A brief history of Health Care and More
Being relatively young and healthy is a great gift bestowed by the Almighty on most of us at some point in our burdensome lives. During these blissful moments everything around us shines with perpetual gloss of unbound enthusiasm and freedom. Alas, such moments are not the only ones we would have to live through. Sure, some would be lucky enough as to just drop dead, unexpectedly in full swing of seemingly healthy existence. Some would achieve the almost impossible through some unfortunate air collision or a car crash. The rest of us are not as lucky as we would witness our own slow exit from our Earthly existence in an incessant succession of personal misery and pain otherwise known as dying of age-related causes or of a long-fight against a serious disease.
Unfortunately, God hardly ever gives us any indication of solid timing. He does not typically shed light on our current situation that marred in strong preoccupations with survival. Had he done so our health care system could have cost us less than its worth to give any sizeable thought to – just like a daily cup of coffee. Well, He does not…
The result is perpetual preoccupation with health care drain on our budgets, wallets and anything else remotely resembling things of value. We all have to have it regardless of circumstances and priorities. When it comes to health only big “I” is capable to give all the answers one truly needs. Even in the direst of situations compounded by multiple wounds and aged wrinkles, an instinct of self-preservation rules paramount, demanding the best and the latest - a plain unmitigated nightmare in other words. Perhaps…
Early Dabblers
Let’s have a brief look at history for whatever educational value it might be worth to see how our ancestors coped with lack of X-rays machines and vasectomy. Starting with ancient Egypt, we find some of the earliest signs of what is currently referred to as health care system. Some folks then, claiming to possess some special and inordinate knowledge, achieved a highly regarded and professional status of healers. They were true privateers. Loathing to till their Nile-drenched fields, they felt smart enough to con others into believing their powers. Conning the next door neighbours was kind of pointless though, as these barely survived most of the time and could not afford much of health care. Those conscripted into slavery trains of pyramid builders did not fare much better. Healing rich officials and priests was a considerably superior business. Getting into the pharaoh’s chambers was the sign of ultimate success save for certain mood swings of their charges that threatened windy gallows on occasion. If avoided, the rest was a piece of cake – scrape some rodent dung, cook up some rat-hide stew and viola, you have a magic potion for everyday needs. All future pharaohs loved the results, as one did not have to wait too long to succeed a previous god, dead in his late teens with an incomplete tomb and chest-full of treasuries – marvellous! Contractors could hardly believe their luck in having all those orders for ever more megalomaniac piles of rubble. Healers hardly did worse as ubiquitous rat-hide stew worked even better on dead people since even maggots refused gold-plated offerings in opulent sarcophagi.
True Fathers
Many scholars argue about reasons of Egypt’s ultimate and somewhat untimely demise. I do not harbour any such nuances – the doctors killed them! Just think who came in their stead – the Greeks. These guys were way more successful due to their much more egalitarian zeal that resulted in bringing health care to the masses. Suddenly, with all that equality, new standards and daring breakthroughs in the profession, doctors disowned their rodent friends. Indeed, our medicinal fathers indulged in dissecting, testing and studying; hence actually managing to bring enormous and positive change. In addition, an upright colossus of a physician named Hippocrates designed a special code of ethics denying some particularly sanguinary brethren a chance to experiment too much – calling patient care a virtue paramount. Imagine that! All were called to some unusually enlightening complex of egalitarian and ethical treatments – what a notion. Not surprisingly, ever since such benevolent approach to treatment of ever cranky, selfish and even some outright non-paying customers led to a rise of one of the greatest civilizations whose core values we still extol.
Unworthy Followers
Then came the mighty boot of Rome. These folks loved to pay lip service to Hippocrates and the like. One of their rank with a humble name of Octavian designed a funny habit of calling himself “first among equals” while seating on a whole pile of porphyry marble atop the Palatine – what a gall! Well, at least he still had some access treasury left, showering his subject with much games, bread and general welfare. Doctors, still somewhat regulated by “do no harm” principle still figured in the scheme of social equality. Well, not for long as Octavian’s many and expansionary successors managed to deplete his treasury and kill his very creation otherwise known as the Eternal Empire. Now, with only rats left running in the rotten treasury boxes, doctors, being above average in smarts, ran off the mythical ship. Everyone in that inconvenient pain and death realm was now back on their own just like in good old days – with the best Greek advances available only to those with purse or sword, or preferably both. The Rome was rotten, slowly dissolving into grey and brutish fabric of Middle Ages. The state was no longer responsible for your unhealthy choices of poverty, bad wine and general lack of luck. C’est la vie, buddy!
It seemed that our great human experiment made its final and irrevocable turn, attending to better fed, housed and sworded with some valiant exceptions moved by God and touched by compassion. Unfortunately, likes of St. Francis of Assisi could not single-handedly assuage all the ravages of egotistical desire to live, the very desire that finds its apogee on the bed of sickness like no other. No amount of holy compassion was enough to revive altruistic roots of Hippocrates and the profession was set firmly on rails of deregulation, private payments and underinsurance. Needless to say, it did not bode well for majority of patents. Rats had a particularly good time. Some of their travelling cohorts even managed to bring much in a way of exotics. Humans were finding some spices and artefacts particularly attractive, rats were not far behind managing to smuggle in a little known novelty that came to be feared as Black Plague.
The results were quick and decisive – the Plague wiped out about third of living humanity that called Europe home. Fortunately, among the victims were some doctors whose alchemic ways could always have done even more harm. Was Hippocrates turning in his bed yet? I do not know exactly, but the deplorable state of private health care persisted all the way to the edges of the Victorian rule with some minor exceptions.
Recalling the Roots
The first ones to disrupt the insolent parade of needless blood draining were the Dutch who aspired to some sort of equality when seated on the pile of riches they acquired through ship building and trade. Besides, I do not think the rulers of this tiny dot on the map could do otherwise. Had they hoarded the treasures from wider masses, we might still be calling it Spain. Here in the low flood planes around trading Amsterdam and ship-building Rotterdam, people realized the social value of keeping the populace generally healthy – a good but not a novel idea. After all, if you lose a couple of knowledgeable captains, a whole multi-million guilder expedition might go to pot. Needless to say that despite all that water the rats did not like the place, and health care, although still very private, became somewhat affordable and certainly available as many seemed keen on keeping some of the ancient Greek idealism. There were true progressives.
OK, OK, sure it is easy to talk about tiny Holland as a paragon of virtues. But what about a bigger place, with much less wealth, health and way more in political scores to settle. Here, looking at Holland the folks scratched their heads for nearly a century, itching to affect change. Then came Marat, Robespierre and the bunch. They tinkered with empty sloganeering, destructive parading and general nuisance for a short while. When all their attempts at raising hell fell mostly on deaf and well-perfumed ears in Versailles, they got a bit pissed off and pulled a few nasty stunts. Gone was the king, and Maria Antoinette’s pale head rolled off the scaffolding. In exchange, the rag-tag masses got their “Liberte, Egailite et Fraternite” with better health care to boot. Now, the state was no longer their enemy and hospital bills, although still private, dropped and those still trapped in desperate poverty even received few freebies. Suddenly very selfish impulses of the sick were greeted with societal rationality and general sense of purpose. Some doctors did not like their dimishing incomes and new expectations of treating worthless peasantry and urban riff-raff alike. The state was clearly stepping on some very individual toes. Many longed for good old times of absolutism and income-scaled services; forget about that “Fraternite” BS. Lucky for them, the disorganized revolutionaries lost their track in the turbulence of events. Marat got killed in his bathtub; rats got their revenge; and a certain Corsican found an outlet for his violent emotions stemming from a “short man” syndrome. For an average destitute French peasant the news was not particularly good. The only reasonable advice was to keep drinking cheap local wine, stay outside (rain or shine) and keep away from pricey help with stethoscopes.
Saxon Ambition
Well, what about those across the Channel? There, things were developing pretty well along the same lines except the revolution was not in the cards following the dark times of ominous Cromwell. Instead, endowed by much new independence from the Crown, nobles tinkered with their large and sprawling estates. Some, having done particularly well in inheriting their castles, decided to indulge in things more noble and elevated. Some wrote unforgettable love stories; others preferred humour and one little man named Adam Smith came up with a revolutionary idea. He thought that greed, so despised and ridiculed by many enlightened, was actually a great thing because it could be self-regulating. In other words, greed was the only thing that propelled progress and since it fed on weaknesses of others, it was always to be counter-checked by popular outrage and disbelief should it get out of control. And if it is so, then why worry about higher ideals of compassion and other similar junk when greed was the best way to produce socially pleasing results. Forget about French regulations and Dutch planning, let each one be for his own and much good will result. Splendid! The rats triumphed; their past golden age born under the shades of mighty pyramids was coming back.
Then came the industrial age. This beast required much in a way of sacrifice. It demanded bodies, healthy ones preferably, to churn out newly found wealth for the lucky elites. At first, the supply was great and there was no need to care for anybody. Impoverished stream of cheap and dispensable labour seemed endless. The economy was picking up steam and good health care for everyone was just out of the question. A little by little, the rats were getting alarmed though as the ship developed some slow but persistent leaks. Working poor, despite many a deprivation, were getting more educated, powerful and demanded change. The word “revolution” was on everyone’s lips. The pressure was growing and some wily rulers developed their own set of coping techniques. Americans found weaker species known as American Indian. British feasted on the spoils of the Empire and French indulged in spreading the beautiful tongue below the equator. Others were not so lucky and desperately needed a popular outlet to let the steam out. Germany deprived of colonies and besieged by internal calls for revolution was the most put out and prepared. After all they were the healthiest of them all with their newly created Bismarck-ian social net. Figuring that the win was in the cards they stomped on tinder box of history as it exploded on one fateful August day in 1914.
The ensuing ravages of stubborn imperial appetites otherwise known as WWI produced much in a way of wonton destruction and waste. Entrenched in deep and muddy holes somewhere in Belgium, the war meat was becoming more valuable with every passing day. The supplies were drying up, culling the youngsters and old geezers alike. The value of human live, noble or common, suddenly acquired a new sense of worth. Armies of newly educated doctors were sent to rat-infested trenches to provide for the troops. Suddenly, the medical science was producing one breakthrough after another, caring for everyone almost regardless of rank. Carrying a bayonet versus a pince-nez was becoming an advantage. Medical socialism got to rule the trenches on both sides. After all the health of everyone, I mean everyone, was important.
Fighting Amnesia
Then came the Treaty of Versailles and good old lessons were forgotten once more. The world burdened Germans with reparations; threats of revolutions subsided and need for socialism was left in the closet once more, as the masses were herded back into the slums to produce wealth for others capable of paying their doctors. The private access to personal sufferings ruled once more.
The party did not last long. Rich and poor asses alike lost their shirts on Black Tuesday; Germans elected a new chancellor with a comedic moustache and a wicked “small man” syndrome; French exclaimed “c’est dommage”; and clueless president Hoover lost his job. The house collapsed and a cure larger than was life seemed to be the only solution. The whole world searched for right ideas as unabashed selfishness of Adam Smith did not produce any improvements. Everyone has suffered under unaccountable individualism; the time for change was ripe. We desperately needed new heroes when John Maynard Keynes[1] arrived on the scene. A Cambridge man with strikingly Greek ideals of collective responsibilities, he proposed things strikingly new. THE RATS DID NOT LIKE HIM.
He proposed something completely different in the world of selfishness that is modern capitalism. He evoked long-lost ideals of collective responsibility. Three rods together are harder to break than each one separately – an old adage was quickly acquiring new taste. Suddenly, amidst economic and political carnage, some influential people heeded his call for larger role of the state. One man suffering from a partial paralysis for most of his life understood it best – FDR. He took on the new ideas with zeal of a recent and most fervent convert. The ideas of non-private health care lurched forward among other good things. Suddenly, even the poorest got some attention as they were once again valued as part of the larger society and their ability to pay was somewhat secondary. The Great Depression was collective in its dire effects, why would one deal with it individually – of course not. Sure, some doctors did not like diminishing income streams but seeing ensuing and growing tides of tangible improvements could hardly spoil the party. FDR got re-elected again and again.
Alas, other men with much more sinister ideas and no less common sense took control of collective impulses across the pond. As a result, a comically moustached German dude found some similarly minded allies in Franco, Mussolini and Hirohito. They all liked collectivism but using it for productive purposes was unfortunately beyond their pail. Bristling with new economic successes they could not control their juvenile curiosity in “what if”. They expanded their experiment, searing a new brand of suffering and destruction on our collective world – WWII. The ensuing carnage revealed our other common and unsavoury proclivities. Our ability to kill, smash and annihilate was paramount. These were only matched by an equal degree of self-preservation. Fortunately, our best impulses prevailed, sending most of the angry and moustached men stumbling down into the abyss of history.
Greater and Lesser Societies
We emerged victorious. Our economy renewed, people enthusiastic and society re-invigorated. What followed was a golden age of health care. Of course, most of it still proceeded along the lines of private, but much more compassionate private, somehow checked and directed by productive emotions of common good at the detriment of individual selfishness. The rats started sailing towards less generous locales.
Little by little, the economic lessons of war and new squalls of human compassion managed to give a good name to the notion of socialism despite the bad connotation with evil regimes in Moscow and other less hospitable places. One by one, progressive countries of Europe and beyond, ultimately realized that the health of the nation as the whole was more important than individual advantages of some. People started getting healthier, wealthier and, surprisingly, at reasonable cost, as new approaches to medicine were finding their permanent anchors in souls traumatized by wars and deprivations. It looked as if ancient Egyptian cures could be discarded once and for all.
The things on this side of the pond did not transpire as fast as our individualistic values were still looming large in many a mind enthralled by Social Darwinism. It took true courage and zeal of some to break the mould. When some dared, they were rewarded with common admiration reserved for those capable of wakening the proverbial silent majority. In Canada, the father of universal health care Tommy Douglas became a national hero eclipsing many others with skates on. He led a wave of reform that eventually saw Canada join the rest of the progressive world in setting a right balance of equality of suffering regardless of means. It has not been perfect but it works most of the time. Since then, universalism has proven to be a model to continue with and improve. It behoves to remember that universal health care is not a natural law such as greed or gravity; it is a model to work on. The results so far have been remarkable with improving trends in access, general health, life span and outright piece of mind.
Alas, the biggest chunk of the free world never found enough resolve beyond efforts of FDR and a couple of his followers to propel the idea far enough. The USA, the land of acclaimed equality, just could not overcome forces of greed and selfishness that led in profound dichotomies as those of the brightest achievements for some and complete lack of coverage for others.
Without its largest ally as a flagship in the seas of economic change, the rats saw an opportunity to come back into the leaking ship. The Egyptians were back in force helped on by a myriad of irresponsible thinkers of tremendous political clout who advocated abolition of the entire social safety net with the health care taking its beatings early on.
No, they argued. Complex artificial models do not really work, they are doomed to collapse and the only way to avoid it is to let greed and self-interest reign in every field, health care or retirement savings alike - let the natural laws of supply and demand settle the equitation. Above all, with much less governmental intervention, private had to be more affordable and efficient. It had to. The rats rushed back.
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When I first moved to the United States in the early nineties, I had to sort out my medical situation pronto since I was then going through some significant health difficulties. Stepping into the magic land of opportunity felt exhilarating and intimidating, all at the same time. My condition required some medical oversight, and it did not promise to come easily or cheaply. Finally, I found a way through an employment health care scheme that easily ate fifteen percent of my entire budget and required deductibles and co-payments but I could not complain. At least, it was something for the shocked product of the free Soviet health care system.
However, even with coverage my problems did not end as getting sick was still an expensive proposition. More so for my co-workers most of whom did not purchase any insurance and at times had to kiss good-bye to their weekly paycheque just to get some fillings done. And as if it was stressful for me, I could only imagine what really sick people felt in this society. I surely did not want to be in their shoes. Hearing tales of people getting financially wiped out by disease just did not sit right with the notion that we still lived in something called a “society” as opposed to “vacuum”.
Work insurance with its costs still did not solve things entirely as it basically expired if one changed work, and when starting at a new place there was always a requirement to wait for three additional probationary months. This felt a little unfair as if I was hiding something, but this was the system. Once, in between jobs, I had to go to a hospital with severe cold. Two hours, one test and a package of pills later, I was back home reading a bill that swallowed by entire weekly paycheque. Well, at least they had a payment plan and I did not hive a kidney stone or worse.
This was in New York but the story did not change as I moved across the country meeting people left and right with fear of sickness on the forefront of their minds. No wonder, depression was becoming a disease “du jour” and Prozac was getting to be as prevalent as candy on Halloween.
Truth be told though, as when in need of medical attention under the insurance coverage I could not really complain. Doctors appeared thorough, polite and attentive. Pills were prescribed, blood pressure measured and even some high tech testing performed. But all at a cost of fear – “what would happen tomorrow?” For some it was not much of an issue but for paranoid character like me it was enough to trigger some sleepless nights.
After four years in American health care, I managed to escape back into a medical nirvana otherwise known as Canada. Shortly after landing, I received a package from the Ministry of Health noting that I was ENTITLED to the universal health care. One could hardly imagine the relief. All of a sudden, I was transported in a place of some assurance and tranquility. Sure, taxes here must be higher but who cares.
My move also coincided with my business studies at UBC and corresponding commute. Being a debate animal of sorts I could hardly forgo a long-acquired habit of talk radio. I twiddled around the Vancouver dial and found just about the only purveyor of constant debates – CKNW[2] (otherwise known as Conservative Knowledge Network). At first, I was delighted in the station that leaned heavily one controversy or another. Besides, it was sort of American in its views making my general transition easier. I loved the controversy. But listening to it for a while I realized that most of the hosts cared little about actual debate, what they cared about were incessant one-directional rants and ratings. I listened carefully – what was burning Canadian psyche?
Universal health care solidly featured in the top three. “What could be wrong?” I pondered. According to the radio hosts it was rotten, inefficient and outright expensive. Really!? It sounded as we urgently needed move to the American model if our health care were to survive. The problem was further compounded by weak and “uncompetitive” Canadian dollar and taxes, prompting many qualified professionals to head south of the border. Oh no, something was wrong and my economic juices were flowing. I had to investigate. I needed clarity but debate was not happening. The ranting hosts constantly bemoaned a lack of debate but never invited anybody with opposing views, preferring to quote some convenient luminaries with Milton Friedman on the top of the list. I waited for the debate to happen anywhere – newspapers, books etc. Alas, outside some tepid governmental pronouncements nobody was standing up on the other side.
I had to get through the clutter on my own. Are any these claims true and we should move back to the dog-eat-dog American style of health care delivery? Well, I started finding out things…
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Since my primary preoccupation at the time was that of a business leader with my newly-baked MBA, I had to approach things as a quasi-economist, and no less. Otherwise I did not have a chance to be honest to myself regardless of compassion levels which were then low but rising.
Magic of Supply and Demand
First, I looked at the whole issue of supply and demand as it is the only one loved by Milton Friedman[3] conservatives and acknowledged by more nuanced men of the opposite camp. In other words, on paper there was some common ground here. The conservative folks point out that in a free unrestrained market environment, demand for any service or good will be met by a corresponding supply with both meeting some place commonly referred to as market price. If one inadvertently produces too much of any one thing, the less his demanded price would be as those who demand would not be rationally willing to pay the same amount for higher quantity of the thing. The opposite happens and less than a needed number of the thing is produced. I learned the equation first hand standing for hours at a time, waiting in line to buy a decent pair of shoes in the cold streets of Moscow. It was the depth of the communism and the only way to get around was to pay black market prices, i.e. actual market prices. The wait as tedious as it was not necessary and with every passing minute I was willing to pay more than the governmental asking price. Many in line were there precisely to cash in the difference, as they profitably re-sold their shoes to those not willing to wait. Who said that laws of supply and demand did not work behind the Iron Curtain?
Back to our Canadian health care and I was finding out very interesting things. First of all, the laws of supply and demand postulate that every incremental change in price was to trigger a change in quantity and visa versa. Well, let’s consider an actual case of a sick and very cranky grandma. She is a brave and well-weathered soul; she went through depression and escaped a POW camp. Now in arthritic pain she is an entirely different person. She is winy, begrudging and really unpleasant at times, even to her beloved grandkids. A while ago, her doctor prescribed a strong, newly marketed drug that has far cost her $3 per day. Well, just this morning she found out that it is going to cost her $3.50 per day. To buy or live with a nasty pain? Do you really think that our grandma would forgo her drug? No way, maybe she will buy cheaper bread or use less margarine, but tinkering with her pills, no way!
As it commonly turns out, no self-respecting and moderately egotistical person would ever dream of rationing his or her supply of life-saving drugs unless outright hunger was in the offing. What this means for our neat laws of supply and demand is that health care is a so-called “inelastic” good/service on the demand side. In other words, suppliers could manipulate prices, at least on the margin, with a complete impunity of rejection or lack of patients. Just imagine someone waiting for a life-saving operation and finding out that it would cost ten thousand instead of eight. Would this person in pangs of unbearable pain be in the position to rationalize and haggle – unlikely!
So of this is the case then our suppliers (medical professionals, pharmaceuticals etc.) cannot claim free markets as the only “natural” regulator of their activities. Why is so important? Because the very push behind the private health care delivery emphasises markets, and only markets, in their miraculous ability to turn selfish ambition in a collective good. When in comes to sports shoes it might be so, but what about health care? Maybe not… I needed to dig deeper.
As we have just seen above, the rigidity of the demand side of the equation makes one issue abundantly clear – people and services on the supply side cannot be left to their own devices to deliver cost effective management. It is like letting a robber into a bank’s vault and hoping that no coloured pieces of paper would go missing. Now, I am not implying for a minute that medical professionals are dishonest or worse, what I am saying is simply a view of their naturally occurring motives of healthy greed that drives them just like the rest of us left to our own devices.
Increase the price of a pair of shoes by five bucks and your sales could plummet. Jack up costs of knee replacement by 10% and revenue would definitely increase. Many indignant members of the economic profession are now ready to pummel me with ridicule and rotten tomatoes - “you forgot that competition can still improve service and depress prices!” Good call in a perfect world, alas it is not about to happen any time soon, as doctors, nurses and other professionals acting in well-intentioned self-interest keep driving their remuneration nowhere but up. They do not operate independently of one another; instead they function as a cartel or a union with no intention to lose. Who is there to counter-weight the push? Consumer? Hardly, do you remember all those gravely sick who are cranky and selfish, willing to do and ingest anything to alleviate pain and suffering? They are not in a state to negotiate rates with hard-selling counterparts. Well, basically one is on his or her own unless helped on by their insurers, public or private.
The Land of the Free
“In perfectly free world both, the rich and the poor, have an "equal right" to sleep under a bridge” – an old joke
In the American system, the counter-weight to costs is provided by private insurers who take your premiums on the one hand, and try to minimise their costs on another, thus creating room for profit. Are they better in controlling costs and improving efficiencies as compared to governments who act as universal insurers with premiums mostly paid through a pull of taxes and additional fees, as we have it here in British Columbia? This is a truly pivotal question. I decided to check the stats on the WHO (World Health Organization) website and what a revelation that was. United States with its system of mostly private delivery managed its total health care bill at 15% of its total Gross Domestic Income (GDP, a measure of national income)[4], far outspending majority of other states that boast much heavier public delivery component. In fact, hardly any other country came close with Canada stuck amidst many others spending anywhere between 9.9% of GDP in 2003. What is going on?
The most obvious first question was - why would we want to emulate the American delivery model as it is much more costly. In fact, so much so that its equivalent here would see every Canadian, young and old, sick and healthy, spend on average $ 1,500 more per year on their health care. The only possible explanation lied in potential superiority of the American system, the superiority that stems from wider access and quality that would inevitably result (all other things assumed equal) in better infant mortality numbers, in longer life expectancy and a variety of other medical outcomes. Well, I checked and Canada shows to lead the United States just about in any category here. But why would the good people at CKNW keep pounding on their chests, convincing the whole world of accepting something as irrational as the US-based health care system?
Maybe there was some more. It did turn out that when one sliced very unequal American health care model in chunks of delivery by income strata, the results reveal some of the answers, as top 30% to 40% of American pay for and receive excellent care that has no waiting lines, offers latest technology and other goodies. The bottom twenty, surprisingly, did not fare too bad either they are frequently covered by Medicaid, a limited state sponsored health care scheme for the poor. The people who really got screwed are those who are just too rich to qualify for bona-fide poverty and too poor to buy coverage. By some latest accounts, there are more than forty million of these folks; they tend to be hit hard by lacking health care coverage altogether, which frequently exposes them to financial ruin and hardship. To emphasise the point further, American bankruptcy statistics show that approximately 80% of all personal filings are related to mounds of unpaid medical bills. In Canada, this category of bankrupt citizens hardly exists.
The Roots of Trouble
The ability to pay clearly is as a major indicator of health care access in America, strengthening my personal experience that straddles the border. But why would this system cost more was still a conundrum. I really wanted to discover deeper roots of this system and why it performed the way it did versus its Canadian and other counterparts. On further examination it turned out that out of the 15% of GDP that Americans spent on their health care in 2003, a whopping 3% percent was qualified as administration. In Canada by comparison, administrative costs were less than 0.5%. Not only this discovery threw a deathly shadow on the CKNW’s argument against Canadian inefficiency but also made me wonder as to the reasons for this high number.
I did not to scratch my head for too long. You see, while in Canadian system everyone is eligible, no-precondition requirements exist and overall risks are pulled in one unmistakable cauldron of health care risks. In the United State it is a completely different picture. Since a typical insurance company is after profits as a matter of their existence, the last thing they want to do is to insure high-risk people who are going to cost them more than their premiums are worth. These folks pre-select their customers, individually or through collective employment pools, assess their risks and charge commensurate premiums. Such system while extremely sophisticated and nuanced is very expensive and time consuming on the front end. And if this is not enough, these folks design many a way to monitor and shrink their coverage in order to pad up their mostly honest profit motives. While these legal activities sometimes echo in our own, very Canadian, haggling over issues mostly relating to elective services, they could at times become something else entirely. While here in Canada we have seen cases of citizens suing some provincial health care services for undue delay in service delivery, some cases in the United States have shown a much worse picture of criminal neglect leading to undue suffering and death. Remember John Grisham’s “Rainmaker”? The only developed country in the developed world where its intriguing and sinister plot was a little more than figment of one’s imagination was America...
OK, let’s subtract the bureaucratic inefficiencies and sweep them under the table. Once insurers assess and accept their clients, after they take their premiums and skimp some on the delivery end of things, the American health care is still costlier than most even after accounting for ever present profits. Why is that?
You see, in the privately run system, insurers are the ones who stand to counterweight cost pressures of medical help, emerging technology and new drugs. And if they are so profit conscious, should they not be able to fight for their profits effectively? For starters, it is difficult as insurers are precluded to put pressure on the closed ranks of service providers on a collective basis. Since many insurers besides fighting for profits, also fight with one another, their ability to exert a coherent countervailing position is limited at best. Quite unlike the government when it acts as the only negotiator – would you not think?
Taxes – the Root of All Evil
There is more to the story and here I have to utter the most repulsive word of the western lexicon than ranks just above Osama Bin Laden and Iran – taxes. These, long made to be the worst evil by politicians and other responsible citizens, play a key part in this debate. But only on one side of it though, the universal side that is. When private American insurers cannot make enough profit fighting rising health care costs from many a side, they frequently resort to a very basic business practice of rising prices or premiums. Citizens, corporate and individual alike, complain but so what. Life goes on, inflation is its inevitable side and ultimately everybody just puts up with unavoidable. Those who cannot cope just drop out altogether. Companies stop offering coverage and individuals prefer to do it at the risk of personal ruin. All of these things are well documented and indisputable, as less and less employers in the United States offer any kind of employer-sponsored plans. In fact, the current levels of corporate health care sponsorship are the lowest since Lyndon Johnson spoke of Great Society. It is so dire that even GM teeters on the brink of collapse mainly to its inability to compete with foreign makers on the basis of its health care costs. While German and Japanese makers derive enormous benefits from their respective universal systems, GM has to do it along and even despite its giant size it is sort of hooped.
On the tax side of equation things are not as simple, as universal coverage and corresponding laws exert high levels of responsibility from governments, provincial and federal alike. And these, collecting their revenue almost exclusively from taxes, cannot pass the buck as easily as their private counterparts. Instead they are mandated to address rising costs in much less popular and more obvious fashion that could include, Heaven forbid, raising taxes – what a horror for conservatives of all persuasions! Taxes, an awkward waif of democracies, make it difficult for governments of any ilk to avoid the wrath of those advocating for private health care advances. When in comes to taxes one does not even need to be awfully objective in order to scare general public to their point of view. For example, in British Columbia perennial levels of health care spending has been relatively constant over the past twenty years when juxtaposed to the overall income (GDP) of the province[5]; and yet that is not what you will hear from the airways. Here the picture is stagnantly different, complete with predictions of imminent apocalypse and rising taxes. “Private is the only option” has become the ever present mantra.
Other Scary Things
“Health care costs rise faster than inflation” is the most amusing centre-piece of the conservative disinformation campaign. They usually forget to tell you the following; since on average our collective income (GDP) rises faster than pace of inflation, the very fact of health care costs rising past inflation is not a cause for concern, it only matters insofar as such rises do exceed our pace of economic growth. Over the past twenty years (on average)[6] they have not, thus not necessitating any raises in hated taxes. But you do not hear much about that. Instead our “beloved” universal health care is about to collapse thus making private the only option. The only thing I fail to understand as to how costs, when transferred from your taxes to private premiums, could actually decrease when cranky sick people of all walks of life still demand very personal and particular attention amidst their plight, regardless of cost. The only way of saving money is to deny services, essential services, feature that universal system can hardly deploy.
We Love the French
Month after month and year after year of endless CKNW pro-private rants, their sell was still having rather hard time finding support among sensible citizens of Canada. People were clearly not inclined to buy the pro-American remedy, especially after inefficiencies of their system started becoming ever more apparent with eighty-old Buffalo grandmas flocking to sunny Ontario not to sightsee the CN Tower but to buy drugs, the very drugs they could not longer afford within the “efficient” system of their. CKNW and their supporters had to re-think their talking points if they were ever to succeed in swaying public opinion that now was counter-balancing many a pro-private government across the county like those of BC and Alberta. These have been rather effective in undermining the very public health care they purported to protect but more about this later.
After some deliberation, CKNW commentators decided to engage in much more subtle campaign of distortive propaganda. It was a dawn of the new century and things American were not selling anymore. Even the pervasive brain drain was becoming ever less apparent. What to do? How about proposing other universal health care solutions that are found in other countries like those with entrenched socialist practices like France, Denmark and Sweden?
Now, before I attempt to repudiate some specific talking points of theirs, let’s be clear. CKNW does not really like socialism any more than the next conservative guy, and would only use examples of France and Sweden when it highly convenient, as hardly any western social democracy, regardless of its fiscal pressures, is likely to abandon universality of access. Canada on the other hand is more susceptible.
One of their propaganda techniques centres on a small number of privately run hospitals that exist in Sweden and France. It follows that of these Pink Commies decided to give in to private, it must irrefutably good and advisable for Canada to follow. To emphasise the point CKNW then would use Sweden’s and France’s higher performance ratings by the WHO to drive the point home: they do better, they have more private facilities, hence private facilities are beneficial and we should follow. A straightforward point that is very attractive and…false. Let me explain.
Yes, Sweden and France do have some privately owned and run facilities but here the true story ends and myth-building begins. For starters, there is no direct link between their existence and favourable outcome ratings by WHO. The only way one could find a connection of any kind would be a proportionately larger share of private expenditures versus public having an effect on the county system as a whole. For example, if Sweden had higher levels of private expenditures and performed better than Canada then one can plausibly make out a link of private delivery achieving better outcomes. Well, the reality is actually quite the opposite as Sweden and France already have lower private heath care expenditures than Canada, making it illogical to connect higher levels of private care with improved outcomes. In fact, the logic of the matter implies the opposite – Canada should increase public portion of all health care expenditures and not decrease it. In addition, looking through some additional info on the web regarding private clinics in Britain and Sweden, it appears likely that some private clinic successes in these countries are primarily attributable to downloading of less profitable procedures from private to public clinics while uploading more profitable ones in the opposite direction. For example, private clinics tend to perform way less heart surgeries while piling up on inordinate amounts of hip replacements. Knowing human weakness for financial success I am not surprised, are you?
Inconvenient Facts
Why do these countries do better in health outcomes than Canada if it is not for private delivery? There is a simple, two-prong answer – national drug policy and higher proportion of doctors per capita. These factors contribute not only to better overall health outcomes and also reduce elective surgery line-ups. So much so that these are virtually non-existent amidst the French health care bliss, the new and unlikely poster child of Canadian conservatives – a strange love connection indeed! The next question to answer is that why with substantially higher levels of doctors and correspondingly better health outcomes, Sweden and France do not spend any more than Canada. It must their private delivery efficiencies, right?
To be blatantly honest, CKNW does not even pose this question correctly as they constantly harangue us on how France and Sweden spend less on health care than Canada. This is not quite true as many other things according to WHO. Canada actually spends fractionally more than Sweden and fractionally less than France, but this is not the key question. The key question is “how come they boast doctor per patient ratios of 50% higher than those of Canada?” This is key factor in improving outcomes.
The answer, unfortunately for my conservative friends, has nothing to do with so called “efficiency” gains that always point towards the private delivery option. No, it is much simpler; doctors in Sweden and France get paid substantially less than their counterparts in Canada. Why is that? Are the followers of Hippocrates more altruistic on the other side of the pond? Hardly! It is just that their governments, and not private insurers, are the ones who not only control key aspects of wage negotiations but also heavily influence professional licensing associations and direction of health policy – precisely the wrong prescriptions for the lovers of unfettered markets! Moreover, these governments have had a gall as to compel many health care professionals to be employed as salaried employees and not independent practitioners as it is done in Canada. Socialism reigns and CKNW supports it, amazing! Not really, CKWN only supports selective and convenient facts.
Another interesting aspect of universal health care system that is heavily touted by CKWN is the notion of co-payments. In fact, these are quite frequently used in France and Italy as an example. The argument for these is to ration health care at the till in such a fashion as to reduce unnecessary system over-use by some perpetual health cranks. Here, I have to admit that my position is ambivalent as it is clear that some positive rationing could be accomplished this way, except that one has to place a carefully-crafted sliding scale on such co-payments lest these become yet another tax on those who can least afford it. And on the flip-side, to set up programs on income test basis might be costly in itself. To sum up, a debate is surely needed, a healthy debate with opposite views getting enough airways. Instead I keep getting daily one-sided rant earfuls. Besides, CKNW never mentions that France, as an example, primarily requires deductibles in a funny area of public health care called dentistry – the very one that is just about entirely private in Canada!
In addition, when using France and Sweden examples of private care delivery, conservatives omit another important fact proclaiming Canada’s inability to deal with incoming crises of relatively rapid ramp up of health care costs in the last few years. Checking WHO stats once again revealed that just about all countries, regardless of whether they offered universal health care or not, experienced similar increases with Canada being right in line. In fact, the system that has feared worse than others between 1999 and 2003 is the very private USA model.
Ageless Age Dilemma
Assuming that I am not the only one who found certain holes in the conservative logic, lately their focus shifted to ageing population – a seemingly good discussion that always leads to private health care, somehow…OK, let’s consider the issue. First of all, let me sat this: ageing demographics affects many, many countries, especially developed ones and as much as it is a fact of life we cannot do much about it other than start outright culling all those pesky baby-boomers. Fortunately, not many are into blood-letting, forcing this question on the higher plain. Yes, the ageing issue is upon us. Yes, it will increase (at least on absolute level) health care costs. Yes, we can undertake some improvements around the edges. That’s it and the rest is simple. Since we are going to assume responsibility over ageing folks anyway, universal health care seemed to be the best option and as it has shown to be way more effective that its private counterparts – why should we change the course now? Once again – the ageing demographics in itself is not produce a case for expanded private care options.
Besides, there is more to it than just ageing. While health care costs for healthy people over 65 do increase when compared to their younger compatriots, the resulting difference is not as significant as one would expect. For example, per capita average annual expenditures while increasing about fifty percent between these broad groups (under and over 65) are actually not that significant in absolute dollar terms amounting to just around $300[7] per annum. This difference, converted even at the highest aged to young population ratio projected for 2031(the very peak of baby boom) amounts to less than 0.2% of our GDP (BC figures). A much bigger factor that really weighs heavily on health care expenditures is the nefarious issue of death, as the final year of life for individual of any age tend to multiply about 75-fold versus any other year of life. So it is not ageing that is an issue, but human efforts at prolonging our lives at all costs that tends to drive health care expenditures. But even so, there is really no particularly case for private care. Moreover, it seems to be the opposite, as under private care option discomforts and anguish of the last year of one’s life could substantially vary depending on financial means! I bet many would find it simply cruel. I find it abhorrent that ageing is used as the reason for introduction of private health care. If we are genuine about end-of-life care than we should have a debate about this on the basis of ethics and not dollar signs, after all it is the fastest growing and most profitable field of private health care in the modern world, and starting the debate with dollar signs strikes me more than unproductive. What do you think?
Queue Rumours
It is about time we delve into the wait-lists as they tend to mostly affect people of age who wait in line for knee and hip replacements. To begin, let me emphasise that these procedures were not even in existence at the outset of the universal health care in Canada. As recently as twenty years ago, we simply suffered without it. So the very idea that our extremely “inefficient” public system even offers these procedures should sound somewhat disconcerting to the proponents of private care. Alas, the issue of waiting lists in the realm of ELECTIVE surgeries is real. Now, how did we get here? For two reason – governments’ complicity in advancing private agenda and unduly restrictive licensing and medical school graduation requirements that remain under firm control of “impartial” professional bodies such as CMA (Canadian Medical Association) and Nurses Unions.
Before, we go any further. Let me tell you a little anecdote. Imagine a town with ten thousand inhabitants with each going through a pair of shoes a year, making it necessary for the local and only shoe store to offer for sale about four pairs daily, Monday through Friday, Let’s say of twenty weekly pairs of shoes, the store decides to supply nineteen instead in the first two weeks. In two weeks two people are without shoes. Why only two, well it is the proportion of folks on waiting lists to the total population. Now, for the rest of the year the store sells all the shoes needed thus skimping only on two pairs out of ten thousand resulting in savings to the overall shoe budget of about 0.02% percent annually at the expense of private pain of two individuals. To correct the situation the town needs to spend a fraction more in order to correct the situation but they do not, creating a huge wave of negative publicity. Most of us take such news on a personal and very emotional level, prompting many unanswered questions. While legitimate, these questions could be debated and answered, instead CKNW and friends jump into the fray with one goal in mind – to prey on our emotions and churn up support for their private solutions.
Government – “Enemy” of People
The governments here play a very subtle and complicit role. They could choose to explain the situation and discharge a workable solution. On the contrary they remain silent. They do not want to admit that relatively small incremental increases in total expenditures would eliminate the waiting lists – why? They need them just like CKNW. In case if you have not noticed, every government, provincial or otherwise, plays this game. The more conservative the ruling party in each given province, the harsher exploitation of facts on the ground – just have a quick look at BC and Alberta. Both ruling parties in these provinces are heavily beholden to various, shall we say non-public, interests who are first and foremost beholden to profits. Now I do not intend to demonize people for their desire to extract profits under the general accepted economic framework. But one has to admit that letting 7% (universal portion of health care) of our entire GDP go untouched leaves many wishing it were not so. This is a perfectly legitimate individual expression of greed, would you not think? Many of us know that for example government in Alberta is very comfortable with oil and gas industry, why not health care INDUSTRY? A good question…
CMA[8], a self-regulating body of physicians alongside of others, provincially based organizations, plays a major part in the whole debate too. Which side of the divide do they stand on? Historically, its stance has varied but the allegiance to its members has always been paramount and for a good reason, as anybody in their shoes would do the same. I would. Sure, all that gobbledygook about Hippocrates and his bloody oath could be used when convenient, but ensuring the livelihood of the members is way more important. If in doubt just check out who is the current president of the body – Dr. Day, indeed! One of the most ardent and ferocious proponents of private care and, incidentally, one of the owners of much maligned and controversial False Creek surgical centre in Vancouver, he and his colleagues are very smooth and sophisticated operators who even manage to ask right questions of the Supreme Court of Canada when in comes to advancing their agenda as shown by the famous Quebec case just heard past summer. They like to use the guise of efficiency and public need when really pursuing crude self-interest, helped on by many a complicit individual in elected positions.
I do not begrudge the fact that majority of individually practicing professionals put their own as opposed to system’s interest on the forefront of their ideology. Remember, the government is there to provide a counter-balance – ideally. Alas, our governments have tended to have much more deference to CMA than to its very own principles. Consider licensing and service procurement as an issue.
“Worthless” Diplomas
Our country is a country of immigrants, recent and well-established. Many of our recent newcomers are qualified medical professionals who are willing and ready to practice their professions in their new homeland. Alas, it is much harder to do so that it seems. Of course, I understand that our standards are different and perhaps more stringent than in many other countries, and yet it escapes me as to how a surgeon with ten years of experience in South Korea has to go through at least four years of additional schooling and residency to resume his or her craft here. Considering that some of these immigrants are burdened with age, families and financial pressures, it becomes hardly a simple task to qualify. Why not? CMA, again with full governmental acquiescence, is not interested in too much professional competition that could depress the financial successes of current members, Heaven forbid! Instead, they stringently cling to artificiality of many barriers to protect them.
On the other side of the coin, CMA and others persistently lobby for North American uniformity of qualification standards - a seemingly benign and even progressive practice that could and probably does result in some efficiency gains. However it poses a major dilemma for our universal system. Remember, the system in the United States is probably more favourable to upward cost pressures, i.e. salaries of medical professionals, thus making many doctors, especially the ones in rare specialties, fabulously wealthy. So by lobbying for open across border interchange, CMA not only introduces some system improvements, but also holds a gun to the head of Canadian governments, essentially saying that they are all but ready to leave if too much downward pressure is placed on them. Much of it of course is just rhetoric but rhetoric potent enough to keep governments, especially conservative governments, very timid indeed.
Again I can understand their position. CMA and Nurses Unions just exploit the system for the benefit of their members. As you see, nobody is perfect. However, the government does not need to sit idle and not resist. For starters, governments can and should expand number of places in medical schools. But this is not all. Remember that even with higher than average tuition rates our medical school students still receive hefty educational subsidies. Why not introduce a mechanism whereby such subsidies would be clawed back if newly baked graduates decided to ply their art abroad. Of course, in the free nation of ours, we cannot prevent freedoms of physical movement, but we sure as heck can place financially redeeming caveats around our public expenditures.
The next issue to tackle is the issue of residency as in order to become a medical doctor for example, one needs to complete several years of residency regardless of speciality. Well, so far CMA and others have been very successful in restricting residency spots, making it difficult for governments to expand medical schools enrolment. Perhaps it is the time when government took a more proactive role?
Other Public Solutions
Finally, it is has been proven that further efficiencies could be gained through expansion of preventative medicine as opposed to the reactive mode that our system frequently finds itself in. Facilitation of such practices requires an introduction of medical centres built around salary-plus incentive models. For example now in the system that is based on fee for service model, many practitioners find themselves prompted by unproductive economic incentives. These stem from the fact that each incremental visit means incremental dollars in doctor’s pocket triggering an avalanche of unneeded visits for renewed prescriptions and discussion of test results. Reduction in such activities could provide more cost savings than co-payment options that we have discussed above. Why not put some of these professionals in salaried positions that could reduce their financial stress and increase the level of care, all the same time? I know that some might say that doctors would become lazy due to lack of financial incentives. Well, when I mean salary, I am not suggesting the system without performance targets and corresponding bonus structure. I am just suggesting a slightly more balanced approach that emphasises core premises of the health care as a whole – compassion and not dollar signs. The emphasis on preventative versus reactive medicine has proven to be extremely workable beyond well-endowed Sweden and France. How about Cuba? This financially poor system somehow managed to beat the United States in child mortality rankings, how is that possible? Simple, the system designed around patients as opposed to individual profit motives could work much better even on a shoestring budget. Maybe there is something to learn here. Well, not in your life time when it comes to CKNW.
Needless to say, governments do very little in the way of suggested; instead they cower in their own shell of ideology that in its essence in not aligned with universal health care as permanent institution. For many, universal health care just simply does not have a future just like hikes in minimum wage. After all poverty does not exist, right Mr. Kline?
It Is All Dope
So far I have spent much time discussing the ways to debate and deal with cost pressures when it comes to services. How about drugs? To be objective, cost pressures of various drugs have come on the forefront of the debate in the last few years and have become major cost drivers in health care delivery of all countries regardless of access, public or private. These of course are mostly driven by very large and powerful multinational pharmaceutical companies who are in pursuit of profits as any other sane individual. The problem is the primarily their size and ability to exert undue pressure on already shaky politicians. So much so that when, under the American public health care program for the seniors (Medicare), the American government introduced a new drug prescription benefit the policy makers agreed on a very strange caveat – states would be prohibited from negotiating drug policy prices with drug manufacturers. A truly astounding achievement of democracy! What is the reason? Well, the drug benefit was introduced after much pressure was brought to bear by senior groups outraged over prohibitively high prices of drugs that drove people even across borders (mostly US-Canada). The new bill is supposed to alleviate the program – but, Goodness Gracious, not at the expense of pharmaceutical companies! Instead, the state budgets (TAXES) are to bear the entirety of the expense as US Fed so far contributed dick all beside the piece of paper.
Of course, the long-standing American tradition of raiding taxpayers for private gain is all too illuminating to the issue of incentives. On this front, to be fair, Canada has done better as its provincial governments dare negotiate with pharmaceutical lobby. The direct result is a well-documented positive cross-border price differential between US and Canada. Is this all we can do? Of course not, as we can manage the issue on country-wide level beyond just bulk purchasing of drugs. We can change the patent laws themselves in order to benefit the public purse. Here, just about anybody off centre is crying foul! How can you say that?! The laws are laws, they untouchable! Hogwash, the laws are there to benefit public interest at the benefit of every individual interest subject to Charter of course. And if there is enough interest in helping our struggling health care, should not we able to change some laws? Of course!
Now, I am not proposing to lead a war of annihilation against pharmaceutical industry. What I am suggesting is to re-evaluate our mutual positions in few of public interest. Sure, it might result in lower profits for large drug developers but given the fact they are already one of the most profitable international business segments, it might be in order. Besides, if these folks are true free market believers in the laws of supply and demand, should they not favour lower prices that trigger huge swings in sales volumes of Prozac and Viagra?
Last Punch
As you can see after the years of non-debates on CKWN I have managed to convince myself of their obvious lack of objectivity. Gone are American solutions, defeated the falsehoods around Swedish private therapies and dealt with are the private incentives. One last straw of an argument worth bringing up is that against those arguing that introduction of private health care alongside the universal system will reduce waiting lists and thus improve the system. Let’s consider. After this, I promise, I will shut up.
OK let’s assume a perfect world in which the only culprit is the government that is not willing to open its wallets and shell out 0.02% more to deal with waiting lists. In this perfect world the doctors are compassionate and constantly lobby the government to release the purse-strings and let them reduce the wait lists. These folks are altruistic and are willing to do it for the same rate as all other operations the governments have so far let them perform. Right…
In reality this is not what happens as by and large the most vocal voices on the CMA side are of those setting up private clinics. Sure, there are conscientious groups of doctors who do not agree with that but by judging the vote outcome at their last general meeting these folks are in minority. So let’s see what happens when private health clinics do get set-up. I would like to do it from a high level perspective, using Vancouver as an example.
Mr. Day set up his False Creek surgical centre to “alleviate” the public waiting lists. He invested a lot of his own money, borrowed some, built/leased a building, invested in latest technology and purchased additional private liability insurance. He is ready to start. He is efficient and mean, ready to take on the government. Let’s see, can BC government do the same in reverse? Employ Dr. Day himself and still do it cheaper. After all, the new wing of VGH still boasts available space making leasing entirely unnecessary. BC government can borrow money way cheaper than very private Mr. Day and his practice within the universal system would be way less litigious, making all his additional liability insurance purchases unnecessary. He would still be a private, fee for service, practitioner with very healthy income and much less headache. Why would he want to go through a painful and argumentative private route of opening his own clinic? Simple, he would never do it unless provided with governmental assurances, implicit or explicit, of its own inaction. I.e. waiting lists would remain as long as Mr. Day and many like him are willing to pursue larger, profit oriented, agenda. By the way if in doubt call him for a fee schedule. Sure as heck his prices are way higher than those paid by the government on a fee-for-service basis. To sum up, yes Mr. Day can reduce wait lists somewhat but at what cost? And how will the lucky patients be selected if not on the basis of their ability to pay, an ability that is hardly commensurate with patients therapeutic needs? I suspect that Dr. Day would not care and why should he? Besides, seeing Mr. Day successes, many in similar situations would be willing to shorten their public hours to earn more on the private side, which could perhaps even further exacerbate the very waiting lists they are trying to alleviate. Good Luck!
THE END
Thank you for managing to get this far, as digesting murky postulates of non-existent debate is never an easy task. But not all is lost, as struggles for clarity continues and universal health care has not breathed its last, yet. The fact that a simple a gesture as your vote at a next provincial or federal election could be of a more informed nature is solace enough. Anything beyond that is just gravy. Just remember, universal health care is not a servant of natural greed laws but a product of well-conceived and sometimes courageous policymaking.
[1] John Maynard Keynes (1883-1946) author of famous “Theory of Employment, Interest and Money”, a staunch proponent of governments’ ability to intervene into economic matters.
[2] From here on when I refer to CKNW, I mean a much larger array of mass media of similar persuasion including TV, magazines and newspapers.
[3] Milton Friedman (1912 – 2006), author of "Monetary History of United States", Nobel Prize 1976, the most prominent and influential force behind arguments for minimal role of government in economic matters.
[4] 2003 number (WHO)
[5] They actually increased at about 0.15% of GDP per year for the past five years. These increases have been primarily attributable to the expansion of new services and not the cost of existing services.
[6] This is the same as the previous point.
[7] Canadian Policy Alternatives BC Health Care Review - 2006
[8] I use references to CMA throughout the paper. These references could equally apply to Nurses and other unions.
