Many sensible arguments have been used to point out the manifold flaws in this line of reasoning. These arguments are generally met with the scornful accusation that Canadians are wedded to mediocrity (an ad hominem argument used to hide the fact there are no logical or practical reasons for the two-tier idea). What is extraordinary, however, is that both sides miss the point that Canada already has a two-tier medical system.
It is, in fact, perfectly legal to practice private medecine in Canada. What is illegal is to mix private and public. In other words, you're either in the system, or you're out. Doctors can't get money from medicare and then bill their patients extra, and they can't have some patients from medicare, and some patients who pay privately. Doctors could, if they chose, try to make a living only seeing patients who paid out of their own pocket. The reason this does not happen at all - the reason there is no substantial private health care in Canada - is that the public system is good enough that there is not enough demand for a private system. Doctors are already pretty accessible, and their average quality is high. Furthermore, Canada's health care system already has a degree of competition built in between doctors, which means that poor doctors can be avoided within the public system.
The real crunch in medicare comes in hospital care. Here, private hospitals are blocked, not by medicare, but by the provincial governments, who must licence hospitals. The reason no private hospitals are licenced is, simply, that whatever the problems with the public system, there would not be enough demand for a purely private hospital to justify the large investment required. The public system may not be great, but it's sufficiently good that not enough people would be willing to pay out of their own pocket, and private insurance would not pay, to circumvent it. On the other hand, there is enough demand for certain intermediate procedures - such as laser eye surgery and physiotherapy - to sustain various small clinics. These clinics are fine, and they are a demonstration that private medecine is perfectly legal already, and active where it is required. Canada already has a two-tier medical system.
In fact, the medicare system at the moment operates on the same principle as the education system, another social necessity that was taken over by government because the private sector could not cope with it. Everyone pays taxes and supports a public system to which everyone has (more or less) equal access. If you are rich enough and dissatisfied enough, you can pay out of your own pocket for a parallel private system. The reason there is not a private medical system as extensive as the private education system is that the public system is already good and accessible enough for most people, and the infrastructure costs of establishing a private system are too high.
The conservative doctors and commentators who call for a "two-tier" medical system are actually calling for the public system to subsidize a private system. What they want is for doctors and hospitals to be supported by the taxpayer, but to save their best, most rapid service for those who can pay extra. They want the taxpayer to pay the bulk of the fees for those who enjoy private medecine. This is manifestly absurd. It is equivalent to arguing that the taxpayers should pay the salaries and maintenace costs of private schools - who would then charge additional private fees which would exclude all but the rich. The private fees would go to pay for even better facilities and top up salaries to draw off the best teachers. In other words, middle-class taxpayers would pay the costs of a better education from which they were excluded. Any idiot can see that this idea would quickly destroy the public education system, which is why no-one has ever suggested it seriously. Yet it is precisely what some right-wing doctors and commentators are calling for in the medicare system.
The call for "two-tier" medicare is actually a call for the public to subsidize private health care. It is important that those who appreciate Canada's medicare system expose this deceptive line of argument whenever it is made.
March 10, 1998
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