The phoney MSA debate

Lawrence Solomon
National Post
November 28, 2002

The debate over medical savings accounts (MSAs) – the proposal to have government give each Canadian an annual health allowance to cover routine health needs – has largely been fought on economic grounds.

Its backers – the government of Alberta as well as organizations such as the Atlantic Institute for Market Studies and my own Consumer Policy Institute – claim medical savings accounts would save money and expand medicare by letting consumers, instead of the health bureaucracy, choose how their health care dollars are spent.

Its detractors – most of the health-care establishment, led by the University of Toronto’s Raisa Deber – say the savings wouldn’t materialize. In fact, she and other health policy administrators have produced counter-studies that claim medical savings accounts would financially gut the health-care system.

But the detractors’ financial claims are a sideshow to the real debate, as Raisa Deber freely admitted this weekend during a debate with me at the University of Toronto’s medical school, before a province-wide gathering of medical students. The health-care establishment’s deep-seated opposition to medical savings accounts lies in its opposition to giving patients choice.

“I submit – and Raisa, please correct me if I am wrong – that if medical savings accounts were proven to save money, Raisa would still oppose them, and so would most of Canada’s health establishment,” I told the audience. “They would oppose medical savings accounts because they wouldn’t trust patients to have so great a say in how health dollars are spent.”

Ms. Deber did not correct me. “Patients don’t want choice in deciding ‘what’s the right answer’,” she confirmed during the debate and in discussions after it. “Patients don’t want to deal with treatment options. They’re not in the least interested in problem-solving decisions.”

Ms. Deber’s opposition to giving consumers choice is not narrow, and limited to her field of expertise, but based on a broad and deeply held belief. Giving consumers choice in telephone services or hydro matters is also wrong-headed, she asserted during the debate. As part of her wide-ranging presentation, she staunchly defended the union movement, too, presumably because employers might want choice in whom they hire. So compellingly did she denounce enemies of the union movement, in fact, that the first question from the floor came from a student who attacked me for opposing union health-care jobs – a subject I have never broached.

Ms. Deber, a professor of health policy, management and evaluation and – next to Roy Romanow – medicare’s leading lobbyist, speaks from the heart when she claims consumers don’t want more responsibility over health-care decisions. Instead, she says, consumers want a relationship based on “trust in partnership” with their doctors, meaning that patients want to put themselves into the care of their physicians, and not have to deal with issues beyond their ken.

In some earlier, paternalistic time, perhaps that desire for an unquestioning, trusting relationship existed. But the evidence doesn’t support its existence today. Consumers are increasingly taking charge of their own health, as seen in the explosion of self-help groups, alternative therapies, medical Internet sites, home testing kits, and medical software programs that allow consumers to diagnose their own conditions by answering a series of yes-or-no questions. Health publications aimed at consumers have become one of the fastest growing segments of the publishing business. Increasingly, consumers are treating doctors as expert consultants, much as they treat other professionals in helping them arrive at their own conclusions about what course of action to take. Seeking a second or even third opinion – once almost a taboo that implied lack of trust in your physician – is now common.

This desire for control explains the public’s attraction to medical savings accounts, which would provide, in addition to hospital and other catastrophic care, generous health-care allowances that would not only cover routine health needs but also give consumers a measure of independence. According to an Angus Reid Group poll, two-thirds of Canadians “believe this system would ultimately promote better health for Canadians because the unused portion of the allowance could be used to pay for therapies not currently covered by medicare, allowing people to choose services more suited to their own health needs.”

Trusting your doctor, as trusting any professional, will always be important. But consumers no longer view doctors as selfless father figures who can be unquestionably trusted to put their patients’ interests above their own. Many consumers, particularly those in lower socio-economic spheres who don’t have the good connections sometimes required to get good service, now see doctors as impersonal and unaccountable to them. As a result, they have suffered most at the hands of our health-care system.

The experience of the less-well-connected also helps explain why so many people are attracted to medical savings accounts. By controlling the purse strings, a majority of Canadians believe they will develop more accountable and more personal relationships. For example, 54% agreed with the following statement: “Because we would be paying our doctors directly, the health allowance system would make my doctor more accountable to me, and foster a more professional and personal relationship between us.” That percentage rose among the young and among Canadians earning less than $30,000 a year, the group most in need of good care.

Ms. Deber, wishing away the data, disagrees: “Not only is controlling the purse strings not important to consumers, it’s the last thing that consumers want when they’re sick,” she insists emphatically, much as she insists the only actuarial study performed to date of medical savings accounts for Canada – by the international health-care actuarial firm of Milliman and Robertson – must be wrong.

In coming weeks, other economic studies are scheduled to be released on the economics of medical savings accounts. Of the ones I’m aware of, all have found medical savings accounts to be economically sound. While that won’t change many, if any, minds in the anti-medical savings account camp, it may change its focus, by forcing it to confront the heart of the issue: Can consumers, using their doctors as consultants, be trusted to make decisions affecting their own health?

Related articles by Lawrence Solomon :

Romanow’s nether regions

Empowerment is the best medicine 

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