All Commentary
Sunday, May 1, 2005

The Price of Free Health Care

Canadian Health Care Should Not Be a Model for the United States

Many health-reform proposals in the United States are modeled on the Canadian healthcare system. The usual claim is that a program similar to the one in Canada would provide all Americans access to the finest medical services while managing to be less expensive than the status quo. Unfortunately, these wonderful visions of socialized health care in Canada tend to ignore the very real costs that Americans in need of medical services would bear if such a program were forced on them.

In Canada, though it is true that we have “free” access to health care (all medically necessary physician and hospital services are free at the point of delivery, entirely funded by Canadian taxpayers), there is still a real cost to be borne by patients: the time they have to wait for care. To an American, that last statement may seem a bit confusing. Of course, everyone has to wait some time for care because of scheduling. But waiting times in Canada are something entirely different. For example, patients in need of lung-cancer treatment will wait about five and a half weeks from the time their general practitioner refers them to specialists to the time they begin radiation therapy. A patient in need of radiation therapy for breast cancer will wait about nine and a half weeks.1

For average Canadians who require something other than radiation therapy for cancer, the waiting times are much longer. To see a specialist in Canada, on average, requires a wait of about eight and a half weeks. Once that specialist decides that a treatment is required, the average wait is nine and a half weeks. This makes a total waiting time of nearly 18 weeks. Canadians must also line up and wait their turn for diagnostic services: five weeks for a CT scan, three weeks for an ultrasound, or a whopping 12 and a half weeks for an MRI.

Wait times for less-critical procedures are even more alarming. Though patients needing chemotherapy for cancer can expect to wait a total of five and a half weeks, those in need of orthopedic surgery (hip replacement, knee replacement, and so on) can expect to wait 38 weeks on average. Patients needing elective cardiovascular surgery wait 11 weeks, while those needing medically necessary plastic surgery can expect to wait almost 36 weeks.

These periods are substantially longer than physicians consider medically acceptable. In 2004, physicians in Canada felt that a waiting time of 5.2 weeks (from the specialist’s decision to treatment) was clinically reasonable. As noted, Canadians waited nine and a half weeks on average.

At this point, it should be clear that there is a real problem with the delivery of health care in Canada. But at least those who are not living here have the opportunity to avoid instituting a similar program in their country. Canadians, on the other hand, find themselves unable to resolve the waiting-time problem under the current structure of medicare.

Consider the following numbers: since 1993 public health spending per capita (adjusted for inflation) has increased by 27 percent, while waiting times have increased by an incredible 92 percent.2 The more Canadians spend on health care in Canada, the longer the waiting times get, a finding that has been confirmed by econometric studies.3 Canadians have powerful and monopolistic public-sector unions and the inevitable inefficiencies inherent in a public monopoly to blame for that performance. Any short-term relief would come at great cost, while the source of the waiting (a lack of competition and financial incentives for patients) would remain.

Just as troubling, the waiting lists in Canada do not seem to be prioritized in any meaningful way. Patients often receive faster access for “non-clinical” reasons, such as personal prominence or political connections, which partly explains why one study of waiting times found no connection between the amount of pain suffered by patients waiting for orthopedic surgery and the amount of time they waited for treatment.4 Put another way, Canadians have no choice but to wait, while the length of the wait appears to have little relationship to their actual level of need or discomfort beyond the simple distinctions “emergency,” “urgent,” and “elective.” Moreover, governments in Canada do not allow citizens to use their own resources to pay for faster access to health care, unless they are able to do so outside the country, in the United States or India, for example.

Don’t Copy Us

A health-care system modeled after Canada’s would clearly not be the utopia that some Americans anticipate. Though there is no doubt that the system provides access to medical services for all Canadians, that access is seriously impeded by long waits. Canadian taxpayers are also not receiving any great benefit from their public monopoly: On an age-adjusted basis, only the United States spends more for health care than we do.5

For our neighbors to the south, it would be a serious mistake to adopt the Canadian health-care system. Though it would mean providing all Americans with health insurance, it would also mean forcing them to wait incredibly long times for necessary services. The system in Canada is clearly in need of change and should not be a model for anyone.


1. Nadeem Esmail and Michael A. Walker, Waiting Your Turn: Hospital Waiting Lists in Canada, 14th ed. (Vancouver, B.C.: Fraser Institute, 2004). Unless otherwise noted, data are from this book.
2. National Health Expenditure Trends 1975–2004 (Ottawa: Canadian Institute for Health Information, 2004) and Esmail and Walker.
3. Nadeem Esmail, “Spend and Wait,” Fraser Forum, March 2003 and Martin Zelder, “Spend More Wait Less,” Fraser Forum, August 2000.
4. David A. Alter, Antoni S. H. Basinski, and C. David Naylor, “A Survey of Provider Experiences and Perceptions of Preferential Access to Cardiovascular Care in Ontario, Canada,” Annals of Internal Medicine, October 1998, pp. 567–72; and J. Ivan Williams, et al., “The Burden of Waiting for Hip and Knee Replacements in Ontario,” Journal of Evaluation in Clinical Practice, February 1997, pp. 59–68.
5. Esmail and Walker, calculations by author.