The debate on user fees heats up here and here.  What seems increasingly evident is that the iconic place of Canada’s healthcare system makes policy discourse awfully hard.  Those who see it as a matter of identity, at the heart of the Canadian self-definition not only protect it from attack but sometimes quite possibly from the reforms that might be necessary to ensure universal access to quality care going forward, given the stresses in the system and the challenges  of an aging population.  The instinct to protect this system is understandable and commendable; it has served us exceedingly well for a long time and in a variety of ways.  But our health outcomes are not where they should be and the system continues to reflect a prior time,  before technological and pharmaceutical developments transformed medical practice.  Canada’ s system has been changing as hospitals, regions, provinces and patients try to cope with the pressures.  Ad hoc changes do not add up to serious reform and medicare deserves better than that.

It is troubling though that user fees have somehow become the symbol of reform.  Some of the advocates for radical surgery on our healthcare system seem to be saying that  anyone who does not support user fees is automatically opposed to reform.  User fees seem to have become an icon for those who want a much larger private healthcare presence and a much smaller federal presence.  This is too bad because it distracts us from the real issues and the real debates.  User fees will never generate enough resources to matter much and they may well discipline use of the healthcare system in ways that we do not intend but may actually be very expensive in the end.  To take one example. do we want parents to delay doctor visits for their children until the problem is serious?  I do not think so.  A tax on sickness is not the way to go.

So let’s have the discussion of what reforms are needed, what should be public and what should be private, and how do we pay.  Let us affirm our objective which I hope continues to be universal access to quality care based on medical need and not income.  Let us recognize that we face tough choices on how we will pay for this fairly and responsibly.  But let’s not make user fees the defining issue.  It is a dangerous distraction.

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