Roy Romanow has made it clear that he wants to ensure that "two-tier" health care continues to be forbidden in Canada. Too late. If you are on workers compensation, are in the RCMP or the military, if your company has its own salaried physicians, if you use a private hospital like Shouldice (which specializes in hernia surgery) in Toronto or one of the country’s private abortion clinics, if you are a member of the medical professions, or know someone who is, or are just articulate and determined or famous and connected, if you travel to the U.S. or any one of a number of other places, you can get better, faster or more satisfactory care than someone who just lets the wheels of Medicare grind on.

Moreover, technology is allowing the remote delivery of ever more health services, so the ability of governments to frustrate patients’ desire to get better and faster treatment is declining, and that decline will accelerate. The debate, therefore, is really about how many tiers and under what conditions. And many of these tiers are beyond government control.

Virtually any kind of pharmaceutical product can now be purchased over the Internet from foreign providers who can evade our government’s controls. You can even get involved in on-line auctions for the drugs you want. Your x-rays or MRI scans can be read just as easily by a radiologist in Boston or Bombay as in Toronto or Truro.

More powerfully, the brain repair team at Dalhousie University recently operated on a patient in Saint John, New Brunswick. The surgeons never left Halifax. Using video cameras and computer controls, they operated robotic arms that actually did the surgery hundreds of kilometers away. When you can go to a surgical booth in Canada and be operated on by the best surgeon in the world, who may be at his office in London or Houston or Minneapolis, the notion of a closed national health system in which people must take what public authorities decide they should have simply cannot survive.

Multiple tiers is a slippery concept. For some, if some people can get a service by paying for it, while others who cannot pay do not get access, that is multiple tiers. On the other hand, there are people who oppose tiers because of an ideology of egalitarianism. Thus two people with similar conditions may both get treated, one more quickly through private payment, the other more slowly, but within appropriate norms for their conditions, by Medicare.

We are not talking about people being denied care based on ability to pay, because anyone willing to wait will eventually get care (although we possess no figures on how many die while queuing for public health care). The complaint is rather that someone got care more quickly. That’s a very different objection: No one should be able to get faster treatment than in the public system, even where such faster access does not affect the quality or timeliness of the care obtained by people who continue to use the public system.

This peculiar brand of egalitarianism suggests that people should not be denied service because of their own inability to pay, but should be denied access because of their neighbour’s inability or unwillingness to pay (through taxes) for the care an individual decides he or she needs.

Canada is almost alone in the Western world in outlawing people paying privately for services that are also publicly insured. One consequence of this is that there are many services, such as drugs or home care, that we cannot afford to cover publicly, whereas they are often publicly insured elsewhere.

Thus, by forbidding people who wish to do so the ability to pay, we satisfy our ideological craving for egalitarianism, but at the cost of an inability to make room in the public budget for a wider range of services that low-income people might truly need.

Now this might be a defensible trade-off if our system were superior to others, and indeed we frequently hear it said that we have the best health care system in the world. But neither the World Health Organization (in its ranking of world health systems) nor the citizens of Canada, nor the poor and the elderly in Canada (based on polling data), agree.

In sum, many of Mr. Romanow’s concerns, and those of the Canadian health care establishment whose views he now repeats, are ideological, and have little to do with the quality of care delivered within the public system. He clings to a system that outlaws private spending on publicly-insured services, in the mistaken belief that parallel systems rob the public system of resources, while both objective and subjective international rankings show that multiple tiers of access are fully compatible with high quality public systems, high levels of care overall, high levels of patient satisfaction and public health outcomes as good or better than Canada’s.