Two-Tiered Health Care
The other day I was standing in the emergency ward of the tiny Montfort hospital and was appalled at what I saw before me. Not only were the beds all full, but the beds were so full that an elderly man on a ventilator was shoveled off to some hallway, strapped like a psych ward patient to his ambulance cart. They were waiting for a bed somewhere to
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Two-tiered is what they've got in the UK, and while have been lucky so far and haven't had to be hospitalized here, I can tell you it doesn't work brilliantly. The NHS (the public tier), has all the problems of the Canadian system, and probably more. Right now the big news is that NHS hospitals are rife with all sorts of superbugs and lots of people are dying. (Okay, so that's familiar.) A big reason for this? They've been sacking their janitors to cut costs. Sounds familiar because that's what they've been doing in Canada as well. My point here is, they are still obsessively cutting costs. Having a two-tier system hasn't made them use their money more efficiently or created a decent public system. In fact, since the attitude is one of cost-cutting (the sort of attitude that is prevalent among Canadian proponents of a two-tier system as well), why WOULD they spend more on the NHS? Having a two-tier system does not lighten the load of the public tier.
Other objections include the very obvious fear that a disproportionate amount of good doctors will go private (I'll admit, there's probably potential ways of regulating this), leaving the public system in a worse mess.
And of course, there's the whole creating further divisions between rich and poor, given that having private hospitals does not really lessen the burden on public hospitals. The rich will get care on demand because they have money, while the poor will be left sitting in the emergency room for hours and hours. Mmmm reinforcing class divisions. It's all fine and good to say that a two-tier system would allow the best for everyone involved no matter what their income, but what actually happens is reminiscent of why trickle-down economics is bullshit, and tax-cuts for the rich do not help the poor even indirectly.
Now, this is not to say that I don't think the Canadian system needs to be fixed, and I think there are a few things that artificially create problems for the Canadian system. For example, setting unrealistic quotas for surgeries; one of the reasons there are long waiting lists for hip replacements etc etc is that people are only given funding to perform a set number of them per year. If there are long waiting lists, it means that they need to be allowed to perform more of them. True, that means more money, but there it is.
I am one of those who agrees with allowing more immigrant doctors to practice, as well as allowing more people into medical school period. Years back, again as a costcutting measure, when they decided that fewer doctors meant less salaries meant less cost... Who the hell thought that was a smart decision in terms of quality health care?
Anyway. I'm ranting. I certainly think that the Canadian system needs to be fixed through reform and measures aimed at greater efficiency. Of course, saying something like that means practically nothing in our world, since I don't know exactly how greater efficiency would be achieved. But I'm convinced that it would not be through two-tier health care, for the above reasons, among others.
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I'd argue that about 15 years ago, with Medicare, we had one of the best public health care systems in the world. Our public system has a lot of potential to work. Spending inefficiencies need to be rectified to some degree, but there will always be some inefficiencies in a public system (by the very premise that their spending is not as accountable as in a business). The biggest problem we face is that they are simply overcrowded. If we lighten the burden on the public hospitals, it's possible they will be able to function at a much better level.
How does a two-tiered system not lighten the burden on public health care? Rich people wait in lines too right now. Every person who ends up going to a private hospital or clinic is one less person standing in front of the guy waiting 5 hours at the public institution. That ultimately means shorter lines.
It's quite possible that a disproportionate number of doctors will go private. Unfortunately, that is already happening. It is commonly coined "the brain drain". Offering private institutions in Canada would be an incentive to keep some of these potentially brilliant doctors in the country. Though these doctors may not be accessible to everyone, they will be contributing to Canadian medical research institutions. Keeping these doctors would be an overall bonus for the country. Other incentives can be put in place to keep good doctors at the public institutions, at least part-time (e.g. a significant tax cut for working X hours at a public hospital).
As for the class division argument, I think that is being blown out of proportion. As much as people preach about equality, the fact is we already have classes. People with money benefit more from the service industry than people without money. Fancier cars, bigger houses, nicer neighbourhoods, fancier clothes, bigger televisions. We have two-tiered education. Ottawa now has two-tiered power. We even have tiers of groceries (if you go to Loblaws, they have 3 tiers: No Name Brand (the cheap stuff), the regular brands, and PC (more expensive specialty stuff)). Having private hospitals might make people in lower socio-economic levels FEEL less equal, but they're not being oppressed in any way. They're not getting a demoted health system, just the same one they have always had.
There has to be a rigorous procedure in place to validate their foreign credentials. I know in India, for example, there are second-rate universities that will offer PhDs and MDs, but these degrees are not seriously respected within the country. In order to know which to accept a lot of research has to be done into comparing procedures and curricula. Would you really want an unqualified and possibly incompetent doctor treating you or a loved one, just so that you can say the country is being more "fair"? Making it difficult to become an accredited doctor in Canada preserves that quality and standard of care. Standards are essential in a first-world country.
As for the point about surgery quotas, I agree that the limitation is largely due to funding. But you also don't want to rush a surgery. These are serious procedures, and people could die from simple sloppiness. Again, standards are essential. I would support more nurses and technicians in clinics to deal with simple things like colds, immunizations, blood work, X-rays, etc.., because the line-ups for these are unnecessary and efficiency could be improved. However, if you improve efficiency too much you also risk taking the humanity out of medical care. We want to ensure that doctors are giving patients their full attention in order to do their jobs properly.
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Just because we already have economic and social class division does not make it right to make these divisions worse. If poor people get worse medical care just because they are poor, that is making the division worse. I'm not talking about feelings of inequality here (nor am I suggesting there will be a workers' revolution) - I'm talking about poor people dying because they are poor. They are disadvantaged enough by their economic situation, and I don't beleive it is right to give them even less of a chance. You can argue all you want that their care theoretically won't be worse, but I think you'll find that in practice money gets you everywhere in this world. Just because I'm stating that as fact does not mean I believe this is how it should be. Things have got to change.
I agree that we need processes and ways of making sure immigrant doctors are up to our standard. I'm not advocating just letting them in and letting them start practicing without asking any questions. But my point is, we should start considering people and putting them through these processes, as opposed to condemning them to be over-qualified taxi drivers.
I'd argue that brain drain to other countries or brain drain to Canadian private clinics is effectively the same in terms of quality of public health care. I don't care whether they are leaving the country or being seduced into staying - they are still getting out of the public system.
I'm also not advocating rushing people through surgeries to get through waiting lists. I'm saying that it's silly to have a fixed quota of knee replacements when the demand for these changes from year to year. They need to be more flexible; there are enough difficulties without imposing artificial limits. I'm just saying that this is one aspect that could be fixed.
What I mean by efficiency has everything to do with helping patients and nothing to do with being a cold, heartless, calculating robot. I think you misunderstan my point. I mean that the system needs to be redesigned to more efficiently use funds, organisation, structure, whatever to better help those who need to be helped. This is from a financial perspective and has nothing to do with the humanity of medical care.
As for two-tiered systems elsewhere other than health care, I don't think you'll be surprised to hear that I was fundamentally opposed to the whole privatizing power thing, and I don't agree with private schools either. I'll admit I rely on buying the cheapest line of products in Sainsbury's because everything in the UK is so fucking expensive (Sainsbury's Basics - a beautiful thing. Every product labeled with an explicit statement of how potentially sub-par it is. At least they're honest.) Anyway, where I stand on privization is clear - and I'd argue that we've seen that competition in markets for things like power and healthcare does not provide better quality anything, but it just makes it more expensive. (Then again, you can call me a communist and I'm certainly not a proponent of free markey capitalism. So whatever. Nobody's asking you to take my pinko ravings seriously).
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I think I did misunderstand your use of "efficiency". Generally when there is a long line for something and people complain for the service to be more efficient, the idea is to move through the line more quickly so people don't wait as long. Clearly that is a bad idea.
As for managing funds more effectively, the primary cause of financial mismanagement is the fact that it is a public service. The government is TERRIBLE about managing money. Why wouldn't it be? The only things keeping it in check are people bitching. A business has to be accountable to shareholders and a board of directors. A business has to produce clear profit margins and compete with others. Subsequently anything private-run will not have the wastes that a public system does. Selling existing hospitals to the private sector (as was done with utilities recently) is perhaps the most effective way to reduce inefficient management and spending.
I respect how you are against a two-tiered society. However, you attend University, do you not? That is a luxury 99% of the world cannot afford or get into one way or another. Even in Canada only privileged people get a University education. The cheaper equivalent would be college. So you are paying more for a better service because you want something better for yourself than what is available for free - that is exactly the mentality behind any two-tiered system. I am not trying to call you a sellout, but merely pointing out that sometimes people want to pay more for a better service and should have the right to obtain that service.
The fixed quota of knee replacements is probably based on other factors.. like availability of equipment, surgeons, bed space, etc. In a private system, the service meets the demands and needs of the public. That is how business works. So if in one year more people need knee surgery, the business will find a way to accommodate for that. It is only in a public system where you impose arbitrary quotas to meet the ridiculous budget requirements imposed on you.
Mathematically, if you have 500 people waiting in line, and even 3 of them are rich and up and leave, then the line shrinks to 497. 497 is smaller than 500. Maybe in practice to an observer the 497 would look like it was still 500, and so the person would feel hopeless and think the situation has not improved. However, that is still 3 less people in the line! It is less of a burden. I make no claims to how great a degree the burden is relieved, but when some people actively choose to attend a private hospital rather than a public one, clearly you are relieving some burden from the public one.
Rich people are people too. Maybe they seem less human. Maybe people see them less often because they are hiding in their vaults of money. But they exist. The upper tax bracket in Canada represents over 10% of the population. This is not a majority, but it is not a select few elite either. Private hospitals in the US do not only service millionaires. You can get simple service at these institutions for maybe a few hundred. Simpler surgeries would be maybe in the 4 digit range. A lot of people in Canada can afford that if it means getting service with a specialist NOW instead of in a year. This is not just the fabulously wealthy, but a significant portion of the population that would benefit in some way.
I'd say opening the avenue to private health care is one step towards a solution. It is better than stagnating and doing nothing (what we are doing now). If funding for public health care remains fixed and incentives are put in place to prevent doctors from leaving the public sector, then how exactly will quality of service for poor people suffer? It should remain the same as it is now.
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If, as you said, the brain drain to private clinics will be the same as the brain drain to other countries (ultimately, the money-hungry doctors) then having private clinics will in no way WORSEN the brain drain with respect to public hospitals. So in that regard, supporters of the public system should be indifferent. However, it would benefit the people that choose to go to the private clinics. Why deny them that quality of service if it is not going to make a difference to the public system?
Also, as I mentioned before, I'd argue that the presence of these doctors in the country contributes to the nation as a whole. Over 50% of their inflated private sector salaries will go to the government in income taxes, helping to fund other liberal-friendly causes like education and the environment (depending on who is in power). Most of the rest of it will end up in circulation, adding to the cash flow in the CANADIAN economy rather than that of the US. And, any research they do at private clinics (which will probably be a lot, since Biotech and Pharmaceutical giants will likely be large shareholders in these hospitals) will contribute to the overall medical research in Canada. These are all benefits for the nation as a whole. Clearly, in the big picture, it is favourable for the greater good to keep these doctors in the country, even at private clinics. The only way it is not favourable is directly in regards to the poor individual - but then welfare state ideology places the greater good above the needs of the individual, so they should all gladly support this.
As for reinforcing class divisions, my point was that in the grand scheme of things the effect would be minimal. Class divisions are already so prevalent that one more two-tiered system would have the approximate big picture effect of selling 3 different types of iPods at Futureshop (nano, regular, and the 60 GB vid ones). And knowing the importance Canadians place on health care, legislation will probably be put in place to ensure quality is maintained in public institutions and that medical insurance for private institutions is accessible for most. (medical insurance could be the key to ensuring accessibility, rather than outright condemning private institutions outright)
People will not die from being poor. I have seen the movie John Q and it makes a compelling argument. However, our public system is FAR better than theirs and that must be remembered before attempting to make any comparisons with the failures in the American health care system. We are starting off with one of the best public health care systems in the world (rated #1 in the G8 for a long time). In creating private hospitals, we are giving poor people less of a chance to survive than rich people would have, yes. However, we are not giving them any less of a chance than they currently have. They would have the same system. So they are not being condemned to die! They may not be given as much of a chance as others are being given, but those are two separate things.
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