By Merrillee Fullerton, July 29, 2015
Despite the reality that Canadian health care is under increasing pressure on many fronts including demographics, economic conditions, and scientific advances, so far the federal political campaigns have shown a paucity of health-related content. The areas that are being raised for consideration are big new federal programs such as a national pharmacare program or a national seniors strategy.
Although these well-intended concepts are gaining traction among some interest groups, there has been no demonstration that they are taking a firmer shape at the political level, which is perhaps for the best. Adding major federally funded programs at a time of already constrained costs is a dubious proposition.
Predictions that creating a national pharmacare program will result in savings on drug costs are arguable. They have been developed without consideration of new pharmacological advancements whose impact has yet to be fully understood. Public pressure on politicians tends to drive up health program spending. This must be appreciated in the context of a national pharmacare program.
Similarly, a national seniors’ strategy would seem to make sense intuitively given Canada’s aging population, but it must be implemented locally. Given previous federal efforts to influence change in provincial health care programs through additional funding or through setting requirements for funding, we should approach this idea with caution.
Canadians don’t need another big federal program. What is needed is fresh thinking that goes beyond tinkering around the edges of medicare. Many politicians are reticent to even to discuss the issue. Why?
It is becoming clear that more public funding is not the solution to ever increasing health care demand. Politicians and specifically Health Ministers are caught between a rock and a hard place. They cannot openly admit that the current health care structure is exhausted and they cannot continue to fund it in ever increasing amounts by running annual deficits and increasing debt. They fear public backlash if they open a serious debate about the future of health care.
Over the past several decades, politicians and policy-makers have endeavored to reform and transform our health care system to create greater efficiencies, better cost control, and improved value for money to preserve our current system. However, the result has been significant rationing of services, hospital closures and amalgamations, bed reductions, restriction of operating room availability, imposed physician contracts, patient queues, and outright denial of care.
It is no wonder that political parties and politicians nudge Canadian medicare with trepidation. One false move and the special interest groups, labour organizations, and various health care advocates react. Occasionally, reforms are pushed through despite protestations and even then they frequently fail to create the desired outcome.
Measuring and monitoring patient wait times, one of the big ideas of the past decade, has not stopped them from growing significantly in many instances. The median wait time from referral by a general practitioner to treatment in Canada has increased almost 100 percent since 1993 and waits are measured in weeks to months, and even years in some cases. It would appear that these efforts at reform have resulted in system-centric preservation rather than patient-centred transformation. In other words, the reforms serve the single-payer system instead of the patient. What is a federal government to do?
The blame game
There has been much speculation and study as to who is to blame for the laggard performance of our publicly funded and supposedly universal system. Some say it is the lack of leadership at the federal level. Others report it is stakeholder self-interest, or the economy. Providers often blame a health bureaucracy that has grown steadily.
Rather than laying blame, we should be asking how a system can be created that allows for flexibility and adaptability to serve patients better even if it requires moving to a hybrid system that combines public and private options for necessary medical care, such as those found in the better performing systems of many developed countries.
Canada is certainly good at producing reports on health care, including those by Barer-Stoddart, Kirby, Mazankowski, Romanow, and Castonguay. None of the resulting policy changes have succeed in creating a more responsive system without breaking the public bank.
The catalyst for true reform is still missing. But this may come, not in the form of another commission or lengthy report, but in the form of the Charter Challenge in British Columbia set to be heard this fall after several delays. It is expected to last many months.
Dr. Brian Day, president and CEO of the Cambie Surgery Centre in Vancouver, argues that government failing to provide timely access to health care violates Section 7 of the Canadian Charter of Rights and Freedoms under the constitutional guarantee to “life, liberty and security of the person”. His clinic has been restricted from charging patients for publicly insured services. Day says it is “only common sense” that Canadians should be able to pay when they can’t get timely care from the public system, and he documents numerous cases of those who have suffered while on waiting lists for surgery.
The Supreme Court of Canada has already ruled in the case of Chaoulli vs Quebec in 2005 that access to a wait list is not access to health care. Unlike the Chaoulli case, which was specific to Quebec, the ruling in this case will be precedent setting for the country.
If politicians are unwilling or unable to make the difficult decisions, the legal system must be called upon to judge the rights of citizens to access medical care beyond the government-funded status quo. The uncertainty surrounding timely access to care is a thorn in the side of health ministries and politicians, although many Canadians have been oblivious until directly affected.
A complex system equals uncertainty
As health care has evolved over the past 50 years it has become an extremely complex system with associated uncertainty. Most efforts at reform to date have created new problems elsewhere.
Take for example the push to improve wait times in five priority areas since 2004. In Ontario, physicians were encouraged to increase their productivity by performing many more procedures which ultimately meant higher utilization costs for government. Physicians have now been held responsible for rising health care expenditures, with the Ontario government imposing a contract containing significant fee cuts for certain high-volume procedures. This in turn jeopardizes the progress made in improving primary care. When federal funding is used to create change at the local level, it is often not possible to predict the results.
Uncertainty for patients and health providers
Even Canada’s ability to use its health human resources effectively has been negatively affected as a result of reforms intended to improve efficiencies and lower costs. Specialist physicians in multiple areas are unable to access publicly funded resources such as operating room time and hospital beds. They have found themselves unemployed without access to infrastructure they require to serve the thousands and thousands of patients waiting in queues for various types of care, including orthopedic and cataract surgeries, and cancer care. This occurs while operating rooms sit idle or are closed for weeks at a time to meet hospital budgetary constraints. Elective surgeries can be cancelled due to capacity issues related to lack of hospital beds and other publicly funded resources.
The Royal College of Physicians and Surgeons of Canada reported in 2013 that 16 per cent of newly graduated medical specialists were unable to find work. This is despite the fact that Canada has a below average number of physicians per population compared to other developed countries. There is not a surplus of specialists; rather, there is inadequate publicly funded infrastructure to meet demand for care.
ER crowding and primary care reform
Another area suffering from unanticipated effects of reforms is emergency room overcrowding. Primary care reforms in several provinces were expected to stem the tide of patients seeking care in the ER. They have not accomplished this in any significant way despite many millions in spending. It might seem intuitive that by providing care outside the hospital for more patients that ER waits would be reduced but multiple studies indicate that the ER capacity issues are related to lack of access to hospital beds and long term care beds. Health care is like a balloon – squeeze one area and another bulges.
Primary care reform in Ontario included Family Health Teams (FHTs) which were hoped to improve access, costs and outcomes. In 2011, the Ontario Auditor General flagged key problems with the new model including increased costs compared to Fee-For-Service. In 2014, a Conference Board of Canada review concluded that the model performed well in some ways but poorly in others. It could not demonstrate improved outcomes over the years studied. An Institute for Clinical Evaluative Sciences study found FHT patients used emergency departments more than would be expected.
We lack the ability to predict with certainty the results of policy changes in a complex system. The result is paralysis among political parties. Fear of uncertainty keeps health care from moving forward to a more resilient system that could absorb unexpected events, disruptive technologies or sheer service volume increases.
National strategies consisting of manipulating the current single-payer system will not solve this problem.
Fix for a generation?
Former Prime Minister Paul Martin’s $41-billion health accord reforms in 2004, which he called a “fix for a generation”, were well-intended but the results were a disappointment. This federally guided cash infusion bought time but it is partly responsible for the delay in achieving a more modern and responsive health care system for our times.
The Health Council of Canada reported in 2013 that the changes created did not keep pace with evolving needs. The absence of federal leadership was cited as one of the reasons for the failure. However, health care is delivered locally. Regionally there are significant differences in need. If $41-billion additional federal dollars earmarked for priority areas was unsuccessful in buying change, it is unlikely that any federal framework could achieve the transformation required at the local level.
Provincial health care systems fail to make difficult decisions
In several provinces, regional and local delivery mechanisms have not improved overall costs or accountability. Alberta’s flip flop from central administration to regionalized health authorities and back to a uperboard is a prime example of uncertainty in cost-effective oversight of care. How a more distant federal influence could create an effective framework for locally delivered care that meets the challenge of regional variations in resources and patient needs is highly questionable.
Until the provinces make difficult decisions regarding their own spending, more and more federal funding will have limited success in improving care. As debt rises at both provincial and federal levels, servicing the debt costs even more, resulting in diminished ability to provide more public services over the long term.
Revisiting the Canada Health Act
It is time to consider the benefits of less government control over health care, not more.
At the federal level, the most significant leadership effort would be to amend the Canada Health Act to allow more freedom to innovate within Canada’s health system towards a hybrid system. Foundational concepts can be found in all the many better performing universal access health care systems around the world. European hybrid systems, notably in Sweden and Germany, achieve universal care with a combination of public and private coverage for medically necessary care and pharmaceutical coverage. Their outcomes are better and access for those with lower incomes have generally not been adversely affected, contrary to the fears of Canadians.
While the CHA does not expressly prohibit private options for medically necessary care, its punitive approach through reductions in federal health transfers to provinces creates an obstacle to change. Even if the federal government chooses not to act to claw back transfers to provinces, the threat still exists and is a source of negative political optics.
Another area of potential change involves the ability of provinces to permit financial contributions by patients. The CHA specifically prohibits user charges or extra-billing for services covered under provincial health insurance plans. This is problematic even by the standards of Tommy Douglas who was a proponent of patients sharing in their costs of care under conditions in which the system was being used excessively. Even though provinces have introduced various additional health premiums to citizens they have avoided outright “user fees” as required by the Act.
In its current form the CHA avoids defining “medically necessary” except in the broad sense. The Act makes a distinction between medically necessary “insured health services” and “extended health care services” which can be charged for at either full or partial private rates. Defining “medically necessary care” is needed to address the growing volume and variety of medical services emerging.
While significant change may be allowed under the current CHA, even the suggestion has been political poison in the past. Federal leadership is required to reset the national discussion.
Public losing confidence and ready for change
Heading into the fall federal election, Canadians are worried. A 2015 Ipsos Reid poll indicates that the majority of Canadians are deeply concerned that their health care system is deteriorating, with 70 per cent worrying that they’ll fall through the cracks in coming years, and 61 per cent lacking confidence that hospitals and long-term care facilities can handle the needs of Canada’s elderly population. While concerns surrounding health care are not new, more and more Canadians are beginning to understand the need for change.
An Ipsos Reid Poll from June 2012 reported that 76 percent of Canadians think they should be able to buy private insurance for treatments outside the public system. It is clear that the public in general is becoming increasingly aware of the need to transform to a more responsive system.
A resilient hybrid model
More federal funding for health care cannot address errors in provincial spending priorities.
To create a truly universal and patient-centred system that can be resilient in response to new demographic and scientific realities, as well as to errors of human policy-making and predictions, federal politicians and political parties need to look for inspiration to European hybrid models that perform much better than Canada’s health care system, which is designed for a bygone era.
Dr. Merrilee Fullerton, Family Physician Emeritus, has 30 years of experience in health care delivery as well as extensive contributions in policy development at national, provincial, municipal, and local levels.