This article appeared in Consent #7 (January-April 1989)


- Murray Hopper

{Mr. Hopper is a founding member of Freedom Party, now in charge of special projects.}

Medicare in Canada has become the object of a national shouting match: federal politicians bicker back and fourth with their provincial counterparts about the sharing of ever-escalating costs; the health care bureaucracy and the man in the street castigate the "wicked" doctors for daring to extra-bill or require user fees; doctors, in their turn, resent growing government intrusion into matters medical; and above all the chaos, hell-bent for election and re-election on their white medicare chargers, ride politicians of every party who advocate further coercive legislation, seek to paper over the cracks, end the tumult, and restore domestic tranquility.

Don't hold your breath, friends.

Seldom has so much heat generated so little light. Thanks to government propaganda over the years, any rational examination of the basic flaws in our healthcare system is precluded. Since the founding principles of medicare (universality, portability, comprehensiveness, and public administration) have been elevated to the status of holy writ (the "Four Commandments"?), no politician dares question them. Among them is Brian Mulroney who is tip-toeing through the medicare minefield, smiling a lot and saying nothing ... since he has no reasonable alternative.

What happened to the perceived bright promise of just twenty years ago? Canadians were to have been freed forever, by the actions of a wise, humane, and benevolent government, from all worries about healthcare. It hasn't happened; the whole system is breaking down. What is to be done?

The bureaucrats, of course, have their answer ready: a continuation and expansion of the present state monopoly, with the full force of government used to make doctors toe the line.

Writing in the Globe and Mail, Mr. Jonathan Lomas, a health policy analyst at McMaster University, attacked what he perceived to be the ailing credibility of doctors. He made, among others, the following points:

  • That the profession has failed in its duty to protect the public interest;

  • That (then) Health Minister Larry Grossman was forced to impose on the profession, for the first time in history, a regulation governing conduct;

  • That doctors should not complain about any perceived threat to their status as independent businessmen;

  • That the College of Physicians and Surgeons was remiss in excluding certain foreign-trained doctors from practising in Ontario.

These four examples illustrate a frightening encroachment of the civil power on the medical profession.

Mr. Lomas manages to refer to the "public interest" twelve times in the course of his article, perhaps hoping by repetition to give some weight or meaning to this tired old collectivist term and of course, failing to do so. There is, in fact, no "public interest" binding upon doctors; their obligation is solely to their patients, surely a private matter, both by custom and by law.

As to the conduct regulation imposed by law, one is reminded of the story of the polite thief who, having asked his intended victim nicely for the money and having been refused, was obliged to bring out his gun to close the deal! And what are we to think of a health policy analyst (not a doctor) whose judgment, even in medical matters, is considered superior to that of the physician?

Mr. Lomas has indeed elevated pipsqueakery to a high art.

On the other hand, Dr. Duncan McEwan, an independent medical care analyst writing in Health Management Forum as long ago as the Spring of 1980, identified twelve realities of medicare as follows:

  1. Even in a democracy, a government monopoly of health services will produce totalitarian results: a centralized bureaucracy providing less and less service at greater and greater cost, to the increasing dissatisfaction of all concerned.

  2. Demand becomes infinite as patients equate a perceived need with a true need.

  3. Public clamour does not indicate true need but is simply the predictable result of the state undertaking to cover everyone for everything regardless of cost.

  4. As infinite demand presses against finite resources, rationing becomes the inevitable result.

  5. Since most of the benefits of the present system go to the bureaucracies and to that great majority of Canadians who are well able to pay their ordinary health-care costs, less resources are left for the truly needy.

  6. Health care delivery becomes a power struggle, with the politicians and bureaucrats who control the system gaining ascendancy by manipulation of public opinion and avoidance of critical issues, over those who provide the services that make the system possible.

  7. Health care managers must convince governing boards and physicians of the necessity of local, efficient management, including peer review in relation to hospital admissions, hospital utilization, length of stay, and turnover interval.

  8. Although government intervention and presence in the health care field will continue, it is important to reintroduce some measure of the marketplace through the development of sundry private health care mechanisms.

  9. Professionals of great technical skill may be grossly incompetent to measure the true outcome of their endeavours as these impact upon resource allocation, priorities, and costs.

  10. Health care managers should always assume that a new treatment is ineffective unless there is evidence to the contrary.

  11. The burden of proof for new resource allocation must always lie with those who seek it.

  12. Managers and decision makers should not be too easily impressed by "conclusions" from "studies" by technical performers, but should require properly designed studies which would eliminate subjective judgement, personal bias, improper controls and the like.

His conclusions: The major defects of Canadian Medicare, fostered by ill-considered legislation, are: wasteful use of existing resources; excessive use of hospital facilities; and demand for programs, gadgets, and other facilities of unproven value. The public must realize that blanket medicare by government is but an illusion. The unchecked demand for total coverage will preclude proper coverage in times of catastrophe.

In the United States, too, medicare is failing. Riddled by fraud, waste, and abuse to the tune of $7 billion or more annually, the program that serves 26 million elderly Americans is going broke. In 1983, costs were approximately $57. 3 billion, up 30% from the two previous years alone. 1983 projections indicated that between 1984 and 1990 costs would double from $65 billion to $130 billion. Already l0% of the American G.N.P. goes to the health care industry. Although attempts are being made to contain costs, success is elusive, and predictions of great problems for American seniors are the order of the day.

One bright spot in the overall medical scene is the appearance of private "emergicare" clinics, which deal with relatively minor emergencies (fractures, cuts, bruises, etc. ) at about half the fees of hospital emergency facilities, leaving the latter free to deal with life-threatening situations.

In addition to the viewpoints of Mr. Lomas and Dr. McEwan, the is a third possibility: a completely private, voluntary system.

First, consider the benefits of the marketplace transaction, where the user of a service pays for it.

  • It links producers to beneficiaries.

  • It provides incentives to reduce waste.

  • It gives information as to what users are willing to pay.

  • It saves in tax revenues.

  • It introduces competition.

The essentials of a rational medicare system are three, and three only: (l) a doctor; (2) a patient; (3) a marketplace. With all political presences removed, the citizens of a community would retain all the dollars formerly consumed by taxation. These dollars would be available for the purchase of needed medical care, for investment in hospital bonds, for donations to medical research, and the like, by free choice, as each individual sees fit. At one stroke, all the costly, wasteful, meddlesome bureaucracies would be swept away and local control firmly established.

But, you may say, wouldn't medical care vary somewhat from place to place?

Of course it would, and rightly so! Since the people in a given area would have exactly the level of medical services that they choose to pay for, such levels would become just one item in the mix of perceived benefits and drawbacks of living in a particular area. A healthy young miner in Kapuskasing would not be too concerned about a lower level of medical services, whereas an elderly man with a heart condition might choose to live in London, close to its University Hospital. In any case, such decisions must remain the subject of free choice by each individual.

It has generally been considered that, in normal times at least, 19 out of 20 people would be ready, willing, and able to pay their day-to-day medical costs. (Incidentally, if it were possible to discover the identity of the bureaucrat who first proposed that this group need not pay, we might arrange a suitable recognition of his genius by, say, giving him a career posting to Frobisher Bay, or perhaps a reverse knighthood.) In any event, surely the 95% mentioned above would have no great difficulty in finding a reasonable, voluntary means of supporting the 5%.

But, you will say, surely medical care must be a matter of right rather than charity. Not so; no right can exist which violates the rights of others. Let us examine how state control destroys rights:

  • When all are forced to participate, freedom of choice and freedom of association are denied;

  • When tax dollars are taken without consent, property rights are violated;

  • When the Christian opposed to abortion is forced to subsidize it, freedom of religion is abridged.

It seems then, that we have three choices:

  1. State medicine, a government monopoly which destroys rights (collectivism);

  2. A "mixed" system which attempts to find a "balance" between the destruction of individual rights and the efficient delivery of health care ... and which will always lead to state medicine (pragmatism);

  3. A completely free-market system which does not destroy rights (individualism).

Collectivism, pragmatism or individualism; only one is consistent with the ideals of a free society.

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