By WILLIAM THORSELL
Monday, March 15, 2004
When the same problem recurs and deepens, and when vigorous efforts to fix it repeatedly fail, it is time to ask what the nature of the problem really is. Is there something wrong within Canada's health-care system that we can fix, and so keep the system pretty much as it is? Or do we have to look at significant changes to the system itself?
Roy Romanow's commission on health care concluded that we could fix the status quo with some new procedures and more public money. Canada's premiers seem to agree, with particular emphasis on the money -- federal money. Three weeks ago they emerged from a confab and said: "We state today as premiers of Canada that without real reform to health-care delivery and without the affordable and sustainable financial base that can only be provided by the federal government, the health-care system as we know it will not survive the decade."
That's pretty dramatic and quite probably true, because neither major internal reform, nor significant new federal funding is likely to occur over the next 10 years. The nature of health-care delivery is deeply embedded in professions and bureaucracies. And Ottawa's capacity to divert even more public resources to medicare from other programs and from the wealthier provinces is clearly limited.
It is time to review the nature of the problem itself. Canada is one of the few nations in the world that insists on a monopoly public payer for basic medical services. And Canada is one of the few nations that effectively prohibits privately owned hospitals and clinics to serve individual health-care needs.
The insistence on a monopoly public payer means that all the financial demands for basic insured care fall on government budgets. Ergo, we can only spend as much on basic health care as governments can afford. We have placed an official, legal cap on basic health-care spending for individuals, a true rarity in the democratic West.
It has predictable consequences. Because health care ranks so high in people's preferences, medicare claims a bigger share of public spending every year, starving other major priorities of resources even as it puts upward pressure on tax rates.
Ten years ago, health care consumed about 40 per cent of Ontario's public-program spending. Now it's 46 per cent, as health spending has risen by 8 per cent annually over the past four years. That's typical of all the provinces.
You wonder why schools, universities, cities and highways are tawdry and second rate? Love that medicare. And the premiers warn that medicare itself is heading for the wall unless we divert even more public spending to the beast.
The problem isn't the stinginess of the monopoly payer. The problem is the system of monopoly pay.
The related issue of reform and innovation derives from the same root: the effective state monopoly on the provision of basic health services (with the exception of most doctors, who remain private professionals contracted to the state).
Enormous bureaucratic systems, webbed by professional and union interests, are fundamentally hostile to significant reform, as legions of health ministers have learned. The problem is not the inertia of the state monopoly administration, it is the monopoly itself.
Yet we say we will fix the monopoly-money problem in good part by reforming the monopoly-administration problem. It doesn't compute.
"The health-care system as we know it will not survive the decade," say the premiers. The implication is that it will either deteriorate beyond recognition, taking most other public programs down with it in a desperate effort to find more funding. Or the monopolistic constraints on pay and delivery will go, allowing far more resources to flow into a system that allows for far more diversity in delivering services.
Behind all the rhetoric, that's really what the premiers are saying. We have a choice; let's start honestly making it. William Thorsell is director and CEO of the Royal Ontario Museum.