The Shotgun Blog
Monday, August 11, 2008
Lemieux: Random health services
Let's say you and nine others are patients of Dr. X, an M.D. overwhelmed with work. Since doctors aren't allowed to make as much money as they want, there are few doctors servicing the same area as Dr. X.
In fact, let's suppose he's the only one.
Dr. X isn't a mean person, but he's only human, and he can't work 24 hours a day. Thus, he puts the names of you and the nine other patients in a big hat, and starts drawing names. Unfortunately, the first one is yours. Too bad; now you'll have to find another doctor. Also too bad, but there's this lump you really wanted Dr. X to take a look at -- might be cancer, might not, and surely you'll be able to find another doctor soon, right...?
But the hat has spoken!
Sound bizarre and unfair? It's happening right now across Canada, as the National Post reports. In northern Ontario, Dr. Ken Runciman resorted to his version of the "sorting hat" to decide which of his patients had to be let go. Says Dr. Runciman:
"It was just my way of trying to minimize the bias ... rather than going through the list and saying 'I don't like you, and I don't like you,' " said Dr. Runciman. "It wasn't something that I wanted to do."
You can't really blame Dr. Runciman for restricting the flow of patients into his waiting room; after all, according to the NP, he's already working 11 hour days.
In this week's column, Pierre Lemieux examines the fallacy at the root of Canada's health care system: the idea that you can reduce the price the user of a good pays to zero, without having to resort to rationing or lotteries in order to determine who gets to have access to that good.
These days in Canada, health care seems to be in short supply. But since the users of health care (qua users, not taxpayers) don't have to pay for the use of the good, demand for it has far outstripped supply -- as it would even if there were a dozen Dr. Runcimans. Thus, the need to ration the good, in one way or another.
Typically, as Lemieux points out, rationing occurs through the health care bureaucracy and its odious waiting lists. These waiting lists have claimed real victims: people like Janice Fraser, for example. In Chaoulli v. Quebec, three Canadian Supreme Court judges found that Quebec's waiting lists were so dangerous they violated the Charter's guarantee of security of the person.
Critics will claim that allocation of health care through the market is just as arbitrary as waiting lists and lotteries. But this is not clearly so. Janice Fraser's friends and family wanted -- needed -- to gather enough money together to pay for her care. This would have been a hardship for them, to be sure, as life-saving expenses often are. However, under Canadian law, they were forbidden from spending their own money on the care of a loved one. How arbitrary is that? In order to secure the integrity of the system's precious bureaucracy, a family was prohibited from taking care of one of its own in immense need.
Now that's arbitrary. Lemieux notes that using a lottery to purge a waiting list is even more random, and even more ridiculous. Health care, but only if you're lucky and the hat favors you that day.
Yet, if you're a golden retriever in Canada, you can still get health care if and when you need it.
Excerpts from Lemieux's column are below the fold.
"Queues are a more neutral and less visible way to solve the rationing problem. Let the gatekeeper open the gate one person at a time and let the others wait their turn. In this system, however, prices do find a way to creep back through non-pecuniary costs, like waiting times and investments in connection building or in learning how to cajole gatekeepers. Those individuals whose time has lower opportunity costs (because they are paid less or have less to do in life) will support the wait, while others with higher opportunity costs will build abilities to jump the queue. Those in between won’t get much — until they are dying."
"Moreover, a lottery is not more just than a system based on any other random factors, like good genes or a better environment. We have come back nearly full circle: from natural random factors as they interact with private property rights to random government allocation interacting with bureaucratic and political right holders. We have sacrificed efficiency and liberty in the move."
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A couple of weeks ago there was a thread about the rights of copyrights holders. I was wondering whether you had the rights to use the Harry Potter picture that you are using in this story?
Posted by: The Stig | 2008-08-11 12:21:59 PM
At least 50% of all users do not need to see a doctor. The lottery system simply proves that making sick people well is not the top priority for most doctors. If they really gave a shit, they'd spend more time explaining to people that they don't need to see a doctor.
It's a lot easier to deal with a healthy person than a sick one. Doctors can production line them through for the same price as someone who obviously needs a thorough examination. Don't be surprised when doctors start kicking more sick people off their patient lists than healthy ones.
Posted by: dp | 2008-08-11 12:31:43 PM
Not all patients have the ability to be objective about what ails them. They do not know that they may not need to see a doctor.
On the other hand, it has been my experience that many people put off seeing a doctor until their problem is either incurable or much more complicated than it would have been had they come in earlier.
No doubt that some patients use the system without much thought.
Interesting that in Sweden, of all places, the private sector has taken on a more significant role without much brouhaha as there is in Canada.
Dr. Birger Forsberg, a professor of international health at the Karolinksa Institute medical school who also advises Stockholm on health care policies says that "ideology is not so important any more, it is just a matter of figuring out how to get the system to work".
In Sweden, many private clinics are paid with public funds and citizens using government funded clinics are charged user fees...hospital stays cost about $13 a day, patients pay $20 for each doctor visit and twice that amount for a specialist visit but after $150 in one year visits are free and no citizen pays more than $300 per year including prescription drugs.
Posted by: merrilee fullerton | 2008-08-12 7:57:36 AM
Defenders of Canada's indefensible position on health care don't want the debate to be heard let alone consider implementation of parallel private health care and insurance for freely consenting adult participation. Canada, Cuba, North Korea, Zimbabwe...
Posted by: John Chittick | 2008-08-12 10:38:26 AM
Of course, here in Alberta we've had a Medicine Hat for some time, but we never took it so literally.
Posted by: ebt | 2008-08-12 11:11:41 AM
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