study in health affairs that concluded that half of personal bankruptcies involved medical bills. although other sources dispute this, it is possible that medical debt is the principal cause of bankruptcy in the united states. a number of clinics provide free or low-cost non-emergency care to poor, uninsured patients. the national association of free clinics claims that its member clinics provide $3 billion in services to some 3.5 million patients annually. a peer-reviewed comparison study of healthcare access in the two countries published in 2006 concluded that u.s. residents are one third less likely to have a regular medical doctor (80% vs 85%), one fourth more likely to have unmet healthcare needs (13% vs 11%), and are more than twice as likely to forgo needed medicines (1.7% vs 2.6%). the study noted that access problems "were particularly dire for the us uninsured." those who lack insurance in the u.s. were much less satisfied, less likely to have seen a doctor, and more likely to have been unable to receive desired care than both canadians and insured americans. another cross-country study compared access to care based on immigrant status in canada and the u.s. findings showed that in both countries, immigrants had worse access to care than non-immigrants. specifically, immigrants living in canada were less likely to have timely pap tests compared with native-born canadians; in addition, immigrants in the u.s. were less likely to have a regular medical doctor and an annual consultation with a health care provider compared with native-born americans. in general, immigrants in canada had better access to care than those in the u.s., but most of the differences were explained by differences in socioeconomic status (income, education) and insurance coverage across the two countries. however, immigrants in the u.s. were more likely to have timely pap tests than immigrants in canada. cato institute has expressed concerns that the u.s. government has restricted the freedom of medicare patients to spend their own money on healthcare, and has contrasted these developments with the situation in canada, where in 2005 the supreme court of canada ruled that the province of quebec could not prohibit its citizens from purchasing covered services through private health insurance. the institute has urged the congress to restore the right of american seniors to spend their own money on medical care. coverage for mental health the canada health act covers the services of psychiatrists, who are medical doctors with additional training in psychiatry but does not cover treatment by a psychologist or psychotherapist unless the practitioner is also a medical doctor. goods and services tax or harmonized sales tax (depending on the province) applies to the services of psychotherapists. some provincial or territorial programs and some private insurance plans may cover the services of psychologists and psychotherapists, but there is no federal mandate for such services in canada. in the u.s., the affordable care act includes prevention, early intervention, and treatment of mental and/or substance use disorders as an "essential health benefit" (ehb) that must be covered by health plans that are offered through the health insurance marketplace. under the affordable care act, most health plans must also cover certain preventive services without a copayment, co-insurance, or deductible. in addition, the u.s. mental health parity and addiction equity act (mhpaea) of 2008 mandates "parity" between mental health and/or substance use disorder (mh/sud) benefits and medical/surgical benefits covered by a health plan. under that law, if a health care plan offers mental health and/or substance use disorder benefits, it must offer the benefits on par with the other medical/surgical benefits it covers. wait times one complaint about both the u.s. and canadian systems is waiting times, whether for a specialist, major elective surgery, such as hip replacement, or specialized treatments, such as radiation for breast cancer; wait times in each country are affected by various factors. in the united states, access is primarily determined by whether a person has access to funding to pay for treatment and by the availability of services in the area and by the willingness of the provider to deliver service at the price set by the insurer. in canada, the wait time is set according to the availability of services in the area and by the relative need of the person needing treatment. as reported by the health council of canada, a 2010 commonwealth survey found that 39% of canadians waited 2 hours or more in the emergency room, versus 31% in the u.s.; 43% waited 4 weeks or more to see a specialist, versus 10% in the u.s. the same survey states that 37% of canadians say it is difficult to access care after hours (evenings, weekends or holidays) without going to the emergency department compared to over 34% of americans. furthermore, 47% of canadians and 50% of americans who visited emergency departments over the past two years feel that they could have been treated at their normal place of care if they were able to get an appointment. a 2018 survey conducted by the fraser institute, a conservative-libertarian public policy think tank, found that wait times in canada for a variety of medical procedures reached "an all-time high". appointment duration (meeting with physicians) averaged under two minutes. these very fast appointments are a result of physicians attempting to accommodate for the number of patients using the medical system. in these appointments, however, diagnoses or prescriptions were rarely given, where the patients instead were almost always referred to specialists to receive treatment for their medical issues. according to the fraser institute, patients in canada waited an average of 19.8 weeks to receive treatment, regardless of whether they were able to see a specialist or not. in the u.s., the average wait time for a first-time appointment is 24 days (≈3 times faster than in canada); wait times for emergency room (er) services averaged 24 minutes (more than 4x faster than in canada); wait times for specialists averaged between 3–6.4 weeks (over 6x faster than in canada). in response to these findings, the physicians for a national health program (pnhp), an advocacy organization comprising more than 20,000 american medical professionals, identified statistical problems with the fraser institute's reporting. namely, the report relies on a survey of canadian physicians with a response rate of only 15.8%. distributing these responses amongst the 12 specialties and ten provinces results in single-digit tallies for 63 per cent of the categories, and often only one physician falling into a given category. conversely, a study conducted by the canadian institute for health information indicated that canada has been successful in delivering care within medically recommended wait times. in the u.s., patients on medicaid, the low-income government programs, can wait up to a maximum of 12 weeks to see specialists (12 weeks less than the average wait time in canada). because medicaid payments are low, some have claimed that some doctors do not want to see medicaid patients in canada. for example, in benton harbor, michigan, specialists agreed to spend one afternoon every week or two at a medicaid clinic, which meant that medicaid patients had to make appointments not at the doctor's office, but at the clinic, where appointments had to be booked months in advance. a 2009 study found that on average the wait in the united states to see a medical specialist is 20.5 days. in a 2009 survey of physician appointment wait times in the united states, the average wait time for an appointment with an orthopedic surgeon in the country as a whole was 17 days. in dallas, texas the wait was 45 days (the longest wait being 365 days). nationwide across the u.s. the average wait time to see a family doctor was 20 days. the average wait time to see a family practitioner in los angeles, california was 59 days and in boston, massachusetts it was 63 days. studies by the commonwealth fund found that 42% of canadians waited 2 hours or more in the emergency room, vs. 29% in the u.s.; 57% waited 4 weeks or more to see a specialist, vs. 23% in the u.s., but canadians had more chances of getting medical attention at nights, or on weekends and holidays than their american neighbors without the need to visit an er (54% compared to 61%). statistics from the fraser institute in 2008 indicate that the average wait time between the time when a general practitioner refers a patient for care and the receipt of treatment was almost four and a half months in 2008, roughly double what it had been 15 years before. a 2003 survey of hospital administrators conducted in canada, the u.s., and three other countries found dissatisfaction with both the u.s. and canadian systems. for example, 21% of canadian hospital administrators, but less than 1% of american administrators, said that it would take over three weeks to do a biopsy for possible breast cancer on a 50-year-old woman; 50% of canadian administrators versus none of their american counterparts said that it would take over six months for a 65-year-old to undergo a routine hip replacement surgery. however, u.s. administrators were the most negative about their country's system. hospital executives in all five countries expressed concerns about staffing shortages and emergency department waiting times and quality. in a letter to the wall street journal, robert bell, the president and ceo of university health network, toronto, said that michael moore's film sicko "exaggerated the performance of the canadian health system — there is no doubt that too many patients still stay in our emergency departments waiting for admission to scarce hospital beds." however, "canadians spend about 55% of what americans spend on health care and have longer life expectancy and lower infant mortality rates. many americans have access to quality healthcare. all canadians have access to similar care at a considerably lower cost." there is "no question" that the lower cost has come at the cost of "restriction of supply with sub-optimal access to services," said bell. a new approach is targeting waiting times, which are reported on public websites. in 2007 shona holmes, a waterdown, ontario woman who had a rathke's cleft cyst removed at the mayo clinic in arizona, sued the ontario government for failing to reimburse her $95,000 in medical expenses. holmes had characterized her condition as an emergency, said she was losing her sight and portrayed her condition as a life-threatening brain cancer. in july 2009 holmes agreed to appear in television ads broadcast in the united states warning americans of the dangers of adopting a canadian-style health care system. the ads she appeared in triggered debates on both sides of the border. after her ad appeared critics pointed out discrepancies in her story, including that rathke's cleft cyst, the condition she was treated for, was not a form of cancer, and was not life-threatening. price of health care and administration overheads healthcare is one of the most expensive items of both nations' budgets. in the united states, the various levels of government spend more per capita than levels of government do in canada. in 2004, canada government-spending was $2,120 (in us dollars) per person, while the united states government-spending was $2,724. administrative costs are also higher in the united states than in canada. a 1999 report found that after exclusions, administration accounted for 31.0% of healthcare expenditures in the united states, as compared with 16.7% in canada. in looking at the insurance element, in canada, the provincial single-payer insurance system operated with overheads of 1.3%, comparing favourably with private insurance overheads (13.2%), u.s. private insurance overheads (11.7%) and u.s. medicare and medicaid program overheads (3.6% and 6.8% respectively). the report concluded by observing that gap between u.s. and canadian spending on administration had grown to $752 per capita and that a large sum might be saved in the united states if the u.s. implemented a canadian-style system. however, u.s. government spending covers less than half of all healthcare costs. private spending is also far greater in the u.s. than in canada. in canada, an average of $917 was spent annually by individuals or private insurance companies for health care, including dental, eye care, and drugs. in the u.s., this sum is $3,372. in 2006, healthcare consumed 15.3% of u.s. annual gdp. in canada, 10% of gdp was spent on healthcare.