Health care’s great divide

A relatively small group of engaged Canadians has become convinced that dramatic reforms are required to our health-care system to rein in surging cost increases while at least preserving — and hopefully improving — quality. This group bemoans the absence of public debate but nonetheless assumes that government will lead the reform charge.

That won’t happen. Most Canadians are not concerned about pending financial threats to health care. To stir this complacency would make toxic politics.

Governments will act only if they are finally boxed into a fiscal corner, as in the mid-1990s. That episode had an unhappy ending: the fiscal savings proved temporary but the bad taste from the threat to the quality of care still lingers.

More sensible reform will have to be led this time by those most directly involved in health care. Doctors, nurses, hospitals, drug companies, policy analysts and others will have to collaborate to develop options and work through the media to communicate the choices to the public. Only when the communications and conditioning have been done will governments step up to the plate.

The latest demonstration of the divide between analysts’ concerns and public perception of health care was revealed in a poll done by the Gandalf Group on behalf of the Healthcare of Ontario Pension Plan and released in late 2010.

It confirmed that health care is Ontarians’ top priority and revealed little concern over soaring costs and the implications for squeezing out other valued public services or causing ever-rising taxes. But then the respondents had little idea that health consumes almost half of Ontario’s program spending or that, as estimated by TD Economics, it could rise as high as 80 per cent by 2030 if things go on as they are. So the complacency on the fiscal threat must be discounted.

The first challenge for any government to lead the reform charge is the awkward juxtaposition of offering a solution to a problem that most people don’t recognize. The second is institutional. The federal government walks on eggshells in this field of provincial jurisdiction. It will be dragged into the issue when it sets the growth rate for Canada Health Transfers when the current deal expires in 2014. Most likely, it will announce a growth rate around 4 per cent, or 2 percentage points below the current rate of annual increase, and say the provinces should be able to sort out things with such financial support.

It would be logical for the provinces to work together as they all face an underlying growth rate of at least 6 per cent annual increases in health care while their revenues will grow much more slowly. But so far there are only a few examples of the provinces acting together, such as addressing tainted blood and promising an agency to bulk purchase drugs.

Ontario will soon prove a testing ground for provincial engagement. With health care the No. 1 priority and the No. 1 fiscal headache, it may seem natural to assume it will loom large in the coming provincial election campaign.

More likely, the Liberals and Conservatives will duck the issue. The Liberals will assume the issue is a mild positive for them due to their actions on wait times and drug costs. They will worry that if they push efficiency the eHealth scandal will be thrown in their face. Conservatives will fear the slap from memories of the Mike Harris cutbacks if they get boisterous on pushing for cost control.

The good news from the Gandalf survey is that Ontarians are not fussed whether health-care delivery is through public or private means, as long as they can pay with their OHIP cards. But so far the debate remains within a small circle. That leaves it up to the stakeholders — the people actually involved in the system.

As gatekeepers of the system, doctors will need to step forward with suggestions for improvements to efficiency and quality. Doctors and nurses will have to sort out respective duties. Drug companies should propose cost savings before governments ultimately impose something on them.

Academics and other researchers need to make concrete proposals and raise the bigger questions, such as how to promote good health and whether drugs and longer-term care should be more in the public sphere. Universities and think-tanks need to bring everyone together. All those involved will have to work through the media to engage the public in a thoughtful rather than threatening manner.

Within the next 10 years Canada must have a very different health-care system — one that is much more efficient and delivers higher quality and greater inclusiveness.

It will likely still have the cherished single public payer feature, and indeed that might be extended to some areas like drugs and longer-term care that are now largely in the private domain. But the delivery of services within that public payer model will likely have a larger private sector presence. And the focus will need to shift to the prevention of health problems.

The path to this destination will not be easy. And the trail will not be blazed by governments. Instead, the stakeholders will have to up their game and bring it into the public arena. Only then will governments feel comfortable in joining the effort.

Don Drummond who wrote the above is a former chief economist at TD, is the Matthews Fellow and distinguished visiting scholar in the School of Policy Studies at Queen’s.