to justify, but the fact remains that all the facilities were needed and overdue. Quebec’s flagship hospitals were crumbling, inefficient and increasingly unsafe. (It’s no coincidence that Quebec had an inordinate number of hospital-acquired infections such as C. difficile.) Quebec’s political leaders should have received credit for their bold investments in health care. Instead, they received derision because they took too long to do the right thing. They lost sight of who really matters: the public. An endless list of excuses was trotted out each time a minister made a new announcement and revised the timeline for construction. But the bottom line is that these hospitals should have been up and running at the turn of the new millennium. The delays served the interests of property developers, construction companies, donors to political parties and various interest groups within the health system, not the sick and injured who needed hospital care.
Almost two and a half decades after planning began, the MUHC finally opened in April of 2015, while the CHUM is slated to open sometime in 2017. That no premier or health minister ever demanded that the shuffling of paper end and the roar of construction equipment begin is a disgrace, plain and simple. In Canada, we talk a good game about patient-centred care. But it will never be a reality unless it becomes a priority and a guiding principle from the upper echelons of power on down.
When even Dr. Optimism is losing faith in medicare, it’s time to fix it
“We have seen a slow and steady decline in what we would all now agree is a deeply troubled health-care system. To be clear, this pillar of Canadian society is eroding … We are losing something of great value. It’s slipping away slowly, incrementally.”
This kind of rhetoric is so commonplace that we have become largely inured to it. At first blush, it’s another medicare-is-doomed pronouncement much as we’ve heard seemingly every day for the past half century or so. But pay attention this time—those mournful words were spoken by Dr. Jeffrey Turnbull, past president of the Canadian Medical Association, in his valedictory address of August 2011.
Turnbull is one of the most unwaveringly hopeful and positive people in medicine. He knows the Canadian health system inside out, and from the bottom up. He cheerfully treats poor, homeless addicts as part of Ottawa’s Inner City Health project. He is equally upbeat as chief of staff at the Ottawa Hospital, a thankless position. He affably headed the CMA, which speaks and lobbies on behalf of the single most powerful and prickly group in the health system, physicians.
If Turnbull is losing faith in medicare, we need to prick up our ears—and roll up our sleeves and fix it. When he expresses his frustration, it is not rhetoric. He backs his feelings with cold, hard facts and incisive anecdotes. “I’ve always been immensely proud of our health-care system—one that was once considered to be one of the best in the world,” he told CMA delegates. “But times have changed and Canada now ranks below Slovenia in terms of effectiveness and last or second last in terms of value for money.” Ouch. Equally scathing is his summary of the frustrations he has heard expressed by patients in his travels coast to coast. “They’ve told us they’re suffering because of a lack of access to timely, effective care, confused by a system that is limited in the services it provides, that is cumbersome and almost too complex to navigate, and angered by a system that fails to put their needs first or even engage them about their health issues.”
That takes care of the international comparisons and shortcomings in care delivery. What about administration of the $228-billion-a-year health system? “I’ve been struck by the lack of leadership, co-ordinated management, accountability, and responsibility—and, yes, needless waste,” Turnbull said. “Worse, we allow staggering inefficiency, ineffective management processes, incoherent decision-making and practice variations that undermine quality and safety.” Despite it all, he remains optimistic. “I do believe this can be changed ... that we can create a better health-care system in the future.”
Turnbull has a diagnosis and a prescription. It begins with getting back to basics. Medicare—and other social programs—were created to address social inequities, to make good health achievable and affordable for all. Yet today in Canada there is “devastating and epidemic health inequity”—and it has become a major driver of health costs. One way to address inequality in health-care delivery is to ensure all Canadians have access to a basic level of prescription-drug coverage, a “glaring failure” of medicare, Turnbull said. Similarly, there needs to be a massive shift in approach (and resources), from the 1950s-style illness-care system we have now to a twenty-first-century health system that emphasizes chronic care and prevention.
In his time as CMA president, Turnbull championed this transformation. He created a blueprint, a document titled Health Care Transformation in Canada: Change That Works, Care That Lasts. It’s by no means perfect, but it’s a start. It does not merely advocate shoring up the system that is eroding but rebuilding it from the ground up—all the while keeping the foundation, the public insurance model. As Turnbull told his CMA colleagues, “Leadership demands vision to see the path before us, the courage to take it and the strength to follow it.” Not just hope, not just words, but purposeful actions.
Is Canada’s public health-care system financially unsustainable?
It is often stated that Canada’s health system is unsustainable—a vague, undefined term that is used as a synonym for unaffordable. The problem is the unsustainability argument is based on a few dubious assumptions:
that annual spending will continue to grow at the same rate as in the past, if not faster;
that the aging of the population will actually accelerate the spending increases; and
that nothing can be done to reduce spending. This, in turn, assumes that nothing can be done to change the way we deliver health care or to keep people healthier longer.
In short, it is a pretty cynical world view. And, more importantly, concrete solutions are rarely proposed to alleviate the problem, other than to privatize more health services. Philosophical arguments aside, doing so does not reduce overall costs but merely shifts them from the collectivity to individuals, from public insurance plans to private ones or, worse yet, to out-of-pocket costs. What this dreary set of assumptions does do, however, is remind us of one of the major failings of Canada’s publicly funded health system: we do very little planning and analysis, especially of a financial nature. That’s why a 2013 report from the Canadian Institute of Actuaries was a welcome contribution, albeit a modest one.
The CIA (the actuaries, not the US spy agency) undertook a straightforward task: to create a model for projecting future health-care costs. They chose the province of New Brunswick as an example of how that model could be used. The limitation was that the modelling exercise examined only steady-state health-care costs—meaning costs based on the assumption that there would be no changes to health-care coverage or financing, and no major changes in the economic environment. But this was nonetheless useful because it provided some concrete data about what health spending would look like if all things remained the same. In this analysis, health costs were predicted to rise 4.43 percent annually until 2020, just as they had done in the previous decade. Practically, that meant the provincial health budget would increase to $4.6 billion in 2020 from $2.8 billion in 2009. Per-capita costs would rise to $5,976 from $3,711 in that same period. Put another way, at the time of the study it cost about $75 a week to provide health care to each of the 750,000 residents of New Brunswick. By 2020, it will cost $115 a week. (That is slightly above the Canadian average.)
Is that unreasonable? Unsustainable? The actuaries’ report didn’t answer those questions. It just crunched the numbers. But data make for a much more concrete discussion than rhetoric.
