Asking the Right Questions
Privatization won’t fix Canadian health care, so what will?
Health care in Canada is broken. That’s the message we hear constantly, and not without cause. There is a tremendous amount of high-quality care provided daily by some of the finest medical professionals in the entire world. Babies are delivered, lives are saved, patients with chronic conditions are cared for with compassion and expertise. We shouldn’t overlook the successes, but the failures are real as well.
“Family doctor shortages, long waits for specialty care and overcrowded emergency departments — these are challenges made even worse as the health system copes with the echoes of the pandemic. As doctors, we share our patients’ and the public’s frustration and fatigue. We are all desperate for solutions.”
These are the opening lines of a recent article in the Toronto Star by Danyaal Raza and Hasan Sheikh, board members of Canadian Doctors for Medicare.
The frustration for patients, and for the providers who try to get them the care they need, is real and legitimate. The burnout and backlog exacerbated by the pandemic has only deepened the sense of dysfunction, and it’s driven us to a familiar place. In Canada, with our history of political battles over Medicare and proximity to the medical marketplace of the United States, trouble in the health care system inevitably brings a push for privatization. The irony of this, given how the most tragic and disturbing COVID outcomes were in for-profit long-term care facilities, is conveniently ignored by those who seek to profit financially or politically by exploiting the crisis. Today’s troubles are returning us to yesterday’s debates.
I love the idea that when someone comes to see me in the clinic or the hospital I get to ask them how they’re feeling, not how they’re paying.
At the turn of the century (as I like to say so that my kids can enjoy making fun of how old I am), I was a medical student at the University of Saskatchewan. One of the things that inspired me to pursue medicine as a career was a belief in Medicare; Canada’s universal health insurance program. I love the idea that when someone comes to see me in the clinic or the hospital I get to ask them how they’re feeling, not how they’re paying. The existence of a nationwide program based on compassion and care, regardless of social and economic status, sends a beautiful message about the intrinsic value of all human beings.
At the time, however, that beautiful idea was under threat. Federal and provincial budget cuts of the 1990s had resulted in major challenges. Wait times were high, provider morale and public confidence were low. The medical profession’s loudest voices were people like Brian Day who were advocating for more privatization of health care with patients of means paying directly to access faster care. This has been shown repeatedly to worsen wait times and quality of care in the public system, but for owners of private facilities like Day’s Cambie Clinic, that was beside the point.
In 2001, Prime Minister Jean Chrétien asked recently retired Saskatchewan Premier Roy Romanow to head the Royal Commission on the Future of Health Care in Canada. Romanow and his team toured the country, hearing from Canadians what they wanted from their health system. Despite Romanow’s deep roots in the CCF/NDP, including time on the front lines of the fight to establish Medicare, some of his early statements gave the impression he was open to more privatization. A parallel process was led by Liberal Senator Mike Kirby, who was seen as even more friendly to the cause of private care.
Worried by the trends we saw, I joined with colleagues in Medicine, Nursing, Pharmacy etc, to start Health Professionals for Medicare, a group of students and practitioners advocating for investments in the public system. This group would later go on to lead the development of the SWITCH student-run clinic in inner-city Saskatoon. Afraid of what our future ability to care for patients based on need would be, we held debates and rallies to promote awareness of and support for universal single-payer health insurance.
Regarding the Romanow and Kirby reports, what we’d feared did not come to pass. The Kirby report, while it did leave the door open for more privatization, had more to say about primary care reform, home care and other needed innovations. The Romanow report was a clear statement of support for the principles of the Canada Health Act and called for further expansion of public care into home care and catastrophic drug coverage (a precursor of today’s push for universal Pharmacare). This led to the 2003 “Fix For a Generation” Health Care Accords between Paul Martin and the premiers. That deal sent 41 billion no-strings attached dollars into provincial and territorial coffers over ten year. These dollars helped to fix some of the more acute access problems but the transfer wasn’t designed in a way that could buy lasting change.
That failure of imagination by the federal government meant the expansions of Medicare the Romanow Report proposed didn’t come to pass. His report did, however, change the conversation in a very important way. The forces of for-profit care didn’t disappear, but the steam behind their latest push had evaporated.
Which brings us to the Canadian Medical Association (CMA), who are currently hosting a series of town halls on private and public care. In 2006, Brian Day was elected president of the CMA. He was succeeded by Robert Ouellet, a radiologist and owner of a suite of private medical imaging clinics in Quebec. The impression at the time was that the CMA was an agent of the interest of the bottom line for doctors, not the best interest of patients.
A group of physicians from across Canada responded to this moment by forming Canadian Doctors for Medicare (CDM). Led by Danielle Martin, author of Better Now: 6 Big Ideas to Improve Health Care for All Canadians, this group had the inspiring tagline of being “evidence-based, values-driven,” meaning they are guided by the latest studies of health system performance but centred their analysis of that literature on what would provide the best care of all Canadians. CDM remains a leading voice for public care to the public and to the profession.
In 2009, CDM worked with doctors across Ontario to elect internist Jeff Turnbull, an inspiring clinician dedicated to the service of the poor and vulnerable in Ottawa, as CMA President. This started off an extended series of pro-public docs (such as Anna Reid, Louis Francescutti and Katharine Smart) at the helm of the CMA, extending to today. Unlike their provincial and territorial counterparts such as the Saskatchewan Medical Association or Doctors Nova Scotia, the CMA doesn’t negotiate contracts for doctors. They are purely an advocacy organization. The change in leadership has seen them shift from doctors advocating for doctors to doctors advocating for patients. This has included substantial campaigns for Pharmacare and interventions on the social determinants of health such as basic income, housing reform and a net-zero health system.
Today, the CMA’s decision to host town halls on the role of private care have sparked a debate among doctors. Again from Raza and Sheikh:
“Into this reality, the Canadian Medical Association is sponsoring cross country town halls asking participants to “wonder if there’s a greater role to play for the private sector.”
Despite the CMA’s scope and size, its framing falls prey to tired pitfalls that have long characterized this health care controversy. A more informed and modern question is this: why does Canada continue to fall behind our peers on publicly financed health care?
Here it is important to bring in a distinction between who pays and who provides. There is care provided by the public system and paid for through public funds, such as in-hospital care. There is care paid for by public funds but provided by for-profit providers, such as walk-in clinics and much of long-term care. And then there’s care provided by for-profit providers and paid for out-of-pocket, like most prescription drugs, psychology and physiotherapy. The CMA has a good explainer on this here: Understanding Private and Public Care, and CDM’s Myths of Privatization Primer is an excellent resource. It’s also worth noting, as Raza and Sheikh do, that despite claims to the contrary, Canada’s system has less public payment than most other countries, including being the only OECD country with universal health coverage that doesn’t include prescription drugs.
“As a share of all health spending, Canada allocates 75 per cent as public investment.
How does that compare? Canada is a standout Scrooge. The Netherlands, Germany, Sweden and France all spend 85 per cent or more via public funding.”
Hasan Sheikh addresses the myths of public and private care at the CMA Health Summit in Ottawa
There are important issues to be considered when it comes to who provides the care. Paying public dollars for someone else to run a surgical centre or long-term care home has fiscal and operational implications. We are too often renters paying someone else’s mortgage instead of owners with the autonomy to operate the best system, too often paying an investor-owned facility to do the easiest and most profitable work while the hardest stays in the public sphere. These are important policy discussions, but the fundamental question is about preserving and expanding access to care for all who need it, not just those who can afford it.
Expanding for-profit out-of-pocket care erodes that access. The evidence for this is overwhelming: properly-funded public care leads to better access and better outcomes than for-profit care.
Again from the CDM docs:
“the debate around private spending has been settled legally. The B.C. Supreme Court found in an 880 page ruling that more privately paid care would result in more waiting and worse care.
The decision was so comprehensive that after losing a second time at the B.C. Court of Appeal, the Supreme Court of Canada declined to entertain the case.”
The tendency to present both sides of an argument as equally valid is common and natural. Once a reasonable level of consensus has been reached, however, arguing the basics over and over again is counterproductive. Timothy Caulfield, in this recent Healthy Debate article Is Bothesidesism Killing Us?, points to the dangers of false balance. We should constantly be debating how to do things better, but we should be building on established facts and scientific consensus to further our knowledge. Returning to COVID, people continued to debate in the media on whether to use Ivermectin long after studies had shown it didn’t work. There is more research to be done on therapeutics, more debate on ideal treatment, but Ivermectin ain’t it. The same is true for the private-public debate: it’s time to move on from solutions that are “neat, plausible and wrong” and tackle the complexities of improving what we have. We need to ignore the arguments to make Medicare worse and do the work to make it better.
And that’s the main problem with getting stuck in the same old private-public debate. The very real frustrations with the health system have people wanting to see any kind of action. To stop talking about the problems and just do something. If the only options presented are between a failing status quo and more private care, people will choose the latter. But there’s no point in taking action that we know won’t work, that we know will only make things worse.
We need to ignore the arguments to make Medicare worse and do the work to make it better.
Fortunately, those aren’t the only options, and this is where the problem with the CMA’s framing comes in. The way you ask the question matters. Rather than focussing on the private-public debate, more fruitful conversations can be had about improving health care in Canada. Some of it requires more money, but a lot of the changes needed require better organization, national standards and accountability for the billions upon billions we’re already investing, and a willingness to scale up successful ideas from across this “country of perpetual pilot projects.”
“The CMA should focus on modern solutions to improve our health care system. Team-based primary care for everyone in Canada, universal pharmacare, single entry specialist referrals and improving work conditions are just a few evidenced-based policy reforms to help.”
There’s a growing chorus of prominent voices, like CMA past-President Alika Lafontaine and former federal Minister of Health, Jane Philpott, now Dean of Medicine at Queen’s University, calling for one of those solutions: a new model for primary health care that takes lessons from the way we organize public schools. Every kid has a school, why can’t every person have a primary care provider? Instead of rosters for particular docs, primary health teams should cover geographic areas so that everyone has access to timely, quality health care.
There are loads of good ways to make Medicare better. Arguing over whether or not to make it worse through further privatization distracts us from these more important efforts.
However, while the framing may fall short, I don’t despair about the CMA town halls. Medicine has come a long way since the turn of the century. The loudest voices have changed. Leaders like Alika Lafontaine or current CMA President Kathleen Ross don’t share Brian Day’s vision of health care. They don’t want to see more out-of-pocket payment for essential health services. And, if the response to the debates at the recent CMA Health Summit is any indication, neither do most doctors across the country. I’m hopeful that the message from these town halls will be, just as it was with the Romanow Commission, that all Canadians - docs included - value the principles of Medicare and are ready to do the work to fulfill that promise.
A reminder that book events are coming up for A Healthy Future.
In Saskatoon, I’ll be joined by Life of Pi author Yann Martel on Sept. 20th at Le Relais.
In Regina, city councillor Andrew Stevens will join me at 1:30 on Sept. 30th at Tuppenny Coffee and Books (1433 Hamilton Street).
More details on upcoming events in Toronto (Sept. 26) and Ottawa (Sept. 27) in the next instalment of A Larger Scale.