Monday, September 19, 2016

Health Care is Getting a Kludge

No, "kludge" is not shorthand for clotted cream fudge, which by the way is deeeeeeelicious!

A little over a week ago, I presented the most likely outcomes of Dr. Brian Day's court challenge to Canadian single-payer health care. Given the similarity of the complaint to the Chaoulli v. Quebec, which landed in Canada's Supreme Court, there are decent odds that the court will decide with Dr. Day and his co-plaintiffs. Assuming that happens, the three likely scenarios are:

1. The government throws up its hands and private health insurance comes to Canada.

2. The Supreme Court sort of obliges the government to act, and the government sort of complies, sort of tinkering with things, sort of letting private health insurance take root.

3. The government throws buckets of money to fix and reform the health care system, rendering the Supreme Court decision moot.

You don't need to attend Hogwarts to predict that #2 is by far the most likely scenario. Canada's top court tends to be conservative - judicially, not politically - in stepping on legislators' turf. In response to Chaoulli, Quebec did reform its health insurance plan, allowing for the sale of private insurance to cover certain procedures like joint replacements. Here's the kicker, though: no such insurance product exists, and insurers couldn't make the business case to offer it.

Why not scenario #1 or #3? Well, doing nothing would make both the B.C. and federal parties in power at the time culpable in the demise of single-payer health care. Consider that Brian Mulroney, the Prime Minister most responsible for enforcing single-payer health care through the Canada Health Act, remains Canada's most despised politician ever (though Kathleen Wynne is giving him a run for his money). Can you imagine how history would view the politician that dismantles single-payer health care? Not. Gonna. Happen.

And as for #3, a massive investment hand-in-hand with fundamental reforms? Also not likely. First, that was the intent of the Romanow report, but the result was a large cash infusion with the provinces not terribly interested in dangling from federal strings.

Moreover, we've got more than 50 years of experience that demonstrates the appetite for health care is essentially insatiable. Any added capacity, particularly training more doctors and expanding access to diagnostic tests, gets taken up very, very quickly. I discussed the reasons in general quite a ways back, and will probably revisit them in the future. Suffice it to say that another big cash infusion would get us more health care, but it's only a matter of time before we're back at the same place.

As for the other systems around the world that supposedly make two-tiered health care work? Though I don't put much stock in arguments about health care defining Canada's "national character" - that's the domain of hockey, Tim Horton's, and Newfie comedians - the case for two-tiered coverage of medical care is not as strong as it's often made out to be, and depends on what it is policymakers aim to "fix": wait times, cost, or quality. The closest comparitor nations to Canada - IrelandAustralia, and Great Britain - have headaches throughout their two-tiered systems, despite adequate regulation to make sure things don't degenerate into the atrocious U.S. model.

So in all likelihood, Canadian health care will wind up getting a kludge - a clumsy, somewhat functional band-aid that will cause eyebrows to furrow that it goes too far or doesn't go far enough, and life will move on. As noted economist Paul Krugman often points out, that's basically what Obamacare is, because to reinvent health financing in the U.S. faced major practical, as well as political, barriers.

What would such a kludge look like? It's possible the government would allow for a quasi-private facility like the Shouldice hospital, only for joint replacements. Or B.C. and the other provinces will follow Quebec's lead, and allow for private health insurance that's in no danger of coming to pass. The feds could finance some sort of a hospital or facility to tackle wait-list cases from anywhere in the country. Or something else. The Commonwealth Fund, that ranked Canada's health care system near the bottom of the international pack, seems particularly excited various quality improvement experiments, hoping they can be scaled up to improve health care where it counts.

(Am I crazy, or does this look a little too much like the way South Park portrays Canadians?)

Feeling dismayed? Deflated? Even despondent? Don't be. Clumsy, half-assed solutions are what Canadian governments do, and they do it on a regular basis. Better that than making an honest go of fixing problems, through bloated bureaucratic monstrosities.

Or, get over your bad mood the old-fashioned way: eating. Have you ever tried clotted-cream fudge? It's deeeeeeelicious!

UPDATE: Very excited to announce that coming in the next week or two will be an as-yet-unnamed podcast series! While there will be some overlap with both the blog and my book, the goal is for each to complement the others. More importantly, once it's up and going, the podcast content will be listener-driven. You want it discussed - in my own inimitable fashion - it will be discussed!

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