The noble, practically unique element in Canada’s health-care system has been its commitment to a single tier of payers. There are flaws but, in principle, everyone pays the same, and gets the same, at least until last week’s Supreme Court ruling. In Europe, you can pay more to get more so there are two official tiers of care, public and private, based on ponying up twice. (The United States, with no universal public system, doesn’t enter the picture.)

It’s true we’ve had a kind of secret second tier: the U.S. itself, where people could go for hip replacements if they wanted to pay extra and not wait. Now a second tier will exist in Canada. It hasn’t destroyed the public system in Europe and need not do so here.

But many people worry about the slippery slope to a degraded public system, and I’m among them. Besides, it is a fine, rare vision we have had. Why is it so hard to maintain?

The problem has not been that it is unaffordable. (I pause here to let the ranks of the punditocracy rise in unison to guffaw.) For the most part, health care is not, like your cable package, discretionary. Someone with a heart condition or a nosebleed will get it treated. The bill will be paid. How to do so is mainly an accounting question. The total amount will not vary much whether it comes through a public system such as ours, a mixed system, or the free market.

Studies show public systems are cheaper, and a single-tier public system is a perfectly good buy. (We are talking about how payment is made; the question of delivery is different and secondary. Your doctor is already in private practice. Whether a huge U.S. medical corporation would give you better care than a Canadian public hospital can be debated. But it’s the single tier for payment that distinguishes our system and provides its unique sense of fairness, equality and justice.)

The argument I want to make is that it is hard to maintain one-tier health care in an increasingly, aggressively two-tier society. In the 40 years after the Second World War, there was a general social levelling. The far ends of the socio-economic spectrum tended to shrink, the middle expanded. In that context, the vast majority saw a value in “universal” public programs such as health care; few felt they could cover such costs on their own. So there was broad support for medicare.

But in the last 20 years, the pattern reversed. The rich and poor ends expanded. The middle began to disappear in the gap between. There is now a sizable constituency that can picture covering some of its own health costs, while using the public system for others. These people are well-connected and donate to political parties. Those at the harder-up end feel stretched, stressed and disenfranchised. The vast but shrinking middle still supports a one-tier system, but is edgy and preoccupied with hanging on.

The point is, it’s difficult to go in both directions at once. Take, as an example, Paul Martin’s 2000 budget. He had a huge surplus. He could have invested it in areas such as health care that he had gutted in earlier budgets. Instead, he chose to dole out $100-billion in tax cuts that mainly enriched the already well-off. So the social gap expanded, raising demand among those with more money for the “right” to pay for procedures the health system already lagged in supplying, due to earlier cuts (and accompanying tax breaks). We still had that great vision, but a crippled health-care reality.

It now falls to Paul Martin to save the system he, more than anyone else, ravaged (while claiming history and globalization made him do it). The good thing about Liberals is that, due to a lack of firm principles (I’m being careful; I don’t say they have no principles, just frail ones) they might occasionally do the right thing, even if they did the opposite for years.

What has all this to do with Michael Jackson, whose trial this week consumed way more media space than the Supreme Court decision? Well, obsession with celebrities is pernicious mainly because it implies that some lives matter far more than others, which is precisely the ugly implication that lies deep in the heart of any two-tier medical system.

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Rick Salutin

Rick Salutin is a Canadian novelist, playwright and critic. He is a strong advocate of left wing causes and writes a regular column in the Toronto Star.