PNHP

Bob LeBow on the Physicians' Proposal

Bob LeBow on the Physicians' Proposal

Robert LeBow, M.D., former president of Physicians for a National Health Program and author of “Health Care Meltdown,” speaking at a press conference at City Hall in Philadelphia, on release of the JAMA article on the physicians’ proposal for single-payer national health insurance:
I frequently hear people tell me that America has the best health care system in the world. And in some cases, that is true. In July, 2002, I sustained a catastrophic injury while riding my bike to work. I am alive today, thanks, in art, to the high level of medical technology that was available for me.But, the U.S. also is the only developed country where getting sick or injured can, and all too frequently does, lead to bankruptcy. In fact, medical bills are the leading cause of bankruptcy. And, many bankruptcies happen to people with health insurance.

Our employer-based health insurance system is outmoded, illogical and needsto be replaced. Perverse incentives make our health care system a poor value for the amount we spend. Health care needs to return to an emphasis on health, not cost or profit.
Over 40 million Americans have no health insurance whatsoever and most of
the rest of us are underinsured. We are underinsured in the sense that even with insurance, there is a lot of cost shifting to the patient. And,for people with chronic illnesses and disabilities, the expense of long termcare, outpatient rehabilitation and prescription drug costs are largely left to private savings.
The “market” had been a failure for health care in America. Health care is not a commodity like fast food or automobiles. For health care, the public sector, in fact, has a much lower overhead than the private sector.
Thousands of doctors have signed on in support of the Physicians’ Proposal for a National Health Insurance program because it will provide comprehensive and affordable access to health care for every person in America, and remedy the loss of dignity that we have inflicted on ourselves as individuals and as a nation. It is time to put the patient first – not last – in the setting of priorities.
Bob LeBow, August 12, 2003
Health Care Meltdown:
https://pnhp.org/publications/health_care_meltdown.php
The Physicians’ Proposal:
http://jama.ama-assn.org/cgi/content/full/290/6/798
or
http://www.physiciansproposal.org/

Bob LeBow on the Physicians’ Proposal

Robert LeBow, M.D., former president of Physicians for a National Health Program and author of “Health Care Meltdown,” speaking at a press conference at City Hall in Philadelphia, on release of the JAMA article on the physicians’ proposal for single-payer national health insurance:
I frequently hear people tell me that America has the best health care system in the world. And in some cases, that is true. In July, 2002, I sustained a catastrophic injury while riding my bike to work. I am alive today, thanks, in art, to the high level of medical technology that was available for me.But, the U.S. also is the only developed country where getting sick or injured can, and all too frequently does, lead to bankruptcy. In fact, medical bills are the leading cause of bankruptcy. And, many bankruptcies happen to people with health insurance.

Our employer-based health insurance system is outmoded, illogical and needsto be replaced. Perverse incentives make our health care system a poor value for the amount we spend. Health care needs to return to an emphasis on health, not cost or profit.
Over 40 million Americans have no health insurance whatsoever and most of
the rest of us are underinsured. We are underinsured in the sense that even with insurance, there is a lot of cost shifting to the patient. And,for people with chronic illnesses and disabilities, the expense of long termcare, outpatient rehabilitation and prescription drug costs are largely left to private savings.
The “market” had been a failure for health care in America. Health care is not a commodity like fast food or automobiles. For health care, the public sector, in fact, has a much lower overhead than the private sector.
Thousands of doctors have signed on in support of the Physicians’ Proposal for a National Health Insurance program because it will provide comprehensive and affordable access to health care for every person in America, and remedy the loss of dignity that we have inflicted on ourselves as individuals and as a nation. It is time to put the patient first – not last – in the setting of priorities.
Bob LeBow, August 12, 2003
Health Care Meltdown:
https://www.pnhp.org/publications/health_care_meltdown.php
The Physicians’ Proposal:
http://jama.ama-assn.org/cgi/content/full/290/6/798
or
http://www.physiciansproposal.org/

JAMA: Physicians reopen the national discussion on

JAMA – The Journal of the American Medical Association
August 13, 2003 Editorial
Universal Health Insurance – Let the Debate Resume By Rashi Fein, PhD
The article by The Physicians’ Working Group for Single-Payer NationalHealth insurance in this issue of THE JOURNAL should re-energize the much needed debate on universal health insurance.
Whether one agrees or disagrees with the approach that nearly 8000 physicians and medical students have endorsed, this group has provided a considerable service by fanning the almost extinguished spark called universal health insurance. Perhaps the most noteworthy aspect of this article is that by offering its approach, the Physicians’ Working Group issues a challenge: those who reject its “solution” are challenged to present its own, better and stronger one as a replacement. Thus, it will not suffice simply to dismiss the Physicians’ Working Group solution as unworkable. The American health care system and American society face a real problem and are compelled to search for an answer.
Now is the time to reopen that discussion. The members of the Physicians’ Working Group have done their job by raising the issue of national health
insurance once again. Those who like their proposal should join with them.
Those who do not should develop and propose something better, more effective, and with fewer untoward side effects. No one should sit back and bemoan the existing state of affairs. The “health care mess” is too real for anyone to ignore it.
http://jama.ama-assn.org/cgi/content/full/290/6/818
The abstract of the proposal:
http://jama.ama-assn.org/cgi/content/abstract/290/6/798
The full proposal:
http://jama.ama-assn.org/cgi/content/full/290/6/798
To view the list of endorsers:

Physicians for a National Health Program


For physicians who wish to add their endorsement:
http://www.physiciansproposal.org/

Universal Health Plan is Endorsed

Published on Wednesday, August 13, 2003 by the Boston Globe

Universal Health Plan is Endorsed
Thousands of doctors back proposal in JAMA

by Liz Kowalczyk and Amber Mobley

Thousands of US physicians have endorsed a broad proposal that would abolish for-profit hospitals and insurers and transfer all Americans into an expanded and improved Medicare program for all ages, reigniting the debate over universal health care a decade after President Clinton’s failed plan.

While the four physicians who wrote the plan — three of whom are affiliated with Harvard Medical School — are members of a nonprofit organization that has long pushed for universal health coverage, the new proposal is important for two reasons: It was published today in one of the country’s most prestigious and its most widely circulated medical journal, the Journal of the American Medical Association, and because of the large number of doctors — nearly 8,000, including two former surgeons general — who endorsed it.

“The doctors said they hope to spark a debate over national health insurance that essentially ended with the death of the Clinton health plan.

Of the Democratic presidential candidates, only Rep. Dennis Kucinich is advocating a single-payer system.

Americans spend $1.6 trillion on health care, which the doctors say is more than enough money to cover every American. The doctors contend that there will be at least $200 billion in administrative savings in a single-payer, national insurance plan.”The Associated Press

JAMA officials said it is unusual for the journal, which has a circulation of about 700,000 worldwide, to publish an article endorsed by such a large number of physicians. JAMA’s editor, Dr. Catherine DeAngelis, said that an editorial accompanying the article represents the journal’s viewpoint that it is time for the country to grapple more seriously with major problems in the health-care system.

“Look, if you don’t agree with this plan, it’s not a foolproof plan, there are plenty of problems with it, come up with something better,” she said in an interview. “Let the debate resume. It’s sort of been on the back burner and it’s time we get on the stick with this. We are the only developed country in the world that doesn’t have a specific health plan for our people. It’s a disgrace. We have too many people not insured, and this is wrong.”

In the editorial accompanying the proposal, Rashi Fein of Harvard Medical School said one drawback of such a comprehensive plan is that it may be too radical to pass the US political system, but that the doctors’ proposal “should re-energize the debate.”

The plan, developed by the Physicians for a National Health Program, based in Chicago, differs from Clinton’s 1993 initiative in fundamental ways. Clinton sought to avoid large new taxes, instead seeking to require all companies to offer health insurance with federal subsidies helping small employers, Fein said. The country’s basic system — employers buying health insurance from nonprofit and for-profit insurance companies — would have remained intact.

The physicians’ plan is more radical and more encompassing, including coverage for the 41 million uninsured Americans as well as incorporating ways to control costs by setting a national budget, providing a set amount of money to hospitals for day-to-day operations and major expansions, paying for nursing home and home care for the elderly, and developing a national list of drugs the program would pay for.

The government would pay for health care through an expanded version of traditional Medicare, the federal health insurance program for the elderly. Most hospitals and clinics would remain privately owned and operated, and the national health insurance program would pay them a monthly budget for operating costs. Investor-owned facilities would be converted to nonprofit status. Private insurance companies would be virtually eliminated. The plan is endorsed by former surgeons general Dr. David Satcher, who served under Clinton, and Dr. Julius Richmond, appointed by Jimmy Carter.

One of the doctors’ arguments is that for-profit companies and multiple insurers are diverting money from clinical care for the demands of business. The physicians estimate that the country would save $200 billion annually by eliminating profits of investor-owned hospitals and insurance companies and by reducing administrative costs for hospitals and doctors who must bill dozens of different insurance companies. Private health insurers now consume 12 percent of premiums for overhead, while Medicare and the Canadian national health insurance system have overhead costs below 3.2 percent, the doctors reported.

Taxes, the doctors said, would increase. But except for the very wealthy, higher taxes would be offset by the elimination of insurance premiums and out-of-pocket copayments and deductibles, they argued.

Lead coauthor Dr. Marcia Angell, a senior lecturer at Harvard Medical School and former editor of the New England Journal of Medicine, said during a news conference in Washington, D.C., that the doctors want to curtail the entrepreneurial aspects of medicine, where insurers and providers avoid unprofitable patients and try to shift costs back to patients. But she said they also sought ways to control costs amid skyrocketing insurance premiums.

Dr. Steffie Woolhandler and Dr. David Himmelstein, both physicians at Cambridge Hospital and associate professors at Harvard Medical School, were coauthors.

Critics and even advocates of universal health insurance said the doctors’ proposal has major shortcomings. Susan Pisano of the American Association of Health Plans said private industry, not the government, has led the way in adopting disease management programs and prescription drug coverage. “Political pressures on Congress make change and innovation very difficult,” she said.

Giving hospitals a set monthly budget is similar to a form of managed care called “capitation,” in which insurers paid doctors and hospitals a set amount of money to treat patients. If they kept under the budget, providers made a profit; if they exceeded the budget, they lost money.

But capitation is now being called a failure by many providers, because it creates a financial incentive to limit care, and many insurers are moving away from it.

Further, many health-care economists questioned whether the proposal is realistic in the United States, given that even Clinton’s more modest plan failed.

© Copyright 2003 Globe Newspaper Company

Doctors Call for National Health Insurance

EMBARGOED UNTIL: August 12, 2003, 3 p.m. Central
Contacts: Steffie Woolhandler MD 518-794-8109
Quentin Young MD 312-782-6006

Doctors Call for National Health Insurance Journal of the American Medical Association Publishes Physicians Proposal for National Health Insurance

Signed by 7,782 Physicians

WASHINGTON, D.C., AUGUST 11, 2003 — In an unprecedented show of physician support for National Health Insurance (NHI), 7,782 U.S. physicians propose single payer NHI in an article in the August 13 issue of the Journal of the American Medical Association (JAMA).

The “Physicians’ Proposal for National Health Insurance” was drafted by a blue ribbon panel of leading physicians. The signers include 2 former U.S. Surgeons General, the former Editor-in-Chief of the New England Journal of medicine,hundreds of medical school professors and deans, and thousands of practicing doctors throughout the nation. The Proposal will be presented in D.C. at The National Press Club on August 12 at 10am in the Murrow room.

“This is an historic moment. Today, thousands of physicians are taking a stand on the side of patients and repudiating the powerful insurance and drug lobbies that block wholesome reform,” said Dr. Quentin Young, a leading Chicago physician who chaired the Department of Medicine at Chicago’s Cook County Hospital and convened the group of prominent physicians that drafted the proposal.”

The doctors’ article also critiques the health reform plans that have been offered by President Bush and the major Democratic presidential contenders. “Proposals that would retain the role of private insurers – such as calls for tax-credits, Medicaid/CHIP expansions, and pushing more seniors into private HMO’s – are prescriptions for failure. By perpetuating administrative waste, such proposals make universal coverage unaffordable,” said Dr. Young.

The physicians call for national health insurance that would cover every American for all necessary medical care – in essence an expanded and improved version of traditional Medicare.

* Patients could choose to go to any doctor and hospital. Most hospitals and clinics would remain privately owned and operated, receiving a budget from the NHI to cover all operating costs. Physicians could continue to practice on a fee-for-service basis, or receive salaries from group practices, hospitals or clinics.

* The program would be paid for by combining current sources of government health spending into a single fund with modest new taxes that would be fully offset by reductions in premiums and out-of-pocket spending.

* The proposed single payer NHI would save at least $200 billion annually by eliminating the high overhead and profits of the private, investor-owned insurance industry and reducing spending for marketing and other satellite services.

* Administrative savings would fully offset the costs of covering the uninsured as well as giving full prescription drug coverage to all Americans.

“In the current economic climate, we can no longer afford to waste the vast resources we do on the administrative costs, executive salaries, and profiteering of the private insurance system”, states Dr. Marcia Angell, Senior Lecturer in the Department of Social Medicine at Harvard Medical School, and former Editor-in-Chief of the New England Journal of Medicine. “We get too little for our money. It’s time to put those resources into real health care for everyone.”

The physicians’ call for NHI comes as rising health costs and premiums, and the increasing number of uninsured have stimulated a new round of health reform initiatives. Yet most politicians have steered clear of NHI, offering proposals for incremental reforms of the current system.

“How bad does it have to get before politicians are willing to prescribe the major surgery our health system needs? Premiums are skyrocketing and we already spend twice as much per capita on health care as any other nation. 41 million people are uninsured, and millions more are under-insured and can’t afford vital medicines. How bad does it have to get before our politicians admit we need national health insurance?” asked Dr. Steffie Woolhandler, lead author of the proposal and Associate Professor of Medicine at Harvard.

###

The full list of signers is available on the internet, but will be password protected until the JAMA’s embargo is lifted. To obtain a password, members of the press may call (312) 782-6006.

Physicians for a National Health Program was founded in 1987 and includes physicians in every state and medical specialty. For local contacts or other information, contact PNHP’s headquarters in Chicago at (312) 782-6006 or visit: www.pnhp.org.
Press/7.15 ver

Uninformed voters threaten health care reform in California

Oakland Tribune
Aug. 8, 2003
Health care proposals featured at forum Fate of reform plans uncertain in light of gubernatorial unrest ,By Rebecca Vesely
Promising to “keep going until I die or pass this bill,” State Sen. Sheila Kuehl, D-Santa Monica, pitched her plan for a universal health care system to a largely receptive crowd Thursday afternoon.

“I’m not talking about short-term fixes,” Kuehl said. “I’m talking about building a system slowly that will be comparable to Social Security or Medicare.”
Kuehl’s so-called single-payer bill, S.B. 921, would do away with employer-based coverage and install a government-run system akin to Canada’s. It would consolidate financing into a state fund and provide a minimum standard of care for all residents.
Another health care bill, sponsored by (Senate) leader John Burton,
D-SanFrancisco, called “pay or play,”… would require employers to cover a baseline of their workers’ health care or pay into a pool that would then cover the workers.

U.S. Rep. Pete Stark, D-Fremont, told the crowd that a state bill was the best hope of reforming health care. Bills passed by Congress and the Senate last month to add prescription drugs to Medicare, by contrast, are “lousy” and “useless,” he said.”I’m counting on the good state Legislature and the continuing service of Gov. Gray Davis to make this happen,” Stark said.
The Oct. 7 election to recall Davis could affect the prospects of both bills. Little is known about where the many candidates stand on health care.Davis has not taken a position on any of the health care reform bills.
http://www.oaklandtribune.com/Stories/0,1413,82~1865~1559248,00.html
Comment: In a well functioning democracy, the citizens have an obligation
to be informed on the important issues facing society. Current polls indicate that Californians are about to elect Arnold Schwarzenegger as governor even though he has not yet expressed any of his views on the crucial issues currently facing the state.
California is in the midst of a health care crisis. Gov. Davis’ silence on reform is unforgivable. But failure of the state’s citizens to ask the hard questions before deciding on how to vote is even more unforgivable.

Who should own the results of publicly-funded medical research?

The Washington Post
August 5, 2003
A Fight for Free Access To Medical Research
Online Plan Challenges Publishers’ Dominance
By Rick Weiss
Why is it, a growing number of people are asking, that anyone can download
medical nonsense from the Web for free, but citizens must pay to see the
results of carefully conducted biomedical research that was financed by their taxes?
The Public Library of Science aims to change that. The organization, founded
by a Nobel Prize-winning biologist and two colleagues (Harold Varmus,Patrick O. Brown and Michael Eisen), is plotting the overthrow of the system by which scientific results are made known to the world — a $9 billion publishing juggernaut with subscription charges that range into thousands of dollars per year.
In its place the organization is constructing a system that would put scientific findings on the Web — for free.Scientists and budget-squeezed librarians have long railed against publishers’ stranglehold on scientific literature, to little avail. But with surprising political acumen, the Public Library of Science — or PLoS
— has begun to make “open access” scientific publication an issue for everyday
citizens, emphasizing that taxpayers fund the lion’s share of biomedical research and deserve access to the results.
“It is wrong when a breast cancer patient cannot access federally funded research data paid for by her hard-earned taxes,” Rep. Martin O. Sabo(D-Minn.) said recently as he introduced legislation that would give PLoS a boost by loosening copyright restrictions on publicly funded research. “It is wrong when the family whose child has a rare disease must pay again for research data their tax dollars already paid for.”
http://www.washingtonpost.com/wp-dyn/articles/A19104-2003Aug4.html
Comment: Should the results of publicly-funded medical research be placed in the public domain, or should the results remain the intellectual property of others, marketed by copyright-protected scientific journals? Should we continue to support the superfluous middleman publishers who control access for the purpose of profit, or should we establish our own “public library” with universal access and lower administrative costs?Just as we are reassessing the high costs, administrative excesses and restricted health care access through our system of private health plans, we should also be reassessing the unnecessary costs and restricted access to the results of medical research that we have funded.

WellPoint reduces medical loss ratio to zero!

American Medical News
Aug. 4, 2003
PPO “administration fee”: Physicians pay to get paid Doctors must pay 3% to 5% of their reimbursement check to a company that organizes health networks. And that company is growing.By Robert Kazel
HealthLink, with no insurance assets of its own, is a “rental” network, a go-between that has signed mostly PPO contracts with at least 25,000 doctors
on one side and more than 400 payers on the other. Middleman networks such
as HealthLink make money by charging myriad payers — unions, self-funded
employers, third-party processors and others — for assembling and maintaining health networks. In HealthLink’s case, however, money is streaming in from both sides; every physician in the network must pay a fee ranging from 3% to 5% of each discounted reimbursement, depending on the doctor’s contract.
Because of corporate growth and mergers, the specter of administration fees for doctors has grown far beyond HealthLink’s roots. Many more physicians are seeing the fees, and more are likely to in the future.
California-based WellPoint Health Networks Inc. purchased HealthLink in 2001, and the company already has roughly tripled the number of doctors in the network by expanding to markets in the mid-Atlantic states and the District of
Columbia.
John Seidenfeld, MD, HealthLink’s medical director:”I think they’re getting very many things for this fee, but they don’t really understand what they’re getting.”
http://www.ama-assn.org/sci-pubs/amnews/pick_03/bil10804.htm
About HealthLink:
http://www.healthlink.com/about_us.asp
Comment: What is there to not understand about being impaled by a shaft between the shoulder blades?WellPoint, formed through the for-profit conversion of Blue Cross of California, is the nation’s leader in innovative health insurance
products.
It is the darling of Wall Street primarily because of its consistently favorable medical loss ratios. That’s Wall Street talk for improving profits by reducing payments for health care services.With lower medical loss ratios, investors gain while patients and providers lose.With HealthLink, WellPoint has succeeded in reducing the medical loss ratio to zero! It has inserted itself into the health care arena, disguised as a PPO, without funding any medical services whatsoever! It is a very expensive middleman that has totally abandoned the principle of insurance: pooling risk. But it is highly successful as a business model since it has diverted 100% of its revenues into administrative costs and profits!
The only benefit that HealthLink offers is price control. But by using this private sector, marketplace model of controlling fees, we are subjected to an inefficient, fragmented, and outrageously expensive mechanism of fee control. In contrast, our Medicare program already controls fees with virtually no additional administrative costs over the very nominal costs to run the system. A universal, public program of social insurance would ensure that costs would be contained and that fees would be equitable while also ensuring administrative efficiency.
Why do our public policymakers continue to commit health policy malpractice
by insisting that private bureaucratic parasites, such as WellPoint, be included in the health care equation?

St. Louis Post-Dispatch Editorial

St. Louis Post-Dispatch Editorial
August 19, 2003

Can 8,000 docs be wrong?

08/19/2003

LAST WEEK, nearly 8,000 doctors called for the government to toss our absurd private health insurance system out the window and establish single-payer national health coverage for everyone. They’re absolutely right.

The group included two former U.S. surgeons general, the former editor of the New England Journal of Medicine and a raft of medical school professors and deans.

They are frustrated at a balkanized system that wastes billions on bureaucracy and marketing, drives doctors to distraction, confounds patients and leaves 41 million Americans with no coverage at all.

The waste is painful. Blue Cross in Massachusetts employs more people to cover 2.5 million New Englanders than Canada employs to cover 27 million Canadians, the doctors group notes. Canada has a single-payer system. Like every other industrialized nation except ours, Canada provides medical coverage for everyone.

The doctors group, Physicians for a National Health Program (www.pnhp.org), thinks a single-payer system could save $200 billion a year. That might be enough to cover the uninsured at no extra cost.

But the politically powerful insurance lobby stands in the way. So do free-marketeers in Congress who think government always equals waste.

When it comes to health care, they’re wrong. American health care economics is capitalism turned upside-down.

The free market works because customers will shop for the best price and quality; that brings efficiency. But health care customers rarely shop based on price, because they’re not paying. Their insurance company or the government are picking up most of the tab.

This warped system leads to spectacular inefficiencies. Left on their own, doctors and hospitals can run up costs with little resistance from patients. To counter that, employers push managed-care insurance systems to leash the docs and hospitals. The insurers create astounding bureaucracies to make providers toe the line. The providers set up counter-bureaucracies to battle multiple insurance companies.

The upshot: Only 87 percent of the private health insurance dollar goes to medical providers, and much of that is eaten up by the providers’ counter-bureaucracy. Billing and administration eat up 26 percent of hospital revenues.

We have something close to a single-payer system for our old people: Medicare. Providers get 98 percent of each Medicare dollar, putting private insurers to shame. So why isn’t the whole country on Medicare? The 8,000 physicians are proposing something close, but better. There would be one government health insurer. The government would bargain a budget with each hospital and set rates for doctors. Naturally, the government would have the financial clout here. Costs would be controlled. And patients would have free choice, since all providers would be in the network.

Deciding how to pay for it would be a problem. But corporations and employees are already paying a mint for health coverage. A combination of taxes on employers and workers would do the trick.

Americans deserve health coverage they can never lose. Single-payer is an efficient way to get it.

Fragmentation is even more destructive than under-funding

The Guardian
July 16, 2003
The oldest and still the best
By Malcolm Dean

In the battle between 10 and 11 Downing Street over the NHS (National Health Service), Gordon Brown has always pushed two arguments for continuing with the current structure: first, that it is even more important today than its launch in 1948 because of its capacity to do so much more; second, because of the spiraling cost of modern medicine, which requires a comprehensive national insurance, such as the NHS, to provide the necessary protection.

If the chancellor had been at an international conference of leading policy makers last week, he would have learned a third reason: the advantages a national health system enjoys over federal or fragmented health systems.

…there are the new initiatives Labour has introduced nationwide: inspectors, systematic assessment of new drugs and equipment, new standards and a modernisation agency. They were described by Sheila Leatherman, an American researcher, who has been looking at their impact as “the most ambitious, comprehensive and intentionally-funded national initiative to improve health care quality in the world”.

But the initiative that generated the most jealousy was the new IT (Information Technology) system that will link all parts of the NHS for the first time: an extra £2.5bn over three years on top of the £2.4bn already planned. Currently there is no coordination among thousands of different systems. This will be a major step towards a crucial goal: better integration of primary care and hospital services.

The US has been trying to do this for years, but has been thwarted by its multiple systems, special interest hospital and insurance lobbies, and deeply fragmented services.

http://politics.guardian.co.uk/comment/story/0,9115,998723,00.html

Comment: It is remarkable what can be accomplished in an integrated system, even with very modest funding. The United States has proven that no amount of funding can correct the dysfunction of a fragmented system designed to meet the needs of special interests such as insurance companies.

Just imagine what 15.2% of the GDP, our current level of health care spending, could do in a universal, integrated, publicly administered system. But then, let’s not merely sit around and contemplate such an altruistic system. Let’s enact it.

(Note: There will be no Quote of the Day messages for the next two weeks while we are in Canada contemplating their altruistic system.)