Category: Politics

Most rulers love popular advice, not honest criticism. Popular advice mixes two parts flattery plus one part suspicion plus 3 parts repeat-what-the-ruler-already-said using your own words. Great rulers despise it.

Medicare almost never has great rulers. Most politicians like to hear experts that congratulate accomplishments (flattery), question doctors’ motives (suspicion) and decorate party platforms with voice-overs from academics.

Doctors must learn to kowtow or get ignored by government. When clinics struggle to pay office staff, doctors must hold their nose, bite their tongues and offer popular advice. Doctors must kowtow to politicians to be included or face being left out of healthcare with left-overs.

Doctors Kowtow

Politicians and bureaucrats enjoy life when they don’t have to waste time engaging doctors. Whether it’s Health Links or Primary Care reform, government has a long resume of coming up with grand solutions, excluding doctors by design.

“You’d better be on the agenda or you’ll be on the menu!” Experts advise.

Do physicians compromise to get on the agenda? Do they avoid speaking out against inefficiency, waste or injustice?

Too often, doctors keep quiet to get included in a process. They reason it’s better to keep quiet about injustice than risk being thrown out of the inner circle.

Workers vs. Stakeholders

In successful businesses, workers speak up to improve operations. Employees risk their jobs if they keep quiet about waste or inefficiency. Companies must innovate or lose out to competitors who do.

In nationalized monopolies, workers speak up as citizens to improve their own lot and the interests of the stakeholders they represent. Stakeholders risk their lunch invitations to Queen’s Park if they speak out about waste or inefficiency. A nationalized monopoly does not need to innovate. It cannot lose.

Whine vs. Challenge?

At every level, Canadian healthcare encourages kowtowing and whining instead of rigorous challenge. Everyone tends to support the party line for fear of being left out of the political process. Ultra-sensitive to voter opinion, politicians would rather hear popular advice and keep their public image untarnished than hear rigorous challenge and risk re-election.

Now, more than ever before, Medicare needs doctors to be recklessly honest. Yes, reckless. Ontario’s doctors have nothing to lose right now, and patients have everything to gain. As things get worse for patients from Wynne’s cuts and underfunding, voters will lash out at government and doctors. They will demand to know why doctors didn’t speak up about mismanagement. They will despise doctors’ attempts to placate politicians.

If political rulers truly care about Medicare, they will welcome critique from outside groups. They will detest popular advice and flattery. They will refuse to listen when doctors kowtow, and doctors will refuse to try.

photo credit: economist.com

The strong steal from the weak: kings from nobles, Castro from Cubans, and Premier Wynne from Ontario’s doctors. English barons wrote the Magna Carta because King John acted like Premier Wynne, a law unto herself.

Magna Carta – “the greatest constitutional document of all times – the foundation of the freedom of the individual against the arbitrary authority of the despot”.

 In fairness, Wynne attacked because no law said she couldn’t. In fact, previous governments did the same thing in the 1990’s social contract years with clawbacks and caps that forced doctors to work for free.

A specialist asked me, “So government can cut us, we have no way to fight back and it’s illegal to bill outside of OHIP. Isn’t that Communism or something?“

Throughout history, governments have stolen power and property – usurped – from their citizens. Tyranny and usurpation still drive immigration. Most Canadians have relatives who fled political tyranny for freedom.

Canadian democracy stands on the rule of law. We answer to the law, not the capricious whims of monarchy or government. And where there is no law, Canadians behave by principles like honour your commitments, deal fairly and tell the truth.

Usurpation in Medicare

Medicare was once an insurance plan. Now it’s an example of government imposing itself on others. In the late 1960s, Medicare simply replaced a few large health insurance companies. Ostensibly, a national plan guaranteed coverage for all citizens and promised administrative savings.

In the glory days of Canadian Medicare, doctors worked and governments paid. But policy experts tickled political ears with whispers of a more robust social utopia, a full-blown, centrally controlled healthcare system.

Social designers had to wait for Medicare to become a national icon before they took control. By the 1980s politicians had what they needed and moved in. Doctors were pushed out and have been blamed for almost everything wrong in Medicare ever since.

How to Usurp and Get Away with It

Aside from a few historic exceptions, whenever doctors organize serious resistance, government pays them off. Docs always settle for less than they wanted; passion fades quickly. Myths about pendulums swinging or cycles of plenty and famine usually turn doctors back to their knitting. They hardly notice that fees are now only 50% of 1970 levels. Citizens tolerate usurpation in small slices over time.

Wynne got greedy and went for a big slice. Her plans cut over 20% from doctors’ net earning by 2017. Incomes have plummeted since 2012 such that by 2017 doctors will have lost 30% of their net in 2012 dollars. Wynne’s usurpation will fail.

Representation Rights

Doctors have had zero protection from usurpation by government for the last 45 years. They cannot strike. They cannot earn income practicing medicine outside OHIP.

For the first time in 4 decades of state healthcare, government acquiesced and promised in legislation to ‘negotiate’ before legislating fees. But even with representation rights, government ’negotiated’ for a whole year and then legislated what they had offered on day one of ‘negotiations’: a rigid cap on total spending for MD services.

How to Win Enemies

Many blame political oppression for terrorism. At the very least, tyranny and usurpation inflames hatred of government and its policies.

Medicare runs on doctors’ cooperation with government. Doctors will never riot or terrorize. But do politicians really believe that Medicare has any hope of survival when they treat physicians with disdain?

When government usurps too aggressively, it starts revolution. Wynne has created a small pack of doctors determined to revolutionize healthcare. Once committed to action, they will not distract easily.

Wynne gambled that doctors never fight back. But some do. I think she might have gambled wrong.

photo credit: magnacarta800th.com

Unions formed to fight bosses who demanded more work for less pay in unsafe conditions. Majority support allowed ruthless employers to dictate wages without negotiation. Labourers built unions to force entitled elites to listen, to back down.

Premier Wynne and Minister Hoskins swagger through parliament. They attack new physician graduates with impunity and slander established doctors without shame. Then they lie about it (see We Expect Honesty from Our Government). Many physicians cry out for a union to fight back.

Union versus Association

Unions bargain collectively. Union bosses fight every instance of oppression. But they also shield low performers, promote incompetence in the name of seniority and willingly kill their young to get higher wages for senior dues-payers. Unionists lust after bigger membership lists, more dues, more power.

Associations work to promote an industry and ideals supported by trade professionals. Associations acknowledge excellence and kick out members who underperform. Individual workers get help only if their case shows potential to harm other members; unique cases get ignored. Unions and associations usually share features; they overlap.

Ontario Medical Union

The government legislates all physicians to be dues paying members of the Ontario Medical Association. The Rand formula makes collective bargaining doable. Even libertarians have no appetite for negotiating separately with over 60 physician specialty groups.

Forced dues and collective bargaining feel like unionism. But government carries the clubs and demands collectivism.

Design

The OMA acts like a union in collective bargaining but was never designed to fight for individual physician rights. There’s no dispute resolution when collective bargaining fails, and no work grievance process. The government can cut as much as voters will allow during ‘negotiations’. And it can treat individual doctors however it likes in between. There are no union bosses around to help.

Over time, the OMA has increased representation for individual physicians and beefed up its legal department. It offers contract review and advice for individual compensation issues. However, it does not show up for every grievance in the way a union boss does for his members.

Even without a 25-30% cut to net income, MDs fume that politicians can mistreat doctors with no legal reprisal. It enrages doctors and fuels cries for unionism. But the current OMA does not have the legislative authority, constitutional structure or mandate to behave like a union. This frustrates physicians even more.

Medical Union = Demise of Medicare

A union of 27,000 physicians would crush Medicare. The Ontario physician services agreement is the largest labor contract in North America. If MDs were fully unionized with dispute resolution and job action, the economy could not produce enough taxes to support such a beast.

The only reason Medicare hobbles along is because politicians can deal unfairly with physicians when times get tough. They make unilateral cuts or massively curb access, like they did all through the 1990s and from 2012 – present.

Patients and physicians face uncertain and troubling times in Ontario. But crisis creates opportunity. Let’s hope physicians and patients get a meaningful voice in the change that follows. When money runs out, governments tend to increase control. Politicians could decide to become even more regressive – more totalitarian – in their management of nationalised industry.

Our toes grip the end of the healthcare diving board this spring. A splash will follow. Let’s hope it’s not a flop.

photo credit: theguardian.com