"Balancing ideologies: Two-tiered health care"

[Guest Ian Wong]

Now that the election has been called, there has been considerable coverage as to plans for maintaining and improving Canada's healthcare system. Today, Paul Martin revealed his plans for rejuvenating our current system, with a large injection of federal funds. There was no mention of increasing support for privately-delivered health care, which seemed to be in contrast to an errant comment uttered by Pierre Pettigrew, the current Canadian Minister of Health (which he hastily retracted the following day).

 

The following article was written by a family physician in Ottawa, which questions why it is so difficult to start an objective and rational debate on the merits of privately-delivered health care.

 

Ian

 

www.medicalpost.com/mpcontent/article.jsp?content=20040523_111348_800

 

If we already have two-tiered health care, why not admit and embrace it?

 

By Jonathan Isserlin

May 25, 2004 Volume 40 Issue 21

 

I suppose this is not the right time to make any sort of reference to the possibility of some privatization of the health-care system. The acute embarrassment displayed by health minister Pierre Pettigrew when forced to recant his passing remarks about the subject confirms the Canadian public, as portrayed by our permanently left-of-centre press, is still mired in a blinkered, tunnel-vision condition that refuses to allow even mention of the word.

 

I am very careful to say "mention" as a precursor to the topic, because, as anyone with the slightest understanding of the subject knows, we already have a semi-privatized system in fully a quarter of all services—and that percentage is rising all the time.

 

Anyone who needs physiotherapy has to pay for the privilege. Anyone who has blood work done outside of the hospital goes to a private for-profit lab. Some hospitals are even getting private labs to do their blood work. If they want certain tests (such as the prostate-specific antigen) they pay for them out of their own pockets. The list goes on. All Pettigrew was saying was that some services would be contracted out to private companies (as is already done with the labs) and he was jumped on from a great height.

 

Why is it that we are stuck on this constant recurring theme? What happens to the Canadian public every time an election is looming that makes sensible discussion of the possibility of paying for some services with the longest waiting lists so unpalatable? There need not be any interruption of vital services for conditions such as cancer or heart disease.

 

These could, in fact, be incorporated into the system. If only we were allowed to actually discuss the notion of having a separate and parallel availability of services. If only we could recognize that as medical services and medical technology becomes more expensive, the health-care system is less and less able to afford everything for everyone. Let's look at a couple of examples.

 

I have a 60-year-old patient who has terrible arthritis of the knee. He is hardly able to walk, let alone do the things he really enjoys, like play golf or cycle. His orthopedic surgeon agrees that he needs a total knee replacement and has put him on the waiting list to get one—in about 18 to 24 months' time. My patient (we'll call him Mr. T.), has been parsimonious all his life. He has not smoked, drank or gambled. He has not spent money in any way recklessly. He has worked out that he has, at best, about 15 to 20 years of activity left to him, and he doesn't want to waste 10% to 15% of that time in pain waiting for his new joint.

 

If Mr. T. were to go out and blow his hard-earned savings on a Ferrari or Boxster, or if he bought a huge mansion with a home theatre, he would be the envy of all and sundry and would qualify for awed looks that praised his talents. Mr. T., however, wants to spend his money on a new knee joint, and for that idea, he is branded a plutocrat and a potential wrecker of the country.

 

By the same token, I have another patient, let's call her Ms. D., who has already had two angioplasties with stents that have clotted up, and she is only 54 years old. She has read all about the new impregnated stents on the Internet and knows they clot up about 2% to 3% of the time compared with about 15% for the regular stents. She would also like to cough up her hard-earned savings—or those of a family member—to improve her chances of growing old enough to see her children finish high school.

 

In the first example, what would be wrong with allowing Mr. T. to put up the money for the operation, have it at a completely private institution, use only private nurses and doctors thereby not inconvenience the system? Mr. T. would get his operation sooner and, it is to be hoped, get back into walking, golfing and biking—maybe even working again—sooner.

 

Each person who, like Mr. T., has his or her operation "privately" would take another patient off the waiting list. If 10% of patients pursued "private" operations, other waiting for new joints would have their wait times reduced by one and a half to two months.

 

In the second example, why should Ms. D. not be able to pay for the proven better technology to potentially save her life? How would this inconvenience the system? The actual difference to the system would be zero, in fact it would be a net financial gain because it would save the hospital the cost of the regular stent while not having to pay for the impregnated one.

 

One argument often made is the option for two-tiered medicine already exists for patients willing to go south of the border. The reality is this is available for the very rich only as hospital expenses in the U.S. are substantially higher than they are in Canada.

 

The very wealthy will get what they want. Queue jumping will happen in any system. Politicians, friends of the powers-that-be in the hospital or health system, and others who have influence, will somehow manage to get their joints sooner or their stents to be impregnated. A friend of a premier, a cabinet minister or a sporting hero is unlikely to lounge on a waiting list for months. Deputy ministers are unlikely to make do with a simple stent.

 

My argument is that if we are dealing with a two-tiered system anyway, let's make it a system that rewards the people who have been responsible in their lives and saved their money; rather than having the government flunkies and lackeys getting their snouts into the trough. More importantly, let's start discussing the problem openly in a general forum without being forced to shut up as soon as the hint of an election is in the air. Let's recognize that our system is ailing and needs to be overhauled in such a way that it can become stronger, rather than allow it to sink to its lowest common denominator.

 

The bottom line is, if it were you or a member of your family, which stent would you want and how long would you be willing to wait for your new joint?

 

Jonathan Isserlin is chief of geriatrics at the Queensway Carleton Hospital and a family physician in Ottawa.

[Guest CaesarCornelius]

Poor article.

 

In both of the examples he uses, he treats health care like a commodity. Equating buying a car to buying a knee, and the more money you have the better car (or knee) you can buy. This, to me, is not something that canada wants to get in to. The problem is that this issue is a slippery-slope, once you start with the private blood labs, the private hospitals that do knee replacements, etc... you are going to end up with exactly what we are looking to avoid, a two leveled health care system. People who can afford to pay, will pay, and those hospitals will be able to buy expensive machines, nice wating room sofas (ha!) and other things. While the public hospital will be for people who can't afford other care and will be forced to receive the 2nd rate stent, and the cracked plastic waiting room chairs.

 

To further this problem, the funding for the public hospitals will decrease, because the people that use them are not in any position of power and will get pushed to the side. THere is also the issue of health insurance, but that is another issue.

 

So, what is my solution to this? We should follow the example of certain european nations. If we followed the system that france has, we would pay our 30% income tax, but 10% of that would be dedicated to health care. Or even on sales tax, 10% sales tax and a 5% health care tax. That money couldn't be spent on anything but health care. also in france, you get a statement from the governmentn that says (You're money went to buy the following items...1)...etc)).

 

The problem we are having is all about funding. One solution has us creating two options for people, one who can afford to fund and one who cannot. The other option requires everyone to fund, so that we all have access to the same health care. That is the benefit AND the price we pay for living in a semi-socialist country.

 

CC

[Guest CH146]

I have to say that I agree with the article. I can't for the life of me make this ideological leap of faith that says that once we embrace things like private blood clinics, that all of a sudden we are doomed to have politicians that legislate lower funding for our regular public hospitals.

 

The anti-private anything in heatlhcare argument is reduction logic to it's extreme. While I wouldn't want to receive second rate care, I also wouldn't be happy sitting on my hands for a year waiting for a new joint replacement. What will be the cause of this second rate care??? Aren't all doctors required to be licensed to the same standard?

 

As far as queue jumping is concerned, it is done all the time by the WCB, the military, federal politicians, RCMP... so in my view, the assertion that our system is fair for all canadians right now is false anyhow.

 

This is my fodder for debate...

[Guest lex]

there's a similar thread in the General Premed Student section (Supreme Court decision re: wait times violating Charter) if anyone wants to check it out.

 

CH146- you're right about the current unfairness in the system but I wonder if building upon that inequality is the most appropriate way to move forward?

 

Sometimes this debate gets a little narrow in scope. It usually comes down to waitlists vs infusion of private money. In the US, healthcare spending is 2x per capital than what we pay in Canada. And yet the US has a significantly lower health status. More money isn't always the solution. The marginal gain in today's healthcare setting has become quite slim so cash infusions tend to get swallowed up fairly quickly.

 

But it is unlikely that the status quo will withstand the growing pressures on the system. Maybe we need to look elsewhere.

 

Consider what was possibly the most important advance in human health in recent history. It didn't come from financing the healthcare system or a new drug; rather, it happened when engineers decided to separate public water and sewage lines.

[Guest CH146]

I hate it when someone comes up with insightful comments...and then my rant just doesn't seem to cut it.

 

good on you Lex

[Guest justanotherpremed]

you are going to end up with exactly what we are looking to avoid, a two leveled health care system. People who can afford to pay, will pay, and those hospitals will be able to buy expensive machines, nice wating room sofas (ha!) and other things. While the public hospital will be for people who can't afford other care and will be forced to receive the 2nd rate stent, and the cracked plastic waiting room chairs.

 

what the?? that's exactly what the author is saying. By your logic it is better to have two people getting a bad stent than having one person get a bad stent and the other person get a good stent.

 

:hat :smokin

[Guest CaesarCornelius]

Well, what I was trying to say was that I don't think we should replace the inequality in our current system with the definite inequality in a 2-tiered system. That isn't logical. I was trying to say that our system is fixable, we just need better management and a more direct source of funding.

 

CC

[Guest justanotherpremed]

The problem we are having is all about funding.

 

I'm not sure that the problem is quite that simple. Throwing more money at this problem is nearly certain to fail. :hat :smokin

[Guest UTMed07]

I heard all the arguments used in the article before. They are the same arguments that Ralph Klein uses and the HMOs use in the USA.

 

I'm going to just take apart one--the "lets create a private system so we can relieve the public system."

 

This argument sounds pretty good--if you don't think about what it really means. The problem is... if you create a second system you need to fund all its supporting infrastructure, pay the staff and run additional administration and accounting department.

 

Infrastructure doesn't just pop out of the ground--it has to be financed and if private money is involved the person who puts up that money wants a return.

 

The Ralph Klein line "...private money will pay for the bricks and mortar so the public doesn't have to" is a fallacy. It sounds great but fails to describe what happens after. The truth is if ...private money pays for the bricks and mortar --LATER the people that use the building WILL PAY for the construction of the building and THEN SOME (through user fees/leasing deals and/or extra billing) so the group that invested the money can recover its capital and then make a profit.

 

The argument tries to make an end run around the fact that publicly funded health care is more cost effective and leads to better outcomes. If there is a lack of facilities and people have to wait it is more effective to invest more money in the public system.

 

Bringing it back to Ms D and Mr T -- and the waitlist.

If 10% of patients pursued "private" operations, other waiting for new joints would have their wait times reduced by one and a half to two months.

If those people were taxed the amount they'd pay for the private operation... we could "buy" more operations and everyone on the wait list would have their wait times reduced more (than if the rich patients buy more expensive private care).

 

The equation looks like this--

1. Buy private care -- for 1.2X the rate... get worse service faster, fund a more expensive system and create a class society

OR

2. Be taxed more and fund a public system that will produce the extra capacity for less money and be more egalitarian.

 

 

Creating a parallel privatize system just moves us closer to the American system... where everything is more expensive. Americans have approximately 40-50 million uninsured people yet spend more money than we do per capita. If they had a (more efficient) public system they could insure all of their population with the money they are spending today***--unfortunately the government there (which is in the pocket of the big HMOs and big businesses) believes that it is important to maintain a system that gives HMO CEOs hundreds of millions in stock options and screws the poor Joe Everyday out of his knee replacement or CABG.

 

 

***Americans spend $5267 US/person--Canadians spend $2931 US/person (OECD data). To be fair--lets assume the Can. dollar has the same buying power (in Canada) as the US dollar in the US-- so the $2931 US spent in Canada really has the buying power of $3908 US in the USA (2931*1/0.75=3908 --- 0.75 being a conversion btw US and Can. dollars). That means Americans overspend $5267-$3908=$1359 US. They have a pop. of approx. 300 million -- 50 million uninsured and 250 insured. So, that means excess spending is $1359*250 million = 339,750 million (or $340 billion US). If you divide $340 billion by $3908 (what it costs to insure a Canadian) you get approximately 86.9 million people. Thus, 336.9 million (=250+86.9) could be insured in the USA if costs were similar to those in Canada.