Category: Politics

Good Monopolies – Medicare?

googles-utopian-vision-quest-benevolent-tech-monopoly-of-the-future12Good monopolies escape competition. A service monopoly often implies a greedy, exploitative weed that thrives off a niche habitat of bureaucratic rot and legislative fertilizer.

Peter Thiel wrote about good monopolies in the Wall Street Journal. He uses Google as an example. Despite protests insisting that Google has real competition, it actually owns its market space. And we love it, because Google treats us well. Google knows that great service is the best way to own the whole market. (see also Google’s Utopian Quest)

Nationalization

Canadian Medicare enjoys a monopoly only if it offers reasonably good service most of the time. Escalating wait times and arbitrary cuts to doctors and nurses undermine the Medicare monopoly and tarnish the whole franchise of parliament.

Nationalization evangelists argue that many industries show ideal conditions for natural monopolies. Take the military. It seems logical to have one army; same thing with the courts.

Looking to other services, large swaths of uninhabited Canadian countryside make basics like travel and telephone a challenge. But people need these basic services. We ought to provide them in the name of compassion, of Canadian values.

Apologists pause at this point in their sermon.

With right hand on chest, they remind us of our success when we all laboured together under the war measures act. They leverage our patriotism and national pride as reasons to support nationalized monopolies in education, health, transportation, hydro, phone and every other service they can imagine.

Queue a few bars of John Lennon:

Natural Monopolies

Forty years ago, Medicare fit the natural monopoly narrative. Widely separated communities defied even the most ardent laissez faire capitalists to come up with a true market.  It’s pretty tough to have meaningful healthcare or educational choice in Atikokan.

Canada looks different since Tommy Douglas first sermonized about Medicare.  Our population is larger (18 million in 1960 vs. 35 million today) and older (average age mid-20s in 1960s vs. 41 yrs old today). We travel more, and do so more easily. The number of Canadians exploited by niche monopolies based on geographic isolation has decreased dramatically. Retailers cannot gouge customers in Shebandowan like they used to. Everyone has eBay.

Same Motivation, Different Reasons

The arguments supporting nationalized services thin and fade with improved technology and population growth. Canadians do not need a national airline anymore. Privatized ones offer better service and quality for a fraction of the cost. We do not need nationalized telephone service or nationalized railways today.

No nationalized telephone service in the 1970s meant Nipigon went without telephone. Now Nipigon has cell phone service as does Marathon, Terrace Bay and all the other communities over the North Shore.

NOTE: Just because nationalized telephone outlived its usefulness does not mean we can do away with government. We need politicians and bureaucrats to do the work that only they can do. We just don’t need them to run telephone or airline companies anymore.

Despite all that has changed, our motivation remains the same. Compassion dictated that we nationalize services in the 1950s. Compassion now dictates we improve Medicare by allowing competition to improve services just like we did with air travel, telephone and mail. Healthcare stands to improve with a bit of competition.

Is Medicare a good monopoly today?

photo credit: bussiness2community.com

Should Doctors Give Up?

churchill“We will never surrender” echoes as perhaps the most memorable line of Winston Churchill’s “We will fight them on the beaches” speech. It stirred England to fight off an invasion, largely alone.

“Never surrender” resonates with our deepest sense of morality. No one has ever promoted running away in battle as virtuous behaviour in any society.  Falling on one’s sword advises suicide before surrender.  Fans hate hockey teams that give up. We want players to fight to the end even when a goal spread guarantees the outcome. The BBC still runs articles about Japan not surrendering in WWII. 

Old Barns

On the other hand, only hobby farmers – romantic ruralists – rescue barns canted towards inevitable collapse. Real farmers, ones that have to make their living at it, let old barns fall or pay someone to tear them down. Rotten bovine cathedrals on crumbling foundations represent a nostalgic waste of time and money (based on personal experience). Systems crumble and fall.  Maybe those with enough time to bemoan their passing have too much time to spare?

Sometimes giving up is wise.

Part time

Doctors spend their lives caring for patients, not fighting government. Government has unfettered control over legislation and regulation. They push relentlessly to change and build a system after their own design while doctors work relentlessly caring for patients. Government makes it harder. Politicians don’t want to hear about real problems, like access and coordination of services, only about ideas that make them look good in time for re-election.

A few days ago, we learned of yet another $20 million health innovation evaluation fund.

Note: that’s politicians-as-doctors spending money to grow the size of government instead of loosening the reins to let doctors take care of patients.

A Dark Place

My mother used to repeat, “If you don’t have anything good to say, don’t say it.”

Maybe surrender is the best tactical move for doctors right now? Fighting government requires full time hours. No one has that kind of time, and those hired to do it don’t seem clear on what it is they should resist.

Doctors Give Up

Are we delusional to think doctors haven’t given up on government long ago?

Either way, perhaps we should let Wynne and Hoskins fly forward under the weight of their hubris? Instead of falling on our sword, maybe doctors should just step back and watch what happens? But standing there doing nothing has never been easy for MDs.

photo credit: metro.co.uk

Healthcare Uncertainty Threatens Entire System

DestroyerMoviegoers love watching actors gape in panic. Fear makes people freeze just before they flail in terror.

Ontario faces healthcare uncertainty of superhero proportions. People hate uncertainty in real life. With political unrest, people seek safety and avoid risk. They put projects on hold, limit new debt, and even put off personal milestones like getting married or pregnant.

Uncertainty freezes progress. It stifles innovation and undermines even basic system functions.

Healthcare Uncertainty

Predictions about the negative impact of Premier Wynne’s attack on doctors have already started to show up. Even where patients have not experienced change, they are starting to worry about it.

Patient uncertainty

In my new rural practice, patients often ask, “How long do you plan to stay?” They have seen many others leave. Will this doctor be able to survive and take care of us?

A colleague shared how his elderly parents worry about their rheumatologist retiring. They’ve seen him for years. Who will take care of them when he closes his practice? There’s no one else around.

Staff Uncertainty

At two separate offices I visited, staff asked a bit too hopefully, “Are you going to come and work with us?” They know their jobs depend on physicians having somewhere to work.

Landlord Uncertainty

An MPP called me in a panic, “Four doctors just left our building! That office has been there for 30 years. The pharmacy depends on them. My office is in a unit in the same mall. The landlord doesn’t know what to do. Any suggestions?“

Program Uncertainty

  • Palliative Care – 2 years of work at the provincial and national level have been virtually frozen. Yet patients desperately need palliative care.
  • The Medically Complex Patients project started important work for our most vulnerable patients. Where will money come from to continue with a fixed physicians’ services budget?
  • Over 3 million patients currently get enhanced care at Community Health Centres and Family Health Teams. Nearly 10 million patients do not. Will FHTs be expanded as promised? They cost 60% more per patient. Will FHTs be cancelled to save money? How can the government uphold the commitments they’ve already made?

Student Uncertainty

Despite waiting lists, cardiac and other surgeons went unemployed recently. That drove trainees into other fields leaving residency positions open in CV surgery. A heart surgeon told me that it’s already becoming hard to find new surgeons again. Even a few years of students avoiding his speciality has made recruitment worse and promises even longer wait-times for surgery.

New grads have to be extremely careful where they set up practice, if they happen to find a job in Ontario. Even in rural areas, the government could close the hospital like they did in Penatanguishene and promise to do in Midland next door.

Physician Uncertainty

A physician group west of Toronto signed a mortgage on a new building just before Wynne’s cuts.  Their current clinic was beyond repair. The cuts mean they probably cannot afford the mortgage. What now?

Doctors cannot hire new staff, renovate, purchase new equipment or sign new contracts. They’ve no idea how big the promised clawbacks will be.

Expert Advice

In uncertainty, we look to wise advisers. Fortunately, only a few say things like I heard from a couple doctors attending the Ontario Medical Association Council meeting this weekend:

“You get paid well. You should take the cut and be quiet.”

“We need to raise taxes to stimulate the economy.”

More sophisticated advisers say, “We need greater system accountability.” But they usually mean ‘physician’ accountability.

“In a system where government is the steward, governor, manager, regulator, funder, negotiator, evaluator, planner, distributor, executioner, paymaster, surveyor, policy-leader, procurement regulator, implementor, vendor…Maybe we need more government accountability?” (M. Lister)

Healthcare Uncertainty on Purpose?

Politicians are smart. Perhaps they want people to act out of fear? Maybe politicians need panic? Maybe they need it to get public support for increased taxes, or to inspire demands for federal health transfers, or to justify taking more control?

A small amount of uncertainty is a fact of life. We take a risk getting out of bed. But we need stability from which to take risks.

Wynne’s bureaucrats demanded fiscal predictability. They bet on cost certainty and sacrificed certainty for everyone else.

Their bond rating was sinking. They’d run out of room in their fiscal lifeboat. Wynne thought she had guaranteed safety by boldly kicking out new graduates to swim on their own. Instead she’s created massive healthcare uncertainty that’s only just starting to surface. Voters love panic at the movies; let’s see what they think of it in healthcare.