In Defence of Public, Universal Single-Payer Health Care

In the wake of the recent Supreme Court of Canada decision on private health insurance, the debate over whether we should have public, private or mixed system has been re-ignited. I believe that the best choice for us is a fully public, universal single-payer system - fix our current system so that it operates as it was intended.

Why a Public System?

1. Public Healthcare serves the Public good, not private stockholders

A public, single-payer system exists to provide healthcare for the citizens of Canada. All decisions made within the system have as their sole criteria the health needs of the patient. Private Insurance and private health delivery exist to make money for their owners and stockholders. They must maximize profits and minimize payouts. Private health insurance is no different. Insurance companies will find reasons to not pay, to disallow claims, to raise rates or to refuse insurance all together (for "pre-existing conditions,"for instance). It is a bitter irony that Mr. Zeliotis, one of the complainants in the Supreme Court decision that opened the door to private insurance, would not have qualified for the coverage he sought.

In the end, private insurance will make money for insurance companies but will not help sick people get faster service. Wendy Hope, vice-president of external relations for the Canadian Life and Health Insurance Association, says that if insurance for medically necessary service comes into being, people on waiting lists won't be eligible. People with pre-existing illnesses or conditions wouldn't qualify for coverage.

"Insurance is a product that protects against the eventuality of something happening," Hope explains. "You can't buy insurance if you're already ill."

If you are sick "that's why there is public insurance."

Only the public system will serve the sick.

That is not to say that I think out system is working properly right now. I agree with the Supreme Court - waiting lists are too long and that does constitute a violation of a person's life and security of the person. It needs fixing after years of mismanagement and underfunding. The solution is not to allow private insurance, which won't help anyway, but to fix the system we have - add new funding and implement the recommendations of the Romanow Report.

Or we can have a healthcare system that is run like our dental care system.

2. Public Health Care is good for business

General Motors pays $1500 per car in health insurance costs in the private system in the US. It pays $500 per car in Canada. That's between 5 and 10% of a car's value. Having a publicly run and administered healthcare system can actually make Canada more attractive to large businesses like GM, because of the money they save on paying for and administering these benefits.

Now they may have to administer extended benefits (extra medical not covered by the public system. These are procedures deemed not medically necessary or extras like single-rooms or free ambulance rides), but this is still much cheaper than the full blown version in the US.


3. Public Health Care is Cheaper to Administer

According to Dr. Arnold Relman, Professor Emeritus of Medicine and Social Medicine at Harvard Medical School and Emeritus Editor-in-Chief of the New England Journal of Medicine, public health care is cheaper to administer and the experience in the United States is that private insurance actually drives up administrative costs. The US spends $752 per capita more than we do on administration. According to some pretty good research by Ezra Klein, that's 300% more. Private ownership also drives costs up.

Clearly then, introducing private healthcare will not make the system more efficient, but actually make it more expensive. That is just not good fiscal responsibility.

Basically, from a more pragmatic point of view, these are the biggest reasons to stay with public healthcare and not allow more private care.

Public healthcare is more client responsive and client focused, is better for business in general and is cheaper to run. It makes good economic sense as well as being more equitable and fair.

Other Questions:

1. 'But France is #1 and it has a mixed system. Why can't we?'

Canada is not France. Their culture, economics and government are different enough that implementing a French-style system here simply won't work. The 'private' part of the system is funded from mandatory deductions similar to the public system:

"The funds are private entities under the joint control of employers and unions, which are in turn supervised by the state. As might be expected, that doesn't work particularly smoothly, and there's a constant battle for authority and control. Creative tension, one might kindly call it. The funds are mandatory, no one may opt-out, and they're not allowed to compete with each other nor micromanage care." - Ezra Klein

There is no way that will work in Canada. In France, even their 'private' healthcare is heavily controlled and managed by the government and unions. French doctors are paid 1/3 what doctors in the US and Canada are paid. How many doctors would be willing to take a pay cut, considering doctors in Ontario almost went on strike a few months ago in order to get a long-overdue raise? Not many.

While the French model may seem great on the surface, it is clearly unworkable in Canada and not the kind of 'private' that the conservatives in this country would support.

2. What about the rest of Europe? They all rank ahead of us with mixed systems too?

The same issues exist. Most European countries do not have the same kind of federal structure to government that we have and if they do, they do not have the same separation of powers between the federal government and the provinces\states that we do. What may work for Germany or Sweden or Japan will not work in our unique Canadian federation, devised by Sections 91 and 92.

Also it is noteworthy that advocates of the mixed system pick these countries. One of the few countries in the world that is most like our own (in government division) is Australia where this didn't work. The advocates of mixed systems never mention Australia.

3. Having a parallel system will reduce the wait times the court talked about.

No according to recent studies. In England and Australia, these studies have shown that wait times in the public system actually increase when a parallel private system exists. In Manitoba, patients whose doctors worked in both systems had to wait 2.5 times longer for cataract surgery than patients whose doctors worked only in the public system (26 weeks v. 10 weeks).

Doctors in such systems have a "perverse incentive" to keep public waiting lists long - it forces people in to a private system where they will pay more and doctors will earn more.

4. User fees will reduce abuse and lower medical costs

Again, according to the Canadian Health Research Foundation, this is not true. What this does is discourage the poor, who are less healthy in the first place, from not seeking early medical attention. They let their illnesses proceed until they end up costing the system much more in the long run. "Penny wise and Pound foolish" best describes the situation. Ironically, this very situation was one of the major factors that lead Saskatchewan to create the first Medicare system in Canada in the first place. Medicare is the solution to this problems, this problems isn't a solution for medicare.

Conclusions and Possible Solutions:

I firmly believe in equality of opportunity and access for all Canadians in healthcare. I believe strongly that healthcare decisions should be made on medical need, not ability to pay. The very rich should not be able to hire away the best medical expertise or buy their way to the head of the queue.

That being said, I recognize that long waiting lists for procedures are in fact endangering Canadians lives and causing undue suffering. I agree with the Supreme Court decision. I also recognize that the very rich can already buy their way to the head of the line by going to the US or to the very clinic our PM attends in Montreal. I recognize that in some instances and in some provinces we have a defacto two-tier (or more) system. What this means is that I recognize that our public system is broken and needs to be fixed, not replaced.

1. Return Federal funding eventually to 50%, as it was in the 70's. This is long term. A good start would be to get it to at least 25%. This will help alleviate 12 years of budget cuts and underfunding.

2. Alleviate waiting lists with the assistance of the medical profession. Look for creative ways to prevent the system from being overwhelmed - specialty clinics instead of ER for frontline diagnosis, SARS like protocols for entry to ERs (I got the fastest service in 10 years when I had to get stitches during the SARS crisis - a lot of people who normally clog up the ER with things that can be looked at by a walk-in clinic or family doctor were not there.).

3. Hire and train more doctors, nurses and nurse practitioners. Much of the strain on the system is because we do not have the people to do the jobs we expect. More doctors will certainly shorten waiting lists.

4. Re-allocate responsibility. In consultation with healthcare professionals, see what kinds of medical attention can be taken care of by professionals other than doctors - nurse practitioners, nurses or mid-wives, for instance. Spread the work more intelligently, so the doctor shortage stops being a bottleneck to care.

5. Reduce costs in other places. Drug costs have eaten up most of the new spending on healthcare. Stopping the "evergreening" of drugs, which prevents the introduction of cheaper, generic version.

6. Invest in new diagnostic equipment and the staff to run them, again to help with early detection so that cheaper, faster treament options are used.

7. Implement the Romanow Report. It's been out for 2 years. The government has done nothing.

8. See number 7.

None of the above needs to mean higher taxes. A re-commitment and re-allocation of funds could certainly do it. This is a combination of spending and conservation.

There may be other ways to help. But we must do something now to ensure that we have a world class healthcare system that can serve all Canadians, regardless of their status of location in the country, rather than give perks to the rich and business opportunities to insurance companies.

What do you think?

For your Reading Pleasure:

The Canadian Health Sciences Reseach Foundation Mythbuster page.
Dr. Relman at the Healthcare Coalition. They also provide more compelling evidence for public healthcare rather than private.
Rick's blogs entries below. Besure to follow the links.
Policagrll has two entries that discuss her personal experiences with the dental system and the drug system, which demonstrate that private insurance won't help. a very compelling read.

The Canada Health Act and an overview.

The Report of the Romanow commission.

Not a read, but be sure to watch this video series about the birth of Medicare in Saskatchewan. See if you can see how many of the same arguments for private insurance weren't born out in reality.