ABOUT 500 miles north of Charleston, Carolyn Molot arrives at Sisters Deli most mornings before 7 a.m. She and her two sisters, Debbie and Andrea, started the eatery in Hamilton, Ontario, six years ago. "We cook, clean, dishwash, scrub bathrooms. There's not one thing our staff does that we won't do," she said. "We're a team. We lead by example."
By 8 a.m., a mix of people in suits, T-shirts, and what-have-you are drinking coffee, hanging out before work, reading newspapers.
The 40-year-old Molot and all nine of the deli employees have health insurance. "Sure we do," she said. "We're Canadians. Our government supplies that to us.
"My dishwasher has the same government insurance as the prime minister has. Our cook has the same as the president of the Bank of Canada."
"When I sliced off part of my finger on the meat slicer, the hospital bandaged me up, and all I had to do was show my health care card and say 'thank you.' We don't have somebody greeting us at the hospital door asking how we're going to pay."
Molot and her employees carry cards from Ontario Health Insurance Plan (OHIP). They are not charged for doctor or hospital visits, optical or prenatal care, dental surgery or home health service. The magic words are medically necessary. "They won't pay for you to have a face lift," Molot said, but if you break your leg while playing Frisbee, get cancer, or get pregnant, your medical expenses are covered.
Molot was amazed to hear about the Chesapeake Bagel store owners' hassles with health insurance. "Thank God we don't have that situation," she said. "We'd be right in there with them. And we'd be constantly paying for things ourselves. That's how my sisters and I are. We feed every orphan, and our mortgages don't get paid."
Molot has never had to worry that a large insurance claim would send her business health insurance premiums through the roof. "One of our workers was painting the kitchen on a ladder, and he stood up, cracked his head on the metal fan and fell off. We rushed him to the hospital, and they ran tests on him and kept him for the night. OHIP took care of it."
If that accident had happened in the States at a business with small group insurance, the cost would have been spread only among employees of that business. In Canada, the expense was spread among 11 million Ontarians.
Ontario — like all Canadian provinces — runs its own insurance plan. To get federal dollars, OHIP must pay for basic hospital and physician care. After that, they decide what else they will include. The federal government pays part of the cost.
A Canadian is covered anywhere in Canada. "Our card is good in all the provinces," Molot said. "If I have a heart attack in British Columbia, I'm taken care of."
Ontario doctors bargain collectively with OHIP every three or four years. The Ontario Medical Association sits down with OHIP, and they negotiate the schedule of fees doctors will get for the next few years.
It is against the law for any doctor or hospital to give a patient an additional bill for services covered by OHIP.
Some employers and individuals buy supplementary insurance to cover things OHIP doesn't: private hospital rooms, duplicate tests, private physical therapy.
Drugs are not covered, except for partial coverage for elderly, disabled, or catastrophically-ill patients and drugs administered in hospitals.
Canadian emergency care is first-rate, Molot says. Emergencies go to the top of the doctor's list. But people wait, sometimes months, for non-emergency surgery, specialist visits or high-tech tests.
In 2002, Americans listed the high cost of care and inadequate coverage of services as their two top complaints about the health care system. Canadians complained about the shortage of doctors and long waiting times.
At least Canadians wait equally. The deli's early-morning customers may have spotted a February Hamilton Spectator article, "Wait for surgery long, but fair: same length for rich, poor." In a seven-year study, Canada's Queens University researchers found that wealthy and poor Canadians alike wait about 30 days for common surgeries.
Dr. Samuel Shortt was the lead author of that study. "If the state declares that it has a monopoly — as in many ways our Medicare system does," he said, "then it's an absolute prerequisite to show that this is an equitable system. In a system of mixed private and public, people buy their way to the front of the line, and equity isn't an issue. That's not what the goal of the [Canadian] system is."
That's the point, Molot said. "I'm glad that we aim for these kinds of things, but right now we're having a little problem hitting the target." The doctor shortage is throwing a cloud over the good things about the Canadian system, she said.
Most doctors in Hamilton are not taking new patients right now, she said. Her own father is a doctor, so if any of her employees have trouble getting a doctor, she can usually convince somebody to take them. Otherwise, they would have to go to a walk-in clinic or the emergency room.
One in 10 Canadians do not have a regular doctor, according to the Canadian Medical Association. "If you don't have a regular doctor, everything is still free," Molot said, "but you may have to wait 12 hours in an emergency room to see a doctor who doesn't know you."
"You have to keep reminding yourself that you could be living in a country where you had no insurance." She has beginning rheumatoid arthritis, she said, and she can just imagine the bills.
'What about this
Molot says she knows Canadian doctors who moved to the United States to make more money. "OHIP will pay only a certain amount per patient," she said. "So some of our docs move to America. Doctors come here and fall in love, then some of them say after five years, 'What am I doing here? I'm not making the money I would in the States.'
"But a lot more of them stay," she said. "Life is not all about money. It's about quality of life, safety for your kids, and health systems, the values people have. For instance, we want to live in a place where we probably won't get nuked.
"In Toronto, last Wednesday night, there were a half million people at a Rolling Stones concert, and they only reported one arrest and one overdose."
One of Canada's leading health care researchers sometimes eats breakfast at Sisters Deli. Dr. Brian Hutchison directs the Centre for Health Economics and Policy Analysis at McMaster University, 10 minutes away, where he works in an office filled with file cabinets and bookshelves stuffed with research reports.
If Molot's words tumble out in an excited stream, Hutchison's march out slowly, in careful order. "There are a lot of myths out there," he said. "I like to let the research speak."
So what about this doctor shortage? Canada is losing a net 200 doctors a year, according to the Canadian Medical Association. Are Canadian doctors fleeing the insurance system as some U.S. politicians say they are?
Actually, he says, if you look at the history, the Canadian government created most of the physician shortage. They made some bad decisions.
In 1988, he said, Canadians told surveyors they were very satisfied with their health care system, which includes doctor supply. In fact, a government-sponsored report predicted a doctor surplus. At the same time, in the early 1990s, the Canadian economy went sour, into recession. The federal and provincial governments cut back the money for health care and just about everything else.
They also reduced the number of medical students who were allowed to enter medical school. As a result, fewer physicians were trained. And they placed tighter restrictions on foreign-trained physicians practicing in Canada.
Seven years later, as fewer graduates began to practice, Canada had a doctor shortage, and the public began to gripe. So in the late '90s, the provincial governments restored some health care funding and medical school slots to early '90s levels, rather than late '90s levels. They also loosened the restrictions on foreign-trained doctors. More students entered medical school. Those students are just now finishing their education.
In retrospect, many people now say the cutbacks in medical school slots were a bad decision. But the people who recommended the cutbacks also recommended that the government increase the number of non-physician providers, such as nurse practitioners and midwives. Those recommendations were not followed.
There has been a lot of finger-pointing over that decision, by anybody's account. But the number of medical students is slowly climbing back up. After they graduate, so will the doctor supply.
People who try to blame the shortage on the insurance system don't know their history, Hutchison said.
The Sisters Deli early morning newspaper-readers may have spotted a March article titled "Health Spending Increases by $1.9 Billion." That money will produce "more doctors and nurses, shorter waiting lists, increased access to technology, better support for mental health, and a stronger focus on keeping people well," said the Ontario Finance Minister.
Couldn't happen soon enough, Molot said. "We're not getting as much as we used to. But then that's happening all over, isn't it? We used to buy hamburgers that were 100 percent beef, didn't we?"
She laughed when she heard what the editor of The New Yorker magazine, Hendrik Hertzberg, recently wrote about Canada. "Their health care system is a mess, but it's a fairer, more humane mess than ours is."
"I would agree 100 percent," Molot said. "As screwed up as our system can be and as angry as we get with our government, we know how lucky we are to have what we have. We wait, yes, but everyone here can get basic care. Nobody is left out. That's the bottom line."
more humane mess
Canadian public insurance is not, of course, really free, Hutchison says. But it costs much less than it does in the United States.
Here are six reasons why this is true:
Prescription drugs cost two to four times more in the United States. The United States does not regulate prescription drug prices or use its group buying power to negotiate lower drug costs. Canada does.
The United States now allows pharmaceutical companies to advertise prescription drugs on TV and radio. Canada does not. The considerable expense of advertising is part of total cost.
Canada limits the amount doctors and hospitals can charge across the board. The United States does so only for the population covered by government programs.
U.S. administrative costs dwarf Canadian costs. The United States pays its health bills through a bewildering number of channels, each of which has its own administrative structure.
Advanced medical technology is more widespread and expensive in the United States.
The Canadian government would be spending more if citizens did not have to wait months for appointments.
Given the much greater expense, Molot questions the notion that hordes of Canadians repeatedly cross the border to get American health care on a regular basis. "Of course, lots of people go down there and get a CAT-scan, if they don't want to wait and can afford it," she said, "but who wants to pay American prices as a habit?"
Hutchison cites a 2002 study in which American and Canadian researchers surveyed 136 Washington, Michigan, and New York state health care facilities. Only seven facilities had seen more than 25 Canadians in a year. "The anecdotal reports of Medicare refugees from Canada are not the tip of a southbound iceberg, but a few scattered cubes," they wrote.
Fact: The United States spends twice as much per person on health care as Canada does. In combined private and public U.S. dollars, the United States spent $4,631 per person in 2002, and Canada spent $2,535 per person, according to the international Organization for Cooperation and Economic Development (OECD).
This does not mean Canadians get less care. The research says that, on average, Canadians visit more with their doctors and spend more days in hospitals.
If you subtract the private dollars, the United States also spends more government dollars on health care than Canada does, per person: $2,051 per person in 2002, compared with Canada's $1,825 (U.S. dollars). This is surprising because the United States covers only 80 percent of bills for only part of the population.
Researchers boil it down to one main reason: prices.
If you want to get a grip on what consumers pay, Hutchison said, you should count both private and public spending. "If you're going to pay for health care, does it matter whether you pay out of the right pocket or the left pocket? You're still paying, whether you pay out of your personal resources or pay in taxes, as we do."
'At least I don't
have to worry'
The presidential election is heating up in the United States. Hutchison says he expects to hear plenty of inaccurate statements about the Canadian health care system coming from the other side of the border.
Meanwhile, Carolyn Molot is planning her next trip to the United States. "We love the U.S.," she said.
She will buy her temporary insurance policy a few days before she goes. The big majority of Canadians buy a temporary health care policy when they travel in the United States, Molot said. "I wouldn't cross the border without one," she said. OHIP will pay only up to the level they would pay in Canada, "and you get stuck with the rest" unless you have temporary insurance.
A few years back, she said, her family took a trip without a temporary policy. Her daughter broke her arm skiing "and I'm still dealing with the hospital bills."
"I would say that 85 to 90 percent of Canadian travelers are armed with special insurance when they cross the border," said Darcy Flarity, a Hamilton insurance agent. "Everybody has heard the stories of $3,000 a day in a hospital."
"There are just too many tales of woe out there about Canadian families holding fundraisers to free their aging parents from hospitals in Florida" after their parents got sick in America without special insurance or enough money to have somebody bring them home.
Canadians over 60 can buy unlimited coverage for 30 days for $79 to travel in the United States, but pre-existing conditions are not covered. One of Flarity's customers, a Canadian in his '80s, had heart trouble last year. He goes to Florida each year in the winter. "He came in this year and wanted to buy extra insurance," Flarity said. "We told him he wouldn't be covered for his heart condition.
"He ended up buying a policy that cost over $2,000 that allowed him to be evacuated by a private jet with a nurse if he had heart trouble," Flarity said.
"That story tells a lot about how we view the American medical system. The health insurance company wouldn't cover him for treatment in an American hospital, but they would pay for him to be evacuated."
The insurance agent used the word 'evacuate,' Flarity added. "That's a word you use for taking somebody out of downtown Baghdad in a Blackhawk helicopter."
"I think the thing that probably aggravates us or entertains us or amuses us — or all of the above — is the fact that it seems as if, when Canadians are seeking out medical help in the States, they get charged for every cotton ball, every Band-aid, every suture. Person after person comes back with American bills, itemized that way. We can't believe it."
"The less scrupulous hospitals will do every test they can do when they find out you're a Canadian with unlimited insurance."
Carolyn Molot, meanwhile, is battling her landlord, who wants to move Sisters Deli out of the building and sign a 20-year-lease with a fast food chain.
"Who knows what's going to happen? If we lose the business, at least I don't have to worry that my employees won't have health care."
To contact staff writer Kate Long, call 348-1798 or e-mail firstname.lastname@example.org