No Payor System

Our common understanding is that universal healthcare will provide us all with access to competent medical care. We expect that should we become ill; diagnostic tests, surgery, and life saving medications will be readily available. This we expect without equivocation.

But healthcare has taken on a different meaning.

Whenever reporters present documentories on universal healthcare services in Europe or elsewhere they ask three standard questions whose answer in America is an embarrassment. But are the expected answers so reasonable?

"Are you happy with your healthcare system?"

This question is asked at random of relatively healthy people. Since they have no obvious need to test the availability of care for serious illness they are indeed happy. But there are increasing signs, as these systems age, that patients with serious illness face roadblocks and outright denial of access to the most efficacious modern treatment. As rationing of services accelerates Supreme Court of Canada:Chaoulli these problems will become more prevalent. But sick patients are always in the minority, so why should their voice count? After all, we all only die once.

"Do you ever pay a medical bill?"

This evokes an aire of amused incredulity. Health is a right. It is guaranteed to everyone. Who should have to pay? But why should this seem to be so strange? Receiving healthcare is a matter of life and death. Should we not take some responsibility for our own welfare? If we do not, can we hold anyone else accountable when the care provided falls short of our needs or expectations? Do we have the right to someone elses labour? Can we legitimately accept someone elses learned expertise as our own birthright? It is difficult to rationalize so frivoulous a dismissal of so vital a human exchange. Are we not accountable for our own lives?

"Does anyone go bankrupt as a result of getting healthcare?"

This is the worst canard. A protection from bankruptcy at the price of reasonable access to critical therapies is a fools bargain. But increasingly this is the bargain that is struck. As economic pressures increase, the system seeks to minimize its exposure to more sophisticated modalities of treatment. This seems especially cynical. You will not go bankrupt but there is a ceiling on the value of your life.

Such superficial questions do little to enlighten us, but perhaps they expose the shallow nature of the inquiry.

Of all the pressing domestic issues in this election year, a successful resolution of the problems in healthcare will have the most enduring effect. Any effort to clarify the issues involved therefore deserves thoughtful consideration. “Sick Around the World,” presented by Frontline, does attempt an even handed comparison of universal care in five countries. Its premise is that among these programs we may find useful suggestions to apply to US medicine. In his summary the narrator, T. R. Reid, identifies three common practices used by these nations to organize their healthcare. First, insurance company profits are limited or eliminated. Second, everybody is mandated to buy healthcare. Government must then provide subsidies to the poor. Lastly, providers (hospitals and physicians) must accept fixed prices.

What does the responsible physician bring to the table? Each physician has an innate belief that his patient’s welfare must come before his own. This healthcare system would have collapsed long ago if this were not the case. The flaw lies in the misalignment of self-interest. To correct it there must be an economic focus through which the diverse interests in healthcare can be resolved.

How do risk-bearing physician owned medical groups provide this focus?

Why should it seem to be a paradox for physicians to manage healthcare? Many blame physicians for the system’s failure. Deterioration in cost of care, ease of access, and availability of services all seem to point toward the profession. Yet it is the constancy of the physician’s dedication that sustains healthcare. Despite steady erosion of income and increased bureaucratic intrusion the profession soldiers on. The myriad factors which sustain the current US system are nicely described in the New England Journal of Medicine by Lawrence D. Brown. But he missed one critical factor. All of the compensating factors he mentions depend upon the input and even generosity of physicians. The system continues to function because the profession consistently places the welfare of its patients above its own. There is an essential iniquity in a society that exploits the humane spirit of its medical profession to sustain its failed healthcare.

As our healthcare system crumbles the mantra of cost containment still emanates from the ruins. Few aspects of healthcare escape this indictment. Physicians, hospitals, pharmaceutical companies and even insurance companies are all cited for their contribution to spiraling cost. But we seem unable to recognize that it is the organization of healthcare itself that creates the problem. As long as the belief is held that fiscal responsibility for care of patients can be divorced from the delivery of that care this chaos will continue. The frenzy to contain cost focuses upon care givers. If only they can be constrained healthcare will be affordable.

This is clearly not an effective strategy.

A recent article in the New York Times, Those Who Pay for Private Care Are Testing Britain’s Public Health System by Sarah Lyall, Feb. 21, 2008, demonstrates how a socialized medical system disintegrates over time. This 60 year old National Health Service (N.H.S.) does not pay for many cancer drugs which are considered to be state of the art in the USA.

Preamble

The recent Supreme Court of Canada decision¹ places a difficult challenge before the Canadian Healthcare system. The Court upheld the contention that when government imposes delays in access to treatment in order to sustain the Public Health System it violates the individual’s right to life, liberty and the security of the person. Although rationing of resources was the primary concern, this decision threatens to provoke a series of challenges which will seriously weaken the political and economic viability of the single payor system. The Canadian Government’s response to this challenge will critically affect its ability to preserve the goals and principles incorporated in the Canada Health Act.

Implementation of Plan

A. Shift to tax preserved funding of health care

1) The current level of health care funding in Canada benchmarks the country’s fiscal commitment to health care. There should be an active review of the adequacy of this funding before the level of tax-preserved funds available to each household is established. The objective should be to establish a level of funding sufficient to provide a comprehensive health care system without the need to ration services.

Synergistic Benefits of this reform

1) Each physician-partnership which acts as a primary insurer answers the Supreme Court’s concern that patients, when faced with inequities in the distribution of care, should have access to an independent source of health care. Independent physician-partnerships obviate the need for government to introduce private health insurance companies. In turn, this eliminates the possible introduction of an ancillary profit motive which would siphon funds away from the delivery of health care.

Effect on Government Programs

1) Once these changes are implemented the Canadian health-care system should continue to evolve, guided by predictable and fiscally justifiable demands for increased tax-preserved healthcare access. The need for tax-based revenue for other purposes should not be affected.

Why don’t Americans have universal healthcare? There are many reasons. Their genesis lies with the ideals of our Founding Fathers. The Declaration of Independence crystallized their aspirations for the nation they created. Central to their beliefs was a unique notion of the individual’s relationship to society. They recognized that life, liberty and the pursuit of happiness are indistinguishable: they are part and parcel of our humanity. By including the pursuit of happiness they recognized a critical feature of our human existence. We are intelligent beings capable of infinite patterns of thought. With this declaration we are at liberty, individually, to find our most satisfying use of that intelligence.

During its many decades, socialized medicine in Canada maintained an enviable record of healthcare access for its people. But its commitment to access took a toll. Over time medicine evolved into an ever more complex and expensive proposition. To sustain universal care, choices had to be made. As in all healthcare systems cost containment became a major issue.

Controlling healthcare cost seems to be impossible. Attempts at constraint imposed by government or managed care fail to show any indication of success. In their wake access to care becomes more difficult. What is the problem?