“This is the first federal government since before medicare that has not wanted the federal government to be active in medicare,” he explained.
While it’s an understandable position, Mr. Simpson said, it leaves opportunity for the opposition parties to come up with a way to introduce their own ideas on the system.
In an interview last week with The Hill Times, Mr. Simpson said they should start with a major expansion that is not only a smart move but also a sustainable one if done right: prescription drug coverage for seniors.
“The federal government should have a social insurance plan to pay for drugs across the country like pensions,” he said, explaining that combining the buying power of the provinces into a single purchaser would mean Canadians would pay less for drugs.
“If I was an opposition party, I would put that to the people,” he said.
For his new book, he read every major study and report on medicare since Tommy Douglas started advocating for a national plan in the 1950s. He spent a week observing at two Ottawa hospitals and followed the travails of a small health-care facility in Nova Scotia.
Mr. Simpson has been working for The Globe since 1977, has won the Governor General’s Award for non-fiction, a National Magazine award for his political writing and two National Newspaper awards.
Chronic Condition is his eighth book.
He said that while universal healthcare is often singled out as Canadians’ top priority in public opinion polls, its status as a symbol of national identity has meant that politicians have shied away from serious debate about its future for fear of the backlash.
Chronic Condition is Mr. Simpson’s attempt to provoke that conversation. “Banish fear,” he said.
This Q&A has been edited for length and style.
You’ve written on so many things, why did you decide to do a book about health care?
“It was an intellectual challenge, but also I was frustrated by what I thought the lack of a serious debate about the dilemmas we face. Too many political people just didn’t want to talk about it, period. Or they talked about it in unrealistic terms, and there were too many election campaigns, both federal and provincial, in which the parties would engage in a kind of bidding war with each other about who could spend more on healthcare. I thought, ‘That’s not constructive.’ If they’re not going to talk about it seriously and objectively, I will. That’s immodest, but that’s why.”
Why is it that they are not engaging? You call health care the “third rail” of Canadian politics.
“It’s fear. They’re afraid of us. Health care in English-speaking Canada is quite unique in the way it’s perceived by the population. In French Canada, people identify the essence of themselves by the fact that they speak French; they are a part of the French culture. But in the rest of the country, if you look at the polling data and you ask people what is the most important symbol in the country, it’s health care. It’s more powerful than the anthem, or the flag, or the RCMP, or bilingualism, or hockey. That’s weird. There is no other country in the world that defines itself largely by its health-care system, and so it’s existential, it’s self-definitional.
“To raise questions about the system is to be accused of being un-patriotic or having some hidden agenda that you want to turn this into U.S. two-tier-style medicine. That’s been a real impediment to having a real, serious discussion.”
If Canada shouldn’t compare itself to the U.S., are there any other countries or systems that we should be looking at?
“I wouldn’t have written this book if we were spending a lot—that doesn’t bother me—and we were getting quality first-class results. If you buy a Cadillac you want it to be a Cadillac, you don’t want it to be a Chevy. So I said, ‘Okay let me look, in particular, at three countries that are—broadly speaking—the closest to us. Obviously every country has a unique system, no two are exactly the same.
“I looked at Sweden, Australia and Britain. Why? Because they all have a universal, single-payer system. The government provides for everybody. In doing that, I was struck by a couple of things. One, how much their systems had changed over the last 10 or 15 years compared to ours. We’re still stuck, pretty much, where we were 15 years ago in terms of how we deliver and organize care. They’ve moved a lot. Secondly, they spend less of their national wealth on health but they have better outcomes. I’m not saying that you can take anybody’s system and holus-bolus adopt it here but it would be wise to look at some other systems and say they must be doing things right.
“There is no country in the world that is changing its health-care system to make it more like the Canadian. They’re all moving in another direction, which ought to indicate to Canadians, ‘Hmmm, something is up.’”
Researching this book, how did your own views on Canadian healthcare evolve?
“When Roy Romanow produced his report, 10 years ago now, I was pretty skeptical about the analysis and the diagnosis and the recommendations. I thought that Roy Romanow was basically saying that the existing system was pretty good, and that if we spent a lot more money on it, and tweaked it here and there, we could make it really good. I called it at that time, ‘the biggest public policy bet of our generation,’ because a year later the government decided to spend $41-billion on the system, indexed at six per cent.
“But I said, ‘Okay, maybe I’m wrong, let’s give it time.’ If you spend all that money you should get some pretty good results, so maybe I’m wrong. I sort of suspended judgment for a while, but I kept reading reports from health councils and from other bodies, the Canadian Institute for Health Information, about how the system was doing with all this money going in. I was more and more convinced that we weren’t getting a much better system for all that money. So then I had to go and figure out why.
“One reason is completely predictable: if you put a lot of money into a system, whatever it is, who is the best mobilized, the most motivated, to grab a big chunk of the dough? It’s the providers. In this case, the doctors and the nurses and the administrators, all of whose salaries and remuneration have gone up much faster than the industrial wage in the country over the last 10 years.
“When you ask why isn’t the system better for all this money, part of the reason is because it just went into the pockets of the nurses and the doctors. That’s a very important thing to learn the next time somebody says, ‘Let’s pour a lot of money into the system.’
“I guess I learned what I had suspected would be the case, namely that spending all that money didn’t do much for the system at all, it just made it more expensive.
“Let me give you an example. Some of this money, this $41-billion, was specifically targeted for reductions of wait-times for five procedures. Two of the procedures were hip and knee replacements, and diagnostic tests like MRIs. In Ottawa, according to the Champlain Health Authority, we have the longest delays in Ontario: nine out of 10 Eastern Ontarians now wait as long as 209 days for MRIs, and that’s more than they waited three years ago. So what did all this money do?
“Similarly, the waits at the Ottawa Hospital have climbed to 271 days from 188. CAT scans have come down in time, in fairness, but that still leaves Eastern Ontario last. In terms of replacements nine out of 10 Eastern Ontarians wait almost 333 days for hip replacements. That’s almost a year. At the Ottawa Hospital, the wait time is 421. Look, we have the worst wait times anywhere in the Western World. I’m not saying that, the evidence is there, go read the OECD reports.
“There’s this remarkable passivity in Canada about the fact that you have to wait, unless you are in an acute situation. Our system is very good if you have an acute problem; if you have a heart attack, if you’ve got serious cancer, it’s very good for that. But most patients aren’t acute. Most patients have other problems, and the system is the worst in the world in terms of wait times. So what are we bragging about? The next time some politician says we have the best system in the world, tell him or her that we have the longest wait times in the world, and that despite all the billions that we put into this system, we still have the longest wait times in the world. So something is fundamentally wrong.
In your book you say that while going for efficiency is positive, it’s not going to be the solution to our health-care problem. Could you elaborate?
“There’s a school of thought, I’m going to call it the Romanow school, that says that whatever sustainability problems you have in the system, and whatever quality problems you have, and whatever wait-time problems you have, can be solved by better-administering the system by imposing more rational planning solutions on the system. The OECD said if Canada could reach the average level of efficiencies of the OECD then we could chop two per cent off the amount of money we’re spending. Two per cent of our GNP, that’s a big number by the way. There have been a whole series of reports over the last 15 years, I’ve read them all, that recommended a whole series of efficiency gains. Many of which have been put in place. You kind of say to yourself, ‘Why hasn’t it happened?’ If this is so easy, you read these papers and commissions, if this is so easy why hasn’t it happened?
“It’s partly because the providers who are in the system have shaped the system to their own convenience, not the patients, the providers. They’re not going to give up easily the way they’ve shaped the system to their own convenience.
“But it’s more than that, the health-care system is immensely complicated. To think that you can bring efficiency gains on such a massive scale to such a complicated system is itself quite illusory.
“Another point, there’s something called Baumol’s cost disease. Baumol’s cost disease is that wage gains in the public sector always eclipse productivity gains. You get doctors and nurses and others getting more money, but productivity doesn’t go up. People are thinking that there are these huge efficiency gains, and yes there are many, but getting them done is far more complicated than people think it is. That’s why I say that efficiency gains are necessary, they are urgent, and they are insufficient. They will always disappoint you. There will never be as many efficiency gains as the proponents of the efficiency gains think.”
What can or should the federal government be doing in that case to provoke a sustainable change in medicare?
“What’s happened with regard to the Harper’s government’s decision is deeply interesting. This is the first federal government since before medicare that has not wanted the federal government to be active in medicare. If you go back to Louis St. Laurent’s day, they began to get active in financing the construction of hospitals. Every federal government since then has wanted to be involved in some way in the health-care system. Sometimes it’s been very frustrating because the provinces haven’t wanted them there. Sometimes they’ve worked out federal-provincial arrangements, but the feds have wanted to be there.
“Secondly, if you read the public opinion data, as I have–there’s a whole chapter in there about how Canadians view the system—they think of it as a national plan administered by the provinces. They think of this as self-definitional: this is us, this is who we are, not just we as Albertans, or Manitobans, or Nova Scotians, but we as Canadians. There’s a double-vacuum that’s been created here. On the one hand, the Conservative position is not consistent with the last half a century of history, and it’s not consistent with what Canadians want. Okay, that’s their view of federalism, I understand that, it’s a defensible view. If you were in the opposition parties, however, you would try to think of some way to respond to both the imperative of history and to this sense of Canadians that it’s a national program, and try to figure out constructive ways that the federal government can be involved in healthcare.
“Our system both gains from having the provinces run the system because they can experiment and they are closer to the people, but it suffers because there isn’t enough coordination in the system. The classic example that I spend some time in the book dealing with is drugs. We have the single-dumbest system in the world for purchasing drugs. Australia is a federation, the states run the health-care system but they have one buyer for drugs. We have 10 formularies, we have 10 buyers. My economics textbook somewhere around the second chapter said if you’re going to bulk-buy you get a better price if you’re representing more consumers than if you’re representing fewer. But we’ve chosen to split ourselves into 10 little fiefdoms to deal with the drug companies, which is just ridiculous, and it’s one of the major reasons why we have the highest drug costs in the world.
“Then if you ask any provincial premier, ‘What are your biggest cost drivers in the next five years, 10 years, down the road?’ No matter who the premier is, on that list will be seniors’ drug costs.
“My view is if you had the federal government buying drugs for one national formulary, the way they do in Australia, then the federal government should have a social insurance plan to pay for drugs across the country like pensions.
“The social contract would be that throughout your life you pay into a scheme the way we do for pensions, and employers pay in and governments pay in, and at the end of your working life, be it 65 or 67, with a deductible paid by you, you get your drugs just like you get your pension. That, it seems to me, is fair because we’ve got this population bulge of seniors that is going to put a lot of pressure on the health-care system, including pharmaceuticals. If you ask the next generation to pay taxes to pay for the costs of these seniors’ drug plans, costs are going to go up and they’re not going to get any benefit from it necessarily. It’s much better to have a social insurance model where you pay in and you get a benefit later, which is what we do with pensions.
“If I was an opposition party, I would put that to the people, I would say, ‘Look, the federal government should get back into the drug game on behalf of all Canadians by purchasing at a lower cost than any one province can.’ That would be a national role for medicare that would be quite constructive.”
What are you hoping your readers will take from this book?
“I’d say, ‘Look, stop being so fearful of a discussion about this. Let’s look at it coldly; let’s look at it honestly. Banish fear is what I’d say. When anybody tries to encumber this discussion with fear—fear of a U.S. system, fear that we’ll lose medicare—just tell them to get lost.
“The bottom line for me is we need to shake up the way we deliver medical services through hospitals and doctors, and be open to different ways of doing that including more private delivery of publicly paid-for systems, which all the other countries have accepted. We should shake that up and then we should think about expanding medicare in a balanced and cost-effective way through social insurance to drugs, which was the dream of the founders of medicare, which we’ve never fulfilled.
“Far from wanting to scrap medicare, I want to expand it, but I want to do it in a fiscally responsible way, and I want to get better results from the system that we’ve got now. The worst thing we can do, I say it at the end of the book, is to put more money into the system and keep doing what we’ve been doing. That’s a recipe for massive waste of money and we can’t afford it.”
Original Article
Source: hill times
Author: JESSICA BRUNO
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