Recently my heart betrayed me, after more than 60 years of excellent service it decided to beat far too quickly. My atria started to beat at nearly 300 times per minute, and my ventricles, unable to beat that fast, responded to every second atrial contraction to beat at 145 per minute, this is a cardiac arrhythmia known as atrial flutter. Although I felt OK in general, I could feel my heart was beating too fast, and after waiting for 30 minutes to see if it would calm down, I decided to take myself off to a local emergency room. I didn’t feel sick enough to call an ambulance, so I called a cab and asked them to take me to the nearest Emergency Room, at the Jewish General Hospital in Montreal. When I arrived, I was seen within seconds by a nurse who triaged me as a level 2 emergency which meant an immediate admission to one of the ‘crash’ rooms. (level 1 means you are actively bleeding or in cardiac arrest!) Within about 5 minutes of my arrival ER, I was in a highly monitored bed, with my ECG displayed for the emergency room doctor to see, an I.V. in place, in a hospital gown, having my vital signs taken by an experienced nurse, who was able to tell me that I was stable and that the doctor would see me within a few minutes, which she did.

In total I was in the ER for about 8 hours, during which time I had an x-ray, 2 formal ECGs, an expensive drug that I had never heard of before, multiple disposables, and a bedside echocardiogram. The expensive drug converted my heart rhythm to normal, after about 10 minutes, and then after a few hours of monitoring, I was able to go home. I got back home in the early hours of Canada Day, the year was the 150th anniversary of the convention that created Canada. Two days later I was seen by a specialist, and had another ECG and a formal echocardiogram by an experienced technician. About 4 weeks after this (I delayed the appointment for my annual vacation)  I had a 48 hour recording of my heart activity, which showed no further evidence of atrial flutter, I was then seen by an internationally reputed expert in cardiac electrophysiology within a month, and we decided together that I should have a cardiac catheterisation and an endomyocardial ablation, which means advancing a catheter into my heart and burning the lining of the heart in a particular place to make it very unlikely that another episode would ever occur.

Three weeks after seeing the specialist in his clinic I was admitted to a day hospital, an ECG showed my heart rhythm was normal, and I was sent to the catheterisation room, one of the most advanced that exists anywhere, where under x-ray control, and with 3-dimensional mapping of my cardiac activity, the electrophysiologist burnt the inside of my heart, and interrupted the pathways that might otherwise leave me at risk of a recurrence. About 6 hours later I was allowed to go home.  

When I got home from that, I thought I had better figure out my bill to make sure I could afford it all:

Taxi to hospital for initial episode $14, taxi home from hospital $14, outpatient prescription drugs $1.84 (outpatient drugs are not completely covered for most people), parking for the first specialist appointment $12. Public transport to get to the Sub-specialist appointment $3.25

Total cost $45.09

That’s it.

Everything else was covered by the provincial healthcare system, paid for by taxes.

Tommy Douglas was a former professional boxer, who was also a baptist minister, and is the father of Canadian Medicare. He was from the Canadian Prairies, has been referred to as the ‘greatest Canadian of all time’ and worked tirelessly to start a Canadian Health Care system which provides care to all, regardless of ability to pay.

Our system (actually systems, there are significant differences between provinces that are responsible for administering health care) is far from perfect, acute and emergency care tend to be favoured, so neonatal care, for example, what I do on an a daily basis, is in a privileged position. Central management has advantages, it makes regionalisation quite effective, so we have almost no avoidable deliveries of very preterm babies in non-tertiary hospitals. Central management also creates problems, with, for example, the size of medical school intakes oscillating as the government tries to decide if we have too many physicians or too few, and keeps changing its mind.

Chronic care, and domiciliary care are the big losers in our system, as it is politically easier to cut budgets when the adverse effects are slowly cumulative rather than acutely visible. Non-urgent surgery is another place where our system does relatively poorly, so a hip replacement might be quite delayed, with consequent avoidable pain and disability. Although, in fact, some type of waiting list for non-urgent procedures his an important way of containing costs, if everyone can get a hip replacement within a few days of qualifying for one, there has to be a great deal of redundancy in the system.

One interesting comparison with the US system was made a few years ago by John Ralston Saul. The cost of US Medicare and Medicaid, divided by the entire US population, (even though those items only cover a small part of the US population) was substantially greater than the cost of Canadian Medicare, divided by the entire Canadian Population; but the Canadian system covers everybody. A system with a layer of administration dedicated to making a profit has to be more costly.

Outpatient drug costs are one area where there are substantial differences between provinces. In Quebec where I live, if your employer does not provide drug benefits there is an ‘individual mandate’ and everyone must buy their own medication insurance. This insurance has a maximum co-pay of about 1/3, but has an annual cap, which means that there is an annual maximum which any individual has to pay of 1066$ in any year. As I have now passed 65 years I am covered by the provincial medication insurance, as is anyone without a job or with a lower income.

I am certainly grateful for the Canadian health care system, both as a patient and as a part of the system, no-one find themselves in debt because of medical costs, those who pay taxes pay for the medical care of those who pay little or no taxes. In a relatively just society, that is how it should be.

I was stimulated to publish this post, which I wrote 3 years ago on hearing of the tribulations of my friend and colleague Nick Embleton, In one of his posts on his blog he mentioned his gratitude that his medical care was covered by the UK National Health Service. He referred to the care as being “free”.

But of course it is not free, the nurses and physicians and technicians and administrative personnel are all paid, the drugs are paid for, the equipment is bought, the hospitals are built and maintained (sometimes poorly!). None of that is “free”.

What actually is happening is that we, as a society have decided, that when anyone gets sick we will all pay a little bit towards their care. Anyone who pays taxes in Quebec contributed a few cents towards my care, the purchase of the 3-dimensional fluoroscopy unit, my drugs, the salary of the nurses who cared for me and my physicians fees. Even those in other provinces contributed a little, as the federal government collects money from taxes and sends then to each province in the form of equalization payments.

This is sometimes referred to as public health insurance, but it isn’t really even that. Insurance policies are paid for by the individual towards an eventual adverse occurrence, in which case their costs will be paid. Paying for health care as a collective is a way of caring for those who are sick at the moment that they need it. No-one has to worry about health care bills or becoming bankrupt. Of course, the young rich and healthy contribute towards the care of the old poor and sick more than they get back… at first. But one day we all need health care, to receive it without having to dread the bills that might arrive is a sign of a healthy society.

There have been attempts to de-fund Canadian Medicare, and the NHS, from ideologues whose idea of society is more a “sink or swim” image. But Medicare in Canada and the NHS in the UK are extremely popular, so attempts in the UK to destroy the system are usually disguised as attempts to “improve efficiency” or “decrease overheads”. Our systems, however, are already incredibly efficient, with much lower proportions of costs going to administration than happens in systems relying on profit-taking insurance companies.

I am privileged to live in a province (Quebec) where these collective principles are never under attack. None of the political parties are opposed to Medicare being funded out of the public purse (i.e. our collective contributions), even though they may have different approaches, and tend to try to re-organize the system every time there is a change in government, with resultant chaotic periods. I can rest assured that the next time I need acute care I will not end up with a bill (if I have to take an ambulance it will be even cheaper, as that is covered also) because my colleagues, my neighbours, and people in far away towns that I will never meet will pay for my costs.

Thank you Tommy Douglas, thank you Canada, thank you Quebec.