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.”
Shawn, you have obviously put a lot of thought into this article. You have drawn from your experience and studying of this complicated issue. It makes sense. Very well done.
Thanks Gerry! Really appreciate that. Talking about system change is a bit like talking about a colonoscopy — not very popular. But it’s got to be done.
A new meaning to the triple P buzzwords: No longer the catchphrase public private partnerships of yesteryear, but now the land of perpetual pilot projects! Sweet!
Every now and again little flashes of insight and illumination escape the swirling, expanding all encompassing fog that is healthcare, and I’m proud that they mostly seem to emanate from our corner of the triangle. It’s not that we’re even in a majority in our sector, but at least we keep trying.
And maybe, if we keep trying, Joe Q Public can get his haemorrhoids seen to before the next ice age.
I agree with Gerry. Bravo Shawn ….
Thank you, Mike!
I agree entirely that insight and illumination always come from those closest to the problem. To be clear, when I said, ‘doctors’, I clarified half-way down that I meant medical associations, regulatory colleges, educational colleges, and training institutions. I’d say that regular working doctors often offer many great ideas … and sometimes we even get our associations, colleges, and universities to listen. But even so, they cannot advance a good idea without the full support of the other parties in the veto triangle.
Very funny comment about haemorrhoids before the ice age! 😀
Thanks so much for reading and posting a comment. This can be changed. We just have to realize what a unique system we find ourselves stuck in — although it feels normal, it is NOT normal!
Cheers
Great piece Shawn.
You intellectualize the issues and problems,need for reform very well.Reminds me of the Greek gods looking down upon humanity and discussing how things will play out.
Your Thatcher analogy is appropriate,as the iron lady had the will to proceed against fierce headwinds.Does Canada have such a hero ?
I’m hoping that the OMA will start the ‘pilot project’ of privately managed publicly funded surgicentres to try and handle the backlog of cases as people start creeping back to docs.Thin edge of the wedge ? Don’t know,but I,like you,will look down from above bemused at the events unfolding.
Thank you, Ram!
I really like your “privately managed publicly funded surgicentres.” Currently, the hospitals trip over themselves to please the Ministry of Health and the sitting government. They humbly submit detailed budgets and receive equally detailed funding letters back outlining what they are allowed to spend and where, down to the second decimal.
As for Greek gods, Thatcher, and heroes, we need ideas first. When 99% of our hospitals are unionized while the broader public sector sits around 34%, and the private sector less than 20%, we have a major problem with union monopoly. When we have ONE medical association for over 40,000 doctors, with the province making it illegal to have another representative association, we have a monopoly problem. I could go on and list all the other concentrations of veto in the regulatory college, ministry of health, etc.
Innovation cannot happen when we have a tripartite veto structure. It must be disrupted. It has been done before.
Thanks again for posting a comment!!
Cheers
Great article Shawn. We are very risk averse in Canada, which reduces our exposure to the upside of innovation. We wait to see what our cousins in the US create ( or capture from Canada) and are simply willing to licence the IP later, far along the innovation curve. We lose healthtech talent to the US where sales cycles are short, and private partnerships are the norm. Will the advances in virtual care due to COVID19 lead to a new wave of domestic healthtech innovation and procurement?
Great comments, Duncan.
We let others pay for R&D, then we steal the tech and criticize them for being so capitalistic. We’ve chased away the pharma industry from Canada and suffered the consequences at the start of the pandemic.
Things do not have to be so hard. We should remove the gatekeepers on innovation.
Thanks so much for reading and posting a comment!
Cheers
Shawn,
Interesting perspective. You bring forward critical areas that need to be well understood and effectively communicated so that those within healthcare’s stakeholder community can thoroughly appreciate the evidence-based reality of our present healthcare ecosystem. Your book,”When Politics Comes Before Patients”, is a foundational reference for those who want, and need, to take a step back and understand our present healthcare system’s journey-to-date so that they understand how our system came to be, what are our desired/expected patient-centric goals and objectives, and how that system is delivering to the meaningful, measurable and timely goals and objectives previously mentioned. This is especially true for one of the critical stakeholders – the patient/consumer of health care services. Depending how small or large the performance gap(s) of delivered services are to expectations should generate a nationwide momentum for meaningful, measurable and timely change.
Thanks Ron. Great to hear from you.
I really appreciate you highlighting the need for patient input. Ideally, funding would follow patients so that no one could pretend patients were an afterthought. … not saying that we intentionally ignore patients … it’s just that their concerns rarely come up during all the ‘important’ work we attend to while managing the system.
The secret to real change rests with allowing experimentation and innovation around delivery. Ask business leaders outside of healthcare how they would organize healthcare services. Don’t ask them how to remove a gallbladder. But we can ask how they might move people around.
In the end, great solutions emerge with an element of surprise. Most of our greatest ideas fail. Something ‘just happens’ to work. This element of surprise turns out to be far bigger than smart planning … not to say we don’t need thoughtfulness and plans … we just need to be even more ready to capture the things which work even better than our plans.
Ok, drifting down a rabbit hole here.
Thanks so much for writing! Really appreciate you taking time to share a comment.
Cheers