With the fear of terrorism hanging heavy in the air and signs of recession all around us, the timing could hardly have been better.
So Tony Clement, Ontario’s Minister of Health, mustered a solemn look and announced earlier this month that the province might have no choice but to resort to user fees in its healthcare system.
It seemed harsh but inevitable. After all, in such tough times, how can we expect to hold on to expensive public programs like Medicare? Surely public healthcare will just be one more thing — like civil liberties — that we will have to learn to live without.
But if it all sounded like part of some unavoidable new reality, let’s not forget that these plans have been in the works for some time. Way back last April, when New York’s twin towers were still standing and Ontario’s coffers were flush with cash, Premier Mike Harris said in a TV interview that he planned to make privatization the focus of the upcoming debate on healthcare reform.
But the idea, long popular on the right, proved to be a dud with the public, which has always been cool to user fees and other types of privatized medicine. With the Harris Tories continuing to drop in the polls, the subject of privatized medicine was quietly moved onto the back burner.
Now, with the new situation of despair and confusion, all of a sudden the idea has legs again.
“I’m not going to fool around about it — we have a slowing economy, we have the effects of September 11. We’re going to have some tough choices to make,” said Ontario’s Deputy Premier Jim Flaherty, backing up Clement.
Of course, it’s true that Ontario’s finances have taken a turn for the worse in the last two months. Alberta, also facing a worsening financial situation, has recently revved up its war with Ottawa over privatizing parts of its healthcare system.
Given the new financial constraints, it might make sense to reconsider the subject — if there was any evidence user fees saved money.
It seems obvious they would. Tacking a small fee on to the cost of visiting the doctor must have a deterrent effect, at least on people with tight budgets, who make up a significant part of the population. One could object this is unfair to the financially strapped, but at least it saves the system money. Right?
But it turns out that the money-saving part isn’t even true, according to Michael Rachlis, a health-policy analyst. The reason is that doctors, faced with extra time in their schedules, tend to encourage more visits — like annual check-ups — on the part of other patients who aren’t deterred by a small fee. Rachlis, a physician himself, says the evidence doesn’t suggest doctors are greedy. But if they have extra time, they will tend to fill it up with more preventative care. He did this more himself when he was a young salaried physician than when he later developed a busy practice.
He points to the case of Saskatchewan. There were no user fees in the public health-insurance scheme first introduced there in 1962 by former premier Tommy Douglas, (leader of the CCF, the forerunner of the NDP). When the subsequent Liberal government introduced user fees in 1968, the poor and the elderly cut back their visits to doctors by 18 per cent. But doctors simply filled up the available time by seeing more of their other patients, who were apparently happy to get extra medical attention. Overall, higher-income groups increased their visits to the doctor.
(Advocates of user fees often suggest exemptions for the poor and the elderly. But this involves creating costly bureaucracies, making financial savings all the more unlikely.)
Of course, discouraging people from seeing doctors does have other consequences — like poorer health results — although such considerations may not count for much in the new era of “tough choices.” Still, for what it’s worth, a major U.S. study, the Rand Health Insurance Experiment, found that an increased risk of dying was one of the consequences for low-income patients who faced user fees. For a 50-year-old man with high blood pressure, the increased risk of dying could be as high as 20 per cent over five years, the study found.
So it seems user fees aren’t effective at saving money, but do jeopardize the health of the population. And since they won’t do anything to improve airport security, it’s hard to imagine just why they should be enjoying their current cachet.
The good news is they’re also unnecessary. Rachlis and several other prominent health-policy analysts argue in a recent paper for the Tommy Douglas Research Institute that major improvements can be made in the Canadian healthcare system — without an infusion of extra cash. They insist just about every problem — from overcrowded emergency wards to under-serviced regions to long waiting lists — can be dealt with through implementing reforms, which are already in place in various parts of the country. (Sault Ste. Marie, for example, cut its waiting list for breast cancer surgery by more than 80 per cent last year, simply through administrative reforms.) Such reforms would hold the line, or even reduce costs.
The one thing that would make problems truly insoluble, they argue, would be moves towards privatizing the system, which make it more difficult to deal with the needs of the whole population.
So it turns out that user fees still don’t make sense, even in an era of despair and confusion.