The Unsolved Riddle of Affordable Health Care and the Medicare Mystique

Imagine that you are suffering from chronic pain due to a condition that can be alleviated by fairly simple surgery. You schedule the surgery but are told that it has recently been re-classified as elective or cosmetic surgery and so is no longer covered by your health insurance. If you want the surgery you must now fork over thousands of dollars.

Or imagine that you live in a rural community that is only a half hour drive away from the second largest city in your province. You have a condition that is fairly common but the city close to you does not have any of the specialists who treat that condition, despite having a decent sized general hospital and several smaller clinics, and so twice a year you must travel half way across the province to see a specialist in the capital city.

How about this scenario? Your spouse has an irreversible, progressively worsening, mentally debilitating condition that requires round-the-clock supervision and extremely expensive medication. As your savings disappear paying for the expensive and ineffective medication you find that you are now figuratively chained to your spouse because the health care system seems unable or unwilling to provide you with relief from the duty of watching over your spouse 24/7.

Suppose you are a young, expectant, mother on the verge of giving birth. You are staying with your family in a rural community that has its own, modest, health centre. When your water breaks you contact the local health centre and are told to go to the hospital in the nearest city which is approximately an hour’s drive away. So you hop in your pickup truck, the father of your child takes the wheel, and off you go but you do not have time to make it and give birth along the road.

Let’s say that an elderly loved one was discharged from the hospital in a particularly harsh winter, taken home by taxi, and later found dead on his porch. What would you think if the provincial health minister were to try and pin the blame for this entirely on the cab driver?

All of these scenarios are real. Two of them are taken from stories that made the news here in Manitoba during the last six months. One describes a situation within my own family. One describes something that friends of mine from church have had to deal with. One is a story that was relayed to me by these same friends.

What all of these scenarios have in common is that they point to the fact that our publically funded health care system is overburdened and unable to meet the demands upon it or the medical needs of Canadians.

That the publically funded health care system is overburdened is not exactly news. For years now Canadians have had to put up with waits to see their family doctor, followed by longer waits either to see a specialist, to have lab work done or both, followed by yet another wait until they actually receive treatment. These waits can be months or even years long, even if the condition is serious enough to require urgent treatment. It is openly acknowledged that there is a problem here and there is also a pre-packed, knee-jerk, pat answer to the question of what the solution is. That answer is to say that the government needs to devote more resources to health care, to put more money into it.

That is the wrong answer but to point that out in Canada is to be like the boy in Hans Christian Anderson’s story who observes that His Imperial Majesty is strutting around naked as a jaybird. This is because it is the only answer that is consistent with the prevalent Medicare mystique.

By Medicare mystique I refer to the ridiculous but popular idea that our single-payer health care system is not only superior to all other systems but a glorious national institution, Canada’s pride, joy, and crown jewel, and that its monopoly on the provision of health care services must be protected against competition at all costs, lest we become like the Americans. I have often heard this mystique put in these words “our health care system is what makes us different from the Americans”.

I wonder if those who put it this way realize how utterly stupid it makes them sound? On the national level, universal, single-payer, health care dates back to the Medical Care Act passed by Parliament in 1966. Not that the Pearson Liberals invented it from scratch. It developed over the course of a couple of decades as the provinces, starting with Saskatchewan under the socialist government of Tommy Douglas, developed provincial public health insurance programs, and the federal government, under both the Liberal and Conservative parties in the ‘50’s and ‘60’s, began to provide funding. Something that is less than fifty years old in its present form cannot be what defines us as a nation and makes us distinct and different from our nearest neighbour. Canada is a parliamentary monarchy and a federation of English and French provinces, formed out of colonies that had remained loyal to Britain when the Americans rebelled and by Loyalists that had fled persecution in the new republic, which developed as a country within the British family of nations rather than through revolt and rebellion. This, and not Medicare, is what distinguishes us from the Americans. I will not dwell on this point further, however, because I am writing about what is wrong with our health care system not what is wrong with our educational system.

The way the system works, each province operates its own public health insurance plan with a large part of the funding coming from the federal government. The province issues a card with a health number on it to each of its residents which they show to the hospital, clinic or doctor’s office. The provincial health plan is then billed for the services.

Public health insurance systems like Canada’s were created in response to the rapid and exponential rise in the cost of health care over the last century brought upon by such factors as the explosion in the development of new health technology. The rise in the cost of health care put it beyond the reach of many people and so public health insurance was developed with the goal of making sure that everybody who needed medical care had access to it and that families did not have to clean out their savings, take out a loan, or go into bankruptcy to pay for life-saving surgery.

This was and is a laudable goal but the problem with public health insurance is that it is an answer to the question how can we make somebody else pay for our health care rather than to the question how can we make health care more affordable overall. Indeed, if we think of the expense of health care as being the problem, public insurance adds to the problem rather than decreases it. Health care that is paid for by public insurance is not free because we pay for it with our taxes, but by separating the payment from the use, it creates the popular illusion that it is free. This in turn leads people to use the system more often than they would if they had to pay per use. When you increase the demand for any commodity you drive up its price and so public health insurance increases the total cost of health care even though you don’t pay for it at the moment of use.

If this sounds like an argument for private health insurance of the sort that we ordinarily associate with the United States, think again. Private health insurance also increases the overall cost of health care, albeit for different reasons. Look at how much the Americans spend on health care every year if you want evidence of this.

If both public and private health insurance drive up the cost of health care then it seems like we are trapped between a rock and a hard place. Paradoxically, however, countries that have both seem to have better overall health care than countries that have only one or the other.

Several decades ago, in an interview that was published in the Paris Review, British novelist Anthony Burgess remarked that despite his loathing of the State he conceded “that socialized medicine is a priority in any civilized country today”. To this, he added that “there’s no reason why a private practice shouldn’t coexist with a national health one”. This, he noted, was how it was set up in England, and then remarked on how the difference in treatment is indistinguishable, except that “the State materials (tooth fillings, spectacles, and so on) are inferior to what you buy as a private patient.”

What Burgess was describing is what exists not only in the United Kingdom but in every other first world country other than Canada and the United States. Canada and the United States do have a mix of public and private in the sense that the United States has had public health insurance for the elderly and low-income families since the 1960s and Canada allows private coverage for procedures not covered under the public plan. In the UK, Europe and Australia, however, a universal public health system exists alongside competing private systems and the health care is generally superior, both in quality and affordability, to that of the North American countries that have taken the more extreme routes of either relying mostly upon private companies for health coverage (the United States) or giving the universal public plan a monopoly (Canada).

Technically it is the provinces that give their public health plans a monopoly, although the Canada Health Act of 1984, one of the last bills passed by the Trudeau Liberals, provides strong incentive for them to do so. While this monopoly was successfully challenged before the Supreme Court in Chaoulli v. Quebec (2005) it has not yet been broken. The refusal to allow private insurance to compete with public insurance is downright stupid and is the single biggest reason why the public system is failing. It is also the sort of thing that outside Canada only exists in Communist dictatorships. Unsurprisingly, it is also the aspect of our health care system that is most protected by the Medicare mystique. You may recall that in the 2000 general election the other parties ganged up against Stockwell Day of the Canadian Alliance and accused him of wanting to Americanize the country by introducing “two-tier health care”. Day’s response was to hold up a sign in the leader’s debate that said “No 2-Tier Health Care”. There is irony in the fact that two-tier health care would have given us the British/European/Australian model and not the American model but this irony is lost on the type of people who, with the twisted reasoning of egalitarianism which in a wiser age was known as Envy, one of the Seven Deadly Sins, would rather have all Canadians waiting in long lines to receive more expensive, poorer quality, health care, than to allow Canadians who can afford it to opt out of the public system and pay for private care, thus relieving the burden on the public system and allowing it to operate better.

As long as this mystique prevails, the burden on our health care system, especially in provinces like Manitoba where the socialist NDP government is determined to cling to the public monopoly even as it finds itself closing rural emergency rooms and obstetric wards across the province, will continue to grow, and the riddle of affordable, quality health care, will go unsolved.