Embed Size (px)
Citation preview
U.S. Newspaper Coverage of the Canadian Health System – A Case of Seriously Mistaken Identity?
Pauline M. Vaillancourt Rosenau
School of Public Health; the University of Texas - Houston P.O. Box 20186; Houston, Texas 77225 USA
[email protected]; Telephone: 713 500 9491
Prepared for Presentation at the World Congress of the International Political Science Association – Fukuoka Japan, 10 July 2006
and To be published in the American Review of Canadian Studies
Submitted: 15 December 2005 Revise: 31 May 2006
Abstract
This study assesses the fairness, accuracy, and comprehensiveness of U.S.
newspaper coverage of the Canadian health system in two influential U.S. newspapers. Quantitative methods, interpretative assessments, and thematic analyses are employed to evaluate coverage of the Canadian health system between 2000 and 2005. Fifty articles from The New York Times and the Wall Street Journal met strict criteria for inclusion. Information from these articles is reviewed for accuracy and compared to published, peer-reviewed research. U.S. newspaper reporting on the topic of the Canadian health system is found to be poor. Points of misinformation are indicated, misrepresentations are specified, and inadequate explanations are denoted. The non-obvious, latent content of newspaper coverage is examined and omissions are identified. Explanations for these surprising results are considered.
Overall, ongoing themes and controversial issues regarding the Canadian health
system receive almost as much notice in U.S. newspapers as actual news events. Anecdotal information plays nearly as great a role in coverage as facts and evidence. U.S. newspaper reports about the Canadian health system are found to be oversimplified. For example, U.S. journalists presume that the Canadian health system is unitary and federally determined. In fact, the Canadian health system remains a work-in-progress between the federal and provincial governments. Information, all too often, is presented out of context and sources are not always sufficiently identified. Coverage is incomplete: all provinces are underrepresented in the U.S. newspapers studied, except Ontario. The full story about why Canadians go to the U.S. for health services is rarely explained. Some articles are confused and a few were found to contain errors. The Canadian health system is often said to be socialist or left wing in U.S. newspaper articles. This leads to confusion because the Canadian health system is not socialist by any generally accepted dictionary definition of this term. Canadian hospitals are largely private, not-for-profit and doctors are paid a fee-for-service (piece-rate) rather than according to a socialist form of compensation. These inadequacies in newspaper coverage mean that the U.S. public is sadly misinformed with regard to the Canadian health system.
1
U.S. Newspaper Coverage of the Canadian Health System – A Case of
Seriously Mistaken Identity?1
Canada’s health system is an important reflection of its values, principles, and its
overall national character. It is said to be a “key distinguishing characteristic” of the
country according to a Canadian Senate report in September 2001 (Crossette 2001). By
most expert and unbiased assessments, Canada’s health system is among the most cost-
effective and high quality in the world today (Anderson and Hussey 2001; Anderson et
al. 2003; Hussey et al. 2004; United Nations Development Programme 2001; Mathers et
al. 2000). Canada pays less and delivers more services per capita than does the U.S.
(Romanow 2002 see for a summary). By almost any criterion employed it is a striking
success. Its citizens live longer and are healthier than those of the U.S. where health care
costs much more (Anderson et al. 2005; Central Intelligence Agency 2005). Experts
suggest that Canada could well serve as an example for the ongoing U.S. health system
reform (Deber 2003). Of course, Canada faces challenges in the organization and
financing of its health system as is the case with all industrialized countries. Many
Canadians are involved in the debates surrounding these issues. While critical of some
aspects of their health system, in general, Canadians remain highly supportive of it. In
2001, 84% of Canadians preferred their own system to that of the U.S. (Mendelsohn
2002).
The part that newspapers play in public opinion formation is complex and
difficult to determine, but it is likely that they influence a country’s national image
1 I would like to thank Tara R. Sklar, MPH candidate, Research Assistant on this project, for her help. Her competence was impressive and her skills much appreciated.
2
(Strouse 1975). There is good reason to believe that, to some extent, the media influences
how individual citizens of other countries, world political elites, decision-makers, and
corporate investing institutions come to view Canada. Those in the general population are
even more likely to be influenced by the press and opinion leaders because they do not
hold strong and stable opinions about the Canadian health system and they have no
personal experience with it (Zaller 1992; Iyengar 1991). There is evidence that
newspapers shape citizens’ perceptions and opinions by cueing the coverage and by their
“choices of language and perspective through which a story is presented to the public”
(Shah et al. 2002; Soderlund et al. 1980). The details journalists select for their articles
subtly construct reality and thereby influence readers.
While it is true that U.S. newspaper readership has declined slightly over the last
several decades, it still remains the case that the better educated are more likely to read a
newspaper than are the less educated (Hagan 2005; Bonfadelli 2005; Tichenor, Donohue,
and Olien 1970). Those with more education are likely to play a disproportionate role in
formulating policy; they are likely to influence others, for example in the “two-step flow”
of public opinion leadership (Strouse 1975).
Historically, U.S. citizens have had a very high and positive opinion of Canada
and its health system, but this may be changing. In 1985 close to 80% of Americans
rated Canada as “highly favorable” (Gallup 1985). There is substantial variation over
time: 83% of Americans had favorable views of Canada in 2002. This fell to 65% in
2003 but moved back up to 76% in 2005 (Pew Global Attitudes Project 2005). In the
early 1990s a substantial majority of Americans preferred the Canadian health system to
their own, but this has declined since that time (Wirthlin Group 1995; Blendon 1988).
3
The goal here is to examine how U.S. newspapers portray the Canadian health
system. Research suggests that the Canadian health system constitutes about 10% of the
Canada-related stories in four U.S. newspapers sampled in mid-2004 (Belch 2004). But
is this news coverage fair, accurate, and complete? Are U.S. citizens fully and fairly
informed about the strengths and weaknesses of the Canadian health system? These are
important questions, particularly if Canada’s national image in the U.S. is related – even
in some small part – to the U.S. newspaper coverage of the Canadian health system.
Methods
To assess U.S. newspaper coverage of the Canadian health system a computerized
bibliographic search of The New York Times (NYT) and the Wall Street Journal (WSJ)
was undertaken for the period of January 1, 2000 through mid-June 2005. These two
major national newspapers were chosen because they are among the top three in the U.S.
in terms of circulation, and because both have a reputation for reliable, accurate
journalism.2 Together these two newspapers offer political balance: The New York Times
is viewed as more supportive of liberal views and of the Democratic Party; while the
Wall Street Journal is more conservative3. LexisNexis Academic Universe’s online
archives of the Wall Street Journal and the New York Times was used to obtain full-text
articles employing the below-mentioned indexed terms in combination with the word
“Canada:” health care, health system, health policy, medicare, hospital, doctor, and
physician. The time period was chosen to assure a fair and unbiased assessment of recent
news coverage of the Canadian health system in these two newspapers.
2 USA Today has the largest circulation but many of its copies are given away rather than purchased. 3 In fact this is largely true of only the editorial pages (Groseclose and Milyo 2005).
4
Only articles with a minimum of 500 words were retained for a complete reading
and assessment. The rationale for the 500 word minimum was that an article would have
to be of substantial depth and length to be significant in forming public opinion.
Furthermore, if the Canadian health system did not play an important role in an article,
then it was not retained for analysis. For example, an article entitled “Spending Doesn’t
Give U.S. Edge on Health Care” had only a few lines about Canada because Australia,
England, and New Zealand were also considered (5/5/2004 WSJ). In another case an
article entitled “Private Doctors in Frantic Quest for Flu Vaccine” (10/21/2004 NYT),
was excluded because it was largely about the U.S. health system. Articles about U.S. re-
importation of pharmaceuticals from Canada were excluded if they did not, at least
indirectly, make reference to the Canadian health system. A few articles about Canadian
elections were also excluded as they referred to the Canadian health system as an election
issue only in passing, without any substantive discussion of these issues. However an
article entitled “Health Care Leads Other Issues on Canada Vote” (5/17/2004 NYT) was
included because it gave considerable details of the candidates’ views of the health
system. Because the goal of this research was to determine if U.S. news reporting was
fair, letters to the editor, opinion essays, commentaries, and obituaries were excluded4 .
Much of the research for this article is quantitative, based on a simple count of
characteristics of the articles. Qualitative methodologies were also utilized, such as those
proposed by Peter Goldschmidt’s “Information Synthesis,” to guide the analysis of these
4 Wall Street Journal editorials and opinion pieces about the Canadian health system were largely negative McArthur, “ Canadian Medicine Isn’t Cheap or Effective” 1/28/2000; Matthews, “On a Bus to Bangor, Canadians Seeking Health Care” 7/5/2002; and Lemieux, “Canada’s ‘Free’ Health Care Has Hidden Costs” 4/23/2004, are examples. The New York Times editorials and opinion pieces were more mixed with Krugman’s “The Medical Money Pit” 4/15/2005 not atypical in its criticism of the U.S. health system and its underperformance compared to that of Canada.
5
newspaper articles. Goldschmidt includes specific research steps to define the topic, to
gather relevant information for studying the topic, to assess the validity of the
information, and to present the results (Goldschmidt 1986). This research project follows
these guidelines: a thorough database search of the two newspapers, comparison of the
newspaper coverage with the information about the Canadian health system in peer
reviewed journals, and the presentation of findings. In addition, efforts were made to
uncover what was left out of newspaper coverage as well as to characterize what was
actually published (Dixon-Woods et al. 2005).
The qualitative methodology used here is also interpretive (Noblit and Hare
1988). The articles in the database were obtained, chronicled, and appraised to produce
narrative summaries and thematic analyses. Prominent or recurrent themes were
identified. Accuracy and adequacy of U.S. newspaper coverage is based on how closely a
newspaper article about the Canadian health systems aligns with established knowledge
as evidenced in published, peer-reviewed journals.
Automatic, computerized content analysis was considered as a methodology but it
was set aside.5 The diversity of topics covered in the newspaper articles would make the
“systematic application of rules,” required by this technique, almost impossible. In
addition, the coding strategies that computerized systems of automatic content analysis
employ often miss topics or themes (Shah et al. 2002). They cannot be programmed to
reveal the “nonevents” or “news selectivity” aspects of coverage that constitute a
dimension of this study (Fishman 1980, pp. 76-77).
5 Hamlet, Intext/TexQuest, TextSmart and NUS*IST are examples.
6
Characterizing U.S. Coverage of the Canadian Health System
Examining five and one-half years of newspaper coverage yielded 38 New York
Times articles and 12 Wall Street Journal articles that met the above outlined criteria for
inclusion – i.e. substantive consideration of information about the Canadian health
system. U.S. newspaper coverage of the Canadian health system can be described on
several dimensions including: i) the proportion of news events versus ongoing theme
stories, ii) the role of evidence versus anecdote, iii) the incidence of
oversimplification/omission, iv) the appearance of material taken out-of-context, v) the
presence of incomplete information due to the exclusion of essential details, vi) the
degree to which reporting leads to confusion or factual errors.
News Events or Ongoing Themes in U.S. Newspaper Coverage
Newspaper articles published during any time period depend, to a certain degree,
on the editor and individual journalist’s judgment as to what is important and
newsworthy (Brindle 1999, p. 40). The stages involved in the news production process
have been described as follows: detect occurrences, interpret the event, investigate the
factual circumstances, and assemble the story (Fishman 1980). Whether a news story is
covered or not also depends on whether an event is judged to be of interest to the
newspapers’ readers. But in addition, editors and journalists have considerable discretion
and may choose to cover non-event-related topics that are controversial in nature.
A descriptive timeline of newspaper coverage of the Canadian health system
points to real world events that The New York Times and the Wall Street Journal covered:
demonstrations protesting the privatization in Alberta (May 9, 2000), the E. coli
contamination of the public water supply in Walkerton, Ontario (May 30), patent
7
problems about antibiotics to treat Anthrax in case of a terrorist attack (Oct, 19,2001), the
Romanow Commission’s report (November 29, 2002), the SARS outbreak (April -June
2003), increased federal funding of health services (September 17, 2004), health care as
an issue in a specific election (May 2004), suspension of the sale of a medication that was
linked to serious side effects (February 12, 2005), lab mistakes (April 14, 2005), and the
Supreme Court of Canada’s decision to permit the sale of private health insurance
policies to cover services provided by the public system (June 13, 2005).
There are articles published about the Canadian health system in U.S. newspapers
that are not actually news. News is usually defined as event-relevant or episodic (about
an episode that has recently occurred or an event that is currently taking place). News
“events” are assumed to be self-evident and to “exist independently of their knower”
(Fishman 1980, p. 31). These “political or disaster news” beats are considered harder
work by most journalists (Gans 2003, p. 23). Fifty-four percent of the articles in this
database were event-related. But forty-six percent of these articles, all of substantial
length published about the Canadian health system between 2000 and 2005, were “soft
news” -- discretionary, about ongoing themes or controversial issues (Williams 1999;
Gans 2003). This type of newspaper coverage plays an unexpectedly important role in
what is published in U.S. newspapers about the Canadian health system.
(Table 1 about here).
For unspecified reasons, editors or journalists sometimes choose theme-related
and controversial issues for their articles. Perhaps they believe the themes will interest
the public and are likely to sell newspapers (Rossides 2003; Hamilton 2004). Such topics
also conveniently provide stories that can be used to fill newspaper column space during
8
periods when there are no news events (Tuchman 1978). Often these types of stories
come “through established ‘news nets’ or ‘beat rounds’ that connect journalists to sources
who are affiliated with business, government, bureaucracies, or other social groups that
subsidize the preparation of news” (Sumpter and Braddock 2002, p. 541; Fishman 1980;
Berkowitz and Beach 1993). These relationships seem to be a mix of trust and distrust,
cooperation and manipulation (Schudson 2003, Chapter 7). If affiliated sources prove to
be dependable dispensers of information, reporters pick them more frequently while
winnowing out those who are less dependable. “Sources that survive this elimination
process thus accumulate more power to determine what will be news”(Sumpter and
Braddock 2002 p.541; see also: Soloski 1989; Berkowitz and Beach 1993; Grabe, Zhou,
and Barnett 1999; Gans 1979; Sacco 1995; Hansen et al. 1994; Ramsey 1999; Ericson
1998; Brown et al. 1987). Institutional sources, “trade press, the specialist weeklies or
monthlies, and tip-offs from readers” are also sources used by journalists to gather
information (Brindle 1999, p. 42).
How and why a journalist chooses a specific controversial topic for reporting has
received little attention. A topic may be chosen because the journalist’s editor is known
to be very interested in it (Johnson 1998, p. 89). Economic incentives are important too
(Hamilton 2004). The need for a newspaper to make a profit means that a news
operation is vulnerable to influence by advertisers (Schudson 2003) (McManus 1994).
Certainly the general commercialization of medical research has an impact on why some
topics are chosen for coverage (Winsten 1985). This type of topic provides an
opportunity to leak negative information about one’s competitors or overly positive
information about one’s own product, research, or procedure.
9
Choice of a specific topic for a news story is sometimes the result of what
journalists identify as a bias toward passive news rather than active news. Passive news
is defined as “news that is brought to the journalists,” by public relations departments of
private companies, government departments, universities, etc. It depends entirely on
what the sources want to make public. The risk with passive news is that the newspapers
end up as a mere publicist for their sources (Gans 2003).
Research in Britain found that some journalists see themselves as watchdogs for
the public and this is another incentive for choosing discretionary topics for newspaper
articles. The same may be true in the U.S. where motivation for writing about a thematic
topic include the journalist’s desire to “scrutinize the activities of health-care providers
and to report on the availability and effects of treatments.” Some journalists develop a
sense of “ownership” about a specific theme and end up campaigning for it. Examples
include more services in a geographical area or more funds for a local hospital. A
journalist’s values shape the choices he or she makes regarding which theme topics to
cover and which to avoid. It is these values that influence whom they consult as a source
and what they write in their article. “Their perceptions of the motives, credibility, and
public authority of information sources are likely to favour some over others” (Entwistle
and Sheldon 1999, p. 124).
In the case of the Canadian health care system, such thematic topics covered in
U.S. newspapers included: waiting lines for treatment, jumping cues for care,
privatization of health care, doctor shortages, Canadian doctors moving to the U.S.,
Canada encouraging doctors from developing countries to move to Canada, patients
traveling from Canada to the U.S. for health services, easing medical marijuana use,
10
ongoing problems with paying for universal health care coverage, importing prescription
drugs from Canada to the U.S., etc. (see Table 1).
Sources of inspiration for such stories could well be in line with those indicated in
the literature and reviewed above. Almost all the discretionary themes covered in this
study reflect what one journalist describes as “the constant stream of people dissatisfied,
and very often angry, with the treatment they have received from public services”
(Brindle 1999, p. 43). This fact may leave newspaper readers with the mistaken
impression that the majority of Canadians are fundamentally dissatisfied with their health
system; however this is not the case (McMurray 2004).
The Role of Anecdotal Information
Anecdotal information plays a large role in U.S. coverage of the Canadian health
system. U.S. newspaper reports of public debates and policy decisions concerning the
health system in Canada are heavily dependent on anecdotal information rather than
studies with verified findings. Approximately 42% of the articles in The New York Times
and 50% of those in the Wall Street Journal included anecdotal information about the
Canadian health system.
Anecdotal stories about individuals and their real world experiences attract the
public’s interest and are included in many newspaper articles. Readers enjoy these
articles because human interest stories present a person with whom we can identify and
something concrete to which we can relate (Tuchman 1978 p. 47-48). Newspapers are
said to be “better at telling an individual story rather than providing meaningful social
analysis” and this accounts, in part, for the prevalence of anecdotal material in the
newspaper coverage. Journalists believe that anecdotes improve the publics
11
understanding and the readability of news articles. When presenting these stories, as Platt
suggests, there seems to be a “compelling need to keep things simple, to keep the story
line straight, if for no other reasons than that this is what the reader wants. For those who
deal in straightforward heroes and villains – the deserving and undeserving – there is no
dilemma here. For those who would try to represent nuance and complexity, it is much
more of a problem” (1999, p. 116).
In coverage of any health system there is always a danger that exceptions -- those
who fall through the cracks or those who are miraculously cured -- will receive
disproportionate attention in the press. Where anecdotal information is merely
illustrative and where its purpose is to increase reader interest, then scientific accuracy
and ethical standards are not compromised. However, when proof-of-point rests solely
on anecdotal information, there is a risk of bias and serious error. The methodological
flaw results from the possibility that the case presented is not typical.
Anecdotal interviews with Canadian citizens who are unhappy with the Canadian
health system play an important role in The New York Times and the Wall Street
Journal’s coverage. Sometimes isolated cases of medical error are presented as routine in
U.S. newspaper stories, and the reader is left with the impression that such errors are
widely tolerated in Canada. Of the non-SARS related newspaper articles that used
anecdotal information in our study (17 articles), about half employed this type of
coverage. The plight of those who fall through the cracks is clearly a tragedy. While such
cases should not be excused, it seems odd that such injustices should be presented as
frequent, typical, and widely tolerated.
It may be the nature of news media to conclude that if Canada’s health system is
12
working well and routinely delivers care to the vast majority of that country’s population,
it is not a “news story.” Ted Marmor’s study of how U.S. newspapers covered
emergency room congestion in U.S. and Canadian hospitals during the flu epidemic in
1999 illustrates this point. He suggests that standards were not fairly applied to both the
U.S. and Canada. He points out that while emergency room overcrowding was
mentioned in reports about both the U.S. and Canada, only in the case of Canada did
newspapers indicate that the health system was collapsing. He concludes that U.S.
journalists tend to look for a shocking anecdote and then assume that it is a general
principle (Marmor 2000a).
In the end, while anecdotal information plays an exaggerated role relative to
evidence, facts, and scholarly knowledge in many U.S. newspaper articles about the
Canadian health system, this does not mean that evidence is entirely ignored. Of the 22
articles that mentioned an anecdote, only eight made no reference at all to sound
evidence. Many articles, then, are a mix of the two.
Historically the function of news media has been to educate and inform. Where
this function is based on anecdote rather than evidence, as is often the case with thematic
articles about the Canadian health system, U.S. newspapers are doing a poor job of
educating their readers. Their coverage is not of the typical or representative case or
about routine problems; rather it functions to make the exception appear to be the rule.
Oversimplification and Omission
There is broad oversimplification involved in U.S. news coverage to the effect
that the Canadian health system is portrayed as a national single payer system, dominated
by the Canadian Federal government. It is generally presented by U.S. newspapers as a
13
unified system without much province-to-province variation. The importance of local
and provincial input is scarcely mentioned. The differences between various provinces,
especially as regards their relationship with the federal government, are almost never
discussed (Krauss 2004a). Or, the provinces are viewed as simply administering the
federally organized health system (see for an example, Krauss 2004b), much like the
relationship between the U.S. federal government and the states.
Scholars generally acknowledge that the Canadian provincial governments are
much more powerful than the U.S. states vis-à-vis the U.S. federal government (Cameron
and Simeon 2002; Bakvis and Skogstad 2003; Rocher and Smith 2003), but only a few
journalists covering the Canadian health system appear to know that this is the case
(Wessel 2004; Crossette 2001 are examples). Those U.S. journalists who are aware of
the enormous power of Canadian provinces are in the minority. Scholars, however,
agree: “By constitutional dictate, Canadian provinces are dominant in the administration
of social policies, including health insurance” (Marmor 2004, p. 53). At present,
Canadian federalism in the health sector is an amalgam of 10 health systems with
substantial variations between the provinces and territories. As testimony to this point,
Canadian provinces can be observed to regularly defy the authority of the Canadian
federal government in the health insurance sector (Derfel 2005). In the end Canada’s
health system is complex; federal and provincial government relationships are constantly
changing.
The medicare agreement signed in Ottawa at the September 15th, 2004 First
Ministers’ Conference between the provinces and the federal government in Canada
illustrates the power of the provinces. It included special separate arrangements for
14
Quebec. The possibility of individual provincial-federal arrangements is thus, formally
recognized, and may be extended in the future to other provinces (Globe and Mail 9-17-
2004). While The New York Times covered this conference, no mention was made in its
coverage of the precedent-creating nature of the agreement, “Asymetrical Federalism that
Respects Quebec’s Jurisdiction,” or the importance of this aspect (First Ministers of
Canada 2005). U.S. newspaper readers should have been informed of this agreement
because federal-provincial flexibility makes the Canadian example more relevant to
successful U.S. health system reform. Canada’s achievements in federal-provincial
health sector relations are not fully recognized and communicated in U.S. newspapers.
The Canadian health system is complex and a legal maze even for Canadians;
therefore it is no surprise if U.S. news reports are sometimes oversimplified. Recent
polls suggest that many Canadians (70%) believe that they should be able to buy services
outside the public health system. The fact is that they can already do so in many
provinces. Canadian federal law does not prohibit purchase of services from doctors who
opt-out of the public system. The same poll, however, indicated that 57% of Canadians
would be happy to see a ban on private health insurance (Ipsos-Reid 2005; Kennedy
2005). The contradiction is indicative of the confusion and complexity of the health
system itself.
One of the problems with U.S. newspaper coverage is that the health system in
Canada is not only complicated, it is also very different from that of the U.S. Too often
U.S. journalists appear to interpret what they observe in the Canadian health system
based on what they know best and are familiar with –their own U.S. health system. This
leads to oversimplification and to misunderstanding.
15
It is certainly unrealistic to expect that journalists can be experts in all the fields
they have to cover, however, such expertise is exactly what is commonly assumed
(Hargreaves 2003). In reality, “journalists have a very difficult time evaluating complex,
major programs (such as Canada’s medicare) through particular stories” (Marmor 2000b,
p.85). Marmor proposes that newspaper journalists covering Canada are stretched too
far. They try to cover too broad a spectrum of topics because they must cover everything
that happens in Canada from immigrants to gun control to beer production. As a result,
they do not have the requisite knowledge or background experience necessary to probe
beneath the surface of events and provide fair coverage of the health system in all its
complexity (Marmor 2000a).
Out of Context
U.S. newspaper coverage is often incomplete because information about the
Canadian health system is not presented in the context of other Western industrialized
countries. Coverage is isolated from context and, because of this, reports are often
misinterpreted. For example, while, wait times in Canada may be an enormous problem,
the fact that they are much the same throughout Europe is not mentioned (Hurst and
Siciliani 2003). The U.S. press also fails to indicate that patients with life-threatening
conditions receive treatment immediately and are not put on wait lists
(www.health.gov.on.ca.). This is not to say that medical errors do not occur and that
patients do not die while waiting for care. Such tragedies occur in Canada as they do in
the U.S. and other countries.6
6 Between 5,000 and 18,000 deaths of U.S. residents between the ages of 25 and 64 are attributable to a lack of health insurance annually (Institute of Medicine 2004; Hadley 2003).
16
Another example of providing information about the Canadian health system out
of context involves privatization as a solution to waiting lists. There is an implied
assumption in several newspaper articles (Beltrame 2000; Brooke 2000) that if Canada
permitted more private sector participation in its health system, then waiting for care
would be reduced. In the U.S., wait times for service for insured patients or those who
pay privately are lower than in Canada.7 However, U.S. newspapers fail to discuss how
the introduction of a private sector negatively affects hospital wait times, even though
such effects are well-documented. Experiments in Canada, New Zealand, Belgium,
Australia, and the Netherlands indicate that introducing a private sector increases the
waiting time for those who remain in the public sector (Sanmartin et al. 2000). If
Canadian policy makers hesitate to introduce a private sector, it may be because they are
aware of the results of this research (Fishman 1980; Besley and al 1998; Duckett 2005;
Hughes and al 2004).
U.S. newspaper coverage is taken out of context, as well, when Canadian-based
information sources -- Think Tanks for example -- are not adequately identified and their
intellectual orientation is not provided. U.S. readers have a difficult time assessing the
fairness and objectivity of the data reported and the analysis provided without some
description of Canadian-based information sources. For example, several articles quote
representatives and studies undertaken by the Vancouver-based “Fraser Institute” which
favors market solutions to health system problems, privatization, and the establishment of
a U.S. type health system in Canada. The Fraser Institute is a source for the conclusion in
many U.S. newspaper articles that the Canadian health system is in “decay” (Beltrame
2000), and that the crisis is deepening (Krauss 2004b). The Fraser Institute’s board of 7 This is not the case for those without health insurance in the U.S. or those who are unable to pay.
17
directors is largely private sector and includes representation from the Canadian branches
of large U.S. companies including the U.S. pharmaceutical industry studies.8 Its research
reports argue that the Canadian health system is “breaking down badly” and that its
performance is inferior to that of most other OECD countries (O'Grady 2004). However,
a wide range of independent health policy researchers and peer reviewed journal articles
disagree with these conclusions, but this research is seldom consulted or quoted by the
Fraser Institute.9 Therefore when newspapers consult a source, it is important for readers
to understand the context of that source. Otherwise the information provided will be
taken-out of context and likely misinterpreted.
Incomplete: Essential Information Is Left Out
In the newspaper articles examined here, it was apparent that U.S. coverage
favored certain geographical areas of Canada and neglected others. U.S. press coverage is
incomplete because French-speaking Quebec and several other provinces are often left
out. Ontario received much more coverage in U.S. newspapers than all the other
provinces put together. In the five-year period studied, 38% percent of all of the
newspaper articles published focused on the Ontario health system (19 articles). Alberta,
British Columbia, and Quebec were each the focus of one article. But the remaining
provinces and territories were not the central topic of any article. The majority of the
articles (28) had a national focus.
8 In 1999, the Fraser Institute was attacked by health professionals and scientists for sponsoring two conferences on the tobacco industry entitled "Junk Science, Junk Policy? Managing Risk and Regulation" and "Should government butt out? The pros and cons of tobacco regulation.” Critics argued that the Institute was associating itself with the tobacco industry's many attempts to discredit authentic scientific work. 9 Up-to-date information about health outcomes is widely available to journalists and Think Tanks by the Treasury Board of Canada in its Annual report to Parliament (Treasury Board of Canada: Secretariat 2005).
18
The reason for the incomplete coverage of so many provinces was not entirely the
responsibility of the U.S. newspapers. In fact, the majority of the event-related articles
focused on Ontario simply because it was the geographical location of the breaking news
that had to be reported: the Walkerton, Ontario water supply contamination and the
SARS outbreak that hit Toronto harder than any other city in Canada. However, this
said, Ontario was also the focus selected for many discretionary articles about thematic
topics and responsibility for this lies with newspaper editors and journalists who cover
the Canadian health system.
The incomplete coverage of Quebec in U.S. newspapers is an especially serious
problem. Only one article was primarily about Quebec in the five and one-half years of
newspaper coverage analyzed here. It did receive passing mention in 18% of the 50
articles that qualified for inclusion in this study. However, it is surprising that this
percentage was not greater because Quebec’s health system is quite different from that of
the other provinces. It has its own public drug plan and a comprehensive childcare
program while other provinces are less generous in these areas. Quebec’s success in
controlling costs contributes to the overall high performance of the Canadian health
system compared to other countries as regards cost (Barer, Lomas, and Sanmartin 1996;
Armstrong and Armstrong 1999). An article in the Wall Street Journal suggested that
Alberta was the leader in Canada regarding privatization and the integration of a private
sector into the provincial health system, despite federal government opposition (Beltrame
2000). In fact, privatization in Quebec has gone much further than in Alberta or any of
the other provinces. Quebec’s provincial government publicly supports privatization.
Ninety-one doctors in Quebec have opted out of medicare and practice exclusively in the
19
private sector. Only two more provinces have done this in all the rest of Canada (Derfel
2005). Quebec had the first private emergency clinic in Canada (Krauss 2004a; Yaffe
2005). There are 15 private radiation clinics in Quebec (Derfel 2005). But most of this
information about Quebec escaped notice in The New York Times and the Wall Street
Journal.
Adding content about Quebec back in to newspaper coverage contributes to
making the picture of the Canadian health system more complex, but it also makes the
picture more complete. So why is coverage of Quebec neglected by U.S. newspapers?
First, little is available in English about Quebec which is Canada’s only French province.
U.S. journalists may have a hard time building up a network of long term contacts and
trusted sources in English Canada but the task is even greater for them when it comes to
Quebec, where both language and cultural differences come into play. Second, many
U.S. newspaper reporters covering Canada may not be fluent enough to undertake
interviews or read what is published about the Quebec health system in French.10
Newspaper coverage of waiting times in Canada is another topic that is often
misunderstood because it is presented in an incomplete manner and essential information
is simply left out. Almost all newspaper articles included in this study failed to mention
important facts required for an adequate understanding of Canada’s waiting lists. For
example, “one way hospitals restrain costs is by trying to always run at capacity. It’s
more efficient to run a hospital that way just as its more efficient to fly an airplane with
every seat filled” (Cherney 2003). Only one article described the efforts in any of the
Canadian provinces to co-ordinate or centralize waiting times and treat patients in nearby
10 Even in English speaking Canada, geographical coverage presents a challenge, especially for smaller U.S. newspapers. Few of even the larger newspapers have bureaus outside of Toronto and Ottawa.
20
geographical areas where there are no waiting list for services (Cherney 2003). No article
discussed the Western Canada Waiting List Project that produces quantifiable criteria for
establishing the optimal time for treatment for cataract surgery, general surgery, hip/knee
joint replacement, and MRI scanning (www.wcwl.ca/tools/). Nor have these newspapers
reported on the efforts by the Health Council of Canada to establish benchmarks for
waiting times, to require clear case prioritization, to encourage inter-provincial
management of waiting lists, or to implement ongoing audits of waiting lists (Health
Council of Canada 2005, 2005). Additionally, the efforts of the Canadian Medical
Association’s “Wait Time Alliance” (www.cma.ca) have never been the subject of a
report in these two major newspapers (Eggertson 2005).
One New York Times article (Krauss 2004a, in this case) presents waiting lists as a
national problem when in fact, they are a provincial responsibility. Waiting times vary
widely by province with some provinces pursuing successful strategies for managing
waiting times and others not (Treasury Board of Canada, 2005). Statistics are kept by
individual treatment facilities and by providers in most cases “so no one can say how
many people in the country—or even in one province – are waiting for a given
procedure” (Canadian Health Services Research Foundation 2005a, p. 1). Each
provincial government has public information about wait times and policies on its web
page. In Ontario, detailed data is published and policies explained: “cardiac procedures
and cancer surgeries take place within days or weeks, while it usually takes months for
elective surgeries such as for cataracts or hip and knee” (Ontario Ministry of Health
2005).
21
Another case where coverage of the Canadian health system in U.S. newspapers is
incomplete involves Canadians going to the U.S. for health services. Without full
information this behavior is commonly misinterpreted. U.S. journalists observe that
Canadians are obtaining treatment for cancer in the U.S.11 This is almost always reported
to be because these services are not available in Canada or waiting lists are too long in
Canada (Brooke 2000). Such is presented as testimony to the fact that Canada cannot
provide health care for its citizens (Beltrame 2000; Krauss 2003).
It is almost always left out of these newspaper articles that health services in the
U.S. are sometimes purchased by Canadian provinces for Canadians under direct
contractual arrangements because it is cost effective. In these cases, Canadian provinces
purchase surplus U.S. health services at hospitals located just across the border for their
citizens. These services come at a lower price than what it would cost the province to set
up and outfit a clinic to provide such services in Canada for such excess, often temporary,
demand. Two articles in the database misunderstood the Canadian provinces’ “make
versus buy” assessments, concluding that healthcare services in the U.S. cost these
provinces more than it would have cost to provide the services in Canada. The journalists
offered a patient-for-patient price comparison as evidence for their point. However, if the
number of patients sent to the U.S. is small, then building a new facility to treat them in
Canada would have been very expensive. Sending the surplus patients to the U.S., after
already-existing Canadian capacity was reached, made good economic sense. The
existence of surplus capacity in U.S. hospitals along the Canada-U.S. border meant the
provinces were in a strong negotiating position vis-à-vis the U.S. providers. The “buy”
11 There is no doubt some Canadians do seek services in the US rather than wait but empirical studies of the phenomenon report that the number is small compared to the number of Americans who seek free health care in the U.S. (Katz et al. 2002).
22
decision was a shrewd choice on the part of Canadian policy makers, yet very few U.S.
journalists understood and explained this to their U.S. readers.
Confusion and Error
U.S. newspaper coverage of the Canadian health system is confused for several
reasons. Most of the time, the articles in the Wall Street Journal and The New York
Times did not make any reference to the political orientation of the Canadian health
system. However, at least one quarter of the U.S. newspaper articles about the Canadian
health system indicated that it is “leftist” or socialist. A socialist system could be
expected to finance the health care of its citizens largely from public funds. Using this
criterion, Canada is quite centrist when viewed in the context of the industrialized
countries. Seventy percent of health spending comes from the public sector in Canada
(Economist 2004). This is a lower percentage than Australia, Denmark, France, Germany,
and Britain (Anderson et al. 2003). The U.S. is the outlier because only 45% of each
health care dollar in the U.S. comes from public money.
If the Canadian health system were to qualify as authentically socialist under the
common definition of the term, health system personnel (including doctors) would have
to be government employees and hospitals would have to be owned by the government.
The Oxford English Online Dictionary defines socialism as “a theory or policy of social
organization which aims at or advocates the ownership and control of the means of
production, capital, land, property, etc., by the community as a whole, and their
administration or distribution in the interests of all.” In the case of the Canadian health
system very few Canadian doctors work for the government. Most doctors in all of the
provinces in 2003 in Canada were paid largely on a fee-for-service basis, as individual
23
entrepreneurs to some extent. This is a form of “piece work” payment. Doctors are paid
according to how much work they do, how many patients they see, and how many
procedures they perform (Naylor 1986). Less than 10% of Canadian doctors are paid a
salary by the government (Martin 2003).
Canadian hospitals are largely private-nonprofit rather than private-for-profit, but
this form of ownership does not qualify as a socialist form of ownership. Ninety-five
percent of acute care hospitals in Canada are in the not-for-profit, private sector. This
means that they are owned by community groups, religious organizations, or lay
organizations (Canadian Health Services Research Foundation 2005b). Historically,
many mental health care hospitals and military hospitals were owned by local and
provincial governments (Tully and Saint-Pierre 1997), but most are being transformed
into independently-governed institutions (Armstrong 2005).
The private sector’s role in the Canadian health system is asserted as unimportant
in many U.S. newspaper articles. In fact, the role of the private sector in the Canadian
health system is substantial and the delivery of medical care is predominantly private
(Bodenheimer and Grumbach 2005, p. 143). The problem is that many U.S. journalists
fail to take into account that the private sector can be non-profit. U.S. journalists often
mistakenly view the private, non-profit hospital sector in Canada as “government” owned
or public because it is nonprofit. Private, non-profit hospitals do not pay dividends to
stockholders or list shares for purchase on the stock exchanges, but they are still a private
form of ownership.
Another inaccuracy in the U.S. press coverage has to do with the assumption that
Canadians would like to trade their health system for the U.S. health system or that they
24
would never recommend the Canadian health system to those in the U.S. (Brooke 2000
and Beltrame 2000, are examples). While Canadians are critical of their own health
system, it would be a mistake to interpret this criticism as an approval of their country
adopting a U.S. style health system (Brooke 2000); there is simply no evidence to support
that claim. In 2000/2001, Statistics Canada found that only 13% of Canadians reported
unmet health care needs (Romanow 2002, p. 20). Sixty-one percent of Canadians are
“‘very’ or ‘somewhat’ satisfied with the availability of affordable healthcare” in their
country while only 27% of U.S. residents answer the same with regard to their health
system (McMurray 2004). If anything, the situation is likely to be the reverse of what
U.S. journalists assume: “substantially more Americans feel very positively about the
Canadian healthcare (49%) system than about the U.S. healthcare system” (34%) (Taylor
2004).
Discussion and Conclusions
This research finds that U.S. newspaper reporting on the topic of the Canadian
health system in The New York Times and the Wall Street Journal is poor. The complex
reality of the Canadian health system would be better understood in the U.S. if coverage
were fairer, more accurate, more complete, and not so often a source of confusion,
oversimplification, omission, and error. Reporting is subjective and issue-oriented as
much as it is event-related, “hard news.” The problem with the observed discretionary
news coverage is that it reinforces preconceived, often mistaken ideas about the Canadian
health system and does little to correct commonly held misconceptions. Heavy reliance
on anecdotal information means that sophisticated social analysis, fine distinctions, and
subtle differences are overlooked. Substantial gaps in knowledge were observed in this
25
sampling of U.S. newspaper coverage adding to the confusion and misrepresentation
surrounding the Canadian health system.
These findings are surprising because the newspapers studied are among the more
highly respected in the U.S. today. The period of time analyzed extended over five years
and the fifty articles assessed were substantial in length and importance. Each article was
signed by the journalist who wrote it, indicating that these journalists were satisfied with
their work and wished to receive credit for it. Opinion pieces and editorials were not
included in the database therefore the articles considered were purportedly objective in
nature.
This study is not the first to find U.S. newspaper coverage inadequate; several
general-level explanations are offered as to why this is the case. Some of these accounts
may apply to this study of coverage of the Canadian health system, though almost all of
them are too general to test directly. Some explanations claim that newspapers, as with
the media in general, are structured to protect the status quo (Tuchman 1978). Others
emphasize that journalists manage public symbols and actually construct events in light
of American values (Gans 1979). Journalists’ values are thought to “influence their
decisions about whether or not to report particular events, who to approach or use as
sources, and how to package different viewpoints.” Their “perceptions of the motives,
credibility and public authority of information sources are likely to favour some over
others” (Entwistle and Sheldon 1999 p. 124). More recently, scholars have pointed out
that the need for newspapers to make a profit and to assure that the stock price increases
may influence coverage and jeopardize objectivity.
26
While no argument is made here that U.S. newspapers consciously distort their
reports of the Canadian health system, it is important to seek more specific explanations
as to why U.S. coverage is inadequate. Journalists depend on expert sources and they
must work with these informants if they are covering a specific topic on an ongoing basis.
They become indebted, to some degree, to those sources they consult (Rossides, 2003
p.170). In the case of Canada’s health system, U.S. journalists may not have the network
they need within Canada to get both sides of each story. For this reason alone they may
be overly dependent on a U.S. based network for information about the Canadian topics
they cover. This means that coverage unconsciously incorporates the previously
preconceived expectations of U.S. sources regarding the Canadian health system.
Marmor argues, “American interest groups provide a spur to critical stories, and
the richest of such groups overwhelmingly want to attack the Canadian model…. To the
extent these North American interest groups bring stories and documentation to the press,
the media’s commitment to evenhandedness actually undermines a balanced view of
/Canadian/ medicare” (2000b, p. 85-6). Highly reputable individuals such as Timothy
Johnson, MD, Medical Editor for ABC for three decades and editor of the Harvard
Medical School Health Letter, supports Marmor’s controversial contention that those in
the field of health and medicine in the U.S. use the media for their own commercial
advantage to the point of “secretiveness and even a cutthroat mentality. They encourage
stories about the faults of their competition…. that prompts blatant attempts to
manipulate the media....” (Johnson 1998. p. 89).
Overall, it would be a serious mistake to dismiss the problematic coverage of the
Canadian health system as unimportant. Public opinion may not blindly follow the press
27
but it is highly likely that the public is influenced by the press. While evidence is not
unequivocal (Golding 1999), several studies indicate that beliefs, attitudes, and
perceptions are shaped by the media (Philo and Secker 1999, Chapter 8). Media sources
are powerful because they sway how people think and behave (Adams 1997; Maclure et
al. 1998; Grilli et al. 1998). Newspapers promote specific policy-related issues that
would otherwise not receive much attention from the public and from policy-makers
(Muncie 1999). They do, in some cases, have a decisive impact on policy, setting policy
agendas (Baumgartner and Jones 1993; Kingdon 1995) and shaping government action
(Jordan 1999). In the case of the Canadian health system, coverage leaves much to be
desired. Newspaper coverage may be misleading the U.S. public as well as policy-
makers. This should be a matter of interest and concern on both sides of the 49th parallel.
This study is not without limitations. Results cannot be generalized to all other
U.S. newspapers; they apply only to those studied for the period of time sampled. No
evidence is presented here that U.S. news paper coverage is better or worse than
Canadian newspaper coverage. Finally, no evidence is presented here about how U.S.
newspapers cover the U.S. health system. These topics are reserved for future study.
28
Table 1: Prevalence of Themes and Controversial Issues12
Waiting Lines for treatment 13 Importing prescription drugs from Canada to the U.S. 6
Privatization of health care 11 Canada’s easing medical marijuana use 2 Ongoing problems paying for universal health care coverage in Canada
14
Luring doctors from developing countries to Canada / recruiting abroad
2
Jumping waiting lines for health care by affluent and connected 3 Canadians traveling to the U.S. for health care treatment 6
Canadians opting out of free government health care & using email w/doctors to save time
1
Overflowing Emergency Rooms 6 Doctor shortages / too few specialists 7 Canadian doctors moving to U.S. 3 Health care funding cuts 4 Medical technology shortages and slow adoption of technology 6 De-listed health services 2 Means testing of Rx benefits 2 U. S. manufacturers are at a disadvantage because they pay for health services
1
Canadian doctors against public health insurance 3 Canadian health system is losing public confidence 5 Canadian family doctors are working shorter hours 2
TOTAL 99
12 Many articles mentioned more than one theme or topic. This accounts for the fact that the counts are greater than the total number of articles.
29
Appendix
Articles from The New York Times and Wall Street Journal that met the criteria for inclusion in this study
Altman, Lawrence K. "The Doctor's World; Behind the Mask, the Fear of Sars." The New York Times, June 24 2003, 1.
Altman, Lawrence K. "The Sars Epidemic: Canada; Health Officials Seek Help from Us to Control Virus." The New York Times, April 23 2003, 6.
Altman, Lawrence K. "The Sars Epidemic: The Scientists; Canadian Strain of Virus Appears to Be Stronger Than the U.S. Variety." The New York Times, April 25 2003, 21.
Altman, Lawrence K. "The Sars Epidemic: The Scientists; More Sars Cases Are Reported; Virus Found to Persist in Patients." The New York Times, May 2 2003, 1.
Altman, Lawrence K., and Marc Santora. "Risk from Deadly Flu Strain Is Called Low." The New York Times, April 14 2005, 16.
Beltrame, Julian. "To Ease Crises in Heath Care, Canadians Eye Private Sector." Wall Street Journal, April 10 2000, 1.
Bradsher, Keith, and Colin Campbell. "New Travel Alert Is Issued for Toronto, but a Glimmer of Success for Hong Kong." The New York Times, May 24 2003, 6.
Brooke, James. "A Crossroads in Canadian Health Care." The New York Times, May 9 2000, 9.
Brooke, James. "Few Left Untouched after Deadly E Coli Flows through an Ontario Town's Water." The New York Times, July 10 2000.
Brooke, James. "Full Hospitals Make Canadians Wait and Look South." The New York Times, January 16 2000, 3.
Carey, Benedict. "Therapists Question Canadian's Move on Drug." The New York Times, February 12 2005, 13.
Carlise, Tamsin. "Synsorb's Experimental E Coli Drug Gains Notice During Canada Outbreak." Wall Street Journal, May 30 2000, 8.
Catto, Susan. "Feel under the Weather in Canada? Log on for an Electronic House Call." The New York Times, October 25 2000.
Cherney, Elena. "For-Profit Center to Treat Cancer Splits Canadians." Wall Street Journal, May 29 2001, 1,4.
Cherney, Elena. "Life Lines: Universal Care Has a Big Price: Patients Wait." Wall Street Journal, November 12 2003, 1.
Cherney, Elena. "New Disease Curbs Visits to Toronto Hospitals." Wall Street Journal 2003, April 3, 3D.
30
Cherney, Elena. "New Virus Caught Toronto Off Guard." Wall Street Journal, April 8 2003, 8.
Cherney, Elena. "Privatization Effort of Ontario Premier Comes under Fire." Walll Street Journal, July 7 2000.
Crossette, Barbara. "Canada's Health Care Shows Strains." The New York Times, October 11 2001, 12.
De Palma, Anthony. "Canadians Lean Towards Easing Marijuana Laws." The New York Times, June 17 2001, 4.
Gross, Daniel. "Economic View; Whose Problem Is Health Care?" The New York Times, February 8 2004, 6.
Harmon, Amy, and Robert Pear. "A Nation Challenged: The Treatment; Canada Overrides Patient for Cipro to Treat Anthrax." The New York Times, October 19 2001, 1.
Heinzl, Mark."In Canada, a Critical Test of Sars." Wall Street Journal, April 2 2003, 12.
Heinzl, Mark, and Chistopher Chipello. "Shock Treatment for Canadian Health Care." Wall Street Journal, June 13 2005, 3.
Krauss, Clifford. "15 New Cases of Pneumonia near Toronto May Be Sars." The New York Times, June 10 2003, 13.
Krauss, Clifford. "Canada's Health Care System Needs More Money, Panel Says." The New York Times, November 29 2002, 27.
Krauss, Clifford. "Canada Agrees to Increase Spending on Its Health Care." The New York Times, September 17 2004, 13.
Krauss, Clifford. "Canada Looks for Ways to Fix Its Health Care System." The New York Times, September 12 2004, 3.
Krauss, Clifford. "Canada to Screen Airline Passengers for Respiratory Ailment." The New York Times, March 29 2003, 6.
Krauss, Clifford. "Disease Has Canada Doubting Its Leaders." The New York Times, April 19 2003, 6.
Krauss, Clifford. "A Doctor-Lawyer-Gadfly V. Canada's Medical System." The New York Times, May 21 2005, 4.
Krauss, Clifford "Going Global at a Small-Town Canadian Drugstore." The New York Times, March 6 2005, 4.
Krauss, Clifford "Health Care Leads Other Issues in Canadian Vote." The New York Times, May 17 2004, 6.
Krauss, Clifford. "Ill Americans Seek Marijuana Relief in Canada." The New York Times, September 8 2002, 4.
Krauss, Clifford. "In Canada, Ottawa Sneezes and the Provinces Catch Cold." The New York Times, April 16 2004, 10.
31
Krauss, Clifford. "Long Lines Mar Canada's Low-Cost Health Care." The New York Times, February 13 2003, 3.
Krauss, Clifford. "The Sars Epidemic: The Overview; Travelers Urged to Avoid Toronto Because of Sars." The New York Times, April 24 2003, 1.
Krauss, Clifford. "The Sars Epidemic: Canada; Toronto Is Stricken from Warning List Issued by W.H.O." The New York Times, May 15 2003, 18.
Krauss, Clifford. "The Sars Epidemic: Canada; Toronto Official Seek End to Travel Advisory." The New York Times, April 29 2003, 12.
Krauss, Clifford. "The Sars Epidemic: Precautions; Toronto, Hard Hit by Mystery Illness, Warily Celebrates Easter." The New York Times, April 21 2003, 9.
Krauss, Clifford. "The Sars Epidemic: Toronto; Now Waning, Illness Takes Political Toll in Canada." The New York Times, May 1 2003, 10.
Krauss, Clifford. "Toronto Again Listed as City with Spreading Sars Cases." The New York Times, May 27 2003, 10.
Krauss, Clifford. "Windsor Journal; Doctors Eying the U.S.: Canada Is Sick About It." The New York Times, October 17 2003, 4.
Medina, Jennifer. "A Canada Connection for Drugs." The New York Times, January 16 2005, 5.
O'Grady, Mary. "In Canadian Health Care Some Are More Equal Than Others." Wall Street Journal, May 21 2004, 11.
Simon, Bernard. "Big Sales of Cut-Rate Drugs from Canada." The New York Times, October 30 2003, 1.
Simon, Bernard. "International Business; Canadian Pharmacy Regulators Seek to Stop Exports." The New York Times, November 15 2003, 4.
Spors, Kelly. "Canadian Drugs Are Getting Cheaper." Wall Street Journal, July 22 2004, 1.
Swarns, Rachel. "West Lures Its Doctors; South Africa Fights Back." The New York Times, February 11 2001, 15.
Wessel, David. "North of the Border: Different Systems, Same Drugs Concerns." Wall Street Journal, August 26, 2004, 2.
32
References
Adams, Chris. 1997. At Northstar Health, CEO's Come and Go, but Problems Endure - A Tiny Company is Plagued by Bickering Boards, Accounting Irregularities - The Links to Bedford Falls. Wall Street Journal, June 20, A1 & A10.
Anderson, Gerard F., and Peter S. Hussey. 2001. Comparing Health System Performance in OECD Countries. Health Affairs 20 (3):219-232.
Anderson, Gerard F., Peter S. Hussey, Bianc K. Frogner, and Hugh R. Waters. 2005. Health Spending in the United States and the Rest of the Industrialized World. Health Affairs 24 (4):903-914.
Anderson, Gerard F., Uwe E. Reinhardt, Peter S. Hussey, and Varduhi Petrosyan. 2003. It's the Prices, Stupid: Why the United States Is So Different from Other Countries. Health Affairs 22 (3):89-105.
Armstrong, Hugh. 2005. Hospitals In Canada. Houston, August 18, 2005 12:07 p.m.
Armstrong, Patricia, and Hugh Armstrong. 1999. Decentralised Health Care in Canada. British Medical Journal 318:1201-1204.
Bakvis, Herman, and Grace Skogstad. 2003. Canadian Federalism: Performance, Effectiveness, and Legitimacy. Edited by H. Bakvis and G. Skogstad. London: Oxford University Press.
Barer, Morris L., Jonathan Lomas, and Claudia Sanmartin. 1996. Re-Minding our Ps and Qs; Medical Cost Controls in Canada. Health Affairs 15 (2):216-234.
Baumgartner, Frank, and Bryan D. Jones. 1993. Agenda and Instability in American Politics. Chicago: University of Chicago Press.
Belch, Christopher. 2004. A View from Abroad: An Analysis of Canadian Coverage in U.S. Newspapers, Political Science, University of Windsor, Windsor Ontario.
Beltrame, Julian. 2000. To Ease Crises in Heath Care, Canadians Eye Private Sector. Wall Street Journal, April 10, 1.
Berkowitz, Dan, and Douglas Beach. 1993. News Sources and News Context: The Effect of Routine News, Conflict and Proximity. Journalism Quarterly 70:4-12.
Besley, T, and et al. 1998. Public and Private Health Insurance in the UK. European Economic Review 42 (3-5):491-97.
Blendon, Robert. 2005. Attitudes to, Satisfaction with, and Access to Health Care Services [Electronic Source]. Louis Harris and Associates for Harvard School of Public Health, July 2005 1988 [cited June 14 2005]. Available from http://www.ropercenter.uconn.edu/cgi-bin/hsrun.exe/Roperweb/HPOLL/StateId/CbiZIutjhJKYbBHNcD1jWm8rZYCJy-Vr_p/HAHTpage/Summary_Link?qstn_id=198404
33
Bodenheimer, Thomas, and Kevin Grumbach. 2005. Understanding Health Policy: A Clinical Approach. fourth edition ed. New York: Lange Medical Books/ McGraw-Hill.
Bonfadelli, Heinz. 2005. Mass Media and Biotechnology: Knowledge Gaps Within and Between European Countries. International Journal of Public Opinion Research 17 (1):42-62.
Brindle, David. 1999. Media Coverage of Social Policy: A Journalist's Perspective. In Social Policy, the Media and Misrepresentation, edited by B. Franklin. London: Routledge.
Brooke, James. 2000. Full Hospitals Make Canadians Wait and Look South. The New York Times, January 16, 3.
Brown, Jane Delano, Carl R. Bybee, Stanley T. Wearden, and Dulice Murdock Straughan. 1987. Invisible Power: Newspaper News Sources and the Limits of Diversity. Journalism Quarterly 64 (Spring):45-54.
Cameron, David, and Richard Simeon. 2002. Intergovernmental Relations in Canada: The Emergence of Collaborative Federalism. Publius 32 (2):49-74.
Canadian Health Services Research Foundation. 2005a. Myth: A Parallel Private System Would Reduce Waiting Times in the Public System. CHSRF 2005 [cited 2005]. Available from www.chsrf.ca; http://www.chsrf.ca/mythbusters/index_e.php
Canadian Health Services Research Foundation. 2005b. Myth: Canada Has A Communist-Style Healthcare System [Electronic Source]. Canadian Health Services Research Foundation 2005 [cited 2005]. Available from www.chsrf.ca http://www.chsrf.ca/mythbusters/index_e.php.
Central Intelligence Agency. 2005. The World Factbook: 2005. Vol. 2005. Dulles, VA 20166: Potomac Books.
Cherney, Elena. 2003. Life Lines: Universal Care has a Big Price: Patients Wait. Wall Street Journal, November 12, 1.
Crossette, Barbara. 2001. Canada's Health Care Shows Strains. The New York Times, October 11, 12.
Deber, Raisa Berlin. 2003. Health Care Reform: Lessons from Canada. American Journal of Public Health 93 (1):20-24.
Derfel, Aaron. 2005. Private Health Care Isn't A Canadian Reality. Gazette, June 19, 2005, IN2.
Dixon-Woods, Mary, Shona Agarwal, David Jones, Bridget Young, and Alex Sutton. 2005. Synthesising Qualitative and Quantitative Evidence: A Review of Possible Methods. Journal of Health Services Research Policy 10 (1):45-53b.
Duckett, SJ. 2005. Private Care and Public Waiting. Australian Health Review 29 (1):87-93.
Economist. 2004. Anatomy Lesson: How Health-Care Services are Financed. The Economist.
34
Eggertson, Lauara. 2005. Wait Time Alliance First to Set Benchmarks. Canadian Economic Observer 172 (10):1277.
Entwistle, Vikki, and Trevor Sheldon. 1999. The Picture of Health? Media Coverage of the Health Service. In Social Policy, the Media and Misrepresentation, edited by B. Franklin. London: Routledge.
Ericson, Richard V. 1998. How Journalists Visualize Fact. The Annals of The American Academy of Political and Social Science 560:83-95.
First Ministers of Canada. 2005. Asymetrical Federalism that Respects Quebec’s Jurisdiction (September 16). Office of the Prime Minister of Canada 2005 [cited September 9 2005]. Available from http://pm.gc.ca/eng/news.asp?id=260
Fishman, Mark. 1980. Manufacturing the News. Austin: University of Texas Press.
Gallup. 2005. U.S. and Asia: Changing American Perceptions [Electronic Resource]. Gallup Organization 1985 [cited June 14 2005]. Available from http://www.lexis-nexis.com/universe.
Gans, Herbert J. 1979. Deciding What's News: A Study of CBS Evening News, NBC Nightly News, Newsweek, and Time. New York: Vintage.
Gans, Herbert J. 2003. Democracy and the News. New York, NY: Oxford University Press.
Golding, Peter. 1999. Thinking the Unthinkable: Welfare Reform and the Media. In Social Policy, the Media and Misrepresentation, edited by B. Franklin. London: Routledge.
Goldschmidt, Peter G. 1986. Information Synthesis: A Practical Guide. Health Services Research 21 (2, Part 1):215-237.
Grabe, Maria E., Shuhua Zhou, and Brooke Barnett. 1999. Sourcing and Reporting in News Magazine Programs: 60 Minutes Versus Hard Copy. Journalim and Mass Communication Quarterly 76:293-311.
Grilli, R., N Freemantle, S Minozzi, G. Domenighetti, and D. Finer. 1998. Impact of Mass Media on Health Services Utilisation. In The Cochrane Library. Oxford: Update Software.
Groseclose, Tim, and Jeff Milyo. 2005. A Measure of Media Bias. Quarterly Journal of Economics 120 (4).
Hadley, Jack. 2003. Sicker and Poorer -- The Consequences of Being Uninsured; A Review of the Research on the Relationship between Health Insurance, Medical Care Use, Health, Work, and Income. Medical Care Research and Review 60 (2):3S -75S.
Hagan, Joe. 2005. Circulation Continues to Decline at Most Major Newspapers. Wall Street Journal, November 8, B7.
Hamilton, James T. 2004. All the News that's Fit to Sell: How the Market Transforms Information into News. Princeton, NJ: Princeton University Press.
35
Hansen, Kathleen A, Jean Ward, Joan L. Conners, and Mark Neuzil. 1994. Local Breaking News: Sources, Technology, and News Routines. Journalism Quarterly 71:561-72.
Hargreaves, Ian. 2003. Journalism: Truth or Dare? New York, NY: Oxford University Press.
Health Council of Canada. 2005. 10 Steps to a Common Framework for Reporting on Wait Times [internet]. Health Council of Canada 2005 [cited December 11 2005]. Available from www.healthcouncilcanada.ca; http://hcc-ccs.com/index.aspx.
Health Council of Canada. 2005. A Background note on Benchmarks for Wait Time [internet], November 14, 2005 2005 [cited December 11 2005]. Available from http://hcc-ccs.com/index.aspx.
Hughes, Tuohy C, and et al. 2004. How Does Private Financing Affect Public Health Care Systems? Marshalling the Evidence from OECD Nations. Journal of Health Politics, Policy and Law 29 (3):359-96.
Hurst, Jeremy, and Luigi Siciliani. 2003. Tackling Excessive Waiting Times for Elective Surgery: A Comparison of Policies in Twelve OECD Countries. Paris, France: Directorate For Employment, Labour and Social Affairs.
Hussey, Peter S., Gerard F. Anderson, Robin Osborn, Colin Feek, Vivienne McLaughlin, John Millar, and Arnold Epstein. 2004. How Does the Quality of Care Compare in Five. Health Affairs 23 (3):89-99.
Institute of Medicine. 2004. Insuring America's Health: Principles and Recommendations: The National Academies Press.
Ipsos-Reid. Canadians React to Supreme Court Healthcare Ruling. Canada West Newspapers & Global TV, June 18 2005 [cited.
Iyengar, Shanto. 1991. Is Anyone Responsible? How Television Frames Political Issues. Chicago: University of Chicago Press.
Johnson, Timothy. 1998. Shattuck Lecture -- Medicine and the Media. New England Journal of Medicine 339 (2):87-92.
Jordan, William. 1999. Bulger, 'Back to Basics' and the Rediscovery of Community. In Social Policy, the Media and Misrepresentation, edited by B. Franklin. London: Routledge.
Katz, Steven J., Karen Cardiff, Marina Pascali, Morris L. Barer, and Robert G. Evans. 2002. Phantoms In the Snow: Canadians' Use of Health Care Services in the United States. Health Affairs 21 (3):19-31.
Kennedy, Mark. 2005. Canadians of Two Minds When it Comes to Health Care. Gazette (Montreal), June 18.
Kingdon, John W. 1995. Agendas, Alternatives and Public Policies. 2nd ed: Addison-Wesley Longman.
Krauss, Clifford. 2003. Long Lines Mar Canada's Low-Cost Health Care. The New York Times, February 13, 3.
36
Krauss, Clifford. 2004a. Canada Agrees to Increase Spending on Its Health Care. The New York Times, September 17, 13.
Krauss, Clifford. 2004b. Health Care Leads Other Issues in Canadian Vote. The New York Times, May 17, 6.
Maclure, M., C. Dormuth, T. Naumann, J. McCormack, R. Rangno, C. Whiteside, and J.M. Wright. 1998. Influences of Educational Interventions and Adverse News About Calcium Channel Blockers on First Line Prescribing of Antihypertensive Drugs to Elderly People in British Columbia. Lancet 352:943-948.
Marmor, Theodore R. 2000a. Canada's Burning; Media Myths about Universal Health Coverage. Washington Monthly July/August 2000:1-5.
Marmor, Theodore R. 2000b. Fact & Fiction: The Medicare Crisis Seen From the US. HealthCare Papers 1 (3):82-86.
Marmor, Theodore R. 2004. Fads In Medical Care Management and Policy. London: The Nuffield Trust for research and Policy Studies in Health Services.
Martin, Shelley. 2003. Fee-for-Service v. Salary: The Debate is Heating Up. Canadian Medical Association Journal 169 (7):701.
Mathers, C.D., R. Sadana, J. A. Salomon, C. J. L. Murray, and A.D. Lopez. 2000. Estimates of DALE for 191 Countries: Methods and Results. Geneva: World Health Organization; Global Programme on Health Policy.
McManus, John H. 1994. Market Driven Journalism: Let the Citizen Beware? Thousand Oaks, CA: Sage Publications.
McMurray, Coleen. 2005. U.S. Trails Canada, Britain, in Healthcare Ratings (June 8, 2004). The Gallup Organization, Princeton, NJ, Load-Date June 15, 2004 2004 [cited October 5 2005]. Available from http://poll.gallup.com/content/default.aspx?ci=11899&pg=1.
Mendelsohn, Matthew. 2002. Canadians' Thoughts on Their Health Care System: Preserving the Canadian Model Through Innovation: Queen's University.
Muncie, John. 1999. Exorcising Demons: Media, Politics and Criminal Justice. In Social Policy, the Media and Misrepresentation, edited by B. Franklin. London: Routledge.
Naylor, CD. 1986. Private Practice, Public Payment: McGill-Queen's University Press.
Noblit, GW, and RD Hare. 1988. Meta-ethnography: Synthesising Qualitative Studies. Newbury Park, CA: Sage.
O'Grady, Mary. 2004. In Canadian Health Care Some are More Equal than Others. Wall Street Journal, May 21, 11.
Ontario Ministry of Health. 2005. Myths about Wait Times [internet]. Ontario Ministry of Health, 05/31/2005 2005 [cited Sept 15 2005]. Available from http://www.health.gov.on.ca/transformation/wait_times/wt_myths.html
37
Pew Global Attitudes Project. 2005. 16-Country Global Attitudes Report Released June 23, 2005. Pew Research Center 2005 [cited September 8 2005]. Available from http://pewglobal.org/reports/pdf/247canada.pdf
Philo, Greg, and Jenny Secker. 1999. Media and Mental Health. In Social Policy, the Media and Misrepresentation, edited by B. Franklin. London: Routledge.
Platt, Steve. 1999. Home Truths: Media Representations of Homelessness. In Social Policy, the Media and Misrepresentation, edited by B. Franklin. London: Routledge.
Ramsey, Shirley. 1999. A Benchmark Study of Elaboration and Sourcing in Science Stories for Eight American Newspapers. Journalism and Mass Communication Quarterly 76 (Spring):87-98.
Rocher, Francois, and Miriam Smith. 2003. The Four Dimensions of Canadian Federalism. In New Trends in Canadian Federalism, edited by F. Rocher and M. Smith. Orchard Park, NY: Broadview Press.
Romanow, Roy J. 2002. Building on Values: The Future of Health Care in Canada - Final Report. 1 vols. Saskatoon, Canada: Commission on the Future of Health Care in Canada.
Rossides, Daniel W. 2003. Communication, Media, and American Society: A Critical Introduction. New York: Rowman & Littlefield Publishers, Inc.
Sacco, Vincent F. 1995. Media Construction of Crime. The Annals of the American Academy of Political and Social Science 539 (May):141-54.
Sanmartin, Claudia, Samuel Shott, Morris L. Barer, Sam Sheps, Steven Lewis, and Paul McDonald. 2000. Waiting for Medical Services in Canada: Lots of Heat, but Little Light. Canadian Medical Association Journal 162:1305.
Schudson, Micheal. 2003. The Sociology of News. Edited by J. C. Alexander. New York, NY: W.W. Norton & Company, Inc.
Shah, Dhavan V., Mark D. Watts, David Domke, and David P. Fan. 2002. News Framing And Cueing of Issue Regimes: Explaining Clinton's Public Approval In Spite of Scandal. Public Opinion Quarterly 66 (3):339-370.
Soderlund, Walter, Ronald H. Wagenberg, E. Donald Briggs, and Ralph C. Nelson. 1980. Regional and Linguistic Agenda-Setting in Canada: A Study of Newspaper Coverage of Issues Affecting Political Integration in 1976. Canadian Journal Of Political Science Xiii (2):347-356.
Soloski, John. 1989. Sources and Channels of Local News. Journalism Quarterly 66:864-70.
Strouse, James C. 1975. The Mass Media, Public Opinion, and Public Policy Analysis: Linkage Explorations. Columbus, OH: Charles E. Merrill Publishing Co.
38
Sumpter, Randall S., and Melissa A. Braddock. 2002. Source Use In A "News Disaster" Account: A Content Analysis of Voter News Service Stories. Journalism and Mass Communication Quarterly 79 (3):539-558.
Taylor, Humphrey. 2004. Americans Rate Canadian Health Care System Better Than U.S. System. Health Care News, August 30, 1-3.
Tichenor, P.J., G.A. Donohue, and C.N. Olien. 1970. Mass Media Flow and Differential Growth in Knowledge. Public Opinion Quarterly 34 (2):159-170.
Treasury Board of Canada: Secretariat. 2005. Canada's Performance; The Government of Canada's Contribution. Government of Canada 2005 [cited December 21 2005].
Tuchman, Gaye. 1978. Making News: A Study in the Construction of Reality. New York: Free Press.
Tully, Patricia, and Etienne Saint-Pierre. 1997. Downsizing Canada's Hospitals, 1986/87 to 1994/5. Health Reports 8 (4):33-39.
United Nations Development Programme. 2001. Human Development Report 2001. Making New Technologies Work for Human Development. Oxford: Oxford University Press.
Wessel, David. 2004. North of the Border: Different Systems, Same Drugs Concerns. Wall Street Journal, August 26, 2.
Williams, Kevin. 1999. Dying of Ignorance? Journalists, News Sources and the Media Reporting of HIV/AIDS. In Social Policy, the Media and Misrepresentaiton, edited by B. Franklin. New York: Routledge.
Winsten, J.A. 1985. Science and the Media: the Boundaries of Truth. Health Affairs 4 (1):5-23.
Wirthlin Group. 2005. Wirthlin Quorum Survey [electronic source]. Wirthlin Group 1995 [cited July 20 2005]. Available from http://www.ropercenter.uconn.edu/cgi-bin/hsrun.exe/Roperweb/HPOLL/StateId/CbiZIutjhJKYbBHNcD1jWm8rZYCJy-Vr_p/HAHTpage/Summary_Link?qstn_id=308586
Yaffe, Barbara. 2005. Medicare's Champion's Are Toothless: Feds Ignore Quebec's Violations. Gazette, June 9.
Zaller, John. 1992. The Nature and Origins of Mass Opinion. Cambridge: Cambridge University Press.
39
