Two Tier or not Two Tier, That is the Question

Just to warn you right off the bat, this blog entry will be filed under the “rant” category.

Is two tier healthcare better than universal healthcare or is the American system better than ours? Do we in Canada already have a two tier system? What does two tier actually mean? These are basic questions that Canadians face on a daily basis, often with a one sided explanation. I will answer these questions (from an unbiased position using real examples of what is actually going on) and give some solutions to help our good but not perfect system. We will explore more healthcare issues in upcoming entries and I welcome your feedback, comments, hate mail and future topic suggestions.

I will answer the questions in reverse order.

Question #1. What does two tier actually mean?

Answer – A two tier system is a model that allows citizens to pay directly for their healthcare. The most obvious example is the USA. Citizens have the choice of paying expensive insurance premiums (which gives them health coverage) or paying the doctor/institution directly. This means that they usually have timely access to their doctor, get very quick diagnostics done and then receive the best treatment with the best equipment. Sounds great right? What if you can’t afford insurance premiums that can cost upwards of $1000 a month? What if you go with the “out of pocket” option hoping you won’t get sick – and then you do? Would you have $200,000.00 laying around for that heart surgery? Just like any system that tries to cover the entire spectrum of the population, there are some pros and cons. I’ll leave it to you to dissect all of the tiny details but the short answer is: if you make lots of money two tier is good and if you don’t make a lot of money two tier is bad. All of the people who fall outside these parameters (disabled, elderly, unemployed etc.) get there healthcare funded by something called Medicaid or Medicare which the government pays for. Sounds almost like the Canadian system eh?

Question #2. Does Canada already have a two tier system?

Answer – YES! Anyone who thinks different is a politician or a fool. I realize that we technically have a universal system, but if you look closely you will realize that we only have a universal system when it comes to acute care, doctor’s visits or prescription drugs. What happens if you have the crazy idea that you would like to try to walk again after having a stroke? Better hope you recover 100% while you are an in-patient which normally lasts 2-3 months. After that you will eventually have to dip into your pocket to reach your goal. Next time you see a stroke survivor who has regained the ability to walk, ask them two things: How long it took them and did they spend any money out of their pocket? Everyone (unless you are smart enough to evade the CRA) pays taxes into this mismanaged pool of money (insert any health scandal you wish) that is supposed to cover ALL of our healthcare, not just SOME of our needs. I understand that this is not an easy task – having to split up all that money across this great big land, try to account for every health condition imaginable, fund research, pay administrators, buy new and fix old equipment blah, blah, blah. The list would go on for pages. I get it, this is a hard job with many things to consider. The bottom line is still that people ARE PAYING out of their own pocket, or through insurance plans or “loophole clubs” or “associations”, but not to see their doctor, get some pills or to receive surgery. I am not out to bash our system, I just want to see it work better. I also don’t want to fool myself into thinking I have something only to realize I actually don’t once it’s too late. Short answer is: people pay for all kinds of healthcare services in Canada that are not provided for free (or government subsidized) to people who can’t afford the service. Sounds kind of two tier to me.

Question #3. Is two tier healthcare better than universal healthcare?

Answer – Yes and No. I’ll explain. Two tier is obviously better for those who can afford it. For those who can’t it’s horrible. It’s a misguided question though. The real question we should be asking is “How do we take the best of each system and incorporate them together to create a new system?” Canadians are fortunate to have some of the best doctors, researchers and clinicians in the world at our disposal. The only problem is we can’t get to see them because there are so many sick and injured people and so few doctors. The fact is we get scared as soon as we hear the term “Two Tier” and instantly shut down. We either think of less than wealthy Americans dying on the street because they couldn’t afford a surgery that is free in Canada; or people pick this moment to become the most patriotic Canadians on the planet and say things like “this is a Canadian institution, our heritage. We’ll never be like those horrible Americans”. We need to wake up and realize that both systems can work beautifully together and that America and Canada already use each others system to some degree. We just need to come out and admit it publicly so we can move on and make the system better. Canadians travel to the US and all over the world regularly for medical services. Why are we letting this money leave our country? Are we worried that people will begin paying for services in Canada and sooner than later not be able to afford healthcare? Or that there will be no doctors left in the public sector? Or that we will turn into the US?

So how do we keep the money in Canada without becoming a two tier system as we currently know it to be? Short answer: Rich people pay for services (which they already do) at private hospitals that are operated by the government where the doctors are all still paid by OHIP. This will shorten the line across the road at the public hospital. The funds generated through the “private” hospitals will cover their own operating expenses as well as create a new revenue stream for our ailing public system. Two line-ups, less people waiting, same doctors treating and everyone is getting paid the same. Best of both worlds! I could go on and on but the point I am trying to make is let’s make our money work for us and trust that we have smart enough people to figure out how to make that happen. Worst case, I’ll do it (for free!).

Technology Review – Everybody do the Dinosaur!

Two high school friends from Scotland were inspired to create this robotic exoskeleton by their mothers who each were confined to a wheelchair.  The two men, engineers by trade, founded REX Bionics and subsequently developed REX, a standing and walking alternative to wheelchairs.  Let’s take a closer look…


Overview: a robotic exoskeleton that enables you to stand, walk, move sideways, turn around and use the stairs
Intended Use: Used by private individuals who can operate a manual wheelchair, self-transfer, and operate hand controls.
Purpose:  to expand physical capability and improve quality of life
Release date: Currently available for international sales. Product based in New Zealand and anyone wishing to purchase REX legs must go there to be fitted for the product and trained for its use.
Cost: $150,000 retail purchase price.

My Take: At first glance, REX appears too large, too loud, and too dinosaur-ish to use as an everyday ambulatory device.  And while all of that is true even at second and third glance, there are definitely some positives when viewed as a rehabilitation tool.

The REX allows its user to stand upright, which has numerous therapeutic benefits.  Unlike the ReWalk, which requires its user to use forearm crutches to be mobile or stand safely, the REX enables one to stand while using his or her hands to perform other functional tasks.  With other robotic exoskeletons, you have to wonder how safe someone would be walking any distance without extra support, but you don’t get that feeling with REX – it seems VERY stable.  Lastly, the REX does provide a means of walking for its user, albeit at a crawling pace, and only on hard, even surfaces.

I would like to have seen a more realistic gait pattern, including at least some knee flexion.  Instead, the REX legs use a hip hiking strategy – exactly the type of thing we try to prevent when doing gait training.  Also, the legs are controlled purely by remote control, with no option for any movement to be initiated by the user’s lower extremity.  So if you are looking for something to help improve or even initiate muscle contraction in your lower extremities, the REX is not your best bet.

Overall, the REX robotic exoskeleton provides a safe device for a user to perform functional tasks in standing, negotiate steps and slopes, and be mobile without a wheelchair.  Unfortunately, its hefty price tag of $150,000 and limited walking capabilities make the REX a tough sell.


If there’s one word I could live without, it’s the word Qi (also spelt Chi, Ch’i and Ki). Generally translated as ‘energy’, this seemingly simple but annoyingly ambiguous word has caused myself and my profession nothing but grief. Qi is one of those words that just loves to stir up controversy. Some say it’s hogwash, others say it’s the essence of life itself. Bottom line, nobody has a very good handle on settling this dispute anytime soon. Well no wonder, the basis for Qi originates from stacks of abstract writing interpreting unexplained observations from thousands of years ago. Quite frankly, it’s a little out dated. So I’m here to clear the air, to wipe the blackboard clean, and hopefully set the record straight.

The bottom line… the word Qi does not refer to a specific thing, it’s a blanket term.

Blanket term: A blanket term is a word or phrase that is used to describe multiple groups of related things. The degree of relation may vary. Blanket terms often trade specificity for ease-of-use; in other words, a blanket term by itself gives little detail about the things that it describes or the relationships between them, but is easy to say and remember.

Now before all you Qi lovers out there start bombarding me with hate-mail, let me show you how nicely this all works.

In physical science there are several recognized forms of energy. These include: thermal energy, chemical energy, electrical energy, radiant energy, nuclear energy, magnetic energy, elastic energy, sound energy, luminous energy and mechanical energy.

In the Chinese language, there are also several recognized forms of Qi. In the context of the Chinese medicine alone there’s Yuan Qi (original energy), Ying Qi (nutritious energy), Wei Qi (defensive energy), Ying Qi (meridian energy), Kong Qi (oxygen), Zheng Qi (healthy energy), Xie Qi (evil energy)… and that’s not even half of them. Then there’s emotions, the environment, metaphysics… all areas with specific and unique definitions for Qi.

You see, even in Chinese, just saying Qi doesn’t clarify much because Qi is NOT JUST ONE THING! As a word, Qi encompasses an overwhelmingly vast scope of meanings, each a notably unique quantity in it’s own way!

My solution: When defining Qi, it’s best to translate it in context. This means the definition will change depending on what you’re talking about. The beauty of this solution is that the word Qi becomes something you can actually understand, and something that there should be no need to argue about. To give you an idea of what I’m talking about, here are some examples:

“Qi is everywhere, it is everything”
This vast universal Qi that people often refer to is called Yuan Qi. Yuan Qi is the primal and original substance that all things are made of, and is actually a very accurate analogy for elemental particles. Elementary particles are the itty-bitty little specs that constitute everything in the universe. Even more interesting is that bosons & fermions, the 2 basic divisions of elementary particle, actually mirror Chinese WuJi and YinYang metaphysical theory to a tee! (cool, who knew all those crazy Daoists were actually the first Quantum Field Theorists!)

“Breath in pure Qi, exhale impure Qi”
As in oxygen and carbon dioxide? Too obvious. In most QiGong and meditation literature, Qi specifically translates as breath. In Chinese medicine there’s also a saying: “Qi and blood move together”, another somewhat obvious reference to oxygen, more specifically oxygenated blood.

“Qi is your living energy”
In Chinese medicine we say that Qi is the energizing force that keeps your body functioning. For example, the Qi of the Heart is it’s pumping action and the Qi of the stomach refers to digestion. Hundreds of years ago the intricacies of physiology may have been a mystery, but these days we understand biology at a cellular level. In particular, we know of the bodies utilization of ATP as an energy source to fuel metabolism. Does this fully explain the profound spiritual nature of life? Well no, but if you didn’t have ATP, you wouldn’t be sitting there reading this blog either.

“The mind leads the Qi”
Qi is commonly used in reference to neurological activity. For example, some Chinese martial arts commonly discuss Yi Qi Li (intent, Qi, power), a 3 step analogy that states: Use your mind to lead Qi and manifest striking power. As a physical training method, this analogy is known as Rate of Force Development (ROFD), a term that refers to the speed at which muscle fibers are recruited in a sudden contraction. The more muscle fibers that contract together in a split second, the faster and more powerful your strike would be… get it?

Another way to interpret this statement is focus or intent. Focus is something you can easily see in the face of a professional athlete in the zone, but Chinese painters and musicians also frequently talk about focusing their Qi when practicing their crafts. My painting teacher told me that I should “feel Qi move from my body through the brush onto the paper”. It’s easy to see why statements like this have some people shaking their heads, but if you were to look at it simply as relaxing your whole body and focusing your mind on the task at hand, it makes a lot more sense.

“Qi will fill your body and make you stronger”
One of my teachers in China forced me to practice ZhanZhuang every day. ZhanZhuang is the practice of standing in static postures for hours (yes it was grueling, but trust me, the physical demands were nothing compared to the sheer boredom of it). My teacher said this would “fill my body with Qi and make me stronger”. Later I learned about piezo-electircity, the electricity created in connective tissues (bones, tendons, fascia etc) when your body is under mechanical stress. This current stimulates some cells to produce more collagen and other cells to increase bone density. If only my teacher had just said that the mild but constant tension created in ZhanZhuang postures would stimulate an electrical charge that would stimulate my cells to increase soft tissue strength and elasticity and increase my bone density! Not to mention, you burn a whole lot of energy holding those postures for so long and that stimulates an increase in your mitochondria count. Mitochondria are the part of a cell that burn energy and can increase your endurance. Have I convinced everyone to stand around all day holding static postures yet?

“Your movements store and emit Qi”
In my TaiJi and martial art training I heard this a lot. Qi can be defined here as mechanical energy, which is composed of potential and kinetic energy. Kinetic energy relates to the continuous movement, while potential energy relates to the power stored in movements like contracting/expanding, opening/closing and twisting/coiling. Trust me, being thrown 10 feet into a tree has nothing to do with projecting magical energy, all you need is really subtle and accurate body mechanics (which helps with the landing part too).

I can think of another 50 examples of Qi being uniquely defined in quantifiable terms, but already in this blog you’ve seen it defined as the building blocks of the universe, as gas, as ATP, as nerve impulses, as your intent and as mechanical energy. Hopefully everyone out there can agree on this as a good starting point and recognize that there’s no need for Qi to remain a mysterious and magical substance that’s existence needs to be argued over… and for those of you who disagree, well don’t Sheng Qi at me.

Oh, that means get angry.