What Canadians should learn from the U.S. health care disaster

ARNOLD S. RELMAN

Special to Globe and Mail Update

August 15, 2007 at 6:49 PM EDT

Arnold S. Rahlman is a professor emeritus of medicine and of social medicine at Harvard Medical School, and is a former editor of The New England Journal of Medicine.

The Canadian Medical Association has recently recommended that private competition be introduced into medicare by allowing physicians to bill patients (or private insurance plans) for services that are covered by medicare, and allowing medicare to purchase covered services from for-profit private facilities.

Those who champion privatization claim these modifications of Canada's publicly funded health-care system would save money, help eliminate waiting times and possibly even improve the quality of care.

Policy-makers need only look to the United States for the evidence such claims have no merit. The U.S. experience shows that private, for-profit medical insurance and investor-owned medical facilities are a bad deal for the public, and that a health-care system that encourages physicians to behave like private entrepreneurs leads to extravagant costs.

Those who would deny this obvious evidence are either blinded by unshakeable faith in market ideology or are biased by their interests in businesses that profit from the privatization of health care.

I have been studying and writing about the consequences of commercialized medical care in the U.S. for many years. My conclusions, summarized in a recent book (A Second Opinion, Public Affairs), are that the high, rapidly rising cost of the U.S. health-care system, its failure to provide insurance coverage for about 15 per cent of U.S. citizens, and the uneven quality and limited accessibility of services it provides to so many more, can all be attributed in substantial degree to the fact that the U.S. has the most commercialized health-care system in the Western world.

This, despite the government's funding of more than half the total cost of U.S. health care, through the Medicare plan for the elderly, the Medicaid plan for the poor, and through many other public programs.

For-profit medical care in the U.S. has usually been found to be more expensive than not-for-profit care, when facilities providing similar types of services to similar patient populations have been carefully compared. Also, the quality of investor-owned services has often been inferior — never better — when compared with those provided in similar non-profit facilities. Physicians in our commercialized, profit-driven system tend to gravitate toward the highly paid specialties, so we now face a major shortage of primary-care doctors.

Financial incentives are also causing an increasing number of U.S. physicians to avoid Medicare and Medicaid patients in favour of those with private insurance, or patients who can pay out of pocket. Uninsured patients, and even many of those insured under public plans, now must wait to receive specialty services. Many poor patients never receive such services at all. Our hospital emergency rooms are increasingly flooded with patients who cannot find or afford care from private physicians. Waiting times for those with limited means are increased — certainly not eliminated — in our privatized health-care system.

If Canada were so unwise as to allow privatization to grow in its health-care system, it would sooner or later experience all of the problems driving the U.S. system toward collapse. One thing is certain: When medical care and health insurance are allowed to become private businesses, costs go up and patients with little or no resources do not get the care they need. That is the lesson Canadians should learn from the United States.

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