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opinion

Michael Bliss, historian and professor emeritus at the University of Toronto.

There are no quick "fixes" to Canada's system of national health insurance. Many prescriptions for change can't be implemented because of public resistance. But it's feasible to reduce the financial burdens of health care on Canadian governments. The history of our other major social programs suggests we can usefully revisit the idea of universal entitlement to benefits. As it does with child care and old age pensions, the state can helpfully subsidize the needy. It doesn't have to pay for everyone's health care.

What are the lessons taught by our history of medicare? My first conclusion is that we should get over being obsessed by the cost of health care, as though it were sinful for us to get sick. We should get used to the fact that health care is our largest industry, can't be substantially cut back, and probably will continue to consume a gradually increasing share of national income.

We greatly value our health care. We want more of it, not less. The cost savings we think we generate through prevention and more efficient delivery tend to be overwhelmed by our expectations for more and better care.

Canadians deeply believe in the commitment to offering basic health care without financial hindrance that was undertaken by our governments in 1968. They have consistently rejected proposals to raise extra revenue and/or deter usage through point-of-service user fees. In Canada, the idea of requiring sick people to pay fees as a condition of being treated seems like blaming the victims of ill health.

Similarly, Canadians have rejected the unequal access generated when private health care flourishes at the expense of the public system. To stop that development in the early 1980s, political pressure forced Ottawa to severely constrain the private system by passing the Canada Health Act. No political party has dared advocate its repeal.

But Canadians have also rejected attempts to control health-care costs through limiting the supply of doctors, hospital beds, imaging machines and other facilities. By the late 1990s, rationing experiments in the single-payer Canada Health Act system had created a backlash of non-confidence. Eventually, the Supreme Court undermined monopoly medicare with its 2005 Chaouilli decision that Quebec had to allow private alternatives if it couldn't deliver timely public care. For most of the past decade, governments have fallen back on throwing money at health care in a desperate attempt to maintain the system. Now that the money is drying up, no one knows what to do next.

When money for social welfare programs first became tight, in the 1970s and 1980s, we responded by phasing out our systems of universal entitlement to baby bonuses and old age pensions. These were replaced by our current systems of granting benefits according to income. We subsidize child care and old age for the needy; we expect the affluent to look after their children and their retirement.

Canadian governments phased out universality in these areas without substantial political turmoil or voter outcry. The key was to use the tax system to calculate and deliver means-based benefits. This avoids the invidious testing and stigma associated with old-fashioned public charity.

The lesson for health care is that it's time to ask why government should continue to pay for care for the well-to-do. Why should taxpayers foot the bills for the banker's coronary bypass, the retired hockey player's hip replacement and the elbow reconstructions for the ladies who lunch? Health care should continue to be universally accessible to Canadians, but Canadians need not be universally entitled to reimbursement for their health-care costs.

Health-care benefits can be recalibrated on a modern income basis, without creating undue hardship and with protection against unusual or catastrophic costs. The Canada Health Act doesn't necessarily have to be abolished, nor two-tier health care allowed to flourish. Politicians can advocate this change without violating the ideals and values underlying classic Canadian medicare.

By bringing the funding of health care in line with our other major social programs, we can sustain a system central to our goal of improving the quality and length of our lives.

Michael Bliss, a historian and professor emeritus at the University of Toronto, delivered the C.D. Howe Institute's 2010 Benefactors Lecture. It can be found at www.cdhowe.org/pdf/Benefactor_Lecture_2010.pdf

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