Harvey Lazar: Why is it so hard to improve our health system?

Self-interest has led to meagre health reform for four decades
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Almost continuously since the second half of the 1990s, Canadians have pointed to health care as their largest national concern and the issue that should receive the greatest attention from Canada’s leaders. Polls taken over the last decade or so have found that health care is typically the highest priority among voters. It is also the policy area in which governments often score most poorly. This sentiment has become so commonplace across the political spectrum of voters that we take it for granted that it was always so.

Yet, in the 1980s, worries about health care barely registered in public opinion data. In fact, up to that point and since the introduction of countrywide hospital insurance in the 1950s, Canadians had been smitten by their universal, publicly financed hospital and medical services. So what’s changed?

It’s not a lack of money. Health spending continues to be a spending priority.

And it’s not the performance of individual healthcare providers, especially when there is an urgent and acute need. Canadians are generally satisfied with quality and the timeliness of the care they receive in critical situations.

But on other health-related matters, the reviews are less impressive. The slow response to the growing need for chronic care has been apparent for some time despite its predictability. The Commonwealth Fund International Health Policy Survey (2010) found that of 11 OECD countries surveyed, Canada fared worst or second worst on several access-related matters, including accessing health care in the evenings and on weekends. Wait times were the worst for appointments with medical specialists and for certain kinds of diagnostic tests. On access to prescription drugs, we scored second worst.

This is a stingingly familiar list of concerns—documented in the 2002 Romanow and Kirby Reports and, before them, in the reports of the many task forces, advisory committees and commissions appointed by both left- and right-leaning governments. Here we are, decades later, and these issues have still not been adequately addressed.

Why is it so hard to reform health care policy in Canada? This is the question my colleagues and I posed in an examination of 30 health reform case studies (published in Paradigm Freeze, McGill-Queen’s University Press). The answers we found are not heartening.

Our study indicates that, by and large, self-interest among vested parties has led to mostly meagre health reform across the country. Specifically, provincial medical associations have been able to protect physician interests, in some cases, by keeping the health reform window shut. In others, by persuading governments to advance their goals through incentives rather than through regulation.

This is a legacy from the foundations of medicare. When provinces first enacted medicare, they adopted a fee-for-service method of compensating physicians that seemed to make sense at the time. However, the logic of fee-for-service led, over time, to a close and growing relationship between provincial health ministries and provincial medical associations. This influence continues today in the complex and opaque “master agreements” between provincial health ministries and provincial medical associations that are rarely subject to public discourse.

The end result is that medical associations have veto or near-veto powers in respect of the many policy related issues that affect physician compensation.

Nurses and unionized hospital workers, on the other hand, have been part of the great Canadian coalition that has successfully protected medicare at all costs. This has afforded them a substantial political voice in safeguarding the not-for-profit hospital sector against proposals to encourage competition from privately-owned hospital corporations. But along with left-leaning civil society groups, and support from the general public, this has had the effect of halting discussion of any possible real reform outside the current model.

There were a few exceptions to these broad findings. In cases of newly elected first-time governments, there were some instances of significant reforms but these were largely within the existing medicare framework.

It appears that supporters of medicare fear that once the medicare genie is out of the bottle, all bets are off. The fear of going backward has created a fear of debating the future—and may be part of what has prevented us from moving forward.

In a nutshell: Provincial medical associations, other health care provider bodies, the labour movement, and the general public all prefer the arrangements that we created a half-century ago than to undertake reforms with an uncertain outcome.

What does that mean for health reform going forward?

It means that the chances of reform on a very large scale—the proverbial big bang—are slim at best. It took the Great Depression and the Second World War to create the political climate in Canada that enabled a new innovative postwar social contract among Canadians in the form of medicare. Without some sort of insurmountable disruptive force, either a major shift in medical science or technology or a catastrophic economic or political crisis, fundamental health policy reform in Canada in the future remains unlikely.

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Bureaucrats
My partner is a clinician with a doctorate in her field, unfortunately a small field that is a tiny slice of a big union that routinely concedes issues for the smaller units to gain for their primary clients. She oversees the work of two assistants and a junior clinician but she does not supervise them: that specific role was given away last contract as a bargaining chip freezing pay for senior clinicians for the duration. Now there are 4 "supervisors," none of whom work on site with those whom they "supervise" and all of whom are bureaucrats. Their official roles include clinical time, but in a decade my partner has yet to see a bureaucrat fulfilling clinical duties: the clinical time is merely a way to hide bureaucrat salary & bonuses under clinical costs. Making the budget appear to be delivering services is the important thing, not the delivery of services themselves.

Spending priorities are set by bureaucrats and Fraser Health gives some wonderful examples of bizarre decisions. When faced with a smaller increase in the budget than anticipated bureaucrats were forced to choose between salary increases & a bonus pool for management or cutting frontline services. The entire community nutrition program was eliminated, 30+ nutritionists laid of plus support workers moved to other job sites but the salary increases & bonuses went through. Bureaucrats even appeared on camera and said that they simply didn't have enough money from Victoria and were very sorry.

This was during the period Fraser Health were planning the additions and renovations at Surrey Memorial Hospital, going through revision after revision as the plans moved from committee to committee. There was so much work that they had to hire more bureaucrats to oversee the range of bureaucrats working diligently on the project. When finally completed they reduced the staffing level per bed but made sure that the new bureaucrats weren't alone in their offices. "Transition officers" and other such BS positions were created and morphed into something else when the fiction could no linger be maintained. Fraser Health now has a $30 million parkade under construction at SMH for 300 vehicles: other similar size structures come in between $10 to $20 million even when built by government. How much of that money has found its way into various bonuses for bureaucrats?
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