The medicare muddle: Finding a way out

Whether the Canadian medical care system is a defining national characteristic is debatable, but one thing is sure: when planning, Canadians have a tendency to just muddle through. Unfortunately, our health system shows it.

Up to the eyebrows in reports, statistics, letters to the editor, and conversations, not to mention attempts to study the problems by commissions, governments, and appointed non-medical experts, it is hard to be optimistic that an effective and sustainable system of medicare will ever be achieved.

There is a tendency to concentrate on the high-profile problems, to give the reassurance that something is being done to improve the provision of care. A reduction of a month in the waiting time for hip or knee surgery is cause for congratulations. However, we do not always know what low-profile services are being delayed even more as a result. 

In case it seems that the government is being unfairly criticized, I give the elected members and the bureaucracy credit for sincere efforts to provide a good and workable system. As individuals, most are doing what they are told to do, or helping to develop policies that will be politically acceptable and effective in providing health care. 

Unfortunately they are all saddled with a system that is too big, beyond its needs, and harder to change direction than it is to stop an oil tanker heading for the rocks.

All proposed solutions of our pro­blems involve getting more money into the system, with federal and provincial governments providing the money. The biggest untapped source of money? We, the people.

We often see references to the need for people to take more responsibility for their own health care. I couldn’t agree more with that idea, as far as it goes. The emphasis is usually on the obvious effects of our lifestyles, such as the over-consumption of alcohol, cigarettes, and food. Many studies have been done to show the extent of illnesses caused by our bad habits, the cost of repairing the damage, and the benefits from changing habits. 

However, the other aspect of the responsibility factor is the responsibility of the patient to pay more of the cost of health care. The federal government has assumed a parental attitude, telling us what services we are allowed, and leaving the provincial governments to administer the resulting inadequate system. The question of heath care premiums is decided in each province, along with the limitations on which services will be provided “free.”

Tommy Douglas is regularly credited for laying the groundwork for medicare, but we seldom hear that his motivation was primarily for protection—insurance—against crippling costs. He wanted to be sure that no­body would have to “sell the farm” in order to pay doctor and hospital bills.

In fact, most people do not generate large medical bills in any one year, and only a small percentage of the population is faced with major ex­penses in any one year. Data supplied annually by the Canadian Institute for Health Information (CIHI) show that health care costs are greatest in the infant and the senior populations. 

From age 1 to age 60 there is a gradual increase in the per capita cost per year. After 60 the health care costs rise more quickly; at age 90 the cost is about five times the cost at 60. 

The real need for medicare is to protect people from the high costs of some treatments rather than pay the smaller costs of most medical encounters. For many, the amount spent on their own care would be less than that spent annually on alcohol, cigarettes, and lottery tickets. It seems that a large proportion of the national wealth is in the hands of seniors, and some of them can well afford the most expensive of health care requirements. 

A fair system would give help, when needed, to those in the lower income levels. This would give the governments the appropriate role as protectors of the people, but return to the people the responsibility for much of their own costs and the freedom to choose their method and place of care.

Limiting patients to one problem per visit is a regrettable trend that has arisen in some practices. This is especially intimidating for older patients who often have more than one problem. If family medicine is really comprehensive and personal it should focus on treating the person rather than the problems. 

One benefit of having patients pay for the cost of much of their care is the freedom to take more time to cover multiple problems and pay physicians appropriately for the time spent. This works for dentists, lawyers, and accountants, so why not for doctors? Those in federal and provincial governments will appreciate the rationale of billing for time spent, as most of them are lawyers.

Financing is always a problem with any system. The imposition of compulsory premiums has the problem of collection from all citizens of a province, with a large number of premiums uncollected. It would make more sense to use general revenue instead of premiums, so that the load would be carried by all tax-paying citizens. 

There would be no need for a costly department or collection agency to collect from delinquents, and everyone would be protected from excessive costs. The minority who would have trouble paying for care must have an arrangement whereby the care would be available without delay by the use of special CareCards. 

We often hear the suggestion that we need innovation to improve the system. It seems that the only innovations so far have been to adjust the current system. What we need most is to remove the rationing of care from the government, which should be considered as an insurance agency protecting us from high costs. 

As with home or car insurance, a deductible amount would provide for the individual to re­ceive care when needed and still eliminate a large number of minor bills to the medicare system. Over the years most of us would pay less in needed care than we do now in premiums.

A workable system would involve relatively simple steps: 
• First, have patients pay for the smaller costs of their care, with the provision that those who cannot pay will receive special support.
• Second, eliminate premiums and finance the medicare costs through general taxation, or even by the GST as originally considered. 
• Third, use the medicare fund to pay for costs that are too high to meet without hardship, at any income level.

These steps would provide a safety net for all citizens, with the costs being distributed fairly between the individual and the government. There would be less administration, and the savings would allow for more money going toward care for patients. Patients would have better choice of treatment alternatives and where to obtain them either across Canada or outside of Canada. 

Opposition can be expected from all parties involved in the system—patients, government, unions, doctors, and for-profit insurance companies. This type of innovation will be considered as politically risky and dis­ruptive to entrenched interests and methods. It would need a courageous government to accept it. I remain hopeful, and slightly optimistic, that we now have a government that has the insight and the courage.


Dr Falk is a retired associate professor of family medicine at the University of Calgary and holds an MSc in health services planning. He currently lives in Sidney, British Columbia.

William A. Falk, MD, FCFPC, FRCGP. The medicare muddle: Finding a way out. BCMJ, Vol. 50, No. 7, September, 2008, Page(s) 426 - Back Page.

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