It's the fact that Binnie didn't see this I find very strange. There's a lot to be sorted out in this descision.

As Cosh says, we really need a Canadian equivalent of Volokh in Canada (a group lawyer blog).

No, you only need to obey me and each of my thoughts.

Oh goody. Now that everyone's on board we can have private medicare. Personally, I'm desperate for the stuff. Oh wait a second, I already have private care! I live somewhere else. It's great though I tells ya. No line ups, they treat you even if you don't need to be treated and it only costs thousands of dollars. I'm terrified that something will really go wrong, something that will bankrupt us, so if I don't feel well I keep it to myself.

I know. I'm a dullard.

Dagnabbit.

I don't have private care and it costs me tens of thousands of dollars! And they told my Dad he can become a f*cking invalid because they can't be bothered to treat old people for hernias except on a 18-24 month time frame! I can't wait to be old and treated like an inconvience!

And of course, that whole "rights" thing is just right-wing loser talk! What about our right to tell other people to act the way that 8-year arts students prefer! That's a real right!

It will be interesting to see if this become a big thing in Atlantic Canada for that very reason. There is a surplus of medical trainees from there who leave because the provinces are unable to support them. This system gets folks back to provide the service but as long as there is a doubling of the system, public-private, there is also a doubling of cost. We pay mucho for the public system in our taxes. If that is to maintain its service level, that payment has to continue. If private insurance is to be added, those additional costs will come from somewhere. Can the folks of Atlantic Canada support them? I suppose if it is a choice as your father has or any of us might face, are we not going to find the money?

PhD bad. Work at McDonald's good. We get ya. Good point.

About your father: Really? They said fucking?

I think they may as well have. That is why I got mine moved to Ontario for the heart surgery. The PEI equivalent is they of the health care system don't give a rats ass who dies in the ambulance on way to heart surgery as long as it happens once you are over the bridge.

No, they said "f*cking". And I don't believe in a hierarchy of superiors and inferiors, except by express merit within a field of endeavor. Don't sweat it though Marian -- the concept that people not like you (such as the little unworthies working at McDonalds) might have wisdom, intelligence, judgment ... especially with regards about how to live their own lives ... is a particularly alien and dangerous thought to a progressive.

Back to the health care system. As with any large organization, they're probably optimizing for only one or two metrics. In the Canadian system, it's the number of people not dying within the system for the dollar spent. You may (or may not) have different metrics that you want to apply to your own life -- for example, convenience (such as only having to take 1 $25 pill/day rather than 3 $5 pills); time to recovery, quality of life, etc..

Ah, yes, the "jewel in the crown", Al? Looking just a little bit tarnished, n'est ce pas?

That is a demeaning comment without content, SN.

Then let me add a little content:

The "monopoly" the Canada Health Act creates is responsible for much that is wrong with Canada's health system. The Liberals have wrapped themselves in this farcical "Canadian value" long enough. Although, I do find it comforting to know that I can zip down the 401 anytime to La Belle Province to pay for a CAT scan when I need one - instead waiting 6 to 12 months from now in Ontario. What a farce. Am I right, that even the son of Justice Emmett Hall (whose Royal Commission on Health Care in 1964 developed the "five principles" of Medicare), Dr. John Hall, an orthopaedic surgeon, left Canada to practice in the U.S.? What does that tell you?

I liken our soviet-style forced support for this one universal government monopoly health care monstrosity (a "fundamental Canadian value"), to the poor animals in Animal Farm, and their unfailing belief in Napoleon's propoganda that his "windmill" was the greatest project in "animal history": "It will bring a better day for animals everywhere". Except, of course, it could never work, and it was simply used to keep the animals "focused" on a useless, resource-wasting, time-consuming project.

As many other have asked, how is it that Canada comes to share, with North Korea and Cuba, the distinction of being one of only three countries in the world that forced upon its citizens a state-run monopoly in the delivery of major health services? That's nice company to keep. Even in China, for goodness sake, its large cities have "gaogan bingfang" or western style V.I.P. wards with state of the art medical facilities and international staffs that are available for paying customers.

In a mature, wealthy, democratic state, it is simply bizarre that I can chose to pay for immediate quality health care for my dog, but not my child.

Sigh. I feel bad[*] for adding heat here. There's the potential for an interesting debate on this subject but the stakes are so high and the chasm between sides so wide. Interesting the Al seems to be more on the libertarian side than usual -- my good influence?

[*] not "badly", BTW.

I suppose my discomfort with the idea of privatized medical care is due to the fact that my family has received better care through the government than we probably would have had we had to pay for it.

I think that my levels of tolerance for two-tier are balanced by the UK version which seems to work and also the rather factual situation in Canada where each province has their own system and even every town has its own level of access to resources. But as to my libertarian nature, I am the king of the leftist libertarians which only means I am much more interested in autonomy than money.

There can be no leftist libertarian ... there is liberty or there is not. A right is a right or it is a privilege. The government cannot backdoor a rights violation. In my world you can be interested in money or not. You can be a socialist or not. You just cannot use the power of the state to make me a socialist.

Oh, come on Joe.

Error. Does not computer. <p>The rightist libertarian, worshipper of money and false autonomy, wallows in government sponsored corporate welfare, business crime protection, environmental harm, subsidized support of trade through or low cost mass goods transportation and publicly subsidized fuel costs. The rightest libertarian depends on the state to make the space for that illusion of autonomy that the bonus money from not paying your fair share brings. The rightist libertarian is a dependent.<p>Conversely, the leftist libertarian admists government but wants to keep it at bay through privacy laws, minimum wages for the incapacitated, programs to get people independent and participating, strong schools to ensure all have the right to be free and autonomous through being intellegent. If you love money more han people you likely won't get the idea but that is to be expected.<p>Perhaps both are hypocrites as the rightist libertarian does not pull his weight and the leftist does not achieve autonomy through the opportunitys collectivity affords. I will grant that.

No Dave, you cannot pick and choose. Al, the left wants to legislate an equal result and the right an equal morality. All I am saying is let's not use force against each other and then live and let live. I do not necessarily want to be alone, i just want to be left alone.

By the way, the "love money more than people" line is classic. are you calling for a budegt "for people.....and the environment"? Don't you really mean if you love telling people what to do and how to do it because they are too stupid or selfish to do it for themselves then you should be willing to use the power of the state to take other people's money and impose your will?

I guess you live on Mars if you do not think that the right wants to legislate morality as much as anyone. Value laden catch-phrases are labels that can be pasted anywhere and if you don't see one on you it is likely it is on you back with "kick me" crayoned it. It you want to point fingers as opposed to explain yourself and ideas, find someplace else to go to tell others they are stupid.

cm et Al et al: In my own family's recent experiences, we found an enormous level of frustrating inefficiency at the front end of the system, from the family doctor through the linkages from that doctor to the rest of the system to the emergency room (two 12+ hour waits for a 70 year old); still, I think if we hadn't gone the emergency room route, my Mom would have died waiting. That said, once we forced it and the connection was made with the surgeon (at the end of the second emergency room visit) - excellent stuff.

Both from an (attempted) objective look at our system, and from first-hand experience, I can see why the addition of private options, particularly at the front end in diagnosis, etc., would be a huge benefit.

Opponents of private care talk of "two-tiered" as though it looks like this: =. Why can't it look like this: II? Or this: H? Or this: Z? Or this: X? Or any combination? ... anyway, y'all get my meaning.

I hear you and is being pointed out there are differing levels of health care already province to province and even with each as, for example, I have a supplemental insurance program through work here I did not have in PEI. I also do not see any problem having privately run corporate clinics which are funded out of the common pot or a combination of the common pot and private insurance as long as the same services is provided to all. Right now if there is emergency services not provided in one province, or even core ones in the case of some of the smaller poorer provinces, citizens are transported to larger provinces or even the USA. There is already much done in this way so to avoid the mischief the case addressed, long waiting periods, surely an innovated answer is available. Interesting, as Andrew Coyne of all people said on the CBC's <i>The National</i> last night, the ruling is very limited in its factual scope and if there is a solution to the waitig period, there is not justification for further <i>Charter</i> action in relation to health care.

I don't understand how private care is a solution to any of this. Private care costs more. So if we introduce private care, it's the opposite of a cost saving measure. That's one thing. The other thing is that there's a shortage of doctors. If we have private clinics this will be a drain on the system in more ways than just taking patients out of the public part. The private system will draw precious resources, including doctors away from the public system. Those who have private care will demand that their taxes be reduced because they no longer wish to support the public system and don't see themselves as being a part of it etc. etc. So, as far as I'm concerned, if we put money into medicare it should go to the public sector because that is where it will be used most efficiently.

All this talk of England and France is a red herring because we're not France or England. We have a unique and tight relationship with the US and because of that relationship it is likely that we will end up with US style care.

Canada has artificially kept it's health care costs below that of the United States by treating patients as things within a machine, doctors as chattel, and providing "one-size-fits-all" service that for many is plainly inferior. People as property is a very progressive concept, but it's not for me. Fortunately, we live in a country with explicity enumerated rights and something of a tradition of respecting them.

I note further that your argument against allowing (more) private care is basically fear mongering of some imaginary worst case scenario future.

Ah yes, here's the stuff:
http://www.fraserinstitute.ca/admin/books/chapterfiles/Executive%20Summary-pages1-6.pdf#1

In OECD countries:
- we're #1 in cost/GDP (11.7%)
- 18th in # doctors per capita
- scary #s for MRI and PT scanners

We have a super health care system for the young and healthy.

I am deeply offended that a report from the Fraser Institute has appeared in my blog not as a negative example. Deeply offended. And on a Friday, too.

But, David, is the universality of access a factor? The trouble with that as a pro-Canada argument is that it only works as against the USA and not the UK which does have two-tier, no?

I don't really understand your last comment (really -- expand pleae).

My _real_ argument is based only on rights: I want health care, someone else wants to provide it to me. So what's your [not you personally, Al] involvement in that? Prohibiting it (a beneficial service, for christ's sake!) strikes to the heart of what liberty is, of what freedom is. It's not sufficient for society to say "well, it makes some people jealous that you can get something that others cannot" or "it undermines the moral order" or "I sat down with my graduate student's union buddies and we decided this will inevitiably lead to a nightmare distopia" or "well, we've decided that Dr. X's services are so valuable, he's no longer free to offer them in a manner he sees fit".

I want universality as if I have and another lacks, there is no human right. A right enjoyed by a human inherent to their nature as human has to be available to all. You may have the right to contract freely but your right to contract freely is different from your right to not be delayed by a system that treats people like statistics. No human rights are enjoyed on average or by only part of the population. That is why property right is a lower right than a human right.

Economically, a separate issue, I am in favour of two-tier universally provided care and frankly I think we have it. I think that sectors of the private world can provide certain services cheaper (specific capital expensive specialty work) but in other areas the volume and low-risk of the public sector can provide other services cheaper (emerg and drugs). That system does not impede your right to

Underlying this is a problem of capacity. Medical science is outstripping the ability of society and individuals to pay for what is possible to provide. Some procedures are simply too expensive and rare. All the mania about the "rights" of Terry Shaivo were based on a court ruling that game an enormous sum of money to pay for treatment no average person would afford. That would certainly be an example of a luxury, the pure delay of certain death, that the public sector, as it does now, ought not to pay for out of the grey zone. This does mean that we do not get services that in the future would be cheaper and perhaps commonplace unless we ourselves pay for them - but that is life. There is a real economic seam through the rights argument in that we cannot afford all our collective rights to all that medical science can do. We have to draw a line and place pay as you go beyond that line. We do that easily for cosmetic surgery. What else goes there?

>> I want universality as if I have and another lacks, there is no human right.

That's begging the question though, isn't it: we don't have a right to government funded health care (or more correctly, the government does not have an obligation to provide universal health care). You, and many others, may want this and I invite you to agitate and petition and whatever else is required to become constitutional matter!

Note more discussion here:
http://davidjanes.com/cgi-bin/abc123.cgi?entry_id=3321

You are right. If the state is involved with somthing, I have the right to have it applied equally. Whether it is involved or not is a policy question but it is one that has been asnwered positively in every nation in the western democratic world so in theory that is more important than in practice.

What exactly is the problem again? Because if it's all about your fundamental human right to seek private medical care if you can afford it, then shaddup and pop over the border. Quit trying to throw a monkey wrench into the public system. I'd offer to pay your bus fare, but if you can afford private care I'm sure you got it covered.

But if the problem is about "artificially" inexpensive public health care, then pray tell how exactly is it artificial? Let's cut through the crap, look at the bottom line, etc etc (plus any other patronising phrases your set like to use). Pare it down to the most basic equations at the heart of it all...

taxes -> gov't -> health care

insurance premiums for those who can afford them -> any number of for-profit middlemen -> for-profit health care

Tell me again which is less wasteful? In spite of loud talk about efficiency and the like, there's some pretty dodgy mathamatics going on in the hard-nosed common sense crowd.

(And anyone who maintains that the awful, inneficient, and bureaucratic gov't administration of health care is somehow less cost-effective than a for-profit private administration of the system would be, please use some of that hard-nosed common sense and think again.)

"Canada has artificially kept it's health care costs below that of the United States by treating patients as things within a machine, doctors as chattel, and providing "one-size-fits-all" service that for many is plainly inferior. People as property is a very progressive concept, but it's not for me. Fortunately, we live in a country with explicity enumerated rights and something of a tradition of respecting them."

I'm assuming the rights of the forty million Americans south of the border who don't have proper health care are not a worry for you.

Please mind the manners. There is more to the complexity of constitutional autonomy and the economics of health-care than one-sided knee-jerkery whatever the side we and ours knees happen to be starting from. We are working out a problem here.<p>But it is true that the myth that a public bureaucracy is more <i>in</i>efficient than a private one. The insurance bureaucracies in the US health system are much more byzantine, over-lapping and bloated than anything in our present exclusive public model because they have competition you have many people doing the same task administratively, more is spent on public health per person and less service is provided. One high-school doctor pal was interviewed by Gzowsy about ten years ago on that point complaining of the insane paperwork in the US. Another applied for a US position and waited about a year before the answer came due to red tape.<p>But the issue is not that or perhaps not just that. It is really how do you run a system which is fulsome at the same time as universal and respects the autonomy of the individual to opt out. It also has to be realistic in the sense that not everyone can have the gold card. But by only comparing ourselves to either the US or, worse...always worst, a generic political theory we do not get the best answer and do the question a great disservice.

http://en.wikipedia.org/wiki/False_dilemma

But to answer you question Marian, no. They have their own country and they are free to run it the way the want. I doubt they're a worry for you either, in the sense that you are prompted to action to do something about it.

I believe your analysis of the situation in the US is wrong Al. Economies of scale do not work in adminstration -- look at how the costs for everything in Toronto went through the ceiling after amalgamation, even though there were 5 different organizations doing the same thing and now there is only one. The advantage of a public beauracry has over a private one is that they do not have to care about the outcome of their actions, which is a great way to artficially lower costs.

Furthermore, the concept of efficiency is usually built on the concept that there is a single optimal outcome for every person -- do you take 3 $5 pills/day or 1 $25 pill/day? This is real questions that doctors have to answer every day. If there's a 1 in 250 chance that a person could be concious during an operation, do you spend $90,000 on a machine (and $25 per operation for wires, attachments, etc.) to prevent %0.4 enjoying the sensation of being flayed alive? And if you don't spend it, do you prevent patients from privately sponsoring this service? If the costs were one tenth that, would you change your mind? If the costs were 10 times that, would you?

I wrote about something similar to this way back when under the title "the managerial disease":
http://blog.davidjanes.com/2002_01_20_davidjanes_archive.html#8867572

US health care is expensive because of litigation and the fall out from that -- massive overtesting, insurance costs, etc.

But again:
http://en.wikipedia.org/wiki/False_dilemma

Doesn't anyone have anything better to do on a Saturday morning? I just took my little girl for her first ride on a subway ... and my first on the Sheppard line.

The inefficiency in private administration is not due to the volume of the administration - it due to the overlap. It is true that Toronto has issues, say, that five smaller administrations had. That is why the converse policy of downloading certain things from the province to municipality (as long as the revenue follows) is a good one. But that is not the private model. Through competition multiple administrations for the same economic sector are required, many fail and the cost of those failures is borne by others in unpaid suppliers, unpaid taxes, etc. Plus, the unharmonized multiple administrators need to be dealt with each by actors in the market. Buying something from more than one megacorp exposes you to their unique weaknesses, costing the purchaser in that market sector money either through evaluating apples v. oranges on the one hand or taking a leap of faith in relation to "brand" thus by definition buying into a falsehood. These factors are never included in the private praiser's model as faith beats out fact.<p>Litigation cost is a bit of a red herring as the total reason though is is one of these factors. Add also the cost of professionalism, that status must be maintained. One of my most interesting cases was inherited from a more locally famous but thicker lawyer who would say that their lifestyle had to be maintained so they could not continue with the resource-demanding work. Why do we accept that a medical professional (or a lawyer for that matter) needs 150,000 or 250,000 per year when the rules of professionalism include monopolitic pressures (ie no "witchcraft" allowed and once you have your professional, you cannot practically continue shopping around).<p>Plus there is the seduction of the new and technological. The tests are taken as much to find out, that they are available, as to protect against litigation. An analogous example of this is the over technologizing of the general workplace. Provision of global email and world wide web is a cost and an inefficiency creator as much as it is an aid.<p>Litigation fear or mania is as much a cost as well. One of the costs we pay in Ontario is the support of a massively over funded medical defence account maintained by the medical association but paid for by the tax payer. Doctors, when sued, are defended with these transferred public dollars and, when successfully sued, are indemnified. Through negotiation of those preventative costs as opposed to repaying real cost after the fact, the public may spend additional funds beyond what is necessary.<p>BTW, I am so achy from soccer that I can't get a good nap in but am not inclined to do anything else. Health is a wonderful thing.

I just went to George's Trains on Mt. Pleasant. Must run privately built railroad in basement! Off to Home Depot to look at privately sold (and inefficiently, since there's many places trying to sell the same) wood for same project.

Remember to buy from the one just starting up or about to fold while they are offering less than full cost recovery!

I chickened out and decided to do a little planning first.

"I doubt they're a worry for you either, in the sense that you are prompted to action to do something about it."

It depends on what you mean by action. If someone says to me, "let's adopt the US system," I say "no." Whenever someone says something inane like: "US health care is the best in the world," I tell them they're wrong. Those are actions and I think they help those forty million people a little because as long as other countries do things differently, there's hope that things will change in the US. And it's the most that can be expected from someone who is not a kingpin, not a US citizen, and who lives thousands of miles away. I'm also not using the injustice of wait times to argue for the further injustice of millions going without as they do in the US. Neither are you. But if this is the end result of the Canadian discussion it will take forever to undo once it's done.

I withdraw the tone of the comment; after considering it all day, I'm being far to aggressive in what I'm saying terms of personal "me" and "you" type stuff.

My other points stand :-)

Says you.

I just wanted to respond to the person who noted that Dr. John Hall, son of Justice Hall ";eft Canada". Technically, s/he is correct but Dr. Hall, who I know and respect as one of the pioneering and leaders in spinal surgery at Harvard and the Boston Children's Hospital did not choose to leave the country for the reasons implied by the writer who I am guessing has never met this wonderful man.

Dr. Hall was in Toronto when he was offered a position at Harvard and the Children's hospital in Boston - which for 16 consecutive years - has been named the best Children's hospital in the United States. I myself studied there and he was a professor of mine and I have to say he is one of the the most caring and compassionate man I have ever met. At the time he left, there was little research money in Canada and Dr. Hall has done some of the pioneering work in the area of scoliosis - which still lacks much research money. He has been integral in the Scoliosis Research Society as well as other spine research areas and is well publsihed. Few doctors I work with h- including myself - have been able to accomplish his record of rsearch, teaching and excellnt patient care and surgical results and innovations.

I studied at Harvard but returned to Canada and have to say there is now more research money available to those of us seeking it. We could always utilize more - needless to say. I might add if Harvard recruited me, I might leave Canada too but it would not be by choice. Dr. Hall is not some orthopedic suregon pratcicing in the boondocks - he has used his skill to teach others, many of us (his disciples you might suggest though he would not care for that term, he is most modest man) have returned or been rectuited to Canada.

Every year, I am recruited by barious hospitals in the United States - some venerable. I do think though that we have one of the very best health care systems in the world and while those I treated in Boston needed to establish their payment plan before admission (even if their home town had raised the money or Medicare plus communith help was paying the costs), there is no such requirement in Canada and I need not worry that whatever protocol I and my team members at our hopsital recommend, cost is not an issue in the same way it is there. It is true that uninsured people can get elp but it is charity and that is not the same as feeling you have the dignity of walking into a clinic and being self sufficient because of your tax dollars and not because you have enough money of your own!

So just to get this straight:

(1) he left because there was more money for research and he was working with better people
(2) "It is true that uninsured people can get [h]elp"
(3) by "your tax dollars", you mean "other people's tax dollars"
(4) showing your OHIP card is not establishing a payment plan? i.e. anyone can walk in off the street and get treated without paying, even non-residents non-citizens. This is somewhat different than the hospitals I'm familiar with.

I don't understand. Where is the reference to John Hall? OH! A Say Nay comment. Never mind. Pointlessness, Jane, but thank you for sharing your personal story and giving the great illustration in reality that our chat group never really gets.<p>David, your #3 is not valid as no one pays no tax given the GST. A child pays it for a piece of gum. Wasn't that the argument in the campaign why the GST cut was fairer than the income tax cut?

Fair enough, you got me on #3, although theoretically that tax is refunded. In regard to the election argument, it wasn't that it was fairer (I'm not arguing either way on that), just that the lowest quintile or whatever will benefit most because they still get the GST refund.

By the way, both my parent's long needed surgeries have been postponed again -- if you're not going to die, you can wait.

Sorry to hear about your folks. It is really the key area about health care where we are in total agreement. My Dad has come though very well but, as I think you know, it required moving to Ontario to ensure the services obtained were the best possible without Mom sitting in a hotel in St. John NB during the recovery.<p>On the tax, I still remember when I was a kid the first time I realized I was getting dinged a penny on the purchase of my 12 cent <i>Sgt. Fury and His Howling Commandoes</i> comic. In my fury I pointed out the sensible argument that I was only six to which the clerk replied something like "welcome to the world, kid."

One of my arguments for a "second" tier^* is that the Canadian medical industry is, like many large old industries, optimizing around a small number of things. The number 1 thing is mortality -- not dying. We're very good at saving savable lives, which is why I have little (actually, no) complaints with regards to how my daughter has faired in the system. Low on the list are things like morbidity, pain, convenience and so forth. Alternate providers can (and should) provide services to people who have a different priority scheme than what the industry is prepared to provide.

<p>
^*I'm using quotes because I believe there's many tiers now

Oh, and that story is a classic. You should write that up as a separate blog post...