Doug Ford’s 3-step plan. Photo by Frank Gunn/The Canadian Press
If we could double the number of doctors in Canada, would papers print headlines about private, for-profit care? Would union leaders clutch their pearls and complain about the collapse of medicare?
Community physicians, although heavily regulated, still have the privilege of paying their own rent, heat, hydro, phone bills, and so on.
The Canadian Revenue Agency views most physicians as ‘independent contractors’ – that is, private businesses. (A few docs are salaried; many more wish they were.)
The End is Near
We have just come through a golden age (3 weeks) of peak public interest in medical politics and policy.
In mid-January, Premier Ford announced a 3-step plan to expand services outside hospitals. Patients will have increased access to publicly funded MRIs, CT scans, and minor procedures. By 2024, Ford hopes to see publicly funded hip and knee surgeries offered in non-hospital facilities.
The establishment had a fit.
I joined the enthusiasm (minus the fit) and have written furiously. Here are the results.
Ford Promises Private, For-Profit Care
The National Post published the first op ed. It feels newsy and light. It tries to put Ford’s announcement in context.
Note: headlines are designed to grab attention, not summarize content. Editors write better headlines than authors.
Finally, the Financial Post published an op ed about disrupting hospital funding. Ford’s plan could succeed where decades of attempts at activity-based funding has failed.
I have another op ed out soon on that-which-must-not-be-named in Canadian healthcare: profit and privatization. Canadians find discussion about profit off-putting, if not immoral.
However, medicare is not a volunteer effort. Everyone profits. The piece should cause some controversy (I hope) – really excited about it.
Please discuss Ford’s announcement with anyone interested. It seems more profoundly misunderstood than I realized.
Thanks so much! Looking forward to your comments.
PS. The original title was “The End is Near”. I thought people would see the joke in it. Some did not. So I changed it to a question – less humour, more clarity.
Here’s a short piece I wrote for The Hub. Be sure to check them out!
Conservative leaders seem loath to mention health care in equal measure to journalists’ delight in raising it. John Ivison, a columnist at the National Post, took a stab at federal Conservative leader Pierre Poilievre last week: “You simply can’t aspire to be prime minister of Canada today and claim that health care has nothing to do with you.”
Ivison has a point. Endless headlines about health care demand a political response: for example, overcrowding in children’s hospitals, federal-provincial funding battles, and emergency department closures, to name a few.
Some leaders love to dilate on health care. Last week, Jagmeet Singh, leader of the federal NDP, threatened to withdraw support for his confidence-and-supply agreement with the Liberals. Singh demanded that the (federal) Liberals detail solutions for (provincial) health-care problems.
Ivison’s demand for details and Singh’s confidence to deliver, “When I’m prime minister,” rest on a shared assumption, a shared vision of how government should address health care. They assume health care is a factory to fix, and Singh knows just how to fix it.
Faulty logic
Their approach contains three problems. First, health care is not a factory. It is one of the most complex sectors of our economy. One tweak by government—for example, introducing national licensure for physicians—could have vast, unforeseen effects.
Visions of economic dials, levers, pipes, and pulleys have delighted central planners for decades. They are deceitful dreams, a feverish mirage. As Robert Heilbroner, erstwhile defender of socialism, famously admitted: the centrally planned economy was “the tragic failure of the twentieth century.”
The first problem misunderstands the nature of what we hope to fix; the second problem assumes we are smart enough to fix it. But if Singh became prime minister, his unstoppable confidence would meet the immovable fact of Hayek’s Knowledge Problem. Friedrich Hayek, the Nobel-winning economist, argued that economies cannot be controlled because there is too much to know. Especially in a service industry such as health care, individual needs, wants, and preferences determine performance. These inputs are internal to the patients themselves and the clinicians trying to care for them.
The third problem is the least obvious but most lethal. It assumes a purchaser can fix the provision of a product or service. Government pays for health care, ergo, government can fix health care.
What is obvious nonsense for every other product or service—from coffee to construction—somehow seems reasonable for health care. Purchasers cannot fix provision. True, a purchaser can influence providers to change behaviour by demanding different products and services. But purchasers have no idea how to reorganize, retool, or redesign to deliver change itself.
A Christmas wish list
Just as Conservative leaders are loath to talk about health care, the rest of us should be loath to offer advice. Politicians know politics; outsiders do not.
Furthermore, Conservatives represent a vast coalition of ideas, especially on health care. Red Tories support welfare in general and Medicare in particular. Prairie populists, classical liberals, libertarians, and a dozen other flavours of Conservative form a salad of mixed feelings. It requires fancy stickhandling to get through all the policy preferences, not just the ones at “centre ice“.
So, take this wish list in the innocence and earnestness of a child at Christmas.
Show enthusiastic support for universal health insurance
Twenty-eight countries around the world have universal care. None of them have government monopolies like Canada. Universal just means everyone needs health insurance, in the same way that all cars on the road need to be insured.
Medicare started as state-funded medical insurance but morphed into managed care. In fact, some argue we should stop thinking about “medical insurance” as insurance at all. Do not let that happen. As long as Canadians remain comfortable and familiar with medical insurance we have a tiny sliver of room for change. If insurance becomes verboten, change will be much more difficult.
Fix health-care governance
As The Hubpublished in April, “Medicare cannot change because it is locked in an iron triangle consisting of government, the medical profession, and public-sector unions.” And in another Hub article, it makes no sense to talk about policy, until we have fixed governance.
Champion (local) innovation
Like politics, all care is local. Care plans must be allowed to evolve based on the needs of particular patients in specific communities. Bold visions and national plans tend to deliver one-size-fits-all services, the antithesis of patient-centred care. Only government can create a regulatory environment that fosters growth, innovation, and expansion of care at the local level.
The crucial element is to allow hypothesis testing to happen, not do it yourself. This means you need to find a way to let clinicians fail as they struggle to innovate towards better care. Easier said than (politically) done.
In summary, all I want for Christmas is for politicians to tell us what they believe about health care, tell us what they think is the biggest problem, and show us what only they can do. Again, this is a childlike Christmas wish. But given all the other advice out there this Christmas, perhaps this offers something new.
Knowledge grows faster than our capacity to learn. Our own knowledge shrinks as a sliver of the total available.
We risk becoming ignorant, provincial — ideological islands separated from all who disagree.
Look at any recent study. For example, on December 8 the Fraser Institute reported that Canadian patients now wait 27.4 weeks for treatment, the longest ever recorded.
What do you do with this information?
Accept it without question?
Try to digest the research?
Or ignore it, simply because Fraser published the piece?
The Fraser Institute does excellent research, but it challenges most of academia and much of the legacy media.
An Inevitable Age of Ignorance
R. Buckminster Fuller proposed the “Knowledge Doubling Curve” in 1982. He noted that in 1900 knowledge doubled every 100 years. By 1945, it doubled every 25 years, and by 1982, it doubled every 12-13 months.
IBM predicted knowledge would double every 12 hours by 2020. (Link for graph). ResearchGate reports there are over 7 million academic papers published each year.
Source: Learning Solutions (link in text)
The situation is no better for doctors.
In 2011, medical knowledge doubled every 3.5 years. Researchers predicted it would double every 73 days by 2020.
Pandemic publications prove the point. In the first 10 months of the pandemic, researchers published over 87,500 scientific papers, just about COVID-19.
Specialization
There is too much to know, but it does not scare us as it should. We take comfort in how much we seem to know, or we find ways to convince ourselves we know more than we do.
