Editor -
You ought to be a bit more careful about letting people call themselves "policy analysts" in your paper - methinks they must be having a good laugh at you right about now, following the publication of "Overhead, so what? Medicare needs competition", by John Graham and Nadeem Esmail, Monday, August 25, 2003.

Does not the phrase "policy analyst" have a rather specific meaning in public policy circles, and carry at least some responsibilities? That is to say, is not one entitled to assume that someone calling him/herself a "policy analyst" is taking a good, overall look at ALL of the pertinent facts of a situation, and offering the best advice he (or she) can think of, in light of ALL of those pertinent facts? And would it not, therefore, throw something of a shadow of doubt (perhaps even a sledgehammer of doubt!) on the recommendations of such "analysts" were it shown that they had ignored any number of highly relevant facts in their "analysis" - facts which, indeed, tended to put their recommendations in a very different light? And if such facts were well-known things, and it could be fairly safely assumed that the "analysts" MUST have known them, might it not thus follow that they were perhaps less "analysts" than propagandists? - who, of course, are paid to put a certain spin on a situation, twisting "facts" and words to mean what they (or the people who employ them) wish them to mean? And should they not, therefore, have so identified themselves? (actually, of course, to those familiar with Canadian affairs and the analysis thereof, they identified themselves when they said they worked for the Fraser Institute - but how would someone from another country - or one less aware of political realities in Canada - be expected to know that the Fraser is an institute which heavily promotes rightwing, neocon policies?)

Of course it is so. And thus I find it surprising that a rather venerable paper like the Globe would allow such obvious untruths to be spread on its pages. In a related way, there have been several stories the last couple of years about people who called themselves 'doctors", and wound up killing and maiming a number of people, who faced rather severe punishment (rightfully so) for portraying themselves as something they were not, to the public detriment. Surely one who presumes to identify him/herself as a "policy analyst", but who turns out to be in reality a paid propagandist, ought to be censured as well - after all, they presume to advise your readers on appropriate directions of public policy, on, in this case, a very important and controversial issue - but their opinions, as such paid propagandists, should surely be given no more weight than the "opinions" of any other citizen, is it not so? Sensationalist tabloids do this kind of thing all the time, with writings from Dr. John (of MailOrderU) on any number of wild fantasies - but surely the Globe would consider itself above such dissembling?

Let me just point out one or two things a *real* "policy analyst" might have factored into his/her considerations concerning medicare in Canada.

For instance, Graham and Esmail complain that our sad healthcare system now has waiting lines for some procedures of up to four long months, up from 9 weeks in 1993, as they promote the idea of opening the health care system up to private hospitals. And so it may be - but surely an honest evaluation would also note that 1993 was the year the current Liberal government took power, and under the direction of Finance Minister Martin began their slashing of all social programs for ordinary Canadians, including, of course, health care - until he could brag a couple of years ago that his government was spending less on such programs, figured in a per capita way, than the Canadian government had spent since 1949 (or some such year). Surely an honest "policy analysis" would have noted this great spending reduction at the same time it noted longer lineups, as any sort of common sensical analysis would be forced to consider that the two things were probably related. Odd though, this pertinent fact doesn't seem to appear in their piece. Nor, along the same lines, do they note the huge cutbacks that the Harris government imposed through the same period in Ontario, firing thousands of nurses and doctors, reducing the number of graduates from medical schools, and closing hospitals all over the province - surely, surely, surely any normal person would say that, in the absence of some great new health discovery that improved everyone's health so they no longer needed medical care, this would tend to lead to longer waiting times for almost everything to do with health care?!?! - but, oddly again, we see no such acknowledgement of this rather basic and important fact in this "analysis".

Onward - Graham and Esmail state "Despite these facts, Prof. Woolhandler and colleagues assume that arbitrarily low administrative costs are the primary indicator of a well- functioning health-care system, and ignore other costs imposed by government monopoly" - well, this is highly disappointing, to say the least, to find this kind of nonsense in a respected newspaper in Canada under the rubric of "policy analysis". It is nothing more than cheap rhetoric - I have read the reports in question, and nowhere do Prof Woolhandler and colleagues say they believe that low administrative costs are the "primary" indicator of a well-functioning health-care system - merely an important consideration, all other things being more or less equal (and imagine the delicious irony of a rightwing commentary trying to argue that reducing expenditures is *not an important public policy consideration!!) - and whatever these haters of Canada and things Canadian may say, they can hardly try to argue about the overall quality of the Canadian healthcare system for most of the last 40 or so years since it was implemented - in every aspect, it has been rated very highly by Canadians, and has been among the best in the world by any reckoning for most of that time - it is, indeed, what we are all fighting to save, in the face of rightwing government cutbacks and ongoing attacks such as this one demanding it be disassembled and turned over to the private sector and opened to private profit. In reality, such nonsense as this tells a great deal more about the ability and credibility of these "policy analysts" than it does about whatever they are criticising.

They go on to say that "Without competition, providers have little incentive to act in the interests of consumers. Hospitals do not feel the need to provide more surgeries to reduce waiting lists or provide higher quality care, because they are secure in the knowledge that patients cannot go anywhere else..."

This idea holds water to about the same extent as GW Bush's accusations of Iraq being an immediate threat to the greatest military power the world has ever known. To start with, regardless of neocon attempts to redefine the language of everything to market terms to enable the marketisation of everything, Doctors are not "providers" and Patients are most emphatically NOT "consumers" - and it is, quite frankly, outrageous to try to subsume every aspect of our lives, including such important things as our health and healthcare, into this market model, whose primary objective thus becomes the "return on investment" of HMOs or some such entity - it is, truly, one of the main reasons the whole neocon movement is becoming so disliked by most people in the world. My father was a Doctor, and I have known many of them in my life, and the great majority of them (and nurses, and other healthcare providers) are dedicated people who do NOT measure their professional success by how much money they make, but by how well they are taking care of their patients. They do NOT callously work fewer hours and create long waiting lists, somehow laughing cynically that they can do so because "there is no competition" - how insulting to them!! - there are long waiting lists, as noted above, because the healthcare system has been progressively starved of the money needed to make it function at a good level for many years now - surely even the neocon "analysts" can see that, with an increasing number of patients from an increasing population, reducing the number of doctors and nurses will inevitably creating longer wating times?!? What kind of perversity leads them to ignore this most basic fact, and use the waiting lines to further attack the system?!? Likewise hospital administators and the other people in the healthcare bureaucracy - how outrageous to assert that they are carelessly wasting money and creating long waiting lists only because their patients have nowhere else to go!!! - again, the huge funding cutbacks have caused this serious problem, and administrators, as well as doctors and nurses, are increasingly dealing with stress and burnout problems - because they DO care about their patients, and are very troubled that they cannot provide the care they want to - because of lack of funding!!

Well. I shall close here - I think the points have been adequately made. But I would urge you, the Editors, to be a little more careful in how you allow your writers to identify themselves, if you have any concern for your own reputation as a journal which attempts to present things accurately. Graham and Esmail are quite welcome to their opinions - but as "policy analysts", they are little more than quacks, and it both surprises and disappoints me that you would allow them to present themselves otherwise in your paper.

In my opinion -

Dave Patterson
Faculty of Natural Resources
Prince of Songkla University
Hat Yai, Songkhla 90112
Thailand
66-074-454271

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Overhead, so what? Medicare needs competition

By JOHN GRAHAM and NADEEM ESMAIL
Monday, August 25, 2003 - Page A11
http://www.theglobeandmail.com/servlet/story/RTGAM.20030825.cofraser25/BNStory/International/?query=nadeem+esmail
Last Thursday, the New England Journal of Medicine published an article stating that administrative costs of health care in the United States are higher than those in Canada: $1,059 (U.S.) in the United States versus $307 (U.S.) in Canada. The lead author, professor Steffi Woolhandler of Harvard Medical School, has written similar articles over the years, all with the conclusion that the United States should embrace government- monopoly health insurance like we have in Canada.

As the authors note, American patients, doctors, and hospitals have to deal with multiple insurers, each of which has different policies and paperwork.

In Canada, patients only have to deal with one government-run insurer per province. The authors believe that competing private insurers cause high administrative costs, and that a single payer would be able to capture this waste and spend it on patient care.

Unfortunately, Canada's experience shows that this is not the case.

In 2002, the average Canadian patient waited almost four months from the time his general practitioner decided that surgery was necessary until a specialist provided the care. That span of time has been growing since 1993, when it was only nine weeks.

Further, Canadians have little access, relative to other developed countries, to doctors and high-tech imaging machines. In a comparison of access to doctors, Canada ranked 17th of 20 countries. Canada also ranked of 17th of 22 countries in a comparison of access to CT scanners, 18th of 23 countries for access to MRI machines, and 13th of 14 countries for access to lithotriptors (used to pulverize kidney stones).

Remarkably, this lack of access comes at a high price. After accounting for the fact that Canada has a relatively young population, it spends more on health care than all multipayer OECD countries outside the U.S. -- countries such as Germany, Switzerland, and Japan.

Despite these facts, Prof. Woolhandler and colleagues assume that arbitrarily low administrative costs are the primary indicator of a well- functioning health-care system, and ignore other costs imposed by government monopoly. With some of the longest waiting times in the world, and age-adjusted health expenditures higher than all other OECD nations with universal health-care systems, the Canadian model is clearly not the rousing success it is purported to be.

Low administrative costs, caused simply by government monopoly, do not necessarily cause a better health-care system or low overall costs.

Consider the automobile industry: Wouldn't it be cheaper if we got rid of all the salesmen, advertising, marketing, and models that differ in trivial matters such as colour? If we all got our cars from the government-run factory, wouldn't we have a fairer and cheaper automobile "system"? They tried it in the Soviet Union and East Germany. The results were Ladas and Trabants.

The article also ignores the fact that both the federal and state governments create a lot of the administrative costs in U.S. health care.

About half of U.S. health care is privately financed, and that share is subject to an increasing burden of regulation that reduces competition and adds to costs. Private insurers in the U.S. are basically selling government-mandated policies.

Without competition, providers have little incentive to act in the interests of consumers. Hospitals do not feel the need to provide more surgeries to reduce waiting lists or provide higher quality care, because they are secure in the knowledge that patients cannot go anywhere else. Provincial insurers are not concerned with long queues for health services or a lack of access to doctors or technology, because those who pay insurance fees will never stop paying, nor will they go elsewhere.

It would be a serious mistake for Americans to fall into this trap and opt for a Canadian-style, single-payer system -- considering only the money saved on administration, and not the needless suffering and money lost unaccountably through lack of competition. For Canadians to take the fact that we spend less than our neighbours do on administration as a reason to be smug would also be a mistake.

Increased competition in health care results in better outcomes and higher quality of care for patients. A small increase in administration costs in Canada, through the introduction of competition, would be a good thing.

John R. Graham and Nadeem Esmail are policy analysts at the Fraser Institute in Vancouver.

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Mon, 25 Aug 2003 12:43:25 -0500


U.S. health no bargain


For years, the United States has spent more than twice as much per
capita on health care as Canada and other leading industrial
countries.

A new report helps shed light on why this is so.

A study published by the New England Journal of Medicine this past
week reports that 31 cents of every dollar spent on health care in
the United States goes to pay administrative costs.

The report found the U.S. spent a whopping $300 billion, or $1,059
for each American, on the salaries of health plan, hospital and
physician-office billing specialists; compensating doctors for time
spent handling paperwork instead of seeing patients; and funding
marketing campaigns for hospitals and insurance companies.

By comparison, paperwork in Canada's publicly funded health-care
system was a relatively lean $307 (U.S.) per person.

Paper-shuffling costs tell only part of the story. The report doesn't
include how much of the U.S. health care dollar is handed over as
profit to the private-sector companies that dominate the system.
Using conservative estimates, profit would take another 10 to 15
cents out of each health-care dollar.

All in all, a lot of money in the system is diverted from spending on
actual patient care. And still, 41 million Americans are medically
uninsured.

Our friends south of the border are getting a lousy deal.

It's incredible, with mounting evidence staring them in the face,
that some political leaders in this country are still trying to
convince Canadians the private sector is the cure for what ails our
public system.

Among them is Ontario Health Minister Tony Clement, a champion of
greater private-sector involvement, including the first in a series
of privately owned magnetic resonance imaging (MRI) and computerized
axial tomography (CAT) scan clinics.

Clement has promised these clinics will deliver care more
efficiently, but he has never provided the backup documents to prove
his case, despite continued prodding.

The American study reminds us of the importance of Canada getting a
National Health Council up and running.

The council was first proposed by Roy Romanow in his report on the
future of health care. It would provide Canadians with an accounting
of whether they are getting good value for the $90 billion in public
money spent on health care every year.

The premiers and territorial leaders reluctantly approved it in
principle in February, after chipping away at its independence and
funding.

Now the provinces are trying to backpedal altogether. They say
they'll proceed only under a new prime minister and only after more
study to ensure the council isn't too expensive, or bureaucratic, and
has the "proper" mandate.

Shame on them. Canadians have a right to know if their money is being
used properly, to provide the broadest range of high-quality services
in as cost-efficient a way as possible.

Canadians can only benefit from setting up a properly funded,
independent agency to supervise, co-ordinate and safeguard the
nation's health system.

Our tax dollars must be put to the best possible use. The American
study suggests we're on the right track. Let's stay on it.