Constructing Canada: The 20072010 United States health care reform debate and the construction of knowledge about

Canadas single payer health care system

Tyler Kinch Sociology Honours Thesis University of Calgary April 13th 2012 Contact: [email protected] Revised: June 03rd 2012

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Introduction
etween 2007 and 2010, America underwent a health care reform debate. It started in the lead up to the 2008 presidential election, and lasted over a year into President Obamas first term, when he secured passage of the Patient Protection and Affordable Care Act. Canadas experience with single payer health care, a system in which there is a single insurance provider for most health care costs 1 , was used by those who advocated for reform and those who opposed reform. The debate had an effect on the legislation. For example, a public health insurance optiona program designed for low income Americans without employer-provided health insurance coverage was dropped from the final legislation in order to ensure that there were enough votes to pass the legislation. While both opponents and proponents of reform used Canada in their rhetoric, they constructed very different knowledges about the Canadian system. Since most Americans do not have direct experience with the Canadian health care system, claimsmakers from both sides were engaging in knowledge construction in a competitive social problems marketplace (Best, 2008, pp. 45-46) in which knowledge was relatively malleable. This malleability enabled claimsmakers to have flexibility in constructing their claims. Certainly, they were freer than they would be if their audience were Canadians who had direct experience with their own health care system. Direct experience is a powerful source of knowledge, and while claimsmakers can still shape this knowledge by providing different interpretations of direct experience, the array of choices available for claimsmakers to construct claims is limited when direct experience is involved. In this paper, I will explore how knowledge about Canadas health care system was constructed by both opponents and proponents of American health care reform, and how this knowledge was subsequently used. I will use a constructivist social problems theoretical framework in order to guide a qualitative content analysis of articles from topcirculating American newspapers. Constructivist social problems
1

This is a description of a single payer health care system. It is important to note that in Canada, there are technically thirteen different single payer systems (one for each province and territory).

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theory is relevant to this study, because different knowledges about Canada emerged out of the problematization of American health care. Proponents of American health care reform grounded their claims in a knowledge that praised Canada, while opponents of American health care reform grounded their claims in a knowledge that was critical of Canada. Historical context is important when considering this debate. This is because health care reform is not a new debate in the United States; it has decades worth of history. And in those decades, Canada has been used by both proponents and opponents of reform. It is also important to note that at one point in history, the American and Canadian systems of health care were relatively similar, until a point of divergence happened. Therefore this paper will provide some historical context and theory in order to better understand the current dynamics of health care reform in the United States.

History
Canada and the United States: Diverging Paths Marmor argues that until Canada consolidated its national health insurance in 1971, the patterns and styles of medical care in both countries were nearly identical (1993, p. 54). Hacker has provided some theoretical insight to explain the different paths that the United Kingdom, Canada and the United States took in health care. For the purposes of this paper, I will focus on his explanations of the differences between Canada and the United States. Hacker (1998) warns against explanations that focus on one crucial variablesuch as economic forces, cultural forces, or interest groups. Instead, he stresses the influence that a countrys structure of political institutions and the countrys history of policy choices have on those variables (1998, p. 60). For the structure of political institutions, Hacker argues that overall government structure is the most important institutional feature that has shaped health policy in Britain, Canada and the United States (1998, p. 74). Overall government structure includes the distinction between presidential and party government parliamentary systems. Hacker explains how party government parliamentary systems function compared to presidential systems:

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National two-party competition is encouraged by the confluence of parliamentarism, single-member districts, and plurality elections. But... another distinguishing feature of these parliamentary systemsespecially when compared with the United Statesis the recurrent influence of small insurgent parties, such as the British Labour Party and the Canadian New Democratic Party. Even without proportional representation, insurgent parties do not face the same barriers in Westminsterstyle systems as they do in the separation-of-powers system of the United States (1998, p. 74). Additionally, Hacker argues that the administrative capacity of party government parliamentary systems is greater than presidential systems. He quotes Sven Steinmo: In the United States, reformers must design and adapt their policies to cater to the objections and desires of a huge number of interest groups and congressional constituencies. In parliamentary systems compromises must be made . . . but when programs have been decided on by relatively small groups of elites, they can [be] and usually are passed through their respective legislatures with very little substantive change or amendment (Hacker, 1998, p. 75). This combination of third party insurgency and the concentration of administrative capacity found in the Canadian political structure could explain Canadas success at adopting a single payer health care system while America has failed to do so. Public health care insurance in Canada began in depression-era Saskatchewan with the emergence of the Cooperative Commonwealth Federation (CCF), a socialist political party (Hacker, 1998, pp. 99-102). When the CCF gained power, the administrative capacity afforded to them gave them the power to implement substantive policy changes that created the foundation for a national single payer health care system. While the CCF has never formed government at the federal level 2 , the creation of a national universal health care plan took place in the context of a minority
2

Nor has its predecessor, the New Democratic Party (NDP).

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Liberal government where the New Democratic Party, predecessor to the CCF, held the balance of power (Hacker, 1998, pp. 103-105). Both the ability for third parties to flourish and the concentration of administrative power are important. This can be demonstrated by imagining a scenario in the United States in which a socialist/socialdemocratic candidate for president overcame the barriers of the presidential system to be elected: he/she would still face substantial obstacles to implementing socialist/social-democratic policies due to the lack of administrative capacity afforded to his/her government. The second important factor that explains differences in countries health care systems, according to Hacker, is the history of policy choices. In order to explain this, Hacker introduces the concept of path dependency. The concept stresses the importance of temporally remote events rather than systematic forces (1998, p. 76) . Hacker argues that even seemingly trivial events at an earlier point in time may have dramatic long-term economic consequences when certain self-reinforcing mechanismslarge set-up or fixed costs, learning effects, coordination effects, and the likeare present (1998, p. 76). In other words, path dependency is about government policy taking a country down one path that influences and limits future policy choices. Hacker identifies three policy decisions, or non-decisions, that are particularly crucial in shaping subsequent political structures. They were: (1) the degree to which private health insurance was allowed to develop and the form that private plans took; (2) the initial target of government insurance programs; and (3) the relative timing of public efforts to bolster the technological sophistication of medicine, on the one hand, and to increase the access of citizens to health care, on the other (1998, pp. 82-83). In the United States all three policy decisions were relevant: private health insurance was allowed to flourish for a long time before national health insurance became proposed; the initial target of American government insurance was narrow (the elderly and indigent); and the medical industry was built up prior to expanding access. All three of these policy decisions set America down a path where implementing a national universal health care plan in the future would be very difficult (Hacker, 1998, pp. 82-83). The decisions cemented a sizable private insurance market... supported by government policy and, once institutionalized... private insurance markets place formidable constraints on government efforts to expand public insurance or

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regulation (Hacker, 1998, p. 80). President Obamas rhetoric when rejecting single payer health care appears to use arguments similar to Hackers, which will be discussed later in this paper. There are other examples of government policy that institutionalized private insurance markets, taking America down one path that limited future policy options. Dobbin summarizes arguments that claim American wartime federal policies aided in constructing a regime of private employment-related health benefits: The wartime rise in fringe benefits is thought to be the result of the confluence of three policies: the excess-profits tax, the wage freeze, and the tax-exempt status of pension and health insurance payments. That is, the wartime excess profits tax spurred firms to increase their before-tax expenditures, and increased labor turnover encouraged them to do so by raising wages. However, the wage freeze stymied them. Caught in a bind between the excess-profits tax and the wage freeze, employers gained relief in the form of federal rulings that employer payments for pension and health insurance were not covered by the wage freeze and were tax-deductible. The huge increases in health and pension insurance during the early forties are attributed by many to this set of circumstances (1992, pp. 1418-1419). Ariel Ducey (2009) summarizes arguments that claim early union efforts for universal health care were undermined by the expansion of employment-related health benefits in the United States. While many employers voluntarily offered these fringe benefits during wartime, the war eventually ended and profit/wage restrictions were lifted and this changed the co-operative dynamic that had characterized relations between the state, industry, and unions during the war (Ducey, 2009, pp. 212-213). In 1946, the Republicans gained control of both houses of Congress and passed the Taft-Hartley Act which greatly weakened the power of unions (Ducey, 2009, pp. 213-214). However, unions were still able to fight for fringe benefits and they did by the end of 1954, twelve million workers and seventeen million dependents were enrolled in collectively bargained health plans, representing three quarters of union members (Ducey, 2009, p. 214). Ducey continues her summarization:

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Unions embrace of employment-based, collectively negotiated benefits made the fight for universal health care immeasurably more difficult. Welfare and benefit funds became the core clients of a private insurance industry and diluted the political will among labor leaders and Americans with secure employment to fight for a universal health care system (Ducey, 2009, p. 215). This dilution of political will is exemplified by the United Mine Workers lack of support for Harry Trumans national health insurance plan. The plan wasnt supported by the union because of the belief that the private health plan they had was better than the proposed national plan (Ducey, 2009, p. 218). Similar reactions from union members could be seen fifty years later when President Clinton proposed health care reform policy (Ducey, 2009, p. 219). History of American Health Care Reform and the Relevance of the Canadian Experience Canadas experience with single payer health care has long played a role in American health care debates. Theodore Marmor argues that this American interest in Canadian health care is characterized by episodic periods of public interest followed by longer periods of inattention (1993, p. 47). Marmor argues that this pattern emerged in the 1970s. He argues that prior to the 1970s very few health policy analysts in the United States knew very much about Canadian experience or paid much attention to it (1993, p. 47). In order to see if this pre-1970s disinterest in Canada extended beyond health policy analysts, I browsed American news archives from that time. While phrases such as socialized medicine (e.g. The New York Times, 1940) and the experience of England (e.g. The Washington Post, 1964) were common, the experience of Canada was almost entirely absent. This is interesting because America was undergoing health care reform debates prior to the 1970s (most notably, Trumans health care plan in the 1940s and Medicare in the 1960s). During the same time period, the Canadian province of Saskatchewan led the way for health care reform in Canada, and a national hospital insurance program was setup in 1957 through the

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Hospital Insurance and Diagnostic Services Act 3 (Canadian Museum of Civilization, 2010). The American mainstream media could have looked at Canada more. However, when Canada completed its national health insurance program in 1971 4 , interest about Canadas experience with public health care grew among not only the American public but also American legislators. Senator Ted Kennedy travelled to Canada, and upon his return he shared with the American people Canadas relative success (Marmor T. R., 1993, p. 47). In 1976, President Carter ran on the promise to enact national health insurance. However, public and legislator interest began to dissipate when the economy became a national priority later that decade and into the early 1980s (Marmor T. R., 1993, p. 62). In 1989, Lee Iacocca, head of Chrysler, argued that rising medical costs was causing a competiveness problem for American corporations relative to Canada (Marmor T. R., 1993, p. 48). In 1990, American physicians that supported a national health care plan came together and formed Physicians for a National Health Plan and published recommendations in the New England Journal of Medicine that made Canada its model (Marmor T. R., 1993, pp. 48-51). The 1990s also saw television specials featuring Canadas experience with single payer insurance on all three major networks, a special on National Public Radio (NPR), and features in major newspapers (Marmor T. R., 1993, p. 51). Congressional committees asked Canadian experts to testify, and political organizations sent representatives to Canada on factfinding missions (Marmor T. R., 1993, p. 51). Marmor and Sullivan argue that this renewed interest in Canadian medicare was part of the new ideas that always come in with a change in presidential administration (2000). These endorsements of the Canadian health care system were not left unchallenged. In 1989, the American Medical Association used its resources to launch the Public Alert Programa 2.5 million dollar initiative with the ostensible goal of telling millions of Americans the facts about the Canadian-health-care system (Marmor T. R., 1993, p. 51). In 1992, the health insurance industry weighed into the debate. The Health Insurance Association argued against a Canadian-style
3

The Hospital Insurance and Diagnostic Services Act only covered costs incurred in hospitals. 4 This program covered the cost of hospital and physician services.

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government solution (Marmor T. R., 1993, p. 48). In the meantime, the New York Times featured editorials embracing managed competition and dismissing the bureaucratic solutions of Canada and President Bush Sr. dismissed the Canadian experience by calling it a failure and irrelevant (Marmor T. R., 1993, p. 50). This opposition to reform continued into the Clinton era, and Clintons health care reform policies were undermined by this continuance of opposition (Marmor & Sullivan, Canada's Burning!, 2000). This is demonstrated by the well-known Harry and Louise ads (YouTube, 2007). In one of the television advertisements, a couple, Harry and Louise, sit at a table as they go through their health care bills. The advertisement takes place in a future where Clinton passes health care reform legislation. Louise claims that her old private health insurance covered more than the insurance she has under the Clinton reforms. The narrator says: things are changing and not all for the better. The government may force us to pick from a few plans designed by government bureaucrats... if we let the government choose, we lose. During George W. Bushs tenure as President, health care reform was almost entirely avoided. Two attempts were made to expand the State Children's Health Insurance Program (SCHIP) but President Bush vetoed both attempts (Associated Press, 2008). I would like to reiterate Theodore Marmors argument that American interest in Canadian health care is characterized by episodic periods of public interest followed by longer periods of inattention (1993, p. 47). In this paper, I consider the 2007-2010 health care debate to be an episode of American public interest in Canadian health care.

Theory
Constructivist social problems theory treats social problems as social constructs. Studying social problems as social constructs is very different than how most people would approach social problems. A social constructivist researchers primary interest is not the actual social conditions that make up the social problem. Instead, the primary interest is to discover how certain social conditions are socially constructed into social problems (Best, 2008, p. 14). Social constructivists do not believe that there is a set of objective conditions that make a particular set of social conditions a social problem. Instead,

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they believe that social problems are social conditions that have been problematized by claimsmakers through a social problems process (Best, 2008, pp. 8-10). Claimsmakers use rhetoric to try and persuade others of their social constructs (Best, 2008, pp. 25-26). This does not mean that social constructionists believe social problems are imaginary; it simply means that the meanings we attach to social conditions are socially derived (Best, 2008, p. 14). If a set of social conditions gets labelled troubling, a social problems claim has been made (Best, 2008, pp. 14-16). The above summary of constructivist social problems theory does not suggest that social constructivists reject social problems. They can see value in problematizing certain social conditions (e.g. homelessness). As members of society, they can make judgements about the claims made by claimsmakers. But when they are doing social constructivist analysis, they must bracket these judgements in order to analyse the process through which social conditions become social problems. In order to use the constructivist social problems theoretical framework, I conceptualize certain actors as claimsmakers and certain actors as counter-claimsmakers. Claimsmakers are those who problematize a set of existing social conditions (Best, 2008, p. 15). Counter-claimsmakers develop claims that are a response to this problematization. In the case under study, those who problematized American health care and proposed Canadian-style health care as a solution are claimsmakers, and those who reject single payer health care are counter-claimsmakers. Best has conceptualized a process that explains the natural history of social problems (2008, pp. 18-23). This process starts with the activities of claimsmakers. The proceeding stages are media coverage, public reaction, policymaking, social problems work, and policy outcomes. A social problem does not need to follow these stages in a linear fashion, and sometimes a social problem does not successfully make it through each stage (Best, 2008, pp. 18, 26-27). Feedback occurs in this process (Best, 2008, p. 327). Claims made by claimsmakers may be picked up and filtered by the media, and subsequently the public reacts to this media coverage. If the public reaction is positive, claimsmakers may continue their rhetoric in an unaltered form. However, if the public reaction is negative, claimsmakers may alter their rhetorical strategy in hopes that the

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modification will lead to a more positive public reaction. For the analysis in this paper, I will mainly be focusing on the media coverage stage; however the media coverage stage provides a window to view the other stages.

Methods
In order to carry out research required for this thesis, I employed a qualitative content analysis of American newspaper coverage between January 1st 2007 and December 31st 2010. I used the University of Calgarys Factiva account to gather the news articles to be analyzed. The newspapers to examine were selected by their circulation. The top five circulating newspapers in the United States for the six-month period ending March 31st, 2011, were The Wall Street Journal, USA Today, The New York Times, The Los Angeles Times, and The Washington Post (Audit Bureau of Circulations, 2011). Since The Los Angeles Times is not accessible via the University of Calgarys Factiva account, it was not included in the analysis. However, the four other top circulating newspapers were. A string of keywords was used to obtain full text articles that were relevant to the study. The following terms were used in combination with the keyword Canada and/or Canadian: socialized medicine, single payer, free health care, Obamacare, Patient Protection and Affordable Care Act, health care reform, and universal health care. The term Canadian style health care was also used. This resulted in 97 articles from the Wall Street Journal, 79 articles from the Washington Post, 55 articles from the New York Times, and 19 articles from USA Today. This sums to a total of 250 articles from all four of the newspapers. The 250 articles were then coded into two categories according to the relevance that they had to the thesis. The two categories were: (1) low/medium relevanceCanada was referred to only in passing and was not the main theme; (2) high relevanceCanada was the main theme in the article and/or the article represented an important stage in the health care reform debate. This resulted in 183 low/medium relevance articles and 67 high relevance articles 5 . Only articles coded
5

The breakdown of the articles coded high relevance is as follows: 27 New York Times; 15 Wall Street Journal; 14 Washington Post; and 11 USA Today.

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as high relevance were included in the analysis. Coding for these categories was based on my own subjective judgement. While this may have been to the detriment of reliability, it is important to remember that this research project is qualitative in nature and is meant to describe an instance of a specific debate and the findings are not meant to be generalized. I also believe that I included additional news articles that would not have been included if I constructed a less subjective selection criteria. This is due to the latent content in these articles that cannot be captured by any systematic coding scheme. Due to the inclusionary aspect of this approach, I would argue that validity has been enhanced. After developing my sample, I immersed myself in the articles and engaged in what Hsieh and Shannon (2005) call conventional content analysis. Conventional content analysis is useful to describe a phenomenon because researchers avoid using preconceived categories, instead allowing the categories and names for categories to flow from data (Hsieh & Shannon, 2005, p. 1279). This is also called inductive category development. This resulted in hundreds of categories to code the newspaper articles, but I followed the steps laid out by Mayring where categories are tentative and step by step deduced. Within a feedback loop those categories are revised, eventually reduced to main categories... (2000). In order to manage and collapse hundreds of tentative categories, I used HyperResearch computer software. The final collapsed categories included article type, stance taken on Canada, actors, moral claims, efficiency claims, rationing claims, decision-making claims, American-values claims, and back-door claims. The first three categories (article type, stance taken on Canada and actors) were used to provide context to the debate and were subcategorized. Article type was coded as: news report, column, op-ed, or editorial. News reports were articles written by journalists to report the news. Columns were opinion pieces written by columnists on the payroll of the newspaper. Op-eds were opinion pieces written by individuals or organizations that were not on the payroll of the newspaper. And editorials were opinion pieces that were authored by the editorial board of the newspaper. Stance taken on Canada was coded as negative, neutral, or positive. Coding was determined by a subjective reading of the article. Negative or positive stances were

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mostly observed in op-eds, columns, and editorials. Most news reports were coded as neutral. The actors category was subcategorized into claimsmaker and counter-claimsmakers and a list of actor names was maintained. The categories of moral claims, efficiency claims, rationing claims, decision-making claims, American-values claims, and back-door claims were constructed in order to track what I considered to be common claims made by claimsmakers and counter-claimsmakers. Moral claims were arguments that made appeals to morality (what is considered right and what is considered wrong). Efficiency claims argued that the Canadian health care system is more cost-effective than the American health care system. Rationing claims argued that health care in Canada is rationed through politics, and that better quality care can be found in America. Decision-making claims were arguments about who makes health care decisions in the American and Canadian health care systems. American-values claims were arguments that invoked commonly touted ideas of what makes America unique. And lastly, back-door claims were arguments that non-single-payer health care reform proposals would indirectly lead to Canadian-style health care.

Findings and Analysis

Stance on Canada While none of the newspapers in this study had the majority of its articles coded as viewing Canadian health care as positive, the New York Times came close with 44%, while only 7 % of articles were coded as negative (see table 5). The Wall Street Journal is on the other side of the spectrum, with 87% of its articles coded as taking a negative stance towards the Canadian health care system, and zero articles taking a positive stance. This coincides with the reputations of the two newspapers: the New York Times is often seen as being supportive of liberal views and the Wall Street Journal is often seen as being supportive of conservative views (Vailancourt, 2006, p. 28). 50% of Washington Post and 45% USA Today articles were coded as taking a negative stance against Canada, while only 21% and 18% respectively took a positive stance.

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Looking more closely at the data, it is apparent that much of this variation in stance happens in columns, op-eds, and editorials (see tables 2-5). The vast majority of news reports were coded as neutral in all the newspapers (see table 1).

Table 1: News Reports Newspaper Wall Street Journal New York Times Washington Post USA Today All Newspapers Negative Stance
0% (0) 0% (0) 25% (1) 0% (0) 5% (1)

Neutral Stance
100% (1) 82% (9) 75% (3) 100% (3) 84% (16)

Positive Stance
0% (0) 18% (2) 0% (0) 0% (0) 11% (2)

Total
100% (1) 100% (11) 100% (4) 100% (3) 100% (19)

Table 2: Columns Newspaper Wall Street Journal New York Times Washington Post USA Today All Newspapers Negative Stance
0% (0) 0% (0) 66% (4) 50% (1) 29% (5)

Neutral Stance
100% (1) 13% (1) 17% (1) 0% (0) 18% (3)

Positive Stance
0% (0) 87% (7) 17% (1) 50% (1) 53% (9)

Total
100% (1) 100% (8) 100% (6) 100% (2) 100% (17)

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Table 3: Op-Eds Newspaper Wall Street Journal New York Times Washington Post USA Today All Newspapers Negative Stance
100% (9) 33% (2) 50% (2) 50% (1) 66% (7)

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Neutral Stance
0% (0) 33% (2) 0% (0) 0% (0) 10% (2)

Positive Stance
0% (0) 33% (2) 50% (2) 50% (1) 24% (5)

Total
100% (9) 100% (6) 100% (4) 100% (2) 100% (21)

Table 4: Editorials Newspaper Wall Street Journal New York Times Washington Post USA Today All Newspapers Table 5: All Types Newspaper Wall Street Journal New York Times Washington Post USA Today All Newspapers Negative Stance
87% (13) 7% (2) 50% (7) 45% (5) 40% (27)

Negative Stance
100% (4) 0% (0) 0% (0) 75% (3) 70% (7)

Neutral Stance
0% (0) 50% (1) 0% (0) 25% (1) 20% (2)

Positive Stance
0% (0) 50% (1) 0% (0) 0% (0) 10% (1)

Total
100% (4) 100% (2) 0% (0) 100% (4) 100% (10)

Neutral Stance
13% (2) 48% (13) 29% (4) 36% (4) 34% (23)

Positive Stance
0% (0) 44% (12) 21% (3) 18% (2) 25% (17)

Total
100% (15) 100% (27) 100% (14) 100% (11) 100% (67)

Constructing Canada Actors

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The claimsmakers that emerged during my analysis included the California Nurses Association, the California Teachers Association, Congress of California Seniors, film-maker Michael Moore, and a group of physician-advocates that call themselves Physicians for a National Health Program. Health Care for America NOW!, a political coalition of several organizations, was also a key actor; however, they did not explicitly endorse the Canadian model. Instead, they advocated for a public option, and defended the Patient Protection and Affordable Care Act from attacks after it was passed. Counter-claimsmakers were more numerous. They included thinktanks such as the Pacific Research Institute, Americans for Prosperity Foundation, the Century Foundation, the Hudson Institute, the Manhattan Institute, and the Cato Institute. Industry groups such as Health Care America (representing pharmaceutical and hospital companies), and Pharamecutical Manufacturers of America also opposed Canada as a model for reform Newspaper columnists and editorial boards acted both as claimsmakers and counter-claimsmakers. In addition, there were think-tanks that reported positive statistics about Canada and showed areas where Canada had better results than America. However, unlike counter-claimsmaking think-tanks, these think-tanks did not have representatives that wrote op-ed articles that took a position on using the Canadian model in health care reform. Therefore, I did not code them as for or against the Canadian model. The large amount of organized counter-claimsmakers compared to organized claimsmakers begs explanation. This can be explained by looking at what is it at stake, and who has the resources in order to protect their interests. Coakley and Donnelly argue that people in positions of power and control know that changes in society could jeopardize their positions and the privilege that comes with them (2009, p. 12) and therefore oppose change. Marmor argues that when the status-quo is threatened by claims that challenge it, those with the greatest stake in the status quo will launch a counterattack (1993, p. 52). Actors with the greatest stake in the status quo have benefited from their position. These benefits include material resources that have been accumulated and that can be deployed by powerful actors in order to fight off claims and protect their interests. Those who dont have a stake in the status quo have benefited very little, if at all. Therefore,

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they have very little resources in order to match the organization of counter-claimsmakers. Looking at the list of counter-claimsmakers, it is easy to identify them as those with the greatest stake in the status-quo. The list is mainly composed of actors from the health insurance industry and the pharmaceutical industry. The list of claimsmakers, on the other hand, contains some unions, a documentary filmmaker, citizen organizations, and some physicians. While these actors may have considerable resources, I hypothesise that they pale in comparison to the resources of counter-claimsmakers. Claimsmakers have huge challenges facing them due to this unbalanced allocation of resources. Claims Moral Claims In my analysis, there were many instances of claimsmakers using moral arguments to persuade their audiences that there was something wrong with the American system. A common argument involved the number of medical bankruptcies in America. In an op-ed, Peter Singer cites a study which claimed that in America more than 60 percent of all bankruptcies are related to illness (2009). This statistic is then compared to the number of medical bankruptcies in Canada, which Singer claims is much lower. While the number of uninsured are often cited as a contributing factor to the number of bankruptcies, Singer claims that there is a worsening situation where even people with insurance are claiming bankruptcy due to inadequate coverage. The practices of insurance companies and the ugly incentives provided by a system in which giving care is punished, while denying it is rewarded are also blamed (Krugman, The Health Care Racket, 2007). In a column in USA Today, Patricia Pearson transforms this argument about bankruptcies into a more substantive moral argument by saying that the bedrock of the Canadian health care system is the belief that no citizen should ever have to choose between health care and rent, or between her care and that of her children (2009). Pearson argues that America lacks this bedrock belief. Through this moral rhetoric, Canada is constructed as morally superior, at least in relation to the provision of health care, when compared to the United States. This has an effect of shaming the United States. This is an essential step in the social problems process,

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because it problematizes the status quo in American health care. This must be done first before claimsmakers can successfully advocate for specific types of changes. Economic Efficiency Claims The rhetoric of claimsmakers goes beyond the moral, and is very often based on claims of economic efficiencies found in the Canadianmodel. A common claim made by advocates of the Canadian-model is that Canada spends less on health care but gets better results. This claim is not limited to Canada, and other advanced countries are often included in the comparison. In a New York Times op-ed, Robert Frank argues, we spend more than twice as much on health care, on average, as the 21 countries in which life expectancy exceeds ours (2007). These claims single America out, and imply that America is lacking something that other modern countries have. Some claims go even further to claim that not only do all the other industrialized democracies spend less and get better results, but unlike the United States they have universal coverage (Pear, 2008). New York Times columnist, Nicholas Kristof, singles America out as breaking an international trend: Throughout the industrialized world, there are a handful of these areas where governments fill needs better than free markets: fire protection, police work, education, postal service, libraries, health care. The United States goes along with this international trend in every area but one: health care. (2009b). Claimsmakers commonly blame overall high costs on high administrative expenses found in private insurance markets. In another column Nicholas Kristof claims, some 31 percent of U.S. health spending goes to administration, more than twice the rate in Canada (2007). Claimsmakers argue that resources are wasted on paperwork, marketing, underwriting, fights over who pays the bill and claims rejection. New York Times columnist, Paul Krugman, describes the situation as an arms race: So it's an arms race between insurers, who deploy software and manpower trying to find claims they can reject, and

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doctors and hospitals, who deploy their own forces in an effort to outsmart or challenge the insurers. And the cost of this arms race ends up being borne by the public, in the form of higher health care prices and higher insurance premiums (2007). Costs are only one part of this argument made by claimsmakers; there are also claims about the higher quality health care found in Canada. Claimsmakers claim that Canada has higher life-expectancies (Krugman, 2007b; Robinson, 2007) , lower infant mortality (USA Today, 2009), and lower maternal mortality (Kristof, 2009). Additionally, claimsmakers argue that the Canadian system provides better long-term survival after colorectal cancer, childhood leukemia or a kidney transplant (Leonhardt, 2009) and longer survival times while undergoing renal dialysis (The New York Times, 2009). Breast cancer survival rates and asthma mortality are also claimed to be better in Canada (USA Today, 2009). Claims about lower cost and better results lead claimsmakers to make the conclusion that the United States should look at the Canadian model when reforming its health care system. Krugman argues that the cost of covering Americas uninsured is $77 billion a year, and that just the administrative savings that could be found in a single payer model would more or less pay the cost of covering all the uninsured (2007). Or as two physicians argue in a New York Times op-ed, only a single payer system of national health care can save what we estimate is the $350 billion wasted annually on medical bureaucracy and redirect those funds to expanded coverage (Himmelstein & Woolhandler, 2007). Through this rhetoric about cost and quality of health in Canada, claimsmakers construct a distinct knowledge about Canada. They argue that Canada must be doing something right if they pay less and get better quality care. But they also point out that Canada isnt alone. The claims construct Canada as a modern country that belongs in the league of other advanced countries due to its affordable, high-quality, and universal health care coverage. Canadas membership in this league of advanced countries is unquestioned. However, due to Americas lack of affordable, high-quality, and universal health care coverage, its membership in this league of advanced countries is in question. This clashes with Americas self image as a world-leading, advanced, and modern country. Some claimsmakers exploit this clash

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when developing rhetoric by comparing the United States with poorer countries, suggesting that the United States may have more in common with these countries than advanced countries like Canada. In the newspapers analyzed, the United States was compared with Costa Rica, the Czech Republic (Kristof, 2007), the Central Africa Republic (Kristof, 2009b), Burundi, and Burma (The Washington Post, 2009c). Counterclaims Claims of Rationing Counter-claimsmakers take issue with claimsmakers claims about higher health care quality at lower costs in Canada. They argue that health spending is limited in Canada because governments restrict the supply of health care by rationing it through waiting (Gratzer, 2009). One columnist argues that President Obama will follow the Canadian model to reduce health costs but warns Americans that when the president promises to get health care costs under control, he is really promising less care (USA Today, 2009b). An editorial in USA Today states: It is a myth that government-run health care systems are better overseas. The Canadian, British, and European counterparts delay and ration care for citizens, limiting access to cutting-edge diagnostic services and medications. They spend less by denying services and using age cutoffs to avoid paying bills for the elderly (2010). In order to bolster these claims, counter-claimsmakers often use anecdotal evidence of Canadians escaping socialized medicine by fleeing to the United States for treatment. One example of this was the case of a Canadian woman who had a brain tumour and went to the United States for treatment. Americans for Prosperity Foundation spent resources on producing and airing a sixty second commercial featuring the Canadian woman in order to urge Americans to oppose Washingtons plans to bring Canadian-style health care to the United States (Mundy, 2009). The narrator warns that, government runs health care in Canada. Care is delayed or denied. Some patients wait a year for vital surgeries, delays that can be deadly (Wolf, 2009). There

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were many other examples of this type of anecdotal evidence being used (Gratzer, 2007; Gratzer, 2009; Wilmouth, 2009). This use of anecdotal evidence rather than population-level data may be a deliberate rhetorical strategy on the part of counter-claimsmakers. Some psychologists have argued that there is an identifiable victim effect, in which people care more about identifiable than statistical victims (Small & Loewenstein, 2003, p. 5). While counter claimsmakers could have relied heavier on statistical evidence about waiting times, in many cases they chose to rely more on anecdotal evidence. Counter-claimsmakers awareness of their audience may have contributed to this. Academic audiences are traditionally trained to be critical of anecdotal evidence, while the general public may be more affected by the identifiable victim effect. Counter-claimsmakers are looking to sway the opinion of the general public, not academics. These anecdotal claims also provide evidence to the general public for more generalized claims made by counter-claimsmakers. For example, Myrna Ulfik argues in a Wall Street Journal op-ed, Canadian cancer patients told to wait months for treatment and diagnostic scans frequently go south and pay out-of-pocket for care in the United States (emphasis mine) (2009). While the word frequently is ambiguous, it may lead readers to believe that this practice is more common than actual statistical data would show. Since statistical data is rarely provided, and anecdotal evidence is abundant, this ambiguity is preserved. Counter-claimsmakers also argue that public health care stifles medical innovation. Specifically, when it comes to the negotiation of drug costs, counter-claimsmakers warn that single payer systems will push down the price of suppliers while ignoring research and development costs (Calfee, 2009). Not only does this prevent future drugs from being discovered, according to counter-claimsmakers lifesaving drugs are denied to patients through the rationing of health care found in single payer systems (Ulfik, 2009). Decision Making Claims The common claim of rationing intersects with another common claim made about Canada by counter-claimsmakers: that in Canada, its the government that makes health care decisions, not the individual. The reason why I say this claim intersects with rationing is

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because counter-claimsmakers ultimately argue that government control will lead to rationing. The Wall Street Journals editorial board argues that patient choice saves lives (2008). Some counterclaimsmakers argue that in Canada medical decisions are made by a central national board (Eggen & Connolly, 2009) or government body that inevitably bases its decisions as much on politics as on science (Tanner, 2009). John Mackey, co-founder and CEO of Whole Foods Market Inc., argues that in countries like Canada and the U.K., there is no intrinsic right to health care. Rather, citizens in these countries are told by government bureaucrats what health-care treatments they are eligible to receive and when they can receive them (2009). One op-ed writer argues that the concept of patient-as-person is lost due to bureaucratic needs of the system (Ulfik, 2009). Matt Miller argues in the Washington Post that government incompetence leads to misallocation of health care resources (Miller, 2009). It is important to note that proponents of the Canadian-model have a parallel argument about individual-decision making that mirrors the arguments made by counter-claimsmakers. In this argument, claimsmakers argue that the existence of a patient-clinician interface in America is an idealized version of reality. Instead, they argue that insurance companies are often the ones in control of patients health care decisions in the United States. Dr. Allan S. Brett, a professor of medicine and bioethicist at the University of South Carolina, argues in a New York Times interview that the single payer systems ability to remove insurance restrictions actually increases choices (Chen, 2009). Claims about American Values Counter-claimsmakers arguments about government decision making are extended even further. Their claims about Canada construct Canada as a country where individual freedom and choice in health care is almost, if not completely, non-existent. Instead government makes these decisions. This sort of system is constructed as being diametrically opposed to commonly touted ideas of American values that emphasize individual liberty and American enterprise (The Wall Street Journal, 2010). Counter-claimsmakers use this clash between American values and the health care-systems of other industrialized nations in order to argue that America is unique and therefore its health care system should be unique as well. This argument directly

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counters attempts by claimsmakers to shame America for not being like other advanced industrial countries. The argument about a uniquely American solution that respects American values has been expressed by influential Democrats. During the debate over health care reform, Senator Max Baucus, then chair of the Senate Finance Committee, stated: There are no enemies and villains here. Most Americans want to reform our system. Most companies, industries, want to reform the system because they know we have a lousy system. We have to work together to find out a better solution, which is still a uniquely American solution, which is public and private. We're not, you know, Great Britain. We're not Canada. We're not Netherlands. We're America (Pear & Herszenhorn, 2009). Claims of a Back-Door President Obama used similar rhetoric as Senator Baucus to reject the single payer model. During a town-hall in Montana, Obama said, now, what we need to do is come up with a uniquely American way of providing care. So I'm not in favor of a Canadian system. I'm not in favor of a British system. I'm not in favor of a French system (The Washington Post, 2009b). However, multiple counter-claimsmakers have claimed repeatedly that Obama is actually an ardent supporter of single payer health care. Their evidence is a video-clip from 2003 where Obama says, I happen to be a proponent of a single payer universal health care program (Cooper, Bosman, & Sack, 2008). When these accusations started to appear in the 2008 Democratic Partys presidential primaries, Obama rejected that he had ever proposed single payer health care as a health care reform option: I never said that we should try to go ahead and get single payer. What I said was that if I were starting from scratch, if we didnt have a system in which employers had typically provided health care, I would probably go with a single payer system (Wilmouth, 2009). During a 2009 town-hall in Northern Virginia, Obama elaborated on his opposition to single payer health care as a model for American health care reform:

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As many of you know, in many countriesmost industrialized, advanced countriesthey have some version of what's called a single payer plan... Now, in a lot of those countries, a single payer plan works pretty well... Here's the problem, is that the way our health care system evolved in the United States, it evolved based on employers providing health insurance to their employees through private insurers, and so that's still the way that the vast majority of you get your insurance. And for us to transition completely from an employer-based system of private insurance to a single payer system could be hugely disruptive. And my attitude has been that we should be able to find a way to create a uniquely American solution to this problem... (The Washington Post, 2009) Obama seems to share the same argument of path-dependency as Hacker. That is, former government-policy that has allowed private insurance to institutionalize is now preventing new policy that would implement a single payer health care system in the United States. Obama argues that only if the United States was starting from scratch would he support a single payer system. But this blank-slate doesnt exist as America took a different path that solidified the role of private employment-based health insurance. Nonetheless, some counter-claimsmakers have used past statements by Obama to argue that the president really wants to take America down the road of single payer health carehes just not being honest about it. For example, a Washington Post column argues that Obama has publicly abandoned his once-stated preference for a single payer system as in Canada and Britain. But that is for practical reasons. In America, you can't get there from here directly (Krauthammer, 2010). Many counter-claimsmakers argue that Obamas plans are really just a back-door to Canadian-style health care. At first they did this by pointing to the public option in Obamas health care plan. The public option was a proposal to provide an option for Americans to buy into an insurance plan that would be offered by the federal government. This was targeted towards those without employment-based health insurance. Many counter-claimsmakers argued that the public option would crowd out the market, putting private insurance companies out of business, and would eventually become a single payer system.

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For example, a New York Times news report in January 2008, made reference to the use of the back-door argument by republican candidates and policy strategists (Sack, 2008). John McCains presidential campaign argued early in the 2008 presidential race that Senator Obama wants to set up health care bureaucracies, take over the health care of America throughas he said, his object is a single payer system. If you like that, you would love Canada and England (Pear, 2008). After Obama was elected, counter-claimsmakers continued to call Obamas plans for a public option a back-door to Canada. In one instance, an editorial in the Wall Street Journal accused Obama of attempting to add tens of millions more people to the federal balance sheet (2008b). The editorial further argued that the public option would offer generous insurance packages because of taxpayer subsidies, making it impossible for private insurance companies to compete. The editorial goes on to say: And because federal officials will run not only the new plan but also the market in which it competes with private programslike playing both umpire and one of the teams on the fieldthey will crowd out private alternatives and gradually assume a health-care monopoly... Eventually, the public option will import Medicare's price controls into the private sector as it tries to manage the inevitable cost overruns. When that doesn't work, Congress will deal with the problem by capping overall spending and rationing care through politics (instead of prices)like Canada does today. Either Senator Baucus and President-elect Obama are making promises that can't possibly be kept. Or they're not being honest about their plans for U.S. health care (The Wall Street Journal, 2008b). There were multiple other instances of counter-claimsmakers claiming that the public option was a back door to Canada (Calfee, 2009; The Wall Street Journal, 2009; Tanner, 2009; The Wall Street Journal, 2010). When a Medicare-buy-in for those aged 55-64 was proposed as an alternative to the public-option, counter-claimsmakers clung onto the argument that the proposal was a back-door to single payer health care. The Wall Street Journal editorial board called the proposal an even faster road to government-run health care in an

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editorial titled, Worse than the public option (2009b). A column in the Wall Street Journal argued that the Medicare expansion would force the United States into Canadian-style care (Fund, 2009). After the legislation was passed without the public option, a Washington Post columnist still argued that the legislation was a backdoor to Canadian-style single payer health care: The left never understood that to nationalize health care there is no need for a public option because Obamacare turns the private insurers into public utilities, thus setting us inexorably on the road to the left's Promised Land: a Canadian-style single payer system (Krauthammer, 2010). By insisting that any sort of health care reform was a back-door to Canada, counter-claimsmakers were using the distinct knowledge about Canadian health care that they had constructed in order to undermine Democrats attempts to reform health care. This has at least two practical reasons. First, counter-claimsmakers have invested a huge amount of resources into developing claims and do not have any ready-to-use claims to launch against the specifics of any non-single payer proposal. Secondly, these claims are familiar to audiences and there are groups of people that have already been persuaded by these arguments. If counter-claimsmakers can successfully argue that Obamas proposals are single payer health care by another means, they will be able to tap into already persuaded audiences. Another way of putting this is that counter-claimsmakers were attempting to make the public-option a condensing symbol for a particular package of claims about Canadian-style insurance. According to Best, a package is a familiar, more or less coherent view of a social issue, including its causes and what ought to be done about it and condensing symbols are shorthand elementslandmark narratives, typifying examples, slogans, visual images and so onthat evoke the package (2008, pp. 145-146). These packages are a part of a stock of cultural knowledge that condensing symbols try to tap into. If done successfully, audiences will treat the public option and single payer health care as synonymous concepts. The existence of a cultural stock of knowledge is apparent when counter-claimsmakers dont spell out the consequences of Canadianstyle insurance. Instead, they assume that their audiences already know

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them. For example, Senator John McCain leaves out the consequences when he claims that if you like Obamas plans then you would love Canada and England (Pear, 2008). Through audience segmentation, McCain assumes that his audience will connect Canada and England with a package of negative claims.

Conclusion
On March 23, 2010, President Obama signed into law the Patient Protection and Affordable Care Act. While this act did not include the public option, it did include many reforms to American health care. Key features of the act include: the individual mandatethe requirement that most U.S. citizens and legal residents have health insurance (enforced with penalties); the creation of state-based American Health Benefit Exchanges through which individuals can purchase coverage, with premium and cost-sharing credits available to individuals/families with income between 133-400% of the federal poverty level; the creation of separate Exchanges to help small businesses purchase coverage; penalties for employers who have employees who receive tax credits for health insurance through an Exchange (exception for small employers); and the expansion of Medicaid to 133% of the federal poverty level (The Henry J. Kaiser Family Foundation, 2011). Throughout this paper, I have been able to isolate two distinct knowledges about Canada constructed by claimsmakers and counterclaimsmakers during the United States health care reform debate of 2007-2010. Claimsmakers use moral arguments to construct Canada as a morally superior country. They do this by juxtaposing Canada with the United States. They argue that the United States is a country where medical bankruptcies are common and a country where if you get sick without adequate insurance you are out of luck. This is the opposite in Canada according to claimsmakers. One claimsmaker asserted that no one needs to choose between rent and paying medical bills in Canada. This is an essential first step in the claimsmaking process, as it problematizes American health care and opens up room for alternative proposals. From moral arguments, claimsmakers move onto arguments involving economic efficiencies. It is claimed that Canada spends less on health care and achieves better results. It is also emphasized that

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every other industrialized advanced country in the world has universal health care. This rhetoric puts Canada in the league of industrialized advanced countries, but it makes Americas membership questionable. In fact, claimsmakers often imply that Americas membership might belong in the league of poorer non-industrial countries. This creates a tension with Americas self image as a modernized society. The knowledge that counter-claimsmakers construct through their claims is distinct from and often contradicts the knowledge of claimsmakers. They make claims that put into question the quality of care in Canada. Health care is said to be rationed by national boards, creating long waiting lists, often resulting in unnecessary deaths. Anecdotal stories of Canadians fleeing to the United States for care are used to suggest that this is a common practice and that Canadians have lost confidence in their system. Counter-claimsmakers argue that innovation in Canada is lacking due to cost controls on pharmaceuticals and imply that Canada is free-riding off the innovation of the United States. Access to innovative technologies are said to be limited in Canada in order to manage costs. Counter claimsmakers also claim that Canada jeopardizes individual freedom in favour of the collective. This is used to make the claim that Canadian health care is antithetical to American values. Counter-claimsmakers directly counter claimsmakers attempts to shame America for not having a universal health care system like the rest of the industrialized world by arguing that America is a unique society. Counter-claimsmakers then use their distinct narrative about Canada, and Americas supposed uniqueness, to oppose a wide array of health care reform proposals. They do this by attempting to connect reform proposals to Canada. Even when the proposal is not a single payer health care system, they claim that the proposal is a back-door to single payer Canadian-style health care. I would like to point out that these knowledges actually exist on a continuum of knowledge, and Ive divided that continuum somewhat crudely into two segments. Differences within these segments have been underemphasized in order to aid in a comparison. With that being said, it was remarkable how small these differences actually were. I would argue that since most Americans lack the direct experience necessary to mediate the claims they hear about Canadian health care, knowledges on either side of the continuum are probably the most common in America. Knowledges in the middle are probably quite

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rare, as Americans dont have direct experience that would temper their knowledge and because there are relatively few claimsmakers with interests that would demand constructing a more moderate knowledge. As I mentioned in the introduction, knowledge about Canadian health care in Canada is not as malleable as it is in America due to this direct experience. I would hypothesize that this direct experience has a magnetic effect towards the centre. While claimsmakers and counter-claimsmakers in Canada might try to tug the Canadian public away from the centre, the effects of direct experience leads the Canadian public to believe neither that their system is perfect nor that it is broken. Marmor points out that while claims about Canada having an ineffective health care system do get airtime in Canada, public opinion polls have consistently demonstrated Canadians approval of Canadian Medicare and their rejection of American health care (2000, p. 78). Marmor also argues that claims made in the Canadian media are sometimes picked up by American media. While this is outside the scope of my paper, a future research project exploring whether or not claims permeate the border would probably garner some interesting findings. Perhaps extreme-right-wing claims that get sidelined out of Canadian public discourse find a home in America, where lack of direct experience allow these claims to enter the mainstream American discourse. Appendix Articles from the New York Times, Wall Street Journal, Washington Post, and USA Today that met the criteria for inclusion in this study: Boffey, P. M. (2007, July 5). Some Thoughts on Sickness After Seeing 'Sicko'. The New York Times . Bosman, J. (2007, October 31). Giuliani's Prostate Cancer Figure Is Disputed. The New York Times . Calfee, J. E. (2009, June 26). The Dangers of Fannie Mae Health Care. The Wall Street Journal .

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Chen, P. W. (2009, September 10). Health Care Reform and 'American Values'. The New York Times . Cohn, J. (2007, April 1). What's the One Thing Big Business and the Left Have in Common? The New York Times . Cooper, M., Bosman, J., & Sack, K. (2008, May 3). Parsing McCain on the Democrats' Health Plans. The New York Times . Cowen, T. (2007, March 22). Abolishing the Middlemen Won't Make Health Care a Free Lunch. The New York Times . du Pont, P. (2009, September 25). Bad Medicine; ObamaCare is hazardous to your health. The Wall Street Journal . Eggen, D. (2009, May 11). Ex-Hospital CEO Battles Reform Effort; Ads Cite Long Waits In Canada and Britain. The Washington Post . Eggen, D., & Connolly, C. (2009, March 5). In Health Plan, Industry Sees Good Business; Lure of New Customers Creates Unexpected Support for Obama. The Washington Post . Frank, R. H. (2007, February 15). A Health Care Plan So Simple, Even Stephen Colbert Couldn't Simplify It. The New York Times . Fuentes, A. (2007, September 19). What's wrong with nationalized health care? USA Today . Fund, J. (2009, December 10). ObamaCare Keeps Falling in the Polls; A business ad campaign could turn the tide even in the House. The Wall Street Journal . Gratzer, D. (2009, June 9). Canada's ObamaCare Precedent; Governments always ration care by making you wait. That can be deadly. The Wall Street Journal . Gratzer, D. (2007, June 28). Who's Really 'Sicko'. The Wall Street Journal .

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Hacker, J. S. (2008, March 23). Let's Try a Dose. We're Bound to Feel Better. The Washington Post . Himmelstein, D. U., & Woolhandler, S. (2007, December 15). I Am Not a Health Reform. The New York Times . Krauthammer, C. (2010, December 10). Swindle of the year. The Washington Post . Krauthammer, C. (2009, February 27). The Obamaist Manifesto. The Washington Post . Kristof, N. D. (2007, May 21). A Short American Life. The New York Times . Kristof, N. D. (2009, September 3). Health Care That Works. The New York Times . Kristof, N. D. (2009, June 15). This time around, we won't scare. The New York Times . Krugman, P. (2007, November 9). Health Care Excuses. The New York Times . Krugman, P. (2007, July 9). Health Care Terror. The New York Times . Krugman, P. (2007, February 16). The Health Care Racket. The New York Times . Krugman, P. (2007, July 16). The Waiting Game. The New York Times . Leonhardt, D. (2009, June 17). Limits In a System That's Sick. The New York Times . Mackey, J. (2009, August 12). The Whole Foods Alternative to ObamaCare. The Wall Street Journal .

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Mahar, M. (2009, November 15). If conservatives ran health care... The Washington Post . Milbank, D. (2009, June 11). It's Healthy to Vent. The Washington Post . Miller, M. (2009, September 8). Why Liberals Should Drop the Public Option. The Washington Post . Mitchell, D. (2007, July 7). What's Lacking in 'Sicko'. The New York Times . Mundy, S. V. (2009, July 27). Health-Care Debate Is Tonic for Local TV. The Wall Street Journal . Page, S. (2009, June 1). Hazards remain in push to revamp health care ; Appetite for change faces familiar hurdles. USA Today . Pear, R. (2010, August 17). Economy Led Americans to Limit Use of Routine Health Services, Study Says. The New York Times . Pear, R. (2008, October 16). Mortgages, Health Care, Free Trade And Truth. The New York Times . Pear, R. (2009, May 28). Warring Sides on Health Care Carry Their Fight to TV and Radio Ads. The New York Times . Pear, R., & Herszenhorn, D. M. (2009, August 5). Obama Pushes Democrats for Unity on Health Plan. The New York Times . Pearson, P. (2009, August 25). The truth about Canadian health care ; I've been treated in the American system and have lived with universal care in Canada. Guess which one is freer -- and more humane. USA Today . Reid, T. (2010, March 14). How health care discourages abortion. The Washington Post .

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Robinson, E. (2007, November 13). 'Socialized Medicine' Snake Oil. The Washington Post . Sack, K. (2007, June 24). For Filmmaker, 'Sicko' Is a Jumping-Off Point for Health Care Change. The New York Times . Sack, K. (2008, January 25). Health Care Up to Public, Edwards Says. The New York Times . Singer, P. (2009, July 15). Why We Must Ration Health Care. The New York Times . Tanner, M. (2009, July 1). OBAMACARE: Seven Bad Ideas for Health Care Reform. USA Today . The New York Times. (2009, November 5). The Taiwanese Project. The New York Times . The New York Times. (2009, August 26). World's Best Health Care. The New York Times . The Wall Street Journal. (2008, November 1). As Arizona Goes. The Wall Street Journal . The Wall Street Journal. (2009, September 7). Daschle's Emotional Appeal Fails to Persuade Many. The Wall Street Journal . The Wall Street Journal. (2008, November 20). The Obama Health Plan Emerges. The Wall Street Journal . The Wall Street Journal. (2010, March 20). The ObamaCare Crossroads. The Wall Street Journal . The Wall Street Journal. (2009, December 11). Worse Than the Public Option. The Wall Street Journal . The Washington Post. (2007, October 31). The Claim: Giuliani's Prognosis Would Be Worse in Britain. The Washington Post .

Constructing Canada The Washington Post. (2009, August 23). Myths About Health Care Around the World. The Washington Post .

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The Washington Post. (2010, August 12). Robert Gibbs, pulling no left jabs. The Washington Post . Troy, T. (2009, June 1). The End of Medical Miracles? Scientific discoveries are neither inevitable nor predictable. The Wall Street Journal . Ulfik, M. (2009, July 31). Health Reform and Cancer. The Wall Street Journal . USA Today. (2007, June 28). Flawed Sicko sparks debate. USA Today. USA Today. (2009, January 13). Give consumers alternative to private medical insurance. USA Today . USA Today. (2009, June 12). Health care debate kicks off in earnest. USA Today . USA Today. (2009, August 10). Misinformation, mayhem mar debate on health care. USA Today . USA Today. (2010, February 1). Overseas Care No Match for U.S. USA Today . USA Today. (2009, May 1). Putting Health Care Principles Into Practice. USA Today . Weintraub, D. (2010, February 28). Senator Pushes His Plan To Overhaul Health Care. The New York Times . Will, G. F. (2008, October 26). Stopping Dr. Statism. The Washington Post .

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Wilmouth, B. (2009, August 3). ABCs Stossel Slams Socialized Medicine, Finds Obama Expressed Interest in Single Payer System. The Wall Street Journal . Wolf, R. (2009, June 26). Cautions against public system. USA Today .

References Associated Press. (2008, January 23). Another failure to override Bush health bill veto. Retrieved April 12, 2012, from MSNBC: http://www.msnbc.msn.com/id/22805359/ns/politicswhite_house/t/another-failure-override-bush-health-bill-veto/ Audit Bureau of Circulations. (2011, March 31). ACCESS ABC: eCirc for US Newspapers. Retrieved September 25, 2011, from Audit Bureau of Circulations: http://abcas3.accessabc.com/ecirc/newstitlesearchus.asp Best, J. (2008). Social Problems. W. W. Norton & Company, Inc. Calfee, J. E. (2009, June 26). The Dangers of Fannie Mae Health Care. The Wall Street Journal . Canadian Museum of Civilization. (2010, April 21). Achieving National Standards for Hospital Insurance. Retrieved April 6, 2012, from Canadian Museum of Civilization: http://www.civilization.ca/cmc/exhibitions/hist/medicare/medic4h21e.shtml Chen, P. W. (2009, September 10). Health Care Reform and 'American Values'. The New York Times . Coakley, J., & Donnelly, P. (2009). Issues and Controversies: Sports in Society (2nd Canadian ed.). McGraw Hill.

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Cooper, M., Bosman, J., & Sack, K. (2008, May 3). Parsing McCain on the Democrats' Health Plans. The New York Times . Dobbin, F. R. (1992). The Origins of Private Social Insurance: Public Policy and Fringe Benefits in America, 1920-1950. American Journal of Sociology , 97 (5), 1416-1450. Ducey, A. (2009). Never good enough : health care workers and the false promise of job training. Ithaca and London: ILR Press/Cornell University Press. Eggen, D., & Connolly, C. (2009, March 5). In Health Plan, Industry Sees Good Business; Lure of New Customers Creates Unexpected Support for Obama. The Washington Post . Frank, R. H. (2007, February 15). A Health Care Plan So Simple, Even Stephen Colbert Couldn't Simplify It. The New York Times . Fund, J. (2009, December 10). ObamaCare Keeps Falling in the Polls; A business ad campaign could turn the tide even in the House. The Wall Street Journal . Gratzer, D. (2009, June 9). Canada's ObamaCare Precedent; Governments always ration care by making you wait. That can be deadly. The Wall Street Journal . Gratzer, D. (2007, June 28). Who's Really 'Sicko'. The Wall Street Journal . Hacker, J. S. (1998). The Historical Logic of National Health Insurance: Structure and Sequence in the Development of British, Canadian, and U.S. Medical Policy. Studies in American Political Development , 12 (Spring 1998), 57-130. Himmelstein, D. U., & Woolhandler, S. (2007, December 15). I Am Not a Health Reform. The New York Times .

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Hsieh, H.-F., & Shannon, S. E. (2005). Three Approaches to Qualitative Content Analysis. Qualitative Health Research , 15, 1277-1288. Krauthammer, C. (2010, December 10). Swindle of the year. The Washington Post . Kristof, N. D. (2007, May 21). A Short American Life. The New York Times . Kristof, N. D. (2009b, September 3). Health Care That Works. The New York Times . Kristof, N. D. (2009, June 15). This time around, we won't scare. The New York Times . Krugman, P. (2007b, November 9). Health Care Excuses. The New York Times . Krugman, P. (2007, February 16). The Health Care Racket. The New York Times . Leonhardt, D. (2009, June 17). Limits In a System That's Sick. The New York Times . Mackey, J. (2009, August 12). The Whole Foods Alternative to ObamaCare. The Wall Street Journal . Marmor, T. (2000). Fact and fiction: the Medicare 'crisis' seen from the United States. Canada Watch , 8 (4-5), 77-79. Marmor, T. R. (1993). Health Care Reform in the United States: Patterns of Fact and Fiction in the Use of Canadian Experience. American Review of Canadian Studies , 23 (1), 47-64. Marmor, T., & Sullivan, K. (2000, July). Canada's Burning! Retrieved April 6, 2012, from Washington Monthly:

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