What the Danny Williams' case says about Canadian health care

Both sides of the border are squawking about the premier's trip to the U.S. for treatment

No sooner did news break that Danny Williams had flown south to the United States for treatment of an undisclosed heart condition than the chronic debate about the state of Canadian health care went critical. Opponents of universal insurance—both in Canada and the U.S.—pounced on his trip as a told-you-so moment. The populist Newfoundland premier has, after all, been an ardent defender of the public system. Campaigning during the 2008 federal election to keep Stephen Harper from winning seats in his province, he warned Newfoundland voters that a majority Harper government would threaten Canada Health Act tenets like universality, public administration and accessibility. “Nothing would be safe, quite frankly,” Williams said, “when it comes to going after sacrosanct principles.”

Those principles don’t say anything—at least, not exactly—that conflicts with the right of a 60-year-old Canadian millionaire-politician to check himself into an expensive American clinic for cardiac care. And Newfoundlanders, by and large, saw it that way, leaping to Williams’ defence through talk radio, Facebook get-well messages, and letters to the editor. Some went so far as to say that what’s good for Danny’s heart is good for Newfoundland and Labrador. “I think he’s looking after his health and his best interests,” said Dean MacDonald, a St. John’s venture capitalist and old friend of the premier. “And clearly his best interests are the province’s best interests.”

Off the island, however, such stalwart declarations of support gave way to conflicting claims. Critics of public health insurance seized on this latest case of high-profile medical tourism as proof the Canadian way must be second rate—and no model for America. “This should be a wake-up call to Congress and the administration,” said a Fox News medical commentator. “It is a fact beyond dispute that the United States remains the global destination for patients from all over the world.” Canadian conservatives pounced, too. “It’s symbolic,” said Brett Skinner, president of Vancouver’s Fraser Institute. “These services are not available at all or not available on a timely basis here in Canada.”

That seemed like a reasonable conclusion to draw. Why else would Williams wing off to the U.S.? However, a chorus of Canadian physicians said they were at a loss to think of any heart surgeries, beyond rare and exotic procedures, done in the U.S. that aren’t readily available at Canadian institutes, although often not in Newfoundland. Dr. Bryce Taylor, surgeon-in-chief at Toronto’s prestigious University Health Network, said Ontario’s heart centres offer the latest techniques with virtually no waiting lists, unless a patient insists on a particular famous surgeon. Taylor was annoyed by pundits who assumed Williams went south to get some better procedure faster. “They were impugning our ability to give patients good access,” he said.

There are, of course, differences between what’s on offer on either side of the border. For example, Taylor said some wealthy patients are enticed to U.S. medical “boutiques” that advertise surgery with very small incisions and sometimes robotic equipment. But those innovations are not proven, he added, to be better for the patient. Doctors in both Canada and the U.S. are divided on them. Another difference is the deluxe service offered, for a price, by some famous U.S. hospitals, such as the highly ranked Cleveland Clinic. “It is true that the Cleveland Clinic has so-called concierge treatment,” Taylor said. “They will meet visitors at the airport in limos. I suppose that might be very seductive.”

Canadian hospitals can’t match expensive U.S. clinics when it comes to upscale amenities. Keeping pace on cutting-edge procedures is another matter. When it comes to repairing heart valves, for instance, specialists in Ontario, like virtuoso surgeon Dr. Tirone David, Toronto General Hospital’s head of cardiovascular surgery, are internationally renowned. Why don’t sick American millionaires come north for such surgeries then? Actually, they often ask to, but are usually turned down. The reason: since 2004 Canadian physicians and hospitals have generally not been insured if malpractice suits are brought against them following elective surgeries in U.S. courts, where judgements can be huge.

No matter how many eminent physicians leapt to the defence of Canadian heart specialists, news of Williams’ decision left a lot of Canadians with the impression cardiac care must be better in the U.S. Dr. Jack Tu, senior scientist at Toronto’s Institute for Clinical Evaluative Sciences, has researched outcomes for heart patients in the two countries. Despite famously contrasting health insurance systems, Tu said there’s little difference. But in a recent, unpublished comparison, he found Canada seems to do somewhat better when it comes to patients having to be readmitted to hospital after being discharged following treatment for heart failure. In the U.S., about a quarter end up back in hospital within a month; in Canada, it’s about one-fifth.

Tu suspects pressure to keep hospital bills down means U.S. patients are more likely to be discharged a bit too soon. “In Canada, hospitals are on a global budget,” he observed. “We don’t have insurance companies bugging doctors to send people home quickly.” In fact, the issue of readmissions has prompted the American College of Cardiology and the U.S. Institute for Healthcare Improvement to launch a program called Hospital to Home, in a bid to find ways to lower that troubling readmission rate. Even the elite U.S. hospitals are seized by the issue. Last year, the Cleveland Clinic appointed a task force to study the problem. Broadly speaking, Tu said American hospitals tend to have the edge in technology and intensive care facilities, but Canada’s health system is better at caring for patients over longer periods, including after they leave hospital, and in making sure they get the prescription drugs they need.

Such distinctions in strong and weak points between the two countries didn’t figure in the Williams uproar. It came down to one rich guy’s ability to exit the system he had insistently championed. “If he wants to buy 20-year-old Scotch, I don’t have an issue with it. If he wants to spend his money on his health, I have no issue with it,” said Dr. David Gratzer, a Toronto physician and critic of the Canadian health system. “My issue is with his hypocrisy. My issue is that he says, ‘This is good enough for you, but if I run into trouble I’m taking my jet to Boston or Cleveland.’ ”

Nobody keeps track of how many well-off Canadians pay out of their own pockets for American care. Occasionally provincial health plans pay for U.S. care for ordinary people when services aren’t readily available at home. Provinces spent $1.14 million on U.S. care in 2007-08—less than 0.001 per cent of total health spending. But that’s no more precise an indicator of shortcomings in the Canadian system than Williams’ trip is. Dr. Lorne Bellan, chair of the Wait Times Alliance, an organization of Canadian doctors aimed at speeding up access to treatment, said those problems are serious, complex, and likely to get worse as the population ages.

According to Bellan, provinces made quick progress after Paul Martin’s short-lived Liberal government cut a deal with them in 2004 to funnel $5.5 billion over 10 years into cutting wait times. Queues for cataract surgery, joint replacements and other high-demand procedures shrank fast. Then the Conservatives won election in 2006 on a promise of bringing in wait time “guarantees.” In 2007, each province signed on to deliver one health service, from radiation therapy to bypass surgery, within a guaranteed period. But Bellan said these were token gestures in areas where the waits were already reasonably short. Real progress stalled as politicians shifted to focusing on issues like climate change and the economy.

At least, until the Danny Williams story. “It’s brought to light again this question of what our system is able to provide in Canada,” Bellan said. “It allows us to point out again that there is unfinished business.” Among the persistent problems, he said: shortages of MRI machines and nerve-wracking waits for surgery for serious but non-life-threatening conditions.

Officials in Williams’ office said his surgery was done on Feb. 4 and he was released from intensive care the next day. He is expected to say more about where he went and why when he comes home within a couple of weeks. Whatever his personal story turns out to be, if those details spark only another round of crude claims about complicated issues, the episode won’t have done nothing to move the Canadian health care debate forward.