During the lull of early summer, while we were calmly waiting for next week's all-Trump gong show at the GOP convention, Ontario's health care system was suddenly thrust back into the news. I don't mean talk of a strike, which is an internal debate only at this stage. No, rather the seemingly-out-of-nowhere tentative deal between the OMA (Ontario Medical Association) and the province, after two years of repeated cuts to doctors' fees, and increasingly toxic relations between the parties.
The details of the agreement are widely available, but in a nutshell:
- the fee cuts of the last few years are still in place
- the province has budgeted for increases in population growth and doctor supply
- the province and the doctors will form a permanent joint committee, charged with ongoing management of the doctors' fee schedule to find savings and keep up with technology
- the province has budgeted for one-time payments to the doctors' services budget, essentially as a buffer if savings don't meet the province's targets
- there will be some sort of discounting mechanism put in place for doctors billing over $1 million
- there will be amendments to the most obnoxious parts of the Patients First Act, pulling teeth from the jaws of my beloved LHINs
- the province is loosening some of the restrictions for new doctors entering practice
- the court challenge for binding arbitration continues, but without consideration of the recent cuts
The doctors aren't happy. In fact, a lot of them are furious, feeling betrayed by an ineffectual medical association seemingly in cahoots with its adversaries, receiving ever smaller pieces of an inadequate pie, and being made solely responsible as a profession for the growing costs of treating the sick. Meanwhile, it seems nurses, teachers, and other public sector workers continue to get raise after raise in their contracts, and it might be years before the doctors' quest for binding arbitration works through the courts. The OMA Board has endorsed the deal, with the ratification vote less than a month away. What should the rank-and-file do?
I don't argue that the contract is something of a raw deal. The recent cuts appear to be etched in stone whether or not the deal is ratified, as is the government's insistence on a hard cap. And the joint committee can be read as an invitation for doctors to choose where in their backs they'd like the OMA to stick the knife. If doctors see the deal as a death trap and nothing more, I see where they're coming from.
As I argued on the doctors' private Facebook page, though, there's some good in the deal that can't be overlooked, as well as one very inconvenient fact. From the mid-2000s until 2012, doctors' real net incomes far overshot the historical trend line dating back to the 1950s (see page 11 of this document). The rollback of the last few years was probably inevitable.
As for the good in the deal? Doctors get a permanent hand on the wheel in how health dollars are spent. There are no more unilateral cuts and no surprises for the next four years. The province will foot the bill for costs associated with unforeseen crises (such as a severe outbreak). If the courts award arbitration, the doctors have that in their pocket for future negotiations. And the OMA won changes to legislation, an uphill task if ever there was one. It's not a good deal, but it's a deal with good stuff in it.
Look, doctors are certainly free to reject the offer, with or without all the answers known. Though I'm 100% convinced that strike action is doomed to fail, I can agree to disagree with those calling for it. Still, before doctors thumb their noses at the OMA and the government of Ontario, I have one simple question: what's your BATNA?
Any business school or textbook will teach you that there are three things you need to decide before entering a negotiation: your opening position, your target, and your BATNA. That's the acronym for Best Alternative To No Agreement - what you have left if one or both sides walks away from the table. Though your opening position doesn't need to be based in reality (Mexico will pay for the wall!), your target does, and your BATNA really does. That means pride, ego, aspirations, and sunk costs (in this case, the outcomes of past negotiations) have to all be left outside the door.
The BATNA being put forth by doctors opposed to the tentative deal goes something like this:
Say no to the tentative agreement. Tell the OMA they've failed in their duty to their members. Demand arbitration before the OMA comes back to negotiate. The unions all have arbitration, and almost always win at arbitration. Doctors are as essential as any other public servant, so there's no reason the OMA won't win back the unilateral cuts. Grass roots doctors will engage in some kind of job action and/or organize to break free from the OMA and/or campaign for the PCs and/or convince doctors to leave Ontario en masse. The public will understand where doctors are coming from and help oust the Liberals from power.
It should be pretty clear there are an awful lot of maybes to that plan:
- maybe the courts will award doctors arbitration (this is far from certain - doctors are not a union and the fee deal is not a labour contract)
- maybe an arbitrator will decide for the doctors
- maybe the OMA can be torn apart
- maybe the government will be willing to deal with a body apart from the OMA
- maybe the public will care about what doctors earn
- maybe job action annoys the public enough to pressure the government
- maybe the Liberals lose the next election
- maybe the PCs will give the doctors back what the Liberals took away
- and so on...
Apart from the Liberals losing the next provincial election (for reasons having nothing to do with doctors), none of those outcomes is terribly likely, and most of them have a slim-to-none chance of coming through.
So yes, doctors might feel trapped, or betrayed, or fucked, or whatever unpleasant verb you choose. Doctors might be mad as hell and itching for a fight. But that doesn't change the fact that choices need to be based on real, not hypothetical options.
So, doctor, how will you cast your vote?