Why do we have a health care system? In their excellent paper, Lewis and colleagues describe the views of a group of relatively well-off and well-educated Americans on the Canadian health care system. Their views are mixed. They would have had the best of the US health care system so, not surprisingly, they rate many aspects of care better in the US. But they also value the fairness and the efficiency of the Canadian system. In the end, these mixed views drive mixed preferences, with relatively similar proportions preferring the US (45%) and Canadian (40%) systems. The temptation is to look at this last number and say that the US system is better. But we have a health care system for several reasons, and most of these reasons favour the Canadian choice—even based on the data in this paper.

The Canada Health Act lays out the rules for the Canadian health care system: everyone is entitled to health insurance for medically necessary care and barriers based on the ability to pay are illegal. The reasons for universal health insurance go well beyond the types of questions that Lewis and colleagues asked Americans and include keeping people healthy, creating an inclusive society and supporting a strong economy. These reasons form the basis for a good head-to-head comparison of the American and Canadian systems.

The first reason to have a health system is to keep people healthy. Health care, whether from your family physician or a high-tech teaching hospital, can help prevent illness, manage illness when it occurs and provide emergency treatment to rescue people from crisis. On this count, the American system seems to do better. The well-off population surveyed found the American system better on five of eight variables, particularly on timeliness and access to care. Recent efforts to reduce wait times for key services seem to be bearing fruit according to data released by provincial governments across the country, but there is always room for improvement and these findings should not be taken lightly. At the same time, however, it’s important to note that the same data sets reported in Table 1 consistently report that Canadians are healthier compared to Americans.

The second reason is to build an inclusive society. Many Canadians will point to our health care system as part of their identity and as one of the ways that we distinguish ourselves from our neighbours south of the border. Compared to the negative way we usually talk about our identity—“we’re not American, we’re not British”—the health care system is a positive distinguishing characteristic of Canada, regularly reported in Canadian and foreign newspapers. The provision of fair access to health insurance is a way of creating an inclusive, stronger society where income does not determine access. The results of the survey are particularly telling on this point. Despite the fact that American respondents would have enjoyed the best of the US system, they consistently rated the personal costs and coverage better in Canada.

The third reason for a health system is to support a strong economy. Health costs are one of the greatest challenges facing US employers. The universal insurance system in Canada is cheaper, and not just cheaper by doing less. The American respondents once again rated the Canadian system higher in terms of its value for money. A number of years ago, labour unions and some business leaders in the US argued that it cost $500 dollars more to build a car in Detroit than in Windsor because health insurance costs were so much higher in the US. This difference may now be shrinking, in part because the range of what is covered by employers in the US is also shrinking, but a cheaper system in the US will only come at the cost of a less inclusive society.

Head-to-head comparisons are a good motivator for improvement. But how Canada decides the future of its health system should be based on how it views its goals as a country, not just on satisfaction ratings from a group of relatively well-heeled respondents. The results so far favour the Canadian approach.

Adalsteinn D. Brown is the Assistant Deputy Minister, Health System Strategy in the Ontario Ministry of Health and Long-term Care and an Assistant Professor in the Department of Health Policy, Management, and Evaluation at the University of Toronto.

ISSN 1911-2092