Governments have often afforded massive expenditures in the face of overwhelming debt if the cause was right. Since Canada is not about to embark on any territorial conquests or defend against an armed invasion, its present government debt, in today's prudent context, seems unassailably massive. Innovative leadership is therefore curbed and Canada's tax-weary people easily deceived.
To what extent can the gross domestic product (GDP) tolerate support of any health care system? Health care, particularly sickness care, its costliest component, contributes only indirectly to the creation of real wealth. At some level of cost, health care therefore becomes parasitic.
The University of Virginia Medical Center's bargain sale of hip and knee replacements is one sign of such an unhappy state in the United States. Since the US system is overcapitalized, it must market its services creatively. Nevertheless, its wealth allows it to tolerate a waste of the US GDP, a waste that would be more damaging in Canada. But even in the United States, the extravagance of the health care system is under criticism. The touted response appears to be "managed health care," which evades the system's real disorders.
Our long waits for hip and knee replacements are indefensible and were foreseeable. Responsibility for this error is shared equally among governments, the health care professions and the public.
Canada's system was intended to spread the risk universally. This is an actuarial zenith difficult to achieve through general revenues. A progressive tax, attached to income tax, has been recommended. Such a tax would make the public groan but, if it were clearly explained and implemented to unconditionally restore and maintain the good health of medicare, it would be accepted.
Lantos' recommendation that health care should be a growth industry is an error. It would evoke terror in much of Canadian industry, particularly the portion that survives through exports. The Canadian health care industry has generally been ranked second in employment and capital investment. Although, as physicians, we may reel at the thought, much of what the industry produces is accounted for as an expense. The health care industry can function effectively without becoming an economic giant. The dangers of such growth are terrifying to consider. Canadians would have a better standard of living if the health care industry were substantially smaller.
John S.W. Aldis, MD
Port Hope, Ont.
That someone jumped a queue for magnetic resonance imaging (MRI) because he or she had financial means is worthy of report because, rightfully, the public should know that the practice exists. If there is indeed an excessive and clinically significant wait for necessary MRI scans, this should be dealt with by an informed public with the use of objective and reliable data from the medical profession. As for private surgery being available for a price in the United States, many patients find that, when there are complications, these have to be dealt with in Canada because it is not feasible to return to the United States for such treatment. Moreover, an unfortunate consequence of US surgery is the higher prevalence of resistant bacterial infections; such infections recently led to a near-epidemic and enormous costs at Toronto's Mount Sinai Hospital. Perhaps Ontarians should examine whether patients who choose to have elective surgery in the United States should be personally responsible for the costs of treating complications after their return to Canada.
Lantos gives no evidence to support his contention that the system is being "wound down." Hospital and health care restructuring are taking place in Canada as well as in every other country, including the United States, where much of the care is based on the privatized, insurance-based model that Lantos proposes for Canada. There is no evidence that research is being compromised in Canada. If anything, we are in a far more favourable research position than many US research centres, which are losing research because private HMOs and their affiliated hospitals have little interest or commitment to academic and research initiatives.[1]
Canada can afford universal health care because it is substantially cheaper than the privatized model in the United States. Moreover, for far less money, more people are insured. All of the evidence supports the contention that, for most medical conditions, Canadians have far greater access to care than their counterparts in the United States, where private insurance forms the basis of the health care system, either through indemnity plans or insurance-based HMOs, which are notorious for limiting access to care.[26]
We in Canada should be able to provide universally accessible, high-quality care and carry out our educational and research goals if we make the best use of our funds and discontinue practices for which there is little evidence of benefit.[7] Having witnessed and experienced health care on both sides of the border, I will take our system hands down, and I will try to improve it rather than look to a privatized model to solve our problems.[8,9]
Michael Gordon, MD, FRCPC
Vice-president
Medical Services
Baycrest Centre for Geriatric Care
Professor of Medicine
University of Toronto
Toronto, Ont.
References
[The author responds to Dr. Gordon:]
My earlier "sweeping statements" pale in comparison with the claims of proponents of universal health care. The quoted newspaper articles were intended not to reflect actual data but rather to exemplify daily reality. As I write, there is a letter to the editor in the June 16, 1996, Toronto Star entitled "Sick child can't wait," written by the parents of a child 2½ years old with excruciating headaches and seizures. "Our pediatrician is excellent but is nagged at every request by our system. . . . We still haven't seen a neurologist. . . . We have been forced to go to Buffalo. . . . Why are we denied proper, responsible medical attention?"
There is good evidence that the system is being wound down: reduced numbers of beds, staff layoffs, hospital closings and replacement of qualified professionals by those with less training. Dr. Gordon claims that "there is no evidence that research is being compromised." In the Prix Galien Award address, Dr. Charles Hollenberg, president of the Ontario Cancer Treatment and Research Foundation, said "It is particularly disturbing to see the low . . . priority assigned to the support of . . . research. . . . It is illusory to expect any level of government to infuse significant amounts of new money in support of basic research. . . . We must look for leadership outside government."[1]
The premise that our universal health care is "substantially cheaper" is dubious. The OHIP budget of $17.7 billion, estimated to cover only 72% of health care services, translates into approximately $1700 per person per year. This is more than the cost of the most expensive and comprehensive US private insurance plan.
In regard to the lack of access to care, I can provide numerous examples from my own practice: a patient with liver failure who never had an "elective" admission and whose spouse had to stay home from work to provide care, an elderly patient with acute renal failure who was never offered dialysis, and two patients needing spine operations who waited months for MRI scans.
Nonetheless, contrary to Gordon's assertion, I do not propose a privatized, insurance-based model. What I propose is the freedom to choose for oneself the health care and time-frame appropriate to one's particular circumstances. One should have the freedom to use alternative systems, to obtain private insurance when one is young and healthy, so as to be covered later when one is infirm and uninsurable, or when the queue gets too long, or when a government bureaucrat decides to delist certain services.
Universality is destined for "the tragedy of the commons."[2] No other public sector so restricts individual freedom. Public education is no worse for private schools; public housing does not cause the prohibition of private homes; the Canada Pension Plan does not obviate private pension plans. Universal health care and its legally enforced monopoly results in "individuals locked into the logic of the commons; free only to bring universal ruin."[3] Let us avoid the inevitable tragedy of the commons that the shibboleth of universality portends.
Gabor Lantos, PEng, MBA, MD
Occupational Health Management Services
Toronto, Ont.
References