I see that my posts regarding the election of Dr. Brian Day as president-elect of the CMA have garnered some interest from bloggers on the right. If these criticisms came from virtually any other conservative bloggers, I would give them the consideration they deserve, which is little to none. But Damian and Andrew are two guys who I respect, but just happen to disagree with politically and philosophically on most points.
Both have expressed distress with my "apocalyptic" language in my posts regarding the CMA election. Since what we are looking at is an event that will most likely speed the end of public health care as we have known it in this country since 1963, I think apocalyptic tones are called for. And what pisses me off about this more than anything is that we are chucking the system not because it doesn't work, but because it has been made to not work.
Public health care in this country hummed along nicely for decades. The system worked well, our infant mortality rates dropped, our average lifespan rose, and people had good access to a broad range of services. In the early 80s, however, a major offensive in the media began: the public health care system is not sustainable, it is too expensive, it keeps Canada's taxes too high. Each of these myths was drummed out repeatedly, and people's confidence in a once successful system began to falter. These messages were being pushed by corporations who sought tax reductions for the sake of tax reductions, or desired entry into the health care market. They found sympathetic ears in the Mulroney government, but did not see their true malignant flowering until the bleak Chretien years. Between 1986 and 1999, $38 billion dollars was cut from health care funding. Despite these brutal cuts (most of which has since been restored), the system still works remarkably well, but each and every misstep in the system is parroted by a willing media and pushed by think tanks and corporations, thereby giving the impression of a health care system tottering on the brink.
It is these corporate forces that are pushing for the end of Canada's system of public health care, enabled by their ideological brethren in governments (both provincial and federal) who chose to slash taxes rather than make an investment in the health of citizens. The system has not broken down under its own weight, nor has it failed due to some inherent flaw in the concept of public health care. Our system has been systematically undermined by corporations eager to get their hands on the public funds currently spent on health care, by a media sympathetic to those corporate interests, and by politicians with uncomfortably close ties to the health care industry.
And this is the heart of my objection: change is being pushed falsely, and is being pushed by the wrong parties. Those advocating greater privatization stress that they want better health care, not "American-style" health care, but the change is being pushed by corporate interests either wholly American or with extensive U.S. ties. They seek to recreate the money machine of HMOs in Canada, not to tinker around the edges of a public system.
The changes in public health care are being pushed by American insurance companies, eager to expand on the gains made through NAFTA, which ended the 25 percent foreign ownership restrictions on Canadian insurance companies. They are being pushed corporations, who see a federal government that will be able to slash taxes dramatically unburdened from the cost of public health care. They are being pushed by ideologues who simply ignore evidence to the contrary and ascribe near godlike powers the free market to fulfil all human needs.
So forgive my "apocalyptic" style, folks, but the election of Dr. Day is an ill wind for public health care. Adding to my fears for our public health care system is the philosophy of Stephen Harper, our current prime minister and former president of the National Citizens Coalition, a corporation front group created in 1967 specifically to oppose public health care. He will now find philosophical compatriots at the CMA, a body whose opinion carries considerable weight with the public when it comes to health-related matters. (Although, to be completely fair to Mr. Harper, he could hardly be less a friend to health care in this country than his Liberal predecessors.)
There could be many changes made to our health care system which would not bring a squawk from me. The Romanow Report had plenty of good ideas, none of which have been enacted. But then, why would they be, since there is a concerted effort to end public health care, not to fix it.
Yet as I address my concerns on this matter, I am called "blindly adherent" to public health care by blind adherents to the all-powerful free market, which I recognize as one of the pillars of our society and economy, but not the be-all and end-all for every situation. In Robert Kuttner's excellent book Everything for Sale, he does a great job outlining the many virtues of free markets, but also the many areas where markets have failed to provide the level of service the public sector has. Health care is one of those areas.
In America, the overreliance on market logic and market institutions is ruining the health-care system. Market enthusiasts fail to tabulate all the costs of relying on market forces to to allocate health care - the fragmentation, opportunism, asset rearranging, overhead, underinvestment in public health, and the assault on norms of service and altruism. They assume either a degree of self-regulation that the health markets cannot generate, or farsighted public supervision that contradicts the rest of their world view. Health care now consumes fully one-seventh of our entire national income. There is no realm of our mixed economy where markets yield more perverse results.
I like the free market. I'm a consumer, and I like my toys as much as the next guy. I like living in an affluent country where we are able to pursue our dreams. But I am not an ideologue who reacts from some unthinking level in knee-jerk deference to free markets. When something works, I like it. When something doesn't work, I like to fix it, but I like to fix it with the right tool. There may be a case for the inclusion of private for-profit clinics in a publicly funded health care system, but so far, they have not proven to be the right tool. Studies have shown they do not reduce wait times, nor do they reduce the burden of costs. They do, however, make a tonne of cash for shareholders and corporate executives.
Can anyone explain to me how that helps our health care system?
Great post. I'll see you your Robert Kuttner and raise you Joseph Heath's The Efficient Society, which might go further toward convincing centrist and centre-right skeptics. Among other things, it's a fascinating, ideology-free (or at least free from any ideology than that of efficiency) account of what which parts of society work better when run by government, and which work better when run by free markets. And he makes a very, very convincing argument that health care belongs squarely in the former category.
I've never even heard of it, I'm sorry to say, IP. Thanks for the heads-up, though. I just took a peek over at amazon.ca and ordered a copy. I love this blurb about it:
Heath's main contention is that Canadians' willingness to let the government step in and maintain programs for "the public good" is what basically sets the country apart. On the issue of gun control, for instance, he says that the argument for bearing arms "may sound persuasive, but it misses the point.... The benefits come from knowing that other people don't have guns. Thus the outcome that everyone wants--a safer society--cannot be achieved through the exercise of individual rights. It can be achieved only if everyone is denied certain rights." But Heath is no ideologue--he criticizes both the right and the left, and it's unlikely anti-globalization crusaders will be putting this book up on the shelf next to Naomi Klein's No Logo after reading his defence of Wal-Mart and Nike. That said, Heath isn't entirely in favour of the status quo either. He notes how "the proliferation of desire" (as fanned by advertising) is the "reason you can't get no satisfaction." Nevertheless, The Efficient Society is a fairly convincing argument that Canada is, in the words of the book's subtitle, "as close to utopia as it gets."
I'm looking forward to it.
As an American, I read your blog regularly, but usually refrain from commenting, as I have little of substance to add.
However, healthcare is an exception. I serve on the board of a U.S. healthcare system, and know its flaws intimately. I also have a passing knowledge of the Canadian system--my son's girlfriend is from Ottawa, and he just returned from spending a month there.
Flawed though the Canadian system may be, it is far better than what we have to offer in America. We give worse care at greater expense. One of the biggest costs of privatization comes from administration. You may be interested in this article. Although it is a few years old, I would think that if anything the gap has widened since it was written.
The free market works well in many areas. Healthcare is not one of them.
Excellent. I've actually been thinking about blogging a review of that book for quite some time (I have many accolades in mind, and a few criticisms as well); maybe I'll go back and do that.
One of the most cynical myths promolgated by the Liberals is the concept of preserving our current system, thus avoiding "two-tier healthcare".
Fact is, we currently already have at least three "tiers" in our healthcare system.
One, that which most of us "peasants" rely on, a rationed system, devoid of measurements of outcomes, lacking in any semblance of what an individual procedure actually costs (because they are afraid of comparisons with the private healthcare providers), and placing everyone in the position of reaching the lowest common denominator in terms of obtaining services.
Second tier: WCB, RCMP, military, prison inmates, unions, all of whom are able to access care immediately and on demand.
Third tier: Those who can afford to access private facilities, either in Canada or in the US or elsewhere. Examples: Robert Bourassa, went to the US for cancer treatment. So did Jean Chretien, having family member(s) visit the Mayo Clinic. And let's not forget the innumerable politicians, SCOC judges and senior functionaires who who were afforded the facilities of the VIP wing of the NDMC hospital in Ottawa to obtain the very best care that medicine had to offer.
Fact is, we have been fed a flawed bill of goods concerning Canadian healthcare. Because those in charge simply did not have to wait in line...they jumped the queue...because they could.
Bruce,
That's true; the wealthiest have already long been queue-jumpers. On the other hand, I can't seem to work up much outrage about it. People who "jump the queue" by leaving the country don't access our already rather overworked pool of doctors. If queue-jumping were allowed *within Canada*, it would be an entirely different story. So saying "it already happens, so we might as well make it legal" is just plain silly in this case.
That's true; the wealthiest have already long been queue-jumpers. On the other hand, I can't seem to work up much outrage about it.
IP, I've never really understood that sentiment - that having our wealthy take their excess health-care dollars out of the country is a positive for public care. Personally, I'd much rather see them pay a premium within Canada, one that went back into the public system to bolster it.
As far as the doctor shortage is concerned, have you considered why that is? I mean, we have more than enough dentists, engineers, lawyers, and other professionals, don't we? Does it not seem at least plausible that the public monopoly on so much of the health-care system in this country actually contributes to that problem? Or do you believe they're entirely separate issues?
I don't think there are many in this country - myself included - who want to emulate the American system. But there's a whole big world out there we can learn from, just as they've learned from us over the years. Much of it has embraced parallel public and private systems. I don't understand the resistance to exploring those options in order to improve how we deliver medical care to Canadians.
Btw, Tim, I appreciate the tone of this post much more than that of the previous one. Not that you write exclusively for my tastes, but this sort of piece is what I've always liked about your blogging.
Damian,
Well, I'm not a medical professional, but a friend of mine who's a doctor and a professor of medicine at the University of Alberta does think that they're separate issues. The main reason why we have a doctor shortage is that about fifteen years ago, provincial governments were wrongly told to cut back the number of spaces in medical schools. There aren't enough doctors now because not enough doctors were being trained then. Increasing the number of spaces in medical schools would increase the number of doctors, but of course in the meantime we have a serious shortage and have to face the consequences of that past blunder.
As for there being "a whole world of options" to explore other than just the American one, I'd actually be fine with that. I've lived in Europe, and while the German and British systems have far worse problems than the Canadian one, the French one is apparently quite good--efficient, sustainable, and fair. There's way too much either the American way or the status quo thinking in this country, and I'd certainly more than embrace an end to that.
The problem is that the politicians (like Ralph Klein and company) who want to tinker with the existing system aren't turning to France; they're consulting with U.S.-based for-profit health care providers. Until they walk the walk on the whole "we don't want American-style health care, we want a third option" thing, I will continue fighting them with everything I've got.
The main reason why we have a doctor shortage is that about fifteen years ago, provincial governments were wrongly told to cut back the number of spaces in medical schools.
Is rationing medical school spaces not symptomatic of the public monopoly? The government dictating how many doctors we need isn't related to the centralized control of our medical system? I'm having trouble with that idea.
Is rationing medical school spaces not symptomatic of the public monopoly?
In Ontario, anyway, it was symptomatic of a Conservative dismantling of any number of structures that had been part of the public healthcare system. Remember Mike Harris telling us that nurses were like "hula-hoops"? We could get more whenever we needed them? (Now we have a nursing shortage.) Remember all the dismissals of hospitals as mere "bricks and mortar"? (Now we are short of acute-care beds -- and trust me: I speak as someone who has done her time in emergency departments with a patient who should not have been there for days.) Remember the privatizing of homecare services (aka the race to the bottom)?
Conservatives do not intervene to control and direct the economy? You could have fooled me.
The argument that some european systems work on a parallel of public and private systems does not hold up.
A) These countries are not working under threat of NAFTA.
B) Doctors are under far more control than they would accept here.
C) Even Britian is now dealing with large American HMO's coming in and taking over. Including United Health Care which has been implicated in a number of scandals yet keeps getting backing from the Bush adminstration.
Your conspiracy theories reveal a remarkable lack of understanding regarding why health care spending in Canada has become unsustainable. You argue that "Public health care in this country hummed along nicely for decades. The system worked well, our infant mortality rates dropped, our average lifespan rose, and people had good access to a broad range of services. In the early 80s, however, a major offensive in the media began: the public health care system is not sustainable, it is too expensive, it keeps Canada's taxes too high. Each of these myths was drummed out repeatedly, and people's confidence in a once successful system began to falter."
There are a number of reasons why health spending has increased dramatically from the glory years in the 60s, including expensive new technologies, increased 'consumer' demand, demographic pressures, and inflated health worker salaries. You blatantly ignore all of these factors, and the actual statistics regarding the escalation of health care spending in your post. I can send you links if you want (I don't know how to add links to a comment section, the way everyone else seems to), because you seriously need to do a bit more research before you extol the virtues of our health care system.
Here's a starter:
http://www.health.gov.ab.ca/resources/publications/conference_board.pdf#search=%22health%20care%20cost%20drivers%20canada%22
Olaf, I agree there are pressures on our health care system, and the reasons are many (although you and I would probably disagree on why many of those reasons exist today). An aging population is part of the pressure, definitely, but so are the misguided policies of many governments in this country and the pressures from corporate groups seeking to end publicly funded medicare.
I don't need to "do a bit more research" just because my beliefs don't reflect your ideology. Nonetheless, if you have other links to send, I would be happy to read them, as I will read the one you have included in your comment.
Idealist:
I'm not upset about those paying to have healthcare in other countries; it's their money and they are entitled to spend it as they wish. My main point was that the multiple-tier system already exists.
I personally find it a little strange that I can pay $2500 for an immediate hip operation for my Golden Retriever, but a friend's wife had to wait 18 months for essentially the same operation, all the while in excruciating pain.
And why have those who are prepared to pay to jump the queue spend their money elsewhere instead of in Canada?
As to the doctor shortage, it is arguable that part of that is being exacerbated by the rationing of the public system. An acquaintance, an orthopedic surgeon, recently advised me that he has given up trying to practice in Canada. He has been restricted to seven hours of operating room time per week (rationing of the public system). All he wants to do is practice his craft...so now he's moving to Los Angeles...another doctor gone.
Another point. I'm not trying to be perceived as slagging our system in its entirety. Judging from the experience of friends, we have an excellent response to emergent cases such as cancer and injuries etc. The problem, in my view, appears to rest with the so-called non-emergent cases...hip, knee replacements etc.
Perhaps it is time to reassess the Canada Health Act and re-define what "medical necessities" actually are, and open those that are non-emergent up to the private sector, at least for those that choose to pay the freight themselves.
At the very least, that money would stay in Canada, and the queue for those services might be shortened for those waiting for the public services.
Waiting lists are a serious problem, but frankly one that's not very hard to solve with a bit of political will and maybe a bit of brains. Some places in Canada have, indeed, solved this problem.
I mean, say you've got a waiting list of 6 months on average for procedure X. And say it's been about that for a long time, or is growing at say, a day per month--that is, current trends would see it at seven months in a couple more years. Clearly, you're doing about enough operations per month, or nearly enough, to deal with the influx of new cases. If the backlog were gone it would stay gone. Or, in the slow-growth situation if you had maybe one more surgeon and operating theatre working, or if the bottleneck is diagnostic if you had one more foo-scan machine operating and staffed, it would stay gone.
So all that's really needed is to have a troubleshooting group, maybe with mobile facilities. They'd have some serious medical talent and some people good with workflow and logistics, ideally headhunted from places that did eliminate their own backlogs rather than hands-off technocrats. They draw up a list of what procedures have backlogs where, go there, kill the backlog, and stay long enough afterwards to give the locals enough breathing space to reorganize a few procedures and identify a few priorities without going under. At places where there's an ongoing structural problem that really can't be dealt with using their existing resources, you then throw money at the problem. Aside from doctor and nurse shortages, poof! Backlog problems gone.
There are probably many other ways of solving backlogs. Steady backlogs are not a sign of breakdown, but of neglect, because they are not inherently an intractable problem at all. At some point in the past, there was some kind of delay (whether from a brief jump in caseload, a reorganization, renovations, or whatever), a backlog built up, and nobody's bothered to do what's needed to get rid of it since. The people on the ground haven't been able to fix it because they're going at full speed dealing with cases so they don't have time to figure out what would be needed to do.
Damian wrote
"Is rationing medical school spaces not symptomatic of the public monopoly? The government dictating how many doctors we need isn't related to the centralized control of our medical system? I'm having trouble with that idea."
This is egregious nonsense. Private sector education isn't outlawed in this country. If free markets were so great, they would have spontaneously offered med-school training the moment the public sector dropped the ball. Nobody was stopping any private company from doing so. Didn't happen? But, but, I thought the private sector was magic and could unerringly anticipate all needs!
So, no, no centralized control or monopoly in medical schools, it's just something that's difficult, expensive, and hard to make a profit at, and likely to be underprovided by any group that doesn't have the welfare of the entire country as its objective. Indeed, the more we allow our governments to cease having the welfare of the entire country (or province) as their objective, the more they start to resemble the private sector in underproviding this good.
Of course, if you want to argue that there should be *no* public education so the private sector can compete, go ahead. But historically, lack of public education has translated largely into lack of education. I suspect you'll find few takers for the notion that the only way to properly reform health care is to completely privatize education.
Tim,
I see your point (and apologies for the rude 'research' quip). Don't bother reading that Conference Board report, it's long winded. Instead, find Janice MacKinnon's (the NDP finance minister in SK under Romanow) article called "The Arithmetic of Health Care" in Policy Matters (it's on the net but I can't get a direct link); she's the best in the business.
According to a CIHI report from last year, the single biggest jump in healthcare costs was the cost of drugs - thanks to "evergreening" prectices of drug companies.
Ironic, isn't it? The major source of cost increase is the stuff coming from the big private sector corporations. And then they use that cost increase to agitate for more involvement of big private sector corporations. And our media are so fucking slanted that lots of people buy it.