To Canadians, a two-tier system is one where anyone at anytime has the right to pay for health care privately, either out of pocket or though insurance.
This notion of choice is attractive to many, particularly to those anxious to avoid waiting lists for elective surgeries.
But that's not the way the health system works in Germany and Holland. There, citizens can't flit back and forth between the public and private tiers. They can't choose to get their knees fixed privately in order to avoid waiting lists and then have longer-term and more potentially expensive problems such as kidney disease attended to publicly...
The other key feature of the European systems is that physicians' wages in the private sphere are tightly regulated. In Holland and Sweden, for example, specialists cannot be paid more privately that they would receive publicly. Thus there is little incentive for doctors to treat private cases ahead of public ones, and for patients little chance that "going private" will result in faster care.
Most of the argument in favour of maintaining one-payer care has focused (and not without reason) on the question of whether we want there to be any capacity to choose to push ahead of other waiting patients in receiving access to a public good. But Walkom's line of argument should be all the more effective.
If the very systems put forward as models for private care are able to function only because they limit choice just as thoroughly as the one-payer system, then there's no apparent reason to shift from a more easily-administered restriction to a more complex one. And it's no answer to that to say that we could avoid the controls, given that such a model would more closely resemble the U.S. debacle than the European models which are comparable to our own in quality.
For all the valid complaints about our underfunded system, the problem is still a lack (and in some cases misallocation) of resources rather than a need for structural change. And the more resources we spend debating (or actively moving toward) a less-efficient two-tiered system, the less we'll be able to apply to any real positive change. It shouldn't then be hard to decide where we want to put our efforts - at least, for those of us more interested in a system that works than in the ideology of the market.