VoteSmart: The Debate
Has medicare been replaced?
Read the two commentaries below and join the debate yourself.

By DAVID GRATZER (YES) and STEVEN LEWIS (NO)

Tuesday, December 6, 2005 Posted at 2:00 AM EST

Yes, and it's about time, says physician and author DAVID GRATZER

As the Supreme Court of Canada concluded in June in Chaoulli v. Quebec,
"access to a waiting list is not access to health care." It took a
while for this idea to sink in.

The defining moment for me came while I was in medical school; it
didn't occur in a classroom but on the way to one. Hoping to save a few
minutes one day, I cut through a hospital emergency room. There in
front of me lay dozens of people on stretchers, waiting. Some moaned in
pain.

Sitting in class, moments later, listening to a professor talk about
the best evidence for patient care, I was struck by the contrast: I
would dedicate a decade and a half of my life for training, learning to
help people as best I could, only to see them failed so badly by the
system itself.

Here is what no politician in Canada will acknowledge: The medicare
patient fades. With each passing year - with each "new" promise of
federal and provincial politicians to save the health-care system -
this harsh reality becomes more obvious.

Overcrowding in emergency rooms - such as I had witnessed on that
cold February morning - has grown so commonplace that newspapers
stopped reporting it. Other problems abound. According to Statistics
Canada, 1.2 million Canadians don't have a family doctor but are
looking for one. M..D. Anderson, the renowned cancer centre in Houston,
now has a Canadian office promising clients timely health care - in
the United States.

What to do about medicare?

We need to acknowledge that a system designed when our population was
young and healthy doesn't work so well for our greying society; we need
to appreciate that the medical revolution has transformed health care
- and its costs. We need to reconsider the very foundation of
Canadian medicare.

We need to experiment with new ideas. Or not so new ideas. In Sweden,
people pay user fees if they want to see a doctor or go to an emergency
room. British Prime Minister Tony Blair was re-elected with a promise
to increase the contracting out of surgeries to 20 per cent of all
National Health Service operations.

France offers a mix of public and private clinics. Some countries have
gone further, such as Singapore, which has medical-savings accounts,
literally putting health dollars in patients' hands, rather than
funding institutions.

The issue is this: Not a single one of these ideas is carefully
considered by our politicians today.

Take private insurance. Any such suggestion of allowing a private
option is greeted with predictions of doom and gloom. So-called experts
suggest dire consequences: Private insurance will erode the public
system because, having opted out, many Canadians will no longer care;
human resources will bleed out of medicare, attracted by the lucrative
private sector.

But Canadians ought to dismiss such arguments - after all, in
Chaoulli v. Quebec, the Supreme Court did.

The judges heard from pro-medicare government witnesses such as
Theodore Marmor. A Yale political scientist, Prof. Marmor is one of the
most quoted health experts in this country. Could he provide any
evidence to substantiate his doomsday predictions?

Madam Justice Marie Deschamps, on behalf of the majority, wrote:
"Marmor supported this argument but conceded that he had no way to
verify it. ..... [He] confirmed that there is no direct evidence to
support this view. ..... [He] testified that there is really no way to
confirm it empirically. In his opinion, it is simply a matter of common
sense."

I focus on Prof. Marmor because of his influence, but others made
similar points before the Supreme Court. Judge Deschamps concluded:
"For each threat mentioned, no study was produced or discussed in the
Superior Court."

Britain allows private insurance. So does Germany, Australia and
Sweden. In fact, no Western country - spare ours - bans a private
option. And the international experience doesn't support the doomsday
predictions.

In fact, the original experiments in Manitoba and Saskatchewan were
never so restrictive. Sydney Green, a former Manitoba MLA and NDP
minister of health, observed: "It was never part of the original
concept that doctors would be conscripted and that it would be illegal
for a doctor and a patient to enter into a private arrangement."

There will be no panacea for Canadian health care. But there are good
ideas we could borrow from other countries. Some of these ideas fall on
the left of our political spectrum - significant reinvestments in
health care, and human resources. Some are ideologically ill-defined,
such as tapping information technology. But some need also touch on the
politically untouchable: user fees and private insurance.

Of course, Canadians fear an Americanization of their health care. We
don't need to think in such terms. Instead, let's seek a Swedenization
of medicare.

David Gratzer, a Toronto physician, is author of Code Blue: Reviving
Canada's Health Care System and editor of Better Medicine, a collection
of essays on health policy.

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No. It still has all we really need, says health consultant STEVEN
LEWIS

Every health-care system in the world merits a mixed report card; none
is without significant problems. Solutions that help some people may
harm others.

It will always be thus; while aspiring to perfection is admirable,
promises to achieve it are lies.

Medicare is an ethical idea. The sicker you are, the less likely you
will be able to pay for high-quality health care.

Hence, after a titanic political struggle in Saskatchewan, in 1962,
Canadians and their governments created a universal system whereby the
healthy and wealthy subsidize the care of the sick and the poor.

The basic structure, enshrined in the Canada Health Act, is that, in
return for federal dollars, the provinces agree to pay for (virtually)
all services provided by doctors and hospitals.

A combination of federal law and interprovincial co-operation defines
medicare as the country's greatest and most influential infrastructure
program.

These arrangements have reliably delivered both justice and efficiency.

The children of poor immigrants scratching out a bare living in the
east end of Montreal are as entitled to organ transplants from
Toronto's Sick Kids Hospital as the children of Belinda Stronach.
American researchers estimate that the United States spends $700 (U.S.)
per person per year more on health-care administration than Canada.

Those 20-page itemized hospital statements, armies of accounting
clerks, insurance company second-guessers of doctors' decisions, and
television ads to get you to sign up don't come cheap.

Yet, critics claim that Canada's system is too rigid, the laws
Draconian, the state as overbearing as a North Korean dictatorship. In
reality, Canadian governments play less active and intrusive roles in
health care than almost any government in the world. The system is
closer to anarchism than Stalinism. Consider these facts:

-Provinces don't have to honour the Canada Health Act if they agree to
forgo some of their transfer payments from Ottawa; it is, therefore, a
contract, not a fiat.

-Six provinces do not prohibit selling insurance for medically
necessary services; the fact that there are neither buyers nor sellers
merely confirms the absence of a market.

-Doctors can opt out of medicare and recruit cash-paying patients,
although some provinces limit the amount they can charge.!

-Governments do not tell doctors how to practise, which patients to
operate on, or where to open offices. Professions are self-regulating.
The existing model sustains both excellent and shoddy performances -
powerful evidence that the model itself is not the problem.

The two biggest problems in health care are quality and waiting - in
that order. The quality problems result from trying to do a
21st-century job with 19th-century tools. To cite but one example, very
few doctors in Canada prescribe drugs using computers. Their
handwritten scribbles are frequently misread. They unwittingly
prescribe drugs that, taken together, cause harm and, often, avoidable
hospitalizations and deaths.

Waiting is usually caused by disorganization and mismanagement, not a
lack of capacity.

In England, if you phone for a doctor's appointment on a Monday, 90 per
cent of the time you will be seen no later than Wednesday. A few years
ago, about 50,000 people in England were waiting more than a year for
surgery. Today, the number is zero. England spends about 7.5 per cent
of its GDP on health care; we're at about 10.5 per cent.

England achieved these dramatic improvements not by privatizing care or
adding legions of new doctors and nurses (which takes years even if
that's the goal), but by implementing modern management techniques and
making a commitment to excellence backed by policy and investment.

The federal government has a limited but crucial role in moving Canada
into the league of high achievers.

Applaud the political party that promises to invest billions of dollars
on information technology, so that every Canadian has an electronic
health record. Likewise, the party that promises to enforce the Canada
Health Act rather than look the other way in the face of countless
brazen violations. And get on your feet for the party willing to
negotiate firmly with the provinces, so that any new money actually
buys better quality, more accessible care for those who need it most.

Health care needs to get better, it can get better, and it will get
better.

Politicians and voters would do well to heed the evidence: No
health-care system ever got better by forsaking equity, and no
health-care service ever got cheaper in the hands of profiteers.

Steven Lewis, president of Access Consulting Ltd., is Saskatoon adjunct
professor at the Centre for Health and Policy Studies at the University
of Calgary.