Albertans will elect Rachel Notley or Danielle Smith on Monday. Healthcare always ranks as a top concern for voters, but it usually falls to almost last place as a concern that will change someone’s vote. But healthcare could be the determining factor in who wins on Monday.
I wrote this piece for the Western Standard today. I thought I’d share it, in case you miss it in your news feeds.
Please forgive me for posting so little! Most of my writing goes elsewhere lately. Shoot me a private email if you have strong opinions about reposts vs fresh content.
Thanks for taking a look!
Fighting an election over healthcare seems stacked in Rachel Notley’s favour. Voters come primed to accept what Notley says. She need not justify her ideas or prove how she will pay for them. Her promises sound familiar to voters, and familiarity feels safe.
For example, Notley has promised $10,000 signing bonuses for added healthcare workers, a tidal wave of 10,000 new trainees and forty Family Health Teams filled with health professionals from all over the world.
NDP ideas about Medicare sound familiar, because Medicare was originally built on NDP ideas.
For the most part, medicare still runs on the NDP thinking that caused our healthcare crisis in the first place.
Consider three common themes.
Every healthcare problem has a government solution. No matter how big or small your concern, you should call government first.
Voters have seen decades of headlines on healthcare. Every article calls on government to do something. No one ever calls for government to do less or to let people innovate themselves.
This makes Notley’s promise of seven medical students for Southern Alberta seem rational. But pause for a moment. If communities need the premier’s office to promise the placement of seven students, then Alberta has far bigger problems to solve. Alberta will need a very big and very strong government indeed.
Here’s another. Every healthcare problem comes from a lack of inputs at some level. Whether it be funding, doctors, nurses, or hospitals beds, every problem can be fixed by simply adding more of what we lack.
Doctors and nurses call for more every day: more services, more funding, more government help. No question, shortages exist and more almost always helps. But in part, calls for more are common, because they are the only messages that get through. Doctors never call for updated purchasing systems, supply chain resilience, or more thoughtful management. No one would know what they meant. So, doctors just call for more; it’s what medicare understands.
Notley loves hearing calls for more. Not only is she eager to offer more, it means no one will ask her about outcomes. No need to talk about performance or wait time guarantees. Just promise more. Campaigns built on inputs never run out of new things to promise. Inputs offer the answer to everything. Besides, spending may not fix everything but it never hurts.
Last one. When all else fails, government should tell people what to do.
For example, consider clinic appointments. Notley promises clinics will stay open in the evening. Patients want more appointments, and Notley will deliver. However, promises like that cannot be met with incentives or suggestions. They require direction, even command.
When faced with healthcare frustrations, governments often wield the power of law, contract, and regulation. The most obvious examples come from Quebec, such as legislation to ban part-time family practice, or $5,000 fines for family doctors who refuse to work in the emergency department. But Quebec is an outlier. Most governments wield power hidden in contract minutiae, regulatory changes, or policy documents. It can be hard to see from the outside, but it animates how the whole system runs.
Medicare lives on NDP ideas, and medicare has been in crisis since the late 1970s. Many voters miss the irony. More socialist thinking cannot solve problems created by socialism in the first place.
Danielle Smith has chosen to swim against the familiar, and talk about something different. She believes voters will see through Notley’s bluster. But Smith is taking a risk by raising fresh ideas. Faced with a healthcare crisis, familiar always seems wise even when it is not.
Medicare does not fail for lack of funding, lack of control, or lack of government solutions. It fails precisely because governments try to fix, fund, and control every little problem, right down to placing seven medical students in a small community.
Prime Minister Paul Martin promised a “fix for a generation” — a 10-year, $41-billion health accord in 2004. It came with detailed “strings attached” defining performance and accountability. It made doctors and nurses richer but did little to nothing for patients. Prime Minister Justin Trudeau did almost the same thing with his own $46-billion, 10-year, strings-attached deal this spring.
Canadian governments seem convinced that, given enough accountability, we can spend our way out of our healthcare crisis. It has not worked yet, but at least it is familiar.
NDP ideas caused our healthcare crisis. Even so, many voters keep supporting Notley as she waves and points at all the things she plans for government. Hand waving works for flagging down help with a flat tire, but having caught attention, flagging does nothing more.
Elections depend on attracting attention. Fixing healthcare requires something more. Notley’s ideas sounds familiar because they have been tried and found wanting for decades. Let’s hope voters can see through them.
Hope this finds you well Shawn. This is my short response (I have a longer version but I do not want to bore anyone with my mental meanderings).
This issue is so incredibly complex. I do not think it can be fixed. Expecting the voters to vote intelligently is unrealistic and hoping for too much. Most are poorly informed. Most can’t even be bothered find out the truth. Most can’t be bothered to vote. Neither Albertan politician’s ideas will work. This is not trying to make a Zodiac inflatable do a U-turn, it is more like turning an oil tanker around. The Canadian health care system is wonderful in that no one will need to go into bankruptcy due to a severe illness but it cannot survive as it is (being fundamentally flawed) especially with an aging population. It will only get worse and will crash and burn. Only then will there be public interest and political interest to start meaningful reform. I am glad I will be joining the corps of the retired fairly soon.
Robert
Well said. Using your aquatic example, far too many limbs attach to the octopus we call medicare. Adding another limb (Notley) or chopping one off (Smith), won’t give us a new fish.
I used to think we could turn the tanker around. Covid proved the emptiness of my naiveté. We do not have the capacity to turn. Turning requires comfort with debate, data, risk, and a dozen other things we’d rather avoid.
Our job is to prepare the soil where we can for the time when it will welcome new seeds. Share ideas. Challenge nonsense.
Twenty-eight countries have universal care. Canadians love insurance. We will see change at some point, but like you said, it may need to crash first.
Good luck with your retirement planning! Great to hear from you.
Cheers
Hi Shawn,
Have seen your posts here and there,as our system continues to circle the toilet.
I have also been watching the Alberta election closely,and have been somewhat alarmed by that province’s pivot left …. given its history.
Alberta has already ventured out with privately managed surgicentres that are raising the ire of ontario socialists,but it sounds like Smith wants to go further …. good for her.
We desperately need a European hybrid health system ….. many have seen me post this before.
The more I see the posts of docs lamenting their professional quality of life,the more I’m convinced of this reform.Will docs take back control of their lives ? Will the public get tired of reduced quality/access ? Will docs blow up useless organizations like the OMA/CMA ?
Will Alberta go socialist …. again ? Ontario made the mistake once, and doesn’t seem close again …. but Alberta ????
Cmon,man ……
Hey Ram
Agree — hybrid works much better. Tommy Douglas had a nationalized shoe factory once. It did not last. The only reason our nationalized medical-insurance-cum-managed-care organization lasts is because it’s a monopoly. Most voters know nothing else.
The Alberta election worried me for a bit. But then again, the faster they fall in pursuit of utopia the sooner they must face reality.
Our medical associations were built to address political needs. Now they serve member-services ends. The CMA and OMA are more like CAA, except CAA actually comes to help you on the side of the road.
Great to hear you’ve seen my scribblings in other places too. I’m convinced we need to put rocks in as many shoes as possible — try to make people think. Perhaps I’m dreaming…
Watching Monday’s outcomes with interest.
Shawn
Thank you for writing once again about the real and the familiar, with your usual insight and eye for the absurd. Your focus on fact provides, as always, an irreplaceable opportunity to contribute to the public discourse.
To that, let me address just 2 small facets of the complex mosaic which is our chosen lifetime endeavour … and burden.
Surgicentres, currently on their way out the birth canal, may very well achieve more efficient cost effective surgical outcomes. I have faith … and trust … but I’d like to know more. Like Ronnie Reagan, I’d like to verify. Unfortunately our involved surgical colleagues and the “system” administrators aren’t sharing. I’d just like to know the what, as in what is different (in Surgicentres) from our existing hospital based surgical service provision? This, will allow me to understand better the why, as in why it might just work; and also, any other issues or problems which are likely to arise. And in the event that exchange of money might occur in this brave new world, I’d like to know the how, as in how the poor might access a needed service in a surgicenter without barriers?
As for our existing institutions, namely the OMA in Ontario and CMA, I am in total agreement that they aren’t working well … at all. But that is never an argument for throwing out the baby with the bathwater. We should work together to make them work better for us, understanding that obvious defects (like the OMA’s Corporate structure) can be changed … and personnel who don’t understand their jobs can be let go. This is something you yourself understand very well, Shawn.
Hope you’re prospering? Retirement is still good.
Best
Mike
Hello Mike,
Insightful comments, as always. Here’s my sense of it.
1. Surgicenters/Independent Health Facilities/”Private” clinics. Shifting services out of hospitals has been happening since the 1970s (since the ’50s in other countries). In 1976, hospitals consumed 45% of health spending. In 2022, it is down to 24% I believe (check CIHI for the latest %).
a. Non-hospital clinics are same as hospitals in that patients access care “with their OHIP card, not their Visa card”. ie, “Free” care.
b. Different from hospitals: Activity Based Funding (ABF), not global budgets. Funding follows the patient. No care provided for a specific patient = no fees billed = no income earned by the clinic. Hospitals have a large budget whether or not they provide care for a particular patient.
ABF works well for procedures and diagnostics, but not as well for counselling, etc. (time units offer a surrogate way to get ABF)
c. Different from hospitals: non-unionized workforce. Hospitals are close to 100% unionized (If I recall correctly, ~79% in the broader public sector; 13.8% in private sector). Thus, non-hospital clinics can INNOVATE
d. Different from hospitals: clinics MUST innovate to improve flow, efficiency, and service. The relative risk of innovation is much lower for clinics, compared with the status quo, than for hospitals. Status quo for hospitals is always the lowest risk path to follow.
SUMMARY: Whether by intention, intuition, or accident, Ford will have shifted services into an ABF environment. Ontario and Quebec have struggled to introduce bits and pieces of ABF for 20 years. Hospitals are incentivized to show all the ways ABF will fail. There’s a great review article published in the last few years … I can dig it out if interested.
2. Medical associations
Yes, indeed, you and I spent several decades trying to keep the OMA and CMA focussed on making it easier for docs to care for patients.
The representative baby was thrown out when they changed the governance bathwater. Bicameral governance (board + council) meant that the board (cabinet) had to listen to council (parliament). Now with unicameral governance, we have an all-powerful, omnicompetent board with a faint wisp of accountability compared to what (little) we had in a bicameral structure.
The OMA has $60-million or $70-million ?? in dues collected by law to fund it to go forth and do good things, whether or not the things help docs … never mind whether or not docs asked for the things in the first place.
The CMA has a $3+ billion endowment and has specifically said it does not care whether doctors do not agree with its vision. CMA wants to partner with anyone who agrees with it. The ‘M’ in CMA no longer means doctors by necessity. It may or may not mean doctors, if doctors care to follow where the CMA determines doctors should go. No, the CMA is not doctors’ friend anymore.
There’s no longer any way to ‘storm the board’, take over, and set things straight. Aside from building personal relationships with individuals on the boards, and hoping they are open to change, and then repeating the process with each new board member, there is no way to make the associations accountable to the people who pay for them (or paid for them, in the CMA’s case).
Time to build something new! 🙂
Really great to hear from you. So glad retirement has been good. My sense is that getting out is the best way to stay sane — evidenced by the now 2.2 million patients without a family doc, in Ontario.
Thanks again for writing!
Cheers
Hi Shawn, I learned many things from your book, and this article is thought provoking too. But I don’t think this election whether UCP or NDP will make pivotal impact on healthcare. In a democracy, when voters want “more”, politicians can only offer “more” . . . whether public or private depending on political spectrum. Yet in a human resource shortage context, “more” doesn’t buy proportionally “more”, and risk widening inequity. As an example, if overnight our government pays me 2.5x more per OMA guide, then as a mid career GP I would definitely see fewer patients, not more. Multiplied many GPs over and you have system impact. I don’t have great ideas, but there are two concepts I like to hear more deliberation, by colleagues and politicians, as a way to work with finite resources both human and monetary. One is “health savings account” where patients choose where to spend their money, with extra allowances for “essential care” however defined. The other is “modelling” to project how policy and spending impact the wider system. Without modeling all we have is rational rhetorics (which you cautioned in your book), loudest-get-heard advocacy, and outdated evidence, like storied stocks. I don’t expect models to be perfect, but without using one to mediate our public conversations, we are forever at the mercy of emotional arguments and visceral responses.
Well said, Adam.
I admit, you are right about elections, too often, not making much difference. Governments of all flavours tend to govern medicare as though it was a giant postal service. Any hint of medicare being an insurance program has almost entirely faded (until the state wants to absolve itself of blame for something).
You are smart to bring the discussion down to individual behaviours. On the one hand, some research suggests docs work to attain a level of income. However, I’ve seen new research suggesting that docs tend to work harder when you pay them more overall. But reducing behaviour to incentives impoverishes us all.
W. Edwards Deming, brains behind Japan’s recovery post WWII, said managers need profound knowledge: a combination of system thinking, variation (stats plus individuality), theory of knowledge (epistemology), and psychology. Managers need a deep knowledge of all four, at the same time.
I loved your ‘loudest-get-heard advocacy’ and “we are forever at the mercy of emotional arguments and visceral responses” comments. Brilliant.
Thanks for taking time to read and share your thoughts! Excellent. And THANK YOU for reading my book — huge honour. Let me know how I can return the favour.
Be well
Shawn
Reading the book was a treat, Shawn. I especially liked the part where you pointed out that doctors are motivated intrinsically . . . something managers miss out and continue to tinker with carrots and sticks. Individually we are unique and go through our own life cycles, having many roles outside medicine. But collectively in our healthcare delivery, I believe modeling can turn conversations from simple cause/effect thinking to “if . . . then . . . and then”. Often people hold a certain rhetoric as an act of faith, but running multiple scenarios through modelling is a new science that has vastly improved weather prognostication, and long applied in military war games. In healthcare I hope we will also employ this tool beyond the pandemic, especially now that demographics and work behaviours are undergoing seismic shifts. And I hope you will continue to challenge people’s thinking with your insights and analyses . . . you have amazing breadth and depth! Thank you! Adam
Thanks for expanding your thoughts on modelling, Adam. This really helps.
My first reaction was to imagine ‘models’ as designs or plans dreamt up by planners to be enforced on us, the unruly masses. But as you describe so well, modelling would be more like hypothesis testing on steroids: “running multiple scenarios” as you say.
Your sense of modelling — the truer sense, I think — is excellent. It means trying lots of things to see what works. As such, it is the exact opposite of dreaming what we think should work and then trying harder and harder when our ideas do not work in reality.
Warren Buffet (I think) said he has often been criticized by the academics. They basically say, “Well, that might work in practice, but it will never work in theory.”
Your modelling idea is a way to arrive at numerous practical options. The theoreticians can tell us why the successful models work, after the fact. 🙂
Very happy to hear you enjoyed the intrinsic vs extrinsic motivators concept. I use it all the time when speaking about healthcare. Thanks so much for sharing your impressions of it!
Be well. Thanks again for helping me understand modelling!