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Health care remains the biggest no-go zone in Canadian public discussion. According to University of Toronto president David Naylor, it's "the third rail of Canadian politics," a U.S. expression denoting something as lethal as the electrical rail in a subway.

Professor Naylor should know. He has been around medicine, public policy and health-care policy all his adult life as a physician, Rhodes Scholar in public administration and dean of medicine. But even he won't touch one part of that "third rail," the competition for public funds that postsecondary education continues to lose to health care. It's too risky a comparison for a university president with a huge faculty of medicine and links to some of Canada's leading hospitals.

Nonetheless, Prof. Naylor is frustrated by the unwillingness of Canadians and their politicians even to debate health care. For him, the essential public system should be maintained, but Canadians don't confront the question of how.

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Health care's share of every provincial budget is rising year after year, but that has led to what he calls "one of those great Canadian evasions." There would be no question of sustaining ever-higher health-care spending if Canadians were willing to pay more tax or constrain other areas of government spending. But they prefer to limp along with costs that grow by more than government revenues adjusted for inflation and population.

"If there's lots of red ink, maybe we could have a go at it," Prof. Naylor says. "We'll only face tough questions when there's a crisis … but is this a conversation Canadians want to have?"

The question is rhetorical, judging by the silence surrounding the issue, except for those "experts," some at U of T, who believe that the answer to any spending pressures from health care is to wring more efficiency from the existing system.

Prof. Naylor doesn't buy that argument. Yes, efficiency gains are always possible, but Canada should look to Europe, where "there are no perfect health-care systems" and "no magic bullets," but where there is a "degree of pluralism in financing and institutions."

In Canada, he says, "almost any time there is talk of a health-care financing change, we imagine a two-tier system. It trips off the tongue with remarkable frequency." Two-tier is political shorthand for U.S.-style medicine, which is not at all what he proposes.

"If we want to be heretical, we should think of a pluralism of financing arrangement with a public backbone of a system," Prof. Naylor says. Health care is not just a "public good" for all of society but a "private good" for individuals, he argues. A balance between the two must be found because at the moment, the scales are tipped toward health care as a "public good."

With so many entrenched stakeholders in health care, change is terribly hard, since each group protects its gains and mobilizes for more. (See the current advertising campaign of the Ontario Medical Association.)

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Prof. Naylor would like to see an integrated system of health-care delivery with physicians paid a salary with incentives for volume, working collaboratively with others in the system, instead of the silo approach now so prevalent and fee-for-service for doctors.

He says he has studied opinion polls about health care, and "I'm not sure what polls are telling us." It would appear that "any reconsideration is unthinkable. But I'm not sure how fixed we should be about that interpretation, because there's a kind of split screen whereby more payments out of pocket would be contemplated if it led to faster treatment for self or loved ones."

He notes that "there is core discomfort with anything that departs from the successful model in which fairness is highly valued. It's just that we might not be adequately served by the system."

Forget opening up a serious debate of the kind Prof. Naylor would appreciate. Politicians everywhere are convinced of the "third rail" politics, in part because Canadians have embraced health care as part of their national identification. Prof. Naylor is correct is noting that "it is a bit disturbing that Canadians would fix their self-definition around a system that is far from unique."

But there you have it: a system that Canadians know and value, that they fear changing, that they will not willingly pay higher taxes to support or agree that other programs should be compressed to pay for its rising costs. Apparently, no debate is the preferred option.

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