Leading Economist Shatters Myth That Public Health Care is 'Unsustainable'; Pins Blame for Soaring Costs on Private Health Care
Canadian Health Coalition release: http://tiny.cc/shjci
" 'Opponents of Medicare claim that public health care is fiscally unsustainable and that the only viable solution is a shift to more private coverage. Bluntly, this is a lie,' Dr. Evans said.
" 'Sustainability is often a code word for privatization and for-profit health care,' Dr. Evans said. 'But any debate on the sustainability of public health care must start from who and what drives health care spending, and include a clear identification of the winners and losers of any erosion or dismantling of Medicare.' "
Interesting that Dr. Evans calls those who say health spending in Canada is unsustainable liars. It is important that people recognize that some of those speaking on this topic are not just wrong or blinded by ideology. Some are deliberately misleading people with a clear profit motive in view.
Also interesting is the quantification of the impact of aging on the health system in Canada as a measly 0.8% per year, a figure well below inflation.
It is important to note that when we speak about health spending going up, we need to recognize that this includes private spending. Private spending impacts public health in a number of ways some indirect but significant. Gaps in access to pharmaceuticals, long-term care, home care, mental health, dental care all increase acute care costs, yet even so the public system is innovative and resilient.
As well when we speak of the budget burden of healthcare we need to recognize two contextual factors: firstly tax decreases and tax shifts from business to individuals and secondly cuts in all other manner of spending. These cuts make health spending take up a greater percentage of overall spending even when it is not increasing appreciably. This is why looking at public health spending as a proportion of GDP is a better way to look at it. Of course there it is a non story as it remains largely a constant.
And people on the right will continue to promote privatization despite the massively more expensive US system that proves the lie.
Governments also contribute to the confusion over health care costs. For instance, the Ontario government has been promoting this idea (a lie, btw) that Ontarians pay more for generics than they should. In fact, 75% of drug costs in Ontario are because of brand name drugs.
Sean, I'm borrowing that link for my FB page!
Pharmacies and generic suppliers admitted that the pharmacies were demanding a kickback if the generic manufacturers wanted to sell those generics to them. It was very persuasive,but, of course, raised the cost of the generics $1 billion plus...
But just the other day the pharmacy suddenly decided to supply me with a generic rather than the brand name drug that they had sold me for three years. As an old fart I only have to pay $6.11 dispensing fee, so I never asked if the generic was available instead. But I'll bet you're right in that the pharmacies are now required to provide the generic where available...in this case, about $100 for three months rather than about $230 (glad I don't have to pay either). Either that or it just happened, the other day, that the (I believe) 20-year copyright on that brand had just expired. I think not.
Exactly right, lp. But in the case of health care, they have to be very, very careful in arriving at their end objective of a privatized world. Lots of folks don't bother about voting but even the most alienated understand sickness and death.
And to support your thesis, we see this morning in the news the tragic, lengthy waiting list of children that required surgery in 2009. Lots of pressure for a private system to look after them, eh? I did not notice a demographic breakdown of those parents who would be able to afford to take their youngster for care in that system.
I believe that health cards should be encripted with a sub code that assess a fee-for-service based on a persons income for the previous year. $0 to $50,000, you pay nothing. Then it should slowly go up incrementally to, say, $500,000 at which point you pay $100% up to a cap (to protect against catastrophic maladies) Children under 18 and elderly over 65 get free treatment across the board.
You know, it's one thing to want everyone to have equal access to health care. It's another thing entirely to give cost-free treatment to someone making a million dollars a year.
The extra revenue would go into the system to increase service levels - hire more people, build more facilities, buy more equipment etc.
INP that is one troubling post - on several levels.
First in order to participate I guess you would need to have a credit card and your taxes up to date-- otherwise no care?
Secondly, you are ignoring the fact that direct fee for service is inefficient and the collection process would eat up substantial parts of the revenues. This is especially so of a means tested system as you describe.
Thirdly, people who pay taxes to support the system ought to expect something from it.If they are supporting healthcare through taxes they should be able to call on it when they need it.
Fourthly, means-tested systems never do well because effectively you deny the people who have the means to defend the system from any benefit from it and ultimately create a two-tier system.
Fourthly, the insurance aspect of the system is not just for low income people. This is not just a question of facing individual medical expenses but also cumulative expenses so the means test would need to track not only what you earn but also what you paid already. For fairness would we account for certain hardships for additional expenses? If so then essentially what you are proposing is to break medical expenses from the rest of our income tax system and effectively pay two income taxes. I can't follow an argument that this is either fairer or more efficient.
Fifth, from the last comment we are lead back to the question of why duplicate what we have? We have a tax system that means tests people, provides some exceptions and additional credits looks at what they make and then has them pay in to a fund to cover all our collective expenses. It is efficient because it manages in a single collection all of those public goods be they for education or health or whatever else. The main purpose to not use the tax system is to punish users to discourage use which is problematic when ti comes to health spending because ignored needs tend to get more expensive as well as add to misery and inequity. Another purpose to not use the tax system is to ration use to assume only those with the money should receive the service (a point you do not concede it seems). Another is to hide accountability for taxes paid so that payers cannot know what they are spending -- however when it comes to hiding taxes paid to government for political purposes we already have consumption taxes which while inefficient are already perfect for obfuscating the exact amount you pay so even that political objective is covered.
So what is being proposed here is a massively expensive collection scheme that would need to be borne by health care users without any actual benefit.
Indeed this is why this system is not popular anywhere. User fees work if you want to punish the poor, help insurance companies make money but then there is no point having them means tested.
The only value I can see with your proposal is if the objective is eventually to ease people in to paying their own medicare and ease society in to abandoning those who cannot pay and eventually allow the less efficient private system to manage it all for the purpose of its own profit. So in that sense it could have a purpose for a while as a transition to a Darwinian health care system. Of course if you think the cost to move to electronic health care records in Ontario has been expensive, this will be much more and of course someone somewhere will make a pot of money. But then if that is the objective why not just say so?
The intent wasn't to punish the poor. The intent was to make the rich pay and financially bolster the system with the money collected. You make a compelling case as to why this particular approach may not achieve that end. I do believe, however, that some alternative to a system funded 100% from general tax revenues may be necessary to ensure the contunied viability of the system as a whole. Wait, let me rephrase. My desire is not to ensure the contiuned viability of the system, it is to enhance, improve and enlarge the system so everyone gets cadillac care. And I still believe that it is obscene for someone driving a mercedes to get cost-free care. Thanks for your thoughtful rebuttal.
BTW, I avoided the argument that health care is a public good because while I believe in this strongly, I suspect that INP is a little too far to the right to be reached by such an argument. Instead I went to the efficiency arguments.
Let's not forget that user fees are not only bad medicine. They are medicine for a disease that does not exist. The point is public spending on health care is actually quite sustainable.
Private spending in fact is not. It is private spending that is out of control, has unintended consequences (the only intended ones being profit), and threatens not only health and equity but indirect damage to every other aspect of society.
Now can we not recognize the disconnect between a belief in collective protection that is at the core of the concept of insurance and the idea that we cannot do this at a national scale? Here we have insurance companies selling private insurance under the same premise that we provide national health care, yet they pretend that somehow by making the beneficiaries more exclusive and hauling out profit, it is somehow better. The only real difference apart from inefficiencies that the private insurers can offer is the creation of profit which as I say is the end in itself. Otherwise the mechanism is the same it is just a question of whether we do this on an efficient and equitable universal national scale or an exclusive members only one.
Let me emphasize if private insurance can even claim to be sustainable, a national insurance plan is more so because of the advantages it brings in universality, efficiency and sustained social purpose. There is simply no possible argument that can be made to suggest otherwise. And even the most rabid privatizer (privateer?) would never argue against the concept of collective insurance of some form (and they all personally carry it when they can) -- they just pretend that exclusive for profit has some kind of benefit other than their own profit.
"I suspect that INP is a little too far to the right to be reached by such an argument. Instead I went to the efficiency arguments"
The ability to reach me in the centre is dependent on how many miles you are to the left of centre. Never once did I suggest that any services should be provided outside the public system. If you think that exploring alternative funding mechanisms for public care is "right wing" well, it is you who is far from the middle, not me.
All I know is the CMA came out in early 90s to say we had too many doctors. The provinces then cut enrollment acceptance to medical deegrees. Then 5 years later we began the CRISIS in medicare with too few doctors, which meant wait lines...umm is there any correlation ...not according to our media there isn't.
Problem is when you have lots of docs available it is harder for them under the current funding formula to make thier 'Quota' to max out income every year, mostly cause each of them is a private businees. No wonder when I go in for 2 things I always have to come back to discuss the other on a different day.
Whatever happen to the romanow report, thanks paul martin.
INP- I must apologize for my sloppy overly personal conclusion. I should not have suggested you were anywhere in particular on the left-right spectrum. User fees are indeed a right wing solution discredited as a means to supporting the system and only presented from an ideological purpose for the most part.
Another left-right perspective surrounds taxes and it is that perspective that lead me to suspect you were right wing. Taxes are in fact collective purchases of public goods and so long as they are sufficiently progressive we have no cause to worry about the person in the Mercedes not getting another bill on receiving care.
I have long understood that we are each individually in the centre as that is where we see things as to the left or right of ourselves. I have no doubt therefore that you are at the centre of your vision. However, inasmuch as there is a common vision in a given context or place you may not be at the centre of that.
There are of course two concerns here: the first surrounds who is paying, access and equity and that can be best satisfied through the ultimate means test: a progressive tax system.
The second is efficiency which is best managed through a single payer system. There are other reasons for this in health care. Health is interdependent and the act of pricing individual procedures leads to a form of inefficient competition not for efficiency but for cost transfer. Individual rather than overall accountability can lead to unintended consequences-- you can save some money in one silo by transferring a cost at greater expense to another. This is one of the reasons why privatization and the pricing of medical care (including activity based funding models) are so dangerous.
Over the last number of years Primary Health Care has increasingly been seen by experts as requiring a holistic vision that is not compatible with localized bean counters. As well we should not underestimate the administrative burden of determining what each individual procedure or element costs. Such analysis can be important if you are getting different people to pay for something or if there are choices but at times it is extremely wasteful and distorting if we are speaking about a necessary procedure being provided at the expense of a single payer.
There is a strong argument that we do not have an overall doctor's shortage. Rather we have too many in some fields competing to create the maximum number of income-generating procedures and too few in others such as GPs, some specialties and in rural locations creating lineups. The market alone does not determine the correct numbers.
Thank you Sean in our Nations Capital. I appreciate your thoughtful comments on this issue.
Let me pitch this to you then. I am a skeptic by nature. I suspect our (relatively) unaccountable centrally administered health care payment system is rife with abuse and manipulation. It wouldn't surprise me ifs a fair number of doctors cheat. They are human and humans are exceptionally falable, especially when it comes to money That's why I would like to see a detailed invoice sent to all users semi-annually or annually. It could include the amounts paid to the provider if only to drive home to the user how much the system is paying for given services. Primarily, though, it would list the services provided the dates and the service providers. Under the current system the user has no idea what service is being billed in their names and the system has no proof that the service was even provided. It astounds me that health systems involving over 180 billion dollars a year could run with such little oversight and such few checks and balances. It is a testament to our trusting nature (read, gullability).
I expect your agrument against this will centre around the logistical difficulties and cost of implementing and administering such a system.
Health care costs in single-government-payer Canada are 9.4% of GDP, vs. 13.9% in the U.S, where most billing is totally transparent (either to the user or to the insurers, both of which are easily verifiable by the user). It takes a peculiar world view to suspect that "cheating" is rife in Canada.
I read somewhere that health care fraud in the US is worth $30 billion a year. They've got all kinds of problems with everything from billing the taxpayers for ghost operations to outright theft. All those insurance companies represent dozens and dozens of duplications of health care bureaucracy in the US. It's way inefficient.
Unionist, I don't see anything pecular about wanting to ensure that Canadian health care providers are held to as high a level of accountability as possible. It also takes a pecular mind to take my argument in favour of more accountability in our system and, in rebuttal, offer some off-the-wall comparison with the American system (which I would never defend, by the way).
Here on the Lower North Shore of Quebec, we are seen by a GP that travels the coast every few weeks. No resident GP in any but two of these communities, and any time there's a medical emergency, we rely on helicopter evacuations to an air ambulance in a larger population centre. We all have community clinics staffed by a resident nurse. No access to a pharmacy either - we fax our orders to a pharmacy at the hospital, and our prescriptions are sent once a week, usually a Friday. No resident dentists, either - the health service sends a dentist from Montreal to the coast every two months for a week. For specialists, we are airlifted out to Sept-Iles to an appointment at the hospital. I'm being sent back to Sept-Iles next week for a follow-up to my eye surgery a few weeks ago. More money in the public system would have more frequent visits to the Coast by GP's, dentists, and medical specialists.
INP- there are a couple ways of looking at this.
I don't like the idea of a "bill" because of both the need to quantify and secondly the philosophy behind the person being billed.
I also feel that there are so many urgent priorities and opportunities that I worry what does not get done while we do that.
I am not against accountability, however.
As we move to electronic medical records that may end up on your medical card on a chip, I think that personal access to medical records is important and people should review them.
Still the fee for service model may not be the best for Doctors either. It may be preferable to place most on salary. Of course then you need others to do case management which may not be a bad thing.
With drug companies raking in uncontrolled billions, and with chronic doctor (especially the lowest-paid) and nurse shortages, I find the notion that we should start cracking down on lazy cheating doctors particularly misguided and regressive.
Great, you figure out how to solve the drug and service issues and I'll deal with the accountability issue. Fair?
INP- I think Unionist may be more categorical than I would but the point being made is one of proportion. When there is so much money to be saved through better management of resources (supporting homecare rather than having it back up into uneeded long term care and from there in to acute care or supporting pharmacare), why would we be spending resources going after the few Docs that are cheating costing the system relatively tiny amounts?
As well, once medical records are fully electronic this problem will disappear.
If you want to look at the accountability issue -- the big bucks are in policy and management choices not individual fraud.
I quite frankly find it amazing that right-wingers put forward the private system as efficient and cheap, as compared to the inefficient, bureaucratic and expensive public system. Funny that they never notice the most inefficient, paperwork-riddled and plain old expensive system is the private one!
One thing I won't back down on is universal medicare.
We could afford medicare when Canada's economy was $600 billion. Now it's $1.2 trillion and we suddenly can`t afford it?
I don't think so.