Albion Monitor /Commentary
[Editor's note: In related news from the U.S., a new report shows a growing trend of HMOs refusing to offer expensive but effective new medical technologies.

According to a study published in the Dec. 5 issue of The American Journal of Managed Care, a survey of HMOs found that new procedures such as laser angioplasty are denied between 25 and 90 percent of the time. The survey also found that the type of HMO and the method of physician payment influences the kinds of medical technology offered.

The study asked questions about coverage of laser technology used in 15 different procedures. Lasers were selected as the focus because that technology is widely used by specialists and accepted as effective and often superior to conventional surgery.

"Although managed care's use of cost effectiveness ... is laudable, it may be necessary to ensure that access to beneficial technology and quality of care is maintained," said one of Johns Hopkins researchers.]

Canada's Health System in Jeopardy

by Nadia Diakun-Thibault

In spite of the enormous amounts of money spent, the average Canadian's health has not improved

OXFORD MILLS, Ontario -- Americans have a skewed picture of Canadian health care, having been lead to believe that the average Canadian has no choice in selecting a doctor, no resources, long waiting lists, and so on.

Canadians also have a skewed picture of their national system. Many can barely recollect the times before universal health care, when medical treatment was a luxury afforded by the wealthy.

And then there's the troubling data that puzzles both politicians and the public: in spite of the enormous amounts of money spent, the average Canadian's health has not improved significantly in recent years.

One of the reasons, according to the authors of "Wasting Away: The Undermining of Canadian Health Care" (Pat Armstrong and Hugh Armstrong; Oxford University Press, $19.95), is because much of Canada's expenses for their "health care system" -- a term that refers to a non-existent and ill-defined concept -- goes for indirect things like administration.

Those with the most to gain are the driving force in the Canadian system

Like its counterpart in the United States, Canada has a system of treatment, not care. Historically, the system has been driven by the needs, wants and interests of physicians and the domination of allopathic medicine over health treatment, according to the authors. Those with the most to gain are the driving force in the Canadian system.

Contrasted are examples of how physicians are paid versus care-givers. Canadian doctors are paid on a fee-for-service basis. Armstrong and Armstrong note, "Fee-for-service is very similar to piece-work payments in factories where workers are paid for each component made. Doctors are paid for each minutiae of 'service' on a specific part treated or task done."

The authors compare that to growing pressures to devolve ongoing care, particularly for the mentally ill and elderly.

The solutions for that problem, say Ontario policy makers, is reviving a sense of "community," as if it existed intact, leftover and untouched since 1950.

The errors in this public policy notion are, first, the nostalgic community does not exist, even in rural areas of the province; second, the community is not necessarily the appropriate place for certain types of care, such as the elderly with cognitive impairments or persons with serious mental illness; and third, it is not something that everyone wants.

At the same time, little recognition is given to the unpaid volunteers caring for the sick. It is the wives, daughter, granddaughter who ultimately takes on the onerous task of caring for a relative with dementia or developmental disabilities. Canada could help ease the economic cost to these women and their families through income tax deductions for mortgage or shelter costs, caregiver relief, and so on. Tax reform would have a genuine impact.

International organizations are pressing to make the Canadian system more like America's

The authors' view that health care is an issue of political economy is not only compelling, but persuasive. "...Health, then, is fundamentally related to the distribution of power and resources as well as to social relations; in short, to the political economy," they write.

Health is inextricably linked with income. If someone can provide adequate food, shelter, clothing and other necessities, it is reasonable that good health follows, provided that it is tempered with behavior that is not risky to health.

But in health care policy debates, the focus is squarely on bean-counting. Charts are dragged out, the number of tests are counted, bed/patient ratios are cited, costs for ancillary hospital services, costs per drug, costs per diagnostic test, and similar fine points are discussed. The debaters forget, as the Armstrong's point out so succinctly, that "Effectiveness and efficiency cannot be measured primarily in terms of money spent and people processed."

The Canadian system is also under growing pressure to cut back on services provided. Armstrong and Armstrong contend that "Organizations such as the World Bank and International Monetary Fund are calling for the privatization of government-owned enterprises and major cut-backs in the provision of services, on the grounds that they are too costly and inefficient."

These international organizations are pressing for moves toward a "free market" system and for-profit provision of health care services at the expense of genuine care.

Pressures are also coming from Canadians who look south to the United States and see the plethora of treatments available. They covet the alleged "best health care system in the world," and believe that privatization is the solution that will halt rising costs. They do not see what is hidden from view: the American failures.

Nadia Diakun-Thibault is Executive Director of the Council on Aging for Lanark, Leeds and Grenville and specializes in health policy and health law. A greatly different version of this essay first appeared in The American Reporter

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Albion Monitor December 11, 1996 (

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