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What’s at risk for Canada in the American health-care war?

Dr. Danielle Martin, MD, is vice-president medical affairs and health-system solutions at Women's College Hospital in Toronto and an expert with Evidence Network. Dr. Sandro Galea is the Robert A Knox professor and dean of the Boston University School of Public Health.

America is facing a growing threat to the health of its citizens. Last week, the U.S. House of Representatives voted to pass the American Health Care Act (AHCA). If the bill becomes law, it could leave millions in the U.S. without health care. And it could have an impact in Canada, too – but not for the reasons you might expect.

Why is the issue of health care in the U.S. so fraught? And is Canada immune to the social whiplash under way just south of us? As physicians observing from both sides of the border, we see two key reasons why this issue continues to polarize opinion in the U.S. But it is ultimately trade policy, not health policy, that will put Canadian medicare in the cross hairs.

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First, unlike Canadians, Americans have not yet come to view health care as an expression of core national values, deserving of protection as a fundamental right of citizenship. In Canada, there is no serious doubt about whether or not the country should continue to have universal health coverage. Rather, the debate is mostly centred around how to expand public financing to broaden coverage (for example, to include prescription medicines and home care on a universal basis), and how to improve systems of delivery to make care better and reduce wait times. This is because the choice to offer universal health coverage is central to the Canadian identity.

For Canadians, health care arose from a national determination to take care of each other during times of need. But the U.S. is still actively wrestling with the question of what it means to offer health care to citizens, and where health care fits in the country's values system.

Second, the U.S. lacks a structural component that has been at the core of Canadian health care for decades – the federal requirement to provide insurance for all necessary doctor and hospital services, sustained through a single payer that guarantees coverage for essential services. In the U.S., there has been no such federal legislative push, and little talk of bringing health care under the umbrella of a single, accountable and democratically supported vision. The existing health-care law, the Affordable Care Act (ACA), is a patchwork of legislative compromises and deals struck between interest groups, administered by many different stakeholders. While the legislative architecture of Canadian health care has unified the system under the Canada Health Act and buffered it from multiple challenges, the more ad-hoc nature of the ACA has left it vulnerable to the type of existential threat it now faces from the Republican Congress.

Until Americans decide that health care is a right that should be supported by the federal government as an extension of national values, and resolve to create a legislative structure with teeth to support that vision, the health-care debate cannot be resolved because it is not grounded in any public consensus.

But Canadians should not feel smug. Not only are internal challenges an ongoing threat to Medicare, the ripples of the Trump administration are soon to be felt north of the border, and will test the resolve of Canadian governments.

What does Trump's agenda mean for Canadian health care? Other than driving doctors to activism that might even send them north across the border, threats to the Canadian system as a result of the Trump agenda relate less to the repeal of Obamacare and more to his intention to renegotiate NAFTA.

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Canadian health care has explicitly been protected under NAFTA, shielding the system from American industry that would otherwise bring not just "American style" health care, but actual American health care across the border. If strong provisions that exclude health care from free trade are not maintained, and in fact strengthened, in any renegotiated trade agreement, American insurance companies and health-care delivery organizations could claim the right to a Canadian private health-care "market." As private insurers stand poised to lose market share in the U.S. with the "repeal and replace" gambit, hunger for access to a new market is sure to grow.

Canadian governments and citizens need to remember that, not far from here, health-care insurance is a good that is sold in the marketplace like softwood lumber.

If the health-care battle and the free-trade battle intersect at the Canada-U.S. border, Canadians may become more than interested observers of the Trump presidency.

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