This paper is unique and important both for the information it provides and the questions it poses. It will not delight the methodological purists. But the authors are fully aware of this shortfall. The novelty of what they have done and how they have gone about it has given us unprecedented and important information.

Conventional wisdom holds that if you can afford it, the best care anywhere is available in the US. Critical analysis has never supported this view. For example, the inaugural issue of Open Medicine published a study demonstrating the quality of healthcare is at least as good in Canada as it is in the US.

In contrast to that comparative study, Steven Lewis and colleagues went straight to the heart of the matter and asked patients what their view was. The selection of the patients was crucial. They solicited the views of “prosperous, highly educated Americans living in Canada”—a very thoughtful choice. These ex-pat Americans are a unique group who could afford “the best” health services in the US and had experienced both the US and Canadian systems.

These 310 American citizens (out of 258,000 living in Canada) constitute an unusual demographic group as the authors point out. They are a privileged group.

What did they think?

First, their expectations were very interesting and indeed two-thirds of them had an opinion before coming to Canada. It was more positive than it might have been given the frequently negative media coverage of the Canadian system by mainstream US media. Twenty-nine percent thought the Canadian system would be better, 35% thought it would be worse and 37% thought it would be the same.

After they experienced the Canadian system their opinions changed but not dramatically. Forty-five percent preferred the American system and 40% stated they would choose the Canadian system.

Other eye-catching results were the insights of the Americans: they liked the cost- efficiency, equity and drug prices of the Canadian system but gave poor marks for wait times, shortage of personnel and quality of care. As the authors commented these views are similar to those held by Canadians.

Despite its strengths, some caveats must be given in regards to the findings of the study. The first is that the information was harvested from April to July of 2005. In the intervening two years an historical level of activity has been directed toward shortening wait times in Canada, with some important successes. Nonetheless, while progress has been made the issue has not been resolved. A survey done in 2007 may or may not reflect the changes.

Secondly, as the authors acknowledge, there is no way to know to what extent the 310 respondents are representative of the larger population of Americans in Canada.

Thirdly, an important question is not answered: how was quality defined? Outcomes of care in Canada are equal to or slightly better than in the US. For example, in the recent analysis published by Open Medicine comparing the two countries, the average mortality rate in Canada was 5% lower than the US. In the absence of a definition of quality, the meaning of the finding of perceived lower quality in Canada is unclear. It is possible that their observations reflected the quality of the location, physical infrastructure or variables other than outcomes of treatment.

Another question is in response to the statement, “Respondents rated the Canadian system as a whole more highly than its component parts.” It rings true. I suspect Canadians feel much the same way. It would be very interesting to explore what this means. Does medicare confer a positive sense of shared destiny of which Roy Romanow speaks, or a feeling of social inclusion, or another explanation entirely?

Nonetheless the paper left me with an appetite for more work to address questions that any good study raises. For example, it would be very interesting to repeat the study with a group which is more representative of the demographic of the US.

In the final analysis this balanced, original and important work has enriched our understanding of medicare. I look forward to the next chapter of their work.

Robert Y. McMurtry is a physician and special advisor to the Canadian Royal Commission on the Future of Health Care. He is actively involved in discussions on creating an accessible medical system for the Canadian public, and has long advocated for more effective public involvement in healthcare policy.

ISSN 1911-2092