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Hill Dispatches: Year's end brings with it the beginning of a new battle for health care

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In the opening weeks of World War II the French and Germans spent a good deal of time shouting at each other.

There wasn't much else to do. France had built up nearly impregnable defences along the Rhine -- the Maginot Line -- and was confident that neutral Belgium and the Netherlands, to the north, provided a buffer of safety.

But France was wrong.

To the Germans this initial period of shouting was merely what historians call the "phony war."

The German plan all along was to slice through that neutral buffer zone and into the heart of France before the French could redeploy their defences; and they did just that. By 1940, Hitler would make his first ever visit to Paris, as conqueror.

Conservatives creeping "on little cat's feet"

The Canadian parliamentary session, thus far, may have been our phony war -- dominated by crime, guns, the Wheat Board, Kyoto, immigration and ephemera such as the restoration of full-throated monarchism.

The first shots of the real battle may have come only after the House rose for its Christmas break, with the Finance Minister's almost laconic announcement on health-care funding.

The Conservatives have been like bulls in a china shop in pushing their crime, guns, greenhouse gas, anti-marketing board agenda through Parliament and (in the case of Kyoto) on the world stage.

But when it comes to health care, they are likely to act more like Carl Sandburg's fog, creeping in "on little cat's feet."

A war of attrition

The Canada Health Act and everything it stands for may be anathema to a great many Conservatives. It's not likely, though, that they will attack it straight on, with all barrels blasting, as they have such targets as the gun registry and the Wheat Board.

What we can expect is something more like a war of attrition on Canada's largely public and universal health-care and insurance system.

And if you want to find out where the current Conservatives would like to nudge us, look no further than the right-of-centre think tank, the Fraser Institute.

Health policy appears to be a high priority for Fraser. It has put out a fair bit of notional research and analysis on health policy issues of late, and when you hear Conservative cabinet ministers talk about the danger of health spending taking over provincial budgets and crowding out spending in other areas, there's a good chance they got that from Fraser.

Universal, public health care not sustainable: Fraser Institute

In a report issued this past April entitled "Canada's Medicare Bubble: Is Government Health Spending Sustainable without User-based Funding?" Fraser's CEO Brett Skinner (who is also Director of Health Policy for the think tank) and his co-author Mark Rovere talk about that "crowding out" problem for the provinces. They say that "when federal transfers are excluded, government health spending currently consumes between 48.0% (Alberta) and 87.7% (Nova Scotia) of total available provincial own-source revenues."

Canada's health-care system is not sustainable, the paper argues, without "supplementary user-based, private financing, [which] would off-load public cost pressures, encourage economic efficiency, and offer a sustainable source of additional resources."

More money from the federal government is not the answer, the Fraser folks say, because the provinces would not have any incentive to "reform" the system. Fraser's solution is the magic elixir of "the market."

Many options for reducing costs, improving health

There is nary a word in the Fraser Institute's literature about any of the wide range of options that health services research and experience point to.

Those options include a variety of "population health" measures that range from focused ones, such as tobacco reduction, to a more broadly-based attack on inequality and poverty, key contributors to negative health outcomes.

There are also system efficiency measures that organizations such as the Canadian Health Services Research Foundation (CHSRF) are exploring.

CHSRF has had noticeable success working with such health-care facilities as Princess Margaret Hospital in Toronto and the Yamkaska-Richelieu health services region in Quebec. The Foundation provides training based on an evidence-based approach. With the help of that training, these facilities have achieved much: reductions in wait times and stays in hospital; streamlining of services; a greater reliance on less-costly home as opposed to in-hospital care; a continuum-of-care model that means the social worker, outreach nurse, specialist and family practitioner work co-operatively in the patient's interest; and other cost-saving improvements.

And then there are the vast efficiencies, and improvements in outcomes, we could realize through the widespread adoption of fully accessible electronic health records for all Canadians.

The "philosopher's stone" of the market

The Fraser Institute is not interested in any of these proven means of cutting costs, while providing a more responsive and effective health-care system.

Instead, like medieval alchemists who believed there was a "philosopher's stone" that would turn base metals to gold, the Institute preaches that all we need is the miracle of the free market and its trusty sidekick, the profit motive.

If you are interested in the future of health care in Canada, you should have a look at what the Fraser Institute proposes in its April, 2011 paper. Here are that paper's main conclusions, with Hill Dispatches' comments in italics:

"The federal government should:
- temporarily suspend enforcement of the Canada Health Act for a five-year trial period to allow the provinces to experiment with new ways of financing medical goods and services.

(Once suspended, would it ever be possible to re-enact the Canada Health Act? The Fraser institute knows full well that the answer is no.)

The provincial governments should:
- encourage the efficient use and allocation of health resources by requiring patients to make percentage-based, co-insurance payments for all publicly funded medical goods and services they use";

(In other words, rather than finance the system through fair and equitable taxation, place the greatest burden on those least able to pay.)

- off-load cost pressures from the public health system by legalizing private payment and private insurance options for all types of medical goods and services, including hospitals and physician services, as is currently allowed for prescription drugs;

(In other words, let's bring on American-style private health insurance, and, maybe, American-style rationing of services through the notorious Health Management Organizations, what Americans refer to as the HMOs.)

- allow health providers to receive reimbursement for their services from any insurer or payer, whether government or private;

(Is it at all realistic to expect that this would not drain services away from the public sector, creating not what many call a two-tier system, but rather parallel business class and economy class systems? Anyone who has flown recently knows how well economy class customers are treated.)

- shift the burden of medical price inflation onto the private sector by allowing providers to charge patients fees in addition to the government health insurance reimbursement level;

(So let's go back to permitting the extra billing that the Canada Health Act eliminated in 1984. How allowing practitioners to collect from the government and then turn around and extort added fees from patients will contribute to cutting costs and increasing efficiency is anyone's guess. Perhaps Fraser believes seriously ill people who could not afford to pay the surgeon or anesthesiologist would choose death over treatment, thus saving the system millions of dollars!)

- create economic incentives for cost and quality improvements by permitting both for-profit and non-profit health providers to compete for the delivery of publicly insured health services."

(Now, adding profit into the system is surely going to make it better and less costly, n'est-ce pas?)

Wait until 2017 at your peril

To buttress their arguments for an effective privatization of health care, Fraser Institute authors frequently claim that Canada's system is much more public and much more restrictive of non-public sector activity than other similar systems. The Institute knows enough not to try to compare Canada in a negative way to the USA; but it often tries to claim that European health-care systems are more flexible and have a better public-private  balance than does Canada's.

That claim is not borne out by the facts. But we will have to deal with that in more detail in the next Hill Dispatches piece. Christmas is coming, after all!

The battle for health care has been joined, even if there are no bugles and cannon volleys.

Those who care about the Canadian public, universal model would be unwise to wait until the 6 per cent per year increases in funding end in 2017. They would be well advised to pay close attention to what privatization advocates, such as the Fraser Institute, have to say, now. We know the Harper government is paying attention.

To be continued...

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