Medicare is not carved in stone
by Robert Fulford

(The National Post, 11 September 2004)

Is medicare in its present form sacred? In secular societies, practical systems sometimes acquire an aura of sanctity, as if their unchanging status were ordained by Holy Writ. We establish what we consider a realistic program, get it running, and only later realize we have created something resembling a cult.

That's what happened with the Canada Health Act of 1984. It congealed into dogma protected by a ferocious conservatism that runs far deeper than party politics. There are many Canadians who believe that merely questioning the dogma is sinful. Unlike almost everyone else on the planet, Canadians have made the shunning of private medicine into a moral issue.

This attitude now freezes thought in most Canadian governments. An assumption has been carved in stone: All medicine must be publicly paid for and everyone must have equal access. If this means long waiting lines, then everyone must have equal access to long waiting lines.

Fairness is the key principle, but do people feel fairly treated if they wait a year for surgery? The law says justice delayed is justice denied; equally, medical care delayed is medical care denied. Delays erode respect for the system and the medical profession.

CBC television on Monday reported that a Calgary man was spending $10,000 to get a hip replaced in India rather than endure another two and a half years of pain waiting for Alberta to accommodate him. He was the third Canadian to visit that particular hospital for that same procedure. Canadians travelling to India for more efficient health care? Nothing could more graphically illustrate our system's collapse.

But Prime Minister Paul Martin, treating the symptom rather than the disease, announced during the last election that he would eliminate or radically shorten waiting lines for surgery. The notion was preposterous, as even he must know by now. Canada has a multitude of disparate regions, and our doctors provide many different levels of service. A miracle would be required for the federal government to influence delivery of services in hospitals across the country. More money from Ottawa will help, here and there, but slowly. Under the purely public system, noticeably shortening the waiting lines in just one big province would be a huge accomplishment.

We need a radical reconsideration of our principles and prejudices, which is unfortunately not on the agenda of the prime minister's meeting with the premiers next week. Our politicians should try to remember why they made "private" a curse-word in medicine and depicted the two-tier system (the one most democracies use) as an ogre that will, if allowed to dwell among us, destroy our universal health care.

But if we blame politicians for our perverse system, we should also sympathize with them. For them, medicare is dangerously unpredictable. Certainly the politicians who established national health care in 1967 (and the voters, like me, who cheered them on) had no idea what it would entail.

We imagined, in our innocence, that medicine would remain much as it was and governments would pay for the kind of medicine already being practised. We didn't dream of imaging machines. Heart transplants were still an exotic idea under development by a few pioneers. In short, we had no idea that medicine was infinitely expandable.

Medicare illustrates the painful truth that nothing comes free. The financial crisis of medicare derives partly from the spectacular success of medicine. Every time science solves a medical problem it creates a political problem. Scientists, bless them, never stop thinking, and we can hardly ask them to; we can't, for example, impose a moratorium for 25 years on MRI-type technology, just so that our political system can catch up. We can't suggest that surgeons curb their ingenuity while we figure out how to pay for their equipment and their operating-room staffs. When doctors prove they can do something marvellous, who will deny them the right to do it?

No matter what political solutions we arrive at in this era, we'll probably be faced with new difficulties and conflicts later. Each generation creates problems for those who come after, as the pioneers of medicare in the 1950s and 1960s created difficulties for the 21st century. We don't know how medical technology will advance in the next generation, or at what cost. Nor do the scientists.

To deal with these changes, the system needs flexibility and variety. In most European countries, taxpayers can't opt out of public medicare but can buy services on their own if they choose. Why is that so harmful that Canada must vehemently reject it? European health services operate roughly like our schools. Canadians all pay taxes to support free schools, but some decide as individuals to pay more money for private education.

Applied to medicine, that sounds unfair to many. But in every other aspect of life we allow people to use their money, if they can, to obtain better goods. Nutrition, housing, and dentistry, to take three notable cases, operate on the usual reward system; pay more, get more. These parts of our lives are often as significant as medical care. In fact, there are days when dentistry matters more than medicine and there are decades when nutrition and housing matter more. Yet no one argues that we should use public ownership to ration dentistry, nutrition and housing.

The two-tier system, of course, already exists in shadowy corners of Canada. As Heather Sokoloff reported on Tuesday, it expresses itself frequently through favouritism among medical people and their friends. Even more remarkably, government agencies conspire in circumventing expressed government policy. As an article in MDCanada Magazine recently noted, the Workers' Compensation Board in B.C. last year sent 1,900 workers needing surgery to 14 private clinics in Canada. While private clinics cost more, they get the work done five or six months faster, which means the patients go back to their jobs much sooner. The public saves money, and the workers avoid months of depressing and debilitating idleness.

The clinics work better for a reason: They depend on the market for their existence. As we learn how to fix our system, we will almost certainly discover that our only hope will lie in the introduction of market elements.

Most politicians probably understand this but believe they must deny it, like priests defending a god in which they no longer believe. That has to change. If we are to improve medicare all of us must learn how to think about it with imagination and even a little daring.

Return to the List of Robert Fulford's Columns

Return to Robert Fulford's Home Page