Thursday, December 09, 2004

Latest in a series

The Monger, MD, points us to an exchange of letters, involving doctors, in the Post. Doctor A says he's moving to the U.S. because he believes the hand of government is negatively impacting his ability to practice in Ontario. Citizen B says that's not fair, because the government trained him to be a doctor with some of their dimes, and A shouldn't be allowed to just bolt. Citizen C, MD, comes back with this:
Mr. Fulton [Citizen B] seems to suggest that candidates for Canadian medical schools sign an agreement requiring a commitment to stay and practise in Canada for a period of time. This is an evolution from the view of physicians as private agents for their patients and their own interests. Does he really want physicians serving the collective goals of a publicly funded health care system?

E. Klimek, MD, St. Catharines, Ont.

The Monger calls this "the single best question I think I have ever seen, addressed to proponents of Medical Socialism". I would agree that it's valuable, insofar that it's a point that can't be made often enough in our present situation. The error here, if I may be so bold as to contradict someone who is clearly smarter than me, is in the characterization of the question.

That ostensibly rhetorical question by Dr. Klimek is not a winning argument on the issue - it is the issue. If any significant portion of the population saw an inherent contradiction in having "physicians serving the collective goals of a publicly funded health care system", we wouldn't be in the kind of mess we're in. But they most obviously do not! ("Doctors want everyone to be healthy, so does the government, so what's the problem?") Probably even 1/2 of the Post readers read Dr. Klimek's question and said, "sure, why not?"

The McGuinty/OMA deal on incentives for reducing prescriptions a few months ago is a perfect example of this, and demonstrates the gulf between the true believers in Our Sacred National Identity and the market reformers. There are two kinds of people in Canada (both of whom were offended by this deal). The first looks at the government bribing doctors to reduce the amount of prescriptions she writes, and thinks, this is the inevitable consequence of increasing demand for a monopoly funded by finite resources. The second looks at it and thinks the only problem is the sum of the finite resources.

Worst of all, and I know the Monger shares some of this frustration, is that the Medical Associations seem only too happy to throw their lot in with group #2. Their reward for this is that now a large segment of their patients view them as agents of the state, rationing their care in accordance with the available government supply. The doctor/patient relationship has, on average, been seriously devalued. Anyone else noticed that despite living in the Best System In The World, the only time you hear the phrase, "that's between the patient and their doctor", rhetorically or otherwise, is concerning abortion?

Which I suppose can segue to today's conclusion, though unoriginal. We may already have a health care model in place that could scale up, that being the model for abortion care (probably not the right phrase). Let's see - mix of private and public clinics. Relatively timely care on the public side despite the existence of timelier private care. The choice of accepting government service on their timetable, or paying your own hard-earned scratch for service on your timetable. No one is denied an abortion because of an inability to pay.

Is anyone opposed to this model besides the health unions?


At 11:46 a.m., Blogger The Monger said...

I think you are right--that my initial reaction ("how could anyone want the health care system to serve collective goals, rather than their own personal goals?") is possibly not shared by many Canadians. But frankly I don't think most Canadians have considered those two goals to be different. They are. The real value of the question (which is, as you say, not an argument but the issue itself) is to compel a choice: collective goals? or my goals?

Your analysis deserves a lengthier reply. I will work on my own, and I hope others do too.

best wishes

At 12:21 p.m., Blogger Matt said...

Monger - I look forward to your further thoughts. I hope you address the definite possibility that Canadians would be collectively healthier and better cared for if the government got out of the way in some instances.

I was thinking of this as another post, but perhaps Monger and other readers could consider this: I've been assuming for the last several years that the breakthrough for market reforms in health care would be via publicly funded private facilities. I've changed my mind now, and believe the breakthrough is going to be patient-doctor transactions entirely outside public insurance.

There is going to be an exponentially increasing number of Canadians who simply won't accept the possibility that their care may be dictated in part by the government supply. They will want to be sure that their medical treatment is based on A) best medical practices, and B) their OWN cost-benefit analysis, not the government's.

Lastly, Monger: to your aside in your post - of course that doesn't happen with other professions, certainly on anywhere near the same scale (there's the 'government employee' - or is it 'state property' - perception again; congratulations CMA). It's doubly strange when you consider that the other professions don't have to supply cheap or free labour to the government while they're training.

At 6:15 a.m., Blogger Greg said...

I am not sure about all this (what else is new, eh?). It seems straightforward that whoever pays the piper calls the tune, be it the government or the insurance companies. The collective goals of either agency will dominate the system. At least with the government, we get a vote. It is well and good to talk about individual choice in health care, but unless you can enter a system as a completely free agent (in other words you have bags of personal cash), someone else will dictate the goals of the system.

At 1:30 p.m., Blogger Matt said...

Valuable comment Greg. You've hit on what (depending on your point of view) is either the weakness of "privatization" or of the privatization argument.

Consider the idea of privatizing Alberta Health Care, something like the Workers Compensation Board (or contracting the whole thing out to Clarica). I might argue that the profit motive will find efficiencies and reduce overall costs, whereas you might argue that costs will go up to feed profits, and the system would be less responsive to individuals. Whoever is right, it almost doesn't matter, because what are we talking about in terms of $$ - maybe 20% either way? Up against the big picture, compared to the cost escalations over the past 10 years, it's not the be-all end-all issue. And considering the risk, uncertainty, transition costs, etc., it's quite possible that I'd be against that version of "privatization".

I believe that successful reform would have to happen starting at a higher ideological level. And, I think it could happen by consensus, if it were based on two guiding principles, to the exclusion of all others:
1) The government should fund medical care for every citizen who wants it
2) The government does not own the bodies of its citizens

There is a whole other post here no doubt. Please chew on what would be the potential pitfalls of restructuring public health policy under these guidelines, and I will look forward to your comments.

I guess I should also snark at your comment (so as not to be too accommodating!) thusly: at least with private insurance, MY choice of insurance doesn't have to affect YOUR level of care. There is some good writings about markets being an efficient and responsive way to accommodate the specific needs of individuals & families.


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