Everything I want to say about this is summed up in a story that happened to my partner Shelley. Shelley and I are partners in a restaurant, and she actually runs it. She had an appointment at the hospital for a procedure, and duly showed up on time. Two hours later she was still sitting there waiting to be called. Now, she was only able to get a two-hour parking meter, so she approached the desk and asked if she could go and put money in the meter. She was curtly told that she was free to go and put the money in, but that if her name were called while she was away, that her name would fall back to the bottom of the queue. So she just decided that she would take the parking ticket as part of the price of getting the medical service she needed. Another two hours passed, and still she was not called, so she again approached the counter, and very patiently and politely explained (as only Shelley can, because she is the soul of graciousness) that she actually had a small business to run, that she was there at the appointed time for her appointment, that she had waited four hours, which is far longer than she had been led to expect the whole thing would take, that she had other commitments because of the business and could they possibly at least give her some idea of how much longer she might have to wait?

Well, the woman behind the counter got on her dignity, drew herself up to her full height, glared at Shelley and said "You’re talking as if you’re some kind of customer"!

There you have it, ladies and gentlemen, the essence of the problem — when the government supplies you with "free" health care, you are not a powerful customer who must be satisfied. They are doing you a favor, and you owe the state gratitude and servility in return for this awesome generosity. They can give you the worst service in the world, but because it’s free, you are totally disempowered. One of the most important lessons I have learned from my contact with the Canadian Medicare system is that Payment Makes You Powerful. And its absence makes you risible if not invisible.

Now the articulate and the middle class don’t let little things like that get them down. Even though they don’t pay, they still get in the face of the people providing service and make their wishes known. But often the vulnerable, the poor, the ill-educated and the inarticulate are the ones who suffer the most because no one’s well-being within the health care system depends on patient/consumers being well looked after. And by depriving them of the power of payment within the health care system, Medicare disempowers them. And the poor see this, because while they may be poor, they are not stupid.

In a Compass poll for the National Post, fully 41% of Canadians were of the view that individuals should be able to choose private health insurance for Medicare if they so chose, allowing them to obtain better, or at least faster, care than at present. Interestingly, for a society preoccupied with the inequities implied in "two-tier health care," more of those earning less than $25,000 a year (47%) were interested in this option than were those earning over $75,000 (39%). Those most satisfied with their health care were not the least educated, but the best educated: those with postgraduate degrees.

These findings are consistent with my view that Canada’s system in fact does create multi-tiered health care where health care services are distributed on the basis of middle-class networks and ability to communicate one’s needs aggressively to professional caregivers. It is the poor, the vulnerable (including most obviously, the sick) and the inarticulate who receive the worst care, because they cannot circumvent the system the way the middle class and its advocates can.