HINTON, Alberta — When Bryan Keith was diagnosed with prostate cancer three years ago, he underwent a blizzard of tests, specialist consultations, a month of radiation treatment and a surgical procedure.

His out-of-pocket costs? Zero.

“I’ve never had to reach into my wallet for anything other than my health-care card,” said Keith, 71, who is now in remission.

In this picturesque mountain town of about 10,000 people, Keith’s experience is the norm — and the model often cited by Sens. Bernie Sanders and Elizabeth Warren as they promote Medicare-for-all as an antidote to some of the problems afflicting U.S. health-care consumers. During the fifth Democratic debate on Wednesday, Sanders pointed to the lower health care costs paid by Canadians, and vowed to introduce a Canada-style Medicare for all proposal in the first week of his administration.

No one in Hinton’s mostly working-class community agonizes over whether they can afford to see a doctor, or take their child to the emergency room. No one faces bankruptcy, or loses their home, because of medical debt. Most residents of Hinton have had babies delivered, broken bones set and cancer treatments provided without ever seeing a bill.

But there are also drawbacks: Some wait months for knee or hip replacements or to see certain specialists. Most also pay premiums for private insurance to cover prescription drugs and other services not included in their government plan.

As middle-class Americans express growing anger about skyrocketing drug prices and mounting co-pays, premiums and deductibles, the Canadian health-care system has emerged as a shadow player in the 2020 Democratic presidential primary contest — offering a window onto a parallel reality where 37 million people’s health-care needs are largely covered from birth to death.

The stories of real people here in rural Alberta show how the health-care system functions in their daily lives — and underscore Canadians’ deep and widely shared belief that health care is a human right, which helps explain their overwhelmingly positive reviews of the system despite its shortcomings.

By all accounts, Canada’s system, called Medicare, is simpler, more equitable and more consumer-friendly than America’s patchwork of public and private plans that leaves millions without sufficient coverage. Every resident of Canada has guaranteed access to covered benefits through provincial- and territorial-administered public insurance plans — and pays taxes to support that system. There are no premiums, co-pays or deductibles for a broad menu of care that includes doctor visits, emergency care, hospital stays, surgical care, and maternal and newborn services.

Notably, the system is far less generous than what Sanders (I-Vt.) and Warren (D-Mass.) have proposed. Key services that are not part of the public plans (but are part of Sanders’s bill) include prescription drugs and vision, dental and rehabilitation services, with details varying by province. About two-thirds of Canadians also have supplemental private insurance, typically through their employers, to help with those costs and for which they do pay premiums.

Canada’s system has its own headaches, from slower adoption of cutting-edge technology and treatments to long waits to see certain specialists or undergo elective procedures, especially hip and knee replacements and cataract surgery. And Canada is facing some of the same financial pressures bedeviling the United States — especially the snowballing costs of caring for an aging population. A government panel in Alberta concluded this year that the province’s health system is a top contributor to its unsustainable spending.

Nevertheless, residents of rural Hinton give their system high marks, with several recounting complex medical ordeals that cost them nearly nothing out of pocket — but that might have set back American consumers by thousands or tens of thousands of dollars, depending on their coverage.

There was Samantha Ellen Gordon’s premature daughter who needed three surgeries and a nearly six-month hospital stay two years ago, and then the May delivery of her second daughter via emergency Caesarean section. There was Rick Zroback’s eye surgery to remove “floaters,” or spots in his vision, and Morris Archibald’s full hip replacement. And there were Helena Christensen’s C-sections, and multiple emergency room trips with one of her sons, including a three-week hospital stay for pneumonia.

“I would have never been able to have three kids in America because I needed all C-sections,” Christensen said. “I like the freedom that you can go to the doctor and not worry about the cost.”

While taking comfort — and pride — in their system’s universal coverage, Hinton residents also acknowledge concerns, chief among them the delays to see specialists or to undergo certain types of non-emergency surgeries.

Morris Archibald, 66, a retired forester, waited nearly a year for his hip replacement. He said he could not walk a block, and he grew depressed because he could not participate in the outdoor sports he loves and that are his main pastime. “It got to the point where we worried about his state of mind,” Jodi Archibald said.

The couple even explored having the surgery in the United States but abandoned that idea after discovering that it would cost tens of thousands of dollars.

Despite that experience, Morris Archibald said he would never trade his Canadian health care for U.S. health insurance. “I still think our system is far superior,” he said.

Archibald’s wait is hardly unique: Thirty-nine percent of Canadians reported waiting at least two months to see a specialist, a JAMA analysis of 2016 data found, compared with 6 percent of Americans. The United States also has more specialists as a percentage of its total health workforce.

Those waits cost Canadians $2.1 billion in lost wages in 2018, with average wait times about 20 weeks from referral to receipt of treatment — 113 percent longer than in 1993, according to studies this year by the conservative Fraser Institute, a public policy think tank in Canada.

“Meekly accepting excessive wait times as the price of a functioning health care system in Canada is the exact opposite of what we should be doing,” the Toronto Sun editorialized after the studies were released.

Even so, Canada has better health outcomes than the United States while spending far less on care. Canadians’ life expectancy is 82 on average — more than three years longer than Americans’, according to a 2019 report from the Organization for Economic Cooperation and Development (OECD) based on 2017 data. It also boasts a far lower rate of deaths from treatable causes, at 59 per 100,000 residents, compared with 88 per 100,000 residents in the United States. The infant mortality rate in Canada is 4.5 per 1,000 live births, compared with the U.S. rate of 5.8.

'Every patient is a paying patient'

Canada’s experience also defies the notion that a single-payer system would disrupt America’s already shaky rural health system. In fact, Canada’s rural hospitals appear to struggle far less than their U.S. counterparts, more than 100 of which have closed since 2010.

“In a single-payer system, every patient is a paying patient,” said Michael Green, one of the editors of the Canadian Journal of Rural Medicine and head of the department of family medicine at Queen’s University.

Hospitals’ budgets, staffing and equipment in Canada are set by provincial governments, which make those decisions based on a community’s size and needs, rather than on whether a hospital can bring in enough revenue from private and public insurance to keep its doors open, as in this country. Rural hospitals occasionally close, but it’s usually because of challenges in recruiting doctors to far-flung towns or because a facility has low occupancy rates that no longer justify the cost of keeping it open. Hospitals are also susceptible to national or provincial budgetary woes — several rural hospitals closed in the 1990s in Saskatchewan as a result of a recession — but politicians typically face fierce pressure from constituents to protect their health-care services.

By comparison, “rural health care in the U.S. is a train wreck,” said Lee Green, chair of the department of family medicine at the University of Alberta, who was a professor at the University of Michigan for 26 years. “Single-payer would be the best thing that ever happened to rural hospitals and rural family doctors in America — not to mention the patients.”

The tax levels that sustain the Canadian system at the federal level aren’t that different from those in the United States. The United States on average collected $14,794 in taxes from each of its citizens in 2015, while Canada collected $13,771, according to the OECD. Direct comparisons of U.S. and Canadian tax rates are difficult because it is unclear what portion goes into health care, which is administered in both countries by the federal government as well as state or provincial governments, and taxes differ by state, province and city.

Nonetheless, grafting Canada’s system onto American soil would be difficult for a gamut of cultural, economic and political reasons.

Alberta leans conservative in Canadian politics, for instance, but the idea of health care as a human right is widely shared. A 2016 poll found that 87 percent of Canadians ranked health care as a top federal priority, and a majority said they would like to see the federal government increase its involvement.

“I really don’t understand why some people feel more entitled to health care than other people,” said Keith, the cancer survivor.

Contrast that consensus with attitudes in the United States, where the very notion of government responsibility for health care is divisive. “More than eight-in-ten Democrats and Democratic-leaning independents (85%) say this responsibility falls to the federal government,” according to a 2018 national survey by the Pew Research Center. “About two-thirds of Republicans and Republican leaners (68%) say it does not.”

The Canadian system is also far better able to rein in costs because of its emphasis on primary care rather than on specialists, or on complex and costly procedures — an approach unlikely to be accepted in the United States. The government also sets payment rates for hospitals and doctors, most of whom are private, and negotiates drug prices directly with manufacturers. In the United States, by contrast, entrenched and powerful industry groups oppose government price-setting — and are already mobilizing against the plans advanced by Sanders and Warren.

'We did not pay a single penny'

All of those factors help shape the care delivered by this community’s sole hospital, the Hinton Healthcare Center, a modest brick building that sits less than two miles down a winding road from the town’s pulp mill, past rolling green hills and snow-capped mountain ranges. Many of its patients are working class — employed by the pulp mill, one of two local coal mines, or the oil and gas industry.

Hinton is too small to justify the cost of most specialists, so like most rural hospitals, the center relies on family doctors like Andrea Rahn, who can be a pediatrician, general practitioner, obstetrician and emergency room physician, sometimes all in the same day.

The community has four family doctors who deliver babies — and three of them, including Rahn, also do obstetric surgery. Two have extra training in anesthesia, so they handle all of the anesthesia for the hospital’s surgeries. And two staff the hospital’s cancer clinic and provide chemotherapy services in conjunction with an oncologist in Edmonton, Alberta’s capital, about a three-hour drive away.

The health center is also one of Canada’s few rural hospitals with a CT scan, which serves those in neighboring communities as well.

An MRI bus visits town about once a month, and various specialists come through every four to six weeks. Hinton doctors also use telemedicine to quickly get help from specialists if they need it, like the time a neonatologist in Edmonton was on TV providing instructions on how to treat a premature baby. In August, a visiting orthopedic surgeon was in town for two days to perform procedures and consult with patients.

About half of Canada’s doctors are family doctors, compared with about a third in the United States, according to the Commonwealth Fund. Most are private and get paid for every procedure or office visit. Several of the country’s medical programs have rural tracks, where students train as family doctors in rural settings and can receive additional training in other specialties so they can handle anything that comes through the hospital’s doors.

Rahn got such an opportunity May 28. She was finishing up clinic visits when she got a call from Gordon, 27, who was days away from a scheduled C-section. “Pain, pain, pain” were the only words Rahn could understand.

Rahn knew, based on Gordon’s medical history, that her uterus had probably ruptured. She and 20 other doctors, nurses and technicians met Gordon at the hospital and performed an emergency C-section. The baby, Annie, wasn’t breathing when they delivered her. They performed CPR and chest compressions, gave her a blood transfusion, and began a cooling treatment for infants who do not have enough oxygen at birth. After nearly five hours, Gordon and Annie were stable enough to be flown by air ambulance to Edmonton for more specialized treatment.

“That was the first time I’ve done that surgery,” Rahn said of performing a C-section on a woman with a ruptured uterus.

Gordon had traumatic deliveries for both her daughters. The first, Amelia, was born April 5, 2017, 17 weeks premature, weighing 1 pound and 3 ounces, and had a twin brother who didn’t survive.

Amelia spent the next 168 days in Edmonton’s neonatal intensive-care unit. Gordon and her fiance, now a heavy-duty mechanic at the town’s pulp mill, had no out-of-pocket medical costs for her care, or for Annie’s. But his costs driving three hours to and from Edmonton every weekend and buying meals at the hospital added up over several months. The Hinton community organized a fundraiser for them and brought in $8,000.

Today, Amelia is a rambunctious toddler who can’t stay still. She and Annie have visits with specialists every few months to make sure they’re developing normally.

“Even with the fundraiser, we still had debt from gas and food,” Gordon said. “As far as care, we did not pay a single penny.”

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