The provinces say they need more federal money for health. The federal government says it wants to be assured of improved outcomes first.
In my view, adding money, even with various provinces and metrics, is not going to be sufficient. We will still have huge problems with inadequate staff, waiting lists, procedures that are simply not offered, lack of innovation, and other problems.
The system cannot be fixed within the rigidities imposed by federal policy that does not allow the provinces enough room to provide the best mix of public and private payment. Almost all other developed countries allow for a reasonable mix. We in Canada have to find our own hybrid. Otherwise, we will continue the paradox: Compared to many other countries, on a per capita basis we pay more and get less.
Let me propose a way forward for Canada. The idea is to seek an approach that can be widely agreed upon from people with different political views, beliefs, and practical experiences. It would invite decision-making based on evidence, not ideology.
First, the Canada Health Act must permit more room for experimentation and innovation by provincial governments. Federalism is a fundamental value of Canada. Provinces have primary authority over health-care delivery. In different provinces, new ideas can be formulated and tested. They may involve some options where patients pay themselves, directly or through private insurance. We can see what works and what does not. The federal medicare legislation was inspired by the introduction of public insurance in Saskatchewan.
Second, the flexibility permitted by Health Canada could be guided by the “mutual reinforcement” principle. More private-pay options will be permitted to the extent that a provincial government has reasonably determined that it will not harm the quality, timeliness, and accessibility of the publicly insured system. The standard is “a private-pay option can be permitted or facilitated by a provincial government if it does not damage, and preferably promotes, the publicly insured system.”
So, the current publicly insured system remains the starting point. The aim is to make it as good as it can be in terms of accessibility, quality, timeliness, efficiency, and outcomes, given all the other constraints on public spending. But the provinces would be permitted to explore whether some private-pay options would in fact (not merely under ideological presumptions) improve the publicly insured system.
For example, in some circumstances, it might make sense to permit a physician to practice in both the mainstream (that is, publicly funded) and also in their own private-pay clinic. If the two roles are properly coordinated, the physician might end up doing more procedures overall and reduce the demand on the mainstream system. The private-pay clinic might be a space where, in response to provider creativity and patient preference, innovation takes place that will eventually be incorporated into the mainstream system.
Some freedom to practice outside of the mainstream system might encourage the physician to remain in Canada or attract other physicians to locate here. Patients who might otherwise seek care outside of the country might instead keep their practices here, and the taxes from their private practice could help support the mainstream system.
You can propose other scenarios in which the private-pay option damages the mainstream system. For example, in some circumstances, it could result in fewer overall procedures being done in the mainstream system. In other scenarios, you might show that the existence of the private-pay option is substantially reducing voter or government enthusiasm for maintaining and improving the mainstream system.
The key point is that increased freedom and flexibility for provincial regulators, for providers, and especially for patients would not be ruled out or ruled in by a reformed federal policy. Instead, there would be a standard: Does an innovation help in some ways and either improve, or at least not hurt, the mainstream system? There would be requirements for applying that standard. Particular innovations would be introduced and monitored on a transparent and evidence-based method, not on the basis of rigid ideology.
An analogy is relevant. It is widely accepted that economic development and environmental improvement can reinforce each other. There is no guarantee, however, that this is always the case. Instead, provinces and the federal government both do environmental assessments. Evidence is reviewed to ensure that a particular development is not in fact likely to harm the environment.
A more flexible federal framework could—at least initially—include additional safeguards. Private-pay options might initially be limited to certain kinds of procedures or operations such as diagnostics, hip-replacements, and other such elective surgeries.
It is not an exaggeration to say that the rigidity of the current system is having a significant effect on some citizens’ quality of life and in some cases, even life itself. We can now proceed in a way that is evidence-based and reconciles different value systems.
The current stifling of debate and policy innovation is causing deadly consequences for Canadians. We can do much, much better for everyone in need.
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