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First,
here are some basic statistics about Canada, from a health standpoint:
Life
expectancy: 81 years
Infant
mortality: 5 per 1,000 live births
Health
spending as a percentage of GDP: 10
Percentage
of health spending that is private: 30
Doctors
per 10,000 people: 19
-Source: World Health
Organization.
Q:
How does the Canadian system provide health care at lower cost than the
American system?
Canada’s national health
insurance, called Medicare, provides hospital and physician insurance
to all Canadian citizens. It does not provide health care directly from
government hospitals or through publicly employed physicians. Just
imagine 10 provincial nonprofit health insurance plans without
deductibles, co-insurance or co-payments for medically prescribed
treatment.
Canada pays for more hospital days
and doctor visits per capita than the United States but spends about 40 percent
less. Canadians pay their doctors, nurses and other medical personnel
less, and provide fewer very expensive equipment and services. Open
heart surgery, for example, would cost about 30 percent less in Toronto than in Chicago. The lower supply of
expensive equipment means Canadians wait somewhat longer for those
services, but in recent years improved management has reduced waiting
lists for services like M.R.I. scans. Canada has more general practice
doctors per capita than the United States does, so basic office
visits are considerably less costly. Private spending, which is about
30 percent of all Canadian health spending, has increased more rapidly
than public expenditures over the past 40 years.
The final reason Canada has lower costs is that the provincial
governments are responsible for financing health care and directly face
the pressure of rising health costs. They must act to control the costs
because other government services compete for public funding.
Q. What does the Canadian health system do particularly well?
Two features stand out. One is that the financing of medical care is
extraordinarily simple for patients, physicians and hospitals. Patients
face no bills for acute services and no co-payments. Doctors are paid
electronically each month according to a set payment rate, and the
hospitals must follow a set budget. Bankruptcy from medical bills, insurance
disputes and billing confusion do not exist as problems.
The second strength is clarity about the purposes public health
insurance serves, and for many Canadians, there is a sense of pride
that access to medical care is not treated as a market transaction.
Medical care is allocated more by ability to benefit than by ability to
pay. However, disparities in medical use still exist between people of
different classes and educational backgrounds.
Q. What is one of our biggest criticisms of it?
The continued nastiness of federal-provincial negotiations about the
shared financing of Medicare is one unappealing feature of the Canadian
system. This dual responsibility leads to endless blaming between the
national and provincial governments for the pressures of medical
expenditures on the budgets of other public programs and tax levels.
This, in turn, has partly prevented Canada from handling drug costs in
the uncomplicated Medicare program.
Q. What is the most important lesson Americans should learn from the
Canadian system?
Until the 1960s, Canada was very similar to the United States in its medical, hospital,
economic and social context. Canada’s experience since then
demonstrates that it is possible to have public health insurance that
largely fulfills the explicit purposes set out in the Canada Health Act
of 1984: universal insurance, comprehensive hospital and physician
benefits (without hidden insurance policy constraints), portable
coverage across the country, clear accountability through the political
process and no significant financial barriers to care.
The great strength of the Canadian system was (and continues to be, to
a great extent) is that it puts everbody,
rich or poor, in the same boat. But of course after 30 years of
neo-liberalism it is now a pretty leaky vessel, with the sharks
circling. The weaknesses of the Canadian system are the following: 1.
it was limited to an insurance plan, albeit a publicly administered
one; 2. coverage was restricted and
highly uneven regionally, and has become increasingly so under the
impact of austerity instigated by Ottawa and implemented by the
provinces; and 3. it failed to dismantle the fee-for-service
payment system for physicians.
Contrast this with the British NHS which, from the beginning, was cast
as a national service which would require conscious planning (leaving
aside the question of a parallel private system which was conceded
early on). There is nothing of this in Canadian medicare
and so our system is significantly under-rationalized, chaotic and
uneven, compared to the UK or indeed to private health
care conglomerates in the US. Of course in the US we are talking about
corporate rationalization to grab more market share which is
tremendously wasteful for the system as a whole and subordinates the
interests of patients and health care providers to the logic of
profit. (Refer to Business Week article on HMO monopolies)
The current right-wing offensive in the US against even the timid
reforms advanced by the Obama administration
are reminiscent of the struggle for medicare
as it unfolded in Saskatchewan in the spring and summer of 1962. At
that time there was a massive extra-parliamentary campaign (the
KOD-Keep Our Doctors) launched by the business class, the press and the
medical profession to defeat the Cooperative Commonwealth Federation
(CCF) government and its medicare plan. This
culminated in a month-long doctors' strike in July 1962. The campaign
was hysterically anti-communist, a semi-insurrectionary free-enterprise
crusade, playing on all manner of prejudice, ignorance and fear.
On the other side were the pro-medicare
forces - the unions, farmers and the base of the CCF- who were
determined not only to defend the medicare
legislation and break the doctor`s strike,
but also to build a network of community clinics that would implement
long-standing progressive health care demands (multi-disciplinary care,
salaried physicians, consumer input and control). In some respects the
dynamic escaped the control of the CCF government and social democratic
party leadership who were almost paralyzed in the face of the right
wing offensive. This episode was certainly a major political
confrontation and time of class struggle which proved to be the midwife
of Canadian medicare.
In the US today, a class
confrontation is also taking place with a similar aggressive
reactionary campaign but with a much weaker response from the left.
These are different times. The workers' movement is much more
demobilized than 50 years ago, and the Democratic Party under Obama lacks even the limited reformist ambitions of
Canadian social democracy in a hinterland province, riding the wave of
post-depression radicalism which was still a force in the early 1960`s.
In Quebec province, privatization has
advanced with the out-sourcing of certain procedures to be followed by
others to 'for-profit' providers. The`free-standing`abortion
clinics in Quebec, which recently were brought more fully under medicare, are now facing prohibitive costs to raise
standards to the level required in the government`s
new legislation for private surgical clinics. Whether this was an
intended consequence is unclear. Although not anti-choice, the Jean
Charest government would have no qualms about favouring
bigger for-profit abortion clinics operated by gynecologists and
requiring substantial patient co-payments.
On another front, the PPP`s (private-public
partnerships) have run into quite stiff opposition from a broad array
of forces including health care unions, medical specialists, architects
and the Quebec branch of Physicians for Medicare (médécins
pour un régime public). There will =e a decision in the fall whether to
proceed with the building of the big mega-hospitals in Montreal on the basis of a PPP. In Ontario there is a battle over PPPs too, including a lawn sign campaign.
Elizabeth and I have such a sign on our front lawn in Toronto now.
The struggle to defend medicare, one of the
most enduring legacies of the post-war Canadian welfare state, entered
a new and more ominous phase since the 2005 Supreme Court ruling in the
Chaouilli case. In a narrow 4 to 3 judgement, the Court upheld the right of Dr. Chaouilli`s patient, George Zeliotis,
to pay privately for a hip replacement for which he lacked timely
access through the public system. Subsequently, the Quebec Liberal
government introduced legislation allowing patients to pay privately
for three common surgical procedures (hip and knee replacements and
cataract removal) if the public system is unable to provide them within
a prescribed time. This represents a small but siginificant
step toward parallel for-profit care competing with an increasingly
stretched public system still reeling from 20 years of neo-liberal
austerity.
At the same time, public pressure forced a retreat by the Alberta Tories
from a law that would have permitted physicians to work in both the
public and private for-profit sectors. The situation thus remains
contradictory. On the one hand, service shortfalls in publicly funded
hospital and primary care are undermining confidence in medicare. Market-driven austerity has taken its
toll and market-style so-called reforms such as public-private
partnerships (PPP`s), out-sourcing and
managed competition are the favoured options
of governments dominated by a business agenda. Yet the majority of
working people in Canada and Quebec are committed to a public system
provided that reasonable quality of care can be maintained.
A Focal Point of Class Struggle
As I mentioned before, medicare occupies
an important place in Canadian political history. It is widely
associated with Canadian social democracy, the Cooperative Commonwealth
Federation (CCF) and its successor the New Democratic Party (NDP), and
in particular to the crusading efforts of Saskatchewan CCF Premier and
later federal NDP leader Tommy Douglas. NDP leaders regularly invoke
this legacy in order to shore up the party`s
popular standing. The federal Liberal Party too claims credit based on
its role in brokering the deal with the provinces that made medicare a pan-Canadian reality. Medicare serves a
key role in legitimizing not only the labour-based
NDP but Canadian federalism itself, and the nationalist ideology that
posits a kinder, gentler Canadian capitalism in contrast to the brutal,
unrestrained market forces that prevail in the United States.
But two important historical realities are obscured by this official
discourse. The first is that medicare was the
product of class struggle. It was achieved only after a hard-fought
battle by working people over several generations, from the first
medical check-off won by the Glace Bay, Nova Scotia miners in the
1880`s, to the failed bid for public medical care in British Columbia
in the 1930`s. Throughout we faced the determined opposition of the
insurance industry, the Liberal and Conservative parties, and
physicians who opposed even modest steps in the direction of socialized
health care.
The decisive battle came in Saskatchewan pitting the provincial CCF
government and its substantial worker and farmer base against the province`s business class led by the Liberal Party,
the Sifton press monopoly and the medical
profession culminating in the 1962 doctor`s
strike. Reactionary forces mobilized thousands in a frenzied
anti-communist, pro-free enterprise crusade. But a defensive counter-mobilization
at the base of the CCF (largely abandoned by the party brass) succeeded
in breaking the doctor`s strike by rapidly
organizing a network of democratically controlled community health
clinics across the province. The international dimensions of the
struggle were highlighted by the active support given by the Canadian
and American Medical Associations to the anti-medicare
forces, and on the other hand, by the recruitment of dozens of pro-NHS
physicians from the U.K. to break the strike.
The mystique surrounding medicare also
glosses over the capitalist counter-offensive of the past three
decades. The recession that hit the global economy in 1974-75 marked
the end of the post-war boom ushering in a period of intensified
competition between capitalist economies internationally. Like its
counterparts elsewhere, the Canadian bourgeoisie began to jettison the
post-war social contract and construct a new relationship of forces
more favourable to Capital. Abandoning
Keynesianism, Canada`s two business parties
coalesced around a neo-liberal program and ideology leaving the NDP and
the trade union leadership with the choice of complying with the new
orthodoxy, or challenging it in a systematic way.
We have all experienced first-hand the regressive impact of this
capitalist offensive: a drastic reduction in the role of government in favour of the private sector, the selling off of
lucrative public monopolies, deregulation, liberalization of trade with
the signing of NAFTA, relentless cutbacks to social programs, the loss
of thousands of unionized jobs and the growth of precarious low-wage
employment. With few exceptions, these changes met with no challenge
from the formerly reform-oriented leaders of the NDP or the labour movement.
The attack on the social wage took the form in Canada of a massive
withdrawal of federal transfer payments to the provinces under
successive Liberal and Conservative regimes. Ottawa originally enticed
the provinces into signing on to medicare in
1968 by paying 50% of the costs. By 1998, the federal contribution had
sunk to 10% with only a modest rise in the last few years.
Medicare was somewhat shielded from provincial cuts to social services
and education because of popular antipathy to attacks on health care
and also because Canadian employers derived a significant competitive
advantage from the public health insurance monopoly. Nevertheless, the
public health care system has been profoundly affected by the shock
therapy of the neo-liberal offensive. Hardest hit has been the hospital
sector with the elimination of scores of hospitals, bed closures,
emergency room congestion and increased wait times for important
treatments and diagnostic procedures. The brunt of the cutbacks have
been born by women who provide most of the labour
needed to keep hospitals running and who have taken on almost all of
the informal unpaid or low paid duties as care has been de-institutionalised and shifted onto individuals and
families.
Countering the Misinformation Campaign of the Right
Canada`s single-payer public health
insurance system has been the target of an ideological offensive by
market fundamentalists which is as mendacious as it is relentless. The
right wing mantra is that medicare is not
financially sustainable, costs are spiralling
out of control, the system would benefit from an influx of private
investment and that competition and consumer choice would improve
quality and efficiency.
It is important to counter these false claims.
The fact is that Canada has spent a fairly constant
share of national wealth on health care over the past 30 years in
contrast to the privatized multi-payer system in the United States. In 1970, both Canada and the U.S. spent the same amount of
GDP on health care – about 7%. By 1998, U.S. costs had doubled to 14%
(with 40 million persons still uninsured) while Canada`s
had risen modestly to 9.4% (5th highest of 17 OECD
countries).
Moreover, relative spending on those areas covered by medicare – hospital care, physician services and
administration – have remained more or less constant over three
decades. Other sectors such as dental care, pharmaceuticals, long-term
care, medical equipment and non-physician
professional services are covered mainly by private insurance or else
paid for privately out of pocket. And it is in this growing private
sector where costs have risen dramatically,
especially drug purchases which rose from 9% of total health
expenditures in 1984 to 15% in 2001.
Thus, costs are rising most rapidly in those areas of health care that
are most privatized. One of the major factors in rising U.S. medical costs is the
absence of the single public payer that exists in Canada.
The claim that private provision of service improves quality is also
bogus. A recent study by Devereaux and
Associates published in the Canadian Medical Association Journal found
a 2% higher mortality rate in `for-profit` hospitals as opposed to
private non-profit or public hospitals.
The right wing likes to hide behind the slogan of 'choice', claiming
that a private market in health care will “empower” patients. Choices
for whom? Private investors in health care make choices on the basis of
opportunities for profit and ability to pay, not on the basis of need
and appropriateness. By siphoning off resources from the public sector,
for-profit care actually reduces choice for the majority of patients. A
parallel private system will only exacerbate the problems of the public
system – diverting needed labour and
expertise, increasing wait times, and exerting more pressure on those with
money to jump the queue. Far from alleviating wait times in the public
system, privatization will ultimately guarantee that you have to wait
unless you pay.
The logic of profit maximization is at odds with the logic of care.
Care is inefficient from a market standpoint and difficult to measure.
For-profit run health care encourages the transfer of functions to
lower paid and less qualified workers, while reducing overall personnel
and intensifying the work for those who remain. Applying competition to
publicly funded health services represents a fundamental shift from
planning, solidarity and cooperation to division, conflict and
fragmentation with any efficiency gained in service provision being
eaten up by increased administrative costs, the alienation of staff and
less coherent treatment of patients.
Privatization is not about governments tapping into sources of private
capital to help fund health care. In fact, it`s
just the opposite. It`s about health care
entrepreneurs, insurance companies, the pharmaceutical industry and
others laying their greedy hands on even more of the $70 billion plus
spent in Canada on health care every year.
The right wing seeks to generate a sense of panic about the crisis in
health care, the better to win acceptance for their destructive
proposals. The left needs to counter this fear-mongering but also to
acknowledge that the serious problems that do exist have their roots in
over 20 years of calculated neglect and irresponsibility by our
political rulers. The antiquated federal system has undoubtedly
exacerbated the problem, but the fundamental cause lies in the
neo-liberal consensus which has gripped Canada, as it has other capitalist
nations. It has acted in advance to exclude any serious public
investment and hence blocked genuine reform of the health care system.
Socialists call for a comprehensive program to re-structure the health
care system, to extend socialization and to open up the possibility for
rational planning of this vital human resource. Such a program would
include:
1. Enforcement of the Canada Health Act to eliminate for-profit care
and enforce standards; restore federal funding to previous levels
(50%).
2. No contracting out of surgical, diagnostic or support services to
the private for-profit sector. Fund public hospitals or clinics
adequately to perform needed services so that expertise and the
capacity for innovation are kept within the public domain.
3. Nullify Private-Public Partnerships in the conversion of existing
hospitals, or the building of new health care institutions. PPP`s transform publicly funded organizations from
being owners of assets and direct providers of services to purchasers
of services from the private sector. They constitute a recipe for
inflated costs and long-term guaranteed profits for investors feeding
at the public trough. They cost more and deliver less.
4. Expand medicare to include comprehensive pharmacare, home care and dental care adhering to
the principles of universality, public administration, not-for-profit
delivery and first dollar coverage (no user fees, co-payments or
deductibles).
5. Eliminate fee-for-service payment and the insurance model; bring
physicians and other health professionals into salaried service under
contract to multi-disciplinary clinics and hospitals which are
accountable to their communities; expand the role of nurse
practitioners, midwives and other health care providers.
6. Nationalize the pharmaceutical industry; short of that, repeal the
monopolistic federal drug patent legislation (Bill C-22), create a
single government purchasing agency to lower drug prices, and fund
salaried pharmacists to promote and monitor appropriate drug
utilization.
7. Empower health care consumers and health care workers to eliminate
wasteful practices, monitor quality of care and determine how health
care funds should be allocated based on the best clinical evidence and
the consideration of broader social needs and priorities.
8. Increase government revenues to fund these and other progressive
reforms by eliminating tax breaks for the affluent and by substantially
increasing the corporate tax share.
These demands restore the link with the original struggle for
socialized health care led by the early labour
and socialist movements. Medicare was a significant but only partial
advance along this path. Its survival against the privatizers
will require not only a resolute defence of
the principles embodied in the Canada Health Act, but also mobilizing
for more far-reaching reforms.
Naturally, the tasks facing socialists, progressives and advocates of
public health care in the USA are bigger, and if I may
say so, they are linked to the need to establish a vehicle for
independent working class political action, that is, a Labor Party in
the U.S. Your progress on all fronts
is extremely important, not only for Americans, but for Canadians and
for everyone on this planet. Because, when for-profit health care is
put to rest in America, it will reduce
privatization pressure everywhere, it will be an important blow to capitalist
rule, and it will be an important victory for the international working
class. Hasta la victoria
siempre!
***** ***** ***** *****
A Note on Cuba
One of the signal accomplishments of the Cuban Revolution has been
the great strides taken in the development of the country`s
health care system. The foundation of this achievement surely rests
with the decision to make free health care available to all and in
particular with the 1961 nationalization of health services when the
government became the sole provider and was able to implement central
planning and control over health care resources and programs. The
introduction of socialized health care in Cuba has been associated with
significant improvements in the health status of the population with dramatic
declines in the incidence of infectious disease, an increase in life
expectancy and improvements in infant mortality which approach that of
many fully industrialized countries and in some cases even surpass
them, as famously in the case of the United States.
This achievement is all the more remarkable when we consider that the
island lost half of its physicians to emigration in the first years
after the 1959 revolution. Because of this professional deficit and the
influence of Che Guevara, himself a trained
doctor, in the revolutionary leadership, there was from the beginning
an emphasis on the quality of professional training. Cuban medical
education has been highly effective so that the country now has over
50,000 physicians, a large skilled nursing work force and substantial
increases in other health professionals such as dentists. Despite its
dependence on the Soviet Union for almost three decades, the Cubans did
not copy the Soviet model with its hyper-centralization, low-paid
largely specialist physicians and weak primary care sector (the
so-called Semashko system dating to the
Bolshevik Revolution and later rigidified during the Stalin years).
Instead the Cubans built up a strong decentralized system of primary
care linked to hospital-based specialist care, with public health
mobilizations appropriate to Cuban conditions (from Dengue Fever to
Hurricane precautions). Cuba has been able to sustain
relatively high levels of motivation amongst health care workers
including physicians.
The high standard of professionalism and organization in Cuban health
care has become an important component of Cuban internationalism. First
of all in the opening of Cuban medical schools to accommodate over 3
thousand students from developing countries. And secondly by sending
thousands of its own physicians and paramedical personnel to work in
teams overseas notably in Latin America and the Caribbean but including
such far flung destinations as Africa and South Asia as we saw recently
in the dispatch of a Cuban emergency health care team to assist victims
of a major earthquake in the mountain reaches of Pakistan. Cuban
medical assistance of this type renders important solidarity to the
revolutionary processes underway in Venezuela and Bolivia as well as to the struggling
masses in Haiti.
It is important not to exaggerate Cuban achievements in health care.
The island is in desperate need of investment in social and technical
infrastructure and health facilities are often terribly dilapidated.
The American embargo imposes acute shortages of important medicines and
equipment. The Cubans have also been driven to market their expertise
to cash paying patients from Latin America, the Caribbean and Europe which inevitably restricts
access for the Cuban population.
The other side of the coin is that the Cuban medical system has had to
become quite self-reliant. The embargo has stimulated a home-grown
pharmaceutical and bio-technology industry which has registered some
important innovative successes. This includes manufacture of a range of
generic drugs for domestic use as well as developing new vaccines and
other proven or promising pharmaceuticals for export.
Nor did the Cubans allow the economic crisis after the collapse of the Soviet Union to undermine their
commitment to social equity in health care. In contrast, Vietnam, China
and the former `socialist` states in Eastern Europe introduced market
“reforms” with predictably negative consequences for equity and the
possibility for planning.
The Cubans elected to ignore the market style reforms trumpeted by the
World Bank and maintain their achievement based on the state as sole
provider, centralized control and planning, a capacity for evaluation
and innovation, a highly motivated health care work force and a
commitment to equity.
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