Healthy, Wealthy and Cunning? Profit and Loss from Health Care Reform

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Those of you who heard last week's lecture by Dr. Fraser Mustard, the President of the Canadian Institute for Advanced Research, will have some idea of the breadth and eclecticism of CIAR research programs. Tonight's address will likewise draw on, and I hope integrate, ideas and research findings from a number of different subject areas. In particular, the first part will be built around some very intriguing work by Professor Tad Homer-Dixon, who is a political scientist directing the Peace and Conflicts Studies program at the University of Toronto. Tad and his associates are interested in environmental change and violent conflict. You may wonder how an economist studying the reform of health care systems comes to be interested in an intellectual apparatus developed by a political scientist interested in violent conflict (or perhaps you may not!). But I hope to show you that there is a connection. I believe that Tad's work provides an intellectual basis from which to think about a number of the things that are going on in the current debates over the reform of health care, not just in Canada, but in many countries in the world. I will, however focus my remarks tonight on Canada.

The down side of the kind of eclectic, broad-based, multidisciplinary thinking that is characteristic of a program like ours in the Canadian Institute for Advanced Research is that it can be mightily entertaining, and extraordinarily shallow. That is the great danger with multidisciplinary research; it's a whole lot of fun, but it can very easily turn into a bull session. The test of the quality of ideas that emerge from such a process of cross-fertilization and synthesis is whether they make sense and seem to be helpful and useful to audiences with a number of different kinds of interests. Do they change and broaden the "frameworks of understanding" through which we try to comprehend the world around us? So in some ways this audience represents the testing environment for these ideas tonight. As we begin to probe them further, we shall see whether, when you try to push a bit deeper with them, you actually do find something useful emerging.

The first question, though, is: "Why does one need a broader framework of understanding at all?" Why do you need to go and look at international political science theory to think about health reform when you're supposed to be coming at the topic as an economist from Canada? And I guess the quick (and honest) answer is: "Boredom." That is by no means a complete answer, but it actually serves as a very good lead into more fundamental motivations. Let me illustrate.

In 1990-91 I served under Mr. Justice Peter Seaton as a member of the BC Royal Commission on Health Care and Costs. When our report, Closer to Home, was released in November, 1991, Jim Hume wrote a very instructive column ("Talk Politics") in the Victoria Times Colonist. He listed several statements characterizing the province's health care system and recommending specific reforms. But he then pointed out that these were not drawn from the Seaton Commission's report. They were from the federal Task Force on the Cost of Health Services of 1969, and from the provincial Foulkes Report (the Health Security Program Project) of 1973. But they could also have been the recommendations of the Seaton Commission, and in fact some of them were. "Only in a few areas do the three major health care reports of the past 22 years vary, and even when they do the variations are slight." And that is an extremely important point - that those same sets of ideas keep coming back, and back, and back, over and over again. It is not, as has been said, that the only thing we learn from history is that we learn nothing from history. We learn quite a lot, but we seem to have great difficulty acting on what we learn.

On another level - even closer to home, so to speak - another commissioner, David Sinclair, brought in a clipping quoting the Dean of Medicine at UBC to the effect that hospital beds were being heavily over-utilized in Canada, and particularly in British Columbia. …

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