Politicians have chased the medicare merry-go-round for decades. Each party pours on money or passes new legislation.
In 2004, Prime Minster Paul Martin’s Liberal government aimed to fix wait times. So it threw $41.3 billion dollars into a Health Accord.
The Harper Conservatives kept Martin’s Accord. But Harper slowed increases in transfer payments to 3%, after the Accord ran out.
While in opposition, Justin Trudeau railed against Harper’s handling of medicare. But after the election, PM Trudeau’s Liberals decided that Harper’s 3% was wise after all.
For all the bluster, political parties act the same. They either maintain the speed of the merry-go-round, or they give it a push and make it spin faster.
Private Practice, Public Payment
Canadians love free health care and hate the idea of bureaucrats controlling the care we receive. Canadians believe that doctors should provide whatever care we need (private delivery), and the government should pay for it (public payment).
Medicare calls it public payment and private delivery. Patients get free care, and doctors get to provide care based on science, not politics. Doctors and hospitals are privately owned businesses.
Dr. C. David Naylor, historian and health expert, captured the relationship in his book, “Private Practice, Public Payment” (1986). The message was clear: Canada is not socialist. We simply have state insurance, with private delivery, of medically necessary care. The government promises to pay and not meddle.
The trouble is that no one sees it that way anymore. All political parties believe that if the public pays, then it should drive. Government pays, so government should be in control.
In November, Premier Jason Kenney’s Alberta Conservative government tabled legislation to force doctors to work in rural areas.
Quebec Premier Legault, of the Coalition Avenir, threatened legislation to arbitrarily change the way doctors are paid.
Premier Doug Ford’s Ontario Conservative government introduced Bill 138, which could potentially give government full control over billing numbers: who, where, and how many.
The Conservatives in Manitoba just reintroduced legislation, Bill 10, that strips doctors of “due process” on billing audits.
Since the 1990s, governments have closed hospitals, amalgamated services, and relocated clinical programs from one community to totally different ones.
Hospitals are not free to serve patients based on need. Hospital administrators must submit detailed budgets to government. Then hospitals must wait for even more detailed funding letters back from government. The letters dictate precisely how hospitals must provide care.
Granted, hospitals shape the funding letters with their initial budget submissions. They do have input. But if government does not like what a hospital has submitted, the hospital cannot proceed.
Does Private Practice Mean Freedom?
This raises two problems. First, private delivery implies that doctors and hospitals have the same freedom as any other private enterprise. Pundits love to point out that hospitals have private boards of directors, and that government does not own most hospitals.
But if government dictates hospital behaviour, down to details about medications and management, in what sense do Canadian hospitals deliver care privately?
The same thing applies to doctors’ offices. If government regulates most of the meaningful decisions in running a clinic, and leaves mundane details to doctors, in what sense are clinics privately operated?
Canada has public payment and private delivery in theory, but in practice, Canada has public payment and public control, through heavy regulation.
Medicare exists in a dream world, where doctors and hospitals get all the responsibility of management, but less and less freedom to manage.
Of course, none of this matters if medicine is just another public service, like the Mounted Police or Canada Post. Police officers and postal workers do what they are told and work where they are needed. Why should doctors and hospitals expect anything different?
Many might even applaud greater government control. Government seems able to run the post office, why shouldn’t it run health care also?
If voters want government to own and operate everything to do with medical care, then governments should stop the charade and abandon pretence at private delivery.
But no sane politician will do it.
Governments cannot afford to own and operate all hospitals and clinics. Furthermore, why would any government want to carry the responsibility of owning hospitals and clinics, when it already has control?
Run Over By The Omnibus
This leads to the second problem. We should not be surprised when self-described socialist governments seek greater control of private businesses. But why do apparent freedom-loving parties do the same thing?
Centre-right parties often table omnibus bills, filled with language that looks like it came from the socialist Leap Manifesto.
The party caucus gets an executive summary, but members rarely have time to digest the details. Even if they had time, legislation has become increasingly complex. It requires content expertise. No elected member of parliament could possibly know all the details and implications of every part of an omnibus bill. Who knows whether a bill is socialist, capitalist, or something else entirely?
To their credit, most elected representatives express surprise, when you meet with them and explain what their bill means to your business. This happens because legislators, for the most part, do not write bills anymore. Content experts and experienced bureaucrats write legislation. Politicians just debate and vote on it, for the most part.
Elected representatives want legislation that sounds reasonable. They do not need to know the details. Politicians want bills that solve political problems. They do not worry about the implications of owning a medical clinic or the fine points of private delivery.
Politicians want laws that make problems go away. If they face immediate problems with an auditor’s report, or the cost of medical care, or access to doctors in rural areas, then politicians are hungry for something to make the problems go away. Politicians do not have time for academic worries about private property and free enterprise. Besides, voters expect politicians to take accountability for health care.
Are We All Socialist?
So, the medicare merry-go-round keeps turning. Every political party runs around it. No one has the courage to make a change, even if they enjoy a majority.
Medicare makes every political party act socialist. Without a government that has the awareness and courage to be something different, we can expect more central control and government rationing of care. At what point will voters ask to get off the ride?
Photo credit: cbc.ca
And hence, the problems we have – No politician wishes to make policy anymore. It’s all about damage control, looking good and winning the next election. Sometimes the hard choices have to be made, but I don’t see anyone with the strength to do that. You can’t please all of the people all the time, etc… but it’s more now about trying to not displease anyone if possible. Often that means the status quo because no one likes the boat rocked – we’re all comfortable in our complacency and mediocrity rather than be willing to take a chance on change. Most people aren’t sick most of the time, so as long as it doesn’t directly effect them, the majority enjoy the same stale bread.
I’m becoming increasingly pessimistic with our leaders. There are many societal and global issues staring them directly in their faces that can be addressed by decisive specific actions yet elicits disregard and dismissal. Perhaps it’s our nature as problem solvers that frustrates us with these politicians. They can fiddle while Rome burns, but eventually that position will not stop Rome’s ultimate fall. I guess when that happens, vive la revolution…
Great comment, Rob
It’s really an insult to voters. Politicians do not even bother trying to argue for unpopular opinions. They just pretend to all support whatever is woke. I’m not sure whether it’s the advisors telling politicians to pursue Milquetoast, or it’s the politicians being too desperate to get the job, this does not bode well for Canada or democracy.
Those of us who can see the fire — hallway medicine, horrendously long wait times, crippling regulatory burden — know that it could be otherwise. We do not have to shackle free enterprise simply because we have universal care.
I guess all the older docs get to say, “I told you so!” They love to warn that friendship with government is enmity towards medicine. Unfortunately, they are right. Regardless of political colour, governments tend to act according to whatever voters will tolerate. In the case of medicare, voters do not seem to blink at flagrant authoritarian socialism on both sides of the aisle.
Thanks again for reading and posting a comment!
Cheers
I told you so.
You did, Gerry! 🙂
Excellent piece Sean….the current charade is about to come to an end…the benevolent masks on the faces of the Canadian provincial health care systems managed by their oppressive bureaucracies are slipping.
The Professional freedoms taken for granted by previous generations of Canadian physicians and surgeons and their patients are to become history.
The dictatorship of the health care bureaucracy is with we Canadians and the democratically elected political class is helpless to prevent their own creation from consuming all before them….first to be gobbled up will be private deliverers, medical buildings and clinics…he rest will follow.
Democracy + public ownership = Socialism.
We will have socialism …in spades…British Medical clinics were seized with the introduction of the British National Health care system…the father of an acquaintance of mine owned a nice piece of real estate in which he had his Family practice…it was seized and valuated…he was told that he would get his money back when he retired at the low interest rate prevailing…when he retired decades later his £4000 property had appreciated into the hundreds of thousands of £’s …but he got his £4000 back with its pathetic accumulated interest rates…taxable of course.
The sad aspect is that our ingenuous profession slept walked into servitude.
The British National Health care system, our system’s mothership, is in deep faeces…it needs 5000 new FP trainees per year to remain afloat …after training only about 20% go into full time general family practice …most are opting for niche focused practices which are more lucrative …governmental reorganizations have led to a FP retention crisis…a third of ER doctors are leaving to work abroad … thousands of MD posts are lying vacant throughout the country…Brexit will compound the problem with the exit of EU doctors filling the gaps.
Much like in Canada each governmental reorganization by those without skin in the game has led to deterioration not improvement…can anyone remember any pointy headed top down “improvement “ that did not end up with deterioration.
This latest primary care reform will not be the last…there will be many many more.
The main cause of crisis in the health care system are solutions to previous crises which were themselves the result of previous solutions to previous crises …which were the result of previous solutions to perceived problems.
Thanks for both of your comments, Andris. Well said…and much to ponder.
I think we need to turn our minds to how we might promote changes that would offer patients more: more care, more choice, more access. This presents a major hurdle for many of us. Many doctors think that patients get too much already. Too often we think patients should get even less than they already do in our irrational rationed system. This attitude, coupled with a centralizing statist zeitgeist, will guarantee our demise, I fear.
We need to offer something good for patients–some good news– that is something other than ‘blow up the whole thing’. I think it’s possible. We can have universal coverage without tyrannical control. We just have to point the way and hope that some political party will have to courage to do it.
Thanks again. I always learn something from your writing!
Cheers
We can only offer “ something good” from ourselves as individual physicians…to expect ”something good” from a pedantic, check the boxes, centrally planned statist system is absurd.
It is hard to respond positively to demanding patients / clients who have been indoctrinated to believe that greedy doctors are the cause of the health care ills….I recall decades ago when I was on the local DHC that one of the committee members told me that “ you doctors are the problem”…she was paid to attend those evening meetings by whatever agency that she represented with me being the only one who was unpaid to attend.
It’s much easier to respond positively to appreciative patients…appreciation goes a long way.
At present the “system” and the media are antoganistic towards the profession, depreciating its efforts, not at all appreciative praising only those colleagues of ours who drank the statist Kool Aid ( Jamestown was only 35 years ago) and who intend to be the overseeing kapos of the soon to be imposed health care structure.
Appreciation costs nothing yet it is denied, in particular to the grass roots of the health care profession who keeping everything upright ad going…it is not the political class nor its central planners nor the health care bureaucracy that keeps the health care system afloat…it remains afloat despite them not because of them.
Again, well said indeed!
I hope I didn’t mean to suggest that we should be more thankful, or appreciative, or some other sop. Gratefulness is good, but it won’t cure the system.
I was suggesting that we need to offer gritty solutions of our own. The trouble is that the best solutions develop organically from trial and error. So our first step at solutions will be “unshackle us and remove regulations so that we can innovate without fear.”
Again, super comments about docs being blamed. It fills the policy books also. A few honest authors admit that it’s the easy way out: pick a villain (usually doctors) and blame everything wrong about the system on them.
Thanks again!
Shawn,
In many ways doctors are caught between a rock and a hard place. These unilateral government moves are transparent (really shameless) attempts at creating a “functional” physician job market without doing what’s actually needed to make it happen i.e. foot the overhead bill and hire the docs for the appropriate FTEs to see the patients. But the cost is prohibitive and the public has little sympathy for doctors as a group (for individual doctors patients are highly supportive). So we end up with these ludicrous dictated schemes, including Patients First’s goal to reverse-engineer primary care along the model of school zones…a fine idea, but of course government *pays* to build schools where they’re needed. Politicians look like they’re doing something, and they’re turfed from office long before the consequences become apparent.
There are two things people never seem to talk about. First is the plain absurdity of it all. You would never hear governments try to regulate access to accountants or plumbers or how much they’re paid. Or on the flipside, when nurses or teachers feel a need to work part time and earn less nobody bats an eyelash, but doctors? For a profession supposedly too autonomous for its own good, doctors are apparently incapable of making decisions around their work without the Powers That Be deciding for them.
The second issue is that these schemes aren’t doomed to fail because doctors are unethical or lazy or selfish, but rather because doctors are doing exactly what they were conditioned to do in med school i.e. following their professional passions. It’s a straight fact that at least 1 in 10 family medicine residents will be working full time in the ER, and many others will do palliative care, sports medicine, hospitalist work, etc. Schools and Colleges encourage them to do so openly, with policymaker endorsement and funding(!). Same with specialists, who can’t help but focus their interests because of technological advancements and the explosion of knowledge in each individual field. Governments can carp all they want, but if I’m not competent to work how they’d like me to work, no amount of regulation or shaming in the press can change it. Second law of thermodynamics.
I’d like to think that politicians will someday clue in. But as I explained in a panel talk to pre-meds some months ago: tomorrow’s doctors are the ones spending a springtime Friday afternoon getting insights (warnings?) about a life in medicine; their future elected leaders are the PoliSci majors getting stoned in the woods behind Saugeen after a night at the bar.
Oh Frank…this is just brilliant. You’ve packed so much into your note. I hope reader take some time to make sure they do not miss it all.
You are absolutely right about reverse engineering family medicine….and then connecting it to the “absurdity of it all” is exactly right. You could have developed this idea for several pages. In fact, you should write a blog on it — I’d be honoured to repost it (if you approved). As you mention about accountants and plumbers, I’ve often said that we never hear the plumbers complaining about a shortage of plumbers! They have the freedom to leverage their training, skills, and abilities to scale up their services. Not so for doctors.
And great point about focussed practice. We will see more of it, as medicine continues to advance, not less.
I could almost understand the drive to control all of medicine, if this was the late 1960s. Even at that time, there were too many details, but there were few treatments and even fewer sick people. Now we are drowning in treatment options, and everyone seems to live longer and longer. Sick people abound! Medical knowledge double every few years. Given all of this, it is totally insane that governments have tried to INCREASE control.
Given increasing complexity, we need to DECREASE control/micromanagement and switch our focus onto attractors and environmental factors if we want to influence change. Politicians do not seem to get that. It’s like raising kids–we can be demagogues with toddlers but forget about it with teenagers! Government tries to do the opposite.
Again, thanks so much for taking time to draft such a thoughtful note.
Be well
Shawn, absolutely! I’ve been delving into literature regarding complex environments and it’s very clear – in complex environments excessive control and micromanagement backfire. Certainly what I’ve witnessed in public Addictions and Mental Health care, especially regarding particularly complex patients.
Exactly. Thanks for this, Tammy! I didn’t know about it’s application to Addictions and MH. It just makes so much sense!
As it stands , Judge Corey’s judgement of 2005 on the medical profession being deprived of natural justice is about to be thrown on the rubbish heap.
The medical profession is being faced by the oppressiveness of pure democracy where the rights of the minority are brushed aside by the majority…the “tyranny of the majority”as Stuart Mill pointed out in 1859.
As George Orwell would have told those entering the medical profession…”if you want to have a picture of your future in medicine imagine a hob nailed boot stamping on your face ….for ever”….”the future is yet in your power, change your life today, don’t gamble that the powers that be will come to their senses, we old ones made that gamble and lost, act now, without delay”.
Again, superb comments, Andris. I don’t think I have read through Corey’s full report…I need to forthwith.
Mill and Orwell remind me that people do not actually like freedom — they like security. It is only when security becomes tyrannous that people remember their love of freedom. It’s Polybius’ theory of government cycles I guess.
Cheers
Frank – magic.
Great article, Shawn with great comments.
The puzzle for me is the popularity of the system.
How bad does it have to be before public opinion turns against it?
And when it does, what will it turn against? As Andris pointed out, it may go against the healthcare delivery professionals who are just another group of victims if the system.
What will it take before the system gets questioned? I’m afraid that it may never happen.
To paraphrase Adam Smith: there is a great deal of ruin in a health care system.
Great thoughts, Zork.
I think it remains popular for two reasons (mainly): 1) Only 4% of the population ever needs hospital admission in any given year. Most of us require non-life-threatening care. We grumble at waits, but we never really worry for our lives. 2) Those of us who do get really sick adopt a Stockholm Syndrome. We become grateful for the bread and water our captors offer.
We exist in an unprecedented situation where the rich can get care in the USA, the well-connected get care inside the system, and only those without connection or voice get left in hallways and on waitlists. It is wrong, morally wrong, regardless of what moral system you hold. We judge societies by how we treat our most vulnerable.
Thanks so much for taking time to read and post a comment!
Cheers
This is the best two paragraph summary of the system that I’ve ever seen.
Still, I have many questions, I will ponder them in my next few posts.
Looking forward to your next blogs! Glad it sparked something for you. Thanks again for commenting, cheers.
Looking at the bright side…the hatred and envy of the medical profession are uniting Canadians from sea to sea to sea.
🙂
Sadly true.