03 June 2012

CC03 - Health Care

Why Health Care is Not a Right

You know, a few weeks ago I was challenged by a feminist to explain why "fair and equal health care" was not a right, mostly because I was arguing that women's insurance being more costly than men's in the US wasn't indicative of systemic gender discrimination. I thought about it and spent about an hour putting my thoughts into a reasonably coherent piece of reasoning.

However, it lead me to think about the nature of our health care system in Canada, about how, specifically, it was more restrictive and less respectful of our rights as citizens than a private system such as the US.

Now, before I get started, allow me to preface myself with a caveat. Socialised health care has benefits and drawbacks just as the private insurance model has benefits and draw backs, so this isn't going to be a "Capitalism > Socialism" rant.  Instead I'm going to try to illustrate how each system's priorities differ in such a way as to radically change the effective result of health care delivery.

Let's look first at the way Canada's health care system is structured. Basically the way it works is that doctors, nurses, orderlies, etc., are all public employees, paid for by the government. All costs associated with offering services are paid by the government through the use of taxpayer dollars or, depending on province, premiums paid by individual citizens. For the most part, what this means is that everyone is supposed to have the same access to health care facilities without concern for cost.

Hospitals, including machinery and equipment, are government owned, built and maintained at taxpayer expense. Doctors, nurses, orderlies, custodians, etc., are all public employees, hired and paid by the government. The health care system is, almost in its entirety, a government bureaucracy, where decisions about health care delivery is made by politicians and bureaucrats, instead of doctors and their patients.

The upside of this is that it ensures that there is SOME kind of health care system available to every citizen to meet his or her medical needs. The downside of this is that it's run from the top down, that decisions are made based on what is best for the government or society as a whole, rather than the patients as individuals.

Now, since this is a social system, and there's only so much money available to pay for services, the concept of a market economy system regulating the prices of health care services cannot work, since there's only one provider of service (the government). So, there's no marketplace within which prices are regulated.

Instead, the government decides how much it will pay for each specific kind of treatment. Usually, this formula is decided by committee, where many different people all debate on what a reasonable fee for each procedure might be, but, in the end, it is the government that decides how much each procedure will cost the system. Then, it uses a cookie cutter method of fitting each patient, regardless of his or her personal needs, into that specific 'mould' for each procedure. What ends up happening, is that the government decides how many of each procedure it can afford to pay for each year, and puts a limit on the number of those procedures that the public system will provide.

If the government decides it can only afford 1000 hip replacement surgeries in a year, and there are 1500 patients requiring hip replacement....well, you can see where we end up. Wait lists that are getting longer and longer as time goes by, simply because the government has artificially limited the number of available procedures.

Another big problem is the cost overrun. Because a socialised health care system has only a single health care provider, there is no competition to bring down prices or encourage innovation. The government just decides for what it will pay and that's the end of that. And, if you're not aware, in Canada, it is illegal to offer private medical services for anything the government is obligated by law to provide. The government basically has a monopoly on delivering health services.

So, consider again the hip replacements. Every year, there are 500 more people being denied services simply because the government decided not to (or is unable to) pay for any more procedures that year, but those patients have no other options within Canada. So, many of them go to the US, where services are paid for by the patients (or the patients' insurance).

Recently there's been a discussion, in Alberta at least, about whether we should be forcing our citizens to head to another country to pay for their medical care in a reasonable time frame. But, because it is illegal in this country to offer medical care that is supposed to be provided by the government, what option is left to the patient when that service is not being provided within a reasonable time frame?

There are currently two schools of thought. The first, often touted by supporters and proponents of socialised medicine, is that the patient should wait his or her damned turn, and that the government needs to ramp up spending in order to meet the demand. 
If only we had more tax dollars to spend on health care.  Lets put in a fast food tax, a tax on pop, and raise the sin taxes even more on regulated products.  Then we'll have lots of money to spend on extra hip replacements.

The second, generally held by opponents of socialised medicine, is that those people, should they choose to, should be granted the option and the opportunity to purchase services outside of the public system, to help them maintain their own health at their volition.  If people are willing to pay out of their own pocket for fast, efficient, and effective health services, then why should we deny them that chance?  It will save the public system money, and shorten wait times, and we don't need more government to do it.

Now, while there are advantages and disadvantages with both options, the pertinent issue in my mind is the personal freedom to choose one's own destiny that is being denied by the nature of Canada's health system.

Consider this: When you rely on the government for your health care, you are giving them the power to decide how your health will be treated.

It is their decision, not yours, what conditions you have that merit treatment.
It is their decision, not yours, when those treatments will be provided.
It is their decision, not yours, where and by whom those treatments will be provided.
It is their decision, not yours, because they are paying the bill.

Now, by preventing a second option to people who would rather keep the power to make decisions regarding their own health care by paying for their own needs, the socialised system is basically denying our citizens their right to self determination. We are being held completely at the whim and mercy of a government bureaucracy.

Now, proponents of socialised medicine will often becry the idea of allowing people to pay for their own health care as condoning or encouraging a 'two tiered health system', in which people who can afford to pay for their own health care go into one line, and those who are unwilling or unable to pay their own way go into another. The very idea that people be allowed to choose and pay for their own service based on what they are willing to spend is abhorrent to these people, mostly because it helps encourage the idea that a person does not NEED to rely on the government for everything.  They think that the end result will be a withered public system, starved for money and incapable of even treating a simple cut, where poor people are sent to die from infection because the rich people don't like them.  They think the private system will be opulent, and expensive, and "gold plated" (as is often a phrase I often hear in the media), where affluent people will go for medical services denied the plebes.  They think that it will help create, or cement, a class system in our country, a 'medical apartheid' (another phrase I've heard used in the media), where people will be denied service simply based on their income.

While this seems to be pretty obvious hyperbole, to me at least, systems like this are found throughout our society.  Only rich people get to drive expensive cars.  If you want a Ferrari, you have to pay for the Ferrari.  If you can't afford a Ferrari, you'll have to settle for a Toyota.  I don't think health care is any different.  Homes, cars, restaurants, computers, education; the higher the quality, the higher the cost.  The main difference between this scenario and the health care debate, though, is that the government subsidises health care, and the standard is set for quality.  The variable, unlike in real estate (which is value), is time.  So, you can either have an expensive private system that's high quality and quick, or an affordable public system that's high quality and slow.

Like industrialists are fond of saying: "Fast, Cheap, Good.  Pick two."

Back to our hypothetical.  Consider this: You have 1000 hip replacement surgeries available in one year through the public system, but you have 1500 patients needing the procedure. However, let us presume that there are three new private clinics, capable of doing 250 surgeries each, offering to do the same procedure for a reasonable personal cost, that 700 of the 1500 patients requiring the surgery are willing to spend. So, instead of having 1500 people in line for 1000 available spots, you now have 800 people in line for 1000 spots in the public system, and 700 people paying for one of 750 spots in the private clinics. So, with less demand on the public system, costs and wait times go down, service goes up, and anyone who is either unable or unwilling to buy their own health care out of pocket actually benefit from allowing the people who are to do so.  We've gone from a shortage of available spots (1500/1000) to a surplus (800/1000 + 700/750), simply by allowing those with the means and the will to purchase their services in a private clinic.  And the best part is that those dollars stay in Canada.

As it stand now, though, there is no second option, and everyone must stand in the same line, for a finite amount of services. Costs go up, quality goes down, and in the end, a purely public system is unsustainable, particularly now that our populace is aging into senior status. The older you are, the more your health costs increase, and the less you contribute to the tax base. 30 years ago this wasn't an issue, because there were far more working class people than seniors, and thus the system was solvent. But now it's the other way around, and there isn't the tax base to support the rapidly increasing costs associated with 40% of our population being of retirement age. So, a purely public system is unsustainable, and I would put forth, unjust as well.

Now, contrast this with the American system, which is much like a car insurance system. Each citizen can choose to pay (or not pay, at least until LOLBamaCare kicks in) an insurance company a regular fee in set intervals over time with the expectation that the company cover unexpected medical related costs in the future.

The HMO system in the USA used to be like car insurance, and was analogous with owning a car. You bought a car, you took out an insurance policy against that car in case of theft, collision, or meteor impact, such that if anything unexpected or catastrophic occurred, you were protected against the loss of the car. But, you were still expected to pay for fuel, and maintenance, and repairs on that car, to keep the car in good working condition, and to drive it safely, at the risk of voiding your insurance.

Now, the health care system in the US was much the same way. Each person was responsible for maintaining him- or herself in good health, and the insurance company was only expected to pay for catastrophic or unexpected medical costs, such as in cases of grievous injury or onset of disease. Going to see the doctor because you had the sniffles was something you paid for out of pocket, just like you paid for the fuel you put in your car.

But somewhere along the line, whether by design or demand, health insurance companies in the US became more and more responsible for paying for the maintenance of one's health, rather than to protect the patient against the costs of catastrophic injury or illness. I don't know how it happened, but I imagine it was something along the lines of an insurance company offering additional services as a way of enticing greater dues from its clients, or as a way to say "Look, we're better than that other guy, let us be your insurer", and after a while, the additional perks began to be seen as entitlements instead of added perks, until now we see any service taken on behalf of one's health as legitimate cause to bill the insurance company. We see the result of that with insurance companies scaling back what they're willing to pay for, and finding whatever reasons they can to deny clients benefits (usually after the fact).

So, the Americans find themselves in the unenviable position of being at a loss for a decent health care system at all. Those who cannot or will not pay for health insurance are responsible for paying whatever costs may be associated with maintaining their health, but health care providers in the US are compelled by law to treat those without insurance despite the fact that they may not be able to cover the costs of their treatment. This tends to lead to huge costs for the hospitals as those who cannot or will not pay for insurance realise that they can still get services despite not being prepared to pay for them. The health providers offset this cost by increasing the charges they bill the insurance companies, which in turn, raised the premiums and decreases the services covered to those willing to pay for insurance. It is obvious that this situation is unsustainable, and also unjust, in that it forces responsible people to carry the cost of the irresponsible, and to force insurance companies to cut services wherever they can to make up the difference.

Now, if the Public system is unsustainable and unjust, and the Private system is unsustainable and unjust, what do we do?

Well, I think the first thing we must do is come to accept that health care is not a right, that it is a service.


It is a specialised, technical, and expensive service, yes, but a service nonetheless. We, as a society, do not have the right to health care. What we have, is the right to buy health care.  We cannot claim as our right the efforts, skills, time, and labour of other people.  Rights are held within ourselves.  We have the right to do things, or not do things, as we choose, but we can only choose for ourselves.  We cannot assume the right to make choices for other people.  The assertion that health care is a right, assumes we, as individuals, have the right to claim as our own, the efforts, skills, and labours of another person.  We have a word for when one person has the right to production of another; it's called serfdom, or indentured servitude.  Personally, I cannot abide any system that treats any of its members as a serfs, and health care delivery is no different

When talking about public vs private health care, we need to understand that each style of health care delivery has its benefits, and each style has its drawbacks.  Luckily for us, each style's benefits and drawbacks are complimentary to those of the other. So, instead of being of one or the other, we take the best of both and mixed them.  If we took the innovation and competition indicative of a private system, and combined it with a publicly funded insurance system, we'd have the best of both worlds.  Instead of having the government decide to which facility or personnel tax dollars go, they instead followed the patient, allowing the patient to decide which facility to use.  That would force the different providers to compete with each other for patronage of patients, and it would allow the patients to access needed services without too much concern for cost.

Alberta in the '90s under Premier Ralph Klein toyed with the idea of what was called a P3 system. P3 is an abbreviation for Private/Public Partnership. It suggested that health care could be privately delivered, like in the US, encouraging customer service, innovation, fair market value for services, and modifying supply to meet demand, while still being publicly funded, like in Canada, ensuring that all citizens would have access to health services.

Now we're kinda sitting in a limbo of that idea in Alberta. There are private clinics who offer services that the government is required to pay for, but they also offer non-publicly funded services to their members, who must pay a yearly fee to access those services. On average, these memberships cost about $600/yr, and entitle the member to health care services that are not traditionally covered by the public system, but for which there was no private health insurance option prior to this P3 innovation.

But to this day there is still rabid opposition to the idea of privately delivered health care, by socialist groups like "Friends of Medicare" and government unions like the Canadian Union of Public Employees (CUPE).  It kind of makes sense, too, when you consider how...invested these organisations are in a purely public system.  They claim to be concerned for the welfare of patients, but I think they're solely motivated by their own interests.  Which isn't a bad thing, to be certain; I just don't think that another person can be trusted to act in my interests if my interests conflict with his.  Better to allow me to act in my own interests, rather than rely on someone who may not share them.

In the end, I believe a privately delivered, publicly funded health care system is the best option we have available to us, and by what right do the proponents of a purely public system feel they can deny us the choice, option, and power to determine our health care on our own?

So, perhaps, my whole point is simply that regardless of whether one is a whole hearted supporter of socialised medicine or not, one does not have the right to decide for another person how (s)he will maintain his/her health, and by denying the private sector a place in health delivery, one does exactly that.

I may not have a right to health care, but I have a right to decide how to secure my own health care.

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