My Wife Is From Montreal. I’m From New York. We Can’t Agree Which Healthcare System is Better

My wife is from Montreal.

I’m from New York.

That means we have spent a surprising amount of our marriage debating a question neither of us seems capable of settling:

Who has the better healthcare system? (Of course the answer is the system you ideally don’t need to use in the first place.)

She grew up with Québec’s system. I grew up with America’s.

Our debates usually follow a familiar pattern.

I point to the speed, choice and sophistication of care that Americans with good insurance can often receive. Depending on the specialty, insurance and location, it may be possible to see a specialist relatively quickly, obtain advanced imaging, schedule a procedure and choose among excellent hospitals and physicians.

The American healthcare system can be extraordinarily responsive—if you have excellent coverage and access to the right providers.

My wife inevitably comes back with a much simpler question:

What about everybody else?

And that’s where our dinner-table argument becomes a public-policy question.

I have a Master of Public Health and a Doctor of Public Health in Environmental Health Sciences. Earlier in my New York City career, I worked at the Department of Health and Mental Hygiene. I am not a clinician and don’t pretend to be one. My professional expertise developed primarily on the administrative side of government: budgeting, procurement, technology, contracts and operations.

That combination makes me less interested in declaring either the American or Canadian system the “winner” and more interested in asking what each system actually produces.

America and Québec Start With Different Promises

Québec essentially starts with a guarantee.

Eligible residents have access to publicly insured hospital and physician services through universal provincial plans.

That doesn’t mean absolutely everything is free. Prescription drugs operate through a separate universal public-private insurance framework, and dental, vision and other services have different coverage rules. Supplemental private insurance also exists.

And universal coverage certainly doesn’t mean immediate access.

Anyone with family in Canada has probably heard stories about waiting for care.

I certainly have.

That’s usually where I enter the debate with my wife.

But America’s fundamental arrangement is different.

The Affordable Care Act significantly expanded access to insurance and changed the American healthcare landscape. It established insurance marketplaces and subsidies, expanded Medicaid in participating states and prohibited insurers from denying coverage because of preexisting conditions.

Those were consequential changes.

But Obamacare did not create universal health insurance.

In 2025, according to the U.S. Census Bureau, 26.7 million Americans—7.9 percent of the population—were uninsured for the entire year.

So my wife and I eventually arrive at the same uncomfortable tradeoff.

The American system can provide remarkably fast and sophisticated care, particularly if you have strong insurance, financial resources and access to good providers.

Québec makes a fundamentally different promise: eligible residents have universal public coverage for insured physician and hospital services.

But guaranteed coverage and timely access aren’t the same thing.

And fast access for some people isn’t universal access.

Maybe We’re Asking the Wrong Question

Our argument therefore shouldn’t really be:

Which country has the better healthcare system?

That’s too simplistic.

The better questions are:

How long does someone wait?

What does the care cost the patient?

Who remains uninsured?

Can patients obtain primary care?

How quickly can they see specialists?

What are the health outcomes?

How much does society spend to produce those outcomes?

How much administrative effort does the system require?

And how much financial anxiety does the financing system create for someone who is already worried about being sick?

Those are questions government can measure.

They’re also the kinds of questions public administrators should be asking.

Because healthcare isn’t only medicine.

It is also finance, technology, procurement, staffing, infrastructure and administration.

A Patient Doesn’t Care Which Department Failed

Large organizations naturally divide responsibilities.

Finance handles money.

Procurement handles purchasing.

IT handles technology.

Facilities handles buildings.

Human resources handles staffing.

Program offices deliver services.

Those divisions are necessary.

The patient, however, experiences the final product.

A patient doesn’t particularly care whether an appointment was delayed because of a staffing shortage, an antiquated computer system, a procurement problem or an inefficient administrative process.

The patient experiences a delayed appointment.

Government frequently measures performance vertically while residents experience services horizontally.

Every department can complete its individual assignment while the overall process still fails.

Healthcare organizations are particularly susceptible to this because they are extraordinarily complicated systems.

Public Health Taught Me to Look Upstream

One thing my public-health education reinforced was the importance of looking beyond the immediate problem.

If someone becomes ill, treatment obviously matters.

But public health asks additional questions.

Why did the illness occur?

Could it have been prevented?

Are environmental conditions contributing?

Is the same thing happening to other people?

Could an earlier intervention reduce the problem?

That way of thinking translates surprisingly well into public administration.

If invoices are consistently late, don’t just process overdue invoices faster.

Ask why they’re becoming overdue.

If procurements repeatedly take too long, don’t simply pressure everyone to work faster.

Map the process.

Where does the request wait?

Which approvals are legally necessary?

Which steps add value?

Which steps exist primarily because “that’s how we’ve always done it”?

In healthcare, treating symptoms without addressing causes can produce recurring problems.

Government administration can make exactly the same mistake.

Healthcare Starts Before Anyone Sees a Doctor

There is another American-versus-Canadian healthcare discussion that comes up regularly in our house:

Food.

My wife still can’t quite fathom American bread.

She’ll look at a loaf that seems to have been sitting around for three weeks, notice that it still hasn’t developed visible mold and ask some variation of:

“What exactly is in this that keeps it from going bad?”

I laugh, but there is a serious public-health point underneath her question.

Healthcare doesn’t begin when someone walks into a doctor’s office.

Nutrition matters.

Exercise matters.

Sleep matters.

Smoking matters.

Alcohol consumption matters.

The environments in which people live matter.

And the food choices that are affordable, convenient and routinely available to families matter.

That doesn’t mean declaring every processed food unhealthy or assuming that a long shelf life automatically makes something bad for you. Food preservation has legitimate benefits, including food safety, affordability and reducing waste. Shelf life by itself tells us relatively little about nutritional quality.

But my wife’s reaction raises a question I think public health should constantly ask:

What have we normalized simply because we’re accustomed to it?

Americans often evaluate healthcare by looking at hospitals, doctors, insurance premiums and prescription drugs.

Public health forces us to widen the lens.

If society spends enormous amounts treating diabetes, cardiovascular disease and other chronic illnesses, we should also be interested in the behavioral, environmental and nutritional factors associated with those diseases.

Healthcare happens in hospitals.

Health happens everywhere.

In the supermarket.

In the school cafeteria.

In the workplace.

In the neighborhood.

And in our own kitchens.

Technology Should Give Healthcare Workers Their Time Back

I spend much of my professional life around technology, and I think one of technology’s most important healthcare objectives should be remarkably simple:

Give people their time back.

A nurse’s time is valuable.

A physician’s time is valuable.

So is the time of pharmacists, therapists, technicians, social workers and administrative employees.

If highly trained professionals spend substantial portions of their days copying information between systems, searching for records, chasing approvals or performing repetitive administrative work that could reasonably be automated, there is an opportunity cost.

Artificial intelligence may eventually help considerably.

Not because machines should replace professional judgment, but because they can increasingly assist with the administrative work surrounding that judgment: summarization, document classification, scheduling, reconciliation, record searches and anomaly detection.

In healthcare, administrative efficiency can ultimately mean more time for patients.

Prevention Is Also a Financial Strategy

My finance background affects how I think about healthcare too.

Healthcare spending frequently occurs after something has already gone wrong.

Public health attempts to intervene earlier.

That isn’t only a health strategy.

It can be a financial strategy.

But prevention programs shouldn’t automatically be declared successful simply because prevention sounds desirable.

Government should measure them.

What did the intervention cost?

What outcome changed?

How many people benefited?

What healthcare utilization was potentially avoided?

Could another intervention have generated greater benefit with the same resources?

Programs addressing important health problems deserve more analytical rigor, not less.

The same should apply to our larger healthcare debate.

Whatever system we prefer philosophically, we should be willing to measure what it actually produces.

Healthcare Administration Is Healthcare

Administration sometimes becomes almost a dirty word in government.

People understandably want money going to “services” rather than “administration.”

I understand the sentiment.

Unnecessary bureaucracy should be eliminated.

But competent administration is itself part of healthcare delivery.

Someone has to hire the nurse.

Someone has to procure the equipment.

Someone has to maintain the building.

Someone has to secure the network.

Someone has to pay the vendor.

Someone has to manage the budget.

Someone has to analyze whether the program worked.

Poor administration eventually becomes poor healthcare.

The answer isn’t eliminating administration.

It’s making administration work better.

My Wife and I Probably Aren’t Settling This Argument

I don’t expect my wife and me to resolve the Canada-versus-America healthcare debate anytime soon.

And perhaps that’s useful.

Living with someone raised under a different system forces you to recognize assumptions you otherwise might never question.

Americans can look at Canadian wait times and reasonably ask:

Why should someone have to wait that long?

Canadians can look at the United States and reasonably ask:

Why should someone’s access to healthcare depend so heavily on insurance status in the first place?

My wife can look at a loaf of American bread and ask why it apparently has a longer life expectancy than either of us expected.

Sometimes an outsider notices what an insider has simply learned to accept.

Neither healthcare system is perfect.

And perhaps the lesson from my ongoing argument with my wife isn’t that one of us has to win.

Maybe good public policy begins by asking what we can learn from both.

I want the responsiveness Americans expect when our system works well.

I want the security Canadians expect from universal coverage.

I want healthcare policy that recognizes the importance of nutrition and prevention before people become patients.

I want technology reducing administrative burdens rather than adding to them.

I want healthcare professionals spending more time practicing their professions and less time navigating bureaucracy.

And I want government measuring whether the enormous resources devoted to healthcare are actually producing better health.

That may be an ambitious combination.

Healthcare policy should be ambitious.

Because when someone is sick, the organizational chart, insurance structure and political philosophy behind the system suddenly become secondary.

The patient simply wants the system to work—and wants to know that it will be there when they need it.