| I was back at the doctor’s last week, having injured my right knee about a month before. I’d been telling people it was probably ligaments – even though I’m pretty vague as to what or even just where ligaments are – but after clicking the joint back and forth, the doctor said it was more serious. "We’ll take some X-rays, an MRI and then an arthroscopy if necessary," he said, handing me the necessary lab forms and assuring me that, yes, I would be able to run again.
Twenty minutes later, a technician was putting the X-rays into a brown envelope. She laughed when I said the MRI was next. The waiting list was weeks long, she told me, and as for any eventual operation, well, that could be months or even longer. Suddenly, a return to running looked less likely.
I hobbled back home just in time to hear the Supreme Court’s 4-3 decision to overturn the Quebec ruling against private health insurance. The implications were obvious. "The prohibition of private delivery is not necessary to guarantee the integrity of the public plan," argued Madam Justice Marie Deschamps. In short, public and private health care could occupy the same universe without either one imploding.
Responses were immediate and more or less predictable. Those already in favour of privatizing health care – the Canadian Medical Association, Premier Ralph Klein, and most columnists in the Globe and Mail and National Post – welcomed the decision. Among those opposed were Roy Romanow (chair of the Commission on the Future of Health Care), the NDP and organizations such as Montreal’s Coalition of Physicians for Social Justice.
Then there was Paul Martin. "We are not going to have a two-tier health-care system in Canada," the prime minister vowed last week, continuing his party’s longstanding defence of the Canada Health Act (CHA) and its commitment to universality. Yet it was Martin who, in 1995, as minister of finance, introduced the Canada Health and Social Transfer (CHST) that consolidated federal funds for post-secondary education, health care and social welfare programs, and left them to individual provinces to apportion as they saw fit.
The result of the CHST was (a) a decade-long fight among universities, hospitals and other institutions for an ever-decreasing supply of federal money, and (b) an accelerated search for new partnerships with and support from the private sector. Colleges and universities also responded by massively increasing student tuition fees, thereby off-loading some of their operating costs to their "consumers." Hospitals were not so fortunate. The involuntary nature of hospitalization meant that patients could hardly be regarded as consumers. Not unless, that is…
…and so as waiting lists grew longer and the public system struggled to keep up with demand, the idea of private health care began to take hold. And nowhere was this more evident than in Alberta. After all, if the sale of liquor and registration of licences could be taken out of the government’s hands, then why not the provision of medicine, too?
It’s exactly that question that resurfaced in the wake of last week’s development – only this time on the national stage. Writing in the Globe and Mail, columnist John Ibbitson argued that "Canadians are still wedded to nationalized health care, despite its expense and inefficiency, because at least everyone suffers equally." For the defence, Roy Romanow warned that "the two-tiering of health care represents going backward in time to when good health care depended on the size of one’s wallet." We’re likely to hear much more of this kind of posturing in the weeks and months ahead, but the point remains that both sides, so far, have simply turned up the volume. What’s needed, if we’re to have a serious debate, are more facts and less fury.
A starting point might be a second look at Clear Answers: The Economics and Politics of For-Profit Medicine (2000), written by Kevin Taft and Gillian Steward. Published shortly before Taft left the quiet world of research to enter the Alberta legislature as a Liberal, Clear Answers was a targeted response to Klein’s proposed support for private clinics, but also a reply to those who argued more generally that profits, not patients, should be the driving force of health care.
Taft and Steward review the arguments for opening up health care to market forces. In most industries, they acknowledge, competition is supposed to drive costs down and efficiencies up. In health care, however, the reverse is true, because the basic premises of free-market economics simply do not apply.
First, they argue, there is an imbalance of knowledge between the seller (i.e. doctor) and buyer (i.e. patient). Patients, Taft and Steward note, "are generally not in a position to make well-informed diagnoses, interpret test results, or undertake clinical procedures. It is one thing to judge a slice of pizza; it is quite another to judge a course of medication."
Second, and more importantly, patients rarely have the luxury of being able to "shop around" for the best deal. "How can a patient ‘test drive’ a cancer therapy?" the authors ask. "A patient can’t return an unsatisfactory eye operation."
Third, a competitive system is likely to have costs that a public system doesn’t. A tax-based, monopolistic provider of health care has no need to advertise or to calculate and collect premiums separately. As citizens, we automatically contribute towards funding the system. Private health companies, on the other hand, do have to advertise their services and pay administrative overhead costs in the day-to-day struggle to survive. In the short run at least, then, the price of health care might well increase, not decrease.
Still, there’s no sound argument why those with the cash shouldn’t be allowed to purchase private health care at whatever price the "free market" determines, as long as their doing so doesn’t lessen the quality of or access to public health care for the rest of us. Whether the two systems can, in fact, harmoniously occupy the same universe remains to be seen. |
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