In case you missed my op ed. It’s available on the NP website also.
Albertans re-elected Danielle Smith’s United Conservative Party with a majority last week. Smith now offers a chance to change the way we think about health care — a radically conservative vision. What might that include?
Many conservatives trumpet out-of-pocket payments as the embodiment of conservative health-care policy. Danielle Smith’s critics inflamed fears of patient payment central in their campaign attacks.
One month before the election, Smith took out-of-pocket payments off her campaign table.
“I believe actions speak louder than anything,” said Smith. “One of the first things I’ve done as premier is sign a 10-year, $24-billion health-care agreement with the federal government, where we jointly agree to uphold the principles of the Canada Health Act.
“One of those main principles is no one pays out-of-pocket for a family doctor, and no one pays for hospital services. That’s in writing.”
Smith’s pledge of allegiance to the Act sounds like other conservatives who have caved before her. True, Smith might govern health care like other “conservative” governments. But her pledge need not bind her. A big opportunity lies at the heart of her pledge, if she has the courage to chase it.
The “accessibility” principle of the Canada Health Act bans out-of-pocket payments: “charges made to insured persons.” Out-of-pocket charges disqualify provinces for federal health transfer payments.
The accessibility principle is the only reason the CHA exists. The first four principles — public administration, comprehensiveness, universality, and portability — come from the Medical Care Act, 1966.
Many conservatives bristle at the Canada Health Act, precisely because of its ban on patient out-of-pocket payments. That is partly right but mostly wrong. Yes, the CHA prohibits federal transfer payments to provinces which allow user fees for medical services. But no, that is not why Canadian medicare suffers.
Conservatives bristle at the wrong end of the bill. Conservatives fume at federal overreach on access but forget the CHA’s first principle, public administration.
Public administration, not payment, is the key to Canadian health care. Medicare does not pivot on whether patients pay for care with their Visa card or their OHIP card. Payment irritates voters, which matters to politicians. But payment for services matters far less to health care than management of care itself.
Herein lies the opportunity.
The Canada Health Act does not say services must be managed by government. It says provincial governments must manage a “health care insurance plan.” Provincial governments must manage payment for services, but they could stay out of managing the services themselves.
A health insurance company is not the same as a health management organization. The federal Medical Care Act (1966) nationalized Canada’s health insurance companies. Governments took control of the health insurance industry, and insurance companies went out of the insurance business. The insurance companies never were in the managed care business.
Over the last 50 years, provincial governments have morphed from health insurance companies into managed care organizations. Each province closely manages medical services and seeks ways to manage even more.
Most conservative governments seem to ignore this by intention. Having been beaten in the out-of-pocket fight, conservatives shrug and get on with managing like a Liberal or an NDP. They tweak and twiddle the levers of control, adjusting regulations, programing, and funding allocations. Conservatives avoid (most) obvious progressive social policies, but it can be impossible to tell the difference in the clinic or at the bedside.
Conservatives could be (radically) different by refocusing on good government. Good government means good governance. And good governance means “noses in fingers out.”
Governments, like boards of directors, need to know what is going on (noses in), but they cause chaos when they meddle (fingers out). Keeping “noses in fingers out” of health care has been hard for Conservative governments — impossible for Liberals and NDP.
Premier Smith has the opportunity to change Canadian health care. She could refocus government on governing and find all the ways to get government out of management.
Perhaps this asks for too much.
Currently, provinces control which medical services Canadians can access. Governments control the price, volume, quality, and management of services. Provinces fund and oversee the training of health care workers. Provinces shape labour relations. Doctors retain the privilege of managing the lease and upkeep on their clinics.
Government has its fingers in so many things it will be hard to imagine anything different.
Smith faces a stark choice. She can take a conservative approach and do what most Conservative parties have done. Or she can chart a new course to rediscover what good governance means. The question is will Smith try?
I always appreciate your well-considered columns and this one is no different.
I would disagree with your assertion that Conservative governments generally manage healthcare like Liberals or NDP governments. I would also not lump Liberals and NDPs together.
What we have seen in the last 5 years in Ontario is an attempt to weaken and dismantle the public provision of Healthcare. Most recently, the Ford Government has made strides to put public dollars into private hands to address the surgical backlog.
This might please conservatives but consider this: why is the government paying private clinics more per procedure than they pay hospitals? Instead of increasing capacity in public hospitals, they are spending more money to provide a profit for people who pick the easiest cases. This will benefit private corporations, no doubt, and weaken the public system that is overwhelmed with more challenging, costly patients. But it will also cost more tax dollars. Does that not go against the very idea of fiscal responsibility?
And there is no reason to believe Smith will be any different.
This is a very different approach than the one taken by New Democratic Parties across the country, either in government or in opposition.
I agree that we need to overhaul the healthcare system, but any system that bleeds tax dollars to shareholders is more inefficient than a properly run public system.
The only reason govt will pay more for procedures in private clinics is because it costs money to run a fascility.Fascility fees are presently paid to all out of hosp clinics for OHIP funded services.Hospitals get these facility fees in their global budgets.
Hosp’s are inefficient,overbureaucratized wait rooms …. after hours procedures have been tried and failed.The procedures that will be done in the surgicentres have been routinely cannabilized by more ‘urgent’ procedures inhospitable whenever there are capacity issues ….. which is ALWAYS.
We desperately need private management which will be more efficient and bring hope for some progress.
Thanks to both of you for posting comments!
Hal,
The Auditor General reported that non-hospital facilities (so-called ‘private clinics’) offer services at 20-40% lower cost compared to hospitals.
Most non-hospital clinics are currently owned by individual physicians or small groups of physicians (e.g., radiologists, gastroenterologists), not giant corporations traded on the stock exchange.
Everyone in healthcare profits. No nurses or MDs work for free. The banks profit from offering loans to students in training or clinicians wanting to open a clinic. Shareholders profit from risking their own income, and small business owners often mortgage their own home to start a business. Why is profit allowed for everyone else who risks time, effort, or income, but it is terrible for shareholders? Even most socialists no longer pursue state ownership of the means of production.
As for Ford’s private clinics, I’ve written at length elsewhere.
Jagmeet Singh uses confusion about private care to support the status quo (National Post)
Ford’s health plan will be good for patients, if he can get it past the unions. (National Post)
Ford’s health-care plan: disruptive innovation, not privatization. (Financial Post)
Ram,
See my link to the Auditor General’s report on IHFs. They cost less than hospitals, which supports your comments about hospitals being bureaucratized.
We need a premier courageous enough to begin dismantling the tentacles of state which impose on every aspect of healthcare. It is a desperate need and not one easily filled. Politicians win votes for building shiny new things. They win attacks from unions, grifters, and free loaders for dismantling state control. It’s painful to watch.
Thanks so much to both of you for taking time to read and post comments!! I hope you are both well.
Cheers
“ Noses in , fingers out”.
Didn’t know how to interpret that coming, as I do, from the pre virtual era I will regurgitate that old idiom ..…”If you don’t put your finger in it you might put your foot in it”.
Advising brown nosing?
Ha! Very witty, as always, Andris.
Advice varies depending on the level it’s applied. At the bedside, we need fingers everywhere. Organizationally, this would mirror management actively managing their department. Boards of directors cause chaos when they try to do the job of management (or clinicians). Thus, boards need to watch and pay attention, but they must never direct management how to do their jobs: noses in fingers out.
I hope you are well!
Brilliant article as always.
May I add, what we need in our system is to maintain the basic floor of services we have presently, but remove the hard ceiling and allow those with means to pay for the services they need. Presently we are all equal, but equally terrible! I believe the vision for public health Insurance was to always be the safety net for a basic standard, and it should remain. But politicians need to remove the ceiling and allow those that want to improve their services to pay for them.
Cheers
Dr. Oz
Great comment, Ozzy.
To build on that, here’s another wrinkle:
We have only two options in our system: fully funded or (entirely) delisted. 100% or 0%. All or nothing. Even if the evidence suggests a 20% benefit of a particular treatment, we either fund it 100% or 0%.
For more than a decade, the “value-based insurance design” movement has been coursing throughout the world. You can see echoes of this in the Canadian Pharmacare discussions, if you pay attention. VBID means that treatments are paid for in proportion to the value they offer. Insulin would be paid for 100%. Other treatments (Viagra?) probably less.
Canada watches from the sidelines of the VBID movement. What’s worse, we don’t offer any help to patients who need treatments currently ‘delisted’.
I guess I’m going on a tangent here … fodder for another article.
Thanks for reading and sharing a comment! I hope you are well
Cheers
I am glad you posted this, Shawn:
“The Auditor General reported that non-hospital facilities (so-called ‘private clinics’) offer services at 20-40% lower cost compared to hospitals.” https://www.auditor.on.ca/en/content/annualreports/arreports/en14/406en14.pdf
There is a groundswell of organizations railing against the Ontario government for trying to increase OR time by allowing “private clinics” to do more surgery. I will be using the above quote and your link in response to social media comments that say that it will be more expensive to get treatments out of hospitals.
Hey Gerry
I’m so glad you liked that comment. I included the link precisely because I hoped someone might find it useful — so you fulfilled my hopes! 🙂
The whole ‘private clinic’ outrage is really just protest against care being offered in anything other than our current, heavily unionized hospital environment.
Great to hear from you!
Cheers
Just to clarify, the report states that certain procedures (MRI, dialysis, and colonoscopies) were found to be less expensive, The report was written in 2014. The question remaining is why should our tax dollars be going to for-profit clinics to fund space and expensive equipment which is already available (and often underused) in public settings. Hours of operation or publicly owned space could be increased rather than funding profit-driven centres which, according to the same report, are poorly monitored by government.
Elizabeth —
I have been off here for the summer and just noticed your comment now. Very sorry! Thanks for posting.
Shawn