Let’s talk about the future of medicare!

The care is pretty good; the system , not so much.
The care is pretty good; the system , not so much.

Columnist’s new book on Canada’s “unsustainable” health spending trends should
start us pushing for REAL reforms – and soon.

By Joan Cohen

For over a quarter of a century Jeff Simpson has been writing a political column for the editorial pages of the Globe and Mail. With its quiet, steady tone and clear-eyed probing of the workings of our public institutions, it was obligatory reading in the offices of the nation’s leaders, political and otherwise. “The best piece of real estate in Canadian journalism,” was the popular description of its daily placing for much of this period in the bottom left corner of the Globe editorial page.

Now, Simpson has put that rich experience and his hallmark, measured appraisal of public issues to work to produce what has to be the most important book of his career. It’s called Chronic Condition and quietly, but unsparingly, it shows Canadians and perhaps above all their politicians why it is factually wrong to assume Canadians have the best health system in the world, as they so often like to tell us. In fact, as he goes on to suggest, we could be putting much that we treasure in the operations of government at risk, and not simply our public health offerings, by making that assumption and continuing to follow our usual ways.

The costs of public health care are rising far faster than is the growth of the economy and  squeezing most areas of government spending, though falling ever further behind in meeting the health needs of Canadians. It is, as Simpsom demonstrates, the same system that Canada’s governments created when they introduced medicare in the mid-sixties. Medicine itself has vastly changed during these 45 or so years. Our society has changed as well, but public health care, then as now, is structured around two entities.

The first, unsurprisingly, is hospitals – the jewels of became the focus of medicare to the eventual detriment of the entire system. That system today is top-heavy with hospitals and short on other, cheaper facilities that could lighten their load and, possibly, bring down overall costs.

The other major component is doctors. In the early sixties, doctors managed to wrestle the endorsement of a fee-for-service payment system from the architects working on the design of Canada’s future medicare program. Fee-for-service remains a core arrangement under medicare — though in places a diminishing presence, notably in Ontario.

With that pay arrangement, doctors continue to enjoy a virtual autonomy in running medical aspects of the system (for example, ordering services like health treatments and tests without accountability to anyone) and enjoying a firewall around their pay system. This allows them to treat and receive payment for however many patients they wish to handle unconstrained by government spending budgets. (Hospital CEOs do however ration their access to operating rooms, and promptly shut the facilities down at the end of the
workday.)

Options aren’t discussed
And so, in Simpson’s very comprehensive and layered study we find many indictments of a system we so often have celebrated – though the book cautions us all not to forget the  positive, and sometimes miraculous things that system still achieves. Still, a running theme in his narrative is the ongoing spectacle of politicians slipping away when opportunities arise to openly present the problem and the options before Canadians.

It’s a system, we are also reminded, where reform will always be hugely difficult and in fact elusive. It is immensely complicated, containing hospitals that are themselves extremely complicated; powerful vested interests such as doctors’ associations and nurses’ unions; vast health-care bureaucracies; federal-provincial agreements; and demands from patients with every conceivable ailment and illness. All this is presided over by provincial governments operating in a charged, partisan environment.

In international comparisons, the findings are not encouraging. Canada ranks among the top five countries for per capita spending on health care (the highspending U.S. with its very different system is not included in the rankings). But, to take a sampling of the reported results, a 2010 survey conducted by the widely cited Commonwealth Fund shows Canada standing sixth of seven countries in rankings on the outcomes of and satisfaction with its health care. The New-York headquartered Fund looks at advanced economies, and its findings have shown a steady slippage in Canada’s standing in public health care since  the mid-2000s.

In international comparisons, the findings are not encouraging. Canada ranks among the top five countries for per capita spending on health care (the highspending U.S. with its very different system is not included in the rankings). But, to take a sampling of the reported results, a 2010 survey conducted by the widely cited Commonwealth Fund shows Canada standing sixth of seven countries in rankings on the outcomes of and satisfaction with its health care. The New-York headquartered Fund looks at advanced economies, and
its findings have shown a steady slippage in Canada’s standing in public health care since the mid-2000s.

He has two or three proposals that go farther, and should, or could, result in a basic  overhaul in the way health care operates. The first, not new but far-reaching in their impact, would put regional health authorities, which exist today in all provinces, in charge  of running the system. That has always been the arrangement here.

As bodies that are closer to the people than provincial governments, Simpson’s very  soundly reasoned proposal would have theses region authorities co-ordinating care among the various institutions and systems: hospitals, home care, nursing homes, long-term care,
family and specialist clinics. It’s a job, as he says, that the hospitals with their own  institutions to run would be unable to do effectively.

What’s needed, he adds, is a fully integrated structure that gives the regional control over  budgets. The provinces (whose vast staff, he hopes, would be seriously reduced), would set standards and organize the overall financing, and then let the regional authorities administer the system.

A second proposal strongly urges the integration of privately delivered health care into  Canada’s medicare system, with the care publicly paid for (although private payments for services could be introduced sparingly, since it would arguably take nothing away from the system and take some pressure off existing institutions).

Simpson deals at length with the proposition that has developed in Canada that in allowing  private health offerings governments would put health care on a “slippery slope” to a two-tier system, where the rich would get quality care and pay for it and poorer people  would be left with the dregs.

He wonders, at more than one point in the book, why it is that a single doctor who in fact functions as an entrepreneur, charging a fee for his service since the dawn of medicare, can be an accepted part of the system while doctors grouped in a clinic and charging fees have aroused the wrath and fears of the public. In response, governments have in the past shut them down. Private care is quite legal, goes back to the beginning of medicare and is specifically allowed under the Canada Health Act for core health services.

A dwindling concern
Simpson says Canadians have become increasingly indifferent about who provides their health service, and a few clinics exist in Canada today. In his view, such clinics offering routine medical procedures could be usefully integrated into the system. Hospitals could
offload much of their current caseload, freeing up beds to those requiring more intensive care; private clinics would pass on the more complex work to hospitals.

Finally, Simpson clearly favours a health regime where doctors are salaried, or at least put on part-salary while collecting lower fees. In Ontario, this system has been adopted in  many of Ontario’s new family health clinics.

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