Why Medicare Survives Unchanged

When Lucy returned to England, her siblings teased her about Narnia. Even Edmund, who had been there himself, pretended she was nuts to save his own reputation.

An almost unsurpassable gulf yawns between those who work on the front lines of care and those who talk about it.

It feels like many of the talkers exist in a land far removed from the real world of patient care.

I have travelled across Ontario speaking with doctors, healthcare leaders and politicians, over the last few weeks.

What I hear disturbs me.

Three Elites

With a view of Parliament Hill in the background, a group of us listened to two members of government and one who works with government.

Speaker #1 complained that pouring money into healthcare hasn’t changed outcomes.

“This would never happen in the auto or aerospace sector.”

He said, we “…need to measure outcomes better…” against “…accepted standards…to enforce outcomes.” Governments should “pay for outcomes instead of pay for care.”

“We have got to dispel the myth about…the expertise of physicians. These are management decisions.”

“We’ve known for 20 or 25 years what needs to be done…The challenge is with the democratic process and how we get it done.”

Speaker #2, a lone voice, said that government wasted $70 million on a diabetes management system and $1 billion on e-health, in Ontario.

“People were afraid to offend people by saying that these decisions were not good decisions to begin with.”

“Politics and bureaucracy sometimes make the wrong decisions.”

Reviewing government, “We [often] found no evidence of how a decision was made. Someone just picked a number.”

“I see abdication of responsibility by government…no one wants to make the decision…”

Speaker #3 said he was “…surprised to hear the health system was fraught with problems. We need to be way more optimistic.”

“What a magnificent system we have!”

We spend “…too much time on blaming, shaming and ‘gotcha’ public policy.”

“If the healthcare process is broken, then the democratic process does not work.  Medicare is the single greatest outcome of the democratic process.”

“If the healthcare system is broken, and you all [the MDs in the audience] cause 70% of the spending, what does that say about our system and the public policy process?”

He dismissed studies that rank Canada near the bottom. “If you regress to the average, there will always be winners and losers.” Canada, “the great loser”, still provides good quality. “There’s really nothing there [in the studies].”

A Conference of the Committed

Several hundred miles West and 3 floors underground, I sat among 3000 eager participants. We celebrated trying harder. We cringed at painful stories.

We heard how uninformed doctors caused psychological pain. We learned that equity, as a social value, ranks higher than justice, liberty or peace.

The atmosphere pulsed, big and hip. The only thing stopping change is our failure to believe or care enough.

Moving stories.

Polished speakers.

It felt like a rally of the faithful, a gathering of the committed. We must do Good Things.

Our system struggles because we hold divisive ideas. We must try harder.

A Group of Elders

Back in Ottawa, just after dark, I watched as conversation turned from taxes to healthcare.

In one of the highest chambers in the land, someone asked me why doctors won’t figure out a way to provide care, despite cuts, like they’ve always done.

Patients always get care, eventually. Why should this time be any different? Are things really so bad?

One questioner dismissed any concerns doctors raise about taxes or cuts. Doctors should be compared with those who earn $30k per year.

Doctors should be quiet. He implied that anyone who works hard and does better than anyone else must be cheating somehow.

It did not strike him that funding for doctors is about patients, not doctors. It does not matter what doctors get. It only matters what patients get.

If giving less to doctors means less care for patients, then we must give doctors more.

But all he saw was classes and power and warfare and envy. Patient care mattered far less than rigid material equity.

I should have asked him what kind of doctor he wanted to see: One who gave up attractive careers to spend 15 years studying, or one who would be happy to work for $30k per year?

Medicare Survives for the Wrong Reasons

I used to think that politicians avoided change out of fear. They worried about touching the ‘third rail of Canadian politics’. I used to think that people who had the power to change things did not care; they could always travel south for surgery.

I might have been wrong. It is not maleficence. It is also not ignorance. Well meaning people know the studies.

Medicare survives unchanged because too many people hold a fixed, false belief that it does not need to change.

This is scarier than maleficence or ignorance. Fixed, false beliefs cannot change without walking through Lucy’s wardrobe. Without being unchained from Plato’s cave, no one realizes that the shadows on the wall are only shadows.

Those of us inside healthcare sound like Lucy, to those outside. We are silly, prone to exaggeration and, perhaps, even a bit fantastic.

A two-year wait for hip replacement? Come now, you can’t be serious.

Hard to find care for frail seniors, you say? How hard can it be?

After awhile, people tire of doctors’ fantastic stories. The stories start to irritate. Doctors become irritating.

We are 50 years into our Medicare experiment. Bernie Sanders parades on Medicare, this weekend in Toronto. He uses the Canadian icon as a pawn for his own political dreams.

Lucy eventually convinces her siblings to follow her through the fur coats into Narnia. They see for themselves. Lucy is vindicated, but only by those few.

Will doctors be vindicated or remain among the few who’ve been to Narnia?

Photo credit: buzzfeed.com

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16 Replies to “Why Medicare Survives Unchanged”

  1. Shawn, I’d implore you to read the first few chapters of The Affluent Society by John Kenneth Galbraith. Not because of the economics in the book…it was written for a specific time and no longer applies. Rather, the opening chapters discuss the popular term “conventional wisdom” i.e. the comfortable things People Know To Be True that are in fact quite the opposite.

    You’ve highlighted the conventional wisdom about Medicare in Canada: we have the greatest and most equitable health care in the world, (except for all the developed countries that aren’t the US), and any problems must be the fault of doctors, who drive up demand (by providing care), have too much power (except when the government strips it away unilaterally), and don’t deserve the pay they earn (in contrast to 9-4 public servants with benefits and pensions).

    Galbraith’s observation is that, “the enemy of the conventional wisdom is not ideas but the march of events.” Canadian Medicare is careening towards an utter disaster, because as you point out, waaaaaay too many people in power cannot be convinced there’s a problem.

    1. Thanks for this, Frank.

      Although Galbraith was a Canadian, and I love to use some of his quotes, I don’t agree with his economics so much. However, I will make a note to check out the chapters you mention, for sure. I love the ‘march of events’ comment….another quote to steal for sure.

      I feel like many people see docs in the same boat as “The End is Near” guys from a Far Side comic strip.

      Thanks again for reading and taking time to share a comment!

      Cheers

    1. Glad it made you smile, Paul. If you had been sitting through his full lecture, you might have not been smiling! We promised not to identify speakers, but we were allowed to repeat what was said in the conference.

      Great to hear from you!

      Cheers

  2. Thank you for sharing this information, unsettling though it is to read. False fixed beliefs can’t change without neuroleptics. Trying to convince one with delusions that their delusion is false is a losing game. We need to continue share our stories and our patients and communities need to speak up. System not working and we can no longer be silent. And I’m an optimist by nature!

    1. Thanks for sharing your optimistic thoughts, Nicole! 🙂

      I still think we can stay optimistic about solutions. But we cannot be positive about the current state without being dishonest. Senator Bernie Sanders’ tour of Canadian healthcare this weekend probably won’t include our hospital that gave up waiting for long term care beds and just converted the Auditorium into a ward after housing patients there for so long.

      This can be fixed. It requires government to give up some power to let innovation take place.

      We all support universal healthcare, but no one else in the world does like we do.

      Thanks for taking time to share a comment!

  3. Speaker #3 obviously lives in a glass bubble likely in a well serviced metropolitan area and donates to the natural governing party.
    Speaker #1 is clearly either a business person and likely voted for Trump
    Speaker #2 is obviously a frontline doctor .
    The conference of the committed sounds like a seminar designed to sell the latest self help craze.
    The Group of elders must be the senate and some socialist got their appointment for some public work or wrote a book .
    The reason our form of medicare seems incapable of change is that we as the supposed stewards of the system allowed things to deteriorate to this point. Stupid political decisions and spending programs got a free pass and validation from paid stooges from academia whose role was to be ‘valid’ yes-people because they completed medical school rather than worked the system on the front lines. Our organization, instead of fighting back took the accommodation route to maintain peace at the expense of our futures. We listen and tolerate the nonsensical views of people with no insight into the realities of healthcare, both economic and scientific. We allow those who are unaffected and not covered by our contracts to vote on ratification, diluting the will of those who have to live by them. The first step in creating change is to change ourselves and the way WE do things.

    1. Great guesses, Ernest! But look again, every speaker was paid by government (or speaking to their role in government).

      I hope that, once we are through negotiations, we can talk about real change leading up to the election. Even tiny changes would help. I know this is a dream…politicians would really rather not discuss healthcare, aside from spending. But we need to encourage a positive discussion that focuses on solutions. Will they take part?

      Thanks so much for commenting!

  4. Where #1 is concerned, typical of the know it all overconfident and comfortable elitists that characterize the upper strata of statist/ collectivist systems and of the tired out of touch, soon to vanish, conglomerates, that failed to recognise the writing on the wall ..their Soviet equivalents are still scratching their heads as to why , despite their brilliant central planning, and the deployment of experts and managers overseeing widgets their ideologically driven creations ended up with a collapse of the whole….their capitalist equivalents ( usually shirtsleeves to shirtsleeve ) wake up in the morning to find that an Amazon came out of seemingly nowhere and ate their lunch.

    #2 sees that the Emperor’s clothing is not as advertised, and likely recognizes the writing on the wall for what it is and would like to be proactive….#2 recognizes that there are far more attractive , better designed , more affordable clothing that could fit Canadians abroad…#2 also recognizes that one would be stoned if one pointed out to them.

    #3 continues to extol the beauty of the Emperor’s clothes, condemning all those who question their beauty, and refuses to recognize that there is anything of note written on any wall….and would happily stone #2 as a heretic.

    #1 and #3 are allied and condemn the anarchist # 2’s.

    The Canadian health care system will not voluntarily change because of inertia ; the Canadian public loves inertia where health care is concerned….and any politician who threatens to shift it a millimetre in a positive evidence based direction will be attacked.

    Change will come no matter what the Canadian central planners , the politico bureaucratic class and the general public have been indoctrinated to think….change is inevitable….the more it is resisted the greater will be fallout of its collapse.

    The inevitable collapse of the health care system will be a time of great peril for members of the medical profession, they have already been set up by the #1’s and #3’s to take on the role of scapegoat despite the fact that they are utterly impotent, working in a health care system not of their own, not of their conception, not of their design, not of their construction and never under their management.

    1. Andris, you demonstrate why readers love the comment section best!

      You make a number of interesting points. This one, especially, made me pause: “The inevitable collapse of the health care system will be a time of great peril for members of the medical profession…” Milton Friedman said that government always adds sweetener to encourage docs to support change. Once the change is in hand, government removes the sweeteners. Many doctors would sooner struggle through the difficulties of the present than envision a different future. Who can blame them? Change is hard. It’s easy to keep asking to prop up the status quo than to embrace real change.

      I worry that, if we do not embrace change now, the “inevitable collapse” will be much more painful than experimenting with change now.

      Thanks again for taking the time to write!

      Cheers

  5. It is nice to see you writing once again Shawn.
    You talk about change and how we can only begin to discuss change when we see what is wrong with the way things are. I worry whether we will even be able to step into Narnia as healthcare providers in the future, given the current way we are trained.
    Any political element in our educational institutions is primarily centered around propagating notions of equity and unbridled compassion, which is fine at the right dose but toxic at high doses when it starts to interfere with rationality, individuality, and liberty.
    Can we see the wrongs of our ways when we are convinced of our righteousness?

    1. Hey Shankar,

      Great to see you taking time to write here, too! 🙂

      Those in training can’t help but absorb some or all of the worldview of their teachers. Academia survives in a reality far removed from where most patients receive care. Keep asking hard questions on the inside…. 😉

      Thanks so much for sharing a comment!

      Talk soon,

  6. Thank you Shawn, another bright article on HC-reform you have posted lately.

    My vision on the matter is quite straightforward: no need to invent a bicycle, there are world-class independent analysts/professionals, who can make the assessment of our HC system & suggest the possible evidence-based solutions (just as well as they do it for many other nations), which can be agreed to implement: there can be a form of Binding Arbitration with public/electorate & the government, so whatever the experts recommend, must be implemented regardless of ideology & politics
    … and the Media should play a big part in communicating the reality to the people, preparing the ways for the changes & creating the nation-wide awareness that the changes are unavoidable, rather than pushing the stories & making fun of other nation’s problems and their leader.

    Also, the systemic problem with “speakers” or debates of this kind are:
    – they are not quite limited in time/duration, often very general & not to the point
    – the good talkers/native speakers get unfair advantage, regardless how shallow/unsubstantiated their messages are
    – they play on emotions and preach politics & values, little facts & figures, just “to win the moment/audience”- approach
    – the response to these talks often is being neglected & so no clear follow-up ( and as the result, “..no evidence of how a decision was made. Someone just picked a number” – #2)

    Same thing applies to board meetings, committees etc (the “Committed”- story): long-winding, time-consuming, big-mouths – over the big minds. Bureaucrats & politicians thrive on those, professionals get talked down & ridiculed.

    Not sure of this culture can be changed in the near future, thou something definitely needs to be done to ensure the productivity & responsiveness.

    1. Great comments, Alexey

      With all the talk of Canadian values, no one ever questions whether giving so much power to a large state is a Canadian value. Too many campaign on the agrarian value of communities helping each other. They ignore the fact that agrarians helped each other because the government was not there to help. Using agrarian, frontierist values to justify government running a whole industry is hardly fair.

      I worry that, as things get worse, the public will cry out for government to ‘fix’ the crisis it created. That always ends poorly for individuals.

      Thanks again for sharing such thoughtful comments!

      Cheers

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