Part 1: Your Care is Not Free, and It's Only Getting Worse

So Part 1. Let's start with a fact- your health care is not 'free' in that it lacks cost, simply free in that access to it is not hindered by your ability to pay that cost at the point of treatment.

Healthcare, I can attest, is actually gawdamn expensive. There is the physical infrastructure to build and maintain- not just the rooms and buildings themselves of course, but the MRI machines and needles and billions of band-aids. There are highly-educated, highly-skilled people to be made- millions of them operating in concert from front-line patient care to information management to surgical specialties. 

The thing is that it has to be paid for. If prescription drugs or nurses or wheelchairs aren't paid for, they can't be had- medical consequences obviously ensue. This seems clear, but in the land of free healthcare where the point is so easily forgotten it's worth reiterating: this system's health and our health consequently are nobody else's problem but our own.

So, who pays for it? Currently, it's a combination of the federal/provincial government (which leverages a massive economy of scale) and private companies (who leverage some of the few bank balances out there equipped for the job). Consequently, it is these entities who have enormous capacity to influence the structure of the system, and contort it to pursue their goals.

The goal of the governments is easy on paper- make it run as cheaply as possible without causing noticeable problems in the delivery of comprehensive care for all patients in the order of their need. The goal of private companies is even easier on paper- make it run as cheaply as possible.

Both approaches result in patients paying more for their care at the point of treatment, a focus on short-term savings over long-term investments, and combine to contribute to a lack of overall cohesion in messaging, service, and bureaucracy. 

This won't do. The systems concerned flirt with catastrophe with every passing year. The task is not just to keep up physical infrastructure with a population which is living longer than any before, requiring investment in long-term care and assisted living, but also to manage the ever-increasing demand for a wider range of preventative and palliative care. Freezing the budget means cuts in the future. Hiking premiums will price the most vulnerable people out. Yet freezing the budget or raising premiums are the options as presented by a wide range of executives and ministers.

Political groups will navigate this period based on ideology and soundbites. Financial ones will navigate it pursuing profit and efficiency. The practitioners themselves do not pull enough strings on their own the really take control of responses to these challenges- and they're usually busy with other stuff, too.

It is patients (the most inclusive group possible) who must take control. They must speak loudly about their own experiences with the health care system, whether as ER visitors, relatives, long-term care residents, or insurance underwriters. We need to develop as clear an idea as possible of what is not working well and where has the most pressing need- and the thing that's nice about systems is that they're easier to diagnose when there is reliable data from throughout the system.

In Part 2, we'll start talking about what patients can do.

introduction/confession

i am going to confess a very important thing.

i work for a major financial company. it is big, the largest in Canada by some measures, and pervasive in the torontréal region. i work in the dungeon, albeit, but i am in a way complicit with a whole lot of things i don't agree with.

now, i live in a historically fortunate time, so i'm not being asked to shoot people or burn schools or anything horrendous like that. but there are times, where, to put it nicely, i'm engaging in processes that are causing needless delay and inconvenience to people in very unfortunate positions. 

you see, i work very closely with something that most people claim to be passionate about- health care. now, working for a major financial company offering services related to health care in canada seems like it should be impossible. sadly, it is not. 

your prescription drugs are not paid for by your taxes, and are thusly not covered by your province (except au Québec, mais quand-même l'adhésion au plan privé qu'offre votre employeur est obligatoire). your dental work (which i can tell you for a fact is expensive) is not covered either. if you need to see a psychologist, the government will not pay for it, a physiotherapist neither. my private company will, if you pay into a trust which acts on behalf of the largest shareholders.

now, there is the obvious argument that if the government does not fund these services, they are not necessary. in a manner of speaking, this can be considered true- leaving out rare exceptions, one doesn't die of a toothache or a bum knee. this argument, however, ignores the point- our public health system is not comprehensive, and there is significant demand for treatments outside of them, and hence private companies that fill in the void.

you don't need to be told why this is bad. companies with shareholders need to keep up their short-term profits so as not to lose value- in a financial company with relatively little physical infrastructure to back their net worth (RIM's facilities on their own are worth billions) the question is increasingly pressing. why it's financial companies, specifically, who have taken over covering medical treatments (rather than, say, a trust acting in the interest of the practitioners themselves) is left as an exercise to the reader.

pursuing short-term profits in 2011 is anathema to long-term investment, because of the sheer uncertainty in the field (uncertainty is defined here as 'things look certain to collapse, will we be stuck holding the bag?'). this financial instability and rapidly rising demands leave financial companies in a uniquely bad position to be supporting/controlling this important part of our total health infrastructure. who should fill in the void?

i have elucidated three options. one is paying into a trust that acts in the interests of the largest shareholders, two is paying into one run by elected officials deciding policy on ideological grounds, and three is paying into one that serves the interests of the practitioners alone. 

in the next five columns, over the next week, and informed by my personal experiences, observations, and anecdotes, i will discuss the fourth option at length.

'the canadian historical metanarrative'

is a real big mess. Even, frankly, defining 'Canadian' (big-c) is a bit of a mess. The government tells us that being Canadian is about the Olympics, avoidance of protest, reverence towards members of our armed forces, and the Queen. There is a very carefully edited, whitewashed, and atlanticist narrative that supports these conclusions, and is internally consistent. 

This is their story: Canada was discovered basically empty in the 16th century by European explorers. The first inhabitants were missionaries and teachers from France, and then later colonists from Britain and loyalists from the United States. The Canadian population was tiny, but fought loyally for Britain against the United States on several occasions, guaranteeing the colony's existence separate from the Manifest Destiny. 

The population grew over the 19th century from successive waves of immigration from Ireland and later Eastern Europe, then in the 20th century earned its independence from Britain through heroic service in two world wars. After the war, Canada became one of the most diverse countries in the world and an innovative economic powerhouse. It retains deep ties to its parent country Britain and its trusted neighbours in the United States.

That's it, right? A Canadian is a person who lives in a society created by settlers from Europe, or one who has been assimilated into it. The Canadian historical metanarrative as elucidated by Canada's New Government is therefore a story of settlement and conquest; it is exclusionary and divisive, disenfranchising millions from their own history. 

Now, let's be clear about one detail- this above narrative is not factually false. The problem is that it is woefully incomplete. The real canadian historical metanarrative depends on you. It depends on where your parents were from, and their parents before that. It depends on when you were born, and where you first lived. It depends if you've moved around a lot, or mostly stayed in one place. It is woven together through generations, through tribulations, and through relationships to others.

Our real history stretches back ten thousand years to the first humans who crossed through our lands on their way to populate the Americas. It is rooted in a deep connection with our environment, our natural resources, and our turbulent weather. It is rooted in community, in working together to thrive against the odds. It is something we all belong to, and something that many of us have no contact with, so steeped in the Coles Notes version above. Canada is not one nation, indivisible- it is many nations interconnected through natural systems and free choice.

We need to restore our real history. We need to reclaim the rights of all canadians, English, French, First Nations, Inuit, Métis and New, to speak on the authority of their relationship with our country. It belongs to all of us, and separate we can not drown out the international influences seeking to claim our national wealth for their private gain. The Harper Government's narrative is divisive on purpose- the more time we spend fighting each other, the less time we can spend fighting those who wish to exploit us. 

We need to keep our wealth here, first to bring equality to living standards and access to sustainable economic opportunity across the country, and next to accommodate newcomers from across the globe as climate change intensifies towards the middle of the century. It's time. It's long past time. It's time to learn our history and preserve our future.