To get a sense of what
Just Healthcare might really be like,
we interviewed Kathleen Connors,
President of Canada's National Federation of Nurses Unions,
about how the Canadian system works.

A conversation with the president of Canada's nurses federation

In Canada, everyone has a healthcare card. And if you need to visit a physician, or get tests, or if you have to enter a hospital, your access to the system is through that card. You present it, and that's it. There are no questionnaires, there are no insurance forms - you're in.

One of the issues that is so foreign to Canadians is the idea that your plan wouldn't cover this or that. Here you have access to everything that is deemed medically necessary.

Every Canadian has access to the healthcare system - whether you have the money or not, whether you have a job or not. In the U.S., people stay in terrible jobs because they have health insurance. That doesn't happen here.

Now, if I don't like the shape of my nose, I might have to pay for that. Unless my nose was broken in an injury - then it would be covered. If I'm diabetic and I become ill, I won't be denied care because I have a preexisting condition. And everybody here is entitled to preventive care. If you have a niggling kind of concern, you have access to your doctor to discuss it.

The financing for the healthcare system in Canada is through both the federal and provincial governments. The money comes out of general tax revenues, which are fairly progressive. Business pays its fair share. In addition, some provinces have an employer health tax. There has been research that shows that what Canadians pay in taxes to finance healthcare is not dissimilar to what you Americans pay for healthcare. You pay for healthcare with out-of-pocket expenses and through foregone wages that were used to pay your health insurance premium. We just pay for it a different way.

Under Canada's Constitution, the issue of healthcare is a matter of provincial jurisdiction. But over the years, there has been federal involvement in financing healthcare and establishing the standards that the provinces have to meet in order to get the federal money. The overriding piece of legislation that governs healthcare in Canada is very simple: It's called the Canada Health Act. In it, there are five principles set out upon which all the provinces have to develop their healthcare system.

These principles are very simple. They are: universality, meaning that all Canadians have to be covered; comprehensiveness, meaning that there has to be a comprehensive range of services available; accessibility, meaning that there has to be reasonable access to medically necessary care; portability, meaning that if you go from one part of the country to the other, your health insurance goes with you; and that it must be publicly administered and not-for-profit.

Now, there are private hospitals here, but they are totally funded by the public dollars. So they have to meet the terms set by the Canada Health Act and by the province.

For the provinces to get the money from the federal government for their healthcare budget, they must be accountable to the federal government. For instance, we had some problems with doctors doing extra billing to supplement their incomes. Under the Canada Health Act, for every dollar that was extra-billed, the federal government withheld a dollar of the province's allocation. So it's a carrot-and-stick approach to eliminate extra billing and user fees. And it's worked.

There are problems. There is heavy pressure coming from the corporate sector to get into the healthcare business. And because governments are looking at how much is spent on healthcare, they try to ratchet down the amount of spending. And there are calls in some parts of our country for a private system to complement the public one.

You can purchase private insurance here. And so if governments decide to cut the amount of services that are covered, the private companies are here to pick up the slack. We [Canadian nurses] have a problem with this, because it puts in place the beginnings of a two-tier system where people with money get extra service, and everybody else waits.

"Accessibility" under our system doesn't mean that you have to have a brain scan or an MRI in every little town. You might have to go to where the services are. I sometimes hear Americans criticizing our system, saying there is a shortage of tests, or there is only one MRI in this city. But I think one MRI, utilized properly, can be as effective as three or four.

One of our right-wing thinktanks recently produced a survey on waiting lists for procedures here. It was very unscientific, based on anecdotal testimony from doctors. But the bottom line is, if your physician says that it's medically safe for you to wait, you may go on a waiting list. But if your health status is compromised by your condition, you will have the surgery, you will get the tests, without a wait. Some people are on waiting lists because they only want Dr. Jones to do the surgery. We do have our choice of doctors here - if you're not happy with one, you can go see another. It's not like what you have in some of your HMOs.

It's not inherent in the structure of our system that there are waiting lists, it's that we have chosen to only allocate a certain amount of money for our healthcare system [the Canadian government spends much less on healthcare than the U.S.]. And looking at the American system, you often don't get on any list - you may never get the surgery or the tests if you don't have money.

Nurses here have some of the same concerns as nurses in the U.S., unfortunately. We aren't filling out insurance forms here or having treatment protocols second-guessed by health insurance companies. But we do have some of the same financial pressures here as you do. Governments have gone through cost-cutting, and there is a reduction in the amount of money available for healthcare spending. I think we spend 9.4 percent of our Gross Domestic Product on healthcare, compared to the 14 or 15 percent that the U.S. spends. Because we have a single-payer system, we save a lot of money on healthcare administration. And that allows us to do other things with the money.

Nurses have concerns about not being able to provide care in the way that we were educated to do. We have frustrations about being able to help patients with their physical needs, but not their emotional needs.

And unfortunately, because of our close proximity to the U.S., one approach some people have taken to the problems we have is to bring up American consultants to tell us how they did it there. The idea, for instance, of substituting lower paid healthcare workers for our RNs has entered our country.

The Canadian system isn't perfect. But there are wonderful lessons to be learned, and you can modify them and make the changes you need to make it serve the American population. Our system is constantly evolving, as it should be.

But even with the problems, there are high levels of support for our healthcare system. If you ask Canadians - and polls have done this recently - what their number one concern is, it is having access to healthcare. There is a reluctance on the part of Canadians to borrow from the American system. If you ask Canadians what makes us different from Americans, they say, 'our healthcare system.' Some people say there are more Canadians who believe Elvis Presley is alive than believe in the American healthcare system!

I find that how much understanding and appreciation you have of the Canadian system often depends on where you live in your country, and how close to the border you are. The citizens who live along the border often understand a fair bit about the system. But I've had some American nurses tell me, 'There can't be a system like that.' And I have to say, 'There is, and I work in it!' It's just so foreign.

Back in 1993-94, when some Americans were campaigning for single-payer healthcare, I spent time speaking in U.S. church basements and community meetings trying to demystify our system. And it worked. Where Canadians can explain the system, it really helps. But if you are just relying on ads you see from the health insurance industry and you don't have any other base of information, it's hard to say you want to move to another system.

I want to say that it's very important to us as Canadians to have a sense that in the U.S. there are people who are willing to fight for a similar kind of program. Because it's hard to fight the pressure from transnational corporations alone, to feel those kind of threats. It's hard to keep fighting to maintain and improve the kind of system we have here. So when we can see that there are groups and individuals who are working for the same principles we have here, that's really important to us.