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

Michael Bliss

The problem of saying no to the sick Add to ...

Modern health-care systems don't work very well. Despite the best efforts by the U.S. Congress, despite the single-payer system in Canada, there is no easy resolution of the fundamental policy issue. This is the conflict between the need to supply health care as a matter of right and the need to control costs.

It wasn't this way in earlier eras when health care was often ineffectual and marginal. But, by the mid-20th century, health care had become so important in advanced societies that demand for it became virtually insatiable. Wonder drugs, lab tests, artificial joints, organ transplants, imaging, expertise, home care, end-of-life care, brain surgery, research breakthroughs - we want it all, and we want to be insured against its costs.

Because we are compassionate, we tend to believe that no one should be denied access to health care for financial reasons. Even in the highly individualistic United States, access to high-quality health care is seen as a fundamental human right.

Nowhere, however, have insurers, public or private, succeeded in controlling the consequence of meeting demands for high-quality universal health care. Costs increase faster than inflation, faster than economic growth.

Major cost-control strategies have proved largely fruitless. In the naive early days of medicare, it was widely believed that preventive medicine would save money by reducing disease. Healthier people get sick less. Or do they?

Gradually, we learned that the war against ill health (unlike, say, reducing car crashes) is only postponement. Pounds of prevention do a lot of good, but they don't give humans an ounce of ultimate cure. Prevention adds costs to the system as we live longer. We avoid one disease only to fall prey to another. The more we succeed at protecting the snowman on the lawn from melting, the more expensive maintaining him becomes.

Strategies to try to limit demand by limiting the supply of health care were particularly popular in Canada from the 1970s through the 1990s as governments tried to use their monopoly power to close hospitals, limit the supply of doctors, ration access to diagnostic facilities and operating rooms, and so on. A dominant school of health economists believed that the public was overserviced and that patients could happily make do with less.

Media and voter outrage were the kiss of death for the supply tinkerers. The demand for health care is not just misperception fostered by self-interested doctors and druggists. It's real and massive, increases as we age, and has media support.

Proposals to give patients and/or providers financial incentives to offer less care take us back to the dilemma of preventive medicine. You can pay me or my doctor a bonus for staying healthy, but I'll still expect you to foot the bill when I finally get sick. Pay me now and pay me later.

We doggedly try to cut fat wherever it's found in health care. Why not pay less for drugs and less for physicians' services? Why not strive for greater efficiency everywhere in the system, for cost-saving innovations, for increased cost-consciousness everywhere?

These are important and, sometimes, effective strategies, except when they lead to shortages of personnel, research and facilities, or wild spending on utopian panaceas such as e-health technology. Not many of us feel very confident about government health bureaucracies as crusaders for innovation and efficiency.

Nor are the political gatekeepers of most health-care systems, certainly not Canada's, willing to unleash anything like the cost-reducing force of unrestrained competition in the health-care marketplace. It seems counterintuitive to suggest that flooding the market with doctors, nurses, hospitals and laboratories, all competing fiercely with one another, might actually reduce costs. Although other industries work this way - think about food and housing - free enterprise in health care is an experiment we are deeply afraid to try.

If we can't hold the line on health-care costs, how can we keep on paying? When governments take responsibility for health care, their only options are to raise taxes, run up debt and squeeze spending in other areas. All of this is happening in Canada, with no end in sight.

The new American tilt toward subsidizing health insurance for everyone may lead to better health care for millions, at least in the short run. But success in meeting citizen demand will lead to greater failure in cost-containment. Most Americans have traditionally insisted on having the best health-care system money can buy, and now almost all of them are going to have access to it, and feel almost as entitled as Canadians.

In both countries, the health-care burden on governments will mount and mount (just as it's rising for Europeans, who, until recently, have expected and settled for less than we rich North Americans). Crippled by debt and resistance to taxes, the United States may be the first country that finds health care's breaking point.

Our history of struggling with the problems of containing the costs of health insurance suggests there are no practical panaceas, quick fixes or easy answers. We can and should rejoice at the wonderful successes that modern medicine and modern social policies have given us in terms of years of extra life, health and productivity. We can just as rightly ring our hands at the mess we create when we lean on other people to help pay to maintain our personal health.

Michael Bliss is a historian and professor emeritus at the University of Toronto. His books include The Discovery of Insulin and biographies of Frederick Banting, William Osler and Harvey Cushing.

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