When I started to grasp the wonders of green economics, about a decade ago, and realized the health, environment and economic benefits of conserving energy rather than supplying more, I figured Ontario Hydro could get the idea and start marketing energy-saving devices with the same push they'd given to selling nuclear and coal-fired electricity. But I came to realize that a company dedicated to producing energy and dominated by an engineering culture couldn't make the switch. Conservation would have to be made and sold by competing energy-saving corporations that make their money cutting clients' energy bills.
I now think in parallel ways about medicare. Medicare is a great way to organize the sickness insurance industry and to guarantee universal access, but it's no way to run a health care system.
That's why the February 6 meeting of provincial premiers with Prime Minister Jean Chretien will be stuck between Romanow and a hard place.
Roy Romanow's solo Commission on the Future of Health Care in Canada gave legs to the movement to save our most beloved government program from the death of a thousand funding cuts, user fees and for-profit operators. Certainly, pressure is now on the politicians to deliver the additional $6.5 billion a year Romanow says is needed to keep medicare alive and well.
But so popular is medicare, so powerful the grip of assumptions supporting it, that no one has yet diagnosed its Achilles heel: it's a sick care medical system, not a health care system. As such, it can't be made financially sustainable in an era of aging boomers, mass obesity, physical inactivity and individuals, cars and industries that smoke too much.
Medicare was the crowning glory of Canada's social safety net, all the programs of which were based on simple insurance principles. That's how we got unemployment insurance and hospital insurance (the I in OHIP), and that's why every Canadian has a Social Insurance Number, not a social security number.
Insurance schemes are based on the principle of pooling risk, not reducing it. Even if private life insurers might benefit if all their clients lived longer, few life insurance companies invest a lot of effort in urging their clients to live healthier or less risky lives. They just adjust the rate to match the risk.
Even if crop insurance corporations would do better financially if the weather were more stable, few of them lined up behind the Kyoto accord, the wisest long-term form of planetary insurance against stormy weather. The companies that insure buildings adjusted their rates after 9/11, but they didn't start funding mental health programs for children in war-torn areas of the world who just might grow up feeling they have a grudge they could settle with an airplane and a high-rise.
And medicare funds medical doctors and hospitals to look after people when they're sick. Medicare does not fund programs that prevent disease or promote health. That task is palmed off on medicare's poor cousin, public health, orphaned in municipalities, the governments least equipped to finance programs fostering health or pass laws affecting the basic determinants of health.
Of 25 risk factors examined by the World Health Organization in its 2002 report on the Americas, the six key preventable ones are blood cholesterol, blood pressure, overweight, low vegetable and fruit intake, physical inactivity and tobacco. According to a report done by Health Canada and Agriculture and Agri-Food Canada in 2000, the economic burden from such risks came to $5.3 billion. The next year, according to a document obtained through an Access to Information request by the Centre for Science in the Public Interest, Health Canada spent all of $1.5 million on its Office of Nutrition Policy and Promotion.
Romanow took some baby steps to start grounding medicare's sustainability in health promotion programs. He devotes one full chapter to what he calls "primary health care and prevention." He calls for a "major emphasis" on disease prevention initiatives. He encourages healthier workplaces and schools that foster physical activity. He wants to see $2.5 billion slated for primary health reform, used partly for "making Canada a world leader in reducing tobacco use and obesity."
Lest the term be misunderstood, primary health care, as used by Romanow and sick care professionals, refers to the effort to make family doctors the pivot of the medical system. It's family doctors, despite their lack of professional training in nutrition or physical fitness, who are expected to counsel their patients to follow healthier lifestyles.
To be honest, this chapter made me feel sick to my stomach. To talk about lifestyles without situating lifestyles within "social determinants of health" is irresponsible. Homelessness and hunger each create highly preventable medical problems, the costs of which are picked up by medicare. Neither problem receives even passing recognition in Romanow's report, perhaps because they are living conditions, not lifestyles. At any rate, the treatment they require is advocacy and support, not counselling.
Nor are obesity and inactivity either medical lifestyle issues, though they express the lifestyle advocated to children in tax-deductible advertisements by super-sized corporations. The treatment of mass obesity and inactivity requires what health aficionados call government-instigated "environmental support" -- removal of junk-food vending machines from schools, taxing ad messages that promote unhealthy eating, provision of safe and pleasant routes for walkers, boarders and cyclists -- more than personal counselling.
Not one federal or provincial ministry of agriculture and agri-food has the production of healthy food for the people of Canada as its main mission. Perhaps devotees of primary care reform could counsel these government departments that such reform is just what the doctor ordered.
If we want to save medicare, we are going to have to think bold thoughts about finding health care champions who aren't tied to making doctors the pivot of the system and the monopolists of its funding.