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Cutbacks, closures, waiting lists
forcing moves towards free-market reforms
Experts consider Alternatives to Medicare
Timothy Bloedow
HEALTH
The value of choice has been thrust into the forefront of political debate
about Canada's socialized medical system with the recent report of Canadians
dying in record numbers waiting for surgery at the Ottawa Civic Hospital. The
conflict between Federal Health Minister, Diane Marleau (Sudbury), and the
provincial health ministers seems also to be consolidating around the issue of
freedom as discussion goes deeper than the expected verbal bantering over one
tier or two.
In the past 17 months, 27 Canadians have died whilst waiting for heart surgery
at the Civic, contributing to questions about the morality of Canada's medical
system as people try to find someone, or something, to blame.
Waiting lists have 320 names while operating rooms sit dark and empty two days
a week because of lack of funds. The average cost of heart surgery is $11,700
and the $3 million requested by the hospital from the provincial government
could take 150 people off the waiting list.
Today's medical system is the legacy of Pearson's Liberal government which
provided national legislative force to the principle of universality first
established provincially in Saskatchewan. In 1984, the federal Liberal
government legislated the Canada Health Act, which Stephen Brooks, spokesman
for Dr. Grant Hill (Reform - MacLeod), Reform Health Critic, said was
instituted essentially to "blackmail" Alberta for extra-billing, but also
entrenched the government's opposition to privately provided essential
services.
In the light of the present escalation in deaths of people awaiting heart
surgery (the average number previously was four to five per year), however, Dr.
Wilbert Keon, director of the Ottawa Heart Institute, has challenged the ethic
of eliminating this free choice from Canadians. He declared that governments
that can not or will not fund health services, but will prevent people from
seeking independent alternatives within the country, are "condemn[ing those]
patients to death."
The Heart Institute advises patients who want to do so to register with other
hospitals that have shorter waiting Iists in neighbouring cities like Toronto.
Danielle C�t�, Community Relations Officer for the Institute, however, said
that it is not in the practise of advising patients to consider travelling to
the U.S. where they could get treatment almost immediately.
The debate over responsibility for such tragedies has not yet reached the
federal level. Mrs. Marleau said recently that "the Canada Health Act [CHA] is
alive and well and able to take on the challenges of the future," adding that
it is "one of Canada's proudest achievements... an affirmation of Canada's
commitment to human dignity."
Her commitment to the CHA led her to order that provincial governments bring
their medical system in line with the Act by October 15. She has persisted with
that demand, refusing to confirm reports broadcast on September 24 that, in
order to fend off confrontation with Alberta, she would begin to permit private
clinics to offer fee-based services to people who do not want to stand in line
at government facilities.
Mrs. Marleau's challenge was essentially in response to reports coming out of
Alberta about its willingness to permit a growing number of private, fee-based
health services. Mrs. Marleau is concerned that market-based health service, in
particular facility fees, "impede access to medically necessary services."
Ironically, some of the criticism of Canada's medical system comes from
Saskatchewan, where Steven Lewis, CEO of the Saskatchewan Health.Services
Utilization and Research Commission, said that standards in the public system
may well be forced up, with the competition of a parallel private system.
The Reform Party has also been attacking the present system, with Mr. Hill
condemning the federal government for withdrawing funds from health care
without permitting private individuals to provide replacement services to those
willing to pay the price. In an article published by The Globe and Mail, Mr.
Hill said that during his medical career he regularly heard people declare
their wish for choice in the area of health care.
Robert Metz, president of Freedom Party (Ontario), suggested that most
Canadians would be willing to pay in for health care if their only other
choices were medicare or death. Left with this choice a growing number of
Canadians are dying prematurely today, he added.
The matter of choice in medical service provision is a fundamental moral
obligation, according to Mr. Metz. He said that if we do not have the freedom
of choice in such a crucial area of human life, we can hardly consider
ourselves to be a free people. "Since money is not infinite, medical services
along with everything else must be rationed." In the view of Freedom Party
supporters, the free market is a more benevolent rationing agent than is the
average bureaucrat.
The Reform Party's "Medicare Plus" proposition affirms the need for
medicare, which Mr. Hill said, "must be nurtured and treasured as Canada's
health-care safety net." But it challenges the idea that medicare equals health
care, a concept which Mr. Brooks said is "a hangover from the 60s." Mr. Hill
said that health care includes medicare, but is so much more. "Should the
government continue to oppose such reform, it will find itself increasingly out
of step with Canadians' desires for a sound, reliable, world-class health care
safety net, and Canadians' desire for choice," he declared.
Mr. Hill said he is glad to see more open debate taking place now about the
possibility of incorporating choice into the system. He pointed to recent
discussions at the annual general meeting of the Canadian Medical Association.
He wants the debate to address real, substantive issues, rather than remaining
in the realm of ideological bantering about one- and two-tier systems and how
we do not want Canada's system to look like that of the U.S., which is
invariably characterized as a free market model.
In fact, conservative critics argue that the American system is over 40%
government controlled and far from being exemplary of a free market approach to
health care. The debate still rages over whether it is the government or the
free enterprise component of the system that is responsible for the rising
costs and other problems.
Mr. Hill has also criticized the present medical system for chasing "three
hundred medical schools worth of highly trained doctors" out of the country
each year. He wrote about one doctor in Sault Ste. Marie who, after years of
fighting the system to set up a privately-funded clinic to address essential
needs not met by medicare, had made up his mind to leave the country. He told
Mr. Hill that he was blocked at every turn so he wanted to go somewhere where
he could use his professional skills "to meet needs and accommodate choices."
Provincial health ministers are now discussing new options for paying doctors
which could significantly affect the future provision of health care services.
Until now payment has been on a "fee for service" schedule. A doctor is paid
based on the number of patients he sees. His financial incentive has,
therefore, been to see as many patients as possible. In England this incentive
program led to a situation in which the average length of a doctor's visit was
less than five minutes, according to the American Foundation for Economic
Education.
The leading alternative being considered by the health ministers is a
"population- based" salary model. This approach, which has also been tried
elsewhere, is not without its problems either, say critics who charge that the
incentive here is to do as little work as possible, since one's income is
constant. The benefit of the idea is that it encourages doctors to keep their
patients as healthy as possible, to limit the amount of work necessary in
treating them. On the other hand, doctors have been known to engage in
"cream-skimming." This is the practise of keeping as many healthy patients as
possible while rejecting those who are chronically ill.
Mr. Metz, appealing once again to free enterprise, argues that, although
allowing market forces to dictate doctors' wages is also not without problems,
it provides the most moral incentive structure because it makes the doctors
accountable to their patients, not to bureaucrats.
Mr. Metz said that if Canadians were willing to look beyond the myths to the
true nature of health care in Canada it would not be difficult to reintroduce
choice. As an example, he noted that the country does not provide universal
access. People living in rural areas do not have the same access to medical
treatment as most individuals living in cities. Adding that the government has
never been able to fund Canada's medical system alone anyway, Mr. Metz noted
the number of fund raisers hospitals use to generate charitable dollars.
Associations and societies for diseases such as Cancer, Muscular Dystrophy and
Diabetes, have also been set up to raise money that the government cannot
afford to put into the medicare system. "Since universality is a myth and does
not work," concluded Mr. Metz, "it is past time to introduce freedom to the
system."
