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But we digress...

Fri Jun 10, 2005 Miss Vicky 

My profound apologies to my Faithful Legion for yesterday's punning digression. I don't know what got into us. I'm going to blame it on the heat and smog, though. Yes, that sounds good. Much better than trying to find a way to avoid blogging about the depressing Supreme Court ruling on health care.

Frankly, I don't know what to say. What alarms me is that this decision has come at a time when our parliament seems incapable of doing anything but namecalling and jockeying for the best position when the government falls. Hardly the time to take concrete action to address the legacy of a couple of decades of underfunding and lack of vision for the future of our health care system. I mean, despite the work that went into the Romanow report, Martin has done little to implement any recommendations. The Health Accord is pretty sketchy, and there's some funding, but not the kind of real reform we need to keep our public system strong and avoid further privatization.

I'll wait to read the decision more thoroughly before I really weigh in. Plenty of stuff on the blogosphere today. It's also worth checking the Canadian Health Coalition for reaction from coalition members. I found this perspective on what this means for low-income Canadians to be particularly enlightening.

Some people were moved to reply

The Webgeek Jun 10, 2005 12:05 PM said:

I've got a rant about this brewing though....

I just have to think about it some more.

Sea Salt & Malt Vinegar Jun 10, 2005 12:53 PM said:

my understanding is that the judgement prevents governments from dissallowing citizens to buy private insurance for publically insured services.

It does not prevent governements from refusing to fund for-profit providers, nor to deny medicare billing rights to doctors who privately bill for publically insured services.

The victory to medicare's foes is more political than legal, I think. For advocates of medicare it is more of a stumble than a reversal.

My reading of the soft public support for private health care is that it is based on the (mistaken) assumption that it will "take pressure off" the public system and that people should have the right to seek private/for-profit care if they can not be adequately served by the public system.
Even within that group there is still strong support for our medicare system.

I say call the health privateers' bluff: they can't have their cake and eat it too. If they want to charge privately for publically insured services, they should be allowed to do so, but it would disqualify them from also billing medicare. I wager that few would do so, since the market is much too small.

The government should also move to make for-profit health care illegal, or at the very least shareholder driven health care corporations.

Will medicare define the coming election?

Even more interestingly, how does it tilt in quebec, where federal regulation of health care gets very mixed reviews?

amckay Jun 10, 2005 12:54 PM said:

Oh, I've already got a rant ready for this one. I'd like to say the decision is a good thing. I'd like to think that it is a first baby step down the road to a better system, but somehow I don't think there is enough foresight in this country among those in power to do anything useful with our healthcare system.

The WHO rates us 30th in the world, and every time someone tries to suggest something to improve that, the old bugaboo of "two tier" gets dragged out of the closet and shaken in front of us all. And then a nice big round of "booga-booga" just to spook us back to our socialist roots. Even though we already have a deeply entrenched 2 tier system. Just compare my health care that I get from work, with what an unemployed person gets. Or, gawd forbid, compare the health care someone gets who has a nice big socialist union negotiating sweet deals with the company. We're so bogged down with an irrational fear of falling into a US-style healthcare system that we fail to see the dozens of other countries out there doing a much better job than us. Like for example France, who rates #1 on the WHO list, and who has a very healthy (pun intended) mix of private and public health care. I'm not sure where Germany ranks, but they also have a very healthy mix of private and public. There, nobody goes without. Meanwhile millions of Canadians have no access to their "free" healthcare because they cannot even find a family doctor. So they go to the emergency room for non-emergency services, costing the system 2 to 3 times what it would have cost to visit a family doctor, thus creating a vicious circle.

I'm not sure what it's going to take to improve our system, but it is clearly not happening. The government wasted millions of dollars getting Roy Romanow to go around the country and draft a report, saying the whole time "we can't just dump more money into it". And what comes out of it? No new ideas, and essentially Paul Martin is just dumping money into the system to try to reduce the time on waiting lists. Nice.

The part that really scares me about all this is that intead of planning a reasonable, well-designed 2-Tier system up-front, everyone is so irrational about the whole thing and so unwilling to even talk about it, that what's going to happen is we're going to end up with a piss-poor hodge-podge that comes about not by proactive planning, but rather by re-active court rulings and reaction to those rulings.

The anti-two-tier group are basically setting us up for a self-fulfilling prophecy because of their unwillingness to view reality and sit down and talk about a better system.

Booga-booga!

Miss Vicky Jun 10, 2005 01:21 PM said:

The only good I can see coming out if it is that it might jog governments in to action. But I don't agree that accepting 2 tier health care should be the starting point. I'm more inclined to agree with Sea Salt - if they want private care, then let's eliminate the profit motive from the equation.

The Webgeek Jun 10, 2005 01:34 PM said:

Actually, key to this whole thing is this little quote in the ruling

"In sum, the prohibition on obtaining private health insurance, while it might be constitutional in circumstances where health care services are reasonable as to both quality and timeliness, is not constitutional where the public system fails to deliver reasonable services...(I)f the government chooses to act, it must do so properly."

So really, the ruling isn't saying that we should allow two-tier health care, it's saying we should FIX THE CRAP HEAP we have.

BTW, amckay,
Just compare my health care that I get from work, with what an unemployed person gets. Or, gawd forbid, compare the health care someone gets who has a nice big socialist union negotiating sweet deals with the company.
Are you saying you've got better or worse health care than mr. homeless guy and/or mr. "Commie Union dude"? You don't really say.

essentially Paul Martin is just dumping money into the system to try to reduce the time on waiting lists.

Actually, I think he's been cutting spending over time, that's why there's a problem. Harris made massive cuts to health care, As did Klien, and even Bourassa in Quebec. Both levels of Governmnet have been slowly (or not so slowly) cutting speanding to health care and closing hospitals, that's why we have massive wait times.

Meanwhile millions of Canadians have no access to their "free" healthcare because they cannot even find a family doctor. So they go to the emergency room for non-emergency services, costing the system 2 to 3 times what it would have cost to visit a family doctor, thus creating a vicious circle.

This isn't the health care system's fault. It's cuts to tuition. If we need doctors, why do we make education so prohibitvely expensive? Doctors don't appear out of thin air. the cheaper it is to become a doctor, the more doctors you will have, and more of them will descide to remain GP's instead of specializing, since they won't have to pay off massive student debts.

amckay Jun 10, 2005 01:39 PM said:

But Miss Vicky, we already have a 2 Tier system so it is by definition our starting point. The benefits I get on my corporate plan are substantial, and not just "supplimentary". Look at dental and mental health for 2 examples of where someone without a plan from work gets nothing, but where I get extremely thorough coverage. There is also substantial rehabilitative care that I get and your average Joe or Jane does not.

Miss Vicky Jun 10, 2005 01:48 PM said:

That's true, and that is a situation that has to be corrected. But what we're talking about is not extended health care, but primary care, and the establishment of a parallel system where those who have the money can purchase insurance to help them jump queues. I agree that dental health, mental health, home care and access to medications should be part of an expanded system, but first we should make sure that people have equal access to the basics. Adding even more opportunities for privileged people to pay for extra treatment is not the answer.

The Webgeek Jun 10, 2005 01:50 PM said:

The benefits I get on my corporate plan are substantial, and not just "supplimentary". Look at dental and mental health for 2 examples of where someone without a plan from work gets nothing, but where I get extremely thorough coverage. There is also substantial rehabilitative care that I get and your average Joe or Jane does not.

Well, those won't last too long. Most corporations (and Gov't agencies) are hiring more and more temp, part time, and contract workers so that they don't have to hand out those sweet benefits packages.

How is opening more clinics where only people with money can get worked on help that lowly person at the bottom? Seriously. It's not about making the seperation between the havers and the have nots bigger, it's about offering better bottom line health care to EVERYONE. Besides. You already pay into public health care through taxes. Why should you than also have to pay on top of that to get *decent* care?

The Webgeek Jun 10, 2005 02:14 PM said:

fixing my spelling again, hon'?

Miss Vicky Jun 10, 2005 02:15 PM said:

god, yes

amckay Jun 10, 2005 05:22 PM said:

Dental and Mental are IMO primary and not "extended". THat's why I pointed them out specifically. They are part of your whole health - something our current system doesn't really take into consideration.

I don't think governments are in the position to fix this. Look at what a political football health care has become. Nobody is interested in solutions anymore, they are just interested in scoring points.

And I especially do not trust government with my hard-earned dollars. Look at some of the recent scandals of where yours and my money is being pissed away. "Billion dollar HRDC boondoggle". Another billion gone on a useless gun registry that was supposed to cost 2 million (and I'm very pro gun control, BTW, and for the idea of a gun registry). I've read about some of the technology wastage in that gun registry, for one. Web geek and I could have implemented it for the original 2 million, and still walked away very rich men. Another half billion on the sponsorship scandal and subsequent gomry. And that's only what we've found out about.

And some want to make government bigger, and give them more of my money? Yikes! How much more wastage can we really tolerate? I'm about at my limit, thank you very much.

pinklitva Jun 11, 2005 04:19 PM said:

I think this is one virtual conversation that I actually have some expertise in! I would really appreciate it if amckay clarified exactly what WHO ranked Canada as 3oth in? I have been operating under the impression that Canada has one of the most expensive health care systems in the world! I am not sure exactly where it is in the rank, its been a while since I've lectured on Canadian healthcare system - but I thought that the amount of GNP spent is right up there in the top 5!
I think it is valuable to look at expenditure in other areas such as defense. However, I cannot help but wonder like some of the other commentators if Canadians use of the hc system -which is very very secondary care based and hence very very expensive - is ready for a radical change. While i think that no-one should have to pay for 'more' service than is already funded publically, I wonder if a fundamental problem with health care system in Canada is the way in which it is delivered (even in primary care) coupled with a highly medicalised society.
In the UK, we don't invest as much of the GNP in the system, but things like dental and presecriptions are free for children, pensioners, low income earners and then only cost £6.5 for everyone else. The thing is, Yes! we have to wait for some procedures. Yes! our hospitals aren't as pretty as they are in Canada and Yes! often highly trained nurses provide primary care services and deliver our babies. Bottom line is that I think Canada can afford a great health care system. I just wonder if (middle class) Canadians are ready to be a little less medicalised in order to ensure that basic and good health care is provided with greater equity?

amckay Jun 12, 2005 09:32 AM said:

They ranked us as the 30th best healthcare system. The ranking was not how much we spend on it. Though I suspect pinklitva is right that we are probably in the top 10 if not top 5 of how much we spend on it per capita. The makes it all the sadder to see us rate 30th overall in effectiveness.

pinklitva is right that our system is in need of a big change, and Miss Vicky is right that we should not automatically assume this means 2 Tier. But the anti-2-Tier folks aren't giving us any better options. "We don't want that! But we aren't really sure what we do want." There is a massive void of new ideas on the health care front in Canada. We wasted millions of dollars on Roy Romanow, and are right back at square one. Yet more government wastage which makes me less-and-less inclined to think that the government can solve this problem, and more-and-more inclined to think that the private sector must.

As pinklitva notes, doctors are expensive and there is no reason for them to be the first point of contact as it usually the case in Canada. Here, doctors delivery 90% or more of babies, for example. In Sweden Midwives deliver over 80% of babies, and their rates of death in childbirth are about 1/3 of Canada's. Being pregnant is not an illness. Why are we treating it like one? This is just one example.

pinklitva Jun 13, 2005 06:22 AM said:

30th best healthcare system in the world and all that money invested!!! WOW! If only Canada could show something for it - like decreasing health differences between the highest and the lowest income groups.

Clearly if Canadians want the system they visualise, free at point of access, dental, eye care, etc, then getting some better value for money may be in order!!! REmember Miss Vicky when you were cleaning out the basement? Well perhaps the same logic needs to be applied to medicare!

Miss Vicky Jun 13, 2005 06:50 AM said:

I completely agree, pinklitva. We need to review the way doctors are paid.... the fee for service system does not keep pace with technology and innovation in surgical practices, it makes no sense when applied to general practice and front-line medical care, it does not accommodate important things like counselling or addiction treatment... that's just scratching the surface, really.

Flanders Jun 13, 2005 10:27 AM said:

There are many things that need doing and a lot of entrenched interests to be overcome. Fee for service is a good place to start. There should be a huge investment in the IT needed to share records electronically inside and between institutions - the potential savings in time and money are massive. We need more 24/7 "clinics" where people without a family doctor can get care (or people with a family doctor can see an affiliated doctor). This is a big, big job, complicated by the fact that health is a provincial jurisdiction. But we can either get it done, or not. Either way, we'll end up with the system we deserve...

The Webgeek Jun 13, 2005 11:06 AM said:

There should be a huge investment in the IT needed to share records electronically inside and between institutions

Speaking as an IT guy, I agree. In fact, a huge overhaul government IT in general would be a boon. There is so much duplication of information from one gov't department and level of government to another that could easily be streamlined, it's not funny.

Unfortunately, every time you try and implement a system like this, all sorts of privacy concerns start popping up. as much as having a central records database would make sense, there are some reasons for people to not want their information shared between offices.

Now, some of the privacy concerns do get blown WAY out or proportion, but I've also worked on government projects, and some of the system designs I've seen are really horrible.

pinklitva Jun 13, 2005 02:53 PM said:

Now I challenge Flanders to re-think the whole walk-in clinic. Must it be a doctor there? Couldn't it be a highly qualified nurse practitioner? Would you be as happy with that service? Would you trust that service as much? It would be cheaper than having a MD in situ and help with the doctors shortage but would you be as satisifed - got your dollar's worth as a tax-paying-citizen?

On another note, I recognise that Canada is running short on docs, but is it really ethical to take doctors from 3rd world countries who have also invested in their education and perhaps need them more? I know there is such a thing as free will and personal choice but to actively recruit????? I've got a friend who was the Dean of the Capetown University's medical school and he felt he was churning out future Canadian doctors. An aside to this debate, I recognise, but it kinda irks me especially when McMaster enrollment in medical school is only 135 next year and Liverpool's first year intake is now 355! And webgeek did mention the university/training issue earlier on.

Flanders Jun 14, 2005 09:31 AM said:

Quite right, Pinklitva, in many cases a nurse practitioner can do everything a doctor can and then some. Nuts and bolts can be worked out - the big concern is getting people out of emergency rooms when they don't need emergency care. But in many cases the emergency room is the only open medical outlet in the evenings/weekends. That needs to change.

I've got no reply to the issue of recruiting foreign doctors...Canada is usually on the other end of the so-called "brain drain"...and the difficulty from our end is usually that we don't recognize foreign accreditation. All I do know is that Saskatchewan would be in serious crisis if not for all the South African doctors who came to Canada to escape apartheid...

Webgeek, you're right about privacy concerns. This is a huge challenge but it can't be allowed to be insurmountable. Think of the needless expense and delays (remember: time delays are at the heart of the Supreme Court ruling) in physically transferring a file/MRI scan/XRAY from one doctor or institution to another - especially when much of the medical imaging is now digital to begin with!

This can be made to work, but many entrenched interests will need to be overturned. But that's OK, it happened before, (with Tommy Douglas in Saskatchewan) it can happen again.

amckay Jun 14, 2005 09:46 AM said:

Entrenched Interests : Indeed! You should see the way Widwives get treated by some Ob/Gyns! Yet the care from a Widwife is far superior. Read my account for details

Privacy Concerns : I think it would be far easier to address this concerns with one central, well-designed database, rather than with many diverse ones. Sadly, we are a long way off in any case. The Ontario government introduced the new health card 10 years ago now, and until the last year each hospital was still issuing their own little blue card to each patient. This is inexcusable.

Brain Drain : that's a tough one, and works both ways as noted. Also, while in general I think we are too tough with foreign trained doctors, this story makes me glad we err on the side of caution.

pinklitva Jun 14, 2005 11:41 AM said:

Just to gain clarification - Saskatchewan 'saved' all those white doctors from apartheid? Good.
But I guess i don't see it quite that way but for those of you who might have the slightest bit of interest in the issue of the 'brain drain' of hc professionals. this article is a useful starting point.

Health Policy. 2004 Oct;70(1):1-10.
"Brain drain" of health professionals: from rhetoric to responsible action.
Martineau T, Decker K, Bundred P.

I can't help but feel uncomfortable with the assertion/justification(?) that the brain drain is going both ways therefore applying that logic - since others are doing it to Canada ( namely the US) it's okay for Canada to other (mostly developing) countries? Hmmmmm....

Ultimately the goal - and tommy douglas' vision- is a fair and equitable healthcare system at the point of access. I guess I hope/dream that when I return to Canada - as a victim of the UK brain drain - there is a hc system that is ethical both locally and globally.

However, when I return to Canada, it will be to act as a health policy advisor to the Minister of Health and then [evil laugh!] the health service revolution will truly begin [irony].....

See Miss Vicky, i do have some political aspirations after all! You're efforts have not been in vain....:-)



amckay Jun 14, 2005 01:25 PM said:

I read an interesting article in Readers' Digest a while back about a white south african dr in Saskatchewan who eventually got deported back after having been convicted of raping patients. Quite a little trickster he was - when asked to give a DNA sample he actually filled little balloons with other patients' blood and surgically inserted them under his own skin so that blood drawn in front of police officers would not be his own.

Flanders Jun 15, 2005 10:56 AM said:

Hang on...I wasn't trying to suggest Saskatchewan "saved" anyone - more a question of providing an opportunity. South Africa exported a ton of people during the apartheid era - people wanting to get out of a nasty-looking situation. This includes journalists in Toronto, MDs/RNs in Sakatchewan, teachers in Winnipeg...(remember Tom Dickens at Kelvin, Miss Vicky?)

BTW - not all the doctors and other professionals who fled South Africa are white...(Beware the default images we all have in our heads!)

All I can say, Pinklitva, is you've raised a good point, and one I hadn't thought of before. In response, a couple of thoughts do come to mind: Canada takes in proportionally many more immigrants than other countries (such as the UK), and there is a great demand for people in many other countries (from both the developed and developing world) to come here. Way more people want to come to Canada than we actually let in. The angle one usually hears is that professional qualifactions earned elsewhere are not recognized here (and so the Moroccan lawyer in our neighbourhood runs a daycare in her home...) I don't know if all of that adds up to Canada raiding developing nations of health care professionals or not. I do suspect, however, if Canada were to ban the immigration of health care professionals from developing nations you would wind up with two very angry groups of people: 1) those professionals who want to come here because Canada is actually a very good place to live, 2) those in remote parts of Canada who are underserviced (compared with urban Canadians if not on a global basis).

amckay Jun 15, 2005 11:12 AM said:

Keep in mind that Canada also trains a lot of foreigners at our universities. I know the NS government used to provide a lot of free education to LIbyans, for example. I don't recall just what the deal was there, but something about NS owing money to Libya or some such, and settling it this way. Then there is foreign aid as well.

So what do you suppose is the balance? Do we give more than we take? Or take more than we give?

The Webgeek Jun 15, 2005 11:19 AM said:

Well, to assume that *most* educated people coming out of South Africa are most likely white is not really an unfair stereotype, since there was this little Bantu Education Act, (Act No 47) of 1953
[This act] established a Black Education Department in the Department of Native Affairs which would compile a curriculum that suited the "nature and requirements of the black people". The author of the legislation, Dr Hendrik Verwoerd (then Minister of Native Affairs, later Prime Minister), stated that its aim was to prevent Africans receiving an education that would lead them to aspire to positions they wouldn't be allowed to hold in society.

As for pissed off proffesionals trying to get in, well, they're already here. They're driving cabs, scrubbong dishes, running day-care out of their homes, or, as my Eritrian uncle did, retaking equivilant degrees here in Canada. My Uncle was trained as a physiotherapist in Italy (not exactly a third-world country) but still had to "re-learn" his proffession here in Canada so he could practice. Now, I don't mind the idea of a streamlined series of "top-up" courses for certain proffesionals, to ensure they're familiar with the Canadian intricacies (laws, procedures, what-have-you) -- but essentially having to start from scratch is a little insane.

I think we could go a long way towards solving the issue just by allowing the immagrant proffesionals who are already here to practice, before allowing more in -- especially if an incentive was attached for filling remote community needs.

pinklitva Jun 15, 2005 04:59 PM said:

Sorry Webgeek but I may just be too cynical. I think that many of the people already in Canada and the UK would not be willing to work in existing health service because of the working conditions and wages/salaries. Consequently, it is easier for western countries to recruit from developing countrieds where the lure of better salaries means that workers might be less inclined to complain about conditions.

Canada and the UK are ACTIVELY going into these countries and recruiting, offering people higher salaries than can be earned in their own countries. The UK is taking nurses from African, Caribbean and Asian countries. My partners hospital recently recruited physios in India. Yet we find many UK trained docs and nurses are leaving the system because of working conditions or the poor wages.
(Aside - the south african doctor used to be waged although now, the majority are private and it is THE place to go for safari and plastic surgery- tits, ass and giraffes.)
If you want docs and nurses in remote parts of Canada, you can find loads who are willing to do this on LOWER salaries than are being paid now in Mexico, Poland, Jamaica, India, etc. Yet it leaves these countries with disparities, and there could be an argumement that they need them more since these countries are plagued by acute illness whereas westerm countries have shifted towards experiencing more chronic illness where biomedicine has less effect.

What is the solution? Welll, I am still working on that...

amckay Jun 15, 2005 08:05 PM said:

I've written several politicians and told them I'll become a doctor and go anywhere they like, as long as they put me through med school. I was a straight-A student in 2 diverse faculties so it shouldn't be difficult.

None of them even bothered to reply to me.

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