Category: Single Payer Healthcare

Desperate Canadians criticized for considering health care outside Canada

Here’s my piece about the hypocrisy of politicians berating patients, who consider care out of country when they cannot access care in Canada. Published in National Post Mar 13, 2024. Enjoy!

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An Ipsos poll for Global News revealed last week that 42 per cent of Canadians would personally pay to travel to the United States for health care, if necessary. This is a 10 percentage point increase from 2023.

Federal Health Minister Mark Holland promptly scolded the 42 per cent.

“Going and paying your way out of your circumstances creates a terrible malady for our system. Because what it means is that private carriers will take the cases that are the most profitable ones, leaving the public system eviscerated,” Holland said at a media conference. “And that is a circumstance we cannot allow.”

Holland asked Canadians “to be patient.” He said we will “get through these health workforce issues.” It is not clear how “workforce issues” explain why 6.5 million Canadians cannot find a family physician.

Leaving aside Holland’s woolly thinking, his comments just seem heartless and cruel. Canadians do not seek care outside Canada on a lark. They’re desperate.

Canadians are underinsured. Canadian governments nationalized medical insurance companies between 1968-1972. With nowhere else to go, patients must moulder in queues with a median wait of 27.7 weeks to see a specialist.

Having nationalized private medical insurance companies and then put people into waiting lines, politicians berate the desperate few who step out of line and flee south for care.

Minister Holland echoes what elites have been saying for decades. In the 1990s, the associate deputy minister of health in B.C. was asked how she felt about patients on waiting lists looking for care in the U.S. She said, “If we could stop them at the border, we would.”

The hypocrisy becomes especially rank when we consider how many of our elected elites have been escaping Canada for care themselves for decades.

Robert Bourassa, then premier of Quebec, had melanoma surgery in Bethesda, Md., in 1993. Danny Williams, then premier of Newfoundland and Labrador, had heart surgery in Miami, Fla., in 2010.  Former Liberal member of Parliament, Belinda Stronach, had breast cancer surgery in California. The late Sen. Ed Lawson, former Canadian trade unionist, also had surgery in the U.S. Former prime minister Jean Chrétien used government aircraft to fly to the Mayo clinic.

The list of elite medical refugees who flee Canada is long and include many of the same people who refuse to change the medicare status quo.

Speaking on 900 CHML, Sean Simpson of Ipsos suggested Canadian interest in cross-border care simply reflected a “post-pandemic world” in which we began to see that medicare was “threadbare.”

But Canadians were fleeing Canada to find care long before the pandemic. In 2019, the Second Street think-tank used Statistics Canada data to determine that more than 217,500 Canadians had left the country for care in 2017. Hospitals in the U.S. advertise to Canadians, eager to meet growing Canadian demand. Patients can buy books to guide them on their quest for surgery abroad, for example: Medical Tourism – Surgery for Sale! How to Have Surgery Abroad Without It Costing Your Life.

But so what? Tasteless comments and elite hypocrisy make us angry, but if wait times are unavoidable, all we can do is stick together and weather the storm, right?

Wait times are not like natural disasters. They are not random. Wait times are created by professional managers.

Dr. Charles Wright, former vice-president at Vancouver General Hospital and wait-list consultant to the BC Ministry of health, said, “Administrators maintain waiting lists the way airlines overbook. As for urgent patients in pain, the public system will decide when their pain requires care. These are societal decisions. The individual is not able to decide rationally.”

Or as a former deputy minister of health of Ontario puts it, “We have waiting lists for some procedures as a means of better organizing our system.”

In other words, patients would not need to wait at all, if elites chose otherwise.

Minister Holland’s comments of last week betray a deep distrust of patients and their ability to make decisions for themselves. Patients should be patient. They should stand in line; wait for care. But as Canada’s foremost health economist, Bob Evans, has explained, the “rational consumer” is a “highly dubious assumption.”

Canada is changing. Last week’s Ipsos poll also found 63 per cent support for private health-care options. Most Canadians do not mind the Toronto-area Highway 407 toll road if it frees up space on the (public) Highway 401 without making it any worse.

Medicare must reform; the status quo is crumbling. While we wait for reform, let’s stop berating desperate patients, who consider leaving Canada for care when wait times grow too long.

 

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.

In July, The Macdonald-Laurier Institute published my report: Equity and efficiency vs. overconsumption and waste: The case for user fees in Canada. Check out the (shorter) press release here.

How can we protect a common good from overconsumption and waste? Everyone can access a common good. The more I use the less you get.

How can we deliver high-value care to those who need it most?

Should one person, who tries to protect medicare, and their identical twin, who abuses it, pay the same premiums (taxes) for medicare? Continue reading “User Fees Promote Equity and Efficiency — New Review Paper”

I wrote this for The HUB — loads of other great content there too.

Government, the medical profession, and public-sector unions are preventing improvements in our health care.

The Honorable Monique Begin (et al.) wrote in 2009, “When it comes to moving health care practices forward efficiently, Canada is a country of perpetual pilot projects.” Governments need “financial control” and remain “leery” of committing to programs. Pilot programs are easy to shut down “to avoid criticism” or if “budget priorities shift.”¹

At first glance, we might blame voters. Canadians rank health care as a top priority in most elections over the last several decades. Voters like Medicare; politicians are loath to change it. The last federal election stood out for (almost) hinging on a debate about health policy. As Sean Speer put it in August, “We are having a Section 92 election in a Section 91 moment.”² Most of the time, politicians from all parties work hard to avoid saying anything meaningful about health care—especially during an election—aside from pledging support for more of the same.

But we cannot blame health care stasis on politicians or the voters they need to woo. Medicare cannot change because it is locked in an iron triangle consisting of government, the medical profession, and public-sector unions.

Veto Power

The health care triangle is stronger than any party inside it; each party holds de facto veto power over major decisions. Each party seeks to improve its standing and power within the triangle relative to the other parties. When a government attempts change from inside the triangle, it can manage only minor tweaks or redesign. For example, regionalizing services, then centralizing them, then regionalizing again.

Veto guarantees that modern Medicare shares more similarities to its 1960s design than any evidence of meaningful innovation since then.

De facto veto power often gets constitutionalized into law. Consider two examples. In 2012, the Ontario Medical Association won a major battle with the government over labour dispute resolution and representation rights. The government agreed to abide by a binding resolution process with doctors. The government also granted the OMA exclusive “representation rights” agreeing to negotiate with the OMA and no one else. Or consider also that in 1991, the government gave the OMA power to collect dues from all Ontario doctors, whether or not doctors were members or even supportive of OMA policy. Ostensibly, The Ontario Medical Association Dues Act, 1991 empowered the OMA to fund its negotiations with the government, but the bulk of every OMA budget has funded issues unrelated to negotiations for decades.

This is not to pick on physicians; nor is it an attempt to reopen the debate about “rep rights”, arbitration, or dues. We could multiply examples of constitutionalized privilege for the regulatory colleges, universities, public-sector unions, and government itself.

The issue is constitutionalized privilege—the iron triangle between government, the medical profession, and public-sector unions. (Note: the medical profession includes medical associations, licencing bodies, and training programs, not individual doctors.)

Iron Lady Breaks Iron Triangle

In the early 1980s, Prime Minister Margaret Thatcher tackled a similar rigid coalition. John Gray, a political philosopher, described it as “the triangular relationship between government, business and the trade unions.”

Thatcher set to work smashing the relationship. However, she left the welfare state “comparatively intact… the political thrust of early Thatcherism was in the direction of the dismantlement of the corporatist policies of the 1960s and early 1970s.”³

Canada needs something similar: break the health care iron triangle while leaving the welfare state comparatively intact. The (once) friendly relationship between government, doctors, and unions has ossified and become hard, brittle, and inflexible: unable to manage stress or major change.

Institutions, like young trees, become weak and spindly shielded from the pressure and strain of social competition. Secure in the functional monopoly afforded by corporatist-style policy, institutions come to see themselves as existing to mitigate frictions between the other parties within the triangle instead of shaping the individuals inside the institutions themselves. As Yuval Levin, an American author, often says, “Institutions become performative instead of formative.”⁴

We have no shortage of ideas to improve health care quality and efficiency, such as funding reform, integration of health services, public-private partnerships, and so on. But these ideas do not even reach the level of tactics to implement change. They are the outcome we hope to see after change has been allowed to occur. We do not lack ideas; we lack strategic vision.

The pandemic exposed the lack of resilience in our health system and the desperate need for substantial growth. All parties in the iron triangle agree the system needs change. But the parties cannot agree to any solution which does not benefit their own weight and influence inside the arrangement.

Health care’s iron triangle rests on the concentration of power—a tripartite monopoly. The best way to undermine a monopoly is to invite new parties into the relationship. Break concentrations of power into multiple smaller units. It can be done: Thatcher found a way to do it in Britain. It starts by addressing the iron triangle as the root of resistance to change. If we do not, Canada will remain forever a “country of perpetual pilot projects.”