Healthcare: Saving the System vs. Saving the Patient

On June 9, 2005, the Supreme Court of Canada issued a decision in the matter of Chaoulli v. Quebec (Attorney General). The majority of the court found that prohibiting privately-funded health care leads to waiting lists. They concluded that those waiting lists can and have led to deaths and to physical and psychological harm and pain. They concluded that prohibiting privately-funded health care creates patient pain without any corresponding public healthcare gain. And, for those reasons, the majority declared Quebec’s prohibition of privately-funded health care is an unjustifiable violation of an individual’s rights to life and security of the person.

The court’s decision does not render private health care prohibitions in Canada’s other provinces unconstitutional, but the reasons for the decision certainly make it clear that prohibitions in other provinces may in the future be found unconstitutional if their respective government health care monopolies leave patients as poorly attended as they are in Quebec’s government-run health care system: according to the reasons for the decision, Quebec’s prohibitions never would have been declared unconstitutional if Quebec’s government-run health care system had provided “reasonable” levels of health care. Throughout Canada now, the left is staring at that “if” without a blink, and they are engaged in an all-out war of words to make sure that Canadians believe that the court’s decision imposes a duty to dump even more tax dollars into government health care. In newspapers, on television, in the board rooms of numerous left-wing health care NGOs, “how can we improve the government system and thereby keep the prohibitions in place in Canada’s other provinces?” is, foolishly, the focus of almost all related discussion.

One would like to think that at least the National Post – arguably the Canadian newspaper most sympathetic to free market economic reforms – could be relied upon to make the case for privately-funded health care. Such has not been the case. Instead, the National Post has published a number of columns and editorials issuing warnings of possible pitfalls of capitalist competition in health care funding, and promoting what is nowadays politely labelled “corporativism”, “public-private partnership” or “the third way”, but what was originally known as “fascism“: a system in which private companies serve a single payor – the government – which sets down rules and regulations dealing with such things as the nature, quantity and speed of services provided, the prioritization of service recipients, and the prices at which services will be provided.

For example, on June 10, 2005, columnist Andrew Coyne re-assured Canadian socialists and corporativists that:

“Despite what you may have heard, yesterday’s Supreme Court decision does not mean the “end of medicare.” It does not even necessarily mean the legalization of private insurance, at least outside of Quebec. …Conservatives who are already citing the court’s ruling in support of a parallel private health care system…are as unconvincing as the Prime Minister’s smug assurances that all is well because of last September’s health care accord….The case for private insurance would be more compelling were there reason to believe the public system was operating at maximum efficiency…Nor are we lacking for detailed plans for reform. These are to be found…in two other recent inquiries: the report of the Senate committee headed by Senator Michael Kirby, and that of the Alberta government commission headed by Don Mazankowski. Both propose radical reforms to the delivery and funding of health care — but within the envelope of public finance. That is, each would seek to import the basic mechanisms that make private markets such efficient allocators of resources – choice, competition, prices — while preserving the “single payer” model.”

On June 11th, Mr. Coyne continued his pitch:

“But the right of an individual patient to purchase private insurance, in the particular circumstances of his own situation, need not be the model for society as a whole. There may be better ways of alleviating waiting times in the public system than by allowing a private system to work alongside it, which would obviate the need for such drastic remedies. And indeed the evidence suggests there is: a system of “internal markets,” along the lines proposed by the Kirby committee or Alberta’s Mazankowski commission.”

On June 17, 2005, the National Post published a colum by Adam Radwanski, who wrote:

Preserving the same system for Canadians of every social, economic and regional background is a noble and worthy goal; indeed, it’s essential to preserving the sense of social responsibility on which this country has been built. But that aim has been clouded by politicians and interest groups who, to either score points against their rivals or maintain a status quo they benefit from, have lumped together universal care with the manner in which it is delivered…Universality is a question of principle; delivery is one of practicality…Last week’s ruling represents an opportunity as much as a threat — a chance for a long overdue dialogue that puts all the delivery options on the table in order to ensure universality for the long-haul.”

Most recently (on June 29, 2005), the National Post ran an editorial that stated:

With the Liberals having bizarrely dismissed the [Chaoulli] decision out of hand, and with Health Minister Ujjal Dosanjh now picking fights with the Canadian Medical Association because doctors dared suggest a role for the private sector in medicare, a Conservative campaign in favour of greater flexibility within the public system could not be more timely.

Given the sort of columns that the National Post has been publishing, that assertion clearly implies private sector delivery of health care services within a system in which government is the only payor. The assertion could not be more counter-productive and harmful to the future of Canadian healthcare. And given that it is coming from a paper that – rightly or wrongly – is widely thought to be pro-capitalist, there is a definite risk that the National Post’s pro-corporativist/anti-capitalist proposal will be mislabeled “capitalist”, thereby undermining the very concept, and defaming capitalism in general. Yet capitalist health reforms, not corporativist partnerships between government payors and private sector service deliverers, are a Canadian patient’s only hope.

He who pays the piper calls the tune. In a system funded only by government, politicians are the only payors. As such, they demand of health care service providers one thing: a system that, by appearing good enough, keeps voter discontent sufficiently low to avoid ejection from office. Vendors – even private sector vendors – respond the only way they can: by rationing healthcare. As a result, patients suffer and die on waiting lists. In truth, this is of little relevance to the politician, because only a minority of voters are in health care waiting lists, and because those who die in line do not vote. It is also of little concern even to a private-sector vendor: having kept the politicians happy, it gets a comfortable, competition-free, seat at the government trough.

Patients do not want better rationing. They do not care if “average wait times” are reduced. They want their own wait times reduced, and they know that decreased averages might have no effect at all on the amount of time they wait. Canadian patients also know that waiting is not the only problem: the quality of service delivered patients takes precedence, as it should, over any socialist, ideologically-driven commitments to “save universal health care”.

Introducing more “private delivery” of publicly-funded health care will not end rationing, it will not improve wait times significantly (if at all), and it most certainly will not improve patient satisfaction. The time is now to allow each Canadian to make their funding of the public system optional. We must allow patients also to be the payors, so that they can call the tune, instead of the government doing so. Their tune, I assure you, will be not “save the system” but “save the patient“. Health care providers then will either play that tune, or go out of business. And that is exactly as it should be.

Let's keep ideas

Toronto Star, Letters

Jun. 20, 2005

Results matter more than broken promises (Editorial, June 19).

That the public cares more about results than about the means used to achieve them is most certainly true. However, I must disagree with your conclusion that “everyone would be better off if politicians promised results instead of mechanics.”

On some level, everyone wants the same things — better services at a lower cost. With all politicians promising those results and avoiding debate on how to achieve them, distinguishing politicians at election time could amount to little more than debates about managerial competence and name recognition.

In response, all parties would be encouraged to choose leaders who were former CEOs or movie stars, no matter how lacking in political vision or courage. But government is not business and it certainly ought not to be show business. To make informed choices in the voting booth, we must each be able to gauge the feasibility of parties’ promised goals by independently evaluating the means by which they propose to achieve them.

Whereas all politicians clearly must “steer clear of empty and counterproductive promises starved of ideas,” it would be an error, and a disservice to the voter, to steer clear of ideas altogether. Let’s not throw the baby out with the bathwater.

Paul McKeever, Leader, Freedom Party of Ontario, Uxbridge

The new insanity

The Globe and Mail, Letters
Wednesday, May 18, 2005, Page A20

Uxbridge, Ont. — Re Is Premier In Vanguard Of A New Politics? (May 17):

To avoid the political cost of spending cuts or tax increases, Ontario Premier Dalton McGuinty pleads for a $5.7-billion contribution of federal revenue to Ontario’s purse.

Such a contribution would violate Canada’s constitution; aggravate secessionist sentiments; blur the lines of political and fiscal accountability; leave Ontario’s spending crisis unaddressed; and spawn harmful copycat efforts throughout all levels of government in all provinces.

Murray Campbell opines that Ontario’s NDP and Progressive Conservative MPPs would “have to be mad” not to endorse Mr. McGuinty’s strategy. If true, the Premier had better beg for an additional, massive federal investment in psychiatric hospitals for those of us who advocate fiscal responsibility, accountability, and respect for the rule of law.

Paul McKeever, Leader, Freedom Party of Ontario

Letter to Toronto Star editor re: Non-confidence motion in Parliament

Toronto Star

May 12, 2005

Procedural `tricks’ postponed vote
A matter of political confidence

Opinion, May 11.

It appears that Professor Errol Mendes has allowed his politics to compromise his intellectual integrity. In asserting that “votes of confidence are grave matters that should not rest on procedural tricks,” he points the finger at the Opposition. Yet, surely his assertion applies with equal force to the government, which has used “procedural tricks” to postpone a vote of no confidence. The professor’s political bias is made most obvious by his lament that, “It is also troublesome that the opposition parties will soon get the chance to make a proper confidence motion …” Troublesome indeed.

Paul McKeever, Leader, Freedom Party of Canada, London, Ont.

Electoral Reform

What are the alleged problems with Canada’s Single Member Plurality (“SMP”) system (often referred to as the “first past the post” system)? What are the proposed solutions?

Different alternative electoral systems address different problems, but several very different systems are being debated at present as though they address the same alleged problems. This brief primer describes the main electoral systems, and explains the alleged problems that each alternative to the SMP is designed to address.

1. SMP: Description

In the SMP system, one legislative seat is allocated to each geographically-defined electoral district. Federally, there are currently 308 electoral districts (a.k.a. “ridings”).

In the SMP system, the ballot in each riding contains a list of the candidates running in that riding. Voters entitled to vote in that riding mark ONE of the candidates’ names with an X. After the polls are closed, the candidate whose name was Xed on the greatest number of valid ballots wins the seat in that riding.

2. SMP: ALLEGED PROBLEMS AND PROPOSED SOLUTIONS

(a) The “Wasted Vote”

When there are only two candidates on a ballot (e.g., in a two-party system), one casts ones vote for the candidate one most wants to win: ones vote is not “wasted” in any sense. However, when three or more candidates are on a ballot, a voter may feel that his favourite candidate has little chance of winning. Under the SMP, such a voter may decide to vote strategically: he may decide to vote only for one of the subset of candidates who he thinks stand a chance of winning. This way, he thinks, he will not be “wasting” his vote. The problem, however, is that by strategically voting, the voter might get the legislator he voted for, but not the legislator he actually wanted most. The primary solution to the wasted vote involves using a “preferential ballot” in conjunction with an alternative vote-counting system

Preferential Ballot Systems

On a preferential ballot, voters rank some or all of the candidates, rather than just choosing one. When used in conjunction with an appropriate vote-counting system, a preferential ballot solves the “wasted vote” phenomenon.

There are two main electoral systems that use a preferential ballot: the Alternative Vote (“AV”) system, and the Single Transferable Vote (“STV”) system. However, counting of the ballots differs between the AV and the STV. Here’s a comparison of the two systems, quoted from an as yet unpublished paper I am working on:

“In the AV system, like in the SMP system, one individual is selected from each electoral district. If at least fifty percent plus one of the ballots all rank a given candidate as their first preference, the candidate is immediately elected. However, if fewer than fifty percent plus one of the ballots rank a given candidate as their first preference, the candidate with the lowest number of first preferences is “eliminated” from the count. The ballots that gave first preference to the eliminated candidate are then assigned to the remaining candidates according to the second preferences indicated on those ballots. The process of eliminating last-place candidate and redistributing their ballots process is repeated until one candidate has at least fifty percent plus one of the ballots.

The STV system differs from the AV system in two key ways. First, in the STV system, electoral districts are bigger, and voters select more than one individual to become law-makers. Second, the STV tallies the ballots in a way that tends to result in “proportional representation” (discussed below). Specifically, in the STV system, the greater the number of seats that are allocated to an electoral district, the smaller is the number of votes that a candidate must receive to win a seat (for convenience, I will hereinafter refer to that number as the “Threshold”). Specifically, in the STV system, the Threshold is equal to 1 + [total number of votes cast] / [number of seats + 1]. As in the AV system, last-placed candidates are eliminated and their ballots are redistributed to the remaining candidates until the number of votes received by a candidate meets or exceeds the Threshold and he wins a seat. However, unlike in the AV system, if a candidate who has won a seat received more than enough votes to meet the Threshhold, his “Surplus” ballots continue are transferred to the remaining candidates according to the next preference on those ballots. In fact, all of his ballots are added, not just the a number of ballots equal to the Surplus, but the value of the votes on those ballots is reduced so that the total value of the votes on those ballots is equal to the number of Surplus votes: each ballot adds a fraction of a vote equal to the number of Surplus votes divided by the Threshold. If, after transfering all of the Surplus votes, the remaining candidates still lack enough votes to win a seat, the candidate with the fewest votes is eliminated and his ballots are redistributed among the remaining candidates according to the next preference indicated on each ballot. The process of eliminating candidates and redistributing the votes of candidates who win seats or who are eliminated continues until all of the seats for that electoral district are filled.

Both the AV system and the STV system eliminate the fear of the wasted vote. Because both use a preferential ballot, voters can rank their preferences. Because, in each system, a ballot is counted even if its first-ranked candidate loses, voters do not have to fear that their vote will be wasted if they give their highest rank to a candidate who is unlikely to win. The voter, in the AV and STV systems, is not cowed, by polls, media opinion, or next-door neighbours into caring whether or not his favoured candidate is likely to win. Strategic voting is forced to take a back seat to the voter’s conscience. The voter does not need to compromise his beliefs and commitments. The voter can, with the AV and STV systems, respect and value elections.”

(b) Minority Rule / Forcing Compromises

Under the SMP system, a the winning candidate is the candidate that received more votes than any other candidate on the ballot. When there are only two candidates on the ballot, the winner needs 50% + 1 of the votes. But the number of votes needed to win decreases with each increase in the number of candidates. Specifically, the minimum percentage of the vote required to win in the SMP system can be as low as (100 / #of candidates) + 1. So, for example, if there are 10 candidates on the ballot then, if the votes are evenly distributed among the candidates, the winner might win with as little as 10% plus one of the votes.

There are those who dislike this aspect of SMP. The most common argument is that the SMP allows a minority of voters to win a majority of seats in the legislature. Equating the voters’ winning of seats with the voters’ control of the legislature (which, I would submit, is a laughable conclusion), those who oppose this aspect of the SMP say that it violates the principle of “majority rule”: the idea that government should do what the majority of VOTERS want it to do.

However, there is another argument raised against SMP. Specifically, it is said that majority governments are bad because they discourage compromise and collaboration. These advocates prefer perpetual minority governments so that, in effect, radical agendas cannot prevail. Another way to put this, bluntly, is that the left doesn’t want a principled party to win a majority and then not compromise its agenda with those who are opposed to the winning party’s principles.

There are two main electoral systems proposed to “solve” the lack of PR that can occur with the SMP in a multi-party system. Both cause PR electoral outcomes, and both make majority governments the exception instead of the rule: the STV and List Systems

The STV

I have described the STV, above. The key thing to remember when comparing the STV with a List system is that, under the STV, the voter votes for his local candidates, not for parties.

List Systems

List systems are sometimes referred to as “pure PR” systems. In list systems, the voter votes for a party (in some versions of the List system, they also get to indicate a preference of candidates within that party). Each party then is given a percentage of seats roughly equal to the percentage of votes received by the party.

The key difference between the STV and List systems is that List systems give parties the power to decide who will fill each of the seats won by the party. The NDP and Green parties, in Canada, have said that they prefer the List systems because they want to allocate the seats they win on the basis of such things as sex and race: they want to use “affirmative action” (i.e., discrimination) in the selection of MPs. Because the STV provides a PR outcome without allowing parties to choose the candidates, the Greens and NDP oppose the STV.

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