Thursday, June 09, 2005

Fix for a Generation

Although this Supreme Court ruling is devastating (or, I suppose, a godsend, depending on your opinion), at the very least it will force politicians to focus on real policy issues rather than doctored tapes, confidence votes, and political bribes. Warren Kinsella has an outstanding post up on what this means for each of the four political party leaders. Warren’s analysis in bang on and, since I agree with most of what he’s said, I suspect the rest of this post will be using a lot of his arguments.

Before I get to what this means for each of the parties, we should remember that this ruling applies only to Quebec and on the issue of the Charter, the decision was split. But it would be naïve to assume that this isn’t a national issue and won’t be the national issue for the foreseeable future. Because of that, each of the four party leaders has a huge decision to make.

Paul Martin

The Stakes: He ran an election as “the defender of health care” and won. He promised to “fix health care for a generation” and proclaimed mission acomplished last fall.

The Dilemma: Has lambasted Stephen Harper for the past year for going against the courts and the Charter on Same Sex Marriage. Has pretty much said he would never use the notwithstanding clause.

The Upside: The Liberals always win when the topic turns to health care. This could be the big issue to make people forget about corruption.

The Downside: Words and spin won’t be enough this time.

What Martin Will Do: He’ll make a lot of grand speeches about “protecting health care” but won’t do a thing to stop two tier health care.

Stephen Harper

The Stakes: He’s down in the polls and his leadership of the party is being called into question.

The Dilemma: Does he embrace the decision and come out strongly in favour of some private health care or does he go against judicial activism?

The Upside: This ruling is a condemnation of the current health care system and, by consequence, Paul Martin and the Liberals.

The Downside: Predictable Liberal scare tactics about the “death of health care” will raise the “hidden agenda” fears during the next election.

What Harper Will Do: Will attack the Liberals for doing nothing without actually clarifying his position (see: missile defense debate for reference).

Jack Layton

The Stakes: Because of the “Greatest Canadian”, everyone thinks Tommy Douglas and the NDP gave Canada health care.

The Dilemma: They want to save health care but don’t want Martin to be the person to do it.

The Upside: Their alliance with the Liberal Party leaves them in a position to make a difference. If Martin and Harper waffle (imagine that…), Layton can look like the one leader standing up for health care.

The Downside: If the debate polarizes between Martin and Harper, NDP voters may jump Liberal.

What Layton Will Do: I think Jack will be bold here and will publicly demand certain actions by Martin as a condition of the continued Liberal/NDP alliance.

Gilles Duceppe

The Stakes: This is a Quebec decision and Duceppe’s position might very well define his PQ leadership campaign.

The Dilemma: Kinsella put it best – Quebec’s legislative autonomy versus public health care.

The Upside: Given he’s currently fighting Paul Martin, Pauline Marois, and Jean Charest, it’s hard to imagine he can walk this tightrope without upsetting someone.

The Downside: The Bloc will ride Gomery to 60 seats regardless of how this plays out. For Duceppe, the downside is a crippling blow to his goal of becoming Premier of Quebec.

What Duceppe Will Do: He will certainly not announce his candidacy for PQ leader until this issue quiets down.


The Stakes: It’s the issue Canadians rank as the most important, time and time again.

The Dilemma: Public versus private. The courts versus Parliament. How to best fix healthcare.

The Upside: Maybe this will lead to health care reform.

The Downside: Two tier health care.

What will Happen: ???


  • A small precision: the Supreme Court use the Quebec Charter, not the Canadian Charter to base it's decision.

    Henry Brun one of the most respected constitutionalist in Canada said that the decision of the court was "strange". It was much more a "political appreciation" than a "judicial decision".

    Some litterature:

    "The gap between U.S. and Canadian spending on health care administration has grown to $752 per capita. A large sum might be saved in the United States if administrative costs could be trimmed by implementing a Canadian-style health care system."
    -New England Journal Of Medecine


    According to the health organization, the higher costs of private insurers are "mainly due to the extensive bureaucracy required to assess risk, rate premiums, design benefit packages and review, pay or refuse claims." Public insurance plans have far less bureaucracy because they don't try to screen out high-risk clients or charge them higher fees.

    And the costs directly incurred by insurers are only half the story. Doctors "must hire office personnel just to deal with the insurance companies," Dr. Atul Gawande, a practicing physician, wrote in The New Yorker. "A well-run office can get the insurer's rejection rate down from 30 percent to, say, 15 percent. That's how a doctor makes money. ... It's a war with insurance, every step of the way." [...]

    The resources spent by private insurers don't reduce overall costs; they simply shift those costs to other people and institutions. It's perverse but true that this system, which insures only 85 percent of the population, costs much more than we would pay for a system that covered everyone.

    -Paul Krugman (NY Times)

    By Blogger David, at 7:49 p.m.  

  • David, c'est qui Henry Burn? je n'en ai jamais entendu parler de lui.

    en tout cas, bref, la decision est claire, elle prend compte des problemes que tu souleves ici ainsi que sur ton site.

    les canadiens ont droit a un system de sante exclusivement publique uniquement si ce systeme fonctionne, car sinon on met les vies des canadiens en danger.

    et voila: rien du mal la-dedans.

    By Blogger matt, at 9:01 p.m.  

  • I will reply with ma poor English.

    Henry Brun is a famous lawyer specializes in constitutional right. He wrote many «bible» uses in many universities.

    I don't want to overwhelm you with number but here are some interesting stats:

    % of private health care:
    –USA: 55%
    –Canada: 30%
    –France: 24%

    •Per Capita Spending:
    –USA: 5 267$
    –Canada: 2 931 $
    –France: 2 736$

    Health Care ranking (WHO):
    France: 1/191
    Canada: 30/191
    USA: 37/191

    Health Care Spending

    13,9% GDP
    37(WHO ranking)

    9,7% GDP
    30 (WHO ranking)

    9,2% GDP
    15(WHO ranking)

    8,7% GDP
    11(WHO ranking))

    8,3% GDP
    2(WHO ranking)

    7,6% GDP
    10(WHO ranking))

    7,5% GDP
    7(WHO ranking)

    % of private health care:

    56% private
    37(WHO ranking)

    31% private
    30(WHO ranking)

    29% private
    7(WHO ranking)

    25% private
    2(WHO ranking)

    19% private
    10(WHO ranking)

    17% private
    15(WHO ranking)

    15% private
    11(WHO ranking)


    Bottom line, we have to realize that:

    1-quality health care is not link with the amount of money spend. Many countries with smaller spending than Canada have a better system.

    2-quality health care is not link with the involvement of private. Many countries with less private than Canada have a better system.

    In fact, when you look the OECD stats, Canada have one of the most privatise system. Except for Australia, all country with high privatisation has a poor health care quality.

    By Blogger David, at 9:31 p.m.  

  • Two things:
    1. My use of French above was cuz I was reading david's blog, had my head in French, and just thought it'd be cool - he can certainly carry on this debate in French, and to be nice to all concerned that's what I ought to do.

    2a. I just got back from France. Prima facie, I have difficulty believing it has a lower involvement of the private sector in healthcare delivery than does Canada. Not to say that david's figures are therefore wrong/made-up, but rather I think it really does matter how and where it gets involved, which is what this decision will force the government to do: deliver public healthcare in ways which get results lest a paralell system spring up. That is, after what the judgment said (and I'm repeating my post above now): you can have public-delivery only, but only if there's delivery.

    2b. If we take david's figures straight-up assume they're accurate, such that Canada already has 30% of healthcare services delivered by the private sector (moreso in Quebec), then today's decision changes nothing. Right?

    By Blogger matt, at 10:35 p.m.  

  • crap. what I meant to say was "he can certainly carry on this debate in English." Freud is having a field day.

    By Blogger matt, at 10:35 p.m.  

  • I believe the saying that you can't be half pregnant. That is the way I see Public vs Private. A 2-tier system will never exist for a long time. If one starts then Public will loose and stop completely after a period of time and Private will be the system we will end up with.

    Why? Well, once people start to migrate towards private they will feel that their needs were met and that is where they will want to go for their next treatment. They will petition that their tax dollars do not go towards a Public system. Once the Public system starts to be affected by the changeing mood of spending then Public facilities will start to decline, not only in the numbers of people that use them but also in how often they are used. Medical professionals and practitioners will migrate towards Private because that is where the public are starting to go and then Public health care will truly become a ghost of a system.

    It will not be like turning a light switch on or off. It may take 5 or 10 years, but once Private (or a 2-tier approach) starts, the end will be written on the wall for the Public system as use declines then funding will decline and the public infrastructure will cease to be relevant.

    And then, while those that can afford it will swear it is the best thing since sliced bread, the ones that cannot afford it will look like those in the US that cannot provide any health care for themselves, their spouses, or their children. We will have lost our greatest asset, universally accessible health care.

    I would rather see the continued support of a Public universally available health care system with one tweak. The tweak is that the existing Public infrastructure lease space and their capital equipment for use at the public facility by private companies.

    A private company can only provide, say, an MRI at a Public facility. There would not be PPP partnerships or private hospitals built. Thjere would be no need for the private sector to have to expend dollars on creating the infrastructure. They would lease time on the public equipment and lease the space at the public facility and charge the going rate as set by the Canada Health Act for procedures they perform. The private leasing company is adminstered by the existing public facility administration which operates under the Canada Health Act.

    The private company does not have to expend dollars to buy capital equipment, nor do they have to build facilities/infrastructure. They use the infrastructure that exists and which they lease. They offer MRIs at, say, 2pm through to 10pm Mon-Fri and 8am to 4pm Sat and maybe even on Sundays. In this way they are not taking away from the need of the public to use the existing universally available public infrastructure because the use of the equipment is leased and only available at scheduled times by the private company.

    The public facility schedules the leased times and patients can either wait for an available public window of time for their procedure (say an MRI) or can pay the private company for one of their time slots witht he public equipment. They can ask for a rush job and perhaps this could be included in a provision of the lease agreement that if a patient wants a rush diagnostic procedure then they (the private company) can charge a bit more (a rate that would be set by the public administration team).

    The public would then still be going to public facilities. Theyw ould still see the need to fund the public system. Doctors and other health care professionals would not be lured away from the public hospiotals with the belief that they can cash in on private health care profits. John Q Public may get their procedures done by publicly paid for staff or they may opt to have the private company and their technician do the procedure. The point is the public will be using and will stay focused on the public infrastructure while also having the ability to take advantage of a private companies ability to offer them a time that helps reduce the delays they are currently experiencing.

    This will also allow for the Public facility captital equipment to be used more often. How many have heard that there is an MRI at a public facility but no technician is available to operate it. Well, the Private company would make use of the public facilities capital equipment (the MRI) and provide their technician.

    By Anonymous Anonymous, at 11:28 p.m.  

  • I realise that I don't put my sources for the stats, my bad.

    Everything came from the OECD Factbook.

    For the chapter about health care:

    France, the #1 health care (WHO):
    Total: 2 736$ (per capita)
    Public: 2080$
    Private: 656$

    Total: 2931$
    Public: 2048$
    Private: 883$

    One IMPORTANT factor, here we have a doctor shortage (not the case in Europe). So each doctor lost by the public system will have a huge impact.

    By Blogger David, at 11:44 p.m.  

  • Anonymous, you make no sense, for three reasons.

    1. If you can only have public OR private, then you do you explain david's list of countries that do healthcare better than us, in mixed fashion, and have done so for decades?

    2. You say if we allow private deliver "we will have lost our greatest asset, universally accessible health care."

    But - and I can't emphasize this enough - the *whole entire point* of today's judgement is that it's already lost.

    3. You then outline a fantastic mixed delivery system. Which exists in lots (but still too few!) of places around the country. And has been recently reoutlawed in Ontario (National Post ran some stories on a U of T hospital's MRI operated between 6 pm and 3 am privately, as an experiment. No unions, same fees, saved money, shut down by McGuinty on principle).

    By Blogger matt, at 12:06 a.m.  

  • We have private schools - and the public school system hasn't come crashing down. Health care will be no different. They can complement each other nicely.

    By Blogger Michael Fox, at 10:56 a.m.  

  • The problem with private school?

    They screen for the best student. All the "problematic case" is left to the public.

    So the public have to deal with the most difficult student. That's way the public school lack founding: dealing with all sort of problem cost money...

    Health Care will be no different. Only the healthiest will have insurance. If you have case of hearth disease in your family you will not have any insurance.

    So the public will have to deal with the most difficult case.

    Also, there's no shortage of teacher. But we have an important shortage of doctor and nurse.

    By Blogger David, at 11:30 a.m.  

  • "They screen for the best student. All the "problematic case" is left to the public"

    There are relatively few private schools. And from what I have seen, they have plenty of 'problematic cases', many of whom have been turfed from public schools; those particular 'problems' just happen to have wealthy parents. By analogy (perhaps a poor one), the private clinics could offer some relief to the public system, but the 'slippery slope' argument has a lot of merit, given the influence of our neighbours to the south.

    I think that Henry Brun's comment was on the mark and that there is less to this than many of the talking heads are making of it.

    By Anonymous Anonymous, at 12:16 p.m.  

  • Action Man: They screen for the best student. All the "problematic case" is left to the public.

    So the public have to deal with the most difficult student. That's way the public school lack founding: dealing with all sort of problem cost money...

    That's just silly. If there were no private schools, there would still be just as many "difficult" students. And as bugsindirt points out, having private schools means the "difficult" students from wealthy (or even middle class, in many cases) families can be enrolled in a private school that specializes in that kind of thing, thus taking pressure off the public system.

    It's the same thing with health care: those who can afford it can pay for private care, thus shortening the waiting lists for those using the public system.

    Of course, the argument against this is as follows...

    One IMPORTANT factor, here we have a doctor shortage (not the case in Europe). So each doctor lost by the public system will have a huge impact.

    And why do you think we don't have enough doctors and nurses? (Hint: If there's a constant shortage of something, it's a good bet that the government is screwing with the market and strangling the supply.)

    By Blogger The Invisible Hand, at 1:13 p.m.  

  • Regardless of whether you are for or against paying to get better, the whole health care situation just shows more incompetance on the part of the Liberals. According to WK, health care is the only things that keeps us from being American, and if they can't even protect that...

    Think, if all of the cash filled envelopes and money-for-nothing-ads (and god knows what else) had gone to healthcare, maybe people wouldn't be suffering in the waiting line.

    By Anonymous Anonymous, at 2:00 p.m.  

  • Two-tier health care is not a downside.

    By Blogger Shameer Ravji, at 2:49 p.m.  

  • I came from a private school. We past test before being admitted. The "problematic case" are screen out. I talk by experience.

    Private health care will not reduce the waiting list (here in quebec). Simply because there not enough doctor. The surgeon you will leave the public for the private will result in longer waiting list.

    The reason for the shortage is not the government screw the market. it's because the education system can't form more doctor. Privatise the system 2morrow and the bottleneck will always be the shortage of doctor.

    By Blogger David, at 4:01 p.m.  

  • " Two-tier health care is not a downside."

    Unless you are poor and can't afford to purchase your way up the queue.

    But who cares about the poor anyway?

    When some doctor or insurance company can extort you to mortgage you house to pay for you medical care or that of your children, leaving you destitute at the end, come back and tell me how a two tier system isn't a downside.

    Availability of medical service should be based on medical need, not ability to pay.

    By Blogger Mike, at 4:04 p.m.  

  • "When some doctor or insurance company can extort you to mortgage you house to pay for you medical care or that of your children, leaving you destitute at the end, come back and tell me how a two tier system isn't a downside."

    I would rather be broke and have healthy children than be at their funeral because of wait times.

    By Anonymous Anonymous, at 5:09 p.m.  

  • Most simple interpretation:

    Our Health Care system as is sucks. People are dying for no reason other than a fantasy.

    Having two tier health care, even if preferential for the rich, is preferable to people dying so we can say we are Canadian. Every other country in the world has a mixed system besides North Korea and Cuba. Who "envies" this?

    That is the core of the issue.

    By Anonymous Anonymous, at 5:28 p.m.  

  • Mike, that is just the same old talking points (ie. scaremongering) we keep hearing from the left, people should also have the choice to visit a private clinic, just ask your buddy Paul Martin.

    By Blogger Shameer Ravji, at 5:35 p.m.  

  • David,

    You claim you went to a private school, and that you "past test" before being admitted. Looking at all of your posts, I have to ask - did they teach basic spelling and grammar at the private school you attended?

    By Anonymous Anonymous, at 6:19 p.m.  

  • A couple of points: while the decision was on the Quebec Charter, McLaughlin and two others reasoned (and I paraphrase) - if the government wants to prohibit something on policy grounds and that prohibition has the effect of killing people then it is in violation of the Quebec charter, the Canadian charter s.7.

    Second, we already have two tiers, Quebec silently left the Canada health Act several years ago and Mr. Dithers formalized that last year. We have two tiers for WBC claimants, federal convicts, members of the RCMP, non-citizens of Canada, aboriginals and anyone with enough money to cross the border for an MRI.

    What the Liberals have done for years is characterized anyone who actually points this out as advocating "American style health care" and the stooges in the Canadian media obediently clap their flippers together and bark at the nasty people who would suggest such a thing.

    The SCC decision injects a degree of reality into a discussion which was mired in partisan fantasy.

    By Blogger jc, at 7:03 p.m.  

  • Paul Martin isn't my buddy. He is the cause of this entire mess, along with the Conservative\Alliance\ PC.

    Our Healthcare system worked very well and was the envy of the world, including the US, in the 70's and 80's. It worked. Wait times were minimal and well within the range of acceptable. No one waited 2 years for knee surgery - my brother waited 3 weeks.

    Then Paul Martin gets in and takes the Conservative\Alliance \PC mantra of slashing spending to his heart. 15 years of deep, drastic cuts to our system, all the while costs for real things like nurses, doctors, equipment supplies and energy cost to run hospitals climb. Guys like Mike Harris go further and slash even more. Fire nurses, close hospital beds, then give us a $200 dollar per person tax refund? Great.

    You think they might have cut in other places perhaps, or stopped cutting when it was obvious things were getting bad, like in 1996.

    Imagine that for 15 years and we have outrageous wait times. Who'da thunk it?

    And now, the same people who have been angry at Paul Martin for years for not cutting spending enough have the gall to stand up in the House of Commons and claim he should have spent more on Health Care? Now that is the CPC fantasy - we can cut taxes and increase spending at the same time. Look how well its worked in the US.

    "I would rather be broke and have healthy children than be at their funeral because of wait times."

    Then you are the kind of rube they are looking for. They know that's how you feel so they will make sure they do it to you. Hot flash from the news room: Insurance companies exist to make money for stockholders NOT to help you pay for healthcare. They will find every loophole and actuarial excuse NOT to pay out or to charge more for premiums - these are the guys who run auto insurance, remember? You child will be just as dead if someone with more money can buy their way in line ahead of you or if they can hire the doctor away so you can't see one.

    I love my children too. So I want the Feds to get their share of the funding back up to 50% so another child doesn't die in the ER because there aren't enough nurses or doctors.

    I find it ironic that the same people who have gutted the public system of funding and human resources for so many years, thus causing the crisis in the first place, are now calling for privatization to fix the public system they broke. I wonder how many of them besides Michael Kirby own stock in Extendacare...

    Sorry for the rant, but I am old enough to remember when the system worked, when it was funded properly. Privatization will make it more expensive not less :

    By Blogger Mike, at 11:11 p.m.  

  • 1. JC: you are smart.

    2. "Anonymous": your comment was unkind, to say the least. David is posting in English, although he is a French-language blogger from Quebec. I'm flattered (on behalf of CG, I suppose) that he's posting here. Feel free to have a look at his blog, as it's quite good - if you can.

    3. Mike: you're missing some facts. I agree that the Liberals ought to have cut in other places. Like the gun registry, or the government Challenger jets, or ACOA, HRDC, etc. Lots of pork to be cut. But being pork, and being Liberal, it wasn't. But back when the system was affordable, drug costs were less, medical infrastructure (i.e. MRI machines) were less, and the population was comprised of young healthy people, not aging boomers. If you're old enough to remember the system when it worked, then I resent your generation ringing up such a tab on my generation's dime. But that's neither here nor there. Merely that deficit financing of a health-care system isn't something we can do. And the current model, per the Supreme Court, is letting people die without treatment. Bear that in mind before saying "but the poor will be forgotten." They are right now too.

    By Blogger matt, at 1:45 a.m.  

  • Mike, again you're missing the point but then again you'll just direct me to partisan websites that support your case which I guess is where you get all your talking points on this subject. Face it, the system is in trouble and all you suggest is keep throwing money at it and the problem will go away. I guess if the left keeps repeating that "universal health care" works in Cuba and North Korea then it must be great here in Canada. Even countries such as Sweden offer a choice but I guess you can't see that in your leftist world.

    By Blogger Shameer Ravji, at 2:20 a.m.  

  • shameer
    Drop the "guilt by association "assertions you keep making with Cuba and North Korea. It's illogical and makes you look like a fool. I might add that if I make the same assertion - the Bush is acting like Cuba, or North Korea or the old USSR when they create a gulag and hold people indefinitely without charge or trial - you guys are the first to jump up and down that its not a fair comparison. How's that moral relativism workin' out for ya?

    As for "partisan sources" I use, well I hardly expect the Fraser Institute to host Dr. Relman's findings. But I'm sure despite Dr. Relman's position, experience and peer reviewed research, he just part of the vast left-wing conspiracy. Here's a nutty idea, why don't you try refuting his findings rather than summarily ignoring him because you don't like the site that hosts his report. If it makes you that uncomfortable, Google his name and get the report from the New England Journal of Medicine, unless you think those guys are leftist sympathizers as well.

    And for the record, I could live with Swedish style health care. But never American style.

    Matt - Saying I'm old enough to remember means I went to highschool and university in the 80's. Our system worked in 1990. And I don't agree with deficit financing (believe it or not nobody in the NDP does, though I'm sure shameer doesn't believe it). I'm with you that boondogles such as HRDC and the Gun Registry - all that stuff was wasting money and could have been done way cheaper. But my biggest beef is that when cost such as MRIs, or drugs started to grow, instead of carefully balancing priorities such that healthcare recieved the proper funds and attention, PM kept slashing. Mike Harris kept slashing. The priority was not maintianing our system, it was slashing spending as fast as possible. Remember in 1996, Mike Harris,laid off nurses, shut down hospital beds and then sent everyone in Ontario a $213 cheque in October. I think that most Ontarians would have happily give that back to have shorter wait times or more nurses. Did they try to stablize things by closing tax loopholes, or taking longer to pay down the debt, or cutting elsewhere? Nope. Just hack and slash. The NDP has been warning about this for a decade.

    My point is, the public system CAN work, like it did, if it is given the proper attention. There is nothing instrinsic about a public system that makes it inferior to a private system. We are where we are because other priorities - corprorate tax relief, spending reductions - took over from maintaining a good healthcare system. A balance could have been found, but the Liberals, at the urging of the various conservative repsresentatives (Reform\Alliance\PC), didn't even try.

    And here we are. I don't disagree with the Supreme Court decision. They are right. People shouldn't die or suffer while waiting for treament. I think where I might disagree is how to fix the problem. Trust me I'm not fond of the status quo either. I just have a healthly doubt that the people who purposely broke our system in the first place can be trusted to fix it.

    By Blogger Mike, at 1:51 p.m.  

  • I'm missing something in the discussion, I'm sure.

    If we only have public [healthcare/education], then that single public system has to deal with all the cream and the problem cases alike.

    But if we reduce the load on the public system by taking away a few cases, even a few simple ones, then somehow the public system suffers? We haven't reduced the dollars flowing; we haven't reduced the tax money available to solve the problems. How can the public system be worse off?

    Then, there's the simple fact that the SCOC recognized in its ruling that we have two-tier healthcare in Canada today, but that (in their words) it's only the very rich, who do not need insurance to pay for it, who can access it and bypass the waiting lines in the public system.

    This ruling was not about the existence of the private system; it was about whether Canadian society should allow ordinary Canadians to access it.

    By Blogger Paul, at 9:46 p.m.  

  • Hey Mike,

    You say, "I find it ironic that the same people who have gutted the public system of funding and human resources for so many years, thus causing the crisis in the first place, are now calling for privatization to fix the public system they broke."

    Far from being ironic, that was the right-wingers' plan all along. Isn't it obvious: if you want people who are happy with a public service not to be happy with it any more, so you can step in and you and your friends can make a profit selling that same service to them, then you have to ruin the public service people are happy with.

    By Anonymous Anonymous, at 11:28 a.m.  

  • Come on guys, why is that everyone tends to forget Canadian doctors' role in all of this - gatekeepers keeping out others so that the pie is not shared by more qualified professionals willing to work in this country.

    Dogs in a manger if ever.

    And of course an unsuspecting public takes the crap for their selfishness

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