As of early October, there was nobody in the who knew what a US health care/insurance reform agreement might resemble " or whether there would be one by year’s end (or even at all). Smart money insists there will be a health care agreement " the effort is ”œtoo big to fail” and failure would permanently scar the Obama administration with intimations of future failure. This judgment reflects recent polling, with a majority of Americans in favour of significant health care reform and legislation passed by year’s end " but with a majority reject- ing current proposed health care legislation. Thus regardless of whether the outcome is akin to a camel (the result of a committee to design a horse) or a pitiful ”œmountain- laboured-and-produced-a-mouse” result, eventually there will be something that can be labelled ”œhealth care reform” " even if passed by party line, simple majority vote, regard- less of the subsequent political costs.

The US debate doubtless both puzzles and irritates Canadians. Puzzles because in Canadian eyes who can be against health care for every citizen? Irritates because critics of a comprehensive US health insurance program invariably world start their criticism with invidious critiques of north-of-the-border health care shortcomings. But Canadians should not take it personally; if the ”œFrench model” for health care were being embraced, critics would be even more pleased to belabour persnickety Parisians. The critics focus on Canada because ”œit is there” " and advocates of something akin to a single-payer system for the US tout its specific virtues of nonprofit, universality, portability, comprehensiveness, and accessibility. Consequently, these virtues are depicted as vices (or inadequate) by critics.

It is not that the Canadian ”œsingle payer” system is flawless. Every engaged Canadian recognizes its flaws but endures them. Canada’s health care fits the national self- image of stoic patience and a strong, caring social safety net. The most obvious of the Canadian health system’s short- comings is that Canadians pay up front for health care through higher taxes throughout their working lives, but, often in their declining years or when expensive diagnostic or quality of life interventions are needed in the form of MRI imaging, cancer treatment, heart bypass surgery, hip and knee replacements, and/or cataract surgery, there is extended delay. There is a ”œfree lunch” " but the service can be very slow. And sometimes the delay is fatal. Always the delay is frustrating and pro- vokes fear in the afflicted and their families. In the end, however, the aver- age Canadian mutters the equivalent of Winston Churchill’s comment about democracy, that it is the worst of all systems, except for all of the others. And we Americans should ignore the Canadian example: we are not Canadians.

There are various canards associat- ed with US health care. Perhaps the most persistent of these among Canadian commentators is that huge numbers of Americans are uninsured, with the coincident intimation that they die scratching on locked emer- gency room doors. This number surges up and down depending on the observ- er and who is being counted (should illegal immigrants be included?) but, for the sake of the discussion, let us say that 10 percent of Americans are unin- sured, perhaps equivalent to the popu- lation of Canada. Dramatic, eh? Of course, approximately 10 percent of Canadians lack a primary care physi- cian, so the right to free care (when nobody is available to provide it) may balance the problems of accessing the care if you lack sufficient insurance.

But while horror stories can be true (although those cited by President Barack Obama in his September 9 speech to Congress were not precisely as depicted), the reality incor- porates nuances that are little appreciated, including:

  • Some decline health insurance for religious reasons, believing that the power of prayer provides the necessary healing. Such beliefs may be best for the healthy, but they are nonetheless heartfelt among believers;

  • Some are young and healthy and, consequently, decide logically that they do not need health insurance and would prefer to use the thou- sands of dollars that would be spent on health care for HDTVs, pleasant vacations, gourmet din- ners, or other personal consump- tion. There might even be those who choose to invest this money, delaying gratification for future security. At most, they might pay for ”œcatastrophic insurance” " the totally unforeseen accident occur- ring while participating in extreme sport, etc. " and purchase more comprehensive insurance only when they acquire responsibilities such as a spouse/children. We might not care to take such chances; however, in a society that values personal freedom of choice very highly, it is not a trivial ele- ment of such freedom;

  • A significant number of the unin- sured choose to practice ”œmedi- cine by emergency room.” Even if they can afford insurance, they go to hospital ERs for their specific complaints, often delaying their treatment over concerns that are more psychological than finan- cial. It is questionable whether universal health insurance would change their pattern of engaging with health services.

  • The truly destitute, even if they can- not pay for the medical services they receive in the ER and/or hospital, are treated. The costs for their services are absorbed by the overhead fees  and charges at individual hospitals. In effect, we all pay for them.

”œDeath panels.” Nobody gets out of life alive. And, in that regard, all expenditures on health care face the green eye shade reality that we die, if not immediately, eventually, regardless of the money spent. And the more that is spent, especially in the end game of life (that famous ”œlast year” that absorbs disproportionate amounts of resources), the more questions arise regarding whether this money could be spent more usefully elsewhere. Do we extend the life of an octogenarian by six months or devote the funding to saving the snail darter? Do we make heroic efforts to save the gang member appearing in the ER with multiple (potentially fatal) bullet wounds or put greater funding into recycling hard plastics? Do we create a societal right to have a child by financing in vitro fertilization rather than extending early age child care for those already born? In short, money is fungible and efforts to save babies born at the edge of viability, individuals ”œbrain dead” from massive traumas, and those whose contribution to society will never be equal to the funds devoted to them mean that other socially worthy projects will not be undertaken. Or they cannot be undertaken at an endurable level of taxation.

This reality weighs particularly heavily on the elderly. Many are des- perate for the last second of life, but others are acutely aware that their chil- dren and grandchildren are sacrificing for these extra moments. In societal terms, probably the perfect citizen is the one who works vigorously throughout an adult life, paying taxes and consuming minimal services, but then dies at the point when just retired (s)he would begin to absorb services, notably for declining health, in excess of current earnings. Thus there is the sotto voce intimation that the responsi- ble citizen has a ”œduty to die” and should voluntarily step onto that leg- endary iceberg and be swept into the hereafter rather than ”œwasting” medical resources by accepting ”œheroic measures” at life’s end.

Normal hospital and medical pro- cedure for those receiving services is to provide information regarding a ”œliving will” as part of the standard operations of medical staff. However, one of the initial variants of the health bill would have provided pay- ment for doctors to deliver such coun- selling " and prompted the reaction that vulnerable elderly would inter- pret discussion of end of life options as a polite ”œgo now” imperative. The proposal has since been dropped; however, it still feeds the real fears of the elderly who know that their life marathon is ending but who are not in a hurry to sprint to the finish.

Consequently, polls suggest that the elderly are most skeptical about prospective changes in insurance/ health programs that appear to be working reasonably well for them. The presidential contention that vast sav- ings will be found in Medicare reform don’t pass the sniff test for the elderly who have seen the ritualistic maxim that there would be vast savings from eliminating ”œwaste, fraud, and abuse” proved risible. And one should always remember that the overwhelming majority of Americans are indeed insured and essentially satisfied with their medical services.

Astronomical costs. The United States pays a disproportionate amount of its GNP (reportedly 16 percent) and significantly more than the OECD aver- age for health care. Reports indicate this cost is reflected in higher salaries for physicians, higher administrative costs, and higher prices for medical services and medications. Americans absorb greater amounts of expensive techno- logical attention in the form of imaging and surgical procedures such as cataract surgery, hip and knee replacement, and Caesarean sections. Such cutting edge technology and the supporting medical research never seems to become less expensive.

Consequently, many were taken aback by the Congressional Budget Office’s estimate suggesting the administration’s proposal would add a trillion dollars to the deficit over 10 years, at a point when gargantuan expenditures relating to great reces- sion rescue have left the USA adrift in stormy seas of red ink, with no indica- tion of a safe harbour near at hand.

There is intense skepticism over the president’s commitment that no health bill will add to the deficit. History says otherwise. Likewise, the question of increased taxes on the average worker is a serious issue. To be sure, the complex compensation proposals for those who cannot afford payment may work, but for the normal consumer of medical services/insurance (and not just those currently uninsured by choice, who will be required to purchase insurance), it looks like a tax grab.

Some existential problems. The two most troubling elements of standard insurance are denial for ”œpreexisting conditions” and de facto denial of con- tinued insurance after significant ill- ness by raising premiums to unaffordable levels. Insurance compa- nies now say they will eliminate these restrictions if all citizens are required to purchase health insurance, which would provide them with a new pool of the young/healthy who will pay but not require expensive services. It is conceivable that a ”œpublic option” " government-funded insurance " could provide an expensive mecha- nism for insuring the ”œuninsurable” but continue to preserve ”œchoice” for the healthy to go without insurance.

Likewise, troubling is the prob- lem of US failures regarding ”œpreventable deaths,” where we stand last among 19 industrialized countries. Some of these problems may be amenable to ”œbehaviour modifica- tion” " if you don’t overeat; if you exercise, stop smoking, limit alcohol; if you don’t do drugs, if you discour- age single-mother pregnancy and stop shooting each other, many pre- ventable deaths would indeed be pre- vented.

A touch of politics. Canadians fought their national health care battle a generation ago; they cling across the political spectrum to a ”œsingle tier” of health care. For the USA, revised health insurance is a political ”œthird rail,” which badly scorched the Clinton administration at its inception and threatens commensurate damage to the Obama presidency. Elected on a flood tide of ”œchange” against a rip tide of recession, Obama’s administration seeks to resolve multiple issues simulta- neously. The list sometimes appears end- less: financial restructuring, health care, domestic security, global warming; Iran, Iraq, Israel, Afghanistan, Russia, China, North Korea, and even the location of the 2016 Olympics, where the presi- dent’s failure to sway the International Olympic Committee judges illustrated the limitations of rhetoric.

In the end, there is one vast pool of alternative funding " the US defence budget. We may be forced to conclude that we can have the world’s best armed forces (at a cost essentially equal to the total of the rest of the world’s national defence budgets) or health care equivalent to current stan- dards extended to the entire popula- tion. But we cannot have both. Such a judgment could force a brutal rebal- ancing of our national priorities, both domestic and foreign.

And nobody is yet ready to address such tradeoffs.