An epic U.S. health-care overhaul

It took more than a year of partisan bickering, deal making and amendments but the U.S. Congress has approved sweeping changes to the way health care is delivered in the United States.
Patients line up on hospital beds outside a crowded emergency room at Montreal's Sacre Coeur Hospital in 2002. ((Paul Chiasson/CP Photo) )
It took more than a year of partisan bickering, deal making and amendments, but the U.S. Congress has approved sweeping changes to the way health care is delivered in the United States.

Despite the passage of legislation by both the Senate and the House of Representatives, the United States political establishment remains bitterly divided over the American health-care system. The almost $1-trillion bill that will eventually extend coverage to as many as 32 million previously uninsured Americans passed without a single Republican vote.

It's the first time in U.S. history that such a major piece of legislation has been approved solely on the votes of the governing party.

Opponents of the bill derided it as a march to Canadian-style "socialized medicine," arguing that it gives the government too much say over the way health care is delivered.

"This isn't radical reform," U.S. President Barack Obama said after the legislation was approved on March 21, 2010, "but it is major reform."

Key changes to U.S. health care

  • Very little change for people with coverage through their employer.
  • More lower-income people under 65 would be covered by Medicaid, the federal health insurance program.
  • Low- and moderate-income people would receive subsidies to help offset the cost of health insurance.
  • Insurance would be available through state-run exchanges.
  • Fines for people who do not buy health insurance.
  • People who lose or change jobs would be able to buy coverage through the exchanges, so they would not lose coverage.
  • Dependent children can stay on parents' coverage until they turn 26.
  • Many plans will be prevented from placing lifetime limits on coverage and they would not be able to cancel coverage for people who become sick.
  • Children could not be refused coverage for pre-existing conditions.
  • Adults who have been unable to get coverage because of pre-existing conditions will be eligible for coverage through a high-risk insurance program.
  • Higher taxes for high-income families.
  • Expensive insurance programs would be subject to a new tax.

While the legislation will soon ensure that more people than ever have access to health insurance, the new rules will mean the U.S. remains the only industrialized nation in the world without universal health-care coverage.

The countries that make up the World Health Organization adopted a resolution in 2005 encouraging countries to develop health financing systems that would provide universal health care, which it defined as "securing access for all to appropriate promotive, preventive, curative and rehabilitative services at an affordable cost."

What the United States and Canada have in common when it comes to health care is that it is administered by insurance companies. In Canada, those companies are public, funded by tax dollars and controlled by the provinces and territories — like British Columbia, Ontario and Nova Scotia.

In the U.S., those companies are — for the most part — private for-profit corporations that sell you or your employer coverage plans. For those who are unemployed, there's Medicaid a government-run insurance program that provides basic benefits to the very poor — only if they meet certain eligibility requirements that vary from state to state.

For those over the age of 65, there's Medicare — another government-run program that provides universal health care for seniors, as long as they meet residency requirements and have paid into the program. It does not cover the cost of prescription drugs or vision and dental care. There are private options that offer that coverage.  

Waiting times for some procedures may be longer in Canada, but you won't be billed afterwards. ((iStock photo))
In 2008, there were 43.6 million Americans  under the age of 65 with no health insurance. For most of them, their main option for care is to go a hospital emergency department when they get sick. Under U.S. federal law, a hospital must treat a person who shows up in the emergency department, regardless of their ability to pay. The hospital can bill the patient and try to collect.

You have to qualify for health-care coverage in Canada as well. Normally you have to live in a province for three months to be eligible. You have to be a Canadian citizen or a landed immigrant. If you're out of work, you're still covered for whatever services your province insures.

Canada's 5 'pillars'

The Canada Health Act sets out the primary objective of health-care policy across the country. That objective is "to protect, promote and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health services without financial or other barriers."

The federal government transfers money to each province or territory to cover part of their health-care budget, as long as they meet the following five criteria:

  • Public administration: provincial and territorial health insurance plans must be administered and operated on a non-profit basis by a public authority whose books are publicly audited. 
  • Comprehensiveness: a health-care insurance plan of a province or territory must cover all insured health services provided by hospitals, physicians or dentists in a hospital setting. The services of other health-care practitioners may be covered. 
  • Universality: health insurance must be available to all who meet residence requirements on uniform terms and conditions. 
  • Portability: you're covered by your home province if you're in another part of the country on business or on vacation. 
  • Accessibility: you should have reasonable access to hospital, medical and surgical-dental services on uniform terms and conditions — and not be charged extra for insured services.

While it may take longer to access some of those services depending on which part of the country you live in, you will eventually receive care.

Under the proposed changes in the United States, as many as 32 million previously uninsured people will join the ranks of the covered. Health insurance would be mandatory — unless you had a religious objection. Anyone else who declined to buy insurance would pay a fine. Low- and moderate-income people would receive government subsidies to help pay their insurance premiums.

It's estimated that as many as 18 million would still be without health insurance. A third of them would be illegal immigrants. In a move to placate Hispanic lawmakers, Obama pledged changes to immigration laws that could make it easier for people in the country illegally to apply for citizenship.

Modified status quo?

Health insurance plans would still be administered by large corporations. The Senate bill does not include a provision for a government-run insurance company as an alternative to the private companies.

In the U.S., health care is administered by many for-profit insurance companies. Canada's system is also based on insurance plans, but they're administered by the provinces and territories. ((iStock photo))
Employers and people without coverage at work could buy plans in a national exchange. But there would be some key changes: insurance companies won't be able to deny coverage to people with pre-existing conditions. Insurance companies would not be able to charge higher premiums based on medical conditions or gender — and they would not be able to set lifetime limits on health coverage.

Even with health-care reform in the United States, Americans will still be paying substantial out-of-pocket expenses. Depending on the details of the legislation that President Barack Obama signs, health insurance may cover anywhere from 60 to 90 per cent of a patient's expenses.

The American Medical Association has come out in favour of both pieces of legislation, saying the changes will improve choice and access to affordable health insurance coverage and eliminate denials based on pre-existing conditions.

One of the key goals of reforming the American health-care system is to get costs under control. Health insurance premiums have been rising much faster than incomes have grown and — depending on which study you believe — administrative costs eat up anywhere from 12 to 31 per cent of all money spent on health care in the United States.

The U.S. spends more on health care ($7,439 per person in 2007) than any country on the planet — yet fails to deliver consistent care to about 15 per cent of the population.

A study published in the New England Journal of Medicine in August 2003 found that the U.S. was spending a lot more than Canada on health-care administration — and that the gap grew from $307 per capita in 1999 to $759 per capita in 2003. The study concluded that the U.S. could save a lot of money by adopting a Canadian-style health-care system.