Wednesday, June 15, 2005

The Great Health Care Debate

There's a good debate going on in the comments section of my healthcare post a few days ago. Since my health care knowledge is limited to "the knee bone's connected to the ankle bone. The ankle bone's connected...", I'm going to save myself some time and effort and re-post some of the better observations from those comments and from around the web.

First, I'd encourage everyone to check out Ezra Klein's blog which has an outstanding country by country comparison of different health care systems. So if you're like me and don't know the intricacies of the Japanese health care system, this is mandatory reading. I'd also point people towards Scott Tribe's post at Progressive Bloggers which is very thorough and brings together comments from around the web. And Andrew Spicer has a suggested plan, complete with diagrams and everything.

Now, a sampling from the comments section of this blog. If you read all the way to the end, I may throw a few of my own thoughts in:

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)

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.


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 administered 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.


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.


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.


That's just a cross-section of opinions. As for my take? I don't mind a role for some private delivery in the system although I can't really understand how private delivery can be cheaper than public due to the profit component. Regardless of that, the debate we're having now is squarely on two tier health care. And once you set up a competing private system, it by default hurts the public system. There's a doctor shortage in Canada right now and I imagine a lot of doctors would leave for the private system. I know I'm being dogmatic on this but if you believe that all Canadians deserve the same health care treatment, then you can't be in favour of two tier health care - it's that simple. And I believe that all Canadians do deserve the same health care treatment.

This ruling pointed out the problem with the current system and because of that, it's likely a good thing. I think we're better off debating this than Gurmant Grewal and it would be naive to say the current system is perfect. But as for two tier health care, I really haven't heard a compelling argument in favour of it.

There's also been a lot of talk about bringing in user fees and I'd be really hesitant to go that route too. One of the biggest failings of our system is that it doesn't address prevention of disease enough and user fees would simply provide a disincentive for checkups and visits to the doctor that catch problems before they become serious.

The house may need renovations but that's not a good reason to blow up the house.


  • I've got a complaint about Ezra Klein's analysis. He says that we only have long wait times for "elective" procedures. Yeah, if you consider cancer-detecting MRIs to be "elective"...

    By Blogger The Invisible Hand, at 4:17 a.m.  

  • CalgaryGrit: Thanks for getting a great dialog going. Blogs are, in a way, the perfect place for some pretty open idea-generation. And that is what we have not had a lot of because of the auto-demonization of anything that can be characterized as "two-tier". So thanks. Now on to my comment...

    You say you have not heard a compelling argument in favour of two-tier health care. I guess, if you ignore both the significant problems of our system, and the fact that every other nation doesn't have a problem with it AND has better health care. We can't get caught up on this idealized view of one-tier/two-tier because (a) it never has been one-tier, ever and (b) that argument is used to shut down any discussion of our options.

    Look at France, the country so many point to as having the best healthcare "system" by many. A much more socialist country than us and a much more open approach to private delivery. Not to give Harper's ideas any support whatsoever, but the world is full of "hybrid" healthcare systems that provide better AND more fully universal healthcare. The notion that opening the door to private delivery will be the end of public healthcare is a ridiculous misunderstanding of how the system works. The countries the WHO ranked ahead of Canada had both a more open approach to private delivery and LESS private delivery. We have to focus on getting better quality healthcare, not on ensuring equal access to poor health care.

    So how do we do that? I like Anonymous’s idea of leasing out unused or underused equipment. This reduces wait times and brings some money back into the system from a source other than increased taxes. I think this is a component of many hybrid systems in place in Europe.

    I’m throwing other ideas around here but what if we opened up family practice to more private delivery? In many Ontario cities I know of, this is the greatest doctor shortage problem. If we opened up family/general practitioners to more private delivery: (1) the gap in doctors might reduced as some doctors become more interested in being generalists/family practitioners, or (far more likely) create their own hybrid practices by splitting their time between both; (2) we could ensure individual health problems don’t exacerbate for lack of treatment by allotting everyone one annual health check-up; (3) for everything else you have to either get private insurance or special public insurance for those in need; (4) but the cost of family practitioners would never be bankrupting for families because if it is a chronic health problem, you get referred to a specialist and that remains covered by public insurance; (5) complete public coverage for all children stays in place.

    OK, just my thoughts, but we have to crack through the mental straight-jacket of “never two-tier” when it is already here and we’ve got bigger problems than clinging to an ideal that isn’t working.

    By Blogger Ted Betts, at 12:58 p.m.  

  • Anyone else find it ironic that the ideas that Ralph Klein has been promoting (and then nationally demonized for) are exactly the issues being raised after the SCC ruling?

    Once again, Alberta leads the nation in progressive attitudes, smart planning, and understanding issues dead on. Yet still recieve little to no representation in Ottawa.

    Time for western seperation folks.

    By Anonymous Anonymous, at 1:43 p.m.  

  • Anonymous: "Yet still recieve little to no representation in Ottawa."

    You know, just because you don't get your way doesn't mean you aren't represented. According to StatsCan, Alberta represents 9.9% of the Canadian population and has 9.1% of the seats in the House of Commons. Ontario, by contrast, represents 38.7% of Canada and has only 34% of the seats.

    I'm so tired of the whining about underrepresentation by Albertans. When you continually vote for a party destined to remain in opposition, where is the source of your complaint? It's like an English Bloc: don't want a say in government, just want to complain. Over on The Shotgun, they even started suggesting that representation by provincial GDP until some bright light pointed out that Ontario would get even more seats based on economics.

    Imagine how this country would look - in my mind for the better - if Alberta started to elect more Liberals and put more Albertans into the cabinet, making them an active player instead of armchair critic!

    By Blogger Ted Betts, at 2:47 p.m.  

  • TB: What a hairbrained idea, if you dont like the status quo, vote liberal!!??

    Yeah makes a lot of sense.

    If Ottawa hadn't been so keen on making out Klein to be some kind of devil instead of looking at his ideas and actually fixing health care maybe we could have saved some lives.

    But the liberals remain in power, Easterners lap up the lies like honey, and Canadians get poorer health care, corrupt leadership, and further regional divisions. You're right, we should all be happy about the Canada of today.....

    You keep up with your attitude, and I'll be happy when we're gone.

    PS- If you honestly believe pure population should be the basis upon which all governments are set up, I suggest you do more research on new democracies. We had two houses for a reason, once upon a time.

    By Anonymous Anonymous, at 4:04 p.m.  

  • Framing the arguement as public vs private is inadequate. We could have:
    1a)public funding of health consumers;
    1b)public funding of health providers;
    2a)private funding of private health;
    2b)private funding of public health.

    1a = consumer-driven healthcare.
    1b = supplier-driven healthcare.
    2a = free-enterprise or insurance-driven.
    2b = 0% deductable public healthcare.

    The construct is:
    public/private vs public/private; ie, paying and delivery are two separate fruits.

    By Blogger Art Hornbie, at 6:21 p.m.  

  • TB; Yes, France has a very good system and it would serve us well to examine them. But from what I've read, it seems that their strength comes from the massive number of doctors and physicians they have. Going to two tier health care wouldn't create new doctors and physicians, unless you buy the argument that thousands of doctors are going to the US and Canadians aren't going to med schools because being a doctor doesn't pay enough.

    Until we train more doctors and physicians, one tier, two tier, it won't make a difference and bringing in a private system will only drain more doctors from the public system.

    By Blogger calgarygrit, at 7:18 p.m.  

  • CG: France does user fees in a complicated but ultimately accessible and highly effective way. That goes a long way to efficient healthcare resource allocation.

    And our doctor shortage is due to a. underfunding of the post-secondary education system w/ too few doctors graduating,
    b. having the US next door where you can get paid more for less hours and more cutting edge work. i.e. the public system in part causes the doctor shortage.

    TB: wtf? Are you seriously stupid? The idea that Albertans could implement those great ideas we have if we just swallowed our pride and voted for the party which campaigns expressly against the province is a non-starter. I mean, if you support substantive Liberal policy, fine. But to vote for them for the sake of power *while that power denounces you* is pretty weasel-like. The current healthcare debate puts that into a crystalline focus.

    By Blogger matt, at 12:14 a.m.  

  • I'm with you on the post-sec Matt. Most universities have brought in differential tuition which means med students pay at least 15 grand a year in tuition, if not more.

    I think a lot of the money we shovel into health care could be well spend funding Canadian universities.

    By Blogger calgarygrit, at 12:55 a.m.  

  • Another big difference in the French system that could be a really positive change here is that it is run more like the social security system, with separate dedicated funding and separate dedicated taxes. The certainty of this would also assist long-term planning (i.e. there is more certainty about how much money will be available 5 years from now.)

    Funding for post-secondary education is critical and it has to start now to get the doctors. But a very large and immediate source of qualified doctors is available right now. There are literally thousands of doctors, fully licenced with years of practice, who have immigrated from abroad but are not allowed to practice. There is not even a streamlined examination process for them to become qualified. They basically have to start from post-university scratch and become interns again.

    And, p.s., I think my earlier comment about Albertans was a bit misconstrued. It was about (a) my observation that a lot of Albertans like Anonymous complain that they are unrepresented - not true - and, not getting their way, threaten to separate - I hate that kind of attitude from Quebec separatists and it is no more helpful coming from Albertans, and (b) my hope that more Albertans would come over to the Liberals because it would bring a fresh infusion of ideas desperately needed by Martin & co. I'm not from Alberta but I recognize that a lot of good ideas have been coming out of the province in the last decade or so that have made the country better (who would have thought balancing the books and paying down debt was such a radical idea!) and can make the country better. My hope is that, rather than disengage in federal politics because of Liberal corruption, etc., as Anonymous suggested, Albertans instead re-engage more vigorously. Anyway, I didn't want to distract from this healthy debate about healthcare options - separatist talk of any sort just gets under my collar. Carry on...

    By Blogger Ted Betts, at 9:43 a.m.  

  • To say that the public system is more efficient or less costly because it doesn't have to pay for profit is a fallacy and simplistic at best.

    That's like saying food is really important, so the government should run a grocery store monopoly so that people only have to pay the cost of producing the food. Every experiment of this kind results in shortages of certain items in high demand and a surplus of items in low demand beacuse there is no incentive to produce more or less of an item. So when items are in short supply, the government rations and people have no choice but to line up. Private grocery stores and food producers, however, have the incentive to compete with one another to deliver those items people want and cheaper than other competitors or by offering specialized services. So they find efficient way to deliver their products to minimize price and maximize profit, or they have a high price and offer something different (say organic foods, etc...) and people decide whether the product offered is worth the price.

    The same applies in healthcare, so we could decide to have public insurance but private delivery. I would envision it working as follows - I need an MRI and the public system says alright, an MRI costs $100 at a public hospital so we will give you $100 that can be used at in a private clinic or public hospital. And so I make my decision - say I choose the private clinic because I heard the care is better there. The public hospital now sees that I'm choosing the private service over the public and therefore works to improve their service so that I choose them next time I need an MRI. Maybe I want to go to a public hospital, but there is a waiting list. Someone sees the business opportunity given the excess demand for MRIs and so buys a machine of his own and takes the excess patients the hospital can't handle. Or I might choose a private clinic because of a specialized service, so I give them my $100 and add $20 out of my pocket because they have a nicer fish tank or a better magazine selection in the waiting room (not intentionally glib, I just don't know specifics about medical procedures).

    Simply put - we can maintain a public insurance system that ensures everyone gets the care they need, but that does not require that the public system also delivers all medicial services.

    As for the fear that all the doctors go to private clinics to make more money, well founded but I think we can overcome the problem. Med students pay highly subsidized tuition rates, paid for out of the public purse. We calculate how much money the full education costs and when a med student finishes school we say either you are required to devote X number of hours to public hospitals over X number of years where you get a public hospital salary, or you pay off the full cost of your education over X many years (just like a student loan).

    By Anonymous Anonymous, at 11:33 p.m.  

  • If by X you mean 40, ok. i.e. Ontario tuition is $20K/yr med, $10k/yr undergrad, cost of living ~$12k/yr. That's >$200k. Takes a long, long time to pay off.

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