http://www.healthaffairs.org/freecontent/v22n4/s42.htm

B O O K  R E V I E W S
July/August 2003
Resisting U.S. Social Ethics

by Uwe E. Reinhardt
First Do No Harm: Making Sense of Canadian Health Reform
by Terrence Sullivan and Patricia M. Baranek
(Vancouver, B.C.: UBC Press, 2002), 120 pp., $14.95

For several years Health Affairs has featured annually in its May/June
issues cross-national surveys designed to fathom public sentiment on
health systems in several nations. The surveys have revealed a
remarkably uniform degree of malaise with health care across nations,
malaise that does not vary with levels of health spending or structures
of the various national health systems.

The overt driver of this global malaise is the ever-rising cost of
modern health care everywhere. Beneath its surface, that cost escalation
has begun to feed a nascent, still partly disguised class struggle in
countries whose health systems have thus far operated on the principle
of social solidarity.

Observing what luxury, technical sophistication, and immediacy of access
in health care money can buy in the much less egalitarian U.S. health
care system, some increasingly vocal members of the upper-income classes
in these other nations have begun to fancy the same level of luxury for
themselves without, however, wishing to be forced, through social
solidarity, to subsidize that same level of luxury for their
lower-income peers who are unable to pay for it with their own incomes.
The solution, of course, is a multitier health care system. The bottom
tier will guarantee all citizens a limited, collectively financed
package of "socialized" benefits delivered under tight regulation and
subject to rationing. One or several commercialized tiers will cater to
those able to afford additional health care, or "socialized" benefits of
a higher quality, including the ability to move ahead of any queue in
health care. While this idea tends to be marketed under the politically
more salable promise of "greater efficiency," that banner is merely
camouflage for an entirely new deal in health care.

It would have been a miracle if Canada, both spatially and culturally
tied to the United States, had escaped this yearning for the new deal.
It has not. A subtext in Terrence Sullivan and Patricia Baranek's
fascinating little book, First Do No Harm: Making Sense of Canadian
Health Reform, is that the almost decade-old debate on health system
reform in Canada, at its core, is really a struggle over this proposed
new deal. The authors firmly come down on one side of the issue: They
prefer the traditional deal.

In developing their argument, the authors provide a quick but inevitably
superficial tour through the Canadian health system, deftly deconstruct
a number of myths and misconceptions commonly held about Canadian health
care, and explore major shortcomings in the current system. These are
chiefly (1) remaining gaps in public coverage of prescription drugs and
home care; (2) the "passive privatization" of Canadian health care by
removing from public coverage services hitherto rendered in covered
settings (such as hospitals) but now more commonly provided in uncovered
settings (such as the home); and (3) Canada's widely publicized queues
for services. On the latter, the authors provide an illuminating lecture
on methodologically sound ways to define and measure queues and on their
efficient management.

However, I find most engaging the authors' clear and explicit
affirmation of Canada's ethical values. These, argue the authors, are
quite distinct from those evinced, if not openly professed, by
Americans. "The U.S. value system respects, above all, the
[individual's] freedom not to be interfered with," they write. Within
that hallowed individual freedom, imply the authors, is the freedom to
use one's own money to jump queues in health care and to procure better
health care than others can afford. "We [Canadians]," the authors
continue, "balance the freedom of non-interference with the freedom to
choose governments that will act in ways that legitimately constrain
individual choice for the public good.Literally in order to save each
other's lives, we have constrained (but not prohibited) Canadians'
freedom to buy their way to the front of the line." Citizens' free
choice to constrain the ability of the well-to-do to buy their way to
the head of the queue, write the authors, is also a way of expressing
individual freedom, different from but not inferior to a well-off
person's freedom to jump the queue.

While Americans may claim that these are just word games-that Americans,
too, favor an equitable distribution of health care-a distinct U.S.
ethic comes across in what Americans actually do in health care, rather
than what they merely profess to espouse. Canadian provincial
legislators, for example, put the same monetary value on a
pediatrician's treatment of a child, regardless of the child's
socioeconomic status. It is achieved through uniform fee schedules. By
contrast, U.S. state legislators think nothing of paying a pediatrician
only $10 or $20 to see a poor child covered by Medicaid, but $50 or more
to see the legislators' own children. A good many U.S. physicians
respond predictably to these value signals by refusing to treat Medicaid
patients altogether.

To illustrate, the Wall Street Journal recently (2 April 2003) reported
that a member of the South Carolina National Guard called to active duty
during the war on Iraq lost the private health insurance that came with
his civilian job. He then discovered that a local doctor would not
perform a colonoscopy on his sick daughter because her military
coverage, Tricare, pays such low fees. To Canadians such a vignette must
appear unimaginable. As the Wall Street Journal reported, such vignettes
are not at all uncommon in the United States, where the expressed social
value of health care frequently is a function of the recipient's
socioeconomic status.

This stark divergence in social values may help explain the widespread
opposition to American-led globalization. Economists can demonstrate
that abstracting from distributional effects within nations, free
international trade makes all trading nations better off overall. In
First Do No Harm, Sullivan and Baranek alert readers to an additional
twist: the associated mutation of social values. Along with many other
Canadians, the authors worry that international trade agreements will
serve as the Trojan horse onto whose back U.S. corporations will load
health care and health insurance services to be sold in Canada, but in
whose belly they will smuggle into Canada the social ethics and raw
political muscling to which these corporations are accustomed at home.
U.S. companies may view such excursions into Canada as just another
harmless way to garner a few extra pennies of earnings per share.
Canadians who are fiercely proud of their traditional social contract in
health care are likely to view them as threats to their preferred way of
life.

Uwe Reinhardt is the James Madison Professor of Political Economy at the
Woodrow Wilson School, Princeton University, in Princeton, New Jersey.

C2003 Project HOPE-The-People-to-People Health Foundation, Inc.

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