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What's the End Game?

We see problems with healthcare across Canada, but when you dig deeper, the specifics, the reaction, and the solutions often look very different. I've often said that there are broad societal trends at work, but they manifest differently depending on where you are. This essay covers the biggest one: the financial sustainability of our healthcare system.

There's a widespread belief that, given the escalating costs, the healthcare system as we know it can no longer be sustained. To preserve a core of public healthcare, the argument goes, it will be necessary to scale back what is provided. Therefore, many things we have traditionally known to be part of the public healthcare system will be excluded. They'll be left to be paid for by private individuals who can afford them. Hack off a diseased limb to save the torso, so to speak.

Is it necessary? If so, who decides what's essential and what's not? And why are we stumbling into this future in such a destructive way rather than pursuing a rational, managed transition?

The Sustainability Question

Politicians will be the first to tell you that they don't understand the details of the healthcare system. Their job is not in the details but in managing the big picture. They know that they're not doing that well right now. They're overwhelmed and trying to cope. Like everyone, they rely on other voices to help guide them. We'll return to who those voices are later.

One consistent theme has emerged across the country (and beyond). The cost of healthcare continues to grow and eats up ever-larger portions of government budgets.

Left unchecked, healthcare spending could easily swallow every dollar available and still want more. At a profound level, this is the message that political leadership has absorbed. Is it true? Probably yes.

Protecting Public Healthcare

Despite what you probably think, I don't know of any mainstream Canadian politicians who want to destroy public healthcare. They all believe in a healthcare system, particularly for "basics"and catastrophic situations (traumas, cancer, etc.), available to all Canadians. That's just part of our DNA in this country.

So how do you reconcile the universal desire for a core system available to all with the financial realities? You find a way to limit what's covered and universally available. Doctors in, dentists out. Cancer care in, medications out. No mystery, this is what we have always done.

What's different now? We're at the point where many feel some services (traditionally available to all) need to be removed to ensure a (smaller) core system survives.

Future of Healthcare

This future can come in various forms, and eliminating public funding for some services does not necessitate a descent into US-style healthcare.

Like dental care, like cosmetic procedures, like medications outside of hospitals, it will not be the end of the world if certain services are no longer funded. A step backwards, sure. But people would adapt. They'd pay privately, rely on third-party insurance, public funding for those with lower income, upsells for premium services, and all the other mechanisms we've used before.

What is an essential and core service isn't some fixed universal truth. It changes all the time.

If some essential services can also be paid for privately, does that necessarily spell the death of public healthcare? Most countries seem to work fine under this model, so no.

Would it be a disaster if implemented in Canada? Done in an uncontrolled way, without carefully managing to ensure that a sufficient service level was maintained in the public system, it would absolutely be a disaster. Is it theoretically possible to be done in a controlled way? Sure. But in practice…

Avoiding the Third Rail

The rational thing to do would be to have an honest public discussion about the hard choices that need to be made. What services can be reasonably excised from the system… still available to those who want them, but not paid for by all.

No politician could ever afford to start that discussion. Healthcare is such an ingrained part of our identity, that any perceived threats are greeted with a visceral reaction. It would be political suicide.

Familiar Reactions to Crisis

As the healthcare situation deteriorates to the crisis facing us, politicians are faced with impossible choices. They've reached the point where they feel pouring more money into healthcare is not viable. At best, it will delay the inevitable while starving every other priority in the process. Yet they can't publicly acknowledge that changes are needed which would involve cutting any services.

When faced with two excruciating choices, what's the usual response? Do nothing.

If changes in the public system are a foregone conclusion, why put themselves in harm's way? Let others be blamed. When family doctors withdraw en masse from public health insurance and move to a direct primary care model, it's not the politicians' fault.

If you squint at it in just the right way, you can almost justify it as short-term pain for long-term gain. Almost.

Protect the Core

How do you square that with the earlier statement that politicians believe in a core public healthcare system?

Faced with what they see as inevitable, they try to protect the parts they consider absolutely vital and essential. Save the core. Who decides what those core parts are? Who decides how they'll protect them? Without public consultation, they rely on their own experiences, intuitions, and advice from those closest to them.

Those experiences, intuitions, and advice vary considerably. And remember, we're not talking about people with a deep understanding of the healthcare system.

Ontario

In Ontario, we see Doug Ford's privatization solution at work. How does that make sense? It's not a secret that a core belief in his camp is that governments do things less efficiently than private businesses. If the existing public system isn't sustainable in it's present form, but you want to preserve as much of a public system as is feasible to do, it's important to maximize the value of every dollar.

So, based on his underlying worldview, shifting as much as possible to private hands is seen as getting the most public healthcare value from taxpayer dollars. Better the government funds an efficient private provider than a lazy unionized government worker. Obviously. That's what's best for public healthcare.

Of course, this is bullshit, but again, look at the worldview of those involved. It makes sense to them, it's how they think, and they can't discuss it publicly.

British Columbia

BC has responded to the same perceived inevitability (that the system isn't sustainable in its current form and will need to contract) in a very different way. Adrian Dix, the health minister driving most of the changes, is about as far away from Doug Ford as you can be. He's a socialist through and through and believes strongly in the power of big government. But, he recognizes that substantial cuts are necessary. His vision is to protect a core part of the medical system by bringing it under government control (where it will be run best) and sacrificing some of the elements on the fringe considered less essential.

So BC has seen the establishment of (incredibly inefficient) government-run primary care clinics, driving small independent family doctors out of business. In the long run, he sees these clinics making sure the core services are taken care of for everybody. Private businesses can (begrudgingly) be left to handle the nonessentials. That will include many things we now consider essential but cannot continue supporting. It's a rough transition, and in the short term it's causing a lot of pain, but that's the solution he sees in the long term.

Two very different ideologies and responses.

The starting point for both is the firm belief that a substantial contraction of public health funding is necessary and inevitable. Better to support a strong core than let the entire thing collapse.

Land Grab

What happens to all those things that are no longer deemed essential enough to be publicly funded? The demand for them does not disappear. That leaves an enormous vacuum to be filled by for-profit businesses.

It's not an exact parallel, but think of what happened after the collapse of the Soviet Union. How resources and responsibilities formerly managed by the government were absorbed privately, often at fire-sale prices. There will be a big shift in who pays for large amounts of healthcare here. Those who get in early stand to benefit the most.

Key Decisions

The battle for the future revolves around two key questions.

First, what services are deemed nonessential and will be excluded from public healthcare funding in the future?

Second, who will be able to provide those services, and with what restrictions?

These are serious questions that should be carefully considered by a wide audience. But as we've seen, that can't and won't happen.

The political decision-makers need advice to better understand the serious decisions they have to make because they don't (and can't) fully understand the system and the consequences. They're trying to do what's best. Many of the experts they turn to have other interests to serve. That's normal.

They try to exert influence, e.g., describing how they can do things more efficiently than a government-run organization. Or how "preventative care" is something different from essential primary care, so why not split that off into an optional private sector service?

And, of course, those who stand to profit the most out of such a transition are at the same time making investments. They want to ensure they're ready to fully take advantage when the time comes, even if that means weakening the public system in the meantime. Outside the politicians' control.

Winners and Losers

There will be big winners and losers based on the answers to those questions. So those who stand to benefit are working hard to influence the decisions being made behind closed doors. And I don't mean necessarily by nefarious methods.

Who is best positioned to have the most influence and best prepared to gain "first mover" advantage? Large, well-organized corporations like Telus and Loblaws.

Certainly not doctors, who are often clumsy and ineffective when it comes to having influence, don't have the skills, and are usually engaged in internal feuds. They're rarely able to present a united front, even in the face of a significant existential crisis.

Inevitable?

It may well be that we need to make reductions in public-funded healthcare services to ensure the sustainability of the system.

However, what those reductions may be, and how small or large they are, is not a foregone conclusion. Many politicians are convinced that not only is the contraction of services inevitable but that the only choice they have to make is how much money they're spending. Trying to fix healthcare means more money, and it's just not there.

They've been led to believe that how they spend that money doesn't matter. But it does.

At the end of all this, we're still going to be spending public money on healthcare. If we use it effectively, we can provide more and better services for the same money than if used inefficiently. That means less needs to be spun off into private hands.

Instead, we're using existing healthcare funding in some of the most inefficient ways possible, whether contracting out services at a higher rate or redirecting massive sums away from front-line care and into administration and over-priced facilities.

The result of that is when things finally collapse, and when the "core" of public healthcare is shored up, it will be much smaller than it could be.

I think that we'd all be better served if individual doctors had more control of scarce public financial resources than governments and large private corporations. As I've talked about before, the incentives are well-aligned to encourage maximal efficiency and public benefit with minimal public risk. By spending the same amount of public money, we'd be able to preserve more of our public healthcare system.

What's Missing?

How much we spend on public healthcare is a question that should be up for open debate. Then spending that money most efficiently, subject to public scrutiny, should be the objective. We can then have the difficult but necessary conversations about what we may not be able to afford and plan for an orderly transition with the least disruption.

Given the multiple competing interests of so many different people and organizations and the raw emotional reactions that crop up regarding healthcare, I don't see that ever happening.

And so, based on the best intentions to preserve this jewel of our Canadian identity, we're instead pursuing a worst-of-all-possible-worlds strategy.

This will result in the largest possible contraction of our public healthcare system.

It is also causing the most severe damage and disruption as we make the transition.

In Canada, we don't have the difficult conversations.