Wednesday, May 30, 2018

Health Care and the Ontario Election

This election campaign has been more painful than sciatica.

Oh, the memories of studying civics in high school. Mock leaders' debates, essays exploring this or that issue, analysis of the daily really stirs a kid's spirit of civic engagement, of patriotism,  and a yearning to reach the age of majority. What better way to affirm your adulthood than to identify with a political leader who resonates with you, and doing your duty to help elect him or her into office? Sure, you might skip the municipal elections - zoning and sewers don't matter much until you've got a household to manage - but at the higher levels of government really meaningful work gets done.

Like the many other false notions we're fed as children - of course you can make the pros, anyone can be a rock star - the thrill of voting loses its sheen pretty quickly. Politicians rarely keep their campaign promises, pile up scandals like most of us pile up dirty dishes, and (understandably) struggle to manage the ups and downs of economic and social forces beyond their control. Still, even the most Pollyannaish voter would be hard pressed to be excited about next week's Ontario vote. Not only are there serious public policy problems that need tackling, the government's finances will be a mess for the foreseeable future.

As it's by far the biggest chunk of the provincial budget (and the focus of this blog), health care is always front and center during Ontario campaigns. Unfortunately, the party platforms don't instill much confidence that the province's health care system will improve much anytime soon, no matter where each party currently sits in the polls. And pity the poor undecided voter that hoped the leaders' debates would clear up any questions. The first debate covered municipal issues unique to Toronto, a friendly reminder that the ten million people living outside Hogtown aren't terribly important to Queen's Park. And the last debate was as enlightening as meatball sub, an endless string of catchphrases and interruptions that loosely resembled the "family chicken dance" scene from Arrested Development.

Kathleen Wynne's Liberals, moribund as their prospects might be of remaining in power, have a shaky record to run on when it comes to health care. The massive federal cash infusions that began in the McGuinty years were used primarily to buy labor peace and expand access to diagnostic testing, with an overhaul of public health delivery for good measure. But frozen budgets and a lack of investment in long-term care have left hospitals critically overcrowded, packing frail elderly patients into hallways and bathrooms. New layers of bureaucracy have erupted - LHINs, sub-LHINs, CCACs - without noticeable improvement in system performance. Home care became a bureaucratic boondoggle, with millions of dollars earmarked for care diverted to executive compensation. Relations with doctors have turned toxic, and now lie in the hands of an arbitrator. And the rollout of OHIP+ - free drug coverage to under-25s - was a mishandled mess.

If the polls somehow turn around in the next few days and Wynne remains Premier, the Liberal plans include: hundreds of millions on hospitals and new nurses, expansion of OHIP+ to cover seniors, a universal (and presumably, more bare-bones) drug and dental plan, and a $2 billion overhaul of mental health without further details. We can safely assume that no matter what an arbitrator decides, the Liberals will carry on with their Patients First scheme to reverse-engineer primary care reform whether doctors like it or not.

Andrea Horwath's surging NDP have pledged eye-popping investments in hospitals and long-term care ($19 billion over 10 years and 15,000 beds, respectively) and the hiring of 4,500 nurses. They will bring in universal drug coverage and a dental plan for those not covered by private insurance. They'll remove arbitrary caps on surgical procedures to reduce wait times. And they'll create a dedicated Ministry of Mental Health and Addictions, whatever good that might do. The platform mentions nothing with regards to the bureaucratic structure of health care the NDP would inherit from the Liberals, nor does the 98-page platform document appear to even contain the word 'doctor'.

Doug Ford's PCs have cobbled together the rough outline of a platform, promising a bunch of "stuff" without full costing or time frames. They've pledged to end hallway medicine, possibly via their plan to build 15,000 long term care beds in the next 5 years and 30,000 over the next 10, though the 5-year target is not at all realistic. They've promised $3.8 billion on mental heath, addiction and housing supports, though Ford has declared his dislike of supervised injection sites. The PCs are also offering a dental plan for low-income seniors. Ford has proposed using tax breaks to encourage doctors to practice in the ever-neglected north.

If we set aside other major issues like poverty, housing, and education - though in the context of health, we really shouldn't - and overlook the dual elephants in the room of Doug Ford's total inexperience in provincial politics and the province being deeply in the red, which party makes the most sense for Ontario's health care system? It's hard to answer anything apart from None Of The Above.

The Liberals remain absolute devotees of heavy-handed bureaucratic schemes, and it's hard to see the union-shop NDP clipping the wings of the public service (union intransigence is one of many reasons Bob Rae's time in power was a mess). Also an eyebrow-raiser is Doug Ford's choice of advisor in the former CEO of Humber River Hospital, a controversial figure to say the least. Will a Doug Ford government have any real grasp of the problems hospitals face outside the big cities? Granted, the investments in hospitals and long term care promised by all three parties are, of course, better than no investment at all. But they might also be too little, too late to stave off an overcrowding catastrophe sometime in the next two years.

While they've all committed large sums of money towards mental health and addictions, there's no sign any of the parties has a clue as to how they might proceed in allocating that money. Will the Centres for Addictions and Mental Health (CAMH) get the lion's share of the money, or be given authority to direct how the money is spent? Will the money be spent on community-driven initiatives or clinical services? On adding psychologist-provided therapy to the basket of services insured under OHIP, or hiring institution-based social workers to provide counseling services? And where are the strategic priorities and time frames?

The Liberal-NDP contest to expand drug coverage is easily the most nonsensical aspect of the parties' respective election promises campaign. The House of Commons has already recommended a national pharmacare plan be put in place, with former Ontario Health Minister Eric Hoskins brought on to lead the implementation. Unless the plan gets torpedoed by a change in the federal government next year, surely there's no harm in waiting. Why overhaul the province's pharmacare bureaucracy if it might be made redundant by the next federal Parliament? Or do both parties imagine Ontarians are too ignorant to understand that a nationwide plan is coming down the pike?

As to doctors themselves deciding where to park their votes, caveat emptor. Judging by their platform document, the NDP seems thoroughly convinced that doctors aren't needed in primary care. And, as they haven't committed one way or the other to honoring the forthcoming arbitrators' decision, nor seem concerned about recruitment or retention of doctors, it's hard to envision MDs having much to look forward to under the NDP. And despite many prominent members of the Ontario Medical Association declaring unabashed support for Doug Ford's PCs, and Ford's promise to "listen to front-line doctors and nurses", there's no evidence the Tories will be any more kind and generous with the profession than the Liberals. Even the tax-break-to-move-north was an off-the-cuff idea (and a silly one at that). Clueless though Doug Ford may be, it's doubtful that everyone around him is. Ontario is still a province deep in the fiscal red, and any provincial government has much higher priorities than making life pleasant for doctors.

The news is not good for Ontario's health care system no matter who gets elected next week. And despite all the pleadings that things can't get any worse, I would tell undecided voters that it can always get worse. If you're lucky, you have a solid rationale for how you intend to vote: a good local candidate; better financial prospects; platform policies around education or hydro; and so on. Because if it's health care that matters most to you, in this election there is absolutely no clear choice. Pick your poison, folks, because the pain ain't going anywhere.

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