Predicting the future is always a tricky business, especially when the subject is politics. In Canada's unpredictable political landscape, prophecy and history seldom agree. Strong Medicine, just released in paperback, opts for a visionary rhetoric about how to solve Canada's health problems. The title implies that the system ails, and therefore requires strong medicine. Most Canadians would attribute our health care system's problems to funding; it was conceived a few decades ago when the government's books were balanced. Now it is quickly running out of money. This fiscal crisis has been triggered for a variety of reasons. Legal jurisdiction over health care resides with the provinces. The Canada Health Act-the federal law that supports Medicare-has in the past been supported by federal tax dollars. But the federal "power of the purse" isn't working too well, now that the purse is empty. Federal transfer payments to the provinces are declining, while the cost of health care is increasing. The baby boom-that population bulge that is not accustomed to hearing no for an answer-is about to have its oldest members turn fifty, in large numbers. They will surely make more demands on the system. This would certainly seem to be a crisis.
Yet Rachlis and Kushner-after raising the idea of a crisis to justify the strong measures they will propose-just as quickly assert that there is no crisis for our state-run system. "Canadians need to know that our method for financing health care insurance is fundamentally sound," they write defiantly. Even the book's new-age terminology-or is it a reference to Jane Jacobs's categories of Guardians and Traders?-has a bit of a defiant ring, and feels like time-travel back to the days when government-which the authors lovingly call "the Guardian"-nationalized Canada's health care system. This now-you-see-it-now-you-don't crisis is one of the things that makes Strong Medicine such a confusing read: they loyally chant the Medicare mantra, while giving many examples that suggest the problems of government-run health care.
For example, they describe how Canadian politicians use hospitals the same way American politicians use army bases-as political pork for their home districts. "Take Saskatchewan," they write, "which has more hospital beds per capita than any other province, many of them in rural facilities too small to deliver cost-effective, high-quality acute care." This is the sacred trust?
Bureaucrats have prospered too, according to the authors, who note that in the Ontario Home Care program "between 35 and 40 percent of long-term-care spending in the community went to administrative overheads." Pork-barrelling and nest-feathering don't seem to faze them. The underlying assumption seems to be that government's abuses of the system are only exceptions to the rule.
In fact, they appear to want to strengthen government control. Why? To use the health care system a launching pad to correct social ills as they see them. Hence health care arguments are peppered with comments on everything from a national daycare program to the Marc Lépine massacre. Child poverty, cigarettes, and gun control are tackled too. "When we protect people's right to buy and use guns, we are also risking lives. In choosing not to limit the `rights' of men to stalk and threaten women, we trade off women's rights to safety and security, and sometimes their right to life itself." Rachlis and Kushner imply that any income inequality must be levelled, because it causes illness. "Is there a steep hierarchy among social and occupational groups? Are there a lot of people in the bottom ranks? Do they feel completely excluded as contributing members in our society? Societies that answer yes to these questions can't escape having major health problems," they say. Their underlying assumption is that in economics, one man's gain must be another's loss. Needless to say, they will propose using the health care system to level income inequalities.
Throughout, Rachlis and Kushner bolster their confidence in Canadian health by attacking America's health care system-as though, for instance, the American failures prove Canadian successes. They assume that the American system is a failure because of the American love affair with individualism: "The deep-seated belief in the boundless potential of the individual and America's commitment to personal liberty don't mesh well with proof that collective problem-solving via public health insurance actually works." This, after a catalogue of public sector failure, is less than persuasive. They do not say that the Americans actually have a mixed system consisting of private and public components such as Medicare and Medicaid for the elderly or less fortunate.
Proof of the failure of the American system relies in great part on the 35 million Americans who are alleged to lack health insurance. They do not cite the source of this figure-a noticeable omission in a book with over 600 footnotes. That's not surprising, though, given how that number was derived. For tax reasons, most Americans get their health insurance through their employer. Therefore, any American worker between jobs-even just for a week-might have a short gap in coverage. This 35 million figure was the result of a 1992 survey estimating the number of Americans who were without health insurance at any time during the previous year. Given that America was still in recession, and anyone who was between jobs-even briefly-was counted, it's no surprise that the number was what it was. What the authors leave out is that the majority of those 35 million uninsured were reinsured within months, or were covered by the American safety net programs of Medicare and Medicaid, or stated that they didn't want insurance.
The authors rely on this caricature of the Americans, to justify more government involvement in health care. Their portrait of Americans shows what they imagine the minds of men and women to consist of, left to their own devices, and without a Guardian: Americans are greedy and they are cheaters; small business men and women are Traders as opposed to Guardians. "Without Guardians minding the shop," they write, "Traders would constantly be tempted to cheat." Who are these cheating Traders? Why, anyone involved in free-enterprise medicine. "Good Guardians are essential to keep criminal activity in check. Guardians must rely on successful and innovative Traders to create wealth and provide the tax base."
Guardians mustn't let the Traders be too productive. "The financial rewards to those who see more patients and work longer hours are there for the taking and provide a strong temptation to go overboard, even to the detriment of the physician's own mental and physical health." Rachlis and Kushner offer to protect these over-achieving, workaholic doctors from themselves. If not for the watchful eye of government, all manner of individual initiative might break out.
Other comments on the US system are inaccurate. They write that America's Great Society programs were "repealed under Ronald Reagan's presidency," when Republicans held "significant majorities in both the House of Representatives and the Senate." But Reagan didn't repeal America's social safety net, he expanded it. And the US Congress wasn't in Republican hands until the sweep just last November, after forty years of Democratic control. Rachlis says that Gingrich's win "killed off any prospects for health reform for the foreseeable future." In fact the Republicans proposed Medical Savings Accounts, a free-market health care RSP, which would clearly be a reform.
Needless to say, the profit motive and property rights are always suspect. Pharmaceutical companies "can buy (or at least rent) scientists, politicians, and even whole countries," say Rachlis and Kushner. His proof? "Multinational" inventors of drugs are given patent protection for their research. (Despite such anti-American, anti-corporate criticism, Strong Medicine was proudly "printed and bound in the USA.")
The only clear answer the authors provide as to how to save Medicare is to make sure that patient choice is definitely out of the question. When the British Columbia Medical Association passed a motion to give "free citizens the right. to purchase services in a free-competitive market," Rachlis hit the roof. Freedom? What an archaic idea! Choice? Only the "ultra-right" would believe in that. The authors prefer the Canada Health Act, a law that permits Canadians to buy private health care for their pets, but forbids free market access for mere humans.
The authors do acknowledge that Canada has significant waiting lines for many medical procedures, but wouldn't let private medicine release this pressure, fearing it would destroy the system. "The implementation of priorization programs for waiting lists will ensure that everyone gets the high-tech services they need when they need them," they say. Translation: take a number, and get in line. Rather than being perturbed by these growing lines, the authors almost fancy that they are great equalizers, and controllers, and they almost brag that "in Canada, hospitals are not free. to purchase expensive equipment such as magnetic resonance imaging (MRI) scanners, without specific approvals from provincial governments. Provinces have strict control." The thousands of Canadians who flee to US clinics every year give us an idea what ordinary Canadians think of such restrictions: MRI's are popular because they allow quick, non-invasive diagnostic assessments.
But surely the authors will admit to the need to streamline hospitals that pay higher than free-market-equivalent wages. No chance. In fact, "there's a very strong connection between unemployment and illness. Losing a job is a very serious health risk. The health care system ought be acting on this knowledge by offering its workers iron-clad employment security."
And doctors will be forced onto salary. No debating the matter, no choice, no competition: that wouldn't fit into the Plan. The authors actually write this way throughout the book: Plan has a capital P, just as Guardian has a capital G. This book purports to be a radical departure from the status quo. Unfortunately, it's not: Strong Medicine turns out to be just a placebo.