Wednesday, February 15, 2017

The Czar Of All Health Care, Part V

The Czar has been accused of writing tweets that are too long. Good, because it's long past time we stopped trying to fix society 140 characters at a time.

As the final part of the plan to fix all health care, the Czar has to fix the societal problems that prevent the system from working properly. From the first post in this series, those problems include:

Population aging, and age-associated chronic illness
Inadequate safe, secure housing, particularly in Aboriginal communities
Food insecurity among low-income Canadians
Poor access to healthy food, in poor neighborhoods and the north
High rates of obesity
Increased "consumerism" in health care
Outdated health insurance legislation, including the Canada Health Act
Political hyper-partisanship and inter-jurisdictional gamesmanship

The most pressing of these problems - inadequate housing, food insecurity, lack of access to healthy food - fall under the umbrella of "determinants of health". Moreover, the so-called epidemic of obesity, for which we have no shortage of bone-headed ideas to fix, is for the most part a consequence of these broader social problems. Accordingly, the Czar hereby decrees:

1. The Canadian government shall make safe, secure housing a right of all Canadians, and invest where needed to build subsidized housing space. 
2. Each province shall adjust its income support programs to meet the needs of a Healthy Food Basket.
3. All levels of government shall revisit their taxation levels and tax expenditures.

You might be wondering what the Czar is talking about. One of the jobs of public health authorities is to advise the government on the price of a "healthy food basket" i.e. what it costs the average family to buy the groceries it needs for a healthy, balanced diet. The figure should help guide policymakers in determining how much money Canadians need to eat healthy diets, and provide income support where there's a shortfall. In reality, the data is largely ignored by most governments, who rarely revisit their social assistance levels to determine their adequacy. In true Canadian fashion, our politicians hire public servants to collect and analyze data that is almost never acted upon.

Where will Canada get all the money to pay for these programs dictated by the Czar, you ask? First, many of these expenditures - clean water and safe housing in Aboriginal communities, universal pharmaceutical coverage - will cost less in the long run than they do on first glance. Building safe, secure homes generates economic activity, and the money stays largely within the economy. Reduced stress on renters will reduce use of the care system, and lower the strains on the legal and legal aid systems. Clean water and pharmacare will reduce adverse health consequences and all the costs they entail.

Second, the idea that Canadians have no room in their tax system is laughable on its face. Canada takes in less taxes as a % of its GDP than all of the "classic liberal" democracies save Australia. Yes, the UK, the US, and New Zealand governments all collect more tax money than Canada's. We are stingy when it comes it social spending, in particularly outside health care. Between RRSPs, TFSAs, historically low capital gains taxes, no financial transactions tax, and no inheritance surtax, Canada's tax system benefits the wealthy well beyond what you've been led to believe. Perhaps if Canadian governments would stop PISSING AWAY BILLIONS, there would be money for long-overdue social reforms.

Okay, I know what the reader is thinking. The Czar is a closet Communist, or Socialist, or Liberal Fascist (never mind that the term's an oxymoron), or other sort of Leftist. Bullshit.

What are these terms supposed to mean when it comes to health care? The most socialized single-payer health care systems in the world are the most economical - with better population health outcomes to boot - while the most market-driven system is far and away the most expensive and most wasteful. If you could build a system from scratch, which would be the more "conservative" choice? And of course, Canada already has the most important parts of its system (hospital, diagnostic, and medical services) under a single-payer insurance scheme. Is a major dismantling and restructuring of the existing system to a regulated market model a left-wing or right-wing idea? All the laws and regulations would surely create large new bureaucracies so the government could maintain its control over system equity. And would the ensuing upheaval in the health care sector align with the prudence dictated by so-called conservative principles?

Like I said: Bullshit.

Lumping people or ideas into these sort of catch-all labels, that are themselves anachronisms from the Cold War, has been one of the singular poisons to functioning democracies. Already suffering from corruption, the hyper-partisanship and social media tribalism has left the US government on the brink of failure as a functioning democratic republic. Anyone who thinks this kind of political dysfunction, and the descent into authoritarian rule that follows, can't happen in Canada...doesn't spend enough time scrutinizing how political discourse has changed in the Great White North. We have free speech in Canada, so censorship is not the way to go, but the Czar has some ideas to reduce partisan hackery and replenish our democracy.

1. Canadian newspapers and current affairs broadcasters will be forbidden from interviewing political partisans apart from elected office holders.
2. Canada shall adopt a secure online voting system, with mandatory voting by citizens.
3. Federal and provincial elections will be held in two stages: an all-party ballot stage, and a runoff stage should the plurality winner fall short of 50% plus 1 of the vote.

The problem isn't partisan media outlets in and of themselves, but rather non-partisan media outlets that give air time and print space to hacks and spin doctors that are free to mislead with accountability to no one. Want to raise money or canvass for one party? Fine. But the media performing its proper function in a democratic society shouldn't reward your party with unpaid advertising.

Now that the Prime Minister decided all by his lonesome to dispense with his pledge of electoral reform, we've entered a new era in political cynicism in Canada. There might never be a magic "fix" for Canada's voting system, but there is nothing to stop the government from ensuring that each member of the legislature earns the majority of the votes in his or her riding. It will mean automatic runoff elections in almost all jurisdictions, but the approach will do away with the problem of strategic voting, and prevent the misplacement of disproportionate power with fringe parties. The Czar believes Canada can also move into the 21st century. If we can bank, pay taxes, and crush candy online, surely we can have a modern, engaged democracy.

Lastly, we come to the two biggest problems that prevent Canada from fixing its health care system, problems that are closely intertwined: an outdated Canada Health Act, and a definition of necessary health care that's impossible to circumscribe, and therefore insatiable to contain.

Right now, the health care system trudges on, grumbling from crisis to crisis or when pushed by the courts, with the ludicrous mission of doing everything possible to indefinitely extend the life of every man, woman, and child in Canada from preconception on, with the promise of that long life to be as free from disease and suffering as science will allow. Setting aside the impossibility of that task, the government continues to exalt the Canada Health Act's principles as enshrining the notion of long suffering-free life without providing the funds to do so. Worse still, there appears to be little penalty paid by the federal government for refusing to commit the money needed to uphold the Act. The Czar therefore decrees:

1. Parliament shall repeal the penalty provisions in the Canada Health Act.
2. Parliament shall hold a process of consultation followed by referendum, on whether to raise general tax revenues or introduce a means-tested user fee to fund health care. 

It's time for Canada's governments to put up or shut up. If something is necessary, it must be paid for, and LIKE ADULTS, Canadians should be allowed to pay the bill. Health care has become a "third rail" of politics only because politicians and pundits say it is, with little evidence to support the claim.

And thus ends the work of the Czar of all Health Care. The Czar takes his leave now, returning to your regularly scheduled blogging about medicine, health care, and high-quality spirits.

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