We all know that health care is expensive. But until Premier Gordon Campbell launched his "Conversation on Health" last September, health-care costs generally weren’t counted down to the second. Now, though, you can go to the government’s Web site (www.bcconversationonhealth.ca/) and see a clock counting the amount of public provincial money spent on health per second: $406.93.
This weekend in Kamloops, the B.C. government will hold its first of 16 regional forums as part of its yearlong Conversation on Health. On Tuesday (February 6), the premier will bring his message to the Vancouver Board of Trade.
Campbell launched the “conversation” a couple of months after the sudden resignation of B.C.’s former deputy health minister, Dr. Penny Ballem. In a June 22 letter to the premier, Ballem claimed that Campbell’s plans for the ministry’s organization were “unsound and reflected a lack of confidence in my leadership on your part”.
Former NDP MLA David Schreck told the Georgia Straight that he fears Campbell will cite this public-consultation process to justify more for-profit care and more health care funded by private insurance companies. This, he suggested, would lead to higher health-care costs and less access for low-income people.
“The Web site seems to be designed to drive a message rather than to engage in a conversation,” Schreck claimed. “The first thing that hits you is this clock about how much money has been spent since you logged on to the Web site.”
Marisa Adair, communications director for the Ministry of Health, said she would not make Health Minister George Abbott available for an interview with the Straight.
In a news release issued last September 28, Campbell noted that this year’s $12.8-billion health budget amounts to more than 40 percent of provincial expenditures. In the same release, he emphasized that the government now spends $35 million each day on health care.
There are five principles in the Canada Health Act that provinces must follow to qualify for federal health funding: accessibility, universality, portability, comprehensiveness, and public administration. In launching the Conversation on Health, Campbell promised to add a sixth principle—sustainability—“to guarantee that our public health care system does not implode for lack of innovation and action”.
“If we don’t act, health spending could consume 71 percent of the provincial budget by 2017,” Campbell claimed.
Schreck, a health economist, said that if the premier is truly concerned about costs, he should look into the prescribing habits of physicians. “I have a friend who just last week went into a walk-in clinic because she had a sore throat and was prescribed antibiotics right away,” he said. “Anybody on the street knows you shouldn’t prescribe antibiotics unless they at least do a swab, because in all likelihood it’s viral [and won’t respond to antibiotics, which only act against bacterial infections]. It’s bad health because it builds up resistance to antibiotics, and it’s a complete and total waste of money. That kind of stuff happens all the time all over the place.”
There are several measures that Campbell could have taken in his first six years in power to contain costs. His government decided against making significant changes to the fee-for-service payment system for doctors. Nor did Campbell put medical-laboratory tests out to tender, even though Ballem advocated this. Instead, lab tests are still charged for on a fee-for-service basis.
Campbell’s government also wholeheartedly embraced public-private partnerships on hospital-construction projects, despite extensive evidence in the British Medical Journal demonstrating that this approach results in higher health-care costs over the long term.
There is no shortage of research in peer-reviewed medical journals highlighting the drawbacks of for-profit health care. In 2004, the Canadian Medical Association Journal published a study noting that for-profit U.S. hospitals have 19-percent higher charges than nonprofit facilities.
The study’s research team, headed by McMaster University health-policy expert P. J. Devereaux, had previously concluded that investor-owned hospitals had death rates two-percent higher than nonprofit hospitals. In an accompanying editorial, Harvard Medical School researchers Steffie Woolhandler and David Himmelstein cited several reasons for-profit hospitals are so much more expensive, including “princely” compensation packages for executives; higher administrative costs; and employing strategies to bolster profitability, among them overbilling Medicare.
The same year, McMaster health-policy researcher Stephen Birch ridiculed those who claim that publicly funded health care is not sustainable. Writing in the Canadian Medical Association Journal, Birch claimed that “in an age of evidence-based health policy, these claims stand out as a beacon of political hypocrisy and intellectual dishonesty, disregarding both the theoretical reasons and empirical evidence” supporting a single-payer (i.e., Medicare) system as the most efficient use of health-care resources.
Curiously, Campbell didn’t cite any of this research when he launched his Conversation on Health. Instead, he focused attention on the impact of an aging population—even though research in peer-reviewed medical journals suggests that this concern is overblown.
“Per-capita health costs skyrocket as we age,” Campbell said, according to the September 28 news release. “Those of us currently in our 50s use an average of about $2,100 in health care each year. When we get to our 70s, that more than doubles to $5,700. And if we’re lucky enough to get into our 90s, we’ll use about $22,000 in health services—ten times what we used in our 50s.”
He also said that if we want great health-care service for our children and grandchildren, it requires “an open, honest conversation with British Columbians”.
One of B.C.’s best-known health economists, Bob Evans, told the Straight that the premier is being less than honest by focusing so much attention on health-care costs as a percentage of provincial government spending. Evans, associate director of the UBC Centre for Health Services and Policy Research, said the standard measure around the world is health-care costs as a percentage of the gross domestic product (i.e., the entire economy). By this measure, B.C. health costs are fairly stable.
“I would be more optimistic if Penny Ballem hadn’t jumped ship,” Evans said. “Her leaving sounds much more like he is trying to soften us up for a significant privatization—not just of delivery, but of costs.”
NDP health critic Adrian Dix told the Straight that the Campbell government has launched a very expensive campaign to convince the public that health care isn’t sustainable, even though B.C. ranks eighth in Canada in per-capita spending on health.
“He’s going to argue that this conversation on health care gives him the public justification to make health care worse for the majority of people,” Dix alleged.
Last month, Ballem told CBC Radio that she also thinks per-capita spending is the most important barometer. “The notion that we’re out of control isn’t necessarily supported by the data,” Ballem told CBC talk-show host Stephen Quinn.
In a 2003 paper entitled “Political Wolves and Economic Sheep: The Sustainability of Public Health Insurance in Canada”, Evans noted that single-payer systems are more effective in controlling overall costs. However, this has an impact on the incomes of health-care providers, including pharmaceutical companies, giving a motive to oppose a single-payer system.
So what about the premier’s claim about rising numbers of elderly people having a catastrophic impact on costs? In his paper, Evans dismissed this as “apocalytpic demography”.
He wrote that elderly people do have greater health needs and cost more to treat. “But it is not true that these patterns will place an unsustainable burden on public health care systems,” Evans noted. “Holding age-specific per capita use and cost rates constant, Canadian population forecasts indicate a rise in per capita costs of about one percent per year—well within the range of prevailing rates of economic growth.”
Evans bluntly stated to the Straight that transferring health-care costs from taxpayers to patients will result in higher overall costs to individuals and lower costs for governments. But total expenditures will go up, he added. That’s because, historically, governments have been much more effective than individuals in containing health-care costs.
As an example, Evans cited B.C.’s “Fair PharmaCare” program, which he described as a deliberate measure to move costs off the government and onto patients. In 2003, the Campbell government created a new income-based drug plan that included “family deductible” payments based on family incomes.
According to a research brief from the UBC Centre for Health Services and Policy Research, Fair PharmaCare led to the “direct transfer of roughly $134 million from the public side of the financial ledger to the private side”. In other words, there was a 17-percent decrease in public expenditures and an 18-percent hike in private charges.
The research brief stated that over time, this would curtail the government’s ability to negotiate the bulk purchase of pharmaceuticals: “As drug costs continue to increase more quickly than household incomes, financial equity across and within income groups may deteriorate.”
Meanwhile, Vancouver health- care researcher Colleen Fuller, author of Caring for Profit: How Corporations Are Taking Over Canada’s Health Care System (New Star Books, 1998), told the Straight that Campbell has “exaggerated” the role of the private sector in European countries. At the same time, she charged, Campbell isn’t spending a dime investigating the role of the private sector in B.C., even though a privately owned urgent- care centre opened in Vancouver.
“How much money are they taking out of the public pot to provide services?” Fuller asked. “Is it worth that expenditure? What are the health outcomes of people who are using private health care? What is the impact on people who can’t afford to buy private health care and [if] services aren’t being covered in the public system? He doesn’t have any idea of what’s going on in the private sector in British Columbia, yet he is telling us everything he knows about what is happening in the private sector in Europe.”
Fuller also claimed that the Campbell government is not interested in learning from the research of Devereaux, Woolhandler, Himmelstein, Evans, or Alyson Pollock (who has extensively researched hospital public-private partnerships in Great Britain).
“It’s not engaging in any dis ussions with anybody based on evidence,” Fuller alleged.
She noted that private surgical facilities have become some of the most aggressive proponents of private health insurance. She claimed it’s because it isn’t in their financial interest to rely on a single payer that might want to drive down costs.
In addition, Fuller said, under the Canadian Human Rights Act, insurance companies have a legal right to discriminate on the basis of a person’s age, sex, and health condition if there is “actuarial logic” to discrimination. She said private health insurers also include “copay” charges and “deductibles”.
“If we have an honest discussion and a knowledgeable discussion about the merits or otherwise of private-sector involvement in health care, this is all the information that we need,” Fuller said. “There is no doubt in my mind that the province has its own agenda on this. They have demonstrated over and over and over again that they are prepared to stand by and not only watch the private sector in health grow and prosper in B.C. but they actually will create the conditions in which those companies can prosper.”
In the U.S. in 2003, she said, the Republican-controlled Congress imposed an 18-month moratorium on the expansion and construction of so-called “specialty hospitals”, which provide women’s health services, urgent care, and orthopedic surgery. “Congress was concerned about a conflict of interest, so they imposed a moratorium, which also included a moratorium on physician referrals to the hospitals in which they owned equity,” Fuller said. “At a minimum, this is what we need to do because we do not understand the direction the surgical clinics are going in.”
She added that the cost of knee- replacement surgery in the public-hospital system averages about $8,000, according to the Canadian Institute for Health Information. “In a lot of the private surgical clinics—orthopedic surgical clinics—they’re charging anywhere between”¦$12,000 and $18,000, roughly,” she claimed.
Evans said he too worries that Campbell will give private insurers more access to the provincial health-care system. “Because otherwise, why is he making such a fuss about this uncontrollable cost escalation, which we know from the numbers is not there?” Evans said. “When people tell you things very loudly that you know aren’t true, it’s hard not to get a little worried.”