Canadian Healthcare at a Crossroads

Canadians generally like their heathcare system, and rightly so. It guarantees basic physician care and hospital care (insofar as such things can be practicably guaranteed, given our geography  and diversity), so that we can get on with our lives, and cope with catastrophic illness when that happens, without having to also worry that it will wipe out our savings or saddle us with huge debts. Most of the world’s leading health economists and health policy experts generally approve of universal care and single payer not just on the grounds of equity and general health outcomes,  but on the grounds of efficiency and cost containment as well: it pools risk, spreads cost, and provides patients generally with bargaining power vis a vis health care providers and drug companies.  From a comparative perspective, the cost  of Canada’s health care system is best described as middle of the pack-- in 2017 we spent about 10.5% of our GDP on health care (7.4% publicly and 3.1% privately), compared to an average among the ten most comparable OECD countries of  10.6%, (7.9% publicly and 2.7% privately),  #11 in spending in the OECD. (The United States, at about 17.3% of GDP,  is far and away the biggest spender.)  The problem is that many of these countries include a broader basket of health  services on a universal basis than we do. 

Canadian medicare coverage has been described as being stuck in a rut that is "deep but narrow". The narrowness comes from our difficulty imagining our dentists, home care workers, pharmacists,  optometrists and physiotherapists, etc. billing the government like our doctors and hospitals do. It also comes from our difficulty imagining a doubling of transfer payments from the federal government to the provinces in order to help pay for the expansion of coverage. Notice that the problem does NOT stem from our single-payer model per se, but from how it articulates with fee-for-service private payment schemes  and our system of fiscal federalism.

Alberta's practice of allowing a small number of visits to physiotherapists to be paid for under Alberta Health (I believe the number is six visits), has a general preventive benefit in terms of encouraging early treatment, as well as enabling workers to gauge the value of physio in managing pain, etc so that they can make an  informed decision about whether to pay for further treatment.  Similar benefits on a larger scale  could be expected from having a basic public dental plan.  I have never studied the economics of dental care specifically, but it seems to me that basic dental care (annual check up and treatment up to $1000, for example) would not only catch many problems early and thereby improve the general health and productivity of the population, but would also act as a payroll tax cut--since our company plans (such as my own) would no longer have to pay for the basic care. In other words, it should not be regarded as a deadweight loss of $1000 to the treasury, or to the economy as a whole. And just think of all the nursing costs and drug costs that could be reduced if we could just remove them from the aegis of hospital and physician care, viz. the most expensive venues imaginable.  A lot of seniors have been housed (at enormous expense) in hospitals because of the lack of space in seniors centres, or the lack of publicly-funded home care. Or kept in a hospital so that their drugs could be paid for. These practices are humane and quintessentially Canadian; but they are also wasteful.If people could access drug treatments and senior care outside of hospitals, we could help more people for the same amount of money.

So the issue is whether we can introduce a broader range of services into our provincial health plans, while still remaining a median country in terms of overall health expenditure.  In Canada , we  probably spend too much of our health care budget  in areas (physician and hospital acute care) that are expensive, and made more expensive than necessary by the fee-for -service system .  We should therefore focus on reducing and modifying fee-for-service, improving the blurred accountability created by federal transfers, and confining any experiments in "new" models of co-payment to the presently uncovered areas of homecare, pharmacare and eye and dental care. In other words,  let’s try not to throw out the single-payer baby with the bath-water.