Michael Bliss: The Problem of Saying No to the Sick





[Michael Bliss is a historian and professor emeritus at the University of Toronto. His books include The Discovery of Insulin and biographies of Frederick Banting, William Osler and Harvey Cushing.]

Modern health-care systems don't work very well. Despite the best efforts by the U.S. Congress, despite the single-payer system in Canada, there is no easy resolution of the fundamental policy issue. This is the conflict between the need to supply health care as a matter of right and the need to control costs.

It wasn't this way in earlier eras when health care was often ineffectual and marginal. But, by the mid-20th century, health care had become so important in advanced societies that demand for it became virtually insatiable. Wonder drugs, lab tests, artificial joints, organ transplants, imaging, expertise, home care, end-of-life care, brain surgery, research breakthroughs – we want it all, and we want to be insured against its costs.

Because we are compassionate, we tend to believe that no one should be denied access to health care for financial reasons. Even in the highly individualistic United States, access to high-quality health care is seen as a fundamental human right.

Nowhere, however, have insurers, public or private, succeeded in controlling the consequence of meeting demands for high-quality universal health care. Costs increase faster than inflation, faster than economic growth....

Strategies to try to limit demand by limiting the supply of health care were particularly popular in Canada from the 1970s through the 1990s as governments tried to use their monopoly power to close hospitals, limit the supply of doctors, ration access to diagnostic facilities and operating rooms, and so on. A dominant school of health economists believed that the public was overserviced and that patients could happily make do with less.

Media and voter outrage were the kiss of death for the supply tinkerers. The demand for health care is not just misperception fostered by self-interested doctors and druggists. It's real and massive, increases as we age, and has media support....

In both countries, the health-care burden on governments will mount and mount (just as it's rising for Europeans, who, until recently, have expected and settled for less than we rich North Americans). Crippled by debt and resistance to taxes, the United States may be the first country that finds health care's breaking point.

Our history of struggling with the problems of containing the costs of health insurance suggests there are no practical panaceas, quick fixes or easy answers. We can and should rejoice at the wonderful successes that modern medicine and modern social policies have given us in terms of years of extra life, health and productivity. We can just as rightly ring our hands at the mess we create when we lean on other people to help pay to maintain our personal health....



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