by Alan Cassels

If you haven’t yet seen the doomsday graph, you should take a look. It’s a government projection of where BC will be spending its collective provincial wealth over the next 10 years. Currently, health eats up 41.5 percent, education 28.4 percent and “other” – things like social services, transportation and other stuff – takes up 27 percent. In 10 years, given a reasonable rate of growth based on past experience, healthcare will eat up 71.3 percent of the overall budget, education will consume 27 percent and “other” will get nothing.
In other words, healthcare, given reasonable projections, becomes ever more like Godzilla – big and ugly and eating everything in sight. Let’s look at the facts:

1) BC’s health budget now stands at nearly $12 billion, having risen about 36 percent in the last five years.

2) Pharmaceuticals lead the growth in health spending. BC PharmaCare’s budget is about $1 billion per year and it grows every year by about another $90 million, or roughly $250,000 per day.

3) It is true that while some new drugs help keep people out of hospitals, very few are breakthroughs. According to Canada’s research-based pharmaceutical companies, between 1983 and 2001, hospitalization rates decreased by 75 percent for ulcers, 71 percent for HIV/AIDS, 44 percent for diabetes and respiratory diseases, and 31 percent for chronic liver disease. Of the 296 new drugs arriving on the Canadian market between 2000 and 2004, nine drugs (0.3 percent) were considered “breakthrough.”

4) The average after-tax return rate of the 10 largest drug companies over the last 10 years was 29 percent, creating enormous pressure on the cost of healthcare, both public and private. On average, those companies spent 2.6 times more on marketing than they did on research and development.

Another fact that seems undeniable, whichever end of the political spectrum you are on, is that healthcare is insatiable. With growth in spending skyrocketing past anything inflation can throw at us, politicians and industry leaders blame the “aging population.” Assorted profit seekers and healthcare entrepreneurs are keen to exploit forthcoming opportunities. All this leads to one inevitable conclusion: open your pockets buddy; here comes private payment for healthcare. Goodbye Canada Health Act. It was nice knowing you.
The scenario of incredibly inflationary health spending, the doomsday graph I referred to, was used as a key backdrop to the Conversation on Health just launched by the BC government. Recently, Finance Minister Carole Taylor noted in a Globe and Mail article how unseemly it was that only three months into the new fiscal year, BC’s health authorities were coming cap-in-hand to the government saying they needed another $1.1 billion. She’d paid them their allowance and they wanted more? Shocking, but true.
But what can we hope for from the Conversation on Health, announced in last February’s budget, as a way to involve the public in decisions about publically-funded healthcare? I’m sure that one of the main goals of this process will be to achieve some sense of public understanding of the cost growth crisis and to then apply creative solutions to solve that crisis.
At least, I hope that’s the goal.
Who could be against that? It’s about time people know what healthcare really costs to enable them to contribute their ideas on how we might collectively deal with those exploding costs. In order to get at the root of the problem, however, I believe BC’s Conversation on Health could be damned from the beginning.
I believe it has to unroll in a way that generates, and even encourages, conflict, rather than consensus. In fact, if anything, involving the public and finding solutions through consensus will likely be the death knell of our publically-funded healthcare system. We need the sparks and fire that come from fierce debate, not polite toadying around the elephant in the room.
Some have said that the biggest cost driver is the drug budget. I am not sure if that’s true, but what is true is that we spend twice as much on pharmaceuticals as we did five years ago. Can anyone tell me what we are getting for all that spending? Did we get any additional benefits? Avoided hospitalizations, probably, but what about additional harms?
No doubt some people were hospitalized or died because of excessive or inappropriate drug use. Ever heard of Vioxx? Some wastage? It’s stunning that unused medication sitting in peoples’ medicine cabinets adds up to millions of dollars worth of wastage. Will the Conversation be about the benefits, the harms and the incredible level of wastage our health system generates?
I hope so, but probably not.
The opening political volleys on the Conversation are about two-tier medicine: public-private payment for health. Asking only who should be paying for healthcare instead of what value we are getting from what we are spending seems fruitless. The more radical approach to dealing with the skyrocketing costs of medication, hospitals and doctors would be to take the current $12 billion we BC taxpayers are contributing every year to healthcare and begin removing whatever is frivolous and wasteful.
I believe firmly in two-tier medicine. The tiers, however, are not between public and private, but between essential and frivolous healthcare. Basically, before you should ask who needs to pay for it, you need to know whether or not a health treatment, a drug or a procedure is worth doing.
Publically, we could easily pay for what is essential from well within the current budget. But how come words such as “essential,” “frivolous” or “waste” never seem to be part of the discussion?
Let’s be clear about one basic fact: those mounting dollars we are spending on healthcare derive from somebody’s income – whether it is a drug company, a professional association or a health authority – and it goes against the laws of nature for people to voluntarily agree to have their income cut. That’s why you need to ask tough decisions about what is essential and what is frivolous and then steer public money away from the frivolous.
A delay in finding solutions to the health cost crisis is good for the status quo. For example, when it comes to their products, the drug companies that abhor any conversation about cost-effectiveness love a delay. Delay is good. Another day passes in BC and we pay an additional $250,000 of our tax money to the drug companies. We’ll hand them another $250,000 tomorrow. Today, tomorrow, the day after and forever.
Some of that money will be well spent. Some will be wasted. And some will be spent dangerously and likely lead to further disability.
This provincial Conversation on Health needs to get off on the right foot, by encouraging us to face the fact that not all health care dollars are well spent, an approach that is sure to generate conflict, not consensus. But that’s a good thing.
According to John Stauber, author of Toxic Sludge Is Good for You and an expert on how public relations agencies have been able to bypass grassroots democracy, the term “consensus process” is a “brilliant misnomer.” Stauber says that since consensus implies a democratic process and is aimed at agreement, it is an essential weapon in the arsenal of government and industry, both of which, to a greater or lesser degree, desire to be in control of any public debate.
He cites public relations experts who see consensus as a key “crisis management tool,” which is used to divide the populous, set the agenda and essentially defeat those who would seriously challenge the status quo, such as those troublemakers who ask, “Why are we polluting our rivers? Do we really need to clearcut the forests? Is it necessary to build freeways through our neighbourhoods?” To which I’d add, “Why do we need to be spending money on health treatments that add no value to the quality or length of our lives?”
Serious social change is likely to challenge the predominance of the status quo; consensus processes are about preserving the status quo. Stauber draws a number of powerful examples of PR firms within the environmental movement that are intent on defeating the grassroots activists working to protect rivers from toxic waste or pristine forests from being cut. He outlines a taxonomy of activism, fitting everyone into one of three categories: radicals, idealists and realists. The corporate goal, he says, is “… to defeat the real social change activists, the so-called radicals, by co-opting the realists and idealists into partnerships and consensus processes, while marginalizing the radicals.”
It’s no stretch to see how the tactics of Big Chemical or Big Tobacco have been adopted by Big Health. You need look no further than those groups “partnered” with the moneyed powers – pharmaceutical companies, professional associations and so on – representing the “realists” willing to settle for a “win-win.” They know on which side their bread is buttered and won’t adopt positions that affect the industry’s most fundamental goal: creating returns for shareholders via growing healthcare spending.
Meanwhile, there are the “idealists” – many disease-groups – which, in Stauber’s words, can be “… counted on to sell out the concerns of the radicals.” They work in the name of pragmatism and become convinced to work with the realists towards “win-win” solutions. Any agency that profits from the continued increases in healthcare wants consensus; it stops people from asking embarrassing questions, such as the ones I tend to pose to the pharmaceutical industry and its surrogates: “Tell us, what are we getting in return for the extra few billion we are spending every year on your products?”
My embarrassing questions finally got me into trouble. Just last month I was shut out of a talk at the Ministry of Health here in Victoria. On September 13, Sean Holman, creator of Public Eye Online (www.publiceyeonline.com) reported the following under the headline Counterpunch:
“Yesterday, we reported University of Victoria researcher Alan Cassels would be speaking to provincial health bureaucrats about his new book Selling Sickness: How the World’s Biggest Pharmaceutical Companies Are Turning Us All Into Patients.
“But, in an interview with Public Eye, the ministry’s communications executive director Marisa Adair confirmed deputy minister Gordon Macatee has decided to postpone that speaking engagement.
“Explained Ms. Adair: ‘Given Mr. Cassels’ very specific viewpoint, the ministry would like to ensure someone representing the other viewpoint is booked (to speak)…’ ”
The main problem comes down to the rather “radical” notion I illustrated in my book: that we, as a society, are foolishly allowing the pharmaceutical industry and its “partners” free rein in defining diseases, and that those definitions are driving the astronomical growth in pharmaceutical spending.
Does my voice seem radical because the realists and the idealists have largely given up on radical solutions? I don’t know. But I do know that we are starting to have a Conversation on Health in this province and people should endeavour to get their voices heard. The more radical the better, I’d say.
But let me leave you with one bit of advice. Before you ask the government to pay for more healthcare, pause for a moment and first suggest what it should stop paying for. Suggest where it might make some savings.
We have a vitally important opportunity to get some public input on how to control the skyrocketing cost of health. Let’s not squander it. Personally, I’m hoping for some fireworks.

Alan Cassels is co-author of Selling Sickness and a drug policy researcher at the University of Victoria. He is also the founder of Media Doctor Canada (www.mediadoctor.ca), which evaluates reporting of medical treatments in Canada’s media.