On the Road Again

George Koch
June 13, 2019
Canadians are inveterate travellers, but they don’t go abroad merely to appreciate the Louvre’s great art, find their true purpose through a swami in India, build houses for the poor in Nicaragua or get sloshed poolside in Cabo. For all-too-many, it’s about maintaining their ability to walk or even saving their life. C2C Journal’s George Koch looks into “medical tourism”, evaluating the statistics and asking how we might keep more health care dollars at home.

On the Road Again

George Koch
June 13, 2019
Canadians are inveterate travellers, but they don’t go abroad merely to appreciate the Louvre’s great art, find their true purpose through a swami in India, build houses for the poor in Nicaragua or get sloshed poolside in Cabo. For all-too-many, it’s about maintaining their ability to walk or even saving their life. C2C Journal’s George Koch looks into “medical tourism”, evaluating the statistics and asking how we might keep more health care dollars at home.
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In just about every Canadian’s repertoire of dinnertime anecdotes is a health-care horror story that beset a relative, friend or co-worker. Poor access to specialists and interminable waits for needed surgery and procedures are common themes. Health Canada’s official “recommended” waiting time for knee replacement surgery, for example, is six months. That’s bad enough – why couldn’t it be six weeks or six days? But last year, nearly one-third of patients needed to wait even longer than that. In Alberta, the waiting time is over two years.

Little wonder that in 2017, Canadians made an estimated 217,500 to 323,700 trips to other countries for health care services and procedures, according to Statistics Canada. They are what’s known as “medical tourists”. To put that number in perspective, it’s equivalent to approximately a dozen sold-out NHL arenas and exceeds the population of Regina or Kelowna. Clearly, significant numbers of Canadians are going abroad for medical care, mainly to the U.S.

There, the median waiting time for all surgery is a little over four weeks, with 82 percent of patients waiting less than three months. If you can pay cash, you can often see a specialist just a day or two after first calling the facility, and be under the scalpel within days. Even Americans on low-income government programs (the ones that critics in Canada typically pretend don’t even exist) wait only about three months to see specialists, half the average waiting time imposed on Canadians.

Health care waiting times
This is what triggers medical tourism, sending hundreds of thousands of Canadians south of the border every year.

Speedily accessing health care can be a life-or-death matter but, even in less acute instances, it’s often the difference between a life fully lived and one that is, to use an archaic term, crippling. Quite aside from mere lifestyle considerations, without properly functioning knees, hips and shoulders, an elderly person might not be able to leave the home even to shop for groceries, and a self-employed tradesman’s business could collapse. Lives are shortened and become difficult and grim. And that’s to say nothing of getting cancer treatment right away.

SecondStreet.org, a Regina-based think-tank that’s dedicated to illuminating how government policies affect everyday Canadians, has been exploring the economic aspects of medical tourism, starting with trying to uncover the actual travel-related data. The organization wanted to know how much money might be leaving Canada each year due to health-care-related travel.

Second Street’s President, Colin Craig, related how his interest had been piqued by a conversation he’d had with an acquaintance named Ken. The father of young children was an energetic person who liked playing racquetball and was active in his community in Winnipeg. Ken related how he had previously developed painful and debilitating shoulder problems and needed an MRI scan to assess his condition. Medical authorities told him he’d have to wait a year. He couldn’t shorten the wait by paying out of pocket, because Manitoba’s government had blocked private clinics from offering MRI scans to the public.

Ken’s choice was clear: either spend a painful year on the sidelines or travel outside the province and pay for an MRI on his own. Ken wasn’t rich, but he was able to afford the approximately $800 (Canadian) charged by a reputable clinic in Minnesota. He received the scan within a few days of calling for the appointment.

In addition to the MRI fee, Ken spent money on fuel, food and accommodations while in the U.S., and also did some Christmas shopping while south of the border. Had he been allowed to use a private clinic in Winnipeg, all that money would have stayed in the local economy. His spending would have supported high-end medical jobs and makers of the sophisticated equipment that go with them. These are the very types of employment and manufacturing that Canadian governments frequently claim to be trying to promote.

What if Canadian governments continued to fund the public system, but allowed patients the option of spending their own money on private health care in Canada? Jobs would be created, not just in health care delivery but a variety of sectors. Businesses would generate revenue, employees would receive incomes, and both groups would pay the full gamut of taxes – some of which would end up helping to fund the public health care system.

Medical tourism
“Would you like a new hip to go with your charcuterie and merlot, sir?”

Instead, hundreds of thousands of Canadians are taking their health care needs and their wallets and going abroad. Countless U.S. hospitals and clinics have staff “concierges” who do nothing but handle medical tourists – some working exclusively with Canadians. Some even travel to Canada and attend events like women’s shows to market their prompt health care services. There are also companies in Canada that match Canadians in need of health care to high-quality and reasonably affordable care all over the U.S. They help Canadians get access to everything from new joints to complex pancreatic cancer surgery that needs to be done within weeks if the patient is to have a hope of living.

The large range in the estimated medical tourism figures cited above – 217,500 to 323,700 per year – stems from Statistics Canada’s collection methodology of surveying random travellers returning to Canada (which, presumably, creates broad room for error). Also noteworthy is that Statscan only counts actual patients. People travelling for medical reasons rarely travel alone, however. The travelling companion clearly needs to spend money on meals, transportation and other costs. So if, for the purpose of estimating economic impacts, we included people accompanying patients – such as a wife going with her husband abroad for hip surgery – then it’s highly likely that Canadian medical tourists exceed half a million annually.

Statistics Canada figures also indicate that in 2017, Canadians spent an average of $1.9 million daily on health care in other countries, covering everything from emergency treatment to cosmetic procedures. This is a striking number, totalling nearly $700 million per year.

But it would be helpful if the government dug into more detail. For example, what types of medical procedures are people paying for in other countries? We can be confident from the frequency of anecdotes that Canadians often seek timely hip and knee surgery. But how many travel for routine dental work or elective cosmetic surgery? Chemotherapy? Life-saving surgery? And which areas are counted by Statistics Canada?

two-tiered health care system Canada
Many other Western nations have so-called two-tiered health care systems, as well as significantly shorter waiting times than Canada.

The federal government provides the provinces with tens of billions of dollars for health care annually. It would only make sense for Health Canada to track more carefully how many patients are leaving the country for health care, what treatments they are seeking and how much they are spending. The numbers we do have suggest there’s considerable dissatisfaction with health care options in Canada. More detailed medical tourism data would help reveal which treatments are in the greatest demand and, accordingly, the shortest supply here at home. Second Street last year filed an Access to Information Act request seeking such data and any associated reports, but was informed by Health Canada that it was “unable to locate any records” to do with the request. More research on medical tourism is clearly in order.

In addition, Statscan’s estimated spending figure seems low. Taking the annual total of about $700 million and dividing it by the average of the estimated number of Canadians travelling abroad for medical treatment – 270,600 – yields spending of about Cdn$2,600 per person-trip. That would certainly be ample for Ken’s MRI. But consider that a single chemotherapy treatment runs US$3,000-$6,000, a course of stem cell injections to fight arthritis about US$12,000, and abdominal surgery even in a smaller regional centre at least US$40,000. That’s some tourism. And it makes one wonder what Canadians are really spending.

For Canadians in urgent need of health care, of course, even more important than having clear statistics is figuring out what should be done. One approach would be for governments to relax the rules around private clinics while continuing to fund Canada’s public health care system. This is consistent with the policies of many other nations including the United Kingdom, Australia and New Zealand. Such pragmatic reform would give Canadians more choice and keep more health care dollars in our economy.

While shortening the public health care system’s waiting lists, this approach would also provide the convenience and sense of security that comes when a person is treated in their own community, with supportive friends and family nearby. Travelling for medical care is itself stressful, and complications arising during the trip home can be disastrous. It’s even possible that Canada could itself become a medical tourism destination. We do have some world-class medical personnel and health care facilities, as well as a competitive currency.

Opponents of so-called “two-tier” health care often claim that more private services quickly erode the public system as the best medical professionals flock to the higher incomes, newer equipment and facilities, and more satisfying outcomes of the private system. But we have had “two-tier” K-12 education across the country for decades and the sky has not fallen on public education. Those systems certainly have their faults, but it’s not due to a lack of funding. Government spending on K-12 education has been increasing at well above the rate of inflation.

private health care Canada
Allowing more privately delivered health care in Canada would keep medical tourism dollars at home, generating high-paying knowledge-sector jobs.

In many cases, innovation in the public school system has been driven by competition with other types of schools. In brief, the so-called two-tier education system has benefitted both tiers, and countless students and families. It’s easy to envision a similar dynamic in the medical sector. And it’s noteworthy that health care systems that perform better than Canada’s – Australia, New Zealand and Sweden to name a few – all maintain a universal public health care system while allowing patients to choose private options.

Opponents also suggest that the real solution is simply to spend more on health care. But data from the Vancouver-based Fraser Institute shows that waiting times more than doubled in Canada between 1993 and 2018 even as per-capita spending on health care rose from $1,687 to $4,397. Access did not improve as a result of governments pouring money into the system.

The problems besetting Canada’s health care system are many and varied. There’s no silver bullet and giving Canadians more private options is no panacea. It would, however, be a solid step in the right direction. It would provide patients like Ken and hundreds of thousands of others with more choice, reduce stress on our struggling public system and give our economy a boost.

George Koch is acting editor of C2C Journal.

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