We have to be careful here. The public loves some features of the system. In particular, there is huge support for the principle that no one should be denied access to needed medical care on the basis of ability to pay. Ideologues in the health care system have tried to stretch the public’s support for that basic principle in all kinds of distorted directions.
For example, there is a view afoot in health policy circles that because Canadians support this basic principle, that they support a health care monopoly on the current model, that Canadians disapprove of private, for-profit business in the health care sector, that only the state should deliver health care services, etc., etc. For example, the recent report of the Royal Commission on the future of health care took as its starting point a picture it painted of Canadians’ values, arguing that those values supported the status quo, only more so (i.e. an expansion of the system into home care and pharmacare, and a major injection of taxpayer dollars).
But in fact, Canadians have shown themselves to be a deeply practical and non-ideological people. The head of the Royal Commission, Roy Romanow has made the case that the debate over the future of Medicare is all about Canadians’ values. But the way Canadians express those values, unfiltered by the work of the Commission, is far different from what Mr. Romanow implies Canadians want.
According to a recent poll entitled The National Pulse on Health Strategy, 80 per cent of Canadians want major reforms of the health care system:
"Two-thirds of Canadians (66 per cent) tend to be supportive, more or less, of a host of new models of financing in order to reduce stress on the system — for example, where everyone (except those with low incomes) pays a small amount for health care services out of their own pockets. They also tend to support strategies such as using nurses or other health practitioners rather than physicians to provide certain services. Just under half (45 per cent) tend to be supportive of market-oriented reforms — greater efficiency, accountability and customer service, including private sector companies delivering health care services" (Environics, October 17, 2002).
The National Post reported that the same Environics poll found that fewer than half of respondents would support increasing taxes to pay for health reforms. But notably, only 10 per cent of Canadians would accept a health care system that excluded those who could not afford to pay for services.
These results need not be seen as a contradiction. As Jane Armstrong, senior vice president of Environics Research Group, says, "Canadians, ever-constant champions of fair play and equity, are devoted to maintaining a system that ensures access to quality health care for all…. They’re willing to make changes, even if this includes new and varied ways of financing the system as well as a greater dependence on market forces such as private companies delivering certain health services." (Environics, October 17, 2002)
Another recent poll, by Decima Research (October 25, 2002) found that more than half (55 per cent) of Canadians were opposed to paying higher personal income taxes even if these funds were designated to pay for health care. An even larger majority of respondents (67 per cent) also believed they would have to rely on their own personal savings to pay for their use of health services in the future.
These public opinion polls appear to indicate that Canadians want a system of health care that provides high-quality medical services and is financially sustainable over the long term at an acceptable economic price, without excluding poorer people from access to medically necessary services. And in a typically pragmatic way, Canadians are not worried whether it is the private sector or the public sector that achieves this; they just want results. In fact, when Canadians do express a preference for either private or public approaches to health reform, the majority are willing to fund their future medical needs themselves rather than pay higher taxes to expand the Medicare model of health care.
That’s why, in the context of the Romanow Report, I like to say that not since the days of Edgar Bergen and Charlie McCarthy has ventriloquism enjoyed such vogue. But at least Edgar and Charlie were good at it, and it was purely for entertainment.
The stakes riding on today’s high profile ventriloquism act are far higher: the future of Canada’s $70 billion public health care system. What does ventriloquism have to do with Roy Romanow’s Royal Commission report on Medicare? Everything.
From the very first Mr. Romanow made it clear that the foundation on which all of his work would be built would be the values of Canadians. That’s powerful: Not many politicians want to be seen as ignoring Canadians’ deeply held views on a topic as important as health care. Thus the title of Mr. Romanow’s report: Building on Values.
He invoked the values of Canadians up front in an attempt to make his recommendations invulnerable to criticism and caviling by politicians and interest groups. But for this gambit to succeed, the methods the commissioner used for arriving at a picture of Canadians’ values on health care must be beyond reproach. Yet his methods were flawed and unprofessional. The report is a thinly disguised attempt to make Mr. Romanow’s own values, and those of his narrow coterie of experts and bureaucrats, pass for the values of Canadians generally. Canadians are the dummy, and Mr. Romanow is the ventriloquist.
If this analogy seems extreme, consider what Mr. Romanow and his colleagues did. They organized focus groups across the country to find out what people were thinking about where they’d like to see health care go in Canada.
What they heard from these focus groups was pretty much what Canadians have been telling pollsters for the last several years and that I’ve sketched out for you here. Canadians are a down-to-earth, non-ideological, practical people. They’re interested in what works and they’re interested in real solutions to the growing evidence of the accelerating decline of the health care system.
So in response to questions from the Commission’s people, they indicated that they were open to a wide range of options that needed to be tried if they might improve things. They were open-minded about things like user fees, allowing more private sector involvement in health care provision, and allowing people to buy health care in circumstances where they’re not permitted to do so today.
But that didn’t square with the views of Mr. Romanow and his merry band. So they marched their focus groups into a room, and presented them with "expert opinion" to show these poor benighted citizens why the things they were willing to try were bad ideas that wouldn’t work, that would harm people’s health and that would be hard on the poor. They presented these views as established facts, rather than as the highly contested arguments of an elite of health policy-makers; an elite whose ideas have been responsible for bringing our health system into its current state of disrepair.
Unsurprisingly, upon being presented with what seemed to be an objective and authoritative debunking of ideas that had seemed practical and worth trying, the members of Mr. Romanow’s focus groups timidly gave in to the views of the "experts". The irony is that there is much evidence in the academic and policy literature that the practical, commonsense things that Canadians were prepared to look at actually do make a difference for the better. The only real flaw in these ideas is that they don’t fit the inflexible and narrow ideology of Mr. Romanow’s colleagues.
Now, anyone in the university polling world can tell you how to avoid such charges of bias in determining what people think about emotional topics like health care. For instance, a reputable arm’s length polling expert would never have allowed people from Mr. Romanow’s own commission to be closely involved in the testing of public opinion. The risk of influencing people to say what the client wants to hear are too great. But the commissioner’s own people did work directly with the focus group organizers. And those organizers were themselves not members of an objective polling group, but representatives of a public policy group closely tied to the people guiding the work of the Commission and identified with their views. This "research" would never have passed muster in a rigorous review by the best university experts.
So by using a flawed process riddled with conflicts of interest and unprofessional methods, Roy Romanow was able to make it look like Canadians were ruling out of court any experimentation with the health care status quo he and his advisors favour. But for someone who made such grand claims about basing his recommendations on hard evidence, the commissioner has issued a report reflecting nothing more than his own prejudices, transformed by the ventriloquist’s art into Canadians’ most cherished values. Good thing we’re not the dummies he thinks we are.