Tom Mulcair - Beware the False God of Private Healthcare

From: Tom Mulcair

To: Canadian healthcare observers

Date: June 5, 2023

Re: Beware the False God of Private Healthcare

Ontario’s Bill 60 was introduced last winter and it’s the latest stealthy attempt to subvert Canada’s public healthcare system by letting for-profit care creep in.

You will never know it by reading the title or anything in it because it all talks about integrated community healthcare.

Good luck trying to find the word private in there anywhere.

But we all know that that’s where this is headed.

So it might be helpful to look a little bit at the history of how we came to our present system and what needs to be done to make the system much better for the future and for our kids.

We’ve always liked to compare ourselves to the Americans, but now we have to start looking at ourselves and what we’re actually delivering. Because the only thing that matters is results. All the rest is debate. We like debate, but we like results even more.

Some history: In the late fifties, Tommy Douglas is in his last election as the premier of Saskatchewan. He promises to bring in universal medical care. His successor actually brought it to life because Tommy marched off in 1961to win the leadership of the newly formed NDP.

Meanwhile in Ottawa, John Diefenbaker's Conservative government knew the power of the prairie populist. Diefenbaker was from Prince Albert and knew what Douglas and the new party could represent in Ottawa.

So he put Supreme Court Justice Emmett Hall in charge of a massive commission of inquiry to come up with a healthcare scheme that could extend Saskatchewan’s model to all of Canada. Over three years the Hall Commission held 80 full days of hearings across the country. It ordered up 26 major studies, received submissions and presentations from more than 400 institutions and groups.

Then the Liberals came in. Lester Pearson's in power.

He starts the work with the provinces and ultimately, in 1966, Medicare as we know it was introduced across the country. That work took five years.

And I would dare say that this is what's singularly missing in Ontario’s rush to Bill 60. Because if you go through the legislation, there’s lots of regulatory power. But you could drive a Mack truck through some of the holes in what's being proposed.

Licensure is going be made easier. We’re talking about competition, but do you really want competition from people who don't have the qualifications? Enforcement is a key driver of all these things.

If you have a rule, you have to enforce it. And in Canada we’re not good at enforcing. When I was the head of the Quebec agency that oversaw the licencing bodies for more than 50 professions, not just in healthcare, but lawyers, accountants and even urban planners and engineers. Its job is to make sure each licensing board is doing its job of protecting the public.

I was the first Canadian on the board of something called the Council on Licensure Enforcement and Regulation, which had badges. This is enforcement. This is a subset of the police power of the state. Americans don’t fool around with this stuff.

We don’t enforce in Canada, as we learned during the pandemic, whether it was the privately run Herron residence in Montreal where 47 seniors died in Covid’s first wave or in Bobcaygeon where another 29 people died in a private care facility.

This was private care, but there was no enforcement because both provinces had actually reduced the number of people overseeing longterm care.

And private care is not unimportant in these matters. Consider the Oxford University study published in the Lancet last summer.

“Private sector outsourcing corresponded with significantly increased rates of treatable mortality,” was the conclusion.

That’s evidence for those seeking evidence-based decision making. And it should shut down the sloppy thinking that has folks saying, well somehow competition will magically produce better results.

And as we all know, private providers cherry-pick their cases, leaving the tough stuff to the public sector. And if a patient has been in private care and the private care has received the money from the government, guess what, if they develop an infection, they’re right back to the public system.

So any reform of our system has to be based on evidence. It has to be done step by step, and it has to be done, dare I say, the same way the first system was introduced: thoughtfully.

Tom Mulcair is the former federal Leader of the Official Opposition. This Memo is drawn from his argument at the C.D. Howe Institute’s last Regent Debate: Be It Resolved: Competition Will Save Canada’s Broken Healthcare System.

To send a comment or leave feedback, email us at blog@cdhowe.org.

The views expressed here are those of the author. The C.D. Howe Institute does not take corporate positions on policy matters.

Christy Clark - Regent Debate: Healthcare Needs a Private-Public Mix

From: Christy Clark

To: Canadian healthcare observers

Date: May 31, 2023

Re: Regent Debate: Healthcare Needs a Private-Public Mix

If we have the most expensive healthcare system or one of them in the world, shouldn't we also have the best healthcare system in the world?

Yes, we should. Sadly, we don’t.

There are 11 quality healthcare systems ranked by the Commonwealth Fund, based on outcomes – all in Europe and North America. The US is the worst, Canada ranks tenth – second to last.

Long wait times for surgery, poor access to doctors and worse outcomes overall, despite the fact that we spend more of our GDP on health than many other nations in the developed world.  

Clearly more money is not the secret sauce for making healthcare work better. If it was, ours would be outperforming every Western European system.

Premiers, facing fast-rising costs with few alternatives to cover them (except cutting other essential services like education) spend days at their yearly meetings debating how to persuade the federal government to make its promised contributions. 

But it’s never enough. It will never be enough. 

More money alone can’t fix the problems that plague our system because it’s the system itself that needs fixing.  People who work in health care have been telling us this for years. The pandemic and all the stress it brought to bear on our hospitals and care providers, have exposed those weaknesses for all to see.

What needs to change? First, we need to stop thinking of healthcare reform as a binary choice. It’s not a choice between what we have now, or having a private, American-style system in which the rich get care and everyone else is forgotten.  

Let’s stop comparing ourselves to the only system worse than ours and start asking ourselves what the nine better performers are doing and see what we can learn from them. 

The systems in Western Europe and Great Britain are each unique in their own ways, but all offer universal health care. All cover every citizen regardless of ability to pay, or existing medical conditions. All are publicly subsidized and regulated.

But all also offer a mix of both public and private care. Many of them a mix of public and privately operated insurance plans.

What they do not all share with Canada is the belief that all publicly funded services need to be delivered exclusively in publicly owned hospitals, nor do insurance plans need to be administered by government alone. Many have found different ways to deliver health insurance and services through both public and private providers, while still ensuring no citizen is turned away.

They recognize that granting choice to patients instead of locking them into a government monopoly, puts patients at the centre of decision making. For staff, who can choose where they want to work, it creates incentives for system managers to improve the environments in which they spend their working days.

Facilities spend less on bureaucracy and more on patient care. They track and report results carefully so that incremental improvements in care are possible. They find waste in the system and reallocate it to the services that directly affect patient outcomes.

The competition between healthcare facilities drives health innovation for patients and providers. We need that kind of profound reform.

Our system was designed for the Canada of the 1960s. It was a remarkable achievement that transformed our country in many ways, but it was built to serve the population of 1966. 

Drugs that cost a million dollars a year to treat just one patient didn’t even exist then. Nor did medicine have the capacity to extend our lives by decades or save the lives of newborns who arrived months early. We didn’t have the incredible (and incredibly expensive) technology that allows us to diagnose problems long before they develop into fatal conditions.

Perhaps most importantly, when Tommy Douglas and Lester Pearson envisioned medicare, the young outnumbered the old. In 1966, about 8 percent of us were over the age of 65. In 10 years that number could be up to 24.3 percent. 

Canadians and our governments did a great job collaborating during the pandemic.  We should be proud of the way we came together. But we’re not the only ones. The British and many European nations did a comparable job. 

Their relative successes weren’t determined by whether or not their governments had a monopoly on providing healthcare. It was the result of living in countries that care about social equity – like we do in Canada, like they do in the UK, France, Germany, and Denmark.

Change in the way we run healthcare in Canada is not just possible, it is vitally necessary. Our population is aging and healthcare costs are soaring. More money alone is no longer enough to keep it from collapsing under the weight of change. We need to change the way our system operates – give people and health professionals some choice about how and where they will get their healthcare.

There are plenty of good examples out there. None are south of the border. 

Christy Clark is the former premier of British Columbia.

This Memo is drawn from her argument at the C.D. Howe’s latest Regent Debate: Be It Resolved, Competition Will Save Canada’s Broken Healthcare System.

To send a comment or leave feedback, email us at blog@cdhowe.org.

The views expressed here are those of the author. The C.D. Howe Institute does not take corporate positions on policy matters.

Shaun Francis - Only Competition Can Rescue Healthcare

To: Canadian healthcare observers

From: Shaun Francis

Date: April 27, 2023

Re: Only Competition Can Rescue Healthcare

Twenty-five years ago, I secured the rights to a state-of-the-art telehealth system and brought it to Canada. Patients called a number to receive instant advice and be directed effectively to a proper level of care. I thought it would greatly benefit Canadians and save insurers millions.

In a single-payer system, like in Canada’s provinces and territories, my solution would have reduced the burden on emergency rooms and helped minimize staffing demands for hospitals.

But the Ontario government didn’t buy it. It ended up buying a low-cost nursing telephone line designed to generate revenue for hospitals, encouraging callers to visit a hospital emergency room.

Why? Because the upfront cost was cheaper – and the decision maker didn’t have responsibility for the operating costs of the hospitals. This type of short-sighted decision-making is characteristic of what happens day in and day out at government monopolies.

This is why we need a competitive private alternative to our universal public program, with a mix of private and public providers and competitive private insurers. Competition and the innate market-driven incentives that exist when customers can select from an array of options. This is what will solve our healthcare crisis.

Consider the debacle around Phoenix, Ottawa’s disastrous payroll software. Launched in 2016, its development and problems cost several billion dollars, yet its errors have affected 500,000 federal public service workers over the past few years. It’s so bad, and so riddled with errors, that it’s being replaced with a new system – at yet another enormous cost.

And what about the now infamous ArriveCan app? Experts have said the $54-million cost could have been less than $1 million. Not to mention the cost overruns and delays endemic to the purchase of the Canadian military’s badly needed F-35 fighter jets and new ships.

All these stories were the product of government monopolies.

In some ways, as Canadians, we’ve learned to expect such mismanagement. Yet so many of us hang on to the illusion that the monopoly in the insurance and provision of Canadian healthcare is somehow different. Our steadfast belief in a healthcare monopoly has resulted in a broken and outdated system.

Consider the 12-week median wait time between a general practitioner’s referral to consultation with a specialist. That’s about three times longer than in 1993. And if you’re in Ontario, how does your doctor make that referral? By fax. A technology so outdated and flawed it’s the leading cause of unauthorized disclosure of personal health information. Nearly 5,000 privacy breaches related to misdirected faxes were reported to the privacy commissioner’s office in 2021 alone.

Consider, too, that the cost of public health insurance for the average Canadian family (two parents and two children), adjusted for inflation, has increased more than 80 percent since 1997 and by almost 108 percent for a single Canadian. We spend about 12 percent of GDP on healthcare, more than 27 other comparable OECD nations. But among those countries, Canada is 32nd out of 38 in number of hospital beds, 27th out of 31 in physicians, and 17th out of 30 in nurses.

Emergency rooms are shutting down simply because hospitals don’t have enough staff. Foreign medical professionals can’t get licences. And too few medical school spots exist for Canadians. Canadians are dying before they get the care they need.

Some might say we just have to fund this system properly, hence the new healthcare accord between the federal government and the provinces. But that’s the same stopgap solution we’ve seen with every new federal-provincial deal.

Healthcare is already the largest budget item for every province, while across the country our population is aging. Per capita healthcare spending is significantly higher for those 65 and older. And spending on those 80 to 85 was already twice as much as all other age groups in 2017. Absent change, the growth in the number of Canadians 65 and older will result in roughly 88 percent more expenditures from 2019 to 2040.

As we run out of money, ideological dogma has given us one of the developed world’s worst-performing healthcare sectors. Often, we consider the United States as our only alternative. No one is suggesting we adopt its system. But in Canada, we don’t have a healthcare system; we have a queue system. And if Canadians want world-class care, we need to embrace world-class thinking.

Every system around the globe – Switzerland, the Netherlands, Germany, Japan and Singapore, to name just a few – performs better and has a competitive private alternative to its universal public program. These systems place the patients at the centre of their processes.

Only a model with more public-private competition can bring more efficiency, with more innovation, reduced wait times and better care than today.

Shaun Francis is the CEO and chair of Medcan Health Management. This Memo is drawn from his arguments at the C.D. Howe Institute’s latest Regent Debate: Be It Resolved: Competition Will Save Canada’s Broken Healthcare System.

To send a comment or leave feedback, email us at blog@cdhowe.org.

The views expressed here are those of the author. The C.D. Howe Institute does not take corporate positions on policy matters.

A version of this Memo first appeared in The Globe and Mail.

Dr. Danielle Martin - Collaboration, not Competition, Will Get Us Through Our Healthcare Crisis

From: Dr. Danielle Martin

To: Canadian healthcare observers

Date: April 28, 2023

Re: Collaboration, not Competition, Will Get Us Through Our Healthcare Crisis

In the real world of health service delivery, the last three years have taught us a great deal. The pandemic has been a test of endurance for healthcare workers for sure, but it has also tested our ability as a collective system to do something we don’t do enough: work together.

Here is an incomplete list of the results:

• We procured massive quantities of supplies and distributed them across the country: Personal protective equipment; swabs; hand sanitizer; ventilators.
  

• We massively ramped up testing capacity; stood up assessment centres, drive-through clinics, mobile outreach teams.

• We trained and retrained healthcare workers; instituted billing codes and protocols for COVID@Home clinics and virtual care for people with acute and chronic medical problems.

• We opened field hospitals and tents in parking lots. We participated in clinical trials to determine which drugs to use and at what doses.

• On the basis of data about who was most affected by the virus, and only because of unprecedented collaboration, we allocated resources accordingly when they were scarce – like testing, drugs and vaccines.

• We moved patients out of hospitals that were overwhelmed, whether that meant from Scarborough to University Avenue or from Saskatchewan to Ontario.
  

• We sent teams of workers into long-term care facilities to try to stem the impact of decades of poor design, understaffing, and under-resourcing on our elders.
  

• And we created one of the world’s most successful vaccination campaigns, learning from early design mistakes and adopting community-based strategies that were unprecedented at that scale.

The result was a world-class pandemic response, built entirely on collaboration and co-ordination. Resolving to eliminate competition and work together was the key to every success we had.

Competition, on the other hand, is what happened in New York City where, in the first wave, hospitals were overwhelmed with COVID patients while for-profit facilities up the street stood empty.

Competition is also what happens in the most dysfunctional parts of our Canadian health systems, where value for money is most elusive and frustration is highest.

Pharmaceuticals: where we have competition between multiple public and private insurers, among the highest drug prices in the world, and millions of Canadians not taking their medicine because of cost.

Long-term care: Where for-profit homes in Ontario competing to care for our elders had a 78-percent higher mortality rate from COVID-19 than not-for-profits.

Electronic records: where vendors compete for our business but have seemingly no incentives or requirements to be interoperable with each other.

Competition, in a true market for any good or service, requires a set of conditions, including a large number of buyers and sellers making homogenous products; perfect knowledge among buyers and sellers; and mobility of the factors of production.

None of these exist in healthcare, in Canada or anywhere else. Patients are not savvy consumers choosing between near-identical products on the basis of price or the bells and whistles. They are sick people in need of compassionate care close to home.

And providers are not in endless supply, able to move freely around the market. They are highly trained, expensive resources, who need to be marshalled to areas of greatest need. The World Health Organization is projecting a global shortfall of 10 million health workers by 2030, and in Ontario alone, there will be a shortage of about 33,000 nurses and personal support workers by 2027-28. Where exactly will the supply come from for competition?

We have a long road to recovery ahead. To suggest that other countries have it better is to ignore the reality plaguing us all: nurses are on strike for the first time in the history of the NHS in England, and President Emmanuel Macron has declared that he’ll be completely overhauling the French healthcare system. Healthcare workers have been on strike over working conditions and wages in the Netherlands, Spain, Germany and more. There is no system, no matter the mix of payment and delivery, that is not struggling today.

We are in tough times in Canadian healthcare and there are more tough times ahead. Service backlogs. Human resources shortages. Mental health impacts. The coordinated effort required to manage recovery will probably dwarf what we have just achieved. More competition and fragmentation is the last thing we need. Collaboration is our only hope.

Dr. Danielle Martin is a professor and chair of the Department of Family and Community Medicine at the University of Toronto. This Memo is drawn from her argument at the C.D. Howe’s latest Regent Debate: Be It Resolved, Competition Will Save Canada’s Broken Healthcare System.

To send a comment or leave feedback, email us at blog@cdhowe.org.

The views expressed here are those of the author. The C.D. Howe Institute does not take corporate positions on policy matters.

A version of this Memo first appeared in the Toronto Star.