User fees work best as a small, flat fee paid at the point of service. Even a few dollars discourage (rational) people from booking an appointment for what they asked twice previously.
User fees shorten the line for limited service and free doctors and nurses to meet greater needs.
Some doctors currently rant about “skimming cream” and colleagues “stealing all the easy patients.” Many shrug at creaming skimming. Sure, it exists at the margin, but it guarantees incompetence. Doctors need sick patients to stay sharp.
Either way, if cream exists, then user fees are anti-cream.
Advocates for national pharmacare assume cost sharing must exist, and patients should share more of the cost of Viagra than Vancomycin (an antibiotic). The same advocates often see first-dollar coverage (free meds) as outrageous for drugs but essential for doctors’ services.
Canada stands with a small group of six countries without any cost sharing in universal care. Canada stands alone in not allowing any access to medically necessary care outside the state health-care system. All countries with user fees have exemptions for the poor, sick, old, and very young.
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I spent several years pulling together a paper on user fees.
In July, The Macdonald-Laurier Institute published my report: Equity and efficiency vs. overconsumption and waste: The case for user fees in Canada.
How can we protect a common good from overconsumption and waste? Everyone can access a common good. The more I use, the less you get.
How can we deliver high-value care to those who need it most? Should one person, who tries to protect medicare, and their identical twin, who abuses it, pay the same premiums (taxes) for medicare?
Insurance companies designed user fees to decrease frivolous insurance claims.
Fees offer one way to address moral hazard: the tendency to act differently when you do not bear the cost of your actions (e.g., ordering dessert when the boss pays).
User fees were not designed to raise revenue. In fact, user fees tend to increase the total cost because fewer low-value (low cost) patients seek care and more needy (expensive) patients receive treatment.
Canada attempted several blunt approaches to user fees in the past. Without surprise, they harmed the poor, sick, and elderly. We need exemptions.
By the way, the Fraser Institute released an excellent 110-page review of cost sharing in June.
Although they appear to have scooped my report, Fraser takes a different approach. It unpacks the economics of health insurance design and the theories behind cost sharing. We arrived close to the same conclusions.
We want equal care for all, so everyone can be free to be healthy. Our love of freedom for health means restrictions to achieve that equality. But people find ways to frustrate the plan, and we end up with overconsumption and waste.
User fees offer a small step to solving the problem.
On a different note, what should we think about post-COVID? Will we be back to pandemic policies this fall?
The pandemic brought a lunatic abandonment of the liberal order, making it hard to write anything beyond accepted dogma.
For example, I suggested in May 2020 that continued hospital lockdowns and cancelled surgeries harmed more patients than all the possible COVID patients who might need hospital care. Was it right to leave hospitals empty through the summer while people in desperate need of non-COVID treatment waited at home?
The attacks I received for my opinion surprised me. Neurotic fear rules out clear thought.
Western civilization grew on the notion, first promoted in ancient Athens, that heterodoxy was a good thing. Divergent opinion should be sought, showcased, and embraced as a way to test popular opinion.
But COVID dementia demanded orthodoxy, even to the College of Physicians and Surgeons of Ontario threatening doctors’ licences to practice medicine.
Liberalism demands freedom and equality. Given freedom, people will demand equality. Given equality, freedom cannot continue unchecked.
Freedom must succumb to equality. Liberalism eats its own tail.
Medicare proves this point.
Shawn Whatley is a physician, past president of the Ontario Medical Association, and a Munk senior fellow at Macdonald-Laurier Institute. He is the author of When Politics Comes Before Patients – Why and How Canadian Medicare is Failing.
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