From the Desk of Carol Wodak:Public or Private?

Public or Private?

Lynda Somerville, SALT, March 2019

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The next Alberta election will present citizens with a stark choice between philosophies.  On the one hand will be a philosophy stressing freedom for an individual, even though that may mean limitations for the many; on the other, one emphasizing the good of the larger community, the welfare of the “all”, even though that may mean restrictions on the “one”.  That is, we will be asked to choose between going it alone and going together.

The former philosophy advocates “choice”.  Who can possibly disagree with that?  After all, freedom to make choices has been fought for through much of human history, most notably the freedoms to choose our own government, to speak our minds in the public square, to assemble peaceably with our fellows, to demand equal treatment under the law.   We make choices every day, between buying a new Lexus and a second-hand Ford, between Chateau Briand and a Big Mac. We can choose what church to attend or whether to attend at all. We can choose our spouses and our friends, our charities and our political affiliations.

Some choices, however, are more controversial.

One such choice promises to allow Albertans to opt for private health care, paid out of pocket or through private insurance, instead of public health care, paid by public insurance. Those who are ill and can afford the fees will be able to see a doctor or get important tests or operations without waiting in the public queue.  This option will be accompanied by promises of lower taxes and healthy competition, leading to greater efficiency, shorter lines in the public medical system. “Hard-working Albertans” will be able to keep more of their own money and spend it how they choose.

Such an offer sound attractive, doesn’t it?  This is the way that society had operated for much of history, and still does in many countries, most notably the United States.  Canada, however, has gone a different route: It has fostered certain “universal” programs, believing that such programs are so essential that they cannot exist purely on individual desires or means; that they are a right and an obligation rather than a privilege, programs such as the Canada Pension Plan, Unemployment Insurance, Medicare, and Public Education.  

The universality of such programs is essential.  Consider the analogy with recent airline pricing.  Once was a time when nearly all of us lined up in the same lines and sat in airline seats with sufficient legroom.  Now, however, airlines offer many different levels of pricing. Those paying more get “priority” lines and “priority” boarding and more leg room.  But the lines for the rest of us have not got shorter and the seats are even more cramped. As more people opt to pay for the shorter lines and the greater legroom, the seats in “Economy” will become fewer and more uncomfortable.

The same will happen in medical institutions if some of us choose to pay privately for more exclusivity and speed of access.

The universality of Medicare is important, with treatment based on medical need, not on the ability to pay.  Young or old, rich or poor, we all wait in the same queues and receive the same services.  Allowing the wealthy to pay more for faster or better service will have the same effect that it has had on airplanes.   Many of the best doctors may want to go private where they can earn extra fees, while still being back-stopped by public insurance and public facilities. And the wealthy, often politically influential people, will no longer have a vested interest in the quality of the public system.  They will claim a deduction for their private fees on their tax forms. They may demand the lowering of taxes that support the public system.

This has already happened in seniors care, where private services, unaffordable for most, have displaced public beds, leaving long waiting lists for the few that remain, even as the frail elderly have increased.  The process has downloaded the costs onto the frail, the sick, and their family caregivers, and onto hospitals, which have nowhere to send those no longer needing acute care.  And twice previous governments have tried to end universality in the seniors’ drug plan, by introducing means testing with escalating co-payments, and twice they have backed off because of outrage from seniors.  Seniors, perhaps more than anyone, know the value of universal health benefits because they remember a time when such benefits did not exist. They do not take them for granted.

Everyone understands the value of universal services for the police or fire or waste management departments.  Everyone agrees that we should have universal rules of the road to keep us from bumping into one another.  We would be horrified if someone could pay to have the firetruck or ambulance come more quickly to his door.

Universal programs, of course, require higher taxation.  And higher taxation is a hard sell on the hustings.  Universal programs are paid for with progressive taxation whereby those who have greater wealth pay more than those who earn less.  These programs curtail the freedom (to spend our money as we choose) for many of us so that all of us can share the benefits of decent health care or a more secure retirement.  Taxes provide insurance against the vicissitudes of life. Because universal programs allow economies of scale, they are cheaper than if we were buying individual insurance, as Americans have found out under Obamacare. This explains why so many Canadians argue for universal Pharmacare and why universal dental, vision, and long-term care plans are equally desirable.   

The next election will ask us to make this philosophical choice.  The choice to go it alone will be superficially more attractive because the choice to share the burden will cost us in the short run.  However, a wise African proverb warns us to consider the implications: “If you want to go fast, go alone; if you want to go far, go together.”