“The Top Ten Things People Believe About
Canadian Health Care, But Shouldn’t”
A talk by Brian Lee Crowley, President, AIMS
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Ladies and Gentlemen,

Of the many ways that are available to tackle the question of what we all need to learn from Canada’s 30 year love affair with the government monopoly, single-payer health care system that we call medicare, I think the model of that great health care analyst and public policy guru, David Letterman, serves our purposes best. I am therefore going to entitle my talk today, The Top Ten Things people believe about Canadian medicare, but shouldn’t.

Number One: Canada has the best health care system in the world.

Not even close. According to the World Health Organisation, Canada ranks 30th in the world, with the US ranking 38th[1].

Ranking criteria:

Bang for the buck

Preventive measures

Access for vulnerable populations

Thus, while Canada and the US are both only middling performers, we both have a very great deal to learn from other places that manage to combine costs that are no higher than Canada’s (and frequently are lower) and population health outcomes (e.g. longevity, infant mortality, etc., etc.), that are as good or better.

Let me offer a comparison that will shake some the complacent assumption that many American seem to have about the equity and effectiveness of the Canadian health care system. Let’s talk about infant mortality for African-American babies vs. Canadian babies. Infant mortality risk is a function of birth-weight, with the risk of death rising as the birth weight falls. Now over the full range of low birth-weights (i.e. any birth-weight below 2500 grams), African-American babies fare better than Canadian babies, except at the very top end of the range, where they are essentially equal. In short, among low birth-weight babies, you are better to be born to an African-American family than you are to be born to the average Canadian family.

Number Two: The Canadian public love medicare

We have to be careful here. The public love some features of the system. In particular, there is huge support for the principle that no one should be denied access to needed medical care on the basis of ability to pay. Ideologues in the health care system have tried to stretch the public’s support for that basic principle in all kinds of distorted directions.

For example, there is a view afoot in health policy circles that because Canadians support this basic principle, that they support a health care monopoly on the current model, that Canadians disapprove of private, for-profit business in the health care sector, that only the state should deliver health care services, etc., etc. In fact, the recent report of the Royal Commission on the future of health care[2] took as its starting point a picture it painted of Canadians’ values, arguing that those values supported the status quo, only moreso (i.e. an expansion of the system into home care and pharmacare, and a major injection of taxpayer dollars).

But Canadians have actually shown themselves to be a deeply practical and non-ideological  people. Commissioner Romanow has made the case that the debate over the future of medicare is all about Canadians’ values. But the way that Canadians express those values, unfiltered by the work of the Commission, is much different from what Mr. Romanow implies  Canadians want.

According to a recent poll entitled The National Pulse on Health Strategy, 80 per cent of Canadians want major reforms to the health care system:

“two-thirds of Canadians (66 per cent) tend to be supportive, more or less, of a host of new models of financing in order to reduce stress on the system – for example, where everyone (except those with low incomes) pays a small amount for health care services out of their own pocket. They also tend to support strategies such as using nurses or other health practitioners rather than physicians to provide certain services. Just under half (45 per cent) tend to be supportive of market-oriented reforms – greater efficiency, accountability and customer service, including private sector companies delivering health care services” (Environics, October 17, 2002).

The National Post reported that the same Environics poll found that fewer than half of respondents would support increasing taxes to pay for health reforms. But notably, only 10 per cent of Canadians would accept a health care system that excluded those who could not afford to pay for services

These results need not be seen as a contradiction. As Jane Armstrong, senior vice president of Environics Research Group, says, “Canadians, ever-constant champions of fair play and equity, are devoted to maintaining a system that ensures access to quality health care for all…. They’re willing to make changes, even if this includes new and varied ways of financing the system as well as a greater dependence on market forces such as private companies delivering certain health services.” (Environics, October 17, 2002)

Another recent poll, by Decima Research  (October 25, 2002) found that more than half (55 per cent) of Canadians were opposed to paying higher personal income taxes even if these funds were designated to pay for health care. An even larger majority of respondents (67 per cent) also believed that they would have to rely on their own personal savings to pay for their use of health services in the future.

These public opinion polls appear to indicate that Canadians want a system of health care that provides high-quality medical services and is financially sustainable over the long term at an acceptable economic price, without excluding poorer people from access to medically necessary services. And in a typically pragmatic way, Canadians are not worried whether it is the private sector or the public sector that achieves this; they just want results. In fact, when Canadians do express a preference for either private or public approaches to health reform, the majority are willing to fund their future medical needs themselves rather than pay higher taxes to expand the medicare model of health care.

That’s why, in the context of the Romanow Report, I like to say that not since the days of Edgar Bergen and Charlie McCarthy has ventriloquism enjoyed such vogue. But at least Edgar and Charlie were good at it, and it was purely for entertainment.

The stakes riding on today’s high profile ventriloquism act are far higher: the future of Canada’s $70-billion public health care system. What does ventriloquism have to do with Roy Romanow’s Royal Commission report on medicare? Everything.

From the very first Mr. Romanow made it clear that the foundation on which all of his work would be built would be the values of Canadians. That’s powerful: not many politicians want to be seen to be ignoring Canadians’ deeply held views on a topic as important as health care. Thus the title of Mr. Romanow’s report: Building on Values.

He invoked the values of Canadians up front in an attempt to make his recommendations invulnerable to criticism and caviling by politicians and interest groups. But for this gambit to succeed, the methods the commissioner used for arriving at a picture of Canadians’ values on health care must be beyond reproach. Yet his methods were flawed and unprofessional. The report is a thinly disguised attempt to make Mr. Romanow’s own values, and those of his narrow little coterie of experts and bureaucrats, pass for the values of Canadians generally. Canadians are the dummy, and Mr. Romanow is the ventriloquist.

If this analogy seems extreme, consider what Mr. Romanow and his colleagues did. They organized focus groups across the country to find out what people were thinking about where they’d like to see health care go in Canada.

What they heard from these focus groups was pretty much what Canadians have been telling pollsters for the last several years and that I’ve sketched out for you here. Canadians are a down-to-earth, non-ideological, practical people. They’re interested in what works and they’re interested in real solutions to the growing evidence of the accelerating decline of the health care system.

So in response to questions from the Commission’s people, they indicated that they were open to a wide range of options that needed to be tried if they might improve things. They were open-minded about things like user fees, allowing more private sector involvement in health care provision, and allowing people to buy health care in circumstances where they’re not permitted to do so today.

But that didn’t square with the views of Mr. Romanow and his merry band. So they marched their focus groups into a room, and presented them with “expert opinion” to show these poor benighted citizens why the things they were willing to try were bad ideas that wouldn’t work, that would harm people’s health and be hard on the poor. They presented these views as established facts, rather than the highly contested arguments of an elite of health policy makers, an elite whose ideas have been responsible for bringing our health system into its current state of disrepair.

Unsurprisingly, on being presented with what seemed to be an objective and authoritative debunking of ideas that had seemed practical and worthy of trying, the members of Mr. Romanow’s focus groups timidly gave in to the views of the “experts”. But the irony is that there is lots of evidence in the academic and policy literature that the practical, common sense things that Canadians were prepared to look at actually do make a difference for the better. The only real flaw with these ideas is that they didn’t fit the inflexible and narrow ideology of Mr. Romanow’s colleagues.

Now anyone in the university polling world can tell you how to avoid such charges of bias in determining what people think about emotional topics like health care. For instance, a reputable arm’s length polling expert would never have allowed people from Mr. Romanow’s own commission to be closely involved in the testing of public opinion. The risk of influencing people to say what the client wants to hear are too great. But the commissioner’s own people did work directly with the focus group organizers. And those organizers were themselves not members of an objective polling group, but representatives of a public policy group closely tied to the people guiding the work of the Commission and identified with their views. This “research” would never have passed muster in a rigorous review by the best university experts.

So by using a flawed process riddled with conflicts of interest and unprofessional methods, Roy Romanow was able to make it look like Canadians were ruling out of court any experimentation with the health care status quo he and his advisors favour. But for someone who made such grand claims about basing his recommendations on hard evidence, the core of the commissioner’s report is nothing more than his own prejudices transformed by the ventriloquist’s art into Canadians’ most cherished values. Good thing we’re not the dummies he thinks we are.

Number Three: Canadian medicare is sustainable

On the contrary, Medicare is not sustainable on its present course.  A modest slowdown in the rate spending increases has been bought chiefly through reductions in services, closure of facilities, fewer health professionals, dissatisfaction among those who remain, increased waiting times and forgoing innovative, but expensive, new technologies.

Medicare as we know it can only be “sustainable” if Canadians are willing to accept less service or more taxes.  Polls, as I’ve already mentioned, indicate that neither is acceptable.  And given increasing consumer expectations for expensive health technologies, drugs and procedures, and the expected health demands from an aging population, Medicare’s problems are only going to grow. In fact, a paper[3] by Bill Robson, the Vice-President at the C.D. Howe Institute, a very prestigious think tank in Toronto, has argued that the unfunded liability of medicare (promises to pay for services for which normal increases in the take from the existing tax load will not cover) is in the $500-bn – $1.2-trillion  range. Canada’s entire national debt, by comparison, is currently about $530-billion.

Yet Roy Romanow has already publicly rejected these arguments and has recommended not only retaining but even expanding the centrally planned, government monopoly model of health care in Canada.

Virtually every other major inquiry into health care, including the Kirby Report (by a committee of the Senate of Canada), the Mazankowski Report (by the Alberta Premier’s Advisory Council on Health, of which I was a member) and the Fyke Report for the Government of Saskatchewan (where Mr. Romanow was premier), identifies sustainability of the health care system as the challenge we face. Mr. Romanow’s own former Minister of Finance in Saskatchewan, underlined this when she appeared to testify before his commission.

But Mr. Romanow denies there’s a problem. We’re spending the same share of GDP today on public health care as 30 years ago. If a little more than 7 percent of GDP was sustainable in 1972, why is that same percentage unsustainable today?

It’s the wrong question. It’s not how much we’re spending, but how we’re paying for it and what we’re getting in return. For years we borrowed and spent on health care (and other services), so we got more than we were willing to pay for. Today, as the only G7 country consistently in budgetary surplus, we pay the full cost of today’s services, plus the interest on money we borrowed for health care and other things in the past. So while the spending has remained constant as a share of GDP, the tax burden has grown and quality has declined.

The irresistible force of demand for “free” services is running headlong into the immovable object of unavoidably limited health budgets. To date, the pressure has been relieved by crumbling health infrastructure, loss of access to the latest medical innovations, declining numbers of medical professionals and lengthening queues. By and large, people have access to ordinary, relatively low-cost services like GP office visits, but find it increasingly difficult to get vital services such as sophisticated diagnostics, or many types of surgery and cancer care, where the waits can be measured in months if not years.

This is the exact reverse of what the rational person would want. We should use the public sector to pool everyone’s risk of expensive interventions, ensuring that they are available when needed, but leaving ordinary interventions whose cost can easily be borne by the average person, to individuals, supplemented by private insurance and subsidies for those on low-incomes. Hardly anyone can afford cancer care, bypass surgery, gene therapy or a serious chronic illness on their own. These are the things that, without insurance, destroy people’s finances.

But as much as 30 percent of the services consumed under medicare are unnecessary, not medically beneficial or even harmful. No one would be financially ruined by having to pay for an ordinary doctor’s office visit if we ensured that people on low-incomes were subsidized and there was a reasonable maximum anyone would be called on to pay. No one would be harmed by an incentive not to go to the emergency room when a visit to the family clinic would do just as well. The biggest health care study in the world, the RAND experiment, found that people who had to pay something towards the cost of their care consumed less of it, but that their health was, with very slight qualifications,[4] every bit as good as those who got totally free care.

The extra infusion of taxes Mr. Romanow recommends will merely put off the day when we realize that we must concentrate scarce public health care dollars where they’ll do the most good, and give users of the system incentives to be prudent about how they spend them. We spend vast sums on procedures of little or no value, while we place patients whose condition endangers their life, in lengthening queues.

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[1] The report of the WHO was released in June, 2000. Details are available at lists.isb.sdnpk.org/pipermail/health-list/2000-June/000010.html.

[2] This Royal Commission was a group appointed by the Canadian federal government to conduct a major inquiry into the future of Canada’s health care system. It was chaired by former Saskatchewan Premier Roy Romanow, and released its report at the end of November, 2002. Throughout this talk, when I refer to the Romanow Report, it is to this document that I am referring.

[3] Will the Baby Boomers Bust the Health Budget? Demographic Change and Health Care Financing Reform, C.D. Howe Institute Commentary 148: February, 2001. www.cdhowe.org.

[4] The qualifications are that for a small number of chronic conditions, such as hypertension and vision care, poor patients in these conditions underspent on care. Part of the advantage of the RAND experiment is in helping us to identify areas, such as these, where poor patients’ health can be improved by targeted subsidies.

Cont’d…