December 2000 Fraser Forum:
Politicians Tiptoe Through Health Care Politics

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Gordon Gibson

The politics of health care (so feared by politicians except when joyously exploiting a rival who has had the guts or foolishness to say something new) fall into three categories. These are the politics of greed, fear, and envy. These reliable motivators of humankind gain extra potency when mingled with the powerful emotions surrounding sickness and death.

Health care became "the issue" of the recent federal election. Well and good; it has long been the issue with the public. And, importantly, the public is not happy. What that means is that the Liberal defence of the status quo—so much the safer strategy in quiet times—didn’t work well once the issue had been opened up. It was a bit like Brezhnev defending Communism when everyone in the Soviet Union knew the system was crumbling.

The health care system ain’t "broke," but it ain’t running well either. Polls show an overwhelming number of Canadians believe it needs fixing. Thus the various parties could not ignore the issue, but none of them got to the true political basics.

The politics of greed and fear, the first two emotions in play, are quite simple. As for the first, the issue is how can greed be harnessed—through the private sector, or through the big government/big union partnership that currently characterizes our system?

The current system is beloved of those who think that the state is the best provider of services. From this position neither cost nor customer service are the issue. What is essential is that the service must be provided by public institutions. One attempted justification of this viewpoint is to claim that only public institutions will treat people fairly and equally irrespective of their financial circumstances. Another commonly-heard statement is that it is not right to make a profit out of illness.

But this position has enormous implications for cost. Public sector operation means public sector wages, benefits, and bureaucracy. Estimates of hospital costs range up to 30 percent for very ordinary, non-medical jobs like doing laundry, making and serving food, and providing janitorial and administrative services. In British Columbia, there is an enormous premium for (de facto) government employees doing this work. A public sector union hospital janitor gets about $26 per hour in wages and benefits. The typical janitor in a mall doing the same work gets about $10 per hour in wages and benefits.¹ Thus, as long as we insist that Jones, the hospital janitor, works for the public instead of the private sector, then there is that much less left from limited budgets to provide actual medical treatment for patient and taxpayer Smith. This is what really drives this part of the agenda behind the scenes. It is not about customer service; it is about employee compensation. In this context, "big is beautiful," say bureaucrats and public sector unions; no surprise here.

Greed is endemic in the private sector too. My dentist does not see me for my sparkling conversation. But if there is a single enduring economic lesson of the twentieth century, it is that private greed is more productive and efficient than public greed. That is why private, for-profit organizations run our food supply system, which is more important than health care by any standard. We simply couldn’t afford government- or big union-run farms and food stores. Everyone knows that. Why should there be a different principle at work in the provision of health services? No party made that basic point with any clarity, though one suspects it underlies the Alliance thinking.

Which brings us to fear, the real and good reason for medicare. Canadians have overwhelmingly agreed that the financial risks of illness ought to be pooled and commonly paid for. It is part of our aversion to the "lottery of life." In this country, no political party veers from the position that every citizen ought to have publicly-paid access to good health care. There is plenty of debate about what standard is affordable, but that is a practical question to be answered in terms of the cost of provision and the ability of society overall to pay. (The wealthy US spends far more per capita on publicly-paid health care than we do. Their problem is fixing holes in the safety net.)

The politics of envy is the trickiest. There is a strong strain of thought in our society, particularly in the Liberal-left and the NDP, that irrespective of hard work or merit or (especially) luck, it is not right that some should have it very much better than others. This view has no bite, no leverage point in the free market sector, and therefore seeks its redress in the political market where decisions can be bought by votes rather than by dollars. Health care is currently largely carried out in the political market, and must not, by this view, be moved to the private sector or the world will become even less equal in result. The politics of envy affects us all to some degree, but does it overwhelm common sense?

What do most Canadians think? Not what the election-coverage press told you. A large (3,000 person) Pollara (the Liberal pollster) survey at the end of 1998 found that almost two-thirds of us believe that those who want to pay for better services should be allowed to do so. A COMPAS survey in 1999 found that "a clear 60% majority supports the right of Canadians to buy medical services outside the government-sponsored health care system," and a Gallup survey just last September found that "fifty percent are either strongly in favour ((21%) or somewhat in favour (29%) of a two-tiered health care system..." (All of these polls contained other data which runs both ways. My citations are my view of the bottom lines.)

Bringing all of this to the grubby reality of the election campaign, the best Alliance strategy was pretty clear. In tactical terms, they ought not to have opened up this issue because it is a dangerous one, but it could not be stuffed back into the bottle once opened up by a (extremely mischievous) Globe and Mail headline. Therefore, the Alliance’s best gambit would have been to exploit their position as the only political party on the side of 50 percent (plus) of the Canadian people. The other four parties could divide up the other 50 percent.

The issue was confused, however, because the press is generally on the four-party side on this issue. The intensity of feeling among those supporting the statist solution may be stronger, and it was a very short campaign in terms of time for public education.

The net result didn’t cover anyone with glory. Those who stand for true reform in the system were too afraid to be honest with the people. Those standing bravely behind the status quo were unmasked as inconsistent, not just in policy terms, but even in the personal health care choices of party leaders.

The lesson? Somehow, we must give our politicians "permission" to honestly examine and debate this topic. There is plenty of good policy advice out there from The Fraser Institute and others, but as long as politicians have to regard this area as an electoral "third rail" that no one dare touch, the status quo will be frozen, just as was Brezhnev’s Communism.

Another Commission of Inquiry might do it, with the right membership. A bold government, federal or provincial, could show leadership. We might even muddle through to new ways of doing things if such simple ideas as small-scale experiments with private providers, user fees, and so on could be tolerated. But as long as the public sector health priesthood maintains complete control, we will spend more and more money, yet get less and less health care for the dollar.

Note

¹Data from the Business Council of BC.

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