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Special Communication
September 2018

Lessons From the Canadian Experience With Single-Payer Health Insurance: Just Comfortable Enough With the Status Quo

Author Affiliations
  • 1Institute of Health Policy Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario
  • 2Women’s College Research Institute, Women’s College Hospital, Toronto, Ontario
  • 3Institute for Health Systems Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario
  • 4Department of Family and Community Medicine, Women’s College Hospital, Toronto, Ontario
  • 5Department of Family and Community Medicine, University of Toronto, Toronto, Ontario
  • 6Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario
  • 7Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario
  • 8Department of Medicine, Mount Sinai Hospital and University Health Network, Toronto, Ontario
  • 9Department of Medicine, University of Toronto, Toronto, Ontario
JAMA Intern Med. 2018;178(9):1250-1255. doi:10.1001/jamainternmed.2018.3568

With single-payer public health insurance again on the political radar in the United States at both the state (California) and federal (Democrat party) levels, the performance of the Canadian health care system during the last 50 years and the lessons it may offer should be considered. Canadians are proud of their universal approach to health insurance based on need rather than income. The system has many strengths, such as the ease of obtaining care, relatively low costs, and low administrative costs, with effectiveness and safety roughly on par with other countries, including those, such as the United States, that spend considerably more per capita. There are increasing frustrations, however, with system performance, especially with issues related to access and coordination of care. Medicine has changed dramatically since the introduction of Canadian Medicare in the late 1960s, which primarily covered acute care physician and hospital services—the needs of the time. Meaningful reforms that match coverage and services to changing needs, especially those of community-based patients with multiple chronic conditions, have been difficult to implement. The status quo represents a compromise struck decades ago between payers and physicians and organizations that provide health care, and the current system works just well enough for those who both need it and vote. Enacting substantial change simply carries too much risk. Perhaps the most important lesson that the United States can learn from Canada’s experience during the last 50 years is that a single-payer health care system solves a lot of problems, but it does not equate to an integrated, well-managed system that can readily meet the changing health care needs of a population.

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