Bliss’s “Critical Condition” lacks Critical thinking

Nowadays Professor Bliss and his friends ascribe a multitude of sins to universal Medicare when the real problem is that we have not followed Douglass original vision to complete our Medicare system. Douglas warned that if we didn’t re-make our delivery system, costs would rise and Canadians would lose faith in our system.

From Britain’s National Health Service to the South Central Alaskan Health Foundation the worlds highest performing health systems are successfully reforming their delivery systems focusing on quality.

Unfortunately, Professor Bliss’s prescription focuses on the elimination of universality, making the wealthy pay for at least part of their care. He doesn’t clarify the mechanisms but presumably there would be adjustments through the income tax system. However, from Justice Halls 1964 Royal Commission onwards Canadian inquiries into health care have concluded that universal first dollar health care isn’t just for fans of social justice. It also makes economic sense.

Single-payer, public finance greatly reduces administrative overhead. If better-off Canadians face paying for part of their own care, they will want private insurance to cover the costs not paid for by the public plan. As with the US Medicare program or in France, these gap policies would add significant administrative costs.

If patients are required to pay user fees at the point of service, there will be financial and social costs. User fees tend to discourage the poor and the elderly from entering the system. But there are no overall savings. Nature abhors a vacuum, and the health care system detests unused capacity. As a result, any beds or doctors freed up because the sick poor cant get desperately needed care end up being used by the well-to-do for more trivial matters.

We even have a natural experiment from Saskatchewan to back this up. When Medicare started under the CCF government in 1962, there were no user charges to see a doctor. However, Ross Thatchers Liberals came to power in 1964 and implemented user fees for doctors and hospital care in 1968. The NDP eliminated the charges after it won the election of 1971. Afterward, researchers were able to look at changes in use over time by different groups. They found that there had been a small drop in use of doctors services, but there was no change in overall health care costs because there was no change in hospital use, which was responsible for the vast majority of expenditures. Further analysis revealed that the poor and the elderly reduced their visits to doctors but that there was an increase in the use of doctors by middle- and upper-income groups.

Some claim that user fees are benign because they discourage only frivolous use. However, a US study involving fairly healthy adults showed that user fees led to a 20 per cent increase in risk of death for people with high blood pressure because they were less likely to see a doctor and get their blood pressure under control. The same study showed that user fees were just as likely to discourage appropriate care as inappropriate care.