Want a health tip? Move to Canada.
An impressive array of data shows that Canadians live longer, healthier lives than we do. What's more, they pay roughly half as much per capita as we do ($2,163 versus $4,887 in 2001) for the privilege.
Exactly why Canadians fare better is the subject of considerable academic debate. Some policy experts say it's Canada's single-payer, universal health coverage system. Some think it's because our neighbors to the north use fewer illegal drugs and shoot each other less often with guns (though they smoke and drink with gusto, albeit somewhat less than Americans).
Still others think Canadians are healthier because their medical system is tilted more toward primary care doctors and less toward specialists. And some believe it's something more fundamental: a smaller gap between rich and poor.
Perhaps it's all of the above. But there's no arguing the basics.
"By all measures, Canadians' health is better," says Dr. Barbara Starfield, a university distinguished professor at Johns Hopkins Medical Institutions. Canadians "do better on a whole variety of health outcomes," she says, including life expectancy at various ages.
According to a World Health Organization report published in 2003, life expectancy at birth in Canada is 79.8 years, versus 77.3 in the U.S. (Japan's is 81.9.)
"There isn't a single measure in which the U.S. excels in the health arena," says Dr. Stephen Bezruchka, a senior lecturer in the School of Public Health at the University of Washington in Seattle. "We spend half of the world's healthcare bill and we are less healthy than all the other rich countries."
"Fifty-five years ago, we were one of the healthiest countries in the world," Bezruchka continues. "What changed? We have increased the gap between rich and poor. Nothing determines the health of a population [more] than the gap between rich and poor."
Gerald Kominski, associate director of the UCLA Center for Health Policy Research, puts the Canadian comparison this way: "Are they richer? No. Are they doing a better job at the lower end of the income distribution? For lower-income individuals, they are doing a better job."
At a meeting last fall of the American Public Health Assn., Dr. Clyde Hertzman, associate director of the Centre for Health Services and Policy Research at the University of British Columbia in Vancouver, analyzed data showing that Canadian women outlive American women by two years and men, by 2 1/2 years.
During the last quarter-century, he says, all income groups in Canada also showed gains in life expectancy. During much the same period in the U.S., death rates widened between America's rich and poor, according to a 2002 study in the International Journal of Epidemiology by American and Australian researchers.
Infant mortality rates also show striking differences between the U.S. and Canada.
To counter the argument that racial differences play a major role, Hertzman compared infant mortality for all Canadians with that for white Americans between 1970 and 1998. The white U.S. infant mortality rate was roughly six deaths per 1,000 babies, compared with slightly more than five for Canadians.
Maternal mortality shows a substantial gap as well. According to the Paris-based Organisation for Economic Co-operation and Development (OECD), a 30-nation think tank, there were 3.4 maternal deaths for every 100,000 births among Canadians, compared with 9.8 deaths per 100,000 Americans.
And more than half of Canadians with severe mental disorders received treatment, compared with little more than a third of Americans, according to the May-June 2003 issue of Health Affairs.
"The summary of the evidence has to be that national health insurance has improved the health of Canadians and is responsible for some of the longer life expectancy," says Dr. Steffie Woolhandler, an associate professor at Harvard Medical School and staunch advocate of a single-payer system.
Of course, some causes of death, such as homicide, wouldn't be much affected by having a single payer system. And the U.S. has "the highest homicide rate of all the rich countries," says Bezruchka.
"Other things might be differences in seat belt usage," adds Robert Blendon, a professor of health policy and political analysis at the Harvard School of Public Health. "We are also disproportionate consumers of illegal drugs, much more than Canada, so it's cultural."
The health of Americans would be better with universal healthcare, he says.
"But there are some things that a single-payer system wouldn't fix -- but which would leave one country looking healthier in the statistics."
In some respects, the healthcare system is "the tail on the dog," says Dr. Arnie Epstein, chairman of the department of health policy and medicine at the Harvard School of Public Health.
"It's other aspects of the social fabric of different countries that seem to have a major impact on how long people live," he says.
In the U.S., African Americans and Latinos "face problems of housing, stress and low income, which have nothing to do with a single-payer system." Canada has a large number of Asian immigrants, he says, but they, like Asian immigrants in the U.S., tend to do well on healthcare measures.
The bottom line is that Canada is doing something right, even if "the reasons are not totally understood," says Kominski of UCLA.