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Why not user charges? : the real issues Stoddart, Gregory Lloyd, 1948-; Barer, Morris Lionel, 1951-; Evans, Robert G., 1942-; Bhatia, Vandna Sep 30, 1993

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WHY NOT USER CHARGES?THE REAL ISSUESGreg L. StoddartMorris L. BarerRobert G. EvansVandna BhatiaHPRU 93:120 DECEMBER, 1993HEALTH POUCYRESEARCH UNITCENTRE FOR HEALTH SERVICES AND POUCY RESEARCH429 • 2184 HEALTH SCIENCES MALI.UNIVERSITY OF BRmSH C01.UMBIAVANCOUVER, B.c. CANADAV6T1Z3The Centre for Health Services and Policy Research was established by the Board ofGovernors of the University of British Columbia in December 1990. It wasofficiallyopened in July 1991. The Centre's primary objective is to co-ordinate, facilitate, andundertake multidisciplinary research in the areas of health policy, health services research,population health, and health human resources. Il brings together researchers in a varietyof disciplines who are committed to a multidisciplinary approach to research, and topromoting wide dissemination and discussion of research results. in these areas. TheCentre aims to contribute to the improvement of population health by being responsive tothe research needs of those responsible for health policy. To thls end, it provides aresearch resource for graduate students; develops and facilitates access to health and healthcare databases; sponsors seminars, workshops, conferences and policy consultations; anddistributes Discussion papers, Research Reports and publication reprints resulting from theresearch programs of Centre faculty.The Centre's Health Policy Research Unit Discussion Paper series provides a vehicle forthe circulation of preliminary (pre-publicauon) work of Centre Faculty and associates. It isintended to promote discussion and to elicit comments and suggestions that might beincorporated withln the work prior to publication. While the Centre prints and distributesthese papers for thls purpose, the views in the papers are those of the author(s).A complete list of available Health Policy Research Unit Discussion Papers and Reprints,along with an address to which requests for copies should be sent, appears at the back ofeach paper.UBC CENTRE FOR HEALTHSERVICESAND POLICY RESEARCHDISCUSSION PAPER HPRU 93:12DWhy Not User Charges?The Real IssuesGreg L. StoddartCentre for Health Economics and Policy Analysis. andDepartment of Clinical Epidemiology and BiostatisticsMcMaster UniversityMorris L. BarerCentre for Health Services and Policy Research, andDepartment of Health Care and EpidemiologyUniversity of British ColumbiaRobert G. EvansDepartment of Economics, andCentre for Health Services and Policy ResearchUniversity of British ColumbiaVandna BhatiaDurham Region District Health CouncilSeptember 1993This work was funded by the Ontario Premier's Council on Health, Well-Being and SocialJustice. Responsibility for the views expressed herein, and any errors or omissions, rests solelywith the authors. R.G. Evansis supported by a National Health Scientist Award from Health andWelfare Canada, and is a Fellow of the Canadian Institute for Advanced Research. G.L. Stoddartand M.L. Barerare a Fellow and an Associate, respectively, of the Institute. Vandna Bhatia wasa staff member at the Council during the completion of background work for this project Theauthors wish to thank the many individuals both inside and outside the health care system whohave taken the time to share their views on user charges.PrefaceThis is one in a series of articles by the authors about the ongoing debate over usercharges in the Canadian health care system.In this paper we examine some of the most frequently heard arguments for user chargesand look at whatevidence there is for claims and counter-claims that are often made. Becausestatements in the "popular" debate sometimes seem inconsistent with each other, or unrelated toor at odds withthe facts, we explore thestatements more carefully, asking what they really mean,what values they are based on, and what fundamental issues are at the heart of the user chargecontroversy. The paper is intended for a wide general audience and assumes that most readerswill have heard - or perhaps made - the arguments described, but will have little detailed ortechnical knowledge of the issues involved.While this paper provides an overview of the issues from a popular perspective, otherforthcoming pape-s focus on specific, and sometimes more technical, dimensions of the usercharge debate. A brief description of each paper follows (titles are tentative)."The Remarkable Tenacity of UserCharges" concisely documents the history of the usercharge debate in Canada. It reviews the participation, positions and rationales of Canadianinterest groups in debates over patient participation in health care financing,"Who Are the Zombie Masters, andWhat DoThey Want?" likens the recurring proposalsfor user charges to zombies - the so-called 'walking dead' - because although they have beenrepeatedly rejected by policy-makers and the general public (and the claims of their supportersrefuted by analyses of the effects of such charges), the proposals refuse to remain buried. Thispaper examines why that is the case, and who stands to benefit from the introduction of usercharges."User Charges, Snares and Delusions: Another Look at the Literature" reviews andextends an earlier in-depth analysis of the effects of user charges which three of the authorspublished in 1979. The paper assesses whether experience and published literature in the yearssince then alter any of the (largely negative) conclusions of the earlier study concerning theability of direct charges to patients to achieve important public policy objectives, includingcontrolling health care costs."Charging Peter to Pay Paul: Accounting for the Financial Effects of User Charges"outlines a formal andcomprehensive analytic framework in which income transfers - theprincipaleffects of user charges - can be traced between groups in the population (e.g. the healthy, thesick,the rich and thepoor), between payers and health careproviders, andamong providers. Thepaper uses the framework to analyze the income transfers associated with different types of usercharges."It's Not the Money, It's the Principle" examines why usercharges exist for some healthcare services and not for others. Thepaperanalyzes the characteristics of services which (do orshould) underlie decisions to charge in partor in whole for specific types of services.2In addition. a bibliography entitled "User Charges in Health Care" provides an extensiveset of references to articles of relevance to the usercharge debate in Canada, drawn from diversesources including academic research andpolicy analysis literature. the popular press. governmentdocuments and reports. and the publications and reports of non-governmental organizationsincluding the professional associations representing a variety of health care providers.Why Not User Charges?The Real IssuesLike the pink Energizer rabbit with the sunglasses and the drum, the debate about usercharges in Canada's health care system keeps going...and going...and going. It began at leastfifty years ago, during discussions abouthow or whether to create a universal, publicly-financedhospital insurance programme, and it has re-appeared at regular intervals ever since [l].The debate seemsparticularly likely to re-appear whenever strong government efforts arebeing made to hold down increases in health care costs. These efforts are most apparent wheneconomic times are tough, and at present they are very tough. With the Canadian economy stillwobbling from recession, provincial treasurers fighting to hold down deficits, the federalgovernment restricting the flow of funds to the provinces for social programmes, and thenewspapers full of stories of cutbacks in public services,the question that more and more people are asking is, "Why not have user charges for healthservices?" Why not indeed?There is no simple answer to this apparently straightforward question, because it isnowhere nearas straightforward as it at first appears. In other articles in this series we identifythe numerous and changing reasons that a variety of organizations and special interests havehistorically used to advocate usercharges [1,2]. We examine the likely impactof different formsof charges on important policy objectives [2,3]. We also examine who gains and who loseswhen usercharges of various types are implemented and how the distribution of expected gainsand losses is, not surprisingly, related to who proposes and who opposes such charges [1,2.4,5].Here, however, we have a more modest goal. In this article we examine the mostpopularreasons given today for introducing user charges, in the language and spirit in which they aretypically presented. Our presentation of the leading arguments is based on a variety of sourcesincluding stories in the media (newspapers, magazines, radio and television), discussions withpeople in government (both elected politicians and civil servants), discussions with health careproviders (including doctors, nurses, otherclinical professionals and hospital administrators) and,most important, conversations with ordinary Canadians with no special knowledge of the healthcare system, nor any special interest in it except that they want it to be there when they need it,providing effective services at a reasonable costWe try to probe popular statements and untangle theirmixture of arguments in an attemptto uncover the fundamental issues in the debate and present moreclearly someof the choices thatCanadians are making, whether they know it or not, when they support or oppose a user chargepolicy. It is an important debate and one that is not likely to end soon, if ever; this is all themore reason to raise the level of information available and to encourage discussion of the ml!!issues.What are User Charges?User charges can take many forms and different people may mean quite different thingswhen they talk of user charges. As its name implies, a user charge is a cost to the patient that2varies directly with the amountof service used - the moreyou use the more you pay. How muchyou pay can vary; charges, like prices, can be high or low, and they may vary from one personto another depending on age, income and how much a person has already paid. When you paycan vary; charges might be paid at the time of service, or later, say at the end of an episode ofcare, or a taxation year. Who collects (or keeps) the charge can vary; charges may be paid toproviders like doctors and hospitals, or may be paid to government What services the chargesapply to can vary;physician services (bothgeneral practitioners and specialists), hospital services(including acute in-patient care, chronic or extended care, emergency room, and out-patientservices), laboratory services or drugs inside or outside hospital, long term residential care,optometry, or any other type of health care may be subject to a user charge policy.How you pay may also vary. Extra-billing by physicians (billing patients for amountsabove the provincial medical insurance plan benefit) and a flat fee per service (a fixed fee foreach physician visit, every day in hospital, every visit to the emergency room, or everyprescription filled) are the types of user charges that Canadians are likely most familiar with.Charges may also take the form of deductibles (the patientpays the entire cost up to some fixedamount, as is common with automobile and house insurance and many provincial drug plans) orco-insurance (the patient pays a percentage of the cost). Combinations of types of user chargesare also possible; for example, a coinsurance charge of 10% or 20% up to a maximum "out-of­pocket" cost to the patient of $200 or $500.Premiums of the type which used to exist in most provincial health insurance plans (andstill do in Alberta and BritishColumbia) are also sometimes referred to as user charges, but theyare not The premium may vary with income or family size, but does not depend on actual useof health care. In fact, these premiums are not really insurance "premiums" at all, but a formof tax. They are unrelated to risk, and are compulsory for most people. Moreover, provincialresidents are fully entitled to health care services whether or not they have paid premiums.(Although this is not widely known, it n the law.) .Two forms of user charges which are increasingly mentioned are deinsurance and taxinginsured health care benefits. The first refers to the removal of specific services from the scheduleof insured benefits for which provincial governments will pay health care providers. Forexample, Ontario recently deinsured visits to physicians to obtain medical certificates requiredby third parties for absences from work, for travel, or for participation in sports, camps or otherrecreational activities. If physicians choose to charge for these, patients (or the third parties) willpay the full cost for each service. The second refers to the inclusion of the value of publiclyinsured health services used during a year in an individual's income, as a "taxable benefit", forthe purpose of calculating personal income tax. For example, if an individual's physician visitsor hospital stays cost the provincial health insurance plan $500 in a year, then the individualwould pay tax on this as if it was $500 of income. Again, this may be combined with someupper limit on the cost for which patients are liable.It would not be useful, and is probably not possible, to try to consider here everyconceivable form of user charge, let alone how each might be applied to different services. This3is done, in part, in other articles in this series [2-4]. In this article we deal with general themesand with characteristics which most user charges have in common. When the point beingdiscussed pertains to one specific type of charge, we make that clear. Also, we focus onphysician and acute hospital services unless otherwise indicated.Popular Arguments for User ChargesThose in favour of user charges usually make one of two popular arguments. The firststresses "responsibility" and the second stresses "affordability". They go something like this:People abuse the health care system because it's free; user charges would reduceunnecessary use and encourage people to act more responsibly.and,Health care costs are out ofcontrol. We can't affordour current system. We need moremoney, and what's wrong with letting people who can afford to pay a little more do so?Let's take a closer look at each of these arguments.The Responsibility ArgumentThere is no doubt that people believe that patients abuse the health care system, thoughwhen asked individually, few think that their own use was unnecessary! More troubling,however, is the fact that people can't seem to agree on what "abuse" means, how important itis, or who really causes it Even if it is significant and patients are to blame, there is a bigquestion about whether user charges are the best way to eliminate itWhat is abuse? The usual reply is that it is use that "isn't necessary", but what exactlydoes that mean? Does it mean the use of services that did not improve the patient's healthbecause there wasn't really a problem requiring medical care (either because the physician coulddo nothing about it or because the patient could have taken care of it personally)? If so, howoften can patients be expected to know that in advance? Perhaps it is not unreasonable, forexample, to expect a parent who has already raised three young children to recognize that acommon cold in a fourth child is only that· a common cold that will go away on its own andthe symptoms of which can be taken care of with home remedies or medications easily purchasedat the drug store. But what if the cold seems "a little different" than usual? And what aboutmore complicated situations, like the person who has been under a lot of stress and feels tightnessin his chest at midnight after eating a spicy meal? Diagnosing problems, including providingreassurance that they do not exist, is an important part of health care. When it is said that usercharges will makepeople think twice before going to the doctor, what that in part means is thatpeople will have to diagnose themselves more often and decide the likely seriousness of theircondition. Often they may make the right decision, but sometimes they may not, and theconsequences may not be good. What proportion of health problems people can accurately judge4for themselves is a question on which there is much disagreement and little evidence.Expertsand officials alsohavedifficulty defining in advance what is medically necessary.Although provincial health insurance plans exist to provide payment for "medically necessaryservices", no province has explicitly defined what that means. Need is often defined by healthpolicy analysts and physicians as thecapacity for the patientto benefitfrom using a service. Butwhat is "benefit", and who determines it? The usual reply is that medical experts are best ableto determine it, though often only after the fact (As a thoughtful physician colleague says,"necessity is a diagnosis of hindsight") A study of unwarranted use found, however, that arandom sampleof one-thousand Ontario family physicians could not agreeon examples of abusewhenever questions of medical necessity were involved, although they were able to agree thatinconsiderate behaviour (like failing to show up for an appointment) was abuse [6].Abuse might also be interpreted to be frivolous use, or use ofservices that isn't worth it.In these cases, there is a medical benefit to the individual patient who uses the service, but it issmall. More to the point, it is seen by others as being small relative to the cost to taxpayers asa whole.This raises a very different set of issues about how society wants to establish prioritiesand/ordistribute the costs of beneficial services. If "medically necessary" doesn't mean any andevery service capable of improving (even by a little) at least one patient's health -- a definitionwhich leads to an infinite range of services - then lines must be drawn. .Research studies can provide important information to help with this task, but they canonly go so far. They can, and should be used to, establish the size of the benefits and costs ofspecific medical services, and determine how these vary across different groups of patients andunder different clinical circumstances. But they cannot decide whether the medical benefitsinvolved are worth buying and, if so, for which groupsor under what circumstances. These arepolitical and ethical judgements rather than technical ones [3,7]. They involve society's basicvalues and the way in which those values will be applied to the financing of health care.How important is patient-initiated abuse? This depends partly on how abuse is defined.Estimates of the extent of abuse will likely be larger if it is defined to be "use that others thinkisn't worth it" than if it is defined to be "use that is not medically necessary". If it is definedas "use that is known in advance to be not (or even probably not) medically necessary", then itwill be smaller still; indeed, with this definition it could be very small.Solid evidence on the extent of abuse, by any definition, is very hard to find, A studyof Montreal physicians shortly after the introduction of public medical insurance in the early1970sfound that they felt that less than 2% of patients soughtmedical advice without reasonablecause [8]. A 1980 study of Ontario physicians reported that they felt that 8-12% of contacts bypatients were unnecessary [9]. These are old studies, however, and weare unaware of anyrecent, more accurate estimates, or more importantly, l!!lY studies that take into considerationwhat patients might reasonably be expected to know in advance of seeking advice. So, although5it is commonly claimed that patient-initiated abuse is important, and most people can think ofone or two good examples of abuse, statistical support for the claim is weak at bestIn fact, it is difficult to see how patient-initiated abuse could make up a large share ofoverall health care use and costs, because patients have little control over mostof the decisionsabout the use of care. Call-back visits. referrals, hospital admissions and prescriptions, forexample, all depend on the judgement and approval of a physician. No doubt there are somepatients who "demand" a hospital procedure or a prescription, but the picture of patients eagerlyrequesting surgery or wanting to take medication just because the services are "free" makes evenadvocates of usercharges laugh. (What is meant by "patient" demands is notalways cleareither.For example, patients are increasingly requesting cholesterol tests, but would they be doing thisif there had not been the massive recent publicity campaign about cholesterol, largely organizedby pharmaceutical companies, despite controversy over the effectiveness of their cholesterol­lowering drugs?)In very rough numbers, physician services make up about 16-20% of all health careexpenditures (hospital services and drugs are the other two main categories). Patients canprobably get access to about half of physicians services (including general practitioners', andsome of the services in paediatrics andinternal medicine) without a referral. So the potential forpatient-initiated abuse exists in approximately 8-10% of total health care spending. But all ofthese physician services are not first-visits initiated by patients. Some are return-visits initiatedby physicians. Norareall patient-initiated, first-visits unnecessary; far from it, mostarejustified.This means that the maximum share of total health care spending caused by patient-initiatedabuse is very small indeed. For example, if one-quarter of physician visits are return-visits, and(say) 10% of the first-visits are unnecessary, then the share of total health care spending causedby patient-initiated abuse is less than 1%. And again, it is even smaller than that if "abuse" islimited to use that patients could reasonably have been expected to know In advance wasunnecessary.Compared to patient-initiated "unnecessary" use, the "inappropriate" use of servicesgenerated by physicians themselves is a much larger problem, and one which user charges willnot address. Research studies consistently show that physicians order or perform services thatare not clinically justified [10,11]. Some procedures are performed too frequently, and othersare used in the wrong situations to be effective. (In addition to this, many current procedureshave never been evaluated, so theireffectiveness isunknown, andmany effective andappropriateprocedures are provided in facilities or with personnel that are more costly than necessary.)Estimates of the extent of physician-generated inappropriate use vary. but are sometimesas large as 30-40% of all services including hospital services and drugs [12,13]. Physiciansthemselves acknowledge that this is a major problem [14,15], andexperts agree that this problemdeserves more attention than the much smaller amount of unnecessary use initiated by patients.The need to evaluate and restructure the way physicians and hospitals provide services has beena consistent recommendation from the many commissions of inquiry into the Canadian healthcare system over the past twenty years. In almost all cases, these inquires have not seen the way6patients~ services to be the problem, nor user fees to be the solution.Do user charges reduce unnecessary use by patients? There is not much evidence thataddresses this question directly, but what evidence there is does not support the claim that usercharges lead patients to decrease their use of only unnecessary or less necessary services. In amajor experiment with user charges conducted in the United States by the RAND Corporation,researchers found that user charges were about equally likely to deter patients from using bothunnecessary and necessary services [16].Although the argument thatpatients will give up the least necessary services when theyhave to pay seems intuitively correct - afterall, common sense says that this is what they shoulddo - the finding that they do not seem to behave this way is perhaps not so surprising after all.Health care isn't like other products and the "market" for health care cannot be analyzed thesame way as the market for shoes or VCRs. As noted above, people often do nothave sufficientinformation in advance to make correct judgements about necessity. This is precisely why theyconsult their physicians.On second thought, the answer to the question, "Who will user charges deter from usingservices?" is "Those people who are sensitive to having to pay a 'price' for their care." Thereis no reason to believe that the "abusers" are necessari1y the people who are price-sensitive, northat price-sensitive people are necessarily theoneswho abuse the system. Whatdoes seem likelyis that people with lower incomes will be more price sensitive, therefore user charges will havea greater impact on those people.The Canadian experience with user charges confirms this suspicion. Between 1968 and1971 the province of Saskatchewan had a flat fee user charge of $1.50 (about $6.00 in today'sprices) for a physician office visit The charge reduced the annual per capita use of physicianservices 6-7%, but the reduction wasmuch larger, around 18%, for low-income people [17]. (Thelarge reductions in use by lower-income people did not translate into corresponding savings incosts, however, because they were partially offset by increases in use by higher-income peopleand because physicians shifted toward a more expensive mix of services -- and negotiated twofee schedule increases -- during the period of user charges.) There was no evidence that usercharges resulted in a decline in the unnecessary use of physician services.The Saskatchewan experience also illustrated the limited impact of user charges onservices beyond the control of patients. A charge of $2.50 per in-patient hospital day (about$10.00 in today's prices) had no effect on hospital use. The summary assessment of the effectsof user charges by the researchers who did in-depth studies of the Saskatchewan experience isworth noting: "The effect of the user charge is simply to transfer costs from public to privatebudgets with the burden of such transfers falling disproportionately on the sicker members of thepopulation"[17].User charges were also found to have a greater impact on low income people by7researcherswho studied the effects of extra-billing in Ontario. A 1980 survey found that lower­income people who had been extra-billed were significantly more likely than higher-incomepeople to report that they had reduced their use of physician services or delayed seeking carebecause of the cost [18]. As for the claim made frequently by advocates of extra-billing thatphysicians did not extra-bill those who could not afford to pay, both the Ontariosurvey and datafrom Alberta refute it In Alberta, for example, researchers concluded, "It is an unquestionablefact that the aged, welfare recipients and the lowest income groups in the province are forced tobear additional out-of-pocket charges in order to receive medical attention" [19].If poorerCanadiansare more likely to be deterred from seekingcare by user charges, andif -- as is also the case -- they are more likely to be sicker than richer Canadians, then insteadof reducing unnecessary use, charges will almost certainly affect the use of necessary services.No doubt there is a (very) small number of patients who (perhaps even blatantly) misuse thehealth care system, but to try to eliminate this problem with a general policy of user charges formost services for most Canadians seems like weeding your lawn with a bulldozer, without anyguarantee that you will get AI! of the weeds!If, as is often suggested, there needs to be a more fundamental change in the way patientsview the health care system and use it -- for example, not going to the doctor for common coldsor other minor problems -- then educating rather than penalizing patients is an alternative thatdeserves increased attention. Physicians could be an important part of this strategy, if theywished to instructpatients in self-careand had some incentiveto do so, preciselybecausepatientslook to them for advice, and because they do control access to the resources of the health caresystem.Critics of user charges make one final point on the issue of unnecessary use. Supposea user charge policy works perfectly, they ask, what then? The discussion and evidencepresented above suggests that the effects of user charges will be far from perfect, but to theextent that they !l.Q eliminateunnecessary use, and just unnecessary use, then the only people leftpaying the charges are people who are truly sick and in need of care. User charges, in effect,become a tax on illness. They redistribute the costs of the health care system from the healthyto the ill, in ways which are discussed further in later sections of this article.Do user charges encourage people to act more responsibly? This is the last part of thepopular argument stated above, and it is hard to disagree with its apparent goal. But again itis difficult to know just what is meant by the words in italics. If acting responsibly means notgoing to the physician for unnecessary services, then it leads back to the questions discussedabove and there is nothing new to be said. It is worth repeating, however, that this argument isnot as straightforward as it seems and not well supported by what we know of how patientsbehave.If acting responsibly instead means taking more responsibility for one's own health, asseems to be implied by some advocates of user charges, then it is a different line of argumentThe question is not whether user charges for health services would make people think twice8about going to the doctor, but whether they would make people think twice about smoking, oreating more fruit and vegetables, or exercising or not driving after drinking alcohol. Althoughit is possible that people might react this way, it seems very unlikely that whatever complexsocial, psychological and environmental factors determine personal lifestyle decisions todaywould be outweighed by the prospect of having to pay part of the cost of possible health caretomorrow.This line of argument about user charges is filled with problems. First, there isconsiderable evidence that many so-called "unhealthy lifestyles" are as much the result of theenvironments in which people live, work and grow up as they are the resultofconscious personalchoices [20]. Second, the argument is a long chain, with many weak links [21]. Two examples:it would be necessary to show that an illness was caused by a lifestyle in a specific individual(or in all such cases), and that usercharges~ actually change personal behaviour nmY,. Third,implementation and enforcement would be major problems - would an emergency roomphysician refuse to treat an injured skier unless he agreed to pay the charge? Fourth, in manycases there are simply better alternative policies -- taxing cigarettes, or arresting drunk drivers,for example. At best, levying usercharges for health care appears to be a very indirect way ofattempting to encourage people to take greater responsibility for their health, and is a methodabout which there is no evidence to our knowledge.There is yet another interpretation of responsibility which mayor may not be related tonotions of abuse, but which is highly significant for the insights it gives about what some peoplemay really be thinking, and about the values they hold. This is responsibility for pavment - theidea that there is something beneficial about the act of patients paying some amount of moneythat is directly related to use of services, preferably (though not necessarily) at the time of use.This sentiment is illustrated by three statements that are frequently heard in conversations aboutuser charges and which progressively shift the discussion from claims about how charges willaffect patient behaviour to claims that are ideologic views about how health care should befinanced - in other words, who should pay.People haveno idea whatthesystem costs; they shouldbe made to realize that theircareisn't free. This popular refrain raises a number of questions. Even if they are unaware of precisecosts, are not most people aware that they are "paying" for health care with their taxes? Wouldknowing what the overall system costs affect YQllI decision to go to the doctor on a particularoccasion? Would evenknowing what yourown visitcost change your pattern of use or the wayyou behave? And are user charges (which usually represent only a small fraction of the cost ofcare) the best way to inform patients of the cost of care? If letting the patient know the cost isall that is desired, wouldn't having the patient sign a card showing. the services that wererendered and their cost to the provincial insurance plan be all.that is required. as is oftensuggested. (This would also discourage fraud.)The unstated, but implicit assumption here may be thatpeople would behave differently­presumably use less care - if they had better knowledge of its cost If this is the underlyingobjective of the usercharge, then there is little new in the argument and we return to the issues9discussed earlier. The objective may be a different one, however. It may be to establish asymbolic act -- paying the physician or hospital for at least a (small) part of the service received-- so that those who are paying in taxes for more than they (are likely to) use know that theiropposites know that care isn't "free". In this argument, distributing a portion of the cost of careon the basis of use is necessary to establish the proper "attitude" toward health care. and towardthose who provide it and finance it, even if it does not lead to more responsible use. This ispresumably what opinion-maker and columnist David From has in mind when he writes, insupport of user charges, that "all too many Canadians... expect something for nothing", and"People who live on the taxes of others should be aware of it" [22]. It is a statement of valuesthat seems to reject the principle that access to health care regardless of ability to pay is, orshould be, a "right" of Canadians.People don't value things unless they pay for them, is a closely related belief that appearsfrequently in the responsibility argument, and which can be viewed in much the same way as theprevious italicized statement If it is meant to be a statement abouthow userchargeswill changepatients' behaviour, then issues of the definition of abuse and necessity, the extent of patient­initiated unnecessary use and theeffectiveness of charges in selectively reducing unnecessary useneed to be worked through and resolved, if possible. If it is meant to imply that peoplefeel thatthey have somehow received a "better" service because they (at least partly) paid for it, then itseems curious and contradictory that user charges are most often supported or advocated byproviders, and opposed by groups representing the consumer of services. On the other hand, ifit is an indirect statement about what social values ought to be used to distribute (more of) thecosts of the health care system, then it must be accepted and debated for what it is, rather thanentangling and perhaps disguising it in discussions of abuse. Then it looks more like the nextstatementPeople should pay for what they get; it's unfair that they get something for free. This isthe clearest and most direct statement of an ideology which often. though not always. is part ofthe responsibility argument Here there are no longer any claims that patients are abusing thesystem, although this may have been where the argument began. In fact, medical necessity -­the need for care - no longer apparently playsa role in the discussion. The statement asserts thatcosts should be borne in proportion to use and impliesthat usersof health servicesare not payingtheir "fair" share relative to other taxpayers whose taxes support the system. This amounts toa statement that the sick (who are also disproportionately the poor) should pay more and thehealthy (who are disproportionately the rich) should pay less.Pushed or carried this far. the user charge debate again becomes one about social valuesand the distribution of financial gains and losses, rather than one about the effectiveness orefficiency of the health care system. The debate also becomes detached from notions of meritor "deservingness". Contrary to the view that illness is not in general a person's own fault, andtherefore that health care should be provided on the basis of need and financed separately, thesocial values being advocated in the statement in italics either ignore the issue, or imply thatillness is (even if only in part) a person's own responsibility.10The Affordability ArgumentLike the responsibility argument, the affordability argument consists of a generalperception that there is a problem, followed by anapparently common sense suggestion as to howto solve the problem through user charges. In the responsibility argument, the problem was thatpeople were abusing the system; here the problem is that the system needs more money. There,user charges were supposed to solve the problem by encouraging people to stop usingunnecessary care; here, user charges are supposed to solve the problem by generating additionalrevenue to help pay for care. In both cases the arguments make usercharges sound desirable inpart because they seem harmless. There are apparently no other, undesirable effects that needto be considered.But, also like the responsibility argument, the affordability argument is not as simple oras innocent as it seems. In fact, the way in which the idea of "affordability" is typically usedin thepopular debate is bothconfusing andmisleading, because the argument begins by implyingthat the objective is to lower health care costs but ends with user charges as the way to "afford"even higher costs.Upon closer examination, the affordability argument is really a mixture of two separateand inconsistent arguments, which may reflect a genuine confusion in Canadians' minds aboutwhether the health care system currently costs too much or too little. The claims "Health carecosts are out of control: We can't afford our current system." are a statement that the systemcosts too much. Usercharges are presumably one way to reduce or control those costs. On theother hand, the claim "We need more money." is a statement that not enough is being spent onthe health care system. User charges are seen to be one way of increasing rather than decreasingtotal spending. Both cannotbe correct, although people making the affordability argument in itsfull form typically ignore this,and those making just one or the otherof the separate, inconsistentarguments typically do not confront each other. .Are costs out of control? It is easy to see why there is a general perception that thesystem is in a financial crisis. Both governments and health care providers constantly talk aboutmoney - in newspapers. on television and radio, in speeches by politicians and in conversationsin doctors' offices. What is not well understood. however. is that this has always been more orless the case sinceMedicare was introduced overtwenty years ago, and that the Canadian systemis designed to produce this tension between health care providers and their paymasters, theprovincial governments acting on behalf of taxpayers.Governments are concerned withlimiting expenditures and taxes; providers areconcernedwith increasing services, incomes and spending. Each side pleads its case to the public. Thisis a natural tension in a publicly-financed system and,although it does not always workperfectly,it has served Canadians well so far and has resulted in a balancing of expenditures, taxes.services and provider incomes that has been a compromise everyone could live with [23]. Oneof the less desirable features of this model, however, is that the general public can be caught inthe crossfire, especially when the tension "flares up", as it does periodically when government,11for various reasons. tries to tighten controls.Worries about the needs of an aging population and the effects of rapidly advancing.expensive medical technologies also fuel the perception that there is. or soonwill be, a financialcrisis. These are certainly developments which will require attention. But they are often talkedabout as if they are things beyond anyone's control· outside forces battering the health caresystem, likemeteorites falling from outerspace. In fact, although there is little that can be doneabout the aging process itself, or even technologic progress perhaps, the choices about how torespond to these developments are well within a society'scontrol [24]. (Furthermore, perceptionsare often exaggerations. For example. careful research has demonstrated that the increase in thenumber of elderly Canadians has had very littleeffectby itself. Rather it is the growing numberof services and procedures done for (or to) the average elderly person that is the source of thecost pressure [25J.) Calling everything thatcomes along "health care" and finding money to payfor it, is one possible response. Carefully considering what should and shouldn't be called"health care", and what to pay for from public money and what not to pay for (a subject we dealwith in another paper [3]) is a different response.This does not mean that there aren't serious fiscal pressures on the Canadian health caresystem. There are, and there always have been. But two recent developments are increasingthose pressures. The contributions of the federal government to the provinces for health carearebeing reduced. and the Canadian economy is not performing nearly as well now as it has inearlier decades. Therefore provincial governments are finding it harder to sustain previous ratesof increase in health care expenditures.It is quite a different matter. however, to conclude from this that costs are "out ofcontrol". The Canadian health care system has always been one of the mostrichly supported inthe world. but costs are not increasing faster now than during the last forty years. Contrary tothe popular wisdom, they are not "spiralling" up; they are continuing to increase at about thesame rate as they always have. What i§. different is that the growth of the Canadian economyhas slowed considerably, so that health care in 1991 took up about 9.9% of our gross domesticproduct But. if the two major recessions of the 1980's had not happened, we would still bespending about the same share (7 1/2%) of our national income on health care as we did in 1971[7].The widespread belief that public funding of health care weakens the ability to controlcosts is also not supported by the evidence. Health care costs rose more quickly on averagebefore Medicare than after it was completed in 1971. Furthermore. since 1971 costs for thecategories of health services included in Canadian public health insurance have increased lessrapidly than those for services outside the public plan [7].The comparison of theCanadian and American experiences is even more dramatic. Bothcountries had similar profiles of health carecost growth prior to 1971, when Canada completedits system of universal, publicly-funded medical and hospital insurance. The U.S., meanwhile,continued to rely extensively on private funding and insurance, with a major emphasis on user12chargesof various types to control costs. In 1971, each country spent approximately 7 1/2% ofits national income on health care; today the U.S. spends in excess of 13%, which is over 3%more than Canada, and the gap is still widening. (It is also worth noting that, internationally.Americans are the least satisfied with their system, while Canadians are the most satisfied [26]).Nevertheless, slower economic growth continues to force Canadian provincialgovernments to choose between tightening spending controls on the health care system orallowing it to consume an increasing share of society's income. Any government that choosesthe first option(tightening controls) will paya political price,as health care providers will almostcertainly accuse the government of "underfunding" health care (no doubt at the same time asother commentators are criticizing the same government for not controlling "runaway" costs).It is not a coincidence that providers' claims of a funding crisis in Ontario, for example, havegreatly intensified just recently. After a decade of average annual growth in Ministry of Healthspending of 11%, which ended in 1992, the increase for 1993 was 1% and is expected to be evenless for 1994 [27].What does'"affordability" really mean? The dictionary defines "afford" as "to be able tobear the cost of'. In a country as wealthy as Canada, it is clearly possible to bear the expenseof the health care system, if that is what its citizens~ to do. So where is the problem? Theproblem is that it may not be possible for governments to do all of the things that they think theircitizens want at rates of taxation that they think the same citizens will accept Thus the pressurefor governments (which really means taxpayers) to "live within their means". Or in todayswords, control or reduce deficits.If deficits are to be controlled or reduced, then one or both of two things must happen -­reduce spending orland raise revenue. But there are further options within each of these routes.If spending is to be reduced, should the health care system be the target? Canadians apparentlydon't think so. In public opinion pollsCanadians consistently rate the health care system as thetop priority for public spending. This would seem to imply that the health care system isaffordable if Canadians are willing to accept less of other things that governments spend moneyon. Is this what people really mean by affordability? It is hard to know, because the populardebate and the opinion polls are not typically framed in these terms and it is difficult even tospeculate on what Canadians might actually do if faced with a real choice of how they wantpublic monies re-allocated. Perhaps it is time for a serious and detailed public exploration ofhow government revenues are spent and whether it corresponds to what people wantThe other option •• raising revenues .- also involves choices. This time the choices areabout m the revenues are to be raised. Which taxes will be increased. or what combinationof taxes and other instruments, like user charges will be employed (and for which publicservices)? In this context affordability boils down not to a question of whether costs can beborne, but rather to m they will be borne. How will the costs, (and maybe the benefits)ofpublic servicesbe distributed among taxpayers and users. Who gains, and who loses? This issue.- how costs and benefits are distributed •• is .the heart of the matter in any debate about any13form of usercharge for any public service, and needs to be put front and centre for exactly whatit is.The way in which revenue is raised, rather than the need to balance expenditures withrevenues, is the gut issue in the so-called affordability argument for user charges for healthservices. It must be, because the argument appears to make little sense otherwise. Supportersof user charges claim that the purpose of the charges is to increase the resources going into thehealth care system, which is currently funded through general government revenues, which inturri rely heavily on personal income taxes. They frequently slate that the system is"underfunded", and that user charges will help to correct this [I]. Taken at face value, this is acall to increase the total spending on health care, by adding private money (directly frompatients) to the public money (from taxpayers) thatis already being spent Analyses of the likelyeffects of user charges on total health expenditures generally confirm that this will indeed bewhathappens [28,29]. But in thecontext of "affordability", this amounts to saying that the samesociety that could not afford the current level of health care spending (out of public funds) £mlafford an even higher level of spending (out of a mixture of public and private funds from thesame people)! At best it is a strange definition of affordability. At worst it is hiding the mainissue, even if unintentionally.Decisions by governments about how much to spend andhow much to tax (and what sizedeficits to allow) are political choices. Similarly, a decision not to control or rationalize healthcare spending, but rather to allow it to increase while shifting more of the burden away fromtaxpayers and onto users is also a political choice. To talk of this as an issue of "affordability"is at best a confused and at worst a dangerously misleading use of that word.Will user charges generate revenue? Yes. With the responsibility argument there wasserious doubt about whether user charges would do what their advocates claimed - reduce (only)unnecessary use. Here there is littledoubt thatuser charges of any type will accomplish thegoalof generating revenue to ease the pressure on tax-financed government budgets. If people haveto pay for at least part of the cost of the care they use, then unless they stop using carealtogether, revenue will be generated. In fact, quite a bit of revenue will likely be obtained,because in general> studies haveshown that the demand for medical and (especially) hospital careis relatively insensitive to charges. Just how much revenue is obtained will depend on how largethe charges are, and how many people or services are exempted or protected from the charge.(However, if the main reason for imposing charges is to raise money, then exempting orprotecting special groups works against the intent of the policy, especially if these groups areheavy users of services.) But overall, if usercharges are intended to generate revenue. they will"work".Does the system need more money? Despite the claims of underfunding by associationsrepresenting physicians and hospitals, almost every commission of inquiry that has examinedhealth care in Canada or in specific provinces has delivered a loud and clear message that theanswer to this question is "no". The common theme of the reports of these commissions is thatthe money already being spent on health care is not being used as well as it could be, and that14there is significant room for improvement in the way the health care system is structured andmanaged.As noted earlier in this article, there is widespread evidence that somemedical proceduresare ineffective or are performed when they are not appropriate. Other procedures and servicesare provided in more costly ways than they could be, because the system is not organizedefficiently or because the incentives simply do not exist for doctors and hospitals to do thingsin the least costly way.Reducing the ineffective, inappropriate or inefficient provision of health care will makethe system more "affordable", in the propersense of that word. It will lower costs. Until now,however, the general public has remained relatively uninformed of these findings and theirimplications for tax dollars that may be being wasted. (This contrasts sharply with the highprofile and steadyflow of storiesabout underfunding in the media.) Although it is too optimisticto expect improved management of the health care system to remove J!ll financial tensions, thereis little question in the minds of experts who have studied the system that this is the place toapply pressure to reform the system in order to get "better bang for the buck". By providing afinancial "escape hatch" for those opposed to reform, user charges will deflate this pressure.Are user charges the way to let the rich help out? Part of the appeal of the affordabilityargument as it is usually presented is the Robin Hood tone of the suggestion. If more money isneeded, let's take a bit more from "the rich" by letting those who can afford it pay user charges.By implication, "the poor" are no worse off and the health care system can go on its merry way.There are one or two nagging questions, such as how to decide who can afford to pay (if toomany people are exempted, then usercharges don't help much) and whetherpeople might foregosome necessary care if the charges are too large (though the smaller they are, the less they help),but these are often brushed off in the popular argument with a comment such as "we're not tryingto hurt anyone who can't pay or who needs care." With these doubts cast aside, the thrust ofthe argument is that all that is going to happen is that more of the costs of health care will beborne by the rich, whoever they are.Is this the case? Well, no, and this is where the affordability argument becomes bothmore complicated and more deceptive than it at first appears.The two main points to keep in mind are first, that there is already in place a methoddesigned to spread more of the costs of public services onto those with higher incomes (thepersonal income tax) and second, that any userchargewill by definition redistribute costs on thebasis of use, regardless of income. Various schemes may be proposed to lessen this effect, suchas making the value of health care used part of taxable income, thereby taxing use by richerpeople at higher rates, but no tinkering with the specific form of the user charge can eliminateit [4]. By definition, for those who pay them, user charges distribute part of the cost of care onthe basis of use, regardless of income and regardless of the need for care. That is precisely theirpurpose.15For any level of health care spending, therefore, user charges shift the burden of costsaway from taxpayers generally (both rich and poor) and onto users of services (both rich andpoor). For people at the same income level, user charges redistribute the costs of health careaway from the "healthy" and onto the "sick", because they are the ones who use relatively morecare. For people who are equally healthy or sick, or more accurately, for people who use thesame amountof care, the same user charge places a greater burden relative to income on thosewith lower incomes.Of course, most people are both taxpayers and patients, so they both gain (as taxpayers)and lose (as patients). Whether they gain or lose overall depends on the amount of taxes theypay and the amount of care they use. In general, wealthy people pay more taxes and sickerpeople use more care; moreover, wealthy people tend to be healthier, and poorer people sicker.The healthy rich thus stand to gain the most from the introduction of user charges and the sickpoor stand to lose the most [5,Figurel]. Viewed this way, well-intentioned advocates of usercharges seem more like the Sheriff of Nottingham than Robin Hood.In another paper in this series we analyze in detail how different types of user chargesdistribute the costs of financing the health care system across particular groups of people [4].There is anotherissue of distribution, however, that is hidden from discussion in the affordabilityargument, and which deserves to be mentioned here. That is the issue of the distribution ofbenefits rather than costs.In moving from a primarily income-tax financed system of paying for health care to asystem with user charges, there is also a change in the criteria for obtaining access to health care.In the current system, access to health care services is intended to be based solely on the needfor care, which in turn depends on whetherpeopleget sick or injured (or perceive themselves tobe sick or injured) and the judgement of their physicians as to whether using services will helpto make them better. In a system with user charges, access to care depends in part on ability(and willingness) to pay the charge. People with higher incomes will thus on average not onlypay a smaller share of the costs of health care; they will receive a larger share of its benefits.Whether there is anything "wrong" with this change in criteria is not for analysts -- be theyeconomists or physicians -- to judge. But it is important for analysts to point it out in thepopulardebate, and for advocates of user charges to acknowledge that it is the case. It representsa change in the fundamental values which Canadian society has chosen to guide the provisionof health care. It seems too important to be left hidden.Not everyone hides it When discussions of the affordability argument reach this point,the response of some (though by no means all) supporters of user charges is quite direct Theysay, "people should be able to pay extra to get better service." But what does "better" mean'!Usually, it means that those able and willing to pay should be able to "jump the queue" if thereis one, and get faster care than those unable or unwilling to pay the charge, regardless of need.A remark attributed to Mr. Steve West, the Municipal Affairs Minister of Alberta, vividlyillustrates this point: "I don't want to retire with a half a million dollars in the bank, be 92ndon the list for hean surgery, and die with all that money in there" [30]. Again, although this is16not the way Canadians have chosen to determine access to care in the past, there is nothingintrinsically or analytically "right" or "wrong" about this position. It is a legitimate statementof personal values and deserves consideration as such. It is important to be clearabout what thevalues are in Mr. West's statement, however. He is explicitly saying that there should be publicSUbsidy of privileged access for those able to pay extra.Although Mr. West's remark seems to be a plea for preferential treatment of the rich ­better access to publicly-funded services for those who are able to "ante up" - this is not its onlypossible interpretation. He, and others like him, may be implying the creation of a separate,private health care system, available to those able and willing to pay for it In principle, theexistence of a truly separate private system, which did notdistort the public system andin whichpatients were entirely responsible for the full cost of their care, without public subsidies of anytype, sounds like a solution to Mr. West's problem. In practice, however, such a "two-tier"system is impossible to implement. At leastnobody (including theUnited States) hasdone it yetAnd in places where private systems co-exist with public ones (especially where physicians areallowed to work in both systems) there are always distortions and/or public subsidies. So, evenin this scenario, the public will end up subsidizing preferential access to care for those who canafford it Again, there is nothing inherently 'wrong' with this. But again, it would represent adramatic departure from the values on which Canadian Medicare has rested for almost threedecades.The Real IssuesOur examination of the debate over user charges has shown that although the mostpopular arguments seem to be clear, simple common sense, they are not Key parts of thearguments, and key concepts and words, are very fuzzy. The same words are used at differenttimes by different groups fordifferent (often inconsistent) purposes, without (perhaps deliberately[5]) spelling out their true meaning. The factors that must be considered are not simple; on thecontrary, they are quite complicated. And what seems like common sense may at some timesbe incomplete and at others downright misleading.When the arguments are broken down into their pieces, and the camera "zooms" in oneach piece, a different picture of what is apparently the same debate emerges. When the claimsthat are often made are examined carefully, and compared to what is actually known about theeffects of user charges, it looks like charges will do only a very few of the things that theiradvocates claim.At the bottom of the usercharge controversy, somewhere in the underbrush ofclaims andcounter-claims, and deep in the forest of media stories about the health care "crisis", there aretwo~ issues that need to be resolved. One involves our values as a society. The otherinvolves ourwillingness to accept the difficult and often uncomfortable work of restructuring thehealth care delivery system to be more effective and efficient Neither is easy.Both the responsibility argument and the affordability argument ultimately require17Canadians to re-examine the fundamental social values on which the current health care systemis based and either to re-affirm or change those values. The creation of a universal hospital andmedical insurance system offering first-dollar coverage for Canadians was based on thephilosophy that the benefits of a health care system should be distributed on the basis of needalone and the costs of the system should be distributed on the basis of ability-to-pay alone. Usercharges reverse this. at least in part, by distributing some of the costs on the basis of need (tothe extent that use reflects need) and some of the benefits on the basis of ability-to-pay.Supporters andopponents of user charges can argue about how big or small theeffects of chargeswill be. and about whether many or few people will be affected. but these are not the issue. Afundamental change in values and philosophy is. You can't be a little bit pregnantWhatever role the so-called "experts" - economists. physicians. nurses. hospitaladministrators. clinical researchers. other health care professionals, government bureaucrats.politicians and even philosophers and ethicists - have played in the debate so far. it isquestionable whether they have much more to contribute on this issue once they have produced. their evidence and clarified the points of debate. For the question of values is one which mustfmally be decided by ordinary Canadians. The experts will each have one vote - like everyoneelse.The responsibility and affordability arguments have another characteristic in common.Each ignores the second real issue and what is perhaps the most important source of fmancialpressure in the current system. namely our failure to manage the system as well as we could.There are many opportunities for reforms that would improve the organization, financing,regulation. administration anddelivery of health careandincrease the effectiveness of taxpayers'money that is currently spent, but they are seldom acted upon. There is a reason for this. Theyinvolve hard work.They involve risky political choices, and sustained commitment to reform over a longperiod. They require negotiations between governments and providers about levels of spendingand methods of payment They require changes in the types of facilities and the types ofprofessionals that make up the system. They require explanation and communication to thegeneral public. and new ways for the public to be involved in decision-making. includingdecisions about who is to get whatbenefits andwhy. But perhaps mostimportant, they threatenpowerful interests by requiring changes to the distribution of both the power and the incomes ofthose associated with the health care system. much closer scrutiny of whether what is currentlydone is achieving its purpose of improving health. and cooperation between many groups withcompeting agendas.Compared to the prospect of a steady and sometimes painful. even if thoughtful.restructuring of what economists call "the supply side" of the health care system. the idea thatit might be possible to avoid all this by going through "the demand side" of the system andcharging patients to raise more money is very tempting. And this is one of the things that usercharges will do - at least in the short run. Bypapering over the structural cracks in the healthcare house with more money. the incentive to make repairs that are overdue will be taken away.18"Ifmoney's not a problem, why should we change the way we de things. Who needs the hassle?"is not an unreasonable reaction for people working in the system. We all mightsay the. same,if we were in their shoes.Butusercharges are still a "cop-out", say their critics. Notonlydoes a usercharge policyfail to address the need for structural and management reforms. the debate about the policydeflects attention even further away from the central issue of reform. It lets those who shouldbe accountable for the effectiveness and efficiency of the health caresystem - whether politicianor health care provider - "off the hook". This assessment seems accurate to us, but it is .stillincomplete. For what seems like a "magic bullet" to solve today's problem of health care costswill not solve tomorrow's. And tomorrow will come. The basic forces which drive expenditureup are Unlikely to change, nor is the inability of the economy to support everhigher expenditures.Responses like "user charges will buy time to work on the big problems" or "torrwrrow'sproblems have tomorrow's solutions" are therefore either naive hopes or shrewd strategies forprotecting established interests.They may also be dangerous, rather than helpful, to Medicare. Once user charges areintroduced, and reform postponed (thus leaving the upward pressures on costs unchanged), it isvery likely that provincial governments will sooner or later find continuing increases in thecharges too tempting to resist If the resulting out-of-pocket costs to patients become significant,then it will be difficult to prevent private insurance from re-emerging. Although this "slippery­slope to the U.S.-style health care system" scenario is by no means a certainty, the road to aU.S.-style system may be both smoother and less reversible than it appears [31]. Even a smallprobability of such an outcome should be cause for concern; Americans themselves admit thattheirs is the most costly and leasteffective model for providing access to needed health careandprotecting people against the financial burden of sickness.It is important to recognize, therefore, that the question "why not user charges?" is notjust a choice about values. There are, or will be, real effects on Canadians in both the shortandlong runs that come along as part of the package, with varying degrees of certainty dependingon the effect Val.ues are not like ice cream ("will that be chocolate or vanilla7"); choices aboutsocial values determine paths that lead to important differences in societies.The effects of user charges, both real and imagined, have been examined in detailthroughout this paper. User charges will generate revenue, and make more money available tohealth careproviders. Those whorepresent doctors andhospitals know this,and it is why claimsof underfunding and proposals for user charges frequently come from them [1,5]. At the sametime, however, user charges will almost certainly increase, not decrease, the total cost of thehealth care system. They are unlikely either to reduce the use of health services significantly,or to discourage unnecessary use and only unnecessary use, or to encourage people to actresponsibly, although theywillsymbolically remind everyone (especially thepoor) thatCanadianhealth care is not "free". In the process they will remove an important partof the motivation forreform of the system to improve its effectiveness and efficiency.HPRU 88:1R Barer, M.L., Gafnl, A. and Lomas, J. (1989), "Accommodating RapidGrowth In Physician Supply: Lessons from Israel, Warnings for Canada",International Journal of Health SlIrvlces 19(1):95-115. Originally relBasBdIn February, 1988.HPRU 88:2R Evans, R.G., Barer, M.L., Hertzman, C., Anderson, G.M., Pulclns, I.R. andLomas, J. (1989), "The Long Goodbye: The Great Transformation of theBritish Columbia Hospital System", Health Services RBsBarch 24(4):435­459. Originally rBIBasBd March, 1988.HPRU 88:3R Evans, R.G. (1989), "Reading the Menu With Better Glasses: Aging andHealth Policy Research", In S.J. Lewis (ed.), Aging and Health: LinkingResBarch and Public Policy, Lewis Publishers Inc., Chelsea, 145-167.Originally rBIBasBd April, 1988.HPRU 88:4R Barer, M.L. (1988), "Regulating Physician Supply: The Evolution of BritiShColumbia's Bill 41", Journal of Health Politics, Policy and Law 13(1):1-25HPRU 88:5R Anderson, G.M. and Lomas, J. (1989), "Reglonallzatlon of Coronary ArteryBypass Surgery: Effects on Access", Medical Care 27(3):288-296.Originally released May, 1988.HPRU 88:6R Barer, M.L., Pulclns, I.R., Evans, R.G., Herlzman, C., Lomas, J. andAnderson, G.M. (1989), "Trends In Use of Medical Services by the ElderlyIn British Columbia", Canadian Medical Association Jouma/141 :39-45.Originally released July, 1988HPRU 88:70 The DBvBlopment of Utilization Analysis: How, Why, and Where It's Going.August 1988. (G.M. Anderson, .J. Lomas)D = Discussion Paper R = Reprint-HPRU 88:80 Squaring the Circle: Reconciling Fee-for-Servlce with Global ExpenditureControl. September 1988. (R.G. Evans)HPRU 88:90 Practice Patterns of Physicians with Two Year Residency Versus One YearInternship Training: Do Both Roads Lead to Ro",." Ssptember 1988.(M.T. Schechter, S.B. Shepll, P. Grantham, N. Finlayson, R. Sizto)HPRU 88:10R Anderson, G.M. and Lomas, J. (1988), "Monitoring the Diffusion ot aTechnology: Coronary Artery Bypass Surgery In Ontario", AmericanJournal of Public Health 78(3):251-254HPRU 88:11R Evans, R.G. (1988),""We'll Take Care of It For You": Health Care In theCanadian Community", Daedalus 117(4):155-189HPRU 88:12R Barer, M.L., Evans, R.G. and Labelle, R.J. (1988), "Fee Controls as CostControl: Tales From the Frozen North", The Milbank Quarterly 66(1):1-64HPRU 88:13R Evans, R.G. (1990), "Tension, Compression, and Shear: Directions,Stresses and Outcomes of Health Care Cost Control", Journal of HealthPolitics, Policy and Law 15(1):101-128. Originally "'leased December,1988.HPRU 88:14R Evans, R.G., Robinson, G.C. and Barer, M.L. (1988), "Where Have All theChildren Gone? Accounting for the Paediatric Hqspitallmploslon", In R.S.Tonkin and J.R. Wright (eds.), Redesigning Relationships In Child HealthCare, B.C. Children's Hospital, 63-76HPRU 89:10 Physician UtlllZlltlon Beforaand After Entering a Long Term CllreProgram: An Application of Markov Modelling. January 1989. (H. Krueger,A.Y. Ellencwelg, D. Uyeno, B. McCashln, N. Pagllccia)HPRU 89:2R Hertzman, C., Pulclns,'I.R., Barer, M.L., Evans, R.G., Anderson, G.M. andLomas, J. (1990) "Flat on Your Back or Back to your Flat? Sources ofIncreased Hospital Services Utilization Among the Elderly In BritishColumbia", Social Science lind Medicine 30(7):819-828. Originally "'leasedJanuary, 1989.HPRU 89:3R Buhler, L., Glick, N. and Sheps, S.B. (1988), "Prenatal Care: A ComparativeEvaluation of Nurse-Midwives and Family Physicians", Canadian MedicalAssociation Journal 139:397-403o =Discussion Paper R =Reprint2HPRU 89:4R Anderson, G.M. and Lomas, J. (1989), "Recent Trends In Cesarean sectionRates In Ontario", Canadian Medical Association Journal 141:1049-1053.Originally released February 1989.HPRU 89:50 Thll Canadian Hllalth Care Systllm: A King 's Fund Interrogatory. March1989. (R.G. Evans)HPRU 89:6R Anderson, G.M., Spitzer, W.O., Weinstein, M.C., Wang, E., Blackburn, J.L.and Bergman, U. (1990), "Benefits, Risks, and Costa of PrescriptionDrugs: A Scientific Basis for Evaluating Polley Options", ClinicalPharmacology and Thllrapeutlcs 48(2):111-119. Originally released April.1989.HPRU 89:7R Evans, R.G. (1990), "The Dog In the Night Time: Medical PracticeVariations and Health Policy", In T.F. Andersen and G. Mooney (eds.), ThllChallllnglls of Mlldlcal Practice Variations, The McMillan Press Ltd,London,l17-152. Originally rllillased June 1989.HPRU 89:8R Evans, R.G. (1991), "Life and Death, Money and Power: The Politics ofHealth Care Finance", In T.J. Litman and L.S. Robins (eds.) Health Politicsand Policy (2nd edition) Part 4(15):287-301. Originally relllased June, 1989.HPRU 89:9R. Barer, M.L., Nicoli, M., Dlesendorf, M. and Harvey, R. (1990), "FromMedlbank to Medicare: Trends In Australian Medical Care Costs and UseFrom 1976 to 1986", Community Health Studies XIV(l) :8-18. Originallyre/llased August 1989.HPRU 89:100 Cho/estllrol Screllnlng: Evaluating Alternative Strategies. August 1989.(G. Anderson, S. Brlnkworth, T. Ng)HPRU 89:11R Evans, R.G., Lomas, J., Barer, M.L., Labelle, R.J., Fooks, C., Stoddart, G.L.,Anderson, G.M., FlHIny, D., Gatnl, A., Torrence, G.W. and Tholl, W.G.(1989), · Controlll ng Health expenditures - The Canadian Reality", NewEngland Journal of Mlldlclne 320(9):571-577HPRU 89:120 The Effllct of Admission to Long Term Care Program on Utilization ofHI/alth SBrvlcas by the Elderly In British Columbia. November 1989. (A.Y.Ellencwelg, A.J. Stark, N. Pagllccla, B. McCashln, A. Tourigny)o =Discussion Paper R =Reprint3-HPRU 89:130 Utilization Patterns of Clients Admlned or Assessed but not Admlned to aLong Term Care Program· Characteristics and Differences. November1989. (A.Y. Ellencwelg, N. Pagllccla, B. McCashln, A. Tourigny, A.J. Stark)HPRU 89:14R Anderson, G.M., Pulclns, I.R., Barer, M.L., Evans, R.G. and Hertzman, C.(1990), "Acute Care Hospital Utilization Under Canadian National HealthInsurance: The British Columbia Experience from 1969 to 1988", InqUiry27: 352-358. Originally raleased December, 1989.HPRU 9O:1R Anderson, G.M., Newhouse, J.P. and Roos, L.L. (1989), "Hospital Care forElderly Patients with Diseases of the Circulatory System. A Comparisonof Hospital Use in the United States and Canada", New England Journal ofMedicine 321 :1443-1448HPRU 90:20 Poland: Health and Environment In the Context of Socioeconomic Decline.January 1990. (C. Hertzman)HPRU 90:30 The Appropriate Use of Intraparlum Electronic Fetal Hearl RateMonitoring. January 1990. (G.M. Anderson, D.J. Allison)HPRU 90:4R Anderson, G.M., Brook, R. and Williams, A. (1991) "A Comparison of cost­Sharing Versus Free Care in Children: Effects on the Demand for Office­Based Medical Care", Medical Cara 29(9):890-898. Originally releasedJanuary, 1990.HPRU 90:5R Anderson, G.M., Brook, R., Williams, A. (1991) "Board Certification andPractice Style : An Analysis of Office-Based Care", The Journal of FamilyPractice 33(4):395-400. Originally released February, 1990. Originallyreleased February, 1990.HPRU 90:60 An Assessment of the Value of Routine Prenatal Ultrasound Screening.February 1990. (G.M. Anderson, D. Allison)HPRU 90:7R Nemetz, P.N., Ballard, D.J., Beard, C.M., Ludwig, J., Tangalos, E.G.,Kokmen, E., Weigel, K.M., Belau, P.G., Bourne, W.M. and Kurland, L.T.(1989) "An Anatomy of the Autopsy, Olmsted County, 1935 through 1985",Mayo Clinic Proceedings 64:1055-1064o =Discussion Paper R =Reprint4HPRU 90:8R Nemetz, P.N., Beard, C.M., Ballard, D.J., Ludwig, J., Tangalos, E.G.,Kokmen, E., Weigel, K.M., Belau, P.G., Bourne, W.M. and Kurland, L.T.(1989) "Resurrecting the Autopsy: Benefits and Recommendations", MayoClinic Proceedings 64:1065-1076HPRU 9O:9D Technology Diffusion: The Troll Under the Bridge. A Pilot StUdy of Lowand High Technology In British Columbia. March 1990. (A. KazanJian, K.Friesen)HPRU 90:10R Sapphires In the Mud? The Export Potential of American Health CareFinancing. Enthoven, A.C. (1989), "What Can Europeans Learn fromAmericans?", Evans, R.G., Barer, M.L. (1989), Comment. Heafth CareFinancing Review, Annual Supplement 1989HPRU 90:11D Healthy Community Indicators: The Perils of the Search and the Paucity ofthe Find. March 1990. (M. Hayes, S. Manson Willms)HPRU 90:120 Use of HMRI Data In Nineteen British Columbia Hospftals and FutureDirections for Case Mix Groups. April 1990. (K.M. Antioch)HPRU 9O:13R Evans, R.G. and Stoddart G.L. (1990) "Producing Health, ConsumingHealth Care", Social Science and Medicine 31(12) 1347-1363. Originallyreleased April, 1990.HPRU 90:140 Automated Blood Sample-Handling In the Clinical Laboratory. June 1990.(W. Godolphln, K. Bodtker, D. Uyeno, L.-O. Goh)HPRU 9O:15R Anderson, G., Sheps, S.B., Cardiff, K., (1990) "Hospital-based UtilizationManagement: a Cross-Canada Survey", Canadian Medical AssociationJournal 143 (10):1025-1030. Originally released June, 1990.HPRU 90:160 Hosplta/·Based Utilization Management: A Lfterature Review. June 1990.(5. Sheps, G.M. Anderson, K. Cardiff)HPRU 9O:~.7D Reflections on the Financing of Hospftal Capftal: A Canadian Perspective.June 1990. (M.L. Barer, R.G. Evans)D =Discussion Paper R =Reprint5HPRU 9O:18R Evans, R.G. Barer, M.L. and Hertzrnan, C. (1991), "The 2G-Year Experiment:Accounting For, Explaining, and Evaluating Health Care Cost ContainmentIn Canada and the United States", Annual Review of Public Health 12:481­518. Originally released s.ptember, 1990.HPRU 90:190 Accessible, Acceptable and Affordable: Financing Health Care In Canada.September 1990. (R.G. Evans)HPRU 90:200 Hungary Report. October 1990. (C. Hertzman)HPRU 90:210 Unavailable for Circulation.HPRU 90:22R Anderson, G.M., Pulclns, I. (1991), "Recent trends In acute care hospitalutilization In Ontario for diseases ot the cirCUlatory system", CMAJ145(3):221-226. Originally released October, 1990.HPRU 90:230 Environment and Health In Czechoslovakia. December 1990. (C.Hertzman)HPRU 90:240 Perceptions and Realities: Medical and Surgical Procedure Variation ALiterature Review. January 1991. (S. Sheps, S. Scrivens, J. Galt)HPRU 91 :1R Nemetz, P.N., Tangalos, E.G. and Kurland, L.T. (1990), "The Autopsy andEpidemiology - Olmsted County, Minnesota and Malmo, Sweden", APMIS98:765-785HPRU 91 :20 Putting Up or Shutting Up: Interpreting Health Status Indicators From AnInequities Perspective. May 1991. (C. Hertzman, M. Hayes)HPRU 91:3R Barer, M.L. (1991), "Controlling Medical Care Costs In Canada" (Editorial),Journal of the American Medical Association 265(18):2393-2394HPRU 91 :40 The Meeting of the Twain: Managing Health Care Capital, Capacity andCosts In Canada. June 1991. (M.L. Barer, R.G. Evans)o=Discussion Paper R =Reprint6HPRU 91:5R Barer, M.L., Welch, W.P. and Antioch, L. (1991) "Canadian-American HealthCare Comparisons: Reflections On The HIAA'S Analysis", Health A"alrs10(3):229-239. Originally rs/eased June, 1991.HPRU 91:60 Toward Infegrated Medical Resource Policies for Canada: BackgroundDocument. June,1991. (M.L. Barer, G.L. Stoddart) Cost: $45.00HPRU 91:70 Toward Integrated Medical Resource Policies for Canada: Appendices.June, 1991. (M.L. Barer, G.L. Stoddart) Cost: $30.00HPRU 91:80 BUlgaria: The Public Health Impact of Environmental Pollution. August,1991. (C. Hertzman)HPRU 91:90 Reflections on the Revolution In Sweden. September, 1991. (R.G. Evans)HPRU 91:100 The Canadian Health Cars System: Where are We; How Did We Get Here?October,1991. (R.G. Evans, M.M. Law)HPRU 92:1R Barer, M.L., Hertzman, C., Miller, R., Pascali, M.V. (1892) "On Being Oldand Sick: The Burden ot Health Care for the Elderly In Canada and theUnited States", Journal of Health Politics, Policy and Law Vol.17(4)763­682. Originally released December, 1991. No charge.HPRU 92:2R Manson Willms, S. (1992) "Housing for Persons with HIV Infection InCanada: Health, Culture and Context", Western Geographic Series Vol.26:1-22. No chargeHPRU 92:30 Environment and Health In the Baltic Countries. April, 1992.(C. Hertzman) Cost $8.00o =Discussion Paper R =Reprint7HPRU 92:4R Barer, M.L., Evans, R.G. (1992) "Interpreting Canada: Models, Mind-Sets,and Myths", Health Affairs 11(1):44-61 No chargeHPRU 92:50 Aids Risk TalcJng Behaviour Among Homosexual Men: Soc/o­demographic Marksrs and Policy Implications. June, 1992. (R.S. Hogg,K.J.P. Craib, B. Willoughby, P. Sestak, J.S.G. Montaner. M.T. Schechter)Cost $5.00HPRU 92:60 The Adequacy of Prenatal Care and Incidence of Low Birth Weight Amongthe Poor In Washington State and British Columbia. June, 1992. (S. Katz,R.W. Armstrong, J.P. LoGerfo) Cost $5.00HPRU 92:70 Medication Profiles on Admission vs. Discharge In Patients at a GeriatricReferral Centre. November, 1992. (J.H. Schechter, M. Donnelly, M.T.Schechter) Cost $8.00HPRU 92:80 What Seems to be the Problem? The International Movement toRestructure Health Cars Systems. November, 1992 (R.G. Evans) $8.00HPRU 92:90 A Compendium of Studies on Environmental Risk Perception In B.C.November, 1992. (C. HeTtzman, S. Kelly, A.S. Ostry, D. Sclarretta. K. K.K.Teschke)Cost $8.00HPRU 92:10R Anderson, J.M., Blue, C. Lau, A. (1992) "Women's Perspectives on Chronic"Illness: Ethnlclty, Ideology and Restructuring of Life", Soc.Scl.Me<!. Vol.33#2, pp 101-113. No chargeHPRU 93:10 Evaluation of VI-Care: A Utilization Management Program of the GreaterVictoria Hospital Society. January. 1993. (G. Anderson, S. Sheps,K. Cardiff) Cost $12.00HPRU 93:2R Barer, M.L., Stoddart. G.L. (1993) "Toward Integrate<! Medical ResourcePolicie s for Canada: Canadian Medical Association Journal Series".Canadian Medical Association Journal 146 (3), (5), (7), (9), (11); 147 (1), (3),(5), (7), (9), (11); 148 (1) $12.00o =Discussion Paper R =Reprint8-HPRU 93:3R Evans, R.G. (1993) "The Canadian Heahh-Care Financing and DeliverySystem: Its Experience and Lessons for Other Nations", Yale Law & PolicyReview 10(2) No chargeHPRU 93:4R Tan, J.K.H., McCormick, E., Sheps, S.B. (1993) "Utilization Care Plans andEffective Patient Data Management", Hospital & Health ServicesAdministration 38:1 Spring No chargeHPRU 93:50 Nursing Resources In British Columbia: Trends, Tensions and TentativeSolutions, February, 1993. (A. Kazanjian, L. Wood)Cost $8.00HPRU 93:60 Hospital Financing In Canada. April, 1993. (M.L. Barer) Cost $8.00HPRU 93:70 Outcomes Management and Resource Allocation: How Should Quality ofLife be Measured?, July, 1993 (D.C. Hadorn) Cost $8.00HPRU 93:8R Evans, R.G.(1993) "Health Care Reform: The Issue From Hell"Policy Options 35-41 No. chargeHPRU 93:90 User Fees for Health Care: Why a Bad Idea Keeps Coming Bacle,August, 1993 R.G. Evans, M.L. Barer, G.L. Stoddart cost $8.00HPRU 93:10R Anderson, G.M. Kerluke, K.J. Pulclns I.R. Heitzman, C. Barer, M.L."Trends and Determinants of Prescription Drug Expenditures In theElderly: Data from the British Columbia Pharmacare Program"Inquiry 30: 199-207 Summer 1993 no chargeHPRU 93:11R Heitzman, C. "Environment & Health: In Central and Eastern Europe "Cost $12.00o=Discussion Paper R =Reprint9

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