NP4 WE NEED CHOICE

National Post - May 9, 2002
We need choice and competition
David Gratzer

This is the final article in a four-part series on fixing Canada's health-care system. Today, Dr. David Gratzer, author of the highly acclaimed Code Blue: Reviving Canada's Health Care System, and editor of Better Medicine: Reforming Canadian Health Care, reflects on medicare and its orthodoxies, which deny Canadians the quality health care they deserve.

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Late last month, the two titans of Canadian health policy sparred in a very public way. Former Saskatchewan premier Roy Romanow, who heads a one-man federal commission appointed by the Prime Minister, dismissed the latest report issued by Liberal Senator Michael Kirby as part of his Senate-initiated review. Senator Kirby concluded that medicare is unsustainable. "I just don't believe it," declared Mr. Romanow, implying the Senate's work was superficial and that the issue required "plumbing into more depth ..." Sen. Kirby disagreed, saying "the preponderance of people, everybody except Mr. Romanow ... have reached the same conclusion."

Much was made of the dispute - it landed on the front page of the National Post. But let's keep some perspective. This isn't a debate between contrasting visions of medicare, it's a lovers' quarrel.

Consider the similarity of their positions. Sen. Kirby feels that medicare is unsustainable with its present financing and favours a major new federal spending binge. Mr. Romanow disagrees with the diagnosis but still likes the idea of more cash. Sen. Kirby wants to look abroad for new ideas - except those involving user fees, private insurance, medical savings accounts or much of anything else in use from Sweden to China. Commissioner Romanow envisions a made-in-Canada solution, meaning no to market reforms. Both believe in greater efficiency within the context of a public monopoly; read salaries for doctors.

The Kirby-Romanow non-debate symbolizes the greater discussion that we have in this country. While Canadians routinely rank health care as the biggest issue of the day, for too long, the debate has been dominated by a narrow view. Call it medicare orthodoxy. It runs something like this: Canada has the best health-care system in the world, a mark of our civility and citizenship. While problems do exist, they can be rectified. For this, look to the government to intervene with greater public spending and better public management. But beware: Any proposed change to this system based on individual choice and competition would be an Americanization, and thus disastrous.

This orthodoxy is held by practically every prominent health economist, policy advisor and government administrator in the country. It has been the defining ideology of health reform for 30 years.

Yet the medicare patient grows sicker. The evidence mounts: In a major international study, the Heart & Stroke Foundation of Canada found that Canadian heart attack survivors have a dramatically lower quality of life than their U.S. counterparts. So poor is our diagnostic equipment, that a legal opinion obtained by the Canadian Association of Radiologists advised Canadian radiologists to tell patients to shop around for facilities with newer equipment, even outside the country. In a study of waiting time for breast surgery in Quebec involving more than 29,000 cases, the authors found a 37% overall increase in waiting times from the mid- to late 1990s.

And the real test lies in the future: Canada's population continues to age. (In their typical way, the most ardent defenders of medicare have turned around and declared that aging doesn't necessarily lead to rising costs, an argument as persuasive as maintaining that DNA evidence, matching fingerprints and motive don't necessarily mean that O.J. is guilty.)

But rather than looking for new ideas, we are stuck with the Kirby-Romanow non-debate. Like an alcoholic, we continue to reach for the same poisonous panacea. Health care reform in this country tends to go through phases. A decade ago, it was district health boards. Today's flavour of the month: primary care reform.

At a time when Sweden is feverishly privatizing hospitals and ambulance service, we're stuck trying to introduce accountability and efficiency into a system that is by its very nature neither. Shouldn't we try to get better medicine?

Around the time of the Kirby-Romanow tiff, a group of Canadians finished a two-year project. I had the privilege of editing and introducing the end result, the book Better Medicine: Reforming Canadian Health Care.

The list of contributors includes a two-time National Newspaper Award-winning columnist, one of the most popular lecture circuit speakers in the country, and an essayist who won a major award for humour writing.

And the contributors aren't simply deft with a pen; they are recognized experts on health care, both in Canada and abroad. One of the most celebrated medical historians in North America traces medicare's history. A Swedish health-care expert overseeing Stockholm's privatization project co-authors an investigation of international health reform. A former senior economist with the President's Council of Economic Advisors performs an analysis of the American health-care system. And a physician who served as president of the Canadian Medical Association opens the book.

We participated in this project because we believe collectively that Canadians deserve better.

Of course, some are critical of our arguments.They wrap themselves in the Canadian flag, but should we accept this? Does being un-American mean that we should accept that our elderly lie on stretchers in hospital ERs for days? Beware the cruel reality of well-intentioned nationalism.

There are no easy changes to make. There is, however, a path worth pursuing. Rather than attempting more bureaucratic control or blindly throwing more money at medicare, we should look to reforming health care along the lines of individual choice and competition. It's time to move beyond the medicare orthodoxy.