In August 2018, I found myself waiting in a crowded downtown Toronto emergency department (ED). An hour earlier, my 16-year-old son Nolan had called from the summer camp where he worked to say that his shoulder had “popped-out” while swimming. My wife and I breathed a sigh of relief—minor health scare—and I hurried to the Toronto Western Hospital (TWH) ED. I quickly found Nolan, in moderate discomfort, in the cramped subacute waiting area and asked him if he was okay that he waited for a little while. He said he was.
As the Division Director for General Internal Medicine at TWH, I fleetingly thought about walking into the ED to speed things along. Instead, I absorbed my angst and resolved that we would not use my workplace connections to expedite Nolan’s care. After 2 h, I asked Nolan if he was still okay. Through a grimace, he said that he could wait, but some sort of pain medication would be good. I prepared to stand up.
Healthcare systems tend to reflect the values of their respective countries.1 US healthcare reflects societal priorities of autonomy and self-determination,2 while the Canadian system reflects a commitment to an equitable distribution of care.3 Canadians, whether billionaires, physicians’ children, or new immigrants, are expected to wait together, though we know this is not always the case. It is easy to advocate for a single-payer system from the quiet offices of academe or the podium of a political campaign.4 The requisite sacrifices are distant and vague. It is much more difficult to resist the visceral desire to ask for special treatment when your loved one needs care.5
In 2014, after 15 years as a physician and health services researcher in the US, I (PC) moved to Toronto with my family. We obtained health insurance through the Ontario Health Insurance Plan (OHIP) after the requisite 3-month waiting period—a process that was delightfully simple. OHIP is the sole insurer for all legal residents of Ontario and provides first-dollar coverage for physician visits, hospital visits, and most diagnostic testing (though not medications or routine dental/eye care). We found a terrific family doctor who provides virtually all the care our family requires. Outside of my work as a hospitalist, Nolan’s injury was our first experience with Canadian acute care.
Back in the TWH ED, just as I was about to ask for assistance, Nolan’s name was called. As we were taken into an examining room, I distinctly recall making eye contact to one of the ED clerks who I knew from my clinical work. She smiled and asked what I was doing in the ED. I told her about Nolan, but otherwise, remained as anonymous as possible. I am far from a saint, but I am stubborn and principled. A significant part of the professional attraction for moving to Toronto was the chance to truly immerse myself in a single-payer system. Given my motivations for moving to Canada, how could I ask for expedited treatment for Nolan when everyone else was patiently waiting their turn?
When time came for the ED staff to reduce Nolan’s shoulder, I excused myself and let them do their work. Nolan was discharged from the ED approximately 5 h after his arrival and referred to the TWH orthopedic fracture clinic for follow-up. When, after 1 week, we had not been notified of the specifics of Nolan’s appointment, I intervened for the first and only time with a polite (and reluctantly written) email to an orthopedic surgeon colleague; we received instructions for Nolan to report to the TWH fracture clinic for an appointment with one of the shoulder surgeons (CV) the following week.
The fracture clinic functions as an all-purpose entry point for all things orthopaedics. The clinic is profoundly functional and extremely busy, no comfy chairs, no computerized self check-in kiosks, 50–100 patients seen in a typical morning. Nolan’s visit was smooth and efficient. After about an hour of waiting, Nolan was evaluated by an orthopedic resident with oversight from a staff surgeon (CV). They confirmed Nolan’s shoulder dislocation and, upon taking a detailed history, found that Nolan had probably dislocated his shoulder 2–3 times in the prior 6 months without seeking medical care. Dr. Veillette recommended physiotherapy, but cautioned us that given his history, Nolan was at high risk for dislocating his shoulder again and would likely require surgery.
Sure enough, in October 2018 Nolan dislocated his shoulder again, though it reduced spontaneously. He returned to the orthopedic clinic on November 27th and saw Dr. Veillette, who recommended an MRI. MRIs can be hard to come by in Toronto, and Nolan, my wife, and I discussed options for expediting things. There are numerous avenues for accelerating access; some I find quite distasteful (e.g., a call from a connected patient or wealthy donor to a hospital CEO), while others bother me less (e.g., a referring physician calling the MRI center to advocate for the patient based on the “urgency”). We decided to wait, and Nolan had his MRI in February. Had we still been in the US, we would have been irritated with the delay; but we have accepted the tradeoffs of our new system. We patiently explained to the worried family members in the US that waiting was “part of the deal.” While Uwe Reinhardt explained excessive US healthcare spending with “it’s the prices stupid,”6 the reality is that the US has both significantly higher prices and higher utilization;7 all things being equal, higher utilization means shorter wait times for tests and procedures including MRIs.
Nolan had a follow-up visit with Dr. Veillette to review his MRI result; surgery was recommended, and he underwent an uneventful outpatient Bankart repair of his shoulder on April 26th. Did we receive preferential treatment because I am a doctor at TWH? I hope not, but it’s hard to say.
We have no real complaints. Nolan probably waited longer than back in the US where our commercial insurance would have made him a desirable patient. Americans—at least those with good insurance—expect care without delay. There is no empirical data that I’m aware of suggesting that Nolan’s surgical delay did any permanent harm, though he missed out on certain leisure activities he would have enjoyed. We also did not have the typical US experience of receiving multiple bills from our insurance company, surgeon, and hospital. While the marginal tax rate in Ontario is 54%, our taxes include our health insurance. Our out-of-pocket costs for Nolan’s shoulder were $40 (for the sling).
We feel good knowing that virtually any Canadian would receive the same care as Nolan. Waiting seems like a reasonable sacrifice to make. But I wonder whether Americans, particularly those with “good” insurance, would be willing to forgo the service to which they are accustomed in order to insure basic care for everyone. I wonder how many of the academics and politicians who publicly champion a single payer or Medicare-for-all would really wait in a crowded public hospital ED or clinic. I suspect many would find ways to jump the queue, either hiding from or rationalizing their hypocrisy. I remember the temptation to use my position to cut the line. I’m proud that I did not, but what if Nolan’s condition had been more serious?
As I watch yet another US presidential campaign where healthcare reform will be the pivotal issue, I find myself dumbfounded by candidates’ (and their healthcare advisors) inability to articulate a simple truth, there is no free lunch.
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We would like to thank Drs. Raphael Rush and Allan Detsky for their comments and editorial suggestions.
The authors have no funding relevant to this work. Dr. Cram is supported by a grant from the US National Institute of Aging (R01AG058878).
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
This manuscript is written from the perspective of PC (father) with input from NC (patient) and CV (orthopaedic surgeon).
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Cram, P., Cram, N. & Veillette, C. Are you Willing to Wait? Tradeoffs and Compromises Required to Achieve Universal Health Insurance. J GEN INTERN MED (2020). https://doi.org/10.1007/s11606-019-05630-2