My last little fulmination was directed at fixing our health care systems in Canada. After all was said and done, I suppose I made only three significant points. The first was that Health Care needs fixing. The second was that it is the responsibility of the Provincial governments to fix it, and they should stop whining about the feds and get on and fix it. The third point was that the Federal Government is more interested in demonstrating that they are the top dogs than they are in fixing the system. 

So, if we need to re-vision the health care system in Canada, what should a revised system look like? There are, of course, multiple health care systems in Canada, one for each province and territory. But for now, let’s talk about them collectively as a big-picture single system.

We, in North America, seem to be suffering from polar opposite forms of paranoia. The Americans are fighting off public health care. It’s not the Amaarrrican way. It’s a threat to their personal freedoms, and every individual has the right, and the need, to buy whatever health care they’d like or can afford. The fact that an awful lot of people can’t afford good health care doesn’t seem to bother the fat cats pushing for the abolition of medicare, Medicaid and Obama-care. 

In Canada, by contrast, we are adamant the health care must, absolutely must, look the same for everyone. We’re not going to let some rich bastard have better health care than anyone else, no sir. 

How are those polarized views serving us? Not well at all, in either country. I found several reports ranking the best health care systems in the world. Criteria and data sources are different for various rankings, so we’re sometimes comparing apples to oranges. In a very wide survey of world countries, CEO World Magazine ranked Canada 23^rd and the US 30^th. In another comparison, this time of just 12 affluent nations, Canada ranked 11^th, beating out only the US.  An insurance company (seeking to rationalize out of country insurance schemes) ranked the top ten best health care systems. Neither Canada nor the US made the grade.

There is no real consensus winner, but there is a pretty strong consensus that Canada doesn’t belong anywhere in the first tier. Across the ratings I’ve seen, the following countries appear to consistently seen as strong performers: 

France, South Korea, Austria, Australia, United Kingdom, Netherlands, Norway, Denmark, Germany, and Switzerland.

Having decided that these ten nations represent a group of strong performers in the health care field, I looked for descriptions of how their health care systems work. They seem to have the following things in common:

• Most costs are paid by general taxes and/or health care specific payroll taxes.
• Across that group of countries, co-payment obligations cover 10% – 15% of costs.
• Although co-payments are expected, co-payment caps or “safety nets” for the chronically ill are common.
• Often health insurance is mandatory. It may be available from a government insurer, but often is bought from private insurers. 
• In many of these top countries, private insurance is used to buy coverage for co-payment fees, but also for better choice of specialists and/or faster access to some services.
• In many of these countries, service is provided by a combination of public and private hospital facilities.

Recently Ontario Premier Doug Ford has advised that Ontario will begin investing in private medical facilities. They plan to invest in both for-profit and not-for-profit facilities with the intention to enable some 14000 additional cataract surgeries per year. They plan to invest in existing facilities to speed up MRI and CT scan diagnostic testing facilities. And they intend, in the future, to licence private facilities to perform hip and knee replacement surgeries.

Those announcements were, predictably, greeted with a chorus of hisses and boos. The Ontario NDP leader Marit Stiles objected to the potential migration of health care workers from the public to the private sector facilities saying “We’ve seen enough of a drain of health-care workers here in Windsor into the U.S. We cannot afford to lose more of those (workers). “ The NDP went on to demonize Doug Ford as a scheming private sector capitalist “He has spent years starving our health care system of resources, demoralizing health care workers with his wage-capping Bill 124 and leaving Ontarians desperate for care and frustrated by his games.”

Federal NDP leader Jagmeet Singh hopped on board the same bus, saying “While negotiating funding with the provinces, we all agree there should be strings attached. I think one of those conditions has to be no privatization. No for-profit corporations taking over health care. No billing patients for anything. No cannibalizing hospitals, sending their nurses and doctors to for-profit clinics.”

The Ontario College of Physicians and Unions condemned the plan as well, citing the same issue – that staffing for-profit specialist private clinics would stress the staffing of the existing public hospitals at a time when staffing is already a crisis issue.

That’s true, isn’t it? Staffing is already a crisis issue, right? Well, perhaps, but not for the reasons you might think. An article in the Economist on January 15^th reported “In almost every rich country more people are working in health care than ever before. Total employment in hospitals in 2021 was 9% higher than in the year before the pandemic in the six OECD countries we surveyed. The latest data suggest that in Canada 1.6m people now work in health care, the most ever.” The Economist postulates that productivity has fallen sharply as indicated by sharp increase in medical procedure wait times. It suggests three main contributors to the productivity issue. The first is that Covid protocols inside the hospitals are slowing everything down. Preventing in-facility Covid spread is preventing our health care workers from doing their jobs efficiently. Second, it has been a brutally hard three years. The Economist suggests that burnt out workers “may do fewer of the things that kept the show on the road, such as staying late to make sure the patients’ register is in order or helping with the treatment of another medic’s patient.” Third, the Economist suggests that “the true explanation for the breakdown lies elsewhere: in exploding demand. 

Coming out of lockdowns, people seem to require more help than ever before. Some of this is to do with immunity. People went two years without being exposed to bugs. Since then, endemic pathogens such as respiratory syncytial virus have bloomed. Everyone you know has the flu. 

But the pandemic also bottled up other conditions, which are only now being diagnosed.”

For close to three years, we’ve done fewer diagnostics, seen fewer patients and addressed fewer conditions before they got serious. So, there’s a backlog, and we’re not working quickly through the backlog because workers are tired and they’re hampered by the ongoing pandemic protocols.

By the way, the Economist article also made this statement: “In the OECD club of mostly rich countries, health expenditure is now not far short of 10% of GDP, having been below 9% before the pandemic… Thus, the immediate problems facing health-care systems are not caused by a lack of cash.” So, hearkening back to the premiers’ claims that they cannot do anything without more money – what’s really holding you back? On January 20^th, the breaking news was that the feds are close to reaching a deal with the premiers on improved funding. That will be welcome, but the truth is that it will solve nothing without an honest and open-minded appraisal of how to modernize the system.

Let’s go back to Doug Ford’s proposals and the reactions to them. I’m not a huge fan of Mr. Ford. To be honest, I think he’s something of a bumbling idiot. His best attribute might be that he takes good advice from those around him. I rather expect that this program is Sylvia Jones’ program more than Doug Ford’s. But I have no evidence for that, other than my low regard for the premier.

Ford announces “we are going to invest in some private care clinics” and the opposition screams “you can’t do that. You’ll create a staffing crisis”. But, we’re already in a staffing crisis. So let’s solve the staffing problem. 

If Covid protocols are handcuffing hospital staff, are we holding onto those Covid protocols too long? Our World in Data estimates that globally “excess deaths” from all causes has been two to four times the confirmed Covid deaths. In Canada, we’ve done fairly well – the two data points are almost even. We’ve lost about 50000 people to Covid and an estimated 43000 to other causes over an above the estimated expected death rate. Perhaps if the really virulent phase of Covid is past us, we should loosen up our protocols and worry a bit more about those excess deaths. 

If you google “doctor shortage” you will come up with a ton of articles, most of which deal with the shortage of generalists – family physicians. And those articles address two shortages. The first is the shortage of family physicians generally, and the second is the even worse shortage of family physicians in rural areas. I live in Ontario so I paid particular attention to those articles that dealt with Ontario.

What I found out is that people within the medical community have solutions for the staffing problems. Solutions include:

• Improving the processes for recognizing and accepting qualifications from other jurisdictions, both foreign and inter-provincial.
• Increasing enrollments in medical schools
• Supporting and enhancing the development of team-based medicine. Team based clinics provide a family physician who remains your family doctor, but provides easy access to a number of specialists.
• Enabling some physicians to work part-time, especially in rural areas, where doctors who value their work-life balance might be tempted to practice.
• Improving virtual access to specialists for rural area emergency facilities.
• Providing financial incentives for trainee doctors (residents) to take on rotations in rural areas. 

I’m not going to spend a lot of time resolving staffing issues. The point is that people in the medical community have ideas on what needs to be done to improve staffing. Governments simply need to get behind those strategies. Saying that we’re frozen in the current inadequate model for provision of medical care because we’re scared that changing the model will expose staffing shortages is just bull-shit. Solutions exist. Fix the problem.

Some of the staffing ideas are about paying people what they’re worth. Ok, let’s bite the bullet on that one. It’s the law of supply and demand, isn’t it? If people are leaving the medical field to work as Walmart greeters or school administrators, or real estate agents because the work is hard and they’re not being adequately compensated, then maybe we really do need to pay them more.

I want to address the hysteria about privatization prompted by Doug Ford’s announcements last week. Here’s a shocker for you. Some of the best and most reputable medical facilities in Canada are private clinics or hospitals. Here in Ontario, if you have a hernia, you really want to have it repaired at the Shouldice Clinic. It performs about 7000 hernia surgeries in a year. A CBC article on the Shouldice Hospital said “its surgeons repair more hernias in a year than most others do over a lifetime.” The Shouldice clinic “claims that its model allows it to perform at a lower cost per case than public hospitals and that wait times are a fraction of those in the public system.” 

Opponents argue that the Shouldice efficiencies brought about by single-issue focus and specialization can as readily be achieved by a public facility. Sure – we should advocate for the creation of centres of excellence within the public system. But that doesn’t imply that we have to choose between public or private. We could allow specialization to grow in both public and private spheres.

I’ve never heard an Ontario patient complain that they had to pay an extra fee for private or semi-private accommodation at the Shouldice Clinic. Nor have I heard them complain that they had to stay three nights instead of being booted out after day surgery. Instead there is a level of pride in Ontario about having an internationally recognized center of excellence available to us.

The Shouldice Clinic isn’t the only for-profit center inside the Ontario Health system. There’s a business called Dynamic Medical Center with facilities in St Catharine’s, Toronto, and Brampton which specializes in colonoscopies, gastroscopies and hemorrhoid procedures. Dynamic Medical says that they accommodate most referrals within 2 to 3 weeks, and all of their fees are covered by OHIP. But, gasp!…they make a profit! There’s gotta be something wrong with that! No, there’s nothing inherently wrong with private facilities. That’s just a useful sound bite for politicians who are willing and ready to polarize the discussion in order to harvest votes rather than looking to adopt best practices from around the world.

That brings me to the other part of Canada’s particular paranoia about ensuring that no-one gets better medical care than me. We will not tolerate extra billing. It’s built into the Canada Health Act, and the Federal Government spends a great deal of energy beating their chest and proclaiming that they’re standing up for us when they make life difficult for provincial governments who have some extra billing outlaws inside their borders.

Here’s my view about extra billing. There is a level of universal medical care that we, the citizens of Canada, can afford. For example, that could be MRI examinations available within target times. In Ontario, you should get an MRI immediately for emergency care (priority 1), or within 2 days, 10 days or 28 days for priorities 2, 3, and 4. Currently, in Grey-Bruce, only 30% of patients get their imaging done inside the target times, and the wait for low priority patients isn’t 28 days, it’s 96 days on average. We could apply more resources to the system, until we were able to get imaging back within target. We could apply even more resources until we could get imaging for even the lowest priority patients within ten days, or five days,  but that would take a lot of money. It would increase our taxes and it would cause inefficiencies within the system as extra capacity sometimes went un-used. So, there’s a practical level that we want to achieve that’s generally good for all of us and doesn’t needlessly add to our tax burden. 

Let’s say that the bureaucracy has it right, and the current target times are about right. What does that represent? Does it represent the ideal medical system? No, it’s really the minimum that we should expect from our system. Now, is there some reason to hold everyone to the minimum available? If some guy with lots of cash really wants his imaging within a week and not 28 days, and is willing to pay for that service, why should he not be able to buy that service?

There are two ways he could buy that service. He could obtain a credit for the publicly funded service and then pay an extra premium to get it faster, or he could pay the whole shot himself. Either way, though, he would be willing and able to afford something better than the publicly funded minimum service. Why is that wrong?

I currently drive an eleven-year old car. Some of my friends are driving brand new Cadillacs and Porsches. I look at those cars and think, “yeah, I would like that. That must be nice.” But, I assure you, I never look at my neighbour’s car and say “That’s wrong. They shouldn’t be allowed to have a better car than mine.” So why would health care be different? If someone can afford more than the standard care and is willing to pay for it, why should they be denied that service?

Well, the answer to that, in the minds of some of those polarizing politicians, is that the provision of a higher level of care to 10% of the population will reduce the level of care available to the 90% who aren’t able or willing to get more than the standard care. That’s a legitimate concern, but is based on a shaky premise. That shaky premise is that there is a fixed level of total health care available, and that isn’t or shouldn’t be true. This goes back to the staffing issues that I discussed earlier. There are good ideas out there about how to address staffing problems. So let’s do that, and let’s add enough staffing in the system to execute the full level of service we expect from our public system, and then let’s add the additional staff required to staff private facilities and for-profit extra-billing facilities that offer a top-end service.

According to that Economist data about medical spending in OECD countries, Canada is currently spending something close to 10% of GDP on medical care.  If we bring in private clinics and extra billing, and 10% of the people in the country decide to spend about 10% of their tax burden on medical care, it would likely increase our medical care budget to approximately 11% of GDP, and the country as a whole would have better medical care than before. In short, if higher end medical care actually unloads the system a little without stealing resources from the public system, we’d all be better off.

Now that’s a big if. There is admittedly a risk that higher salaries offered by a for-profit business might draw critical resources from the public system. But we need to go boldly forward. What we’re doing now is providing MRI examinations that take 3 or 4 times as long as we should expect. So, this isn’t working. I’d like to remind you about some of the elements of the best systems in the world. Co-pay systems with safety nets for the poor are common. Public and private facility mix is common. Public and private health insurance schemes that provide better choice of surgeons or faster services are common.

Look, let’s get over the paranoia about somebody else getting a better service than you. The world is not designed to deliver equal outcomes to everyone – in any field of endeavour that you can think of. Let us adopt an open-minded attitude and go out and really examine health care systems in other countries, and bring back the best practices that will allow us to rapidly improve our medical care systems.

I would like to see:

• Financing for a comprehensive staffing improvement initiative for Canada.
• Integration of systems across the country to improve flexibility in professionals moving from one province to another.
• A visioning of a public/private health care mix that adopts methods accepted in those countries that are deemed to have the best health care.
• A total re-work of the Canada Health Act so that the federal Department of Health is more focused on delivering health care and less focused on the dreadful evil of extra billing.

I’d be interested in your views.