America’s health, and our own
The health-reform legislation now moving toward law in the United States, and the divisive political debate surrounding it, contain a profound lesson for Canada.
From Japan to Taiwan to the nations of the European Union, all advanced Western societies eventually gravitate toward a health system that combines private choice and universal coverage. For very different reasons, both the United States and Canada have resisted this trend. Barack Obama and Nancy Pelosi have found a way to break this resistance down — but at the cost of a wrenching political crisis that has consumed the nation for more than a year, and a tangled legislative process that has handed America a dog’s breakfast whose effects will not be fully understood for decades to come. Here in Canada, we can do better.
For all the trumpeting of the U.S. health system as a symbol of the American free-market spirit, its structure is entirely an accident of history. Throughout the 20th century, various American leaders have tried to create a universal, government-supported system — an ideologically eclectic list that includes Harry Truman, John F. Kennedy, Lyndon Johnson, Richard Nixon and Bill Clinton. The main reason they failed was that during the Second World War, wage controls pushed the country toward another type of quasi-universal system: Employer-provided health plans underwritten by favourable tax treatment.
For the majority of workaday Americans, such plans made sense. But they left unemployed Americans in the lurch. They also became outdated as Americans began moving from job to job more frequently, or set up shop as independent contractors. And so over the years, America created a de facto system of universal care that strung together charity hospitals, government programs such as Medicare, Medicaid and SCHIP, legally mandated emergency-room care and other patchwork remedies. The result is a bloated, economically inefficient system that consumes one- sixth of American GDP — a far higher ratio than in any other nation in the world, while delivering care that, though great for the wealthy, is mediocre (by Western standards) for everyone else. More than 40 million Americans (the exact number is in dispute) lack any form of health insurance — an absolute disgrace in a nation as wealthy as the United States.
True, Americans do not have to deal with Canadian-style waiting lists; but they often are bedeviled by endless bureaucratic stand-offs with health insurers, which terminate the policies of morbidly ill patients because of arbitrarily defined “pre-existing conditions.” (Even putting aside the evil that attends such policies, the U.S. health system wastes about 30% of is expenditures on administration — triple the level in Canada.)
This is one of the main problems addressed by the Democrats’ health reform, which will increase the share of Americans with health insurance from 83% today to 95% in 2019. The tragedy of it is that such reform could have been accomplished in a far more humane, efficient and comprehensive manner had it been implemented decades ago, before the industry’s various players cobbled together the $2.5-trillion public-private monster called the U.S. health-care system.
Here in Canada, we are headed for a similar moment of health-care truth — but from the opposite direction.
Like the United States, we have resisted the growing consensus in Europe and East Asia — of a universal system that makes room for private insurance and individual choice — for largely ideological reasons. Left-wing politicians and public-sector unions have convinced their followers, perversely, that the sanctity of our “national identity” rests on the administrative structure of our health system, an administrative structure that puts us alongside North Korea as the only nations in the world that forbid the use of private insurance for core health needs.
As in the United States, Canadians have spent the last few decades inventing ad-hoc methods to make their broken system work. While nominally paying lip service to “one-tier” health care, we have permitted a welter of private solutions: Worker’s compensation health networks, private clinics in Montreal, Vancouver and Toronto, a private pharmacare system, and, of course, the reality that legions of Canadians — including Newfoundland Premier Danny Williams — simply head to the United States, where they pay cash at the door.
The least that can be said for Barack Obama is that he has come to terms with the fact that the U.S. system is broken, and put his political capital on the line in an attempt to fix it. Where is the Canadian politician with the courage to make a similar commitment