News

The truth is that medicare is already dead and gone , Margaret Wente wrote in The Globe earlier this week.

"You can believe in the Romanow report and Tinkerbell, but not all the clapping in the world will bring them back to life," she argued in a provocative column written before the Canadian Medical Association chose as its president-elect for 2007-08 a man described as "Dr. Profit."

Brian Day, a high-profile provider of for-profit care, defeated a challenge from Jack Burak, a veteran Vancouver family physician who presented himself as the defender of medicare and a more appropriate spokesman for Canada's 62,000 doctors.

So is the traditional view of medicare really dead?

Ms. Wente was online earlier today to take your questions on that topic.

For example, she argues in today's Globe that the issue of being fat or fit is much simpler than most people think.

"For the first time in history, the most affluent and well-educated are less fat than everybody else," she writes. "So my advice on how to be svelte: Go to university and get a good job."

Margaret Wente was born in Chicago and moved to Toronto with her family when she was in her teens. Ms. Wente has been editor of Report on Business and managing editor of the paper and since 1992 has written a popular column twice a week. She is also a frequent commentator on television and radio. Ms. Wente holds a BA from the University of Michigan, and an MA in English from the University of Toronto.

Editor's Note: globeandmail.com editors will read and allow or reject each question/comment. Comments/questions may be edited for length or clarity. HTML is not allowed. We will not publish questions/comments that include personal attacks on participants in these discussions, that make false or unsubstantiated allegations, that purport to quote people or reports where the purported quote or fact cannot be easily verified, or questions/comments that include vulgar language or libellous statements. Preference will be given to readers who submit questions/comments using their full name and home town, rather than a pseudonym.

Scott Deveau, globeandmail.com: Thank you Margaret for joining us today and taking our readers' questions. We have a lot of questions to get to, but before we do, I would like to ask you what do you made of the CMA's choice of Dr. Brian Day, owner of Canada's largest private health-care clinic, as its president, and what do you think it will mean for the future of health care in Canada?

Margaret Wente:I thought the CMA's choice of Brian Day was a brave vote for candor and progress. It's' time to move the debate forward instead of chewing on all the stale old rhetoric, as if the status quo were an option. But last year's Chaouilli decision, among many other things, means the status quo is gone for good. The Chaouilli decision means that people who can't get timely care can go outside the system. It has forced the issue.

Helen Rose from Palmerston Canada writes: Ms. Wente: How does private medicare impact on those who can't afford it?

Margaret Wente: That's a subject of huge debate and it's very theoretical right now. What's important to keep in mind is that nobody is suggesting that we ditch universal public medicare. The discussion is around (1) whether we should allow more private clinics to offer public care (which would still be 100 per cent paid for by the government, just as it is now), (2) whether people should be able to buy health insurance for either extras or medically necessary services, and finally (3) whether people should be allowed to pay for access to private clinics where they might get treated faster.

Donald Berkowitz from Maple, Ontario writes: Those who favour a privatized system have never been able to explain why the US spends more than twice as much per individual per capita in health care, while leaving between 20 per cent and 30 per cent without any health coverage whatsoever. At the same time their privatized system has allowed the managed care providers to make medical choices for patients, taking away their individual freedom to choice their own doctor. I know our system isn't perfect, but how can such an alternative be considered an improvement?

Margaret Wente: Hi Donald. Nobody in Canada favours a privatized system on the U.S. model. Those who want more private elements in the system are looking to Australia and European countries, all of which have a blend of private and public medicine.

Gavin Charles from Halifax Canada writes: Under the provisions of NAFTA, even a slight official allowance for private care could allow American investors to involve themselves in the Canadian system. Only a fully public system is exempt from this provision. In other words, Canadian control over the Canadian system can only be maintained if Canada maintains a fully public system, with no ifs or buts allowed. The current system is exempt (despite some private clinics in existence in Canada) because the official governmental position remains opposed to two-tier or private care. Would you be willing to see American involvement in Canadian health care?

Margaret Wente: Well, I'm going to be controversial here -- but why not? We buy food from the Americans too, I believe. So long as they are subject to Canadian regulations, I don't see any particular problem. Besides, we already export plenty of Canadian health-care dollars down south. Governments send patients to the U.S. for treatment in cases where they can't get it here, and patients also send themselves.

Henry Allen from Toronto Canada writes: Margaret, you love to provoke reactions and you're half an inch from the political far right. So, I'm not surprised you're taking the absolute position that Medicare is dead and gone. But, that's like saying Medicare is a light bulb that's burned out, total blackness. That can't be right because my doctor hasn't demanded a cheque. So, let's try a better analogy, a rheostat, like a dimmer switch. So, with 0 being George W. Bushian privatization and 10 being Tommy Douglasian utopia, what number would you give the current state of Medicare and why?

Margaret Wente: Henry, you're right about the first part (I like to provoke reactions) and not so right about the second -- I really don't want to kick the indigent sick and dying out into the streets. By the way, Tommy Douglas NEVER envisaged the system we have now, which offers unlimited services to everyone for free. (Of course it's really not free, but it seems free.) He always thought there should be some type of user fee for those who could pay. And he never envisaged the explosion of progress in medicine, which allows us to do more things to more people for much longer than we could when Medicare was introduced.

We already spend around 30 p.c. of our health care dollars privately (on things like physio and dental -- although personally I think we should have universal dental care for kids.) So on your scale of 1-10 I'd say we're about a 3, and maybe we should aim to be about a 5.

Miles Lunn from Vancouver Canada writes: Hi Margaret. For too long, many people have assumed any private involvement in health care means the end of it and that we will end up with a US styled two tiered health care, when in reality many other countries including ones generally to the left of Canada such as Sweden, Germany, Netherlands, and France have blended systems that produce better results overall and the public system has survived. Why is it that we are so afraid to have an honest debate on health care and look at all the alternatives. Why does the debate have to be between a complete private or complete public system rather than how much private and how much public we should have

Margaret Wente: Obviously I couldn't agree with you more. Sweden has private hospitals. France has doctors who practice in both public and private sectors. And so on. Canada is the great exception in the world, not the rule.

Jim Shepherd from Lima Peru writes: The best advice in North America seems to be not to get sick in the first place, or if you do, consider treatment in countries that have high quality and low cost private health care. What is your opinion of 'medical tourism'?

Margaret Wente: Medical tourism is inevitable so long as there are waiting lists. You can get a pretty good hip replacement in India. If you have to wait in line for a couple of years here, that's going to look like a good deal.

Political Junkie from Canada writes: A couple of thoughts: Obviously the self-selected voters on the Globe website don't constitute a scientifically valid sample, but they seem pretty ambivalent about 'Canada's defining characteristic.' Currently 46 per cent of 23,000 voters aren't 'troubled' by the idea of two-tier healthcare. Secondly, despite the low rankings given to Canada's system by outside observers, defenders of the status quo claim that our medicare system is among the best, if not the best, in the world. Is there any credible jurisdiction anywhere currently studying our system with the aim of replicating it?

Margaret Wente: Nobody would replicate the Canadian system. That's because it's fiscally ruinous to governments. When you combine unlimited demand (for health care) with limited resources (tax dollars), you're going to hit the wall.

If governments kept paying for all the health care Canadians want to consume, they would soon run out of money for everything else, including schools and roads. So we've got to find a way to inject more (private) money into the system without shutting out the poor.

Andrew Fergusson from Ottawa writes: Would there be any problems for allowing patients to pay for their procedure at a public hospital, and thus keep the money within the public system, allay the fears associated with two-tier health care, and satisfy the Chaoulli decision?

Margaret Wente: Andrew, that's a good question. But how would we decide who pays and who doesn't?

Timothy Bancroft from Taiwan writes: Ms. Wente: Two questions. 1. Why do you think so many see the question of for-profit care as a question of opposing Canada to the United States, when those countries that have the highest level universal health care, like Sweden and Norway, have combined systems? Is this a case of false nationalism? 2. Do you think that 'splitting' care in Canada would lead to a more streamlined approach in the public sector hospitals (i.e. nurse-practitioners dealing with minor stitches and abrasions rather than doctors dealing with everything)?

Margaret Wente: Hi Timothy, Your first question is extremely interesting and I think you've hit it on the nose. One of our defining myths about ourselves is that we are a kinder, gentler nation that would NEVER allow people to go bankrupt because of catastrophic illness. And so a great way to shut down debate about our system has been to invoke the terrible example of the United States. That has worked for 20 years. But now I think people are beginning to smarten up. In fact I think a lot of them are ahead of the politicians on this issue.

I do think competition would encourage more rational work practices in the public sector. But the unions will fight tooth and nail against this. And the doctors are a pretty powerful union too. I have no idea why we send people through umpteen years of medical school so they can spend half their time telling people their kid has a cold, not a virus.

Larry Robinson from White Rock, B.C. writes: Margaret - I believe that Medicare is now truly medical care industry as opposed to community health care, as when Saskatchewan enacted the plan. Medicare no longer has anything to do with prevention and lifestyle. We do not visit our doctors twice a year for a chat and check-up. I believe that Cuba is the only country that still follows this route. The Medical Industry is pharmaceutical companies, insurance companies, professional and health worker unions and government administrators. The medical care that Tommy Douglas experienced is gone. The questions become - how much public money do we throw into a private industry? and can Governmental agencies ever become an efficient tool for health care?

Margaret Wente: Larry, you're asking a very challenging set of questions. The most dramatic change in medical care is that it is becoming overwhelmingly high tech.

I think the government's most important role is to keep serving as the single payer for a basic universal system, and to regulate the players. The single-payer system is incredibly efficient. But when government agencies deliver services, they're pretty inefficient. Right now, each province has a giant government health bureaucracy whose main impact, so far as I can see, is to stifle innovation and stand in the way of change. The health care system is run by middle-level bureaucrats. And that works about as well as you'd expect.

As for how much public money to throw in -- that's the zillion-dollar question. Medical costs throughout the developed world are increasing at around 6 per cent a year (because of ageing populations and new technologies.) The economy is only growing at around 3 per cent a year. So where's the difference going to come from? Not from public money, unless you want to have your taxes go up much faster than your income.

Scott Deveau, globeandmail.com: That is all the time we have for today. Thank you Margaret for taking the time this afternoon to answer our readers' questions, and thanks to all of you who submitted questions.

Margaret, do you have any final thoughts you'd like to share on the subject?

Margaret Wente:I want to thank the audience for some great questions. In fact I'm pretty optimistic. In spite of our challenges, we do get some of the best health care in the world. And I think we're tiptoeing -- slowly but steadily -- into a period of innovation that will eventually strengthen the system.

Scott Deveau, globeandmail.com: Thanks again