Healthcare (3) User fees again

I have been asked why I describe user fees as a “dangerous distraction” so here goes.  There are many reasons but let me focus on the 2 big ones.

First, they would have a negative impact on the quality of care and therefore the quality of Canadians’ health.  While it is probably true that smallish user fees would likely not discourage most of us from using healthcare services, it is certainly true that they would have that effect on, say, the working poor.  Imagine a working family of four barely making ends meet.  Twenty-five dollars here and twenty-five dollars there (times 4) surely do matter. Parents may delay seeing the doctor for themselves and even for their children until the problem is obviously too serious to ignore – and more costly and difficult to treat.  Some might respond that fees could be waved for low-income Canadians, for children, etc. but where do we draw the line and by the time all the exemptions kick in and the administration is in place, how much net revenue will we get?  A tax on the sick is not the way to go.

The second issue is perhaps more subtle.  As soon as we start paying a fee for a service, the relationship between client and service provider changes.  We pay, expectations escalate.  We expect choice and  say in the level and nature of the service we pay for directly.   Our public system to succeed must demonstrate that it can be more patient-centred but limits to choice are built in; a system of public health insurance means that we all get access to the services we need, not necessarily those we may want.  The  most obvious example: We don’t get the choice to buy our way to the head of the line, to bump other users.  In other words, small user fees may seem harmless but they are a backdoor way to introduce private expectations into our public system, private expectations that would challenge the fundamental concept of medicare.   Perhaps that is why those who want the federal government out of medicare and also want our system to be more private like user fees.  This is an easier argument to sell in Canada than would be a more direct frontal attack on medicare.  How can we object to a few dollars of fees that would yield needed revenues and discipline use?  The consequences, whether unintended or just unspoken, are bigger than that.  User fees are a dangerous distraction and maybe a ploy too.

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