Cut the rhetoric, not health care

November 19, 2001

It is an old rule of persuasion: people are rarely receptive right away; you have to work at making them so. If you want to change someone's mind about something, you first have to shake them out of their complacency, sow uncertainty in their minds, get them worried, make them eager for new answers. The Ancient Greeks were masters of the art and wrote extensively about it.

The rules of the game have long been known, but propaganda-mongers still apply them with success. How many times have we seen them create a sense of crisis in the population, in order to smoothe acceptance of controversial policies?

Health care is a case in point. There are political and business interests in Canada which have never come to terms with the Canada Health Act and would dearly love to throw health care wide open to profit-seeking enterprises. Yet most Canadians are strongly attached to the principles of not-for-profit, public health care.

Anyone trying to change their mind would have to rattle their confidence in the public system. One approach could be to exploit dissatisfaction with the care they receive. This is what the Fraser Institute tries to do with its regular reports on hospital waiting lists. Provincial governments have certainly encouraged such dissatisfaction by slashing hospital budgets and under-investing in the education of specialists and other medical personnel. Yet, the great majority of Canadians still express satisfaction with the health care they receive personally.

A more promising line of attack has been to tap into widespread insecurity about public finances. In the early 1990s, the federal and provincial governments were extremely successful in persuading many Canadians that the state was virtually bankrupt and could no longer be expected to provide the services it did in the past. The triumph of this strategy can be measured by Canadians' quiescence as their hospitals, universities, schools, unemployment insurance, and other services have been starved of funds over the last decade.

The propaganda campaign about out-of-control public spending continues today. Its focus is no longer on slaying the deficit dragon, but on preventing health care from bankrupting our children and grandchildren. Hardly a day goes by without a major speech, newspaper editorial or television report about the crisis in health care spending. Politicians like Mike Harris and Tony Clement in Ontario, or Ralph Klein in Alberta, regularly warn that it is eating up an ever-greater share of their budgets and must be cut back. The fault, they say, lies in Medicare itself: its goal of universal, accessible and comprehensive health care is unsustainable. Their solution is equally simple: privatize financing--e.g., introduce user fees--and give the private sector a big role in providing health care.

The latest report of the main authority on the subject, the Canadian Institute for Health Information (CIHI), would seem to confirm this. It states that public health spending over the past five years has increased by 28 percent and will continue to grow at a similar pace.

But before we jump to the conclusion that Premiers Harris and Klein are on the right path, we would do well to pay attention to the fine print in the CIHI report, i.e. the parts that did not make it into the press release. The first important point is that present growth rates in health care spending are very much in keeping with the overall trend over the past twenty years. So it is not like there has suddenly been some great surge over the past decade.

In fact, and this is a second point, the overall growth in public health care spending was interrupted in the mid-1990s by an "unprecedented" five-year period of decreasing spending between 1993/1994 and 1997/1998. As a result, even though spending in 2000/2001 "will be over 15 percent higher than the level in 1991/1992," this is still less than would have been spent "had the trend before 1993/1994 continued." In other words, the apparent rapid increase of the last five years has merely been about catching up to where we would have been without the years of austerity.

A third, crucial point consists of putting health care spending in context. The real issue is not whether we spend more on hospital beds, pharmaceuticals, soap or automobiles. It is whether we are spending an increasing share of our income on them.

Provincial governments, such as Ontario, say we that are. They point to a bigger share of the provincial budget going to health care. However, they forget to mention that they have cut back significantly on the other areas of spending, such as social assistance, education and the environment. It is not that the piece of pie has gotten so much bigger--it is that the pie itself has shrunk!

The more pertinent yardstick is health care spending as a share of gross domestic product (GDP). How much of our national wealth as a country is being spent on health care? CIHI has some interesting statistics on this, too: "The provincial and territorial health expenditure to GDP ratio reached a high point of 6.9 percent in 1991/1992, then dropped to 5.8 percent by 1996/1997." In 1999/2000, it was 6.1% of GDP. Preliminary forecasts indicated that it would reach 6.3 percent in 2000/2001, and 6.5 percent in 2001/2002.

In other words, as a country we have been spending less on health care for the past decade than we did in 1991/1992! Talk about health care spending soaring out of control. The only thing out of control is the rhetoric and arithmetic of some of our politicians.