Means Tested Healthcare

November 26. 2010

Few issues have dominated Canadian political discourse as much as healthcare. And while it holds a place of pride in our collective Canadian identity, its difficult to find anyone overly optimistic about its ongoing prospects. Depending on who you ask, the system is simultaneously unaffordable, deteriorating in quality, and inaccessible.

For historian Michael Bliss, the problem seems to be all of the above, universal coverage, affordability, and quality. In a recently published lecture for the CD Howe Institute, professor Bliss writes that “in 2010, in the aftermath of the traumatic recession of 2008/09, Canadians again have begun to experience national frissons of anxiety about the future of healthcare. It does not seem possible to imagine that heavily indebted governments could continue to make larger investments in healthcare than real economic growth or the state of their revenue seems to warrant without retrenching on other desirable forms of social spending.”

As a historian, Bliss examines Canada’s healthcare system from the beginning, tracking its evolution in relation to other social programs. He writes that it does not “seem possible that an aging population with constantly increasing expectations of entitlement to first-class modern healthcare would accept less than first-class healthcare in the age [of increased accountability]. Yet there seems to be no political will to change the status quo. There seems no basis of political support for cutting back on medicare benefits, refunding the system through substantial tax or premium increases, or expanding private sector healthcare. How can Canada’s most expensive and most popular social program, now showing many of the strains of its own aging, be sustained?”

How then, do we sustain an expanding and universal social program like healthcare, while also ensuring high standards, accessibility, acceptable wait times, and affordability? Healthcare spending has surpassed the 50 percent of total budget expenditure threshold for all provinces. Excluding federal transfers, which are up for negotiation and renewal in 2014, provincial and territorial spending on healthcare has increased from approximately 48 percent of total budget expenditure in 1986 to almost 60 percent in 2008. And with a slow-growing economy and a confluence of other factors, that costs are expected to increase in the coming years.

What, then, does Professor Bliss propose as solutions? In the first place, Bliss suggests that Canadians must “reconcile ourselves to the fact of Canadians’ demand for a high and probably growing level of healthcare expenditure in a predominantly public system.” In other words, our national infatuation with healthcare isn’t going away and neither is the severity of the issue. Simply, Canadians want comprehensive healthcare and to get it, the system must evolve.

Bliss’ main proposal, however, is that healthcare must become income-tested, as were Old Age Security and Child Benefits, both of which were once universal. Not only have Canadians adjusted to the reality of means tested programs, Bliss argues, but the scale back was politically palatable. He writes that “after several stops and starts, the Mulroney government did succeed in limiting eligibility for the previously universal old age pension, which since its inception also had enjoyed the aura of inviolability.”

More to the point, Bliss asks, “Why should government continue to pay for the healthcare of the well-to-do? Why should the state pay for the banker’s coronary bypass, the retired hockey player’s hip replacement, elbow reconstructions for the ladies who lunch? And so on. Does the state entitle everyone to all the healthcare they need, or does it entitle the economically needy to the benefits of modern healthcare?”

According to Bliss, the answer is obvious. If we want a high quality and affordable system, we ought to make those who can, pay. While he insists that stripping universality from Canadian healthcare is largely a political matter, he does have a number of suggestions. For one, means testing should be tied to income tax assessments and the costs should be levied on insurance premiums paid at the provincial level, as they are currently in Ontario.

Additionally, Bliss suggests that other forms of healthcare premiums should be considered, such as medical savings accounts, compulsory catastrophe insurance, and a policy of designating healthcare expenditures as the individual’s partial responsibility in progressive proportion to income.

The details are complex, but for Bliss, they are “secondary, a plumbing issue” and thereby ignores the practical and political realities of abandoning universality – redefining it doesn’t count. The important recognition, he argues, is that many Canadians can afford to meet some portion of their own medical needs, and doing so will ensure high quality and access for all Canadians.

Canadians often view the healthcare system as inviolable. But with so many forces causing health costs to rise faster than the economy can grow, its obvious that at some point something will have to give. Means testing is certainly controversial and not the only or even most desirable solution. Fundamental structural change in how healthcare is delivered is probably more fruitful. But whatever the choice, more of us, politicians, experts, and citizens alike, will have to be willing to bend healthcare before we risk breaking it.