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The politics of health care

Health care is a polarizing issue; it always has been. Because it is a service that is offered privately in some places and publicly in others, there is an ongoing debate about its ethics, its efficiency, and its reliability. The ethical debate is simple: in countries with private health care, the rich receive much better treatment than the poor. The efficiency debate is more complex: most argue a publicly-funded system is more efficient, saves costs, and treats all patients equally, while others argue the private system is superior. Reliability is a characteristic that is frequently brought up in health care discussions: wait times, availability of general practitioners, availability of equipment. But it often is difficult to get behind the political double-speak to the reality of health care provision.

Health care is a crucial factor in planning more socially equitable cities and regions because anyone can be affected by health problems or accidents, and public health care protects the middle and lower classes from bankruptcy and homelessness. Before the US mortgage crisis, medical bills were the leading cause of bankruptcy in the country, affecting 2 million people annually (this 2005 Harvard study showed that three quarters of these had health insurance at one time, 56% were middle class and over half had attended college). A 2009 study published in the American Journal of Medicine reported that 62% of bankruptcies in the US were due to medical bills and 80% of these people had health insurance. A 2008 study in Health Matrix: American Journal of Law-Medicine showed that for 49% of homeowners going through foreclosure, the foreclosure was caused by illness, unmanageable medical bills, lost work due to a medical problem, or caring for sick family members.

The biggest debates at the moment are happening in the US, the only industrialized country that does not have public health care. US President Barack Obama has been getting a lot of flack for his proposed health care reforms, which would introduce a government-run insurance program to make health care more affordable. Obama’s approval ratings have fallen nine percent since July 2009, to 52 percent, which critics say shows waning support for a national health care program. Because of our proximity, the US and Canadian systems are constantly being compared. The scary thing is that while many Americans are terrified of the Canadian system, pro-economy Canadian politicians want our system to be more like the Americans’, with private clinics offering services such as MRIs in Quebec. American politicians will cite long wait times for surgeries and MRIs, inability to find a general practitioner, and rumoured higher costs as evidence that public health care doesn’t work. However, these comparisons are faulty for several reasons.

The myths demystified

First, the long wait times have only existed since 1996, when the Liberal government, faced with a budget shortfall due to a prolonged economic recession, cut overall spending levels and merged health care transfer payments to the provinces with transfers for other social programs. Serious cuts were also made to federal housing programs and education, resulting in an erosion of the social welfare state. These cuts, in addition to an aging population and high inflation rates in health costs, have caused problems with the system such as fewer available beds, shorter recovery time for surgeries, and increased workload for doctors and nurses. Fees have also been introduced for certain services such as travelling to a hospital by ambulance, eye exams, and physiotherapy. In BC and Ontario, each resident now pays a health premium annually. But the government has made significant strides in reducing these wait times: in 2004 a $5.5 billion Wait Time Reduction Fund was established and most provinces now have websites that allow us to check on wait times for specific services in our areas. Long wait lists are not a form of government rationing, as some Americans believe, but an unfortunate side effect of decreased government spending on health care. The wait lists, rather than prioritizing wealthier patients, ensure that all patients have equal access to scarce and high-demand services. Most health statistics in Canada are at or above the OECD average, including life expectancy, infant mortality, perinatal mortality, and percentage of health care costs paid by government. On the contrary, health care in the US is consistently ranked the lowest in the developed world by organizations as venerable as the World Health Organization.

Second, there are many studies showing private health care is much more expensive. Malcolm Gladwell, in a 2005 New Yorker article, wrote that “One of the great mysteries of political life in the United States is why Americans are so devoted to their health-care system.” He writes that efforts have been made to introduce universal health care six times: during the First World War, the Depression, the Truman and Johnson Administrations, the Senate in the 1970s, and the Clinton years. Americans spend $5,267 per capita on health care every year, almost two and half times the industrialized world’s median of $2,193; the US spends more than a thousand dollars per capita per year—close to four hundred billion dollars—on health-care-related paperwork and administration, whereas Canada spends only about three hundred dollars per capita.

In 2005, Dr. Quentin Young, national coordinator of Physicians for a National Health Program said that “The paradox is that the costliest health system in the world performs so poorly. We waste one-third of every health care dollar on insurance bureaucracy and profits while two million people go bankrupt annually and we leave 45 million uninsured. With national health insurance (‘Medicare for All’), we could provide comprehensive, lifelong coverage to all Americans for the same amount we are spending now and end the cruelty of ruining families financially when they get sick.” This year, the World Health Organization showed that the US spends 12.7% of its GDP on health expenditures, well above the worldwide average of 8.7% and 3.4% in South-East Asia. Canada spent 10.5% of its GDP on health expenditures in 2007. A 2007 report from the Coalition for Health Care said that national health expenditures were expected to outpace the growth of the GDP. The higher costs get in the US, the more people are uninsured.

Third, because we have the world’s most inflated health care costs just across the border, many of our more profit-hungry doctors are lured south. This means fewer doctors for Canadians, particularly general practioners. This, in addition to rampant health care cuts by successive neoliberal governments, is the reason for our doctor shortages.

I may as well put to rest other myths of universal health care voiced by the American public and mocked in Michael Moore’s Sicko: yes, we can choose our own doctors. No, the government will not force euthanasia on you. No, we’re not communists. And no, the economy will not collapse if universal health care is introduced.

As Gladwell writes, “moral hazard”, the idea that insurance can change the behaviour of the person insured, has become entrenched in American economic thought, policy and legislation. If Americans had universal health care, the idea goes, they would “waste” it; making them pay for it ensures it’s only used when it’s really necessary. But this only works if we treat health care like a consumer product, which it plainly is not: we only go to the doctor when we’re sick, and even then, we don’t really want to go. And there’s no way of knowing when a visit to the doctor could make sound economic sense: in the case of having moles checked for skin cancer, or having regular Pap smears. Early detection could save the health care system a good deal of money. Many insurance companies have moved to the “actuarial model” which charges more to insured people with serious health conditions, and their employers, basically guaranteeing that, in many states, these people cannot get health insurance. Under the social-insurance model, which Canada, Germany, the UK, Japan, and all other industrialized nations follow, everyone pays equally into health care, and everyone benefits equally.

The long fight for universal health care: Tommy Douglas

The reality is that health care has always been a political issue, and not just in the US. Tommy Douglas, the “father of health care” in Canada, fought long and hard to achieve universal health care in 1961. Douglas was leader of the Co-operative Commonwealth Federation (CCF) from 1942 and premier of Saskatchewan from 1944-1961. The fact that Douglas led the first socialist government in North America was intrinsically tied to his bold introduction of universal health care. There was also a personal connection: Douglas injured his leg at age 10 and developed osteomyelitis. He would have lost the leg to amputation had a local doctor not seen the condition as a good subject for his students, agreeing to treat Douglas for free. Unable to volunteer for service during WWII due to the old leg injury, Douglas set his sights on health care reform.

Douglas attended Brandon College to prepare for his future as a Baptist preacher. He was attracted to the social gospel movement, which fused Christian principles with social reform. While in his religious capacities at Calvary Baptist Church in Weyburn, Saskatchewan during the Great Depression, Douglas became a social activist and joined the CCF. He was elected to the Canadian House of Commons in 1935. He led the CCF to provincial victory on June 14, 1944, winning 47 of 53 seats in the Legislative Assembly of Saskatchewan. They won five straight victories until 1960, and were responsible for the creation of the publicly-owned Saskatchewan Power Corporation; Canada’s first publicly-owned car insurance service; a large number of Crown Corporations; legislation that allowed unionization of the public service; a significant passage of the Saskatchewan Bill of Rights that preceded the adoption the UN’s Bill of Rights by 18 months; and the first program in Canada to offer free hospital care to all citizens. Thanks to the postwar boom, the Douglas government also paid off the huge public debt left by the previous Liberal government and achieved a government surplus.

In 1958, newly elected Prime Minister John Diefenbaker, also from Saskatchewan, promised that any province seeking to introduce a hospital plan would receive fifty cents on the dollar from the federal government: this promise was renewed in 1959. The Saskatchewan Medical Care Insurance Bill was introduced in October 1961 and given Royal Assent in November, while Douglas went on to lead the newly formed New Democratic Party. Woodrow Lloyd became his successor as premier of Saskatchewan.

On May 1st, 1962, the Saskatchewan Medical Care Insurance Act was to be adopted, but the province’s doctors went on strike and 90% closed their offices, forcing Lloyd to delay adoption of the act. The government brought in doctors from Britain, the United States and other provinces in order to staff community clinics set-up to meet demand for health services. The Act was passed July 1st, 1962. By mid-July some of the striking doctors returned to work. Lord Taylor, a British physician who had helped implement the National Health Service in the United Kingdom, was brought in as a mediator and the “Saskatoon Agreement” ending the strike was signed on July 23, 1962. As a result of the agreement, amendments to the Act were introduced allowing doctors to opt-out of Medicare and raising fee payments to doctors under the plan, as well as increasing the number of physicians sitting on the Medical Care Insurance Commission. By 1965, most doctors favoured the continuation of Medicare. The strike was a significant test for Medicare. Its failure allowed the program to continue and the Saskatchewan model was adopted throughout Canada within a decade. The political divisions within the province aggravated by the strike contributed to the Lloyd’s government defeat in the 1964 provincial election. However, even though the Saskatchewan Liberal Party of Ross Thatcher had opposed the plan, Medicare was so popular that Thatcher’s government left it in place.

The program’s success led Diefenbaker to appoint Justice Emmett Hall, a noted jurist who also hailed from Saskatchewan, to chair a Royal Commission on Health Services in 1962. In 1964, Hall recommended the nationwide adoption of Saskatchwan’s model of public insurance. The program was created in 1966 under Lester B. Pearson’s minority government, with the NDP, who held the balance of seats, putting significant pressure on the Liberals. The federal government was to pay 50% and the provinces the rest. In 1984, the Canada Health Act was passed, prohibiting user fees and extra billing by doctors.

The moral dilemma

As Gladwell writes, the universal health care question is really quite simple: “Do you think that redistribution of risk is a good idea? Do you think that people whose genes predispose them to depression or cancer, or whose poverty complicates asthma or diabetes, or who get hit by a drunk driver, or who have to keep their mouths closed because their teeth are rotting ought to bear a greater share of the costs of their health care than those of us who are lucky enough to escape such misfortunes?”

As a Canadian whose parents (both registered nurses) immigrated to the country the year universal health care was introduced, I’m proud to say that we do not feel this way. Canadians, including Shirley Douglas, daughter of Tommy Douglas, have rallied to save our publicly-funded health care system throughout recessions and political changes. A 2009 poll by Nanos Research found 86.2% of Canadians surveyed supported or strongly supported “public solutions to make our public health care stronger.” A 2009 Harris/Decima poll found 82% of Canadians preferred their healthcare system to the one in the United States, more than ten times as many as the 8% stating a preference for a US-style health care system for Canada. A Strategic Counsel survey in 2008 found 91% of Canadians preferring their healthcare system to that of the US. In the same poll, when asked “overall the Canadian health care system was performing very well, fairly well, not very well or not at all?” 70% of Canadians rated their system as working either “well” or “very well”. Since the passage of the 1984 Canada Health Act, the Canadian Medical Association has been a strong advocate of a publicly-funded health care system, including lobbying the federal government to increase funding, and being a founding member of (and active participant in) the Health Action Lobby (HEAL), although some provincial medical associations would like to see a larger private role. Tommy Douglas was inducted into the Canadian Medical Hall of Fame in 1998 and voted “Greatest Canadian” in a nationwide Canada Broadcasting Corporation (CBC) contest in 2004.

No one should die because they cannot afford health care, and no one should go bankrupt or lose their home because they get sick. Period.


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