U.S. senator says Canada’s small population makes public health possible, but experts disagree

Democratic debate: Bernie Sanders praises Canadian healthcare system
WATCH: While offering his thoughts on the U.S. health-care system Thursday night at the Democratic primary debate, U.S. Sen. Bernie Sanders spoke about the health-care system of his "neighbour to the north."

In response to Vermont Sen. Bernie Sanders’ praise for the Canadian health-care system during the second night of Democratic debates, Colorado Sen. Michael Bennet implied that Canada’s relatively small population made public health easier to implement.

“When Sen. Sanders says that Canada is single payer, there are 35 million people in Canada. There are 330 million people in the United States,” Bennet said.

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According to experts, however, the opposite is actually true.

How does Canada’s health-care system work?

“It’s not a question of how big the population is. In an insurance system, you need [a] broad enough sample of the population to spread the risk,” said Allan Maslove, a public policy professor at Carleton University who specializes in health-care funding. “In other words, you can only have people who are at high risk of using health-care services in the pool. The costs will just go out of control.
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“You have to have healthy people in the pool to help pay the bills so it’s not a question of how big the population is. It’s a question of getting enough cross-section of the population,” he continued.

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Furthermore, he added that since every Canadian citizen is eligible for basic public health care, the system likely has the necessary diversity.

As expected, health care was front and centre during Thursday’s debate as candidates discussed a wide variety of proposals to implement a public health-care plan in the United States. During the discussions, Canada’s system was often referred to as a single-payer health-care system, whereas the U.S. system is referred to as a multi-payer health-care system.

Single-payer means that one party or group — most likely the government — covers an individual’s health-care costs.

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Dr. Danyaal Raza, a family doctor at St. Michael’s Hospital in Toronto and the chair of Canadian Doctors for Medicare, clarified that Canada’s system can actually be best described as a combination of single-payer and multi-payer health-care systems.

This is because while Canada has publicly funded health care (single-payer) for physician services and doctor’s visits, Canadians often receive coverage for services or products outside those two domains, such as prescription drugs, from employers or insurance companies (multi-payer).

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Raza adds that the greater the population enrolled in a public or insurance-based health-care system, the stronger its financial security.

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“That’s actually one of the big arguments in favour of bringing pharmacare or prescription drugs into our single-payer health-care system here,” he said. “It’s more administratively efficient. You can do things like bulk buy. You can take advantage of economies of scale in ways that you could never do in a multi-payer system.”

What are the Democratic candidates proposing?

While Medicare for all seems to be the new standard for the Democratic party, the 23 presidential hopefuls have different thoughts on whether private insurance should be abandoned altogether. The majority of candidates propose a system similar to the Canadian structure (public and private insurance), including Bennet, Corey Booker, Amy Klobuchar and Beto O’Rourke, according to a roundup completed by the Washington Post.

Some of these candidates, including South Bend Mayor Pete Buttigieg and New York Sen. Kristin Gillibrand, intend to use private health insurance as a way to transition to a fully single-payer health-care system.

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Sanders is the only candidate who’s pledged to abolish private health insurance entirely, and other big names such as former vice-president Joe Biden, Sen. Kamala Harris and Sen. Elizabeth Warren have not taken a clear stance.

Currently, the U.S. government provides two kinds of health coverage — Medicaid and Medicare — though these are specially designed for elderly, disabled, young and poor members of society. Otherwise, Americans may receive health-care coverage through their employer. A study by academic researchers published in February 2019 revealed that medical debt is the biggest cause of bankruptcy among Americans.

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Examples of other public health-care systems

Britain — Single-payer+

Britain provides another example of a single-payer system that goes a step further than Canada. The government finances and provides care through the National Health Service, according to a roundup completed by the New York Times.

In this system, most services are free to citizens, with the system being largely funded through tax dollars. However, a private system does exist alongside the public one. According to the Times, government spending accounts for 80 per cent of all health-care spending.

France and Australia — Complete coverage 

France operates a more extensive public health-care system in which citizens must buy health insurance, which covers between 70 and 80 per cent of all health-care costs, according to the Center for European and International Liaisons for Social Security (CLEISS).

Citizens must register with an insurance agency and go through their doctor for most procedures.

The United States is currently the only highly developed country (those with a high human development rating on the Human Development Index) without some form of universal health care.

Raza stops short of saying that any of the systems described above can be directly implemented in the United States, but he does note that most research supports some sort of public health care.

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“It’d be very presumptuous for me to say Canada’s health system could be exactly duplicated in the U.S.,” he said. “What I can say is the fundamentals upon which the universal part of our health-care system is based on, those fundamentals are sound.”