Ask people in Canada what they make of U.S. health care, and the answer typically falls between bewilderment and outrage.
Canada, after all, prides itself on a health system that guarantees government insurance for everyone. And many Canadians find it baffling that there's anybody in the United States who can't afford a visit to the doctor.
So even as Canadians throw shade at the American hodgepodge of public plans, private insurance, deductibles and copays, they hold in high esteem a little-known Affordable Care Act initiative: the federal Center for Medicare & Medicaid Innovation.
CMMI was a hot topic on a reporter's recent visit to Toronto to study the single-payer health care system.
Wonky as it seems, the center's mission — testing innovations to hold down health care costs while increasing quality — is drawing praise from many policy analysts. Researchers and clinicians talk about its potential to foster experimentation and how it has led the United States to think creatively about payment and reimbursement models.
"It is gaining traction in many circles here," says Dr. Robert Reid, who researches health care quality at the University of Toronto.
Thanks to the ACA, the center for innovation is equipped with $10 billion each decade and sponsors on-the-ground experiments with doctors, health systems and payers. The idea is to devise and implement payment approaches for health care services that reward quality and efficiency, rather than the number of procedures performed.
"There have been some good efforts — they have tried more things than we have," agrees Dr. Kaveh Shojania, an internist at same university who studies health care quality and safety.
Still, despite the praise emanating from north of the border, the U.S. program doesn't get the same love on the homefront. Since taking office, President Donald Trump has moved to roll back the center's reach.
Canada has its own reasons for seeing potential in this sort of systemic test kitchen.
Health care's growing price tag — and a payment system that doesn't always reward keeping people healthy — is not just an American problem. The vast majority of Canadian doctors are paid through what Americans call the "fee-for-service" model. And Canadian policymakers are also looking for strategies to curb health care costs — which are a big part of federal and provincial budgets in Canada, too.
"The whole world is confronting the same issue, which is, 'How do you pay and incentivize doctors to keep people out of the hospital and keep them healthy?' " says Dr. Ezekiel Emanuel, a former adviser to President Barack Obama, who pushed for the center's initial development.
"Different places are looking at how to break out of that system, because everyone knows its perversions," Emanuel says. "This is one place where ... we are in the world among the most innovative groups."
Emanuel says he's not surprised to hear of the center's appeal in Canada. He has received similar feedback from health ministers in Belgium and France, he says.
And, so far, the Trump administration has taken steps to reduce by half the size of one high-profile Obama administration project that bundles payments for hip and knee replacements. Under the bundling program, the hospitals performing those are paid a set amount, rather than for individual services. The administration has also canceled other scheduled "bundling" projects that target payment for cardiac care and other joint replacements.
Seema Verma, Trump's administrator of the Centers for Medicare and Medicaid Services, wrote in The Wall Street Journal in September that the innovation center was going to begin moving "in a new direction."
A federal document recently issued by CMS suggests that the center for innovation will now emphasize cutting health care costs through strategies like market competition, eliminating fraud and helping consumers actually shop for care. It also says the innovation center will favor smaller-scale projects.
At least for now, it's hard to interpret exactly what this means, says Jack Hoadley, a health policy analyst at Georgetown University who has previously worked at the Department of Health and Human Services.
Limiting CMMI's footprint in the U.S. would be problematic, Emanuel says.
Meanwhile, the center's influence in Canada, seems to be growing.
"We definitely looked to it as a model as something we can do. Like look, this happened, and why can't we do the same thing here?" says Dr. Tara Kiran, a Toronto-based primary care doctor who also researches health care quality.