A commentary by a former deputy health minister in B.C. and Saskatchewan who served on two royal commissions on health care and was awarded the Order of Canada for “innovative leadership in the fields of health policy and administration.”
Medicare cannot live on “love alone” conveyed in chest-thumping press releases. Daily accounts of overflowing emergency rooms, long wait times for surgery and lack of primary care providers prompted a review of history including the Hall Report, 1964, and subsequent reports examining strains in Canada’s health system.
Reviewing history highlights the reforms needed to ensure timely services with fairness and equity for all Canadians. Primary care must be reformed to provide appropriate community services.
The Emmett Hall commission’s Canada-wide consultations in the 1960s, and Roy Romanow’s in 2002, heard Canadians demand health services be fair and equitable.
Hall considered all funding options. Parliament passed legislation with unanimous support for universal, publicly funded, single-payer health insurance. All parties supported the socially progressive and economically sound policy as it is the most cost-effective approach to hospital and medical care insurance and the most equitable and fair approach to ensure people who are less well-off are served as well as others.
The values of fairness and equity guided the legislation in 1957 for hospital insurance, in 1966 for medical insurance and in 1984 for the Canada Health Act. Commissions from then to the present continue to find Canadians want health services to be fair and equitable; but importantly, the services must be available when needed.
We are in the current crisis because policy decisions for the past 30 years focused on lowering taxes and downsizing services.
Privatizing assets such as Connaught Labs, cuts to public housing, cuts to transfer payments to provinces, closing institutions without providing community-based services were penny wise and pound foolish.
As public services were cut, mental-health problems, addictions, homelessness, and wait times grew. As public pressure increased governments resorted to the ‘blame game.’
Provinces blame lack of funding and the federal government dumps truckloads of money onto the provinces to spend as they see fit.
In 2004, the federal government provided $23 billion over five years and within months the provinces were calling for more money.
Commitment to reform lasted about as long as the press conference announcing, “the fix for a generation.”
Why? Because the federal government did not require meaningful and enduring accountability from the provinces. Without accountability, provinces set their own priorities.
Many used the funds to give tax breaks. In 2023, rather than investing in change, the federal government is buying more of the same, billions of dollars without required reforms and accountability.
Canadians have collectively loosened their grip on a sustainable quality health service. This may be because of our demands for tax cuts or because Canadians take our health system for granted or assume it can reform itself.
It may also be that Canadians view health services as mainly doctors and hospitals and suspect government’s attempts to reform services are an attack on ‘their’ doctor.
This view is not discouraged by the institutions and professions who benefit. These views encourage everyone to turn a blind eye to what is happening and what needs to be done.
While our health care was amongst the best in the world, comparison of quality tells a different story today. Canada is ranked 10th among 11 developed countries and Canada’s expenditures are above the average with below average outcomes.
Ironically, the United States, with poorer quality, spends more per capita than all others. U.S. spending per person almost doubles Canada’s.
Health commissions tell us that Canada’s health services need substantial reform in primary health and at most, a little more money, to implement the reforms. So far, the opposite is happening. We continue to treat the symptoms and not the cause.
Primary health services are the foundation of organized health systems throughout the world. They are the first contact with the health system for those everyday needs to remain healthy.
The current services in Canada are not able to meet today’s health needs because illness and impacts on health have changed from infections and childhood diseases to chronic conditions, cancer, and issues relating to aging and climate change.
Health needs today require a broader range of knowledge, skills, and practice. Drug therapy is more complex, and nutrition knowledge is essential for issues of obesity, diabetes, and other chronic diseases.
This is also true of physical fitness and mental health. While aging is not a disease, meeting the needs of the elderly enables them to live purposeful lives.
Without addressing the mismatch of health needs to practices there will be continued calls for more doctors. Having more doctors will not equip them with needed skills nor enable them to provide services 24 hours a day, seven days per week.
Family medicine role in diagnosing and caring for the wide range of issues within the diversity of our population is extremely complex. In the words of Dr. Michael Green, professor of family medicine, Queens University, 2023, “a system that relies only on doctors is not going to get us out of this crisis.”
Family physicians cannot do it alone. They need to be part of a multi-disciplinary team comparable to teams in hospitals to support people at home and in community 24/7. Health issues today require teams of physicians, nutritionists, nurse practitioners, midwives, pharmacists, mental health professionals and others.
Services designed 50 years ago and focused on hospitals and physicians can’t do it. The lack of organized primary health service is overloading emergency rooms and causing seniors and others to be admitted to hospitals.
When surgical beds are occupied by people who cannot get the services they need at home, surgeries are cancelled, and the wait times grow longer.
Thirty years ago, the B.C. Seaton Commission frequently and clearly heard that services must be provided in the home, not just in hospitals.
Family physicians have worked diligently to serve everyone’s needs, practising volume-driven medicine with payment by fee-for-service. Their work has become increasingly mismatched to modern health needs that cannot be met by multiple visits, tests, and referrals. Family physicians need a new compensation arrangement that rewards quality and recognizes today’s reality.
Unless primary health services are reformed, we will continue to hear calls for private pay, two-tier system that allows those with financial resources to go to the head of the line.
Justice John Steeves, in a B.C. Supreme Court decision in 2020, detailed the futility of private pay. Parliamentarians warn that moving to a private two-tier system has major risks of U.S.-style health insurance because of the trade agreements with the U.S. and Mexico.
Canada’s corporate leaders recognizing that single payer publicly funded universal health service provides a competitive edge for Canadian business state, “to set aside our system would be a moral error but also a grave economic error.”
We are at a crossroads. One leads to meaningful reform within the public service and the other leads to private pay with care based on ability to pay.
Benign neglect from government and the public is destroying our treasured health services. Medicare needs tough love to ensure equity, fairness, timely access, and accountability.
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