Colby Cosh writes the first cogent argument in favor of health care user fees that I've ever seen:

Maybe it wouldn't help anything: we don't have very good hard data on the degree of stress placed on the system by hypochondriacs, lonely seniors, and confused drunks. But that's precisely the point--we don't have any good way of ascertaining that, or of reading people's minds to see if they're using the system "appropriately". Prices are how we find out.

Asking the doctor to collect information doesn't seem to work. Forcing the doctor's office to collect money and using that as a proxy for the information we need is very clever. Unfortunately, user fees are still a bad idea, for several reasons.

First, there's the additional cost associated with accepting payments. The fee Colby proposes -- CAD $20 -- might actually cover the increased costs in training, supplies, accounting and surveillance caused by requiring user fees. I know that the typical US copay is in the $5 - $10 range, which is near the break-even point for doctors. Surveillance is a cost because petty theft is a real problem with cash copays -- I've heard doctors discuss hiring office staff in terms of keeping the theft at a reasonably low level.

Second, any user fee will have the effect of discouraging use of the system -- which is all to the good when the system is being abused by hypochondriacs, idiots, or the incompetent. But if we're aiming to control costs by providing cheap preventive services to avoid expensive emergency services, user fees are not the way to go.

And although we can use the market, and the prices it assigns, to estimate the value of most services, the market is distorted by the infinite demand for life-saving health services. We can't price emergency health care like we price avocados: "You're going to die if I don't do this -- how much is it worth to you?"

No, the value that government health care provides to the public is the privilege of not stepping over dying indigents as we walk the public sidewalks. In this regard, the public health systems of the U.S., Canada, and the U.K. all succeed.

Which is not to say that they can't be improved.