Toronto Star

 Apr. 2, 2002

 Blaming patient won't cure medicare

 Thomas Walkom

  SHOULD SICK people be penalized for their bad health? If the question is
phrased this way, most Canadians would  probably say no. But if you ask the
question slightly differently - for instance, whether smokers and drinkers
should pay more for health care than those who do not indulge in these pastimes
- then the answers often change.

  The argument usually given is that those who knowingly jeopardize their health
because of so-called lifestyle decisions should pay extra when they need medical
treatment.

  Michael Walker, head of the taxpayer-subsidized Fraser Institute, made that
point last month to federal health
commissioner Roy Romanow. Canadian medicare, he said, is too generous.

  More than 50 per cent of illness, he claimed (without citing any evidence)
results from bad personal choices



? such as overeating or alcoholism. Why should
the public pay for the treatment of alcoholics who damage their livers or fat
people who suffer heart disease?

  Others, even those who are not quite as far to the right on the political
spectrum, make similar arguments.

  "We are becoming a nation of obese people," federal Health Minister Anne
McLellan told a Commons committee last  month.

  Her explicit point was that such lifestyle choices place intolerable financial
strains on the country's health-care system. Her implicit point was that if
Canadians want to keep medicare, they should diet.

  Already, politicians are flirting with the notion of lifestyle taxes linked to
health.

  Alberta Premier Ralph Klein defended his province's last tobacco tax hikes as
"addiction fees," explicitly tying them to costs in the health system generated
by people who smoke.

  Behind this growing trend to blame the patient, there is some truth, much
falsehood and considerable danger.

  The truth is contained in a truism: People use the health system less if they
don't get sick. That's what politicians mean when they talk of "wellness
strategies."

  So yes, it is true that people, on average, live longer if they don't smoke,
don't drink too much alcohol, don't eat too many fatty foods, don't mainline
heroin and don't engage in ultimate sports.

  Anyone who wants to avoid the intensive care units of hospitals ? and who has
a choice ? might keep this in mind.
  What's false about the new blame-the-patient theory is that lifestyle choices
are the major cause of illness ? unless you count poverty as a lifestyle choice.

  Study after study after study points out that the major determinant of illness
in Canada is income. The less you have, the worse your health.

  Michael Kirby's Senate committee looking into medicare has said this. Even the
Alberta panel under former federal finance minister Don Mazankowski, whose
report is driving many of Klein's contentious health reforms, made the same
point. If you are poor, you are more likely to get sick. Period.

  Dennis Raphael, a health policy professor at York University, points out that
income levels, rather than lifestyle differences,  are far better predictors of
illnesses such as heart disease and cancer. The weight of evidence supports him.

  Responding to those who talk of changing middle-class lifestyles in order to
combat disease (jog; eat fruit; take up yoga), Raphael has come up with his own
tips for better health. These include: Don't be poor; don't have poor parents;
don't  work in a stressful, low-paid manual job.

  In fact, he argues (in a 1999 article in Canadian Review Of Social Policy)
that income inequality is a major threat to the   sustainability of Canada's
health care system, one that governments choose to ignore.

  What's dangerous about the new interest in blaming the patient is that it
could introduce a new level of resentment to the  health system.

  Resentment is powerful. Ontario is a case study. Here, the Mike Harris
Conservatives used class resentment against  welfare recipients to win power in
1995 (middle-class Ontarians became convinced, for some bizarre reason, that the
province's ills were caused by single mothers on the dole).

  By drawing arbitrary distinctions between the deserving and undeserving sick,
blame-the-patient has the same potential to rip apart Canada's national
consensus on medicare.

  Some in the liberal-left have already flirted with this idea by begrudging
medicare benefits to those who have the temerity to fall ill outside of Canada
(the argument being that if you can afford to rent a trailer in Florida you
don't deserve the public health insurance you've paid for all of your life).

  The right seems prepared to go even further.

  Done shrewdly, blame-the-patient could be a way for a skilful politician to
sell the public on drastic reductions in the scope of public health insurance.

  Why should medicare cover a 20-year-old man who breaks his leg in a skiing
accident? He didn't have to ski.

  Why cover an 80-year-old woman who breaks her leg slipping on the sidewalk?
She could have been more careful. She could have stayed inside the rest of her
life.

  Thomas Walkom's column appears on Tuesday. He can be reached at
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