Tuesday, January 3, 2017

The Czar Of All Health Care, Part I

If Russia is going to be pulling the strings of the U.S. government, we should welcome nothing less in Canadian health care. But...if we're going for Russian-style autocracy, we need to forget about the Putin-Trump bromance, the legacy of Communism, and go for old-school autocratic rule.

Confession: I stole this idea from Barney Adams, founder of Adams Golf, who wrote a series of online columns suggesting ways to reverse the waning popularity of the game among casual players. Of course, I lack the expertise to tackle as sophisticated a subject as golf (and I'm terrible at the game), but I firmly believe we can use the same sort of dictatorial approach in ameliorating Canada's health care woes.

Why a Czar? First of all it's a defunct label for a dictator, one of the few that's no longer relevant (and therefore acceptable) to North Americans. More to the point, almost every problem in health care, from the immediate crisis of overdose deaths to jurisdictional squabbles over money, has implications for dozens of departments at all levels of government. Only a mighty and muscular Czar can bring all parties to heel to effect real change. And yes, I'm under few illusions as to the size of Czar Frank's influence on government or public opinion (i.e. none), but after spending the holiday period promoting a book and getting a crash course in mailing lists, it's fun to get back to some good-old-fashioned wonkery.


Even the Czar has to operate under real-world assumptions, that not only reflect political, legal, and logistical realities, but also respect history and Canadian values. No wholesale scrapping of Medicare, no federal takeover of health care, and no death panels.
  1. The Czar is accountable to the citizenry and bound by the courts, but is not beholden to any politician, political party, union, or association. 
  2. The Czar has full authority to direct legislators, Ministries and municipal governments, and they will do as instructed in good faith.
  3. The Czar has full authority to expand, merge, restructure, or dismantle Ministries and bureaucracies, except where Treaty rights are enshrined. 
  4. The Czar understands that health care coverage must remain universal (everyone is insured) and portable across Canada.  
  5. The Czar may play with taxation, but Scandinavian-level tax rates are off the table.
  6. The Czar may order governments to issue new debt and/or direct the Bank of Canada on monetary policy, but cannot endanger credit ratings nor allow inflation outside present-day targets. 
  7. The Czar may not amend the Canadian Constitution nor Charter of Rights and Freedoms.
The Problems

The Czar is fully aware that the issues plaguing Canada's health care are legion. They can only be addressed, however, in a logical and prioritized manner. As it stands, there are too many people doing too many things at cross-purposes. Making massive investments in electronic health records (EHR) as a panacea is lunacy in a country where people lack access to clean water. Leaving money earmarked for home care at the table - over politics(!) - when hospitals are overcapacity with alternate level of care (ALC) patients is myopic and irresponsible. Dictating how and where primary care providers will work while refusing to negotiate with those same providers is self-defeating. Under the Czar that ends today. So where to start?


You can't repair a house that's actively burning. No decisions or plans around funding models, obesity prevention, or screening programs are to be made until the urgent crises are dealt with. They are:
  1. Epidemic overdose deaths, largely from opioids
  2. Hospital overcrowding 
  3. Unsafe drinking water in Aboriginal communities 
Proximate Problems

Once the Czar is satisfied that the fires have been put out, it's time to get to work. The mess is very broad and very deep, but not beyond repair. These are issues that can be dealt with relatively quickly, and largely within the health sector.
  1. Inadequate, inaccessible, and poorly distributed mental health care
  2. Inadequate home care and long-term care capacity
  3. Inadequate hospice and palliative care services 
  4. Toxic labor relations, particularly with doctors
  5. Burnout and cratering morale among health care workers
  6. Metastatic bureaucratic/political interference and micro-management
Long-Term Health System Challenges
  1. Poor geographic distribution of primary health care services
  2. Excessive wait times for medically necessary diagnostic services and surgeries
  3. Secular changes in the physician workforce
  4. Patchwork coverage for non-medical services, including pharmaceuticals, vision care, physiotherapy, and basic dentistry
  5. Costly novel technology, particularly biologic therapeutics
  6. Suboptimal funding schemes and outmoded remuneration schedules
  7. Corruption of medicine as a profession by industry influence, with catastrophic effects on the population
  8. Incompatible EHR systems
Long-Term Societal Problems Affecting Health System Supply and Demand 
  1. Population aging, and age-associated chronic illness
  2. Inadequate safe, secure housing, particularly in Aboriginal communities
  3. Food insecurity among low-income Canadians
  4. Poor access to healthy food, in poor neighborhoods and the north
  5. High rates of obesity
  6. Increased "consumerism" in health care
  7. Outdated health insurance legislation, including the Canada Health Act
  8. Political hyper-partisanship and inter-jurisdictional gamesmanship
The Czar recognizes the list of problems will always be incomplete, as well as the interconnected nature of many of these problems. Certainly one cannot tackle obesity without ensuring access to nutritious food, nor can the Canada Health Act be brought up for debate when politics is reduced to a zero-sum game over a shrinking proportion of undecided voters.

Next time: the Czar of all Health Care lays out a battle plan, and puts out the fires


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