Senator Bernie Sanders is making an all-out push to bring single-payer, universal health care to the United States. His “Medicare for All” plan would expand the single-payer model of health insurance for seniors to all Americans. Sanders has been so persuasive that some pundits now suggest support for “Medicare for All” will be a litmus test for Democratic candidates in 2020.

Unfortunately, Sanders conflates single-payer health care with universal health care, and fundamentally misunderstands the reality of single-payer health care. He seems primarily interested in achieving universality, that is, coverage of all Americans for health-care services regardless of the ability to pay. His website says health care should be a “right” not a “privilege” and every American should be “able to access the health care they need regardless of their income”.

In reality, the link between single-payer health care and universality is incredibly weak to the point of being non-existent. Amongst industrialized countries (referred to as the OECD), Canada stands alone in its approach to using a single-payer (government) system to achieve universal health-care coverage. Almost all of the major industrialized countries with universal health care, of which there are at least 28 in addition to Canada, achieve universality through other means such as mandated health insurance. Put simply, single-payer health care is not a prerequisite for universal health care.

There are, therefore, critical lessons for the U.S. from the Canadian experience with single-payer health care. First, it’s important to recognize that single-payer, universal health care simply ensures universal insurance for health services. As Canadians across the country can attest, it does not guarantee access, let alone timely access.

It’s widely recognized both within and outside of Canada that wait lists for medical services are a standard feature of the country’s health-care system. The latest national data (2016) for wait times indicates that the median wait to see a specialist for treatment after receiving a referral from a GP was 20 weeks, the longest on record.

Further, the latest international report by the Commonwealth Fund, which compares 10 industrialized countries with universal health care and the United States found that Canadians suffered wait times more than any other country surveyed. Specifically, 30 per cent of Canadians reported waiting two months or longer for a specialist compared to 3 per cent in Germany, 6 per cent in the U.S., 7 per cent in the Netherlands, and 9 per cent in Switzerland.

These wait times impose real costs on patients and their families including increased physical pain, mental anguish, loss of wages, and too often poorer medical outcomes including transforming potentially reversible illnesses into chronic, irreversible conditions, or even permanent disabilities.

Moreover, Canada’s health-care system is riddled with poor access and performance. As summarized in a recent comparative report, Canada ranks 25^th out of 29 OECD countries with universal health care on the number of doctors, and last for acute care beds (adjusted for population and age structure of the population). Similarly, Canadians suffer from a lack of access to medical technology including MRI units (20^th out of 27 countries), CT scanners (22^nd out of 28) and PET scanners (18^th out of 24).

Crucially, these results are not for a want of resources. Canada ranks third in terms of spending on health care as a share of the economy (GDP) among industrialized countries with universal health care. Indeed, the previously cited Commonwealth Fund report concluded that Canada was an “underperforming country” in terms of the amount of resources spent on health care compared to performance.

Therefore, as Senator Sanders and others in the U.S. push for “Medicare for All,” the Canadian experience can be instructive. One of the main problems with Canada’s universal health-care system is that it’s based on a single-payer model, which means centralized government has come to dominate the regulation, financing and delivery of health-care services. This combination of relatively high spending and comparatively poor performance should be a warning to those advocating its duplication in the U.S.

Jason Clemens and Niels Veldhuis are economists with the Fraser Institute, a Canadian-based, independent research organization.