this difference is a relatively recent development. in 1971 the nations were much closer, with canada spending 7.1% of gdp while the u.s. spent 7.6%. some who advocate against greater government involvement in healthcare have asserted that the difference in costs between the two nations is partially explained by the differences in their demographics. illegal immigrants, more prevalent in the u.s. than in canada, also add a burden to the system, as many of them do not carry health insurance and rely on emergency rooms — which are legally required to treat them under emtala — as a principal source of care. in colorado, for example, an estimated 80% of undocumented immigrants do not have health insurance. the mixed system in the united states has become more similar to the canadian system. in recent decades, managed care has become prevalent in the united states, with some 90% of privately insured americans belonging to plans with some form of managed care. in managed care, insurance companies control patients' health care to reduce costs, for instance by demanding a second opinion prior to some expensive treatments or by denying coverage for treatments not considered worth their cost. through all entities in its public–private system, the us spends more per capita than any other nation in the world, but is the only wealthy industrialized country in the world that lacks some form of universal healthcare. in march 2010, the us congress passed regulatory reform of the american 'health insurance system. however, since this legislation is not fundamental healthcare reform, it is unclear what its effect will be and as the new legislation is implemented in stages, with the last provision in effect in 2018, it will be some years before any empirical evaluation of the full effects on the comparison could be determined. healthcare costs in both countries are rising faster than inflation. as both countries consider changes to their systems, there is debate over whether resources should be added to the public or private sector. although canadians and americans have each looked to the other for ways to improve their respective health care systems, there exists a substantial amount of conflicting information regarding the relative merits of the two systems. in the u.s., canada's mostly monopsonistic health system is seen by different sides of the ideological spectrum as either a model to be followed or avoided. medical professionals some of the extra money spent in the united states goes to physicians, nurses, and other medical professionals. according to health data collected by the oecd, average income for physicians in the united states in 1996 was nearly twice that for physicians in canada. in 2012, the gross average salary for doctors in canada was cdn$328,000. out of the gross amount, doctors pay for taxes, rent, staff salaries and equipment. in canada, less than half of doctors are specialists whereas more than 70% of doctors are specialists in the u.s. canada has fewer doctors per capita than the united states. in the u.s, there were 2.4 doctors per 1,000 people in 2005; in canada, there were 2.2. some doctors leave canada to pursue career goals or higher pay in the u.s., though significant numbers of physicians from countries such as china, india, pakistan and south africa immigrate to practice in canada. many canadian physicians and new medical graduates also go to the u.s. for post-graduate training in medical residencies. as it is a much larger market, new and cutting-edge sub-specialties are more widely available in the u.s. as opposed to canada. however, statistics published in 2005 by the canadian institute for health information (cihi), show that, for the first time since 1969 (the period for which data are available), more physicians returned to canada than moved abroad. drugs both canada and the united states have limited programs to provide prescription drugs to the needy. in the u.s., the introduction of medicare part d has extended partial coverage for pharmaceuticals to medicare beneficiaries. in canada all drugs given in hospitals fall under medicare, but other prescriptions do not. the provinces all have some programs to help the poor and seniors have access to drugs, but while there have been calls to create one, no national program exists. about two thirds of canadians have private prescription drug coverage, mostly through their employers. in both countries, there is a significant population not fully covered by these programs. a 2005 study found that 20% of canada's and 40% of america's sicker adults did not fill a prescription because of cost. furthermore, the 2010 commonwealth fund international health policy survey indicates that 4% of canadians indicated that they did not visit a doctor because of cost compared with 22% of americans. additionally, 21% of americans have said that they did not fill a prescription for medicine or have skipped doses due to cost. that is compared with 10% of canadians. one of the most important differences between the two countries is the much higher cost of drugs in the united states. in the u.s., $728 per capita is spent each year on drugs, while in canada it is $509. at the same time, consumption is higher in canada, with about 12 prescriptions being filled per person each year in canada and 10.6 in the united states. the main difference is that patented drug prices in canada average between 35% and 45% lower than in the united states, though generic prices are higher. the price differential for brand-name drugs between the two countries has led americans to purchase upward of $1 billion us in drugs per year from canadian pharmacies. there are several reasons for the disparity. the canadian system takes advantage of centralized buying by the provincial governments that have more market heft and buy in bulk, lowering prices. by contrast, the u.s. has explicit laws that prohibit medicare or medicaid from negotiating drug prices. in addition, price negotiations by canadian health insurers are based on evaluations of the clinical effectiveness of prescription drugs, allowing the relative prices of therapeutically similar drugs to be considered in context. the canadian patented medicine prices review board also has the authority to set a fair and reasonable price on patented products, either comparing it to similar drugs already on the market, or by taking the average price in seven developed nations. prices are also lowered through more limited patent protection in canada. in the u.s., a drug patent may be extended five years to make up for time lost in development. some generic drugs are thus available on canadian shelves sooner. the pharmaceutical industry is important in both countries, though both are net importers of drugs. both countries spend about the same amount of their gdp on pharmaceutical research, about 0.1% annually technology the united states spends more on technology than canada. in a 2004 study on medical imaging in canada, it was found that canada had 4.6 mri scanners per million population while the u.s. had 19.5 per million. canada's 10.3 ct scanners per million also ranked behind the u.s., which had 29.5 per million. the study did not attempt to assess whether the difference in the number of mri and ct scanners had any effect on the medical outcomes or were a result of overcapacity but did observe that mri scanners are used more intensively in canada than either the u.s. or great britain. this disparity in the availability of technology, some believe, results in longer wait times. in 1984 wait times of up to 22 months for an mri were alleged in saskatchewan. however, according to more recent official statistics (2007), all emergency patients receive mris within 24 hours, those classified as urgent receive them in under 3 weeks and the maximum elective wait time is 19 weeks in regina and 26 weeks in saskatoon, the province's two largest metropolitan areas. according to the health council of canada's 2010 report "decisions, decisions: family doctors as gatekeepers to prescription drugs and diagnostic imaging in canada", the canadian federal government invested $3 billion over 5 years (2000–2005) in relation to diagnostic imaging and agreed to invest a further $2 billion to reduce wait times. these investments led to an increase in the number of scanners across canada as well as the number of exams being performed. the number of ct scanners increased from 198 to 465 and mri scanners increased from 19 to 266 (more than tenfold) between 1990 and 2009. similarly, the number of ct exams increased by 58% and mri exams increased by 100% between 2003 and 2009. in comparison to other oecd countries, including the us, canada's rates of mri and ct exams falls somewhere in the middle. nevertheless, the canadian association of radiologists claims that as many as 30% of diagnostic imaging scans are inappropriate and contribute no useful information. malpractice litigation the extra cost of malpractice lawsuits is a proportion of health spending in both the u.s. (1.7% in 2002) and canada (0.27% in 2001 or $237 million). in canada the total cost of settlements, legal fees, and insurance comes to $4 per person each year, but in the united states it is over $16. average payouts to american plaintiffs were $265,103, while payouts to canadian plaintiffs were somewhat higher, averaging $309,417. however, malpractice suits are far more common in the u.s., with 350% more suits filed each year per person. while malpractice costs are significantly higher in the u.s., they constitute a small proportion of total medical spending. the total cost of defending and settling malpractice lawsuits in the u.s. in 2004 was over $28 billion. critics say that defensive medicine consumes up to 9% of american healthcare expenses., but cbo studies suggest that it is much smaller. ancillary expenses there are a number of ancillary costs that are higher in the u.s. administrative costs are significantly higher in the u.s.; government mandates on record keeping and the diversity of insurers, plans and administrative layers involved in every transaction result in greater administrative effort. one recent study comparing administrative costs in the two countries found that these costs in the u.s. are roughly double what they are in canada. another ancillary cost is marketing, both by insurance companies and health care providers. these costs are higher in the u.s., contributing to higher overall costs in that nation. healthcare outcomes life expectancy vs healthcare spending of rich oecd countries. in the world health organization's rankings of healthcare system performance among 191 member nations published in 2000, canada ranked 30th and the u.s. 37th, while the overall health of canadians was ranked 35th and americans 72nd. however, the who's methodologies, which attempted to measure how efficiently health systems translate expenditure into health, generated broad debate and criticism. researchers caution against inferring healthcare quality from some health statistics. june o'neill and dave o'neill point out that "... life expectancy and infant mortality are both poor measures of the efficacy of a health care system because they are influenced by many factors that are unrelated to the quality and accessibility of medical care". in 2007, gordon h. guyatt et al. conducted a meta-analysis, or systematic review, of all studies that compared health outcomes for similar conditions in canada and the u.s., in open medicine, an open-access peer-reviewed canadian medical journal. they concluded, "available studies suggest that health outcomes may be superior in patients cared for in canada versus the united states, but differences are not consistent." guyatt identified 38 studies addressing conditions including cancer, coronary artery disease, chronic medical illnesses and surgical procedures. of 10 studies with the strongest statistical validity, 5 favoured canada, 2 favoured the united states, and 3 were equivalent or mixed. of 28 weaker studies, 9 favoured canada, 3 favoured the united states, and 16 were equivalent or mixed. overall, results for mortality favoured canada with a 5% advantage, but the results were weak and varied. the only consistent pattern was that canadian patients fared better in kidney failure. in terms of population health, life expectancy in 2006 was about two and a half years longer in canada, with canadians living to an average of 79.9 years and americans 77.5 years. infant and child mortality rates are also higher in the u.s. some comparisons suggest that the american system underperforms canada's system as well as those of other industrialized nations with universal coverage.