So how do we drag medicare, kicking and screaming, into the twenty-first century? Our favoured response has been to throw more bodies and more money at problems. But the solutions need to be more fundamental and come on two levels: funding and delivery.
Let’s start with delivery. Action is required in five broad areas:
Primary care. Essentially, we need to take our hospital-based care system and turn it on its head to make community-based primary care the focus. We need to move away from an acute, episodic-care model to a chronic-care model. Every Canadian needs a medical home, a central co-ordination point for their care—preventive, acute and chronic—and an electronic medical record. And care should be delivered by teams, not individual practitioners, due to the complexity.
Drugs. We need to extend universal health coverage to prescription drugs. Currently, through a patchwork of public and private schemes, about thirty-five million Canadians have drug insurance (twenty-four million are covered by private plans and eleven million by public plans, but hundreds of thousands have no drug coverage). A public plan need not pay for everything from Aspirin to Zyprexa, just the essentials. Nor does it have to be a centralized bureaucracy. Quebec has demonstrated that a universal prescription drug program—a mix of public and private insurance—is feasible and affordable.
Home care. We need to treat people where they live, in the community, not in expensive, soulless, germ-ridden institutions. Too expensive? Not if it’s an alternative to hospital and nursing-home care. For example, seventy-five hundred Canadians currently live in hospitals—meaning they have been discharged but have nowhere to go—and that’s the tip of the iceberg.
Social determinants. We need to invest in prevention efforts, particularly for socially disadvantaged and marginalized groups such as indigenous people. Let’s stop pretending that health is merely a medical issue, and spending as though it were. Good education, housing, income and the environment are essential to good health. A whole-of-government approach is required.
Quality. Safe, prompt and effective must be the guiding principles for care delivery. For the most part, these are engineering and administrative issues, not medical ones. Care is rationed in every country. You can ration by creating financial barriers, as they do in the United States, or you can ration based on results—which ensures everyone gets basic, effective care. Quality care is cheaper in the long run.
Reforming the delivery of care is the easy part. In Canada, funding is unquestionably the Gordian knot.
Spreading risk—and health costs—across the entire population, as we do with medicare, is a good model. But an essential element is missing that undermines medicare: a failure to define clearly what is covered by public insurance and what is not. Canadians have to accept that public-health insurance covers only the basics. At the same time, those who oversee the system have to recognize that physician and hospital care is not enough in the twenty-first century. We need to expand the areas medicare covers—into drugs, home care, long-term care—while at the same time limiting coverage across the board to the essentials.
Universal coverage is not a synonym for unlimited, open-ended coverage. There are choices to be made. They include:
As stated already, defining clearly what is covered by medicare and what is not.
Paying only for what works. Many interventions are of dubious value or are not cost-effective. They shouldn’t be covered by public insurance.
Paying a lot more attention to patients with complex needs because they drive costs. One percent of patients account for 25 percent of costs, and 5 percent account for half of all spending.
Instituting a means test. An equitable system does not mean providing equal services to all at equal cost; user fees and co-payments are not necessarily unfair, but these approaches have to be used smartly.
Regulating rather than outlawing private insurance and care. One of the most important lessons we should take from Europeans is that we need a combination of a well-regulated private system and a well-managed public system.
The so-called public–private debate is the third rail of Canadian health politics. But it’s a false dichotomy. Every health system worth its salt has a mix of private and public delivery and payment. In every country, including this one, most delivery is done by private providers. (That includes not-for-profits, for-profit businesses and independent contractors such as doctors.) On the funding side, the split is usually in the 70:30 to 80:20 range, public–private. The only unique feature of Canadian medicare is the bifurcated payment system. Hospitals and doctors are 100 percent publicly funded. Other services—drugs, home care, long-term care and dental—get between zero and 50 percent public funding.
The question is not whether or not we have private and public care. It’s getting the mix right. Private enterprise does certain things well, and public and non-profit enterprises do certain things well. Let’s be pragmatic and benefit from both, as most European countries do. We need to pay much more attention to equity—making sure everyone is cared for—and less to who is delivering the services.
Implementing these changes will, of course, require leadership. But nothing is radically new in these proposals. The real challenge in Canadian health care is implementing what we already know is needed. Everyone has a role to play: Ottawa, the provinces and territories, health professionals, allied workers, labour, business, consumer groups, patients and citizens. But they all have to put a little water in their wine—and whine a little less. Reform is going to happen only if the political environment changes, if we stop shouting down every proposal for change because it threatens vested interests. It’s time for the interests of patients—and society more broadly—to rule. We don’t need a values debate. We don’t need more tiresome private–public rhetoric. We don’t need Chicken Little screaming that medicare is unsustainable. We need a debate about structure and funding and priorities.
Let’s be frank. For many years, we have failed to live up to our responsibilities. We have been lazy and we have been profligate in our spending. But there is reason for optimism. The public isn’t just ready for change—the public is demanding it. It’s time to stop talking and start acting.
Stop moaning about medicare
In April of 2005, the Los Angeles Times ran a fascinating story about a growing underclass of Americans who have been dubbed the “insured poor.” The story is still relevant today. Reporter Daniel Costello told some chilling tales about working stiffs struggling mightily to pay their monthly health-insurance premiums. It was noteworthy that the people profiled—the working poor, middle-class white-collar and blue-collar workers, small business owners—all had stable, long-term employment, yet they were all on the precipice of joining the forty-five million Americans without any health coverage.
There was Terri Matthews, a teacher’s aide, who spent US$613 a month for her family’s health insurance, one-quarter of her take-home pay. Rather than go without coverage, she skimped on other basics. Matthews stopped heating her home and dropped her car insurance. Ron Dybas owned a lumber company for seventeen years, but he shut it down to take a job with a business that had health benefits because he could no longer afford to pay one-third of his income, US$729 a month, to insure his family. “Such sacrifices for health insurance are far from rare,” Costello wrote. “As employees continue to absorb more of their health-care costs, an increasing number of people—even healthy ones—are drastically altering their lives simply to hold on to their insurance. They are delaying home ownership, putting off saving for their children’s education, or otherwise sacrificing their financial security to guard against a catastrophic medical bill.”
In Canada, we like to moan and groan about our medicare system. The care is never fast enough or good enough. We have too much rationing and not enough choice. The solution that is invariably