Roy Romanow, Canada’s one-man health commission, believes that the poor need good health care and that any reform of Canada’s health care system must provide it to them.

February 12, 2002

Mr. Romanow also believes that Canadians, as health care consumers, need more say in the health services available to them.

Enter the medical savings account, a government-funded system that gives individual Canadians a personal health care allowance that they can use to purchase any government-approved health care good or service. Unlike punitive systems based on user fees, medical savings accounts are wildly popular with lower-income Canadians.

The Angus Reid Group is the only research organization known to have studied Canadians’ attitudes toward medical savings accounts in detail. Its startling findings, published four years ago, were largely ignored until Alberta’s recent inquiry into medicare discovered them. The Angus Reid Group study confirmed that medical savings accounts promoted Alberta’s goal of a system that was responsive to consumers, and it contributing to the Alberta inquiry’s decision to recommend medical savings accounts.

In all the aspects that Angus Reid surveyed, it found strong support – generally overwhelming support – for the medical savings account concept. For example, 67% of Canadians believe medical savings accounts would promote better health for Canadians because Canadians could use their allowance to pay for therapies not currently covered by medicare. This proportion rises to 70% among those with incomes under $30,000 per year. Seventy-two per cent of Canadians believe giving Canadians these allowances would make Canadians more aware of the true cost of health services, leading them to use the services more carefully. This percentage rises to 76% among Canadians with incomes under $30,000.

The Angus Reid Group study also unearthed a rich-poor gap that goes a long way to explain why lower-income Canadians so strongly back medical savings accounts. Canadians, whether affluent and well educated or low-income and poorly educated, agree that medical savings accounts provide great benefits by giving Canadians more choices, by making Canadians more aware of health costs and by improving the health of Canadians. But the views between rich and poor differ dramatically when it comes to the doctor-patient relationship.

Affluent, well educated people tend to be confident in dealing with their doctors, who generally come from similar social sets. When asked if a medical savings account system would make their doctors more accountable to them, and help foster a more professional and personal relationship, the majority of university-educated Canadians thought not. Only 21% of this elite group, for example, strongly agreed that medical savings accounts would improve the patient-doctor relationship.

Lower-income Canadians held the opposite view. A majority (58%) felt that medical savings accounts would make their doctors more accountable to them, 31% of them strongly agreeing. What the majority of low-income Canadians are saying – are you listening, Mr. Romanow? – is that their relationship with their doctors leaves much to be desired. Sometimes they feel they are taking up too much of their doctor’s time. Sometimes they’re reluctant to insist that the doctor investigate a concern that the doctor seems to discount. Sometimes they feel that they’re charity cases, and not entitled to make their doctor accountable to them. Because they are not purchasing a service in a professional, businesslike relationship – where their money is good as the next person’s – low-income Canadians, more than others, today feel they must rely on the good graces of their doctors. They would prefer to maintain their dignity in a more equal relationship, something the power of the purse would provide.

All Canadians should prefer that low-income people become empowered in this way as well. Because many low-income Canadians do not relate well to doctors, they overuse hospital emergency rooms, raising costs and worsening service for others. Then, too, the poor get sick more than others because the lack of empowerment, in itself, contributes to poor health. And although society consequently diverts disproportionate resources to the poor, under the current system the extra money helps too little: The poor continue to get sick more often, and to die sooner, than others.

Mr. Romanow knows that, to help the poor, medicare must reform. “When we first started debating medicare 40 years ago, ‘medically necessary’ health care could be summed up in two words: hospitals and doctors,” he states in his report. “Today, hospital and physician services account for less than half of the cost of the total system. More money is spent on drugs than on physicians.” The current system, in other words, shuts out low-income Canadians who can’t afford drugs. Medical savings accounts, low-income Canadians well understand, would give them the right to drugs and other essential medical services that the government does not now provide.

The 1964 Royal Commission on Health Services and the 1985 Canada Health Act both protected the needs of the poor, Mr. Romanow’s interim report says approvingly. Now it is his turn to ensure that the views of low-income Canadians are heard and acted upon.

Lawrence Solomon is executive director of Urban Renaissance Institute and policy director at Consumer Policy Institute, divisions of Toronto-based Energy Probe Research Foundation.