Shortly after being appointed federal health minister, Allan Rock floated the idea of health care report cards, issued to every province, in order to increase accountability. Like so many of Rock's ideas - defining quality for the Canada Health Act, co-ordinating regional efforts, national home care - the initiative faded before the press releases were faxed out.
Maybe it's just as well. Imagine how such a report card might read:
Timely access to health care: FAIL. Numerous studies suggest that Canadians wait too long for heart bypass surgeries, angiography, hip replacements, and radiation therapy.
Diagnostic equipment: FAIL. A study by the Canadian Association of Radiologists shows that on a per capita basis, Canada ranks far behind the United States and Western Europe, rivaling Colombia in the number of MRI scanners.
Retention of young physicians: FAIL. Eva Ryten, a former research director with the Association of Canadian Medical Colleges, estimates that nearly half of all graduating doctors move abroad.
But what about equal access to health care? Canadians, after all, tolerate many of medicare's flaws because even if the system is bad, it's fair. Everyone from a pauper to prince gets the same treatment. To do anything less would be un-Canadian.
It's a point politicians are particularly emphatic about.
Why do we apply such standards to health care? No one, after all, frets about the fact that some wealthy people choose to eat caviar or live in 10-bedroom houses. The concern is that the poorest not starve or die of exposure.
With health care, then, is our true goal that Mr. Smith, who owns three cars, not be allowed to get a quick (private) cataract surgery? Or is it that Mr. Jones, who just makes rent every month, gets (publicly funded) heart surgery when he needs it?
The way medicare advocates carry on, you'd think that it was fine that Mr. Jones suffered crushing chest pain after walking three steps just as long as Mr. Smith had to stumble around blindly for six months.
Supposedly, though, unequal treatment is unacceptable. Maybe there's some method in the madness: Canadians see their high taxes and the declining standards of their health care system and they need to cling to something. Americans might have more MRI scanners; our young physicians might head south; Canadians with money might go to the Mayo Clinic. But at least our system of health care is more compassionate.
What a pity. It turns out that our health care system isn't so perfectly egalitarian after all.
Last week, the New England Journal of Medicine published a study written by three Ontario researchers. Following 54,000 heart attack patients from 1994 to 1997, the study looks at survival after a year. And, the authors conclude, income matters a great deal. For every $10,000 increase in average neighbourhood income, incidence of death drops 10 per cent.
Now, medical researchers have long known that income affects health outcomes. Poorer people are less likely to follow up with their physicians, take drugs appropriately, and modify lifestyle. But the study found that poorer Canadians also have less access to health care - affluent patients receive more specialist services, both treatments (such as bypass surgeries and its non-surgical equivalent, angioplasties) and diagnostic tests (angiographies).
This isn't the only study of its kind. In another published earlier in the year, Dr. William Mackillop and his Queen's University research group found that bypass surgeries are performed 20 per cent more frequently in wealthier neighbourhoods.
"We have become accustomed to thinking Canada is an egalitarian society, but in most ways, it isn't at all," explains Mackillop. "Despite our best intention . . . the people likely to push for service are more likely to get it promptly when there isn't enough service to go around."
Celebrity status and connections were the subjects of another research effort. Last year, researchers from the Institute for Clinical Evaluative Sciences in Toronto surveyed cardiologists about preferential treatment.
In a nutshell, the study's authors wanted to know whether the heart specialists were willing to help certain patients queue jump. Eighty per cent responded that they did. (On a whim, I brought this study up one afternoon with a group of medical students. The consensus was that 20 per cent of the cardiologists had blatantly lied.)
So how surprising is all this? Medicare resembles the old Soviet system: all patients are equal - it's just that some are more equal than others.
Equal treatment for all? Not here. Income matters. Connections matter. Celebrity status matters.
Medicare, in other words, is not an egalitarian utopia. It is, rather, a system in need of an overhaul. That politicians like Allan Rock refuse to recognize this suggests that they should be issued a report card of their own.