Here are two responses that were published on 6/29/98:
"We Prefer Our System, Thank You"
Your June 17 editorial, "Doctors Who Go on Strike," criticizing the
Canadian health-care system and urging "our politicians" to reject
regulation of our HMO-controlled system, left out two significant facts:
(1) in 1996, Canada spent $2,000 per person on health care, just over
half of the $3,700 the U.S. spent; (2) Canadians have achieved universal
access plus much lower costs without restricting patient freedom to
choose their doctor and without creating an army of HMO bureaucrats
whose function is to interfere with the patient-doctor relationship.
Had you mentioned these facts, your readers would have been less
inclined to accept your argument that "the market" can solve the U.S.
health-care crisis and that "'free' medical care [in Canada is]
feverishly pushing up prices."
One is less inclined to think health-care inflation in Canada is
"feverish" when one understands that Canadians pay far less for drugs
and health-care services than do Americans. For most people with open
minds, the huge disparity in U.S. and Canadian costs triggers a
question: How do the Canadians do it? Answer: Canadians do not funnel
their health-care dollar through insurances companies so that insurers
can skim 20% to 30% before passing on the remainder to providers; and
Canadians refuse to allow doctors, hospitals and drug companies to
charger whatever they like.
KIP SULLIVAN
Minneapolis
* * *
You claim that Canadian doctors are government employees. In fact more
than 90% of practicing physicians are self-employed, and some have
incorporated their practices. They bill provincial medical plans on
a
fee-for-service basis. Provincial medical associations negotiate their
fees with provincial governments, and if the total billings exceed
the
negotiated budget, then doctors have to repay the excess.
Like all others paid by the public purse, physicians have experienced
cutbacks in their pay in the past seven years. These cutbacks have
been
cheered by conservatives, including your editorial board. However,
they
have devastated the Canadian health-care system. For example, more
than
40% of all of the nurses in Alberta lost their jobs between 1993 and
1996. Meanwhile, Canada's federal government will have a substantial
surplus this year, estimated at 1.5% of GDP. This surplus is largely
due
to lower interest rates and economic growth rather than cuts in program
spending.
The problems with Canada's doctors are caused by government cutbacks
and
the failure to change methods of physician renumeration. In the
meantime, the Canadian system is much more affordable than the U.S.
system (in 1996 costing 9.5% of GDP vs. 13.6%). It also covers all
Canadians, while at least 40 million Americans have no insurance and
tens of millions of others have inadequate coverage. All health systems
have their problems but according to public opinion surveys show clearly
that most Canadians prefer their problems while most Americans would
prefer those in other countries.
MICHAEL RACHLIS, M.D.
Toronto
Here is the response written by a Canadian and published in the Physicians
for
a National Health Program List:
Response to the Wall Street Journal Article
(Bill Blanchard)
There is so much error in fact and reasoning in this article it is difficult to know where to begin.
But perhaps we should begin with the one small bit of truth in it. It
is true that our Doctors are extremely dissatisfied with the current state
of our Medicare System, but so also are the
majority of Canadians. But from there on, the article goes down hill.
First, the bald statement shouted out in the headline that our doctors
are on strike is a misrepresentation. Doctors in several of the Provinces
have engaged in various forms of
"job action" which are intended to express their dissatisfaction but
designed in such a way as
to protect patient safety. Second, the consistent inference that our
doctors do not support our system is simply untrue. The great majority
of our doctors are fully in support of the five principles
of our Canada Health Act:
Universality (everybody is covered)
Comprehensive (covers all medically necessary treatments- for everybody)
Publicly Administered (contrary to the implication of the article we
do not have socialized
medicine in Canada. Doctors are independent practitioners, not employees
of the state.
They are reimbursed by the state for their services, but are free to
opt out of the system
for private practice if they wish).
Accessible (Is reasonably available both in time and geographically--to everybody)
Portable (It goes with you even if you change jobs or province)
It is true that when Medicare was first introduced many doctors objected.
But now, after
thirty years of success the great majority of our doctors strongly
favor our system because
it frees them to concentrate fully on the medical problems of their
patients without keeping
one part of their attention focused on whether or not the patient can
pay the bill. (I have
been in doctors offices in the U.S. where at least one persons full
time role is to keep track
of the paper work generated by health insurance companies).
What both the general public and the medical practitioners in Canada
object to is the
extremely reduced level of financial support that our Medicare has
received since the early
90's. Like governments all over the world, including yours, both our
provincial and federal governments have been intent on reducing deficits
and paying down debt. Unfortunately, and unnecessarily, they have done
this by Draconian cuts to Canadian social programs, in which Canadians
take great pride, including Medicare. For example, our Alberta Provincial
Government has reduced the per capita amount spent on health care from
over $2000 in 1992 to $1600 today.
It is obvious to anyone who wants to deal with our realities, rather
than their own mythical conception of them, that a system cannot take a
reduction of nearly one fourth of its budget and function adequately. It
is a mistake to think of, or to portray, our doctors as only asking for
more money for themselves. They are also demanding adequate funding for
the system as a whole.
These seemingly deliberate misrepresentations are all too prevalent. But coming from a presumably prestigious publication like the Wall Street Journal they are simply unacceptable.
But what is even worse is the errors made in economic thinking underlying
many of the articles propositions. One gets the feeling that the writer
got his basic economics from the Primer
of Libertarianism (see Boas, Libertarianism: a primer, 1997) and has
never opened a cover of a book on the economics of health care. All such
books that I have read make it abundantly clear
that the health care market is different from the market for lipstick
and hair dyes that are made just for men. The theory of supply and demand
do not directly apply to health care. First, standard theory assumes that
the consumer is fully knowledgeable about matters of health. This is patently
not true, nor could it ever be reasonably expected. Even doctors have
to consult specialists.
Second, health care consumables are not things that most people hanker
to have more of simply because they are there (this is the myth of the
"welfare Burden"). We don't opt to have as many operations as possible
just because they are "free". And if our family doctor [and we still have
them in Canada, and we are free to choose any one we wish] tells us we
need an appendectomy we
don't let our fingers do the walking through the yellow pages to shop
for the cheapest cutter in town.
But perhaps the most objectionable is the implicit ethical position
which underlies much in this article:
The article states that we cannot afford Medicare. This is a statement
commonly made without qualification as though there were some law of nature
that prohibited us from spending more.
This is simply not true! In one of the richest nations on earth (and
we are a rich nation, contrary to some perceptions of us as the poor northern
cousins) there is plenty of wealth to support a more than adequate Public
Health System. It comes down to a matter of the choices that we must make.
And whenever we make choices we are always drawing on our values (which
do we
value more, this or that). And in the case of medical care we are dealing
with matters that are central to the quality of life, and even to life
itself. So the values that we draw on here are ethical or moral values.
What do we want? More million dollar sports heroes or adequate prenatal
care for our young women? The question we should always ask when politicians
(or others) say we can't afford good medical care for our people is ..."On
what other good things are we going to spend the money that we save?"
The article denigrates our system of rationing health care. All
societies must ration almost every good there is, including health care.
You simply do not give a precious heart for a transplant in a man who is
102 years old. The question is how you ration. We agree with the article
to the extent that
Canadians don't like our present governments' approach to rationing,
which can only be characterized as "slash and crash". But then to suggest,
as the article unashamedly does, that
the "market" will simply and painlessly solve the rationing problem
is either naive at best, or deliberately deceptive. Sure the "market" will
efficiently ration health care. The rich, or those covered by adequate
insurance, will get the best, and all the rest can beg. (I saw a discussion
on U.S. TV
several years ago which brought together experts from both countries,
yours and ours. The one statement that has stuck with me over the years
was made by a Canadian Nurse. She simply asked, "Don't you Americans care
for one another?").
The elites in both the U.S. and Canada seem to have been caught up in
the now popular "Libertarian" philosophy of distributive Justice (See Boas).The
essence of this philosophy
idolizes the individual and ignores mankind's historic and continuing
need for community. The fundamental right in Libertarianism is the right
to liberty. And it follows from this that whatever goods a person has rightfully
gained for herself cannot be taken without her consent. "Market forces"
are the best protection that this right to liberty can have. Governments,
by their very natures, limit freedom, so the only function of government
is to protect that freedom( police, defense and contract law are the only
legitimate functions of government should have). Under Libertarianism we
are free to give voluntarily to charity, including charities for health
care, but our money cannot be "arbitrarily" be taken away from us (Taxes
are theft).
Most of us would reject this philosophy, and adhere to a more communitarian
creed. Not that we would denigrate liberty, which is important, nor the
importance of the enterprising individual. But we would recognize that
mankind has survived and prospered over the millennia not only because
of the energetic, inventive and industrious individuals but also because
of the community which succored and supported these individuals. We need
both. And it is our belief that democratic government is the most effective
tool (with all its warts) for taking the collective actions that support
community values (like caring for one another).
Bill Blanchard
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