A second opinion on Canadian and American health care
Posted: March 20, 2010. Conrad Black
Most Canadians have watched with astonishment, and some with smugness, the fierce and tortured American debate about health-care reform. There are some important lessons in it for Canada.
It has been a Canadian truism for decades that an American who suffers a medical emergency and does not have proof of medical insurance or a credit card will not be picked up by an ambulance. Of course, this is nonsense: All Americans receive medical care. But uninsured people who are not wealthy can be impoverished by a serious medical problem, and the indigent will be treated only until their condition is stable, and then released. They are entitled to Medicaid, which the government provides to everyone who is poor, but it is often an overstressed, understaffed medical care system by the standards of advanced countries that have universal health insurance.
Still, medical care for rich and middle-class Americans truly is the best in the world, which is why three quarters of Americans like the system as it is, as they are fully insured and their employers pay for all of it. Many American hospitals are world-renowned. It is the leading country for medical innovation, and people with serious medical difficulties who can afford it go to the United States for treatment. Over $7,000 per capita is spent on health care annually in the United States — about $2.4-trillion — over $3,000 per capita more than in any other country, including Canada.
The high cost of health care in the United States arises from a Second World War-era U.S. government decision not to tax medical benefits received by individuals from their employers. The inevitable result — as in any situation in which people can get all they want of a good thing without paying for it — is that most Americans are over-insured against extremely remote contingencies. The mad litigiousness of American society has required a huge focus on exploratory treatment and has inflated insurance premiums. The United States does not regulate drug prices as most advanced countries, such as Canada, do, so American drug consumers effectively subsidize the customers of “Big Pharma” in other countries.
U.S. states are protectionist in regard to their medical-insurance industries and there are many inappropriate relationships between the health-insurance industry and state legislators. As Dwight D. Eisenhower put it nearly 60 years ago, in describing American politics more generally: “Political chicanery and corruption are shot through the whole business.”
Having a ring-side seat at this 25-round American political brawl, with all the brass knuckles, rowdy fans, low blows and ear-biting customary in the high-level public policy debate in the United States, should have been a pleasant divertissement for Canadians, convinced as most of them are of the superiority of their own health-care system.
However, one point all factions in the U.S. debate agree on is their determination not to emulate Canadian health care, which they all consider a textbook case of what not to do. American researchers have found aspects of the health-care systems of Australia, France, Germany and Japan worthy of emulation; but from left to right, they consider that Canada stifles doctors and reduces them to almost unionized public-service employees, inflicts intolerable delays on people in urgent need of prompt attention, retards medical research and imposes government interference on the doctor-patient relationship to an extent that American doctors and patients would not accept. Even comparatively radical Democrats in the Congress would never try to abolish private medicine or impose absolute equality of treatment on everyone, regardless of their means, as Canada does.
I submit that it has become much clearer in this debate how the health-care systems of both countries could be improved, if just by listening to the other’s critique of their neighbour’s system.
The United States should tax medical benefits beyond a standard level that includes emergency and chronic cases; or Washington could provide tax credits for people who pay for health insurance out of pocket, in a system that would permit individuals to make their own health-care choices, with a back-stop catastrophic health insurance system for all in need of it. Legal liability should be cut back to genuine negligence cases. Maximum interstate health insurance competition should be encouraged. Some sort of reasonable price restraint should be imposed on the pharmaceutical industry, and the highest national standards of hygienic and administrative efficiency should be applied to the hospital system. The Medicaid system could be strengthened by having all starting doctors serve three months of their internship in it.
No one in the U.S. health-care debate disputes that it is too expensive in its current form but neither does anyone identify the parties from whom it is proposed to claw back large savings. If the per-capita cost of U.S. health care were reduced by just two thirds of the gap with other advanced countries, by $2,000 per person annually, that would dispose of nearly $700-billion of medical-care costs each year.
It would also mean $700-billion less for doctors, lawyers, paramedicals, pharmaceutical companies and medical insurers (who are not, contrary to a lot of noisy demagogy, overly profitable now). Barack Obama’s administration already has caved in to organized labour and the trial lawyers; and the Republicans, after pyrotechnic posturing, show little disposition to take on the doctors and the drug companies (though their last election program for altering the payment system was creditable). They would have no compunction about cuffing the unions and lawyers around a bit. Both parties are required to roll back misplaced health-care costs from all the main beneficiaries.
There was an opportunity for bi-partisan, comprehensive change a year ago but it was squandered. Any bill that passes now will be jammed through by Democrats using dubious procedures, and will achieve much less than is needed. But carping foreign critics should remember that elected politicians in all countries are rarely in a hurry to make changes in a vital program that three-quarters of the people are happy with nor to seize $700-billion annually from powerful and unremitting professional and industrial groups at the summit of the service-industry economy.
As for Canada, it should abandon its nonsensical ban on private medical insurance for essential health-care needs, a policy that leaves it in the company of Cuba and North Korea. Brian Mulroney and Michael Wilson were absolutely right to jettison universality in 1985 and should not have allowed John Turner’s boffo histrionics and accusations of “sleaze” to deter them. There should be a medical-visit user fee for those who can afford it and absolute guaranties against unacceptable waits. In the name of equality, Canada has imposed what amounts to a capricious and inhumane health-care rationing system that should be acknowledged and ended.
These two very advanced countries should learn from each other what to keep and what to drop, so they no longer disdain each other’s health-care systems. Let’s use the formerly unguarded, now over-bureaucratized border usefully, even if we have to give the Dudley Dorights and Homeland Security Palookas massed along it stethoscopes and thermometers. All cross-border travellers know, to their irritation, that they already have the latex gloves.