Summary of Key Points
Both the UK and Canada have implemented systems of healthcare that are considered "public welfare" (free healthcare), but the underlying models differ significantly: In the UK, the government is responsible for both the provision and financing of healthcare services (a comprehensive approach), while in Canada, the government acts as the sole payer, with the provision of services contracted out to private entities. Both systems achieve universal coverage, and the proportion of healthcare spending as a percentage of GDP is much lower than in the United States. However, they both face challenges such as long waiting times, health inequalities, and significant financial pressures. The lessons from these examples for China are as follows: The essence of public welfare healthcare is universal coverage, but its weakness lies in the lack of flexibility in service delivery. It is essential to combine investment in the supply side with diverse payment options; otherwise, the problem of long waiting times will only worsen.
I. What are the Differences Between the Two Systems of "Free Healthcare"?
Despite both being called "free healthcare," the approaches in the UK and Canada are quite different:
- The UK's NHS System: The government acts as both the employer and the funding source. Introduced by the Labour Party in 1948, the NHS is funded by taxes, and both hospitals and doctors are publicly owned. Patients do not need to pay anything for medical treatment. It's like the government running a large cafeteria, where the ingredients, chefs, and facilities are all provided by the government, and everyone can eat for free. The advantage is unified management, but the downside is the lack of flexibility—the government decides how many hospitals to build and how many staff to hire, and any additional resources depend on the budget.
- Canada's Medicare System: The government is the sole payer for healthcare services. Established in 1984, hospitals, clinics, and doctors are mostly private, but the government sets the prices and prohibits doctors from charging extra fees. It's similar to the government issuing meal vouchers that can only be used at designated, privately-owned restaurants. The advantage is that the supply is market-driven, which theoretically offers more flexibility, but in practice, waiting times are long due to the low prices set by the government, which discourages private providers from investing more.
Additionally, the UK covers a wider range of services, including medication and dental care, while Canada traditionally does not cover these costs, which patients have to pay out of pocket.
II. Public Welfare Healthcare: Saving Money, but Facing Limits on Life Expectancy and Inequalities
The benefits of public welfare healthcare are clear:
- Lower Costs: In 2024, healthcare spending as a percentage of GDP was 11.1% in the UK and 11.3% in Canada, compared to 17.2% in the US—meaning more people can be served with less money.
- Longer Life Expectancy: The life expectancy in the UK and Canada is significantly higher than in the US, closer to that of Western Europe.
However, there are also significant issues:
- Stagnation in Life Expectancy: From 2010 to 2021, the life expectancy for men in England increased by only 0.3 years, and for women by 0.5 years, compared to a 1.6-year increase in Sweden, due to limited government funding for healthcare.
- Health Inequalities: There are significant differences in life expectancy between the poorest and richest areas in the UK, with a gap of over 10 years for men. In Canada, the life expectancy for First Nations is 71 years, compared to 85 years for non-First Nations, indicating that even with free healthcare, not everyone receives equal quality of care.
III. Waiting Times: The Most Painful Consequence of Public Welfare Healthcare
The biggest challenge of public welfare healthcare is the long waiting times:
- UK: The standard for referral to treatment is 18 weeks, but this has not been met since 2015. In 2025, only 60% of patients receive treatment within 18 weeks, with 7.1 to 7.4 million people on waiting lists. The goal of seeing an emergency patient within 4 hours is no longer achievable, and the standard for cancer treatment is only met in 70% of cases.
- Canada: The situation is even worse. In 1993, the waiting time for referral to treatment was 9.3 weeks, which has increased to 28.6 weeks in 2025, with neurosurgery waiting times reaching nearly 50 weeks. Approximately 5.7 million people in Canada do not have a regular doctor, making it difficult to get medical attention when sick.
The cost of long waiting times is not only in terms of time but also in productivity—Canada estimates a loss of about C$4.2 billion in 2025 due to missed work hours. However, public welfare healthcare does save money on administrative costs. The average administrative cost for healthcare in the US is $2,497 per person, compared to $551 in Canada, as the single-payer system eliminates the need for commercial insurance's underwriting and denial processes. But this savings comes at a cost of time; the US invests in efficiency, while the UK and Canada trade time (and potential health complications) for lower costs.
IV. Lessons for China
The experiences of the UK and Canada show that public welfare healthcare can achieve universal coverage and cost control, but it cannot guarantee timely access to care and meet diverse healthcare needs. For China:
1. Maintain the Essence of Public Welfare: Universal coverage is essential to ensure that no one is denied healthcare due to financial reasons.
2. Invest in the Supply Side: If budgets are limited, private capital should be encouraged to enter the healthcare sector (such as through private hospitals and premium clinics) to meet the needs of different populations.
3. Diversify Payment Options: Relying solely on government funding is not sufficient; commercial health insurance should be developed to provide more payment options and reduce the financial burden on the government.
In summary, public welfare healthcare can ensure fairness, but it cannot guarantee timely access to care. The key is not who pays for the services but who provides them. Reforming the payment system must be accompanied by investment in the supply side; otherwise, the number of people waiting for healthcare will continue to increase.
(The translation uses everyday analogies and data to explain the advantages and disadvantages of public welfare healthcare in the UK and Canada, as well as its implications for China in a way that is easy for non-financial professionals to understand.)