Health Care Reforms

Our health care system is collapsing before our eyes and clearly status quo not working. Yet any talk of reforms or more private involvement sees your usual suspects screaming US two tiered system. I believe this is unhelpful. I understand fear and anxiety but when something is not working, you need to make changes. And making changes understandably worries some. And maybe changes will make things worse. But I am always of view better to try and fail than not try at all. And if things don’t work, then you go back to drawing board and try something else. We should only settle for status quo once all alternatives have been tried and all end up being worse. In this blog, I divide into two sections which one is on role of private sector and what I support and why and what I don’t. Second is on other reforms that don’t involve more private involvement.

In much of Canada, universal health care is almost like a national religion. Unlike many other countries whose identities are tied to language, culture, and history; universal health care has probably become one of the most defining features of what it means to be Canadian. Living next door to US and being so similar in many ways is probably a big reason we look for something to separate us even though I would argue differences between our two countries bigger than many realize and threat of becoming American is overhyped. For private involvement, there are basically three possibilities: 1. Privately delivered but publicly funded 2. Parallel private system whereby public free for all but those who wish to pay privately can and 3. Outright privatization. First two I am okay with if done right, but key is must be done right. The third I am dead set against, but I think threat of it happening is close to zero and I believe many suggesting Tory premiers or a federal Conservative government would do this are doing so on fearmongering not reality.

Doug Ford has promised to allow more private clinics to treat backlog in surgeries while still ensuring funded by OHIP. Many are losing their minds over this despite here in BC with an NDP government that is already being done. Contrary to popular opinion, most of our health care is already privately delivered but publicly funded. Unlike UK, our doctors are not employees of state but are instead self employed or partnerships. It has always been this way and anyone actually familiar with medical system will be fine with this. As for private for profit clinics funded by public dime, I am agnostic here. They may work or they may not, but I think we should take an open mind and avoid private better or public better and instead look at each on its own merits. Even better, how about have two surgery centres; one a community based non-profit clinic and other a private for profit clinic both funded by provincial plan. We can observe in real time first hand which works better and then whichever delivers better outcome use for future clinics.

The second but more controversial is allowing patients to pay for publicly covered procedures in a separate parallel private system. Canada is only industrialized country that attempts to ban this yet we underperform most who allow it. I would be fine banning it if we had best health care system on earth, but we do not. I realize allowing such is not a panacea as even though other systems all have elements we ban either through provincial legislation or Canada Health Act. There are lots of possibilities and most still put rules in place to ensure private system doesn’t undermine public one and that public system remains dominant system. They just do so through softer rules to limit harmful impacts rather than the sledgehammer of banning outright. There are basically three things we disallow but I think we should be open to, which are duplicate private health insurance for covered procedures, dual practice of doctors working in both private and public systems, and user fees and/or co-payments for covered procedures. Each has risks and must be done right as if done wrong could make things worse.

Contrary to popular view, Canada doesn’t totally ban a parallel private system. Rather a combination of laws plus public opinion have meant that outside Quebec, we have not seen the emergence of one. Rules in Quebec similar to most other provinces but reason for developing there but not elsewhere is more politics. Rather less controversial in Quebec so doctors going private have less fear governments will change rules to stop practice while in other provinces much more controversial so even if legal; fear government will change rules to ban it is main reason doctors don’t bother. BC and Alberta interestingly enough do have a few opted out doctors, but numbers in both are in single digits while in Quebec around 400. Asides Ontario, in any province a doctor can go private, but they must leave public system completely. Likewise most but not all provinces, ban buying private health insurance for medically necessary services covered by public plan thus further dampening demand and in few where allowed; they are all small provinces with not a large enough market so no such policies are available anyways. However if a doctor opts out completely and one pays in cash, then it is technically legal. Reason not widespread is more fear will get banned if too many do it. In BC, we have seven such doctors, but all relatively small clinics and not widely known so unlikely to cause a political headache for government of day. If Brian Day at Cambie Surgery centre and all surgeons there opted out, I suspect public backlash would be strong enough, government would either outright ban practice or place a moratorium on future opt outs as Ontario did in 2003. Likewise Canada Health Act doesn’t even specifically ban duplicative private health insurance or dual practice. It only bans extra billing and user fees. But thanks to vagueness, a lot depends on government of the day and Liberals have shown they take a very broad interpretation of it and won’t hesitate to use it for things they dislike such as private diagnostic clinics. So provinces fearful of that have strict rules and even if federal government was okay with it, fear some future won’t be is reason provinces haven’t challenged this.

On private health insurance for covered services, Canada is virtually alone in industrialized world in largely banning this. Iceland doesn’t have it like Canada, but no law banning it, just not large enough population to make it profitable. Some like Germany force one to choose and ban being on both (its one or the other) while others like Netherlands and Switzerland primarily rely on private health insurance to fund system, but unlike in US must accept everyone and rates set by government not market so more a case of contracting out to private sector than a true private system. Japan and France use it mostly to cover user fees and co-payments rather than to pay for faster service and in fact Japan does ban duplicative health insurance too but unlike Canada it only covers part of cost not full and private to cover rest. France doesn’t, but almost all buy it to cover user fees and co-payments not for separate parallel private system. UK and Australia by contrast allow it and in case of UK unlike Canada, most who buy it do so for faster care, not to cover procedures public plan doesn’t. I believe such bans are unnecessary and should be lifted. I have no problem if government wishes to tax them, in fact maybe that might help health care whereby allow them, but tax them heavily and use revenue raised to help improve public health care. If UK is any indicator, it wouldn’t be mostly rich buying it, but mostly middle class working for large firms who would include it as part of company plans much like ours do for supplemental coverage. And as long as doctors going privately heavily regulated as I will discuss later I fail to see an issue. In fact position of Labour in UK is to tax them more not abolish them and I think that is correct approach. I however do not support going to Australian system that subsidizes it or penalizes those above certain income who choose not to purchase it. Likewise Irish system where those above certain income must rely on it solely is an option, but should be only done as last resort if we do not have financial means to cover everyone, not if there are other alternatives. Dutch and Swiss systems work well for most part, but too radical a change and we can achieve same thing with much less radical changes. German system I have no issue with and ironically in BC where I live you can opt out of MSP (although unless a complete idiot, no rationale person would) but not sure even if allowed many would opt for this. BC up until 80s actually had a multi payer system like Germany, yet the two private plans went bankrupt so everyone ended up on public plan eventually.

Next is dual practice whereby doctors work in both public and private systems. While Canada is not only country to ban this, we are one of the few. I believe dual practice should be allowed but with very strict restrictions. Doctors should only be allowed to spend surplus time in private system as that will reduce wait times for all. They should not be allowed to cut back time in public system to do more in private system, that needs to remain illegal as that will make wait times worse for those who cannot afford to go private. I went private for my shoulder surgery at Cambie Surgery Centre and paid for it. Doctor who operated on me only got 10 hours a week in public system so I think it is wrong he cannot spend additional time in private system. If govt wants to end this, give surgeons more OR time and problems stops.

Final is user fees and co-payments. Canada and UK are only two G7 countries that do not have them for primary care and likewise number of OECD countries without them is in single digits. I am okay with them to help fund system, but must exempt children, seniors, and low income individuals and only for non-emergency visits, not for hospital visits. Many say this will just keep poor away from system and fair point, but yet in the Eric Hoskins report on pharmacare, he called for a $5 dispensing fee for prescription drugs to deter overuse so why is that different? More importantly we have user fees in all provinces for using an ambulance and I would think user fees for ambulance rides is more detrimental than visiting a family doctor. Ironically in Japan, ambulance rides are free but doctor visits are not and that seems more logical than what we have. That being said I am okay if we don’t have them and if do they need to be very low ($10 maximum per visit and $100 maximum per year). Unfortunately such fees banned by Canada Health Act which is why I have long advocated eliminating it as I feel it stands as barrier to reform and fear that without it, it will mean end of universal health care is overblown. Any politician that wholly privatized health care would likely see party wiped off political map. Doing such thing is political suicide and no politician even if privately wants this (I don’t think even most on right want this) would do so as all politicians also want to win to meaning they can only go so far.

On the issue of full privatization, it is such a ridiculous idea that I don’t think even worth discussing. It is really just fearmongering parties on left push as a way to beat conservative parties. I understand living next door to US and fact we are so connected why some may fear it, but I believe the fear if you think about it rationally lacks merit. Its a lot like people who are afraid to fly due to worry about a plane crash. Many do have such fears and understandable emotionally, but when think about it rationally there is no reason for such fears. However for mixed systems and private elements I discussed above there are many arguments why bad idea and below I will say why I disagree with them and even though most have lots of merit.

Common arguments I have heard against private will be addressed below in point form.

1. Corporations have to make a profit so either costs more or leads to lower quality. This is a risk, but also can lead to more innovation as there is a reason private sector does most things better than public sector (not all but most) as need to meet consumer demands and be innovative to stay profitable. I think concerns here are true in some cases but not all and like most things in real world, real life doesn’t neatly follow any theories and tends to have both examples that favour different theories.
2. There are only so many doctors in system so if you allow private, the good doctors will leave meaning longer wait times for those who cannot afford to go private. There are two big problems for this. One this assumes absence of rules which would not be case. If doctors cut back time in public to go private this will happen. But if they work surplus hours in private it shortens wait times for everyone as those who go private leave the queue altogether so shorter for those still in public. Also except for really cheap procedures, most cannot afford to go private and if too many go private, they will end up going out of business. Simply speaking you make more money if you have a broad consumer base not narrow. Thus as much as people say market doesn’t work in health care, it does to some extent in that it isn’t profitable for too many to go private as simply not enough people willing to pay for it to be profitable for most doctors. Never mind wealthy tend to use health care less than poor making it less profitable as under fee for service system as doctors get paid by how many patients they see.
3. It is immoral as health care should be based on need not ability to pay. This is more a philosophical idea and I’ve believed governments should try to be pragmatic and avoid bringing ideology into decisions. I fully agree with idea it should be based on need not ability to pay. But like on any subject I believe there are trade offs and world is imperfect so this ideal you strive for but also accept reality that like most things in life you will probably fall a bit short as world is imperfect. Having equity in health care if it means substandard for everyone is not something we should aim for. Never mind our social safety net is built on providing a baseline no one falls below, not perfect equality. Whether it be pensions, social housing, education, we ensure available to all but we also don’t ban those who wish to go private from doing so.

Now as for benefits of allowing private, I see a few

1. Monopolies of any type almost never work. When there is an alternative that will put pressure on public system to do better as people will have an actual comparison
2. When we have surges such as Omicron last year or more recently RSV, surplus capacity is key. I believe during such surges governments should have right to temporarily take over private system as UK and Spain did during first covid wave. This can avoid triage and/or future lockdowns. A big reason last January much of Canada was in lockdown while rest of world was not as due to fear of system collapsing so private system can act as safety valve to deal with surges. Heck even in BC where NDP opposes such system, they still are using it heavily to deal with backlog in surgeries and without private clinics it would be even worse.
3. There is no right to pay for private health care but at same time I am of view governments should only ban things if they can show are harmful, not over philosophical reasons so for health care those wishing to ban parallel private system need to show it is harmful, not just they dislike it ideologically.
4. Funny thing is wealthy still get faster service anyways as they can just go to the US. So if going to get faster anyways, I believe much better if done in Canada as at least money stays in our economy. Never mind many nurse and doctor grads cannot find work in Canada so private may allow them to stay here thus contribute to our economy and pay taxes here rather than move abroad.

While I have discussed private involvement in detail as this is most controversial, I believe there are many reforms that should be far less controversial that don’t involve increasing private involvement. Canada has 11x per capita the number of health bureaucrats Germany has. I believe cutting those and using savings for frontline workers could save a lot. We need more university spaces as back in 80s medical associations lobbied for fewer spaces and we are now reaping impacts. We also need a quicker way to recognize foreign credentials and those that don’t quite meet Canadian standards should be allowed to upgrade their knowledge to meet it and begin practicing. Likewise more telehealth and centres of excellence can help. For waiting times, have a national database and allow people to fly to other provinces with government funding if there are openings. Establish a wait time guarantee which we were promised years ago and if not met, government will pay for it in another province, private clinic or even abroad at no cost to patient. Consider having it done by one level of government exclusively. I believe having it jointly handled is a massive mistake as leads to too much finger pointing and voters don’t know who to blame when things go wrong. If handled by one level, there is far more accountability. So either amend constitution to have federal government take over and this probably will cost less thanks to economies of scale. Or scrap Canada Health Act and CHT and offset by increasing equalization while cutting all federal taxes so provinces have room to raise by same amount. Most countries with universal health care have it handled by one level only. Likewise could even have federal one as an opt in so provinces that wish to keep it under jurisdiction can, but those who wish to transfer to federal can and I believe if federal worked better, all holdouts would follow eventually as public would demand it.