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.
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- 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.
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- Fix health-care governance
As The Hub published 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.
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- 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.
Merry Christmas!
All quite true but it falls on deaf ears. There is an inherent conflict of interest when the payer and the provider are the same. It is an unreconcilable conflict as the resolution would involve political courage, an oxymoron. Just as the Ford government fiddled while the “freedom convoy” held Ottawa to siege, they will still do nothing until forced. The only force that could do it is a general strike by healthcare workers and that is held in check by the college’s belief that striking is forbidden. When educational workers are legislated not to strike and win court injunction against unconstitutional bargaining tactics , our representatives cower in fear of retribution for taking the government to court.
Hey Ernest,
All valid points. We’ve welded politics and patient care together. We can’t change care unless it promises to improve political support.
Notwithstanding your comments, I think we can still suggest things for politicians to do and say. It will prepare the soil for when real change can happen. (Irrational optimism perhaps)
Hey, great to hear from you. I hope you are well!
Thanks so much for posting.
Cheers
Unlimited “free” first dollar health care for all “medically necessary” health care for every person is impossible. Any attempt by Canadian politicians to say otherwise can be deadly to their political aspirations. There are no perfect solutions. Any attempt by politicans to improve the current situation in health care is met with derision; for example, Ford’s plan to free up some beds in hospitals during the current shortage has been met with derision.
Laying low for someone who is leading in the polls makes sense. The slings and arrows being thrown by Ivison’s article are the price Poilievre is paying is the lesser of bad strategic choices.
Shawn, Merry Christmas, Happy Holidays and a Happy and Healthy New Year to you and all you hold dear.
Great points, Gerry.
It frustrates me hearing journalists demand a plan from politicians who eschew central planning.
We have to separate politics and patient care. This will require politics, unfortunately.
Hey, Merry Christmas, Happy Hanukkah, and best wishes for whatever other holiday you might be celebrating!
Thanks so much for posting a comment — excellent as always.
Are Sweden, France, Germany, or Norway having these same endlessly vexing questions?
Covering everything healthcare for everyone in Canada via Ottawa to each provincial capital doesn’t work. So why therefore, do we continue to reverse ever so slightly and plow forward into this wall again and again?
Rick
What a fantastic word picture: “we continue to reverse ever so slightly and plow forward into this wall again and again”
I’ve been wrestling with my next book about how to ‘fix’ healthcare for several years now. Medicare is a social construct. It’s more like an unwritten constitution, than a system. There’s much we can say about management and organizations, but the issue is political-social-philosophical.
Thanks for posting a comment!
I guess my point is others (nations) seem to have a better functioning system than ours where care seems to be provided to all efficiently enough. And yet we are inextricably addicted this notion of free everything for everyone (now teeth). A paradigm shift is required – clearly this “no man left behind” isn’t cutting it. The life threatening things get attended to promptly however everything else has a lengthy queue. Other nations have varying personal health insurance and national health insurance systems combined for overall healthcare.
Well said. Agree entirely.
Other countries do not tie their national identity to healthcare. They see it as a practical issue of patient care, not a grand vision of national values. Roy Romanow has called it, “a defining aspect of our citizenship,” and a “great, redistributive program.”
The Charter of Rights and Freedoms, the Canada Health Act, and the replacement of parliament in favour of rule by judges has made medicare an essential leg in the three-legged stool of a modern (liberalistic) Canada. Medicare has been twisted together with liberalism. Change in the first is understood as abandoning the second. It is irrational, but that seems to be the way much of Canada sees it.
So, our task is much larger than adopting new policies, changing legislation, or seeking excellence in management. To date, we have only been allowed to propose ideas which align with the fundamental principles of a lopsided liberalism tilted towards meliorism and sentimentality.
Tilting it back seems futile. Better to let it fall onto its pillow of misguided empathy, mediocrity, and dysfunction.
There is a better way. It is hard. It will require work. But providing great patient care to all patients need not feel so impossible.
Hey, thanks again for posting, Rick. Have a Merry Christmas, Happy Holiday (whatever you celebrate), and a great New Year!
Cheers
Not “liberal”Shawn, but “Liberal”.
Ha! — I agree … was trying to be too nice (as usual).
To be clear, liberal just means free.
Liberalism is something else, so too the Liberal Party. I’ve been using liberalistic lately to distinguish those who are animated by liberalism. Calling liberalistic people ‘liberals’ seems generous to the point of dishonesty.