Rethinking the Welfare State: The prospects for ... - e-Library

Health care 119
redeem the government funding. The need for baseline safety and quality standards is of
particular importance in the domain of LTC, as consumers are, by definition, vulnerable.
Further, as Geron notes, “for those consumers who are unable or ill-prepared to take on
these tasks [choosing providers], too much choice may not result in greater
independence—but rather in a sense of powerlessness.” 119 A regulatory framework for
setting baseline standards will help to alleviate the concern that these individuals will
receive inadequate care in a consumer-directed system.
Geron suggests that an appropriate LTC delivery model should contain both regulated
standards of safety and quality as well as consumer-derived quality measures. This would
include the implementation of sector-wide safety standards because “quality problems are
not eliminated when consumers are given the responsibility to determine the quality
standards for their care.” 120 However, consumers should be able to control their care to a
large extent, particularly in the case of non-medical home-based services where concerns
about safety are limited, by defining their own standards of quality and retaining the
freedom to hire and fire caregivers pursuant to these standards.
Extra billing
A final issue that arises in designing a voucher regime is that of extra billing or “topping
up.” Here the issue to be confronted is whether individuals should be free to negotiate for
services above the minimum standard (assuming a minimum standard can be defined).
Specifically, the question arises as to whether patients should be permitted to use voucher
entitlements as a credit towards higher quality, more expensive or more expeditious
essential services and pay the difference themselves, or alternatively opt out of the system
altogether. Again, the familiar efficiency versus equity trade-off arises. Prohibiting extra
billing for basic covered services suppresses the price system and its value as a signal of
and reward for superior quality, although permitting it is likely to seriously compromise
equality of access goals and perhaps attenuate the political efficacy of voice in
maintaining the value of basic voucher entitlements. Extra billing has traditionally been
prohibited in Canada out of concern that those with the ability to do so would essentially
exit the publicly financed health care system in favour of a superior, largely privately
financed one. The public system left behind would then lose the support of those
individuals with the political voice necessary to ensure the maintenance of high-quality
health care delivery. Conventional wisdom in Canada asserts that forcing the entire
population to put their health in the hands of the public system ensures that those with
sufficient political voice will use it to ensure their own well-being and thus, by extension,
the well-being of all. In this respect, the system is seen as an important expression of
social, even national solidarity. Although this line of reasoning has some cogency to it, it
is arguable that at least some tailoring of services to meet individual preferences could be
permitted without compromising the quality of the publicly financed system—especially
given that in some ways, a two-tiered system already exists in Canada as the wealthy can
pay for additional services, for example, private nurses, private hospital rooms or
traveling to the United States and making use of US facilities and physicians. 121
Implementing a “topping up” tax, for example, as suggested by Sherry Glied 122 is one
means by which this could be achieved. With such a tax in place, individuals who choose
to do so would be permitted to purchase health care services whose value exceeded the