Fighting to deliver ‘free’ healthcare: a blood sport
Milan Korcok discusses the public healthcare situation in Canada
Ask any given group of Canadians about ‘privatising’ medicare – their national system of publicly – funded provincial health insurance plans – and you’re sure to hear primal screams from a majority: “No way!”. It would be as blasphemous as calling for a TV blackout of hockey on a Saturday night.
Medicare is the great unifier: the national icon that differentiates Canadians from Americans (who just can’t seem to get their healthcare right). It’s what Canadians brag about to people of other nations. But it’s also what they increasingly complain about at home, among themselves, for its shortage of family physicians, long wait times for specialist care, hospital bed crowding and emergency room backups. Sound familiar?
You have only to look at England’s NHS, to find a doppelganger – sort of. Back in the 1940s, when Britain’s health secretary Aneurin Bevan was launching the publicly–funded National Health Service; and Tommy Douglas, Premier of Saskatchewan was setting the model for what would become North America’s first universal healthcare system – to be known 20 years later by all Canadians as medicare (small m), there was enthusiastic public support for a social experiment that would provide all necessary healthcare to all people ‘free’ at the point of service without their having to endure the humiliations of ‘charity’ care. (Actually, Saskatchewan introduced universal hospital insurance in 1944, four years before Bevan launched the first NHS hospital in Manchester).
Two separate, national plans, both premised on a similar principle that healthcare was a national responsibility to be paid for by public funding out of tax revenues – with little intrusion by private sector (i.e. for–profit) interests dedicated to making money off the sick and bereaved (as some more zealous proponents for mission purity would often put it).
Though similar in intent and ideology, there are some major differences in the two systems: one especially key one being that Canada’s medicare bans private health insurance for core medical services (virtually anything medically necessary). There is one regional exception—we’ll deal with that later. But essentially, private insurance is allowed only for supplemental items like dental and eye care, elective services, executive checkups, pharmaceuticals (except for the elderly), and some adjunctive services like chiropractic or naturopractic.
The same but different
Unlike the NHS, the vast majority of Canada’s hospitals are private, non–profit entities
funded largely by global budgets provided by health ministries; and doctors are private business owners – mostly paid for their services by one single payer – the government.
In the UK, parallel private health insurance is allowed, and about 10 per cent of the population takes advantage of it and pay fees for it. Private practitioners, mostly specialists, provide the services in privately owned hospitals and clinics where many NHS salaried physicians also ‘moonlight’ to supplement their NHS salaries.
Though both systems are solidly supported by their publics – poll after poll attests to that – their evolution over the years has generated powerful reactions by many groups, most vociferously by doctors’ organisations fearful of restraints on their relationships with patients, their own working conditions, their abilities to control use of resources and not least, their own earnings.
Both systems have spawned a history of physician strikes, work stoppages, opt–out schemes, acrimonious labour negotiations worthy of the surliest of coal miners’ disputes and yet, they have survived, and grown, and grown and grown.
And there’s the rub. Have they grown so much over the years that they threaten their own basic, fundamental values and mission: to provide all necessary healthcare to their respective populations without discrimination based on age, health status or financial circumstances and at public expense? Have they just become too expensive for the public purse alone to sustain – or perhaps more pertinent, are there other ways governments choose to spend tax money?
To judge by the deteriorating relations between NHS trusts and their doctors– – more work, less pay, longer hours; and the hate–filled fee–setting negotiations between physicians and government healthcare administrators in Canada’s largest province Ontario in recent years, one might hold on to one’s ballot.
Fast forward
According to the NHS’ own data, the NHS in England deals with over 1 million patients every 36 hours – it caters to a population of 54.3 million and employs around 1.2 million people – a workforce which it explains is one of the top five largest in the world along with the US Department of Defence, McDonalds, Walmart and the Chinese People’s Liberation Army.
neither the NHS nor Canada’s provincial health insurance programmes can avoid the ravages of underfunding
Canada’s medicare can’t match those numbers, but it can boast of being one of the developed world’s (OECD) top seven spenders on healthcare (more than 11 percent of GDP), and of having more healthcare government bureaucrats per population (0.9 per 1000) than any other OECD country with a universal healthcare system. According to original research by Matthew Lister, Senior Director Strategic Planning with the Ontario Medical Association, Canada’s 32,000 healthcare bureaucrats account for a ratio of 0.9 per 1000 population. By comparison, Sweden has 0.4 healthcare bureaucrats per 1000 population, Australia 0.255, Japan 0.23, and Germany (one of the most effective and efficient systems tracked by the OECD) has but 0.06 per 1000 population.
Stalwart though they are, and firmly rooted in the sanctity of public funding and accountability,
neither the NHS nor Canada’s provincial health insurance programmes can avoid the ravages of underfunding and its fractious effects on hospital services and staffing, physician availability and access, technological obsolescence, and public frustration with accessibility.
According to the highly–respected British think tank The King’s Fund, there are approximately 240 NHS and foundation trusts providing NHS ambulance, hospital, community and mental health services in England. Just five years ago, in 2010/11, just five per cent of those trusts overspent their annual budgets. The most recent figures show that 51 per cent of all trusts are planning to end the 2016/17 year in deficit, and last year 66 per cent actually ended their year in deficit. Nearly three–quarters of these trusts are acute care hospitals.
Furthermore, in 2012/13 NHS providers recorded a surplus of nearly £600 million in aggregate. Since then, provider finances have deteriorated sharply with an overall deficit of £2.5 billion recorded in 2015/16. And according to the Royal College of Physicians, the NHS in 2016 was: underfunded – 85 per cent of physicians believed that current health service funding was not sufficient to meet demand; underdoctored – falling numbers of medical students and a shortage of doctors were training to be medical specialists; overstretched – doctors–in–training were working an extra five weeks a year on top of rostered hours.
A similar picture of public underfunding exists in Canada where healthcare spending for 2016is projected at CA$228 billion, up 2.7 per cent over 2015, amounting to 11.1 per cent of GDP and equalling CA$6299 spent per each individual Canadian. That puts Canada among the top seven highest OECD spenders – most of whom have hybrid or mixed public/private funding sources: well behind the US, which spends a whopping 17 per cent of its GDP on healthcare, but in a cluster with France, Switzerland, Germany, Sweden and the Netherlands. (The UK is down at around 9.9 per cent of GDP – about the average of all OECD countries.)
As analysts at the Canadian think tank the Fraser Institute have noted, for a country that spends so much on healthcare, “Canada has substantially fewer human and capital medical resources than many peer jurisdictions that spend comparable amounts of money on healthcare. After adjustment for age, it has significantly fewer physicians, acute–care beds, and psychiatric beds per capita compared to the average of OECD countries,” and while it has the most gamma cameras per million population, “it has fewer other medical technologies than the average high–income OECD country with universal healthcare, for which comparable inventory data is available.”
The number one target
But what is perhaps most significant, according to the Fraser Institute’s annual tracking of patient wait times for consultations to specialists and referral to appropriate services, is that at any given time, almost one million Canadians (out of a total population of 35 million) are on waiting lists for necessary medical services – a record exceeding that of any other OECD country with a universal healthcare system.
Despite such waiting lists, and with provincial governments all fighting growing budgetary deficits, it’s inevitable that healthcare, which accounts for 30 to 40 per cent of any province’s budget, is the number one target for politicians and bureaucrats wielding budget restraints, and the methods used are not subtle.
In the province of Ontario, which is home to some 30,000 physicians – the vast majority of whose earnings are based on publicly–negotiated fee schedules – vehement arguments over fee cuts and other restraints in 2015, 2016 and 2017 have almost drawn blood from dissident groups in the Ontario Medical Association who feel their own association (the OMA) has capitulated to health ministry bureaucrats in its fee negotiations. The tensions between the factions earlier this year surfaced in ugly social media exchanges that resorted to obscenities and even physical threats.
In a warning shot fired in January 2017, OMA President Dr Virginia Whalley asserted: “It is with profound disappointment that we (Ontario’s physicians) must consider job action in order to achieve binding arbitration, which is necessary to right the current power imbalance with the government….The government is knowingly underfunding the medically necessary care that patients need and have forced the creation of long waiting lists for tests and treatment.” The OMA ultimately won the right to binding arbitration: the results yet to be known.
At the NHS, strikes, boycotts and battles between doctors fighting for what they believed was their right to retain independent contractor status rather than become salaried employees have dated back to the earliest days of the system, 1947, and have resurfaced regularly in the interim.
Jack Saunders, a research fellow on the Cultural History of the NHS Project at the University of Warwick writes in an article for The Guardian: “Over its 67 years of existence, doctors in the NHS have forged an increasingly strong relationship to the service and to colleagues. Decades of working together for an embattled public institution seems to have forged a new solidaristic collectivism, enabling them to now use ‘defence of the service’ and inter–occupational solidarity as an increasingly important weapon in their collective action.”
On both sides of the Atlantic, therefore, the ‘us vs them’ mentality is strong and thriving among medical professionals and the services in which they work.
Early this year, after Treasury rebuffed a request for more funding, NHS England’s chief executive Simon Stevens approached hedge fund investors to borrow up to £10 billion to update hospital buildings and equipment systems, improve specialist care at GP surgeries, develop quicker treatment for cancer and mental illness, and a whole range of other critically needed fixes. The revelation of his appeal alarmed privatisation sceptics, especially media who characterized the advances to private lenders as ‘supping with the evil’ or worse – one step closer to privatisation.
the NHS has a not–altogether happy history of dealing with hedge funds and other private investors and some of these activities have resulted in bottom line losses to the service in the recent past
Indeed, the NHS has a not–altogether happy history of dealing with hedge funds and other private investors and some of these activities have resulted in bottom line losses to the service in the recent past.
In revealing Stevens’ approach to hedge fund investors, The Times commented that the Treasury has a poor opinion of NHS financial management skills, particularly in dealing with fiscally sophisticated hedge fund ‘bosses’. Referring to a programme of Private Funding Initiatives from the Tony Blair era, The Times noted that “Although this helped dozens of shiny new hospitals get built, many believed that they would have been cheaper in the public sector. The NHS is still paying £2 billion a year under PFI deals, with some hospitals claiming that they have had to cut other services to meet inflexible repayments.”
In Canada, eventhough private insurance is banned for core medical services, 30per cent of healthcare costs are covered by private sources through supplemental insurance, out-of-pocket charges for drugs, eyeglasses, dental and elective services, and increasingly – private clinics, some of which contract their services to public sector facilities.
Private clinics, such as MRI facilities and outpatient surgeries, are also emerging in more locations, allowing people who can afford out–of–pocket services to ‘beat the queue’ and avoid waiting months for scans at their public community hospitals.
Can the ‘free for all model’ be recaptured?
Though the expansion of such entities appears to be irreversible, it continues to stoke hostility by anti–privatisation constituencies who see private funding as an attack on the very ideology that spawned public healthcare.
Many opponents of privatised services complain that it’s unfair to allow people who can afford to pay for certain services any advantage over those who can’t: the consequence of which is to disadvantage all.
In 2005, the Supreme Court of Canada, took up a case in which Dr Jacques Chaoulli and a patient who had to wait several months for a hip replacement sued the province of Quebec claiming it was unjust to disallow citizens buying private insurance for publicly–insured health services that couldn’t be accessed. In a surprise verdict, the court sided with Dr Chaoulli and ruled that the provincial government could not prevent people from paying for private insurance for healthcare procedures covered under medicare, that “access to a waiting list is not access to care.”
The case emboldened supporters of private healthcare funding across the nation: in Winnipeg, a privately funded surgical centre offers MRIs for $695 to people exhausted by waiting for diagnostic services in the public Queue. The MRIs are done by technologists who left the public service. In Quebec the government itself is allowing private medical insurance for higher quality treatments. The governments of Nova Scotia and Alberta are exploring the use of private facilities to bolster their public services.
And in British Columbia, private clinics offering outpatient surgery and other services are thriving. One of them is directed by Dr Brian Day, a past president of the Canadian Medical Association, now a leader of what he terms is “Our constitutional challenge against government laws that ban private insurance for medical services…”
The challenge to the ideology of ‘free’ medical services for all – in England or Canada – is whether it can be advanced without degrading health services or diminishing those who must provide them. One must be able to support one’s ideology, or if the money isn’t there, be prepared to compromise – even if it means supping with the devil: an exercise in having it both ways.