There is perennial debate in Canada about whether we should allow a “two-tiered” healthcare system. The debate is a bit confusing – by many measures we already have a two-tiered system, with private clinics and private insurance – but ultimately hinges on the ability of doctors to mix fees. Currently it is illegal for a doctor to charge anything on top of the provincially mandated fee structure. If the province is willing to pay $3,000 for a procedure, you cannot charge $5,000 and ask your patients (or their insurance) to make up the difference.
Supporters of a mixed system argue that it will alleviate wait times for everyone. Detractors argue that it will create a cumbersome, unfair system and paradoxically increase wait times. It’s enough to convince me that I don’t know what the fuck a two-tier healthcare system would have as its first order effects.
But I oppose it because I’m pretty sure I know what the second order effects would be.
It is a truth universally acknowledged that an industry, temporarily in possession of good fortune, must be in want of a really good lobbyist to make that possession permeant.
This is how we end up with incredibly detailed tax and regulatory law. There are a whole bunch of exceptions and special cases, vigourously lobbied for by special interest groups. These make us all a bit worse off, but each exception makes a certain person or small group of people very much better off. They care far more about preserving their loophole or unfair advantage than we do about getting rid of it, so each petty annoyance persists. Except, the annoyances aren’t so petty anymore when there are hundreds or thousands of them.
I dearly don’t want to add any more “petty” annoyances to healthcare.
As soon as we allow doctors to mix public funding with direct payments from patients or insurance, we’ll unleash a storm of lobbying. Everything from favourable tax treatment for clinics (we don’t charge HST on provincial care, it’s unfair to charge it on their added fees!) to tax breaks for insurance, to inflated fees for private clinics to handle some public cases will be on the table.
If the lobbyists do their job well, the private system will perch like a mosquito on the public system, sucking tax dollars from the public purse and using them to subsidize private care. This offends me on a visceral level, sure. But it’s also bad policy. Healthcare costs are already outpacing general inflation; we should not risk throwing fuel on that fire. We might end up with having the same sort of cost disease as America.
If we can keep healthcare relatively simple, we can keep it relatively cheap. One of the most pernicious things about cost disease is that it mainly affects things the government pays for. Because of this, the government has to collect more and more tax dollars just to provide the same level of service. As long as healthcare, education, and real estate are getting more expensive in real (inflation adjusted terms), we have to choose between raising taxes or making do with less service. When there are two systems, it’s clear that the users of the private system (and their lobbyists) would prefer decreased public services to increased taxes.
When there is only the public system, we force the lion’s share of those who plan to lobby for better care to lobby for better care in the public system 1. This is true not just in healthcare; private schools are uncommon in most Canadian provinces. Want better school for your children? Try and improve the public schools.
There is always option to lobby for subsidies for private systems, but this has generally been unproductive when the public system is effective and entrenched. Two-tiered healthcare is back in the news because of a court case, not because any provincial government is committing political suicide by suggesting it. When it comes to schools, offering to subsidize private schools may have played a role in dooming John Tory’s bid for the premiership of Ontario in 2007.
I wonder if there isn’t some sort of critical mass thing that can happen. When the public system (be it healthcare, education, or anything else) is generally good, all but the wealthiest will use it. The few who use private systems won’t have the lobbying clout to bring about any specific advantages for their system, so there will be a stable equilibrium. Most people will use the public system and oppose changes to it, while the few who don’t won’t waste their time lobbying for changes (given the lack of any appetite for changes among the broader public).
If the public system gets substantially worse, those with the means to will leave the public system for the private. This would explain why generally liberal B.C. (with its decade of nasty labour disputes between the government and teachers) has much higher enrollment in private schools than in conservative and free-market-worshipping Alberta (which has poured decades of oil money largesse into its schools) 2.
Of course, the more people that use the private system, the more lobbying clout it gains. This model would predict that B.C. will begin to see substantial government concessions to private schools (although this could be confounded if the recent regime change proves durable). This model would also predict that if we open even a small crack in the unified public healthcare system, we’ll quickly see a private system emerge which will immediately lobby to be underwritten with public dollars.
From this point of view, one of the best things about public systems is that they force the best off to lobby for the worst off. Catch-all public systems yoke the interests of broad parts of society together, increasing access to important services.
If this model is true, then getting healthcare and education right are just the table stakes. It is vitally important that the provinces institute uniform rules and subsidies for embryo selection and future genetic engineering technologies. Because if they don’t, then in the words of Professor Jennifer Doudna, we will “transcribe our societies’ financial inequality into our genetic code”.
Both IVF and genetic screening are becoming easier and quicker. According to Gwern, it’s already likely a net positive to screen embryos for traits associated with higher later earnings (he lists seven currently screenable traits: IQ, height, BMI, and lack of diabetes, ADHD, bipolar disorder, and schizophrenia), with a net lifetime payoff estimated at $14,653[^3]. Unfortunately, this payoff is only available to parents who can afford the IVF and the screening.
Recently, Ontario began covering one round of IVF for couples unable to conceive. This specifically doesn’t include any genetic testing or pre-implantation diagnosis, which means that if we see a drop in heritable genetic diseases in the next generation, that drop will only be among the better off. Hell, even though Ontario already “covers” one round of IVF, they don’t cover any of the necessary fertility drugs, which means that IVF costs about $5,000 out of pocket. This is already outside the reach of many Ontarians.
Not a lot of people are running analyses like Gwern’s. Yet. We still have time to fix the coverage gap for IVF and put in place a publicly funded embryo selection program. If we wait too long here, we’ll be caught flat footed. The most effective way for rich people to get the reproductive services they will want wouldl be by lobbying for tax breaks and help for their private system, not for the improvement of a good-enough public system.
There’s a risk here of course. IVF isn’t particularly fun. It might be that the people with the longest time horizons (who are perhaps likely to be advantaged in other ways) will be the only ones who would use a public embryo selection system. This would have the effect of subsidizing embryo selection for whichever groups have the longest time horizons and the most ability to endure short-term discomfort for long term payoff.
But anything less than a public option on embryo selection makes entrenching social divides as genetic divides almost inevitable. We could ban all non-medical embryo selection, which, as Gwern points out, would just move it to China. Or Singapore3. Or even America. This would shrink the problem, in that fewer people would have access to embryo selection, but wouldn’t stop it altogether.
Embryo selection is just the beginning here too. Soon enough, we’ll see treatments for genetic diseases using CRISPR. Hot on the heels of that, we’ll see enhancements. Well, we ostensibly won’t in Canada, at least without some amendments to the Assisted Human Reproduction Act4, which bans changes to the DNA of germline cells. I say “ostensibly” because it’s the height of naivety to assume that you can end demand simply by banning something, but then, that’s Canada for you.
The advent of CRISPR should usher in a sudden surge in genetically engineered humans. Parents will optimize for intelligence, height, and lower disease risk/load. It will be legal somewhere and therefore some Canadians will do it. If we have a legal, public system in Canada, then it will be available to anyone who wants it. If we don’t, then it will become very hard for the children of normal Canadians to compete with the children of our elites.
Throughout this post, I’ve assumed cost is no object. That’s probably a bad assumption. We’re talking about horrendously expensive voluntary medical procedures here. Gwern gives the cost of an IVF cycle with embryo selection at $22,000. There are 393,000 babies born in Canada every year. If this technology was both subsidized and adopted by 10% of all parents seeking to conceive, the total cost would be something like $864 million, or an increase in total healthcare spending of about 0.4%. Given that healthcare spending is allowed to grow by 3% per year, this would eat up more than 10% of the total yearly increase.
I’m not holding my breath for that sort of new spending on reproductive medicine. A more practical system would probably be a lottery, with enough spots for 1% of prospective parents. That has a more reasonable price tag of $86.4 million. While they’re at it, the government could start paying surrogates, egg donors, and sperm donors and institute a similar lottery there. I can dream about Canada having a functional fertility services industry, right?
A lottery isn’t my preferred solutions. Wealthy people who put their name in and aren’t drawn will still go elsewhere. But it could help with the lobbying problem. A lottery establishes a plausible path towards a broader system, which people would at least consider lobbying to expand. It won’t capture everyone. It might not even capture a majority. But if an expanded public system is the most palatable system politically, it might just win in the long run.
If you take just one thing from this post, I want it to be “it’s really important to have good public systems, so that lobbying effort is focused on improving those systems”. If you have room in your mind for another, it should be “having a public embryo selection and genetic engineering program in place is very important if we don’t want to social stratification to become much more permanent”.
Epistemic Status: Model
In this post, I’m talking about industries where there is either a clear need to serve the public good, a market failure, or both. In these cases, “use markets to lower prices and increase services” is an unappealing alternative. ↩
This would also predict that America, with its cluster-fuck of a public school system would have generally higher rates of private schooling than neighbouring (and better performing on standardized tests) Canada. This is true – ten percent of American children are in private schools, compared to eight percent of Canadians. I think there is a smaller gap between the two then there otherwise might be, due to the extreme heterogeneity of American schooling. That is to say that Canadian public schools might be better than American public schools on average, but everything I’ve heard suggests that the standard deviation is much higher in America. Well off students going to good public schools may account for why America’s private school enrollment isn’t higher. [^3]: This number will get higher and higher as we better understand the genetic determinants of IQ. ↩
Singapore has a history of hosting the biotech advances the west finds distasteful. ↩
This bill could perhaps be more truthfully be called the No Assisted Human Reproduction Act. In addition to banning germline genetic engineering, it also bans any paid surrogacy, egg donation, or sperm donation. This had the predictable effect of inconveniencing the wealthy not at all, while making it impossible for anyone else to find any surrogates, egg donors, or anonymous sperm donors. With a side-helping of encouraging surrogacy in countries where surrogates have the fewest legal protection (remember, my whole thesis here is that if you don’t give people a good pro-social option, they often optimize for maximum personal gain). ↩