The Top Ten Things People Believe About Canadian Health Care, But Shouldn’t
Posted: 10/16/2003

Number Six: Under Medicare, people get the health care services that they need

A whole host of things need to be said here, and I don’t have time for them all. Let me start by saying that while the
language of Medicare is that Canadians get "medically necessary services" paid for by the state, this is not at all so.
Among the services that are not covered are pharmaceuticals (increasingly important as many forms of surgery, etc. are
now being supplanted by drugs regulating the body’s functions), dentistry, home care, chiropractic (in most provinces),
and a number of other services. And there is a wide range of new diagnostic and other services that it is not yet clear
that Medicare will cover. Such as gene therapy. In fact, one of the "brilliant" research papers for the Romanow
commission argued that in fact technology need not be a cost driver for the health care system because it was only a
cost driver if we actually used these technologies….

Let’s talk about a few other aspects of whether we get the care that we need in Canada.

Queuing

Queuing is a controversial measurement, not least because there may be many explanations for the queuing, many of them
medically justifiable, so that aggregate queuing figures may conflate those whose waiting poses no health or other risk
with those whose health may be impaired or may suffer pain while waiting.

That being said, in a system in which health services are free at the point of consumption, queuing is the most common
form of rationing scarce medical resources. And since patient satisfaction plays no part in determining incomes or
other economic rewards for health care providers and administrators in the public system, patients’ time is treated as
if it has no value. There are no penalties in the system for making people wait.

It is thus not surprising that the measures of queuing now available, including the Fraser Institute’s annual report
card Waiting your turn,[5] indicate a lengthening of queues for a great many medical services, including access to some
specialists, diagnostic testing and surgery. What is surprising is that those administering the system must rely on
external studies, not having implemented modern information systems to monitor waiting periods and to identify those
who have had excessive waits.

I’d also like to point out that while we talk a lot about queuing in the Canadian health care system, and we talk as if
we know how many people are waiting and how long they wait, in fact we do not know this at all. In fact, ironically for
the largest single program expenditure of governments in Canada, we know astonishingly little about what we get for our
money. As my colleague David Zitner, Director of Medical Informatics at Dalhousie University in Halifax, and Health
Policy Fellow at my Institute, likes to say, no health care institution in Canada can tell you how many people got
better, how many people got worse, and how many people’s conditions were left unchanged by their contact with their
institution. None of them can give you an answer. No one knows how many people died while waiting for needed surgery.
No one knows how many people are queuing for any particular procedure, or how many people cannot find a family doctor.
Mostly we have guesswork, anecdotes and subjective measures, not objective ones (such as the Fraser Institute reports
mentioned earlier). We don’t even know how long someone has to wait before they’ve waited "too long", because the
health care system does not establish official standards for timely care, although presumably even Mr. Romanow would
agree that someone who died while waiting for care may have waited a tad too long.

All of this is due, as I argued in a major paper I co-authored last year,[6] to the conflict of interest at the heart
of Medicare, in which the people who are the ultimate providers of health care services in Canada are also the people
charged with regulating the system and with quality assurance. Since no one is a competent judge of their own
performance, and no one likes to be held accountable for their work, the result is that the health care system simply
doesn’t set tough standards or collect the information that would allow us to hold the system’s administrators
accountable for their stewardship of our health care and the billions of dollars they spend. The people who would
collect the information are also the people whose performance would be assessed if useful information were made
available. There appears to be no legal obligation for governments actually to supply the services they have promised
to the population. This is an appalling double standard, as no responsible regulator would permit a private supplier of
insurance to behave in this way, as a recent background paper for my Institute makes clear.[7]

Access to doctors and medical technology

Aggregate numbers of doctors per 1000 population do not give a good picture of access to physicians in, say, cities
versus rural areas within countries, nor of proportions between scarce specialists and plentiful GPs, nor of the
quality of medical training. On the other hand, it does provide a crude measure of the overall state of access to
qualified practitioners. On this measure, Canada performs badly. In 1996 this country had 2.1 practicing physicians per
1000 population, while of the comparison group only two (Japan and the UK) had a lower ratio: Australia (2.5), France
(3.0), Germany (3.4), Japan (1.8), Sweden (3.1), Switzerland (3.2), UK (1.7) and U.S. (2.6). Thus, even in countries
with lower per-capita spending than Canada, there is greater access to physician services.

With respect to medical technology, Canada’s performance is also unimpressive. In a study[8] comparing Canadians’
access to four specific medical technologies (computed tomography or CT scanners, radiation equipment, lithotriptors
and magnetic resonance imagers), with the access of citizens from other OECD countries, Canadians’ access was
significantly poorer compared to three of the four. Despite spending a full 1.6% of GDP more than the OECD average on
health care, Canadians were well down the league tables in access to CT scanners (21st of 28), lithotriptors (19th out
of 22) and MRIs (19th out of 27). Moreover, access to several of these technologies has worsened relative to access in
other countries over the last decade.

Number Seven: "Free" health care empowers the poor

Everything I want to say about this is summed up in a story that happened to my partner Shelley. Shelley and I are
partners in a restaurant, and she actually runs it. She had an appointment at the hospital for a procedure, and duly
showed up on time. Two hours later she was still sitting there waiting to be called. Now, she was only able to get a
two-hour parking meter, so she approached the desk and asked if she could go and put money in the meter. She was curtly
told that she was free to go and put the money in, but that if her name were called while she was away, that her name
would fall back to the bottom of the queue. So she just decided that she would take the parking ticket as part of the
price of getting the medical service she needed. Another two hours passed, and still she was not called, so she again
approached the counter, and very patiently and politely explained (as only Shelley can, because she is the soul of
graciousness) that she actually had a small business to run, that she was there at the appointed time for her
appointment, that she had waited four hours, which is far longer than she had been led to expect the whole thing would
take, that she had other commitments because of the business and could they possibly at least give her some idea of how
much longer she might have to wait?

Well, the woman behind the counter got on her dignity, drew herself up to her full height, glared at Shelley and said
"You’re talking as if you’re some kind of customer"!

There you have it, ladies and gentlemen, the essence of the problem — when the government supplies you with "free"
health care, you are not a powerful customer who must be satisfied. They are doing you a favor, and you owe the state
gratitude and servility in return for this awesome generosity. They can give you the worst service in the world, but
because it’s free, you are totally disempowered. One of the most important lessons I have learned from my contact with
the Canadian Medicare system is that Payment Makes You Powerful. And its absence makes you risible if not invisible.

Now the articulate and the middle class don’t let little things like that get them down. Even though they don’t pay,
they still get in the face of the people providing service and make their wishes known. But often the vulnerable, the
poor, the ill-educated and the inarticulate are the ones who suffer the most because no one’s well-being within the
health care system depends on patient/consumers being well looked after. And by depriving them of the power of payment
within the health care system, Medicare disempowers them. And the poor see this, because while they may be poor, they
are not stupid.

In a Compass poll for the National Post, fully 41% of Canadians were of the view that individuals should be able to
choose private health insurance for Medicare if they so chose, allowing them to obtain better, or at least faster, care
than at present. Interestingly, for a society preoccupied with the inequities implied in "two-tier health care," more
of those earning less than $25,000 a year (47%) were interested in this option than were those earning over $75,000
(39%). Those most satisfied with their health care were not the least educated, but the best educated: those with
postgraduate degrees.

These findings are consistent with my view that Canada’s system in fact does create multi-tiered health care where
health care services are distributed on the basis of middle-class networks and ability to communicate one’s needs
aggressively to professional caregivers. It is the poor, the vulnerable (including most obviously, the sick) and the
inarticulate who receive the worst care, because they cannot circumvent the system the way the middle class and its
advocates can.

Number Eight: Canadian Medicare is fairer because no one gets better care than anyone else

Roy Romanow has made it clear that he wants to ensure that "two-tier" health care continues to be forbidden in Canada.
Too late. If you are on workers compensation, are in the RCMP or the military, if your company has its own salaried
physicians, if you use a private hospital like Shouldice (which specializes in hernia surgery) in Toronto or one of the
country’s private abortion clinics, if you are a member of the medical professions, or know someone who is, or are just
articulate and determined or famous and connected, if you travel to the U.S. or any one of a number of other places,
you can get better, faster or more satisfactory care than someone who just lets the wheels of Medicare grind on.

Moreover, technology is allowing the remote delivery of ever more health services, so the ability of governments to
frustrate patients’ desire to get better and faster treatment is declining, and that decline will accelerate. The
debate, therefore, is really about how many tiers and under what conditions. And many of these tiers are beyond
government control.

Virtually any kind of pharmaceutical product can now be purchased over the Internet from foreign providers who can
evade our government’s controls. You can even get involved in on-line auctions for the drugs you want. Your x-rays or
MRI scans can be read just as easily by a radiologist in Boston or Bombay as in Toronto or Truro.

More powerfully, the brain repair team at Dalhousie University recently operated on a patient in Saint John, New
Brunswick. The surgeons never left Halifax. Using video cameras and computer controls, they operated robotic arms that
actually did the surgery hundreds of kilometers away. When you can go to a surgical booth in Canada and be operated on
by the best surgeon in the world, who may be at his office in London or Houston or Minneapolis, the notion of a closed
national health system in which people must take what public authorities decide they should have simply cannot survive.


Multiple tiers is a slippery concept. For some, if some people can get a service by paying for it, while others who
cannot pay do not get access, that is multiple tiers. On the other hand, there are people who oppose tiers because of
an ideology of egalitarianism. Thus two people with similar conditions may both get treated, one more quickly through
private payment, the other more slowly, but within appropriate norms for their conditions, by Medicare.

We are not talking about people being denied care based on ability to pay, because anyone willing to wait will
eventually get care (although we possess no figures on how many die while queuing for public health care). The
complaint is rather that someone got care more quickly. That’s a very different objection: No one should be able to get
faster treatment than in the public system, even where such faster access does not affect the quality or timeliness of
the care obtained by people who continue to use the public system.

This peculiar brand of egalitarianism suggests that people should not be denied service because of their own inability
to pay, but should be denied access because of their neighbour’s inability or unwillingness to pay (through taxes) for
the care an individual decides he or she needs.

Canada is almost alone in the Western world in outlawing people paying privately for services that are also publicly
insured. One consequence of this is that there are many services, such as drugs or home care, that we cannot afford to
cover publicly, whereas they are often publicly insured elsewhere.

Thus, by forbidding people who wish to do so the ability to pay, we satisfy our ideological craving for egalitarianism,
but at the cost of an inability to make room in the public budget for a wider range of services that low-income people
might truly need.

Now this might be a defensible trade-off if our system were superior to others, and indeed we frequently hear it said
that we have the best health care system in the world. But neither the World Health Organization (in its ranking of
world health systems) nor the citizens of Canada, nor the poor and the elderly in Canada (based on polling data),
agree.

In sum, many of Mr. Romanow’s concerns, and those of the Canadian health care establishment whose views he now repeats,
are ideological, and have little to do with the quality of care delivered within the public system. He clings to a
system that outlaws private spending on publicly-insured services, in the mistaken belief that parallel systems rob the
public system of resources, while both objective and subjective international rankings show that multiple tiers of
access are fully compatible with high quality public systems, high levels of care overall, high levels of patient
satisfaction and public health outcomes as good or better than Canada’s.

Number Nine: Medicare-type spending is the best way to improve health

Again, a lot of people seem to believe this, but it just ain’t so. In fact there are many forms of spending that are
far more likely to improve health outcomes than health care spending. Consider, for example, that there is a very close
link between health and wealth. The wealthier you are, the more likely that your health is to be good. This implies
that spending that is likely to improve the wealth creating capacity of society is also an investment in health. That
means things like education, economic infrastructure, and a reasonable tax burden are all key determinants of health.
So too are public health measures like sanitation, water quality, environmental protection, preventive measures such as
pap smears, etc., etc.

The irony is that as the health care budget expands in Canada, it is crowding out many of these other forms of public
spending. For example, the provinces, who have responsibility in Canada for the delivery of most services, such as
health care, primary, secondary and post-secondary education, roads, environmental protection, water provision, etc.
have seen health rise from around 30% of provincial program spending to nearly 50%. In all provinces it is expected to
exceed 50% within a decade. And Canada’s tax burden is about 8-10 percentage points of GDP higher than the United
States, so that our tax burden is uncompetitive with you, our major market and major competitor, while the health care
budget is cannibalizing scarce public dollars that could be spent on things much more likely to produce superior
population health outcomes. But the politics of health spending is powerful, and have proven nearly irresistible to
date.

Number Ten: Medicare is an economic competitive advantage for business

In the United States, in the ordinary course of things, as the price of health care increases, so too do insurance
premiums since, ultimately, all insurance payments come from the pool of premiums collected from the insured. Since
people usually obtain this type of insurance through their places of employment, it is often thought that the rising
cost of insurance constitutes an increased cost to employers. This view is especially widespread with regard to health
insurance in the United States, where it is often said that health insurance premiums make up a larger part of the cost
of building a car than steel does. Canadian politicians are prone to argue that since, under Medicare, Canadian
companies do not have to bear this extra cost, they have a competitive advantage in world markets. As with so many
statements concerning Medicare, this too is wrong.[9]

Economic theory predicts, and empirical evidence confirms, that the full cost of the insurance premiums is passed back
to workers in the form of lower take-home pay. Canadian workers pay the costs of Medicare through income taxes; U.S.
workers pay the cost of their health coverage through the pass-back of premiums. Even the part nominally paid by the
employer actually comes out of the pool of funds available for paying labor and therefore comes out of the workers’
pockets before it even reaches them.[10]

SOURCE: Mackinac Center for Public Policy
http://www.mackinac.org/article.asp?ID=5863

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