In the sophomoric movie Hot Tub Time Machine, some middle-aged men, their hopes and dreams dashed by the mundane realities of grown-up life, travel back in time to the 1980s, looking to magically relive their carefree youth and make things right.
The plot, lame as it is, is frighteningly reminiscent of the debate surrounding health-care financing in Canada. Just last week, Quebec Health Minister Raymond Bachand became the latest politician to wade into the hot tub time machine. In the provincial budget, he proposed, among other measures, introducing user fees for physician visits - a decidedly 1980s idea.
Those who know their medicare history - something all too rare among politicians and policy-makers - will recall that the eighties were a time of galloping inflation, with health-care costs rising by double-digit percentages.
In the 1980s, there were dire predictions that medicare would bankrupt the country because health spending was already gobbling up almost 25 per cent of provincial budgets. (We never tire of some old tunes.) To rein things in, the federal government cut transfer payments to the provinces, which responded by freezing and rolling back wages for health professionals such as doctors and nurses. (Then, like now, salaries and benefits made up the majority of health spending.) Doctors, in turn, started charging user fees - demanding that patients make a cash payment in addition to the fees the doctors received from the provincial health plan, a clear violation of the spirit of medicare. Many hospitals did the same.
Ultimately, to resolve what came to be known as the extra-billing crisis, Ottawa adopted the Canada Health Act.
The legislation spells out the guiding principles of medicare: public administration, comprehensiveness, universality, portability and accessibility (all of which were in previous, disparate pieces of legislation).
A contentious issue at the time, the act says that if extra-billing or user charges occur in a province, those amounts can be deducted from the cash contributions the federal government makes to the province.
Contrary to popular belief, the Canada Health Act bans nothing - not private care, not user fees, not special health taxes. But it does allow for a potentially punitive holdback of funds, though the measure is rarely applied.
In the wake of the budget in Quebec, where plans were announced to study a $25-per-physician-visit fee, there was much gnashing of teeth.
While the move clearly violates the spirit of the Canada Health Act, it is not at all clear that it could trigger the holdback of funds allowed under the law. Because the measure is expected to raise $500-million a year, the question is a significant one.
Under Quebec's plan, in which the new measure is called a "health deductible," patients would not have to fork over cash. Rather, they would have to declare on their provincial income-tax return how many times they visited a physician, and each consultation would be assigned a $25 value.
So it could be argued that the measure is a tax, not a user fee.
In Canada, we often get caught up in this legalistic hair-splitting and lose sight of the more fundamental questions.
In this case, the key question is: Do user fees (or health deductibles or whatever euphemism is chosen) work? The goal, presumably, is to create a financial disincentive so that patients will cut back on unnecessary visits - seeing a doctor for a hangnail because it's free, or going to the emergency room for a cold. (Under Quebec's proposed law, you would not only pay $25 for each physician visit but an additional fee if you go to an inappropriate provider - say, to emergency instead of a walk-in clinic.)
All the evidence says user fees do not achieve that goal.
First, despite some apocryphal tales, there is little evidence that Canadians use health-care services frivolously. Too many patients end up in the ER because of the inadequacy of primary care, not because they enjoy waiting in a dank hospital for 10 hours.
Second, the only people who will be discouraged from visiting a doctor because of the perception it may cost money are the poor - meaning the elderly, people with chronic illness, those with mental-health problems.
User fees are, in effect, a punitive tax on the poor; they are regressive and counterproductive. Not to mention that the approach has been tried, time and time again in various Canadian provinces, and has always failed.
The only way health-care costs are going to be reined in is by tackling, head-on, the three areas where spending has increased relentlessly for decades:
1) salaries paid to health-care providers (by ensuring that the right provider provides the right care and ending the practice of highly paid professionals doing mundane clerical tasks);
2) prescription drugs, by limiting the medications covered by public plans and adopting policies such as substituting generics for brand-name drugs;
3) expensive new technologies with marginal additional benefits, which should not covered by public health plans. There also needs to be investments in patient safety and information technology (electronic health records), but those are measures to improve the quality of care, not necessarily to save money.
Those are the grown-up realities, and they have been since the 1980s.It's time to get our heads out the sand - or the hot tub - and start dealing with those realities instead of proposing, over and over again, tried and failed measures.