Our health ministers need to take a lesson from hockey coaches

Those of you who are tired of my rants about the demise of our once great health system will be pleased to know that this is my last editorial. I am retiring from the BCMJ Editorial Board; currently, I am the longest-serving member (more than 20 years). I have been a supporter and fan of the journal for even longer; my first BCMJ article was published in 1981.[1]

It will surprise no one that I will end my term with a commentary on the state of medicare. The topic has gathered a lot of media attention recently, related to the nationwide suffering of patients. Ironically, the Conservative premier of Ontario, Doug Ford, has been attacked for contracting out procedures to private clinics, something that was started under the BC NDP government of the 1990s and continues today. His decision resulted in me being deluged with many media interviews and caused me to write an editorial in a national newspaper.[2] My philosophy is largely based on the premise that no monopoly serves the recipients of its services well. The evidence is clear that competition in health care saves lives and reduces costs.[3]

The five principles of the Canada Health Act are public administration, comprehensiveness, universality, portability, and accessibility. But governments are not conforming to the latter four, and even the first principle should be renamed “state control.”

The principle of comprehensiveness is not respected. Physicians understand that excluded provisions such as medications, ambulances, physiotherapy, artificial limbs, psychologic counseling, speech therapy, preventive care, and even dentistry (an abscess in a wisdom tooth may penetrate to the brain) are more “medically necessary” than the diagnosis or treatment of tennis elbow in a recreational tennis player with a sore elbow after a 4-hour game or a mild case of plantar fasciitis after running back-to-back marathons.

Most Canadians are unaware that virtually all the excluded services listed above are covered in every developed country that offers universal health care.

As president of the Canadian Medical Association (CMA) in 2007–2008, I lobbied hard for prescription drugs to be available for all. Canadians are 3 to 5 times more likely than residents of comparable countries to skip prescriptions because of cost issues. A 2012 Ontario study[4] estimated that the lack of insurance for medications for working-age individuals with diabetes was associated with 5000 deaths and nearly 2700 heart attacks over a 6-year period. Nationally, of course, this toll would be far greater. Physicians are aware that many Canadian patients (a CMA report revealed it was 1 in 3) who do not have private extended health insurance go without necessary care.

However, my recommendation on extended coverage was intended not to expand state bureaucratic control, but to fund premiums to existing independent providers for the minority who lack and cannot afford such coverage. I can illustrate my concerns with a hypothetical three-phase scenario.

Phase 1: In a pre-election speech, the Minister of Health announces that, if re-elected, his party will add coverage for all currently excluded services (as listed above) to the existing medicare system.

Phase 2: The promise leads to re-election with a massive majority. Extended health plans and self-funding for such services are all rendered unlawful since the state will now cover them all.

Phase 3: Within 2 years the costs have become so high that the government caps funding and rations access to pharmacists, physiotherapists, ambulance services, dentists, prosthetic limb suppliers, etc. Long wait lists to access those services result, and those in need suffer.

The above accurately describes the current state of our medicare system regarding physician and hospital services. I view the elimination of choice in the presence of enforced rationing as unethical and immoral. I hope the highest court in the land will also find it unlawful.

Our governments have historically deemed the concept of equality as paramount, when in fact, Canada ranks very low among its peers in terms of equality and equity. This is not a rich versus poor discussion. There is no health care system in the world in which the rich suffer. An Italian law expert described Canada’s health care system as being designed for the wealthy who can afford to travel to the US if they really need care.[5] Many politicians have extolled the virtues of our system while following that route themselves.

If there is a perception that a private option offers better care, the state has two choices. Make the public sector better and eliminate the need for private care or pay the premiums for those who can’t afford them. Australia has a publicly funded system but also subsidizes private insurance premiums for 9 million lower-income families.

The Commonwealth Fund ranks Canada next to last and the United States last of 11 developed countries. Of the 10 countries with universal care (i.e., excluding the US), Canada was last overall and tellingly last in equity and outcomes. It was also the most expensive.[6] The head coach of the bottom teams in hockey looks to emulate the top teams. Let’s do the same for our health system.
—Brian Day, MB

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References

1.    Day B. Arthroscopic surgery of the knee joint. BCMJ 1981;23:273-284.

2.    Day B. Private facilities will bring much needed competition to Canadian health care. 20 January 2023. www.theglobeandmail.com/opinion/article-private-facilities-will-bring-much-needed-competition-to-canadian.

3.    Gaynor M, Moreno-Serra R, Propper C. Death by market power: Reform, competition and patient outcomes in the National Health Service. Am Econ J Econ Policy 2013;5:134-166.

4.    Booth GL, Bishara P, Lipscombe LL, et al. Universal drug coverage and socioeconomic disparities in major diabetes outcomes. Diabetes Care 2012;35:2257-2264.

5.    Barcellona G. Lo strano caso del dottor Brian Day. Pubblico e privato nella sanità canadese: alla ricerca di un equilibrio. Academia. Accessed 31 January 2023. www.academia.edu/29782039/Lo_strano_caso_del_dottor_Brian_Day._Pubblico_e_privato_nella_sanit%C3%A0_canadese_alla_ricerca_di_un_equilibrio.

6.    The Commonwealth Fund. Mirror, mirror 2021: Reflecting poorly. 4 August 2021. Accessed 31 January 2023. www.commonwealthfund.org/publications/fund-reports/2021/aug/mirror-mirror-2021-reflecting-poorly.