Cancer Care Ontario couldn't ask for a better spokespatient than Marilyn Markou for its "Buffalo patients." That's the rubric for people the province pays to send to the US for treatments Canadian hospitals too backlogged to handle.
Canada's state-paid healthcare is often seen as fairer and more cost-effective than the American system. But Canada also needs to rely on America for medical services that it can't provide.
Ms. Markou, who spent seven weeks in Buffalo, N.Y., last summer receiving radiation treatments, has nothing but good things to say about the care she received. She even saw her summer sojourn as an opportunity to do some sightseeing. "I had never gotten to know Buffalo."
Still, she has some pretty stern criticism of Canadian Medicare, universal, government-paid medical care.
"The government has to pull its socks up.... I was sort of embarrassed that I had to go to another country because my own country couldn't look after me. That was not a good thing."
The existence of re-referral programs like Cancer Care Ontario's - and the waiting lists that produced them - are taken by many Canadians as sure signs that something is wrong with their beloved healthcare system. If this system - that to Canadians makes their country a kinder, gentler alternative to their neighbor to the south - is so great, then why does Canada have to send people to the US for treatment?
Province after province is experiencing medical inflation in the double digits. Poll after poll reports that the public identifies healthcare as the leading issue facing this country. But neither the public nor the politicians seem to have many ideas of how to fix what's broken. It's the policy debate that hasn't happened.
"There's an appallingly low level of public debate ... with a 'know-nothing quality' to it," complains historian Michael Bliss of the University of Toronto.
Indeed, a recent Internet poll asking, "Do you prefer the Canadian approach to providing health services or the American approach?" found 96 percent of the 447 respondents favoring "the Canadian public pay system." Exactly one respondent said, "I prefer the American private pay system." Three percent favored "a combination of the two." In fact, both countries have a "combination," albeit with much greater public involvement in Canada.
That "the public tends not to be knowledgeable," as Michael Rachlis, a health-policy consultant in Toronto, tactfully puts it, impedes debate. So does the tendency to see the options as either/or, public-pay Canadian medicine vs. greed-driven American medical care.
In the political arena, the genuine complexity of the challenge is compounded by fingerpointing as federal and provincial governments vie to see who can offer more in the way of tax cuts. Healthcare analyst Fred McMahon at the Consumer Policy Institute in Toronto describes the dialogue between Ottawa and the provinces: "What everybody says is, 'Money's not the answer. Real reform is needed.' Then the next sentence is, 'You're not giving enough money.' "
The most concrete reform proposal is Alberta Premier Ralph Klein's Bill 11, which would modestly expand the range of minor surgeries private clinics can provide. It's been hugely controversial; the banner headline across a recent letters page in the Toronto Star was "Klein's way is the law of the jungle in fine dress."
Federal Health Minister Allan Rock made a special trip to Calgary March 10 to give a speech raising questions about the proposal, but he hasn't offered much in the way of reforms of his own.
Huddle on healthcare
The provincial premiers, who will huddle on healthcare at the end of this month, have asked for a meeting with Prime Minister Jean Chrtien on the issue. Later, he has responded - like maybe November or December.
Meanwhile, some provinces continue with stopgap measures like re-referral programs for cancer care. Ontario's program, for instance, has been in place since last April and handled nearly 1,000 patients.
In the case of transborder referrals, the treatment costs nearly seven times what it would in Ontario. In Ms. Markou's case, the province paid the tab for the treatment itself (at a private hospital, she notes). It also paid for her lodging at a Buffalo hotel, gave her a meal allowance, and reimbursed her for mileage.
Similar transborder re-referral programs have been in place in both Manitoba and Quebec. Quebec officials have been reported to be discussing a deal with Vermont: easier access by Canadians to American cancer clinics in exchange for American access to lower-cost Canadian pharmaceuticals.
Analysts aren't holding their breath waiting for speedy changes. "There's an enormous inertia caused by the fact that we have had a health-policy establishment whose members are wholly committed to socialized medicine," says historian Bliss.
As a result, he suggests, there are fewer policy options being floated. There is, he adds, "a huge interest in Ottawa in saving the Canada Health Act - no readiness for root and branch reform."
Bliss, himself of the distinctly minority view that the current state medical monopoly is "unworkable and an affront to citizens of a free society," criticizes the system for overreliance on government healthcare planning. "A lot of the public still buys the idea that if you plan it better, it will work."
Mr. McMahon makes a similar point: "People get all upset when I say this - but we manage our healthcare system like the old Soviet economies.... If the last half-century has taught us anything, it's that heavily bureaucratized systems don't produce efficiency."
Describing himself as the Canadian political equivalent of a Clinton Democrat, he says he sees maintenance of the state as single payer as critical: "No civilized society should allow people to die of a treatable condition."
But some sort of market incentives are needed, he says, and so he is proposing medical savings accounts. Each citizen would get a healthcare annual allowance, and anything not spent by the end of the year would be split between the state and the consumer. A special fund would be available for those who exceed their annual allotment. But the idea would be that individuals would have an incentive to help control costs.
Dr. Rachlis sees the problem as not too much government control but too little. Canadians are aghast at the idea of corporations profiting from treating sickness, if radio call-in lines are any indication. But, he says, fee-for-service medicine is alive and well in this country, as it hasn't been in the US "since the insurance companies took over." The Ontario Health Insurance Program pays 98.5 percent of all physicians' claims within 28 days, he says. "American physicians literally faint when they hear this."
He is untroubled by claims that an aging population must necessarily be a more intensively medicalized one. Older people are healthier nowadays, for one thing, he notes. And the care for people with chronic conditions can be managed with lower-cost alternatives.
"Fee schedules have always paid more for cutting and prodding than for listening and thinking," says Rachlis.
The challenge is to find ways to encourage more thoughtful and more appropriate treatment by encouraging listening and thinking.
(c) Copyright 2000. The Christian Science Publishing Society