Rebuttal

CMAJ 1998;159:500-1

© 1998 Canadian Medical Association

Repeating unsubstantiated assertions and faulty logic does not make them valid. None of the points raised in the rebuttal by Gordon and colleagues rescues their case.

Their principal claim is that taxing the sick to raise some revenue, rather than taxing everybody to raise all the (public system's) revenue, promotes efficiency and improves fairness. These are important and entirely unsubstantiated claims. To claim that the implicit transfer of income from the sick to the healthy serves to save medicare may get high marks for its bizarre creativity, but it fails on all other counts.

The choice is not between a user-fee system and a taxing-the-sick regime proposed by Gordon and colleagues, as they would have us believe. It is between their scheme and the progressive, universal, tax-based system we have now. They are fixing a problem we don't have by destroying principles most of us cherish.

Saskatchewan Health used to send people annual statements of the costs of the services they had used. It quit doing that. People didn't know whether they should feel guilty or virtuous, and the government couldn't explain what the point was. Nor was there any attempt to calculate costs (particularly hospital costs) accurately on an individual basis.

The proposed system must discriminate against the old and the sick to raise revenues, and must hit individuals hardest when they are sick and old. Only if all of us were precisely identical in health status and service use over a lifetime would the proposal be non-discriminatory. Fantasy cannot eliminate discriminatory taxation; sound policy can.

Gordon and colleagues assert, but do not document, that my estimates of how much revenue their scheme would gross (not net) is "way off the mark." My analysis points out the fundamental flaws in their assumptions and transparently recalculates revenue potential, erring if anything on the high side. Let careful readers decide who's on and off the mark.

Steven Lewis, MA
Health Services Utilization
and Research Commission
Saskatoon, Sask.

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