Rebuttal

CMAJ 1998;159:500

© 1998 Canadian Medical Association

Steven Lewis (page 497), by dismissing our commitment to Canadian medicare,¹ misses the main point of our article. Our view is that recent health care cutbacks have resulted from governments relying on "distortionary" income taxes, at high rates, to fund health care expenditures. If one were to shift to a more efficient and still equitable source of revenue, the cost of raising revenue to fund public expenditures would decline, thereby allowing governments to spend more on socially valuable programs.²

Our proposed tax-based benefit system would improve efficiency by making service providers more accountable and recipients more conscious of the costs and treatment options of health care delivery. Lewis views the lack of accountability as a good thing because it saves costs. We believe that the current funding system promotes inefficiency and thereby imposes significant societal costs. Concerns about the costs of tracking utilization are exaggerated, especially since Ontario is already implementing a system to inform patients of their care costs.³

An alternative funding scheme based on user fees, which is gradually creeping into the system, encourages efficiency but sacrifices equity. Our proposal is more equitable than a user-fee system, in which poor people suffer disproportionately compared with rich people, a point not apparently understood by Lewis. The funding mechanism we propose would be progressive because the amount paid would increase as a proportion of income (low-income people would be exempt). In addition, it could allow for an expansion of health care services covered by medicare (e.g., dentistry, universal drug coverage, home care), a move contrary to the recent step-wise increase in services falling into the private sector.⁴

The issue of equity can only be considered over the lifetime of the individual. The discussion by Lewis of our revenue estimates is way off the mark. One cannot look at a single year and suggest that the tax is unfair to elderly people and those who are sick in that year. Everyone uses the health care system at some time. On a lifetime basis, our proposal would not discriminate against the sick.

We support a publicly funded universal health care system. It is a matter of how to fund the system in an efficient and equitable manner that may determine its long-term viability.

Michael Gordon, MD
Jack Mintz, PhD
Duanjie Chen, PhD
University of Toronto
Toronto, Ont.

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1. Gordon M. A system worth saving. CMAJ 1996;154:1395-6.
2. Dahlby B. The distortionary effect of rising taxes. In Robson WR, Scarth W, editors. Deficit reduction: What pain, what gain? Toronto: C.D. Howe Institute; 1994. p. 44-72.
3. Patients to get peek at what doctors bill OHIP. Toronto Star 1998 July 10;Sect A9.
4. The health report. Macleans 1998;June 15:14-44.