Sunday, October 23, 2016

Should the Feds Wash Their Hands of Health Care in Canada?

Thought experiments can be fun. After sitting through those Hillary vs. Trump debates, God knows my brain could use the workout.

If you haven't yet, please check out the introductory podcast at this link series, and leave a comment with questions or feedback!

You don't need to have a defibrillator handy to hear that federal-provincial health care funding talks didn't go well this past week, nor that past "saviors" of Medicare think the feds need to stick to their guns in demanding some form of accountability from the provinces. This is the way these talks go, almost in ritual fashion, and sooner or later the spigots will open and the dollars will flow once again.

Must it, though? Do we really need to bear witness to our elected representatives bickering for days at a time every few years over health funding, or throwing hissy fits over a tweet? As the provinces embark on ever more convoluted restructuring plans to their health care systems, is there really a need for the feds to toss in more administrative headaches, headaches that almost certainly do nothing to help the average Canadian?

What would happen if the federal government went whole-hogger on getting out of the health care business, minus the stuff it's done forever like approving medicines and so on? Let's play it out.

For starters, this is probably something only the federal Liberals could pull off. It's possible the Conservatives under Stephen Harper could have done this when they had their majority, but it's politically risky for a right-of-center party, handing left-of-center parties a deciding issue come election time. The NDP wouldn't ever consider it, given their support base of unionized workers, nurses included.

There would need to be a large and permanent transfer of tax room from the feds to the provinces, along the lines of what was done in the 1970s, and amounting to whatever the federal portion of health care funding could be agreed upon going forward. There would necessarily be some fudge factors, analogous to equalization and to account for Aboriginal Canadians that are under federal responsibility, but let's assume for now those can be decided upon painlessly (as if). Most likely the feds would have to be extra generous, as it's the only way to get the political heat off themselves for any length of time.

Federal largesse would put a lot of pressure on the provinces to resolve their various health care labour disputes, particularly with doctors but nurses' unions as well. We won't see a return to mid-2000s-level generosity - there's too much red ink across the country - but backing off of contentious global caps seem likely.

Similarly, the provinces will be pressured to open their coffers to increase access to cutting-edge therapies, particularly for cancer. As with the post-Romanow "fix for a generation", buying labour peace and funding novel biologic therapy will siphon money away from badly-needed investments in long-term care, home care, and mental health. Health care workers might complain less, but "bed blockers" in hospital beds and crowded ERs will still be with us.

The Canada Health Act would become a redundant piece of legislation in terms of the strings it attaches to funding. The feds could re-legislate the universality and portability criteria, and possibly outlaw user fees, but the Act couldn't otherwise survive in its current form and scope.

Assuming it returns the Conservatives to power, Alberta would probably be the first province to experiment with privatization of health care financing, given its political culture. Private insurance is probably less likely than permitting cash payment. There are implications to private insurance under NAFTA that would invite opposition from other provinces. The other provinces, flush with cash and control over health spending in the short term, would wait to see the outcome of the Alberta experiment.

Would we see net migration of health professionals from other provinces to Alberta? To a degree. The collapse in oil prices has taken some of the "promised land" sheen off of Alberta. Nurses and doctors both need jobs, and it's not like there would be a glut of work in a private-pay setting. One would anticipate that a private tier of care would attract experienced doctors first, with unemployed recent grads back-filling, especially new surgeons. Even allowing private care, there would likely be some kind of restrictions on licensing or billing...maybe a mandatory return of service before being allowed to work privately? Minimum hours of work in the public sector each month?

Free from federally imposed shackles, the provinces will have all the leeway and money they need to see their restructuring plans through implementation. So the LHIN 2.0 "Patients First" scheme, privatization of the province's EMR system, and whatever the hell the Atlantic provinces are doing to torment doctors...all of it goes ahead.

Do the provinces even want this? Provincial politics would be all health care, all the time, even more so than it is now. Premiers would lose their go-to excuse for health care woes - federal underfunding - meaning more blame on system problems will fall on doctors and hospital CEOs.

At the end of the day, health care in Canada won't look all that different than it does now, give or take the wealthy being spared the nuisance of a flight to the States for their MRIs. The provinces will remain convinced of the genius in their half-baked schemes, and redirect money from where it's needed to where the votes lie. Health professionals will get a few years' respite from abuse but continue to have stress and burnout from working in a system stretched past capacity. Every funding experiment will still be labeled as the first step down the slippery slope to U.S.-style health care. And the ones who need health care the most? Yeah, they'll still get the short end of the stick.

Doing away with federal interference in health care? One more emperor in need of clothes.

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