The call came from Bernie Sanders, the long-time Independent congressman and senator from Vermont. He would, of course, later become famous in his spirited run for the Democratic candidacy for president in the 2016 election. His staff knew about the organization I helped found, Canadian Doctors for Medicare—the voice of Canadian doctors who believe in strengthening and improving Canada’s publicly funded single-payer system for doctors and hospitals. At that time, I was regularly giving talks at conferences and meetings, writing reports, submitting op-ed pieces to Canadian newspapers, and engaging in public debates with people who favoured privately funded, for-profit solutions to Canada’s health care challenges. This seemed like another such presentation—but the source of the invitation sure was different!
As chairman of the U.S. Senate Subcommittee on Primary Health and Aging and a strong advocate for universal health care, Senator Sanders had organized a hearing on what the American health care system could learn from other countries about controlling costs and ensuring universal coverage. Senator Sanders wanted to know: would I come to Washington to talk about what the United States can learn from Canada?
I was honoured and a bit surprised. I accepted his invitation. In the ensuing weeks I went through a standard vetting process: I sent the senator’s staff my résumé, and was interviewed by staff members for both Senator Sanders and the senior Republican member of the subcommittee, Senator Richard Burr from North Carolina. I assured them of my academic bona fides and answered their questions about what I was likely to say.
With the help of a terrific policy analyst from Women’s College Hospital, Kyla Pollack Behar, who had worked on Capitol Hill, I submitted a written brief in advance of my appearance and drafted my remarks. Then I headed to Washington with Kyla as my guide.
I rehearsed my comments the night before, over and over, alone in my hotel room, timing myself with the stopwatch on my mobile phone. Kyla had warned me that my microphone could be switched off if I went over my five minute time allotment. The following morning I was standing outside the Senate building, at the end of a very long lineup, forty minutes before the hearing was scheduled to begin.
“These guys need a wait-times strategy,” I texted Kyla, who was waiting inside for me. I’d been looking on as the people in line were slowly screened, one by one. There was a huge bottleneck at the one screening machine, where bored-looking security staff stood back and watched one person do most of the work. I worried about arriving late for the hearing. Meanwhile, I could see through the lobby to the other side of the building, where a second entrance—also staffed by security guards—stood empty.
I made it into the hearing with seconds to spare, and sat down at a long table alongside other presenters who’d been invited to speak about their nations’ health care systems. We each had five minutes to discuss what the United States could learn from Denmark, Taiwan, France, and Canada, and then there would be a question-and-answer period.
I had two simple goals heading into that Senate session.
First, I wanted to stand up for the values that underpin the Canadian health care system, without being an apologist for it.
Of course our system has problems, and I wasn’t there to defend the indefensible. My role was to explain what we’re doing in Canada to address our problems, and why we want to do that without giving up on the principle of fairness that defines our publicly funded system. I needed to walk that line between sticking up for Canadian medicare and defending the status quo.
Second, I wanted to keep my cool. I understood that this was political theatre. The senators weren’t really talking to each other but over each other in a conversation that was taking place as much for an audience outside the room as inside it. I had a small cameo in a much larger performance. I needed to stay composed and play the role assigned to me, knowing that nothing I could say in a brief presentation would change anyone’s mind in the American health care debate.
My remarks ended just shy of my allotted five minutes. There were a few heated moments in the Q&A, but I felt good about how I handled them. Soon the two hours were over and Kyla and I were headed back to the airport.
On the flight home, I told Kyla that I thought the session had gone really well in terms of my two goals. “It’s too bad no one back home will ever know about it,” I said. “Do you think if I wrote one, Maclean’s would publish an article about what it’s like to be a Canadian doctor who gets grilled about our health care system by U.S. senators?” She shrugged in a way that gently suggested most people wouldn’t be very interested, and I had to agree.
The following evening, as I was heading home from the hospital clinic, my phone started to buzz. Then it buzzed again, and again, with text messages and voicemail from people who’d seen clips of the hearing. It didn’t stop buzzing for about three weeks. Everyone I knew was telling me that they were watching or listening to those clips. I was on CTV. MSNBC. CBC. Radio. TV. Trending on Twitter. On Facebook. On Yahoo News. “You’re breaking the internet!” a friend texted. The next day my face was on the front page of the Toronto Star (and so was Kyla’s, sitting right behind me).
The entire hearing had been filmed, as are all hearings of the U.S. Senate. Within hours of my departure from Washington, Senator Sanders’s staff had posted a clip on YouTube of a particularly biting exchange between Republican Senator Richard Burr and me. The Los Angeles Times picked it up under the headline “Watch an Expert Teach a Smug U.S. Senator About Canadian Health Care”—and the next thing I knew, the clip was everywhere.
The video that landed me on the front pages of Canadian and international news media culminated in the following exchange:
SENATOR BURR: Dr. Martin…why are doctors exiting the public system in Canada?
DR. MARTIN: Thank you for your question, Senator…in fact we see a net influx of physicians from the United States into the Canadian system over the last number of years. What I did say was that the solution to the wait-time challenge that we have in Canada…does not lie in moving away from our single-payer system towards a multi-payer system…Australia used to have a single-tier system, and in the 1990s moved to a multiple-payer system where private insurance was permitted. A very well-known study…[found that] in those areas of Australia where private insurance was being taken up and utilized, waits in the public system became longer.
SENATOR BURR: What do you say to an elected official who goes to Florida and not the Canadian system to have a heart valve replaced?
DR. MARTIN:…In fact the people who are the pioneers of that particular surgery which Premier Williams had…are in Toronto at the Peter Munk Cardiac Centre, just down the street from where I work. So what I say is that sometimes people have a perception—and I believe that actually this is fuelled in part by media discourse—that going to where you pay more for something, that that necessarily makes it better. But it’s not actually borne out by the evidence on outcomes for that cardiac surgery or any other.
…
SENATOR BURR: Dr. Martin, in your testimony you state that the focus should be on reducing waiting times in a way that is equitable for all. What length of time do you consider to be equitable when waiting for care?
DR. MARTIN: Well, in fact the Wait Time Alliance in Canada, sir, has established benchmarks across a variety of different diagnoses for what’s a reasonable period to wait….You know, I waited more than thirty minutes at the security line to get into this building today, and when I arrived in the lobby I noticed across the hall that there was a second entry point with no lineup whatsoever. Sometimes it’s not actually about the amount of resources that you have but rather about how you organize people in order to use your queues most effectively. And that’s what we’re working to do because we believe that when you try to address wait times you should do it in a way that benefits everyone, not just people who can afford to pay.
SENATOR BURR: On average, how many Canadian patients on a waiting list die each year? Do you know?
DR. MARTIN: I don’t, sir, but I know that there are forty-five thousand in America who die waiting because they don’t have insurance at all.
The ensuing weeks were a blur. I received emails and letters from all over the world. I was interviewed by media wanting the back story. I was called a “national hero” by people who liked my message and “Joan of Arc” by people who didn’t. I was stopped in the street and the grocery store. The speaking invitations started rolling in. The chief of surgery at my hospital said to me, “You should write a book.”
Of course it was fun to experience those few minutes of fame, but it was also informative. I had touched a nerve.
From that groundswell of support and media attention, I came to the following conclusion. Many, many Canadians still care deeply about—in fact are wildly proud of—our publicly funded health care system, what we call medicare. (The same name is used to describe the American public insurance system that covers people over age sixty-five.) In poll after poll, medicare is cited as our most defining social program. Its importance to our national psyche is indisputable: in a 2012 Leger Marketing poll, 94 percent of those surveyed said it was an important source of both personal and collective pride.
I fully grasped the intensity of that enthusiasm for public health care only when—for a brief moment—it was directed at me. It is not an exaggeration to say that for many people across this country, medicare is what it means to be Canadian. It strengthens our economy, improves our social stability, and exemplifies our values.
That’s the dual promise of medicare. To deliver accessible, high-quality services in an equitable way. And to give us something to be proud of.
This dual promise means that to improve medicare, we need to think not only about better delivery of services—a promise that is hard enough to keep—but also about making it a social program worthy of its iconic status. Medicare should still inspire us.
The “iconic” nature of Canadian health care is not news. Indeed, it’s often discussed, sometimes in a derisive way, in books and articles about health care system reform. Some of this commentary claims that our commitment to the principles of medicare prevents us from improving the system—because we’re blinded to its imperfections and because we’re afraid that any change at all will drive us into American-style, for-profit health care. We can’t, the argument goes, see our way to solutions, because doing so would require us to change an iconic program, the political cost of which would be too great. Through this lens, Canadian pride in our health care system appears stubbornly childish, a barrier to what some call the “adult discussion” we need to have about the future of health care.
I disagree. The fact that Canadians are deeply committed to medicare isn’t an impediment to change. Our commitment is—or should be—the foundation for change. This was what former premier Roy Romanow meant when he called his report on the future of health care “Building on Values.” Having a commitment to the value of equity isn’t childish. The notion that a social program like publicly funded, universal health insurance has become a symbol of our nation is something we can be proud of—as long as it doesn’t cause us to rest on our laurels. We won’t turn our backs on the basic structure of the program or sacrifice our principles. We don’t have to. Instead, we need to address the challenges in health care in ways that build on what’s good about what we already have in place.
I haven’t done every job in the health care system. I’m not a surgeon or a subspecialist. I’ve never worked outside Ontario. But I do think that my current roles as a practising doctor, a hospital administrator, and an advocate have helped me see at least some of what works and what doesn’t work in our health care system.
Peter Selby, a Toronto family doctor with expertise in public health and mental health care, once suggested to me that to see health care clearly, we need “bifocal vision.” One lens must focus on what has to be done right up close, at the level of the individual patient sitting in a doctor’s office needing help. The other lens must focus at a distance, giving us a long-range, overall perspective on the system. Through that lens, the population—not the individual—is the unit of analysis. I hope that this book will offer both lenses: a bifocal vision for the future of Canada’s most cherished social program.