How about a second helping of hospital food? No, really. They’ll even trim the crusts off the egg salad sandwiches for you. They being the bistro staff at Ottawa’s Queensway Carleton Hospital, not the politicians endlessly praising our health system while doing their utmost to make it horrible. Click here to read the rest.
Practically everything about government budgets makes me want to scream, from reckless spending to vacuous rhetoric. Take Thursday’s federal “Economic Action Plan 2012”… please. First, it was awful. Then almost everybody said exactly what you’d expect if they’d written their press release, column, or news story before the thing even appeared.
Reaction on Thursday was predictable. The Green Party said Jim Flaherty delivered a budget that was "tough on nature"; the Ottawa Citizen said he delivered one that "includes major changes to ... the size of government"; the Communications Workers of America Canada said: "Federal budget threatens Canada's social and cultural fabric". But I was there and I can tell you the government did not deliver a budget at all. Click here to read the rest.
Despite his hard-won reputation for unreliability, I pay attention when Dalton McGuinty talks, about Ontario's debt or anything else. I know I can count on him ... to be misleading in important ways. Click here to read the rest.
Premier Dalton McGuinty is getting pseudo-tough on spending. He even paid Don Drummond $1,500 a day to chair a Commission on the Reform of Ontario's Public Services, whose 362 sensible recommendations delivered Wednesday won't help. Click here to read more.
If Barack Obama were elected Prime Minister of Canada, how would he fix health care? It is not an idle question. American politics is necessarily interesting to Canadians for several reasons. It's inherently fascinating, even horrifying, because it's so exuberant. In American politics things actually happen, whereas here you get the feeling that if Christ were to return in glory, commentators would assess its impact on Tory prospects in Quebec.
Also, American politics affects what the hyperpower might do next, interesting to everyone but especially its largest trading partner and closest neighbour. And finally, while in many ways unique, the U.S. also shares many traits and some public policy problems with Canada. Including the crippling stress of public health care on the government budget.
I know, I know, people say the U.S. doesn't have a public health care system. It's time to wonder what else such commentators don't know, since Medicare and Medicaid already consume 20 per cent of the American federal budget, with much worse to come.
Don't take my word for it. I'm cribbing here from a Nov. 4 talk by Dr. Cindy Williams, sponsored by the University of Ottawa's Centre for International Policy Studies. She's a senior research scientist in the MIT security studies program and former Assistant Director of the Congressional Budget Office with a PhD in mathematics, so my guess is she got the numbers right.
By comparison, under the heading "Federal transfers in support of health and other programs," the Canadian federal government only spends about $33 billion out of $240 billion, or around 13 per cent, which includes support for higher education as well. On the other hand, American states are better off than Canadian provinces: Comparing the two most populous, in California "Health and Human Services" takes around $40 billion of $144 billion in spending or 28 per cent whereas in Ontario it's around $40 billion out of $96 billion or 42 per cent. But put the two levels together in either country and the result is alarming in a strangely familiar way.
Especially as Ms. Williams, who I suppose I need to add was not there to shill for the Republican party, went on to show us a very scary projection by the Congressional Budget Office of what would happen to the U.S. federal budget if current trends continued and program eligibility conditions were maintained. (You can see for yourself, at www.cbo.gov/ftpdocs/88xx/doc8877/12-13-LTBO.pdf.) Compare that to recent Fraser Institute projections of our provincial budgets, and weep.
Ms. Williams went on to point out that the United States has managed its fiscal affairs in the last quarter-century, to the extent that it has managed them, primarily by steadily reducing defence spending from nearly 10 per cent of GDP in 1968 to under five now. Despite another Canadian myth, defence only gets 22 per cent of the American national government budget, one percentage point more than Social Security, while "Other Mandatory" (mostly food stamps, unemployment insurance and public pensions) gets another 13 per cent of federal spending and interest a further seven. But as health care grows, the U.S. will among other things have to surrender any ambition to be the guardian of world order to keep funding middle class entitlements. It seems a high price to pay.
I asked at the outset what Barack Obama would do about Canadian health care. In fact I don't even know what he'll do about the American stuff since during the election he promised a massive expansion of a system already threatening the federal government with insolvency and abdication of its core responsibilities. Yes, he also said he'd go through the budget line-by-line eliminating waste. But I downloaded the detailed "Appendix" to the "Budget of the United States Government Fiscal Year 2009" and it's 1,314 pages long. If Mr. Obama can get through one page an hour deciphering the items and making intelligent judgments about what to cut, by how much and how, and devotes 10 hours a day to it seven days a week despite a few other duties attendant on the presidency, he'll be at it from Inauguration Day until late on the morning of June 1, so after lunch he can start trying to get Congress to go along with his cuts. Which will either come from the 54 per cent of the budget that's entitlements or won't make much difference. And either way won't alter the lethal long-term trends.
If he were in charge in Canada, he'd have a remarkably similar problem and dismal lack of solutions. Which surely tells you something about the sustainability of public health care. And politicians who promise to save it by expanding it.
[First published in the Ottawa Citizen]
How much is your life worth? Oh dear me no. I don't mean to you or your family. I mean to the Finance Ministry. You see, news out of Britain informs us that their government just isn't willing to spend that much to save lives. The National Institute for Health and Clinical Excellence (known scarily as NICE), which has already rejected various expensive drugs available in the U.S. and elsewhere in Europe, has now formally declared that "There is a powerful human impulse, known as the 'rule of rescue', to attempt to help an identifiable person whose life is in danger, no matter how much it costs. When there are limited resources for health care, applying the 'rule of rescue' may mean that other people will not be able to have the care or treatment they need. ... The Institute has not therefore adopted an additional 'rule of rescue'."
Of course government health providers should try to control costs, especially when medical care now consumes, not untypically, 46 per cent of the Ontario budget. And they have been trying in Canada, since at least the ill-fated 1992 decision to cut medical school enrolment by 10 per cent to reduce the number of doctors treating people and submitting bills. One is tempted to file it under "Be careful what you wish for." But the crucial point is that you didn't wish for it. They did.
Which takes me back to a century-old warning from Albert Venn Dicey about a then-novel wave of legislation intended to protect citizens from their own poor judgment or weak bargaining position, real or imagined. "The point is elementary," he wrote, "but it is worth insisting upon, since there is a constant tendency on the part both of theorists and of so-called practical men, to forget that protection invariably involves disability, i.e., limitations on the individual liberty of the protected person."
I remember when it was those on the "right" who had to insist that we think sensibly about tradeoffs in public policy. Thus Thomas Sowell once asked in exasperation: "Would anyone really spend half the Gross National Product to wipe out the last vestige of shop-lifting, or every minor skin rash?" But NICE is hardly conservative. And while Dicey's massive white beard and solemn praise for the Victorian constitution might tempt us to classify him as conservative, reactionary, even a fogey, as a Benthamite defender of political innovation in the name of laissez faire he doesn't quite fit today's pigeonholes, despite dating from an era when desks actually had such. So let's just read his words and see if they tell us anything.
They tell us that when the law prevents us from doing something that might be contrary to our interests, the tradeoff for the possible protection is the inevitable prevention. In this case, the prohibition on buying and selling medical care in the free market might protect you from being unable to afford it, buy more than you need, get worse care than the rich, etc. But in doing so it necessarily prevents you valuing your own life or health more than the government does. Which is every bit as bad as it sounds.
As things stand, you do not merely pay for health care what Dalton McGuinty says you should. You get the treatment he makes available to you, when and where he makes it available, of the sort and in the quantities he makes available, and nothing else. And if you don't like it, you cannot take your business elsewhere. It has, in every important sense, ceased to be your business.
If you were responsible for your own health care you would, of course, try to ensure cost control, as I presume you do in every aspect of your life with varying degrees of determination, skill and success. You'd want to look after yourself but you'd also want a car, a home, education for the kids, a retirement fund, a bit of bacon in your porridge and a decent chance of living long enough to enjoy all these good things. In short, you'd worry about getting the right mix of cost and service.
When you hand over health care to government, or your fellows do it for you, these still-necessarily value-for-money calculations are not merely done by someone else. They are also done very differently. They are generally not done well, for familiar reasons that need not be reviewed here. For now consider only that, even if the state did not have serious problems making rational tradeoffs, public servants and politicians would still make their calculations of efficiency based on different criteria.
Including, most importantly, that if you died they wouldn't miss you nearly as much as you would. But they'd sure miss the money needed to treat you. And you'd better think about that, because they are.
[First published in the Ottawa Citizen]
Put down the pill bottle and back away slowly. Aha! What’s this? Expired antibiotics? You’re in big trouble, buddy. Actually we all are. Antibiotic-resistant bacteria are everywhere, swarming over hospital towel-racks and bedsteads and heading right for our soft bits when we’re already feeling sick. Nature is, proverbially, short of mercy. But we’re making the problem way worse by misusing what were once “miracle drugs,” but have somehow become “whiny entitlement drugs.”
Look at this new study conducted for the Public Health Agency of Canada. According to Tuesday’s Citizen, the study “found almost one in three Canadians either wrongly believes antibiotics are effective against colds or doesn’t know if they are. Only 44 per cent know antibiotics kill bacteria, but not viruses. Close to half incorrectly think recent use of an antibiotic protects against reinfection or don’t know whether it does … one in 10 Canadians has used leftover antibiotics from old prescriptions belonging to them or someone else.”
Of course people wouldn’t be able to hoard expired antibiotics and take them for colds and other virus-based illnesses if doctors didn’t sometimes prescribe them just to get loud rude people out of their offices. In Britain, where the problem is so bad the government just issued strict new guidelines to doctors not to give antibiotics for coughs, colds and ear infections, the Daily Telegraph notes that family doctors “claim they often feel under pressure from patients who are angered if they are refused treatment.”
I can’t help thinking it’s a breach of medical ethics to give in to make these cretins go away. But I have a lot of sympathy for Canadian and British doctors, who are overworked, underpaid and treated like serfs by a public that seems to think their state-given rights include not only free access to whatever treatment does exist, but who also think that a treatment must exist for whatever is bothering them.
Those doctors willing to pacify us with pills, as though we were children getting lollipops, are responding to what is plainly widespread and socially condoned behaviour. (In fact they’d probably get in a lot more trouble for giving candy to kids in an age that gobbles antibiotics, but shuns sugar.) And knowing the difference between a bacterium and a virus, even in the “information age,” isn’t snobby pedantry like knowing the Venetian from the Florentine school of Renaissance painters. We aren’t going to die if we mistake a Donatello for a Tortellini. Yet far more people know their star sign than their blood type even though the latter won’t even help you get a date any more. And people succumb to ridiculous scares about cell phones but don’t pay attention to bugs that can kill their kids.
Most people also have no idea what it was like to live in an era without antibiotics. “Hey, I scratched my finger.” “Oh. Goodbye.” Of course not every wound was fatal. But American president Calvin Coolidge had an all-too-typical experience of watching helplessly in 1924 as his 16-year-old son blistered a toe playing lawn tennis on the White House grounds, developed blood poisoning, and died. It would be silly to go back to those days because we can’t be bothered to read the label or just decide not to believe it.
On that last point, pollsters and analysts have recently hailed a “decline in deference” among Canadians, as though rudeness were a virtue. That deference is a bad thing is a common misconception among intellectuals, though it’s odd to hear it from the same people who praise Canada’s differences from the famously egalitarian United States. In any case, the American ideal required people, in place of deference to their superiors, to be self-reliant and community minded.
Abusing free drugs manifests neither quality. And insisting that the government look after our health care sounds deferential to me, even if we’re also whiny. But let’s make the best of it. The only proper way to get antibiotics, aside from a few ointments, is from a pharmacist on the advice of a doctor. And they both tell you exactly what to do. Take the pills as instructed, complete the treatment even if you feel better, don’t hoard old pills for some arbitrary use later on. Oh, and if you get the sniffles don’t go to the doctor. Just take some quack remedy you found online and the cold will be gone in seven days instead of lasting a whole week.
I don’t want to die of some wretched superbug because people were too lazy or insolent to follow simple directions on a bottle, or had a misplaced sense of entitlement that the universe owed them a cure for the common cold. So I say again, put down the bottle and back away. Doctor’s orders.
[First published in the Ottawa Citizen]