Paul Jacob

Two weeks ago, in my column "About-face up north," I discussed a recent poll of Canadians that showed surprising, majority support for establishing a "two-tiered" medical system, allowing private medicine to work alongside public medicine. This in itself was surprising, since Canadians always appear to be staunchly in favor of their socialized system.

Of course, I took the story as occasion to warn Americans off of the popular panacea of government-run monopoly health care.

I had expected a nasty backlash. I've read quite enough Canadian blogs and letters-to-editors, and am familiar with the venom that some Canadians unleash upon critics of their system. (The stereotype of the milquetoast Canadian does not apply to political partisans!)

But I got none of that. Instead, I got interesting, insightful letters, most of them sympathetic.

Patients Go South

In my article, I suggested that Canadians were lucky to have the American medical system close by. A number of readers concurred:

One could even go so far as to say that the only reason that the Canadian system works at all is because so much of Canada is within fairly easy reach of the U.S. Ask any doctor in border states how many of their patients are Canadian. My brother's family lives near Bellingham, Washington, and my sister-in-law has said that half of the patients in her doctor's waiting room are Canadian. Not just rich ones, either ? just ones that need timely care and have the willingness and ability to pay for it.

I guess it's nice to see Canadians "outsource" their health care needs. But it's unfortunate the lengths they have to go to:

Living in Florida we see, first hand, the number of Canadians that come here for the winter and get all their health issues taken care of while they are here. My understanding is that the Canadian government has to pay for the care they get here.

Let it not be said that Canadian politicians have done nothing. In 2002, Senator Michael Kirby of the standing Senate committee on social affairs, science and technology argued for a "care guarantee," and proposed that Canadians who cannot get fast service nearby should be sent elsewhere ? including America ? at government expense. From my research, this proposal to pay for outsourcing was not put into effect, however. They had run into a snag: How to pay for the added expense. So as far as I can ascertain, the Canadian government is not paying for Canadians' Florida medical junkets.

Harsh Realities

A number of readers thought I downplayed the horrors of the Canadian system:

Things are much worse in Canada than your article suggests. It is not only elective matters that are delayed, emergency treatments are also delayed. For example, my wife's aunt was rushed to a hospital in southern Alberta with severe coughing. She was forced to wait for over ten hours before she was looked at. By this time she had suffered a massive heart attack and her life was over.

We should never forget the worst result of a bad system: the cost in human life. This is a sad story.

Another reader reminds me of another result, chaos and strife:

Earlier this year, 43,000 British Columbian health care workers were on strike. Surgeries were postponed, patients not seen, etc.
Health care workers are unionized ? at one point, there were wildcat strikes by other unions: ferries and the border crossing were two noticeable ones. The plan was to shut down the province. . . .
While Canadian TV was filled with stories about health problems, bureaucratic problems, and horror stories about neglected patients, the U.S. press was still carrying stories praising the Canadian system. The usual election-year socialist propaganda for the Democrats.

Perhaps the standard journalistic ethos is: better a few old people die in emergency rooms than anyone have to save for and pay for good health care!

Basic Philosophy

Not a few readers expressed a wider, more philosophical view. Here is one eminently sensible letter:

I do not think our medical system is a "notorious disaster." I think we expect too much from it.
In what other market does someone spend $100,000 and expect not to have to pay for it?
In what other market do 75% of the costs not help the recipient? (last week of life)
We have chosen a two-tier medical system. One tier is constrained by costs (private), the other is beginning to be constrained by access (government). The major problem today is the inability for certain people to jump from one tier to another. In other words, would most young people like the government model of waiting for health care in exchange for less cost? Probably, but they can't have it. Would most older people like the private model of paying for instant access to health care? Probably, but they can't have it.

Let me interrupt this letter for a moment. My basic reaction to most talk of medical care, and nearly every solution offered, is one of incredulity at the amount of coercion most people are willing to put up with. Yes, America has a two-tiered system, and moving from one tier to another ain't easy. Why? It's the law. In the case of American seniors, avoiding Medicare is almost impossible. You have to be rich indeed, and then pay for what you want in cash. Why? Because seniors are forced into Medicare upon retirement. The only way to avoid it is to foreswear Social Security benefits! And now that Medicare is firmly ensconced in our culture, just try getting medical insurance over retirement age. Insurance companies will offer "Medigap" insurance to seniors, but full coverage? Slim pickin's.

Government solutions rely heavily on force ? as readers of my free Common Sense e-letter well know. In my column, I used the word "regimentation" to describe Canada's system. But it also describes our own, in too many instances.

But back to this final letter:

The other problem is the masking of true medical costs. Not many people see the bills (and discounts) from medical practitioners to evaluate from a cost/return standpoint.
People would be able to see the true cost of medical care if the companies' portion of insurance were taxable.

True enough. Economist Milton Friedman has explained the origin of our medical insurance system. During World War II, wage and price controls prohibited businesses that supplied war goods to the government from raising wages to attract the workers they needed. Businesses cleverly offered a "fringe benefit" of medical insurance. By the time the IRS figured this out, workers had fallen in love with the system. So Congress legalized this loophole around the upper wage limit, and from that day on Americans have increasingly expected their employers to provide insurance.

An idiotic system, really. Economizing becomes barely possible. You choose the way you pay your medical bills along with your choice of employment. Talk about a cumbersome package deal!

As my reader suggests, it would be easy to fix: repeal the tax exemption. Then, maybe, Americans would begin thinking about their medical care in a rational way, as they begin to shoulder their burdens responsibly.

Just don't look north for that model of rationality and responsibility.


Paul Jacob

Paul Jacob is President of Citizens in Charge Foundation and Citizens in Charge. His daily Common Sense commentary appears on the Web and via e-mail.