Twenty eight countries have universal healthcare. Twenty two of them have some form of cost sharing.
User fees offer one example.
They work best as a small, flat fee paid at the point of service. Even a few dollars discourages (rational) people from booking for what they asked twice before.
User fees shorten the line for limited service. They free doctors and nurses to meet greater needs.
Some doctors rant about “skimming cream” and colleagues “stealing all the easy patients.”
Many shrug at creaming skimming. Sure, it exists at the margin, but it guarantees incompetence. Doctors need sick patients to stay sharp.
Either way if cream exists, then user fees are anti-cream.
Advocates for national pharmacare assume cost sharing must exist. Patients should share more of the cost of Viagra than Vancomycin (an antibiotic).
The same advocates often see first-dollar coverage (free meds) as outrageous for drugs but essential for doctors’ services.
Canada stands with a small group of six countries without any cost sharing in universal care. Canada stands alone in not allowing any access to medically necessary care outside the state.
NOTE: All countries with user fees have exemptions for the poor, sick, old, and very young.
Two New Reviews of User Fees
I spent several years pulling together a paper on user fees.
The first will fight for neighbours. If attacked, these citizens lay down life for family, community, and flag. Whether new citizens or old, these people think ancestors and descendants matter more than one’s own short life.
The second sees citizenship as a system of rights and privileges afforded by the state. Some may fight to protect such a system. But given external threat or possible collapse, these citizens would sooner run away to a system better suited to their needs.
The first sees Canada more like a giant, extended family. The second sees Canada more like a bureaucracy. The first feels a mutual bond with neighbours that transcends time and space. The second shares access to something owned by the state.
The first grieves at a politics of division. The second sees division as an inevitable outcome of atomized individuals served by big government. Canada is a bureaucracy: a gigantic soup kitchen. No ethos. No fabric. Just an efficient machine delivering tax-funded services.
The first citizens share ideas about what is good, true, and beautiful, starting with the country they share in common. A good country is not perfect, but it is worth defending. The second shares only the notion that Canada must change before it can be good.
Note: This has nothing to do with your country of origin or how long you’ve been in Canada. Each type of citizen can come from any kind of background: young, old, new Canadian, or old Canadian.
Happy Canada Day!
If you celebrate Canada Day, and I hope you do, know that you take a counter-cultural stand.
Celebration of nation — home, people, heritage — is an anachronism. Offensive to many. Out of touch at best. If this becomes majority opinion, you have no country, no nation.
In this sense, Prime Minister Trudeau thinks Canada ended long ago. The New York Times Magazine interviewed Trudeau in 2015.
“There is no core identity, no mainstream in Canada.” Canadians’ shared values make “us the first post-national state.”
What kind of citizens fill Canada today?
Are we more of the first kind, like the ones who fought world wars?
Or are we the second kind: citizens of Trudeau’s post-national state?
The End of the West
We stand at a crossroads in Western civilization.
COVID did not just show us how unprepared we were to face a pandemic. It showed us the state of our social fabric, our lack of institutional capacity, the fragmentation of what it means to be a citizen.
A nation has always been more than what politicians and pundits say it is. As we exit the pandemic, how we respond will show whether Canada still exists. Is Canada still alive, in the old sense of something we would die to save? Or is the old sense gone, and Canada is now something new?
A multidisciplinary team of doctors, residents and nurses meet at the Halifax Infirmary in Halifax on Friday, Feb. 25, 2022. Andrew Vaughan/The Canadian Press.
The Hub published my op ed. You can read it at TheHub.ca or below. Enjoy!
When it comes to fixing health care, governance matters more than policy
Without good governance, new policy will struggle with implementation like all the old policy.
Few voters had first-hand experience with hallway medicine or Canada’s world-famous wait times before the pandemic. Lockdowns changed everything. Health policy failure moved from fear-filled headlines into a tangible crisis everyone could feel.
Failure begs for better policy, or new policy to fill gaps. Planners and policy writers jump to offer solutions: surgicenters, funding reallocation, redesigned models of care, and so on.
New policy, however, cannot fix old policy, unless we know why the old failed in the first place. Most policy fails on implementation, not from bad design. Furthermore, we cannot fill policy gaps unless we understand why gaps exist. Gaps form around constraints and incentives, not from a lack of creativity. The policy environment dictates viable policy options.
How a system functions has more to do with how its governed than with the policy ideas in play. Implementation failure, constraints, and incentives all fall under the larger umbrella of governance. Governance and policy overlap, but they are different.
To fix health care, we need to start with governance: how do we make decisions? Who gets to make them? If we do not, a new policy will deliver the same old results.
Policy to the rescue
Take surgicenters as an example. Surgeons and specialists join together to build a non-hospital, outpatient surgical facility. Each centre offers a specific basket of specialty care, for example eye, orthopedic, or endoscopy services. Surgicenters can offer comfort, convenience, quality, and efficiency that hospitals struggle to match.
Surgicenters exist around the world. They are not new. In Canada, we have been trying to move care out of hospitals for decades. We want to save money and shorten waitlists. Why aren’t Canadian cities littered with surgicenters?
Current incentives and constraints make surgicenters impractical and onerous. Currently, hospitals supply nursing care, equipment, and use of the facility. Physicians use everything but do not pay for it, making non-hospital facilities a tough sell. On top of this, billing rules, regulation of independent health facilities, licensing for necessary lab and imaging services, as well a basket of other restrictions all weave together into a policy environment intolerant of (publicly funded) independent facilities.
We do not need a policy about surgicenters. We need research on why surgicenters do not exist in the first place and what to do about it.
Thomas Sowell, American economist and author, said once, “The most important decision about every decision is who gets to make the decision.”
Sowell expanded this in his book, Knowledge and Decisions: “The most fundamental question is not what decision to make but who is to make it—through what processes and under what incentives and constraints, and with what feedback mechanisms to correct the decision if it proves to be wrong.”1
Before making a change, every hospital administrator must ask, “Who needs to be in the room?” Spectacular new policy will fail in even more spectacular fashion if you ignore governance. Informal governance can matter even more. Decision makers are often not the ones listed on the organizational chart: colleagues influence through personality without title or position.
Governance eats policy for breakfast
Peter Drucker, the legendary management consultant, once said, “Culture eats strategy for breakfast.”2 We can say the same about health policy: governance eats policy for breakfast.
Dr. Dave Williams, a former astronaut and leader at NASA, served as CEO at Southlake Regional in Newmarket. He said, “It’s not clear who runs the hospital.” He was making an observation, not a complaint. “Compared to what I’m used to, it’s challenging to get things done.”
Without clarity and fidelity to best practices, governance will drift. Sowell, again, sums this up:
Even within democratic nations, the locus of decision making has drifted away from the individual, the family, and voluntary associations of various sorts, and toward government. And within government, it has moved away from elected officials subject to voter feedback, and toward more insulated governmental institutions, such as bureaucracies and the appointed judiciary.
Is this a problem in Canada? Brian Lee Crowley, managing director of the Macdonald-Laurier Institute, thinks so. Governance drift leads to central design—a temptation for all political parties.
In his book, Gardeners and Designers: Understanding the Great Fault Line in Canadian Politics, Crowley dilates on how gardeners approach governance.3 A gardener prepares the soil, removes waste, provides support, and tends to progress. Gardeners celebrate the surprise inherent in what grows and blooms. They do not manage growth for a specific policy outcome they designed in advance.
Designers dream about how to make health care better. Gardeners ask the more important question: how can we get good ideas to grow? A gardening approach to governance leaves plenty of essential (gardening) work for government. It empowers those closest to the problem and leaves design, experimentation, and implementation to them.
We cannot try to “fix” health care with new policy. Without good governance, new policy will struggle with implementation like all the old policy. We need to do first things first. Governance eats policy for breakfast.
Twenty eight countries have universal healthcare. Twenty two of them have some form of cost sharing.
