all before giving birth.
Overall U.S. mortality
We would have expected to see steady decreases in deaths per thousand in the mid-twentieth century, because so many new drugs and procedures were becoming available. But neither the Canadian nor the American mortality rate declined much; in fact, Canada's leveled off for an entire decade, throughout the 1960s. This was a period in which private care was increasing in Canadian hospitals, and the steady mortality rates reflect the fact that most people simply couldn't afford the new therapies that were being offered. However, beginning in 1971, the same year that Canada's Medicare was fully applied, official statistics show that death rates suddenly plummeted, maintaining a steep decline to their present rate.
In the United States, during the same period, overall mortality rates also dropped, reflecting medical advances. But they did not drop nearly so precipitously as those in Canada after 1971. But given that the United States is the richest country on earth, today's overall mortality rates are shockingly high, at 8.4 per thousand, compared to Canada's 6.5.
Rich and poor
It has become increasingly apparent, as data accumulate, that the overall improvement in health in a society with tax-supported health care translates to better health even for the rich, the group assumed to be the main beneficiaries of the American-style private system. If we look just at the 5.7 deaths per thousand among presumably richer, white babies in the United States, Canada still does better at 4.7, even though the Canadian figure includes all ethnic groups and all income levels. Perhaps a one-per-thousand difference doesn't sound like much. But when measuring mortality, it's huge. If the U.S. infant mortality rate were the same as Canada's, almost 15,000 more babies would survive in the United States every year.
If we consider the statistics for the poor, which in the United States have been classified by race, we find that in 2001, infants born of black mothers were dying at a rate of 14.2 per thousand. That's a Third World figure, comparable to Russia's.8
But now that the United States has begun to do studies based on income levels instead of race, these "cultural" and genetic explanations are turning out to be baseless. Infant mortality is highest among the poor, regardless of race.
Vive la différence! Genetically, Canadians and Americans are quite similar. Our health habits, too, are very much alike -- people in both countries eat too much and exercise too little. And, like the United States, there is plenty of inequality in Canada, too. In terms of health care, that inequality falls primarily on Canadians in isolated communities, particularly Native groups, who have poorer access to medical care and are exposed to greater environmental contamination. The only major difference between the two countries that could account for the remarkable disparity in their infant and adult mortality rates, as well as the amount they spend on health care, is how they manage their health care systems.
The facts are clear: Before 1971, when both countries had similar, largely privately funded health care systems, overall survival and mortality rates were almost identical. The divergence appeared with the introduction of the single-payer health system in Canada.
The solid statistics amassed since the 1970s point to only one conclusion: like it or not, believe it makes sense or not, publicly funded, universally available health care is simply the most powerful contributing factor to the overall health of the people who live in any country. And in the United States, we have got the bodies to prove it.
This article was adapted from Holly Dressel's book God Save the Queen—God Save Us All: An Examination of Canadian Hospital Care via the Life and Death of Montreal's Queen Elizabeth Hospital, to be published in 2007 by McGill/Queen's Press.
1Terry Boychuk. The Making and Meaning of Hospital Policy in the United States and Canada. University of Michigan Press, Ann Arbor: 1999.
2David U. Himmelstein, et al. Health Affairs, Jan.–June 2005,
3Professor James Kahn, UCSF, quoted in Harper's Magazine, “Harper's List,” Feb. 2006.
4National Health Expenditure Data,
5Devereaux, Dr. P.J., et al. “A Systematic Review and Meta-Analysis of Studies Comparing Mortality between Private For-Profit and Private Not-For-Profit Hospitals,” Canadian Medical Association Journal, May, 2002.
6Nancy A. Ross et al. “Relation between income inequality and mortality in Canada and in the United States: cross sectional assessment using census data and vital statistics,” Statistics Canada, reprinted in Health Geography, GEOG-303, ed. Nancy Ross, McGill University, 2005, pp. 109-117.
7CIA World Fact Book.
8See, among many studies blaming race, Child Health USA 2003, Health Status – Infants; HRSA, with graphs such as “Breastfeeding Rates by Race/Ethnicity, 2001”; “Very Low Birth Weight Among Infants, by Race/Ethnicity 1985-2001”; .