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Certified coach Kathleen Muldoon discusses her article, “Choosing between care and country: a dual citizen’s Independence Day reflection.” As a dual U.S. and Canadian citizen and mother to a child with complex health care needs, she explores the profound tension of navigating two vastly different systems. Kathleen recounts the painful, personal decision to turn down a job in her native Canada after discovering its universal system, while philosophically aligned with her values, would likely fail to provide the timely, specialized support her son requires. The conversation delves into the “quiet grief” of choosing the fragmented but fast-moving U.S. system to meet her son’s needs at the cost of her own well-being and a return to her homeland. Kathleen explains how this trade-off informs her work in medical humanities, highlighting how health care systems reflect deep cultural priorities about interdependence and worthiness, and the hidden emotional costs for the caregivers who must live within them. The key takeaway is that no system is perfect, and true citizenship involves loving a country enough to name its limits and bravely holding the tension of uncomfortable choices.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome back Kathleen Muldoon. She is a certified coach and a professor of medical humanities. Today’s KevinMD article is “Choosing between care and country, a dual citizen’s Independence Day reflection.” Kathleen, welcome back to the show.

Kathleen Muldoon: Thank you for having me.

Kevin Pho: All right, so what’s your latest article about?

Kathleen Muldoon: My latest article came together as I was sitting in this space that we all just went through as a country. In North America, we have three important shared countries with very different systems of care. It just so happens that I am Canadian-born, and I moved here for grad school in 2000, so I experienced the Canadian health care system growing up but became of age as a medical educator, a coach, a caregiver, and a parent in the U.S. system. I am a parent of a child with significant medical complexity.

Especially this year in 2025, in that time period between Canada Day, which is July 1st, and Independence Day, July 4th, was also the time period where Medicaid cuts were being discussed and bounced around between the Senate and the House. It just really struck me: that tension of navigating systems that are meant to support care. What does that mean, both for myself, as someone who trains future health care providers and who works with physicians who are experiencing the moral injury of the stress on the system here in the U.S. and elsewhere, and as a caregiver myself? What does this mean that we’re thinking about where our priorities lie in terms of how we support the health of our population? That’s where the article came from.

Kevin Pho: All right, so like you, I’m a dual citizen myself. I actually grew up in Canada as well, but I’ve been in the States for 30-plus years, so that time period between July 1st and July 4th, I can understand. I still have a lot of family in Canada. I can understand that liminal space, as you put it in your article, every year between those two dates. In your article, you talk about a choice between working in Canada and working in the United States. So tell us about that story.

Kathleen Muldoon: I was recently faced with a choice about accepting an offer for a position, which would’ve been wonderful, and actually in my hometown where a new med school is being built. I really wanted to go. There’s a large part of me that misses home, being close to family, and espouses those Canadian values of diversity, interdependence, and community care. But what I realized in considering that choice is that I bring my whole self there, including my family and including my son, who has something like 22 health care specialists that support his needs. I have aging family, and watching them trying to navigate the system of home and community-based services, which I think I’ve become quite an expert at managing here for my own family, is hard.

I had to come to the decision. Canadians really view our health care system with a sense of pride, and I think even as expats. For my son, who exists at the exceptional level of care, a universal system doesn’t always meet his needs. I understand that there are some conversations about having a mixed model and what this means moving forward in Canada. But it forced me to reckon with the fact that the systems here are very individual-focused, and a lot of the care coordination falls to the parents and the caregivers. I say caregivers in terms of the person managing the care, and a lot of times that is the guardian or the parent with maybe some support in the U.S. from a support care coordinator.

What I was forced to reckon with, and the reason why I turned the job down, is that I don’t think it would be the best fit for my family right now. Given that the universal system is built for the majority, and as he exists at the exceptional level, I just don’t think that his care needs could be met. So I had to make this choice. It’s closer to my family, and I’d have more natural supports, maybe, and a community through blood there. I built a community through commonality of caregiving experience and advocacy here. And this is, for now, what suits my family, even if my heart belongs home.

Kevin Pho: So let’s talk about the distinctions between the Canadian and American health care systems. You mentioned earlier that many Canadians view their health care system with pride. For those who aren’t familiar with the Canadian health care system, just broadly speaking, why is that so?

Kathleen Muldoon: That’s a big question. When I was first learning about Canadian history as I was growing up, experiencing it and all those things, oftentimes we think about it in terms of how we are different and how Canada’s been shaped by being in such close proximity to the United States. So there have been different choices that Canada made about achieving legislative independence from England and the pattern of choices around conversation and peacekeeping that have shaped Canadian nationalism.

Health care is intimately tied into that. Tommy Douglas, who is one of the co-founders of the universal system, is, I think, considered a Canadian hero. When I think of Canadian heroes, I think of Terry Fox. I think of people that did a lot for bringing to national attention the way that we care for each other and have that interdependence.

The universal system in Canada espouses those values that we are a collective society that values caring for each other across the life spectrum. That is just ingrained into everything, from beer commercials to a lot of the CBC programming. So, I just think it’s hard, and I think we are called into community to collectively take a look at how this is serving us and how is it moving us forward, which is really hard for anybody to do, but think about an entire nation being called into doing it.

Kevin Pho: It’s tough.

Now, you mentioned earlier that one of the decision points was because you’re a caregiver, obviously, and your child required—you mentioned—20-plus physicians and specialists. So talk more about that decision and how that highlights some of the distinctions, the strengths and weaknesses, between the two systems.

Kathleen Muldoon: My son has significant care needs, and in Canada, it is tougher. My son is 11 years old now. Moving an 11-year-old child who didn’t grow up and accumulate those providers—that team—through his growth to go and try to construct a team of pediatric specialists is difficult. It’s more difficult to come by those pediatric specialists. It’s difficult to navigate wait lists, especially when you have ongoing and chronic conditions that require preventative management. What I saw is that it’s difficult not only to get into the specialist but also to create that team of care, especially if you’re not in a metropolitan area. The home and community-based services are based on more of a rehab model instead of ongoing care.

The difference is that my son’s team here was constructed as he grew, so I’m very comfortable with the number of the members. We even collaborate outside of his care on some research projects and things. But here, especially as it is a state-by-state basis how Medicaid is enacted, there is no… Arizona has typically been ranked as the number one state for supports for people with disabilities, and so there are no wait lists to care. I can self-refer to specialists. His home and community-based services will be, as it stands currently, ongoing in support, and we shift the goal. It’s not graduating.

For example, my son uses a wheelchair and an augmentative communication device. It’s understood that the goal is not to get my son walking. He’s not going to jump out of the wheelchair and start dancing around. But how do we strengthen and use the skills that he does have for function, for as much independence as he will have? That includes helping to stand for transfers, being able to communicate in multiple and varied situations with his eye-gaze communication device, and using his head switch array to drive his wheelchair on his own.

These are all very exceptional circumstances that require ongoing support, not in magnets where you get five sessions and then you graduate, which has been my experience supporting from a distance some of my family members who have in-home care needs in the Canadian system. The difference is that he is able to get that individualized level of care because of the shared system between our private insurance, which covers some of that, but most of it’s actually put off into the Medicaid system for those home and community-based services, which are not typically covered by private insurance.

Kevin Pho: So I hear that you’re, of course, couching these services because we don’t know what’s going to happen in the future. From where you stand, tell us about how some of these threats and cuts to Medicaid will affect some of these services going forward.

Kathleen Muldoon: Medicaid, I think what people don’t recognize, and what I’ve been advocating hard for over the last few months here with our legislators in Arizona, is that Medicaid is actually the invisible backbone that keeps our health care system in the U.S. functioning. It keeps the industry working. It keeps it funded. Even if you’re not somebody who uses Medicaid, without those supports, therapy clinics close, and special education departments have to let staff go because that’s all underwritten by Medicaid funding.

Premiums can skyrocket—and when I say premiums, I mean private insurance premiums—because people who have been using Medicaid to support home care, oftentimes with institutional and hospital-level of care but getting it in the home through Medicaid, can no longer access those services. They go to the hospital, hospitals become overwhelmed, wait times increase and become unmanageable, and people end up in hospitals. So they’re using systems in ways that they weren’t built for because that infrastructure that we all take for granted is being challenged.

A narrative that I’m hearing is either, “My son is so disabled, it won’t affect us,” or, “That’s not an issue I’m involved with because I don’t use Medicaid.” I think that there is a misunderstanding about how much Medicaid ties the whole system together. So I think that we will feel the impacts across the board. I say that as someone who’s training health care professionals and coaching people through their fears about what’s to come. I say it as a caregiver and seeing how this is going to directly impact my family, but I also say this to this clinician audience: You are also the frontline workers of this care. If care is the core value that we hold, then I think that we need to recognize that those systems are about to be challenged.

Kevin Pho: Do you ever feel that you may revisit your decision and perhaps consider a transfer to the Canadian system going forward?

Kathleen Muldoon: I think about it often. The thing that kept me here is the supports that we have been very grateful to interact with so far. If that changes, then I think at the core of all of my decision-making, a lot of my writing, especially for your pages, centers on the fact that I am authentically and holistically a professional, a mother, and a caregiver, and I center my family in all of my decisions. So if the best care moving forward would be to move to Canada, I am open. If anybody’s watching, I’m open. I’m just kidding. But yes, because I think sometimes we have to choose between our shared values, and to me, part of that is loving something enough to name its limits, and that includes the systems that we work within.

Kevin Pho: We often hear about many things that the United States can learn from Canada: the universal system. Some proponents are going to be supportive of health care being more government-run. Are there some things that the Canadian system can learn from the United States? Essentially, after considering everything, you decided to stay partly because of the vast number of support systems for your son. Does that point to some things the Canadian system can learn from the Americans?

Kathleen Muldoon: I definitely think so. I think that especially as more medical schools are popping up in Canada, my understanding is that there needs to be a conversation around how are you growing those residency spots? How are you increasing access to care so that the wait lists for preventative and ongoing care are reduced? To my knowledge, there is no system of, for example, physician assistants in Canada. I teach in an osteopathic medical school; that’s not a type of training that exists in Canada at the current time. So I think in terms of how you create space for increasing the health care workforce to decrease the burden, that is something to be considered.

But I also think one of the things that I value here is that you have to be able to meet the needs of people, even at those extraordinary levels of care. Everywhere, as health care has gotten better, people are living longer, and disability includes old age. Having those support systems in place to reach individuals who need and would fare better with in-home supports includes having better systems of home and community-based services that are not based on a rehabilitative model but are based on quality of life. Palliative care comes up often in our conversations, as does primary care. What does that look like, and how do you support people to move into these models?

Those are the things that I think are valuable from the American system as it exists right now: that there’s a partnership between private levels of insurance and maybe… I actually read a piece on your website about what a mixed model looks like and whether there are advantages to having private insurance, especially for people who have exceptional levels of care that could be shared with a government-based public system. But we have to move away from the model that public health care is sick care and more towards public health care actually supporting quality of life. All the research shows that this is best occurring with natural, essential support and in people’s homes and in their families.

Kevin Pho: We’re talking to Kathleen Muldoon. She’s a professor of medical humanities and a certified coach. Today’s KevinMD article is “Choosing between care and country, a dual citizen’s Independence Day reflection.” Kathleen, as always, let’s end with some take-home messages that you want to leave with the KevinMD audience.

Kathleen Muldoon: What I really want to encourage people is: don’t be afraid of those tough questions. In order to really engage with making a system better, which to me is an expression of love, we have to be able to name its limits. For me, the big questions to grapple with are: What does it mean to be part of a profession where care is at its core and where we’re having to navigate difficult choices to provide the best care for the people that we love? That could be someone in our family, or it could be our patients. So don’t be afraid to wrestle with those questions because I think that’s where the answers are going to come from.

Kevin Pho: Kathleen, as always, thank you so much for sharing your story and perspective, and thanks again for coming back on the show.

Kathleen Muldoon: Thank you.