Leading Economist Shatters Myth That Public Health Care is 'Unsustainable'; Pins Blame for Soaring Costs on Private Health Care

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Thu, 2010-06-17 11:06

Sean in Ottawa

Canadian Health Coalition release: http://tiny.cc/shjci

" 'Opponents of Medicare claim that public health care is fiscally unsustainable and that the only viable solution is a shift to more private coverage. Bluntly, this is a lie,' Dr. Evans said.

" 'Sustainability is often a code word for privatization and for-profit health care,' Dr. Evans said. 'But any debate on the sustainability of public health care must start from who and what drives health care spending, and include a clear identification of the winners and losers of any erosion or dismantling of Medicare.' "

Interesting that Dr. Evans calls those who say health spending in Canada is unsustainable liars. It is important that people recognize that some of those speaking on this topic are not just wrong or blinded by ideology. Some are deliberately misleading people with a clear profit motive in view.

Also interesting is the quantification of the impact of aging on the health system in Canada as a measly 0.8% per year, a figure well below inflation.

It is important to note that when we speak about health spending going up, we need to recognize that this includes private spending. Private spending impacts public health in a number of ways some indirect but significant. Gaps in access to pharmaceuticals, long-term care, home care, mental health, dental care all increase acute care costs, yet even so the public system is innovative and resilient.

As well when we speak of the budget burden of healthcare we need to recognize two contextual factors: firstly tax decreases and tax shifts from business to individuals and secondly cuts in all other manner of spending. These cuts make health spending take up a greater percentage of overall spending even when it is not increasing appreciably. This is why looking at public health spending as a proportion of GDP is a better way to look at it. Of course there it is a non story as it remains largely a constant.

Thu, 2010-06-17 18:21

Sineed

And people on the right will continue to promote privatization despite the massively more expensive US system that proves the lie.

Governments also contribute to the confusion over health care costs. For instance, the Ontario government has been promoting this idea (a lie, btw) that Ontarians pay more for generics than they should. In fact, 75% of drug costs in Ontario are because of brand name drugs.

Thu, 2010-06-17 18:37

Boom Boom

Sean, I'm borrowing that link for my FB page!

Thu, 2010-06-17 22:08

George Victor

Sineed wrote:

And people on the right will continue to promote privatization despite the massively more expensive US system that proves the lie.

Governments also contribute to the confusion over health care costs. For instance, the Ontario government has been promoting this idea (a lie, btw) that Ontarians pay more for generics than they should. In fact, 75% of drug costs in Ontario are because of brand name drugs.

Pharmacies and generic suppliers admitted that the pharmacies were demanding a kickback if the generic manufacturers wanted to sell those generics to them. It was very persuasive,but, of course, raised the cost of the generics $1 billion plus...

But just the other day the pharmacy suddenly decided to supply me with a generic rather than the brand name drug that they had sold me for three years. As an old fart I only have to pay $6.11 dispensing fee, so I never asked if the generic was available instead. But I'll bet you're right in that the pharmacies are now required to provide the generic where available...in this case, about $100 for three months rather than about $230 (glad I don't have to pay either). Either that or it just happened, the other day, that the (I believe) 20-year copyright on that brand had just expired. I think not.

Thu, 2010-06-17 22:15

leftypopulist

Let us remember the cuts to health care funding started by the Neo-Liberal and Neo-Conservative monopoly back in the early 1990's. Ralph Klein in Alberta, then Paul Martin in Ottawa, then Gordon Campbell in BC.

They like to starve the 'evil' socialist health care apparatus. Then, when it's broken, they like to usher in a privatization 'solution'.

That's the rightwing agenda and well documented historical policy pattern. Break it, then 'fix' it.

It's all about shovelling more wealth to the top 10%.

Thu, 2010-06-17 22:25

George Victor

Exactly right, lp. But in the case of health care, they have to be very, very careful in arriving at their end objective of a privatized world. Lots of folks don't bother about voting but even the most alienated understand sickness and death.

Thu, 2010-06-17 23:02

leftypopulist

Correct, sir.

But those Libs & Cons are very crafty and aware of the public backlash WRT life-sustaining essential services being cut. So, they implement some occasional, superfluous *re-funding* of the decimated programs right before election time and then boast about how committed they are to their funding pledge, not mentioning the overall (net)health care funding decline.

Fri, 2010-06-18 08:56

George Victor

And to support your thesis, we see this morning in the news the tragic, lengthy waiting list of children that required surgery in 2009. Lots of pressure for a private system to look after them, eh? I did not notice a demographic breakdown of those parents who would be able to afford to take their youngster for care in that system.

Fri, 2010-06-18 10:15

INP

I believe that health cards should be encripted with a sub code that assess a fee-for-service based on a persons income for the previous year. $0 to $50,000, you pay nothing. Then it should slowly go up incrementally to, say, $500,000 at which point you pay $100% up to a cap (to protect against catastrophic maladies) Children under 18 and elderly over 65 get free treatment across the board.

You know, it's one thing to want everyone to have equal access to health care. It's another thing entirely to give cost-free treatment to someone making a million dollars a year.

The extra revenue would go into the system to increase service levels - hire more people, build more facilities, buy more equipment etc.

Fri, 2010-06-18 10:38

#10

Sean in Ottawa

INP that is one troubling post - on several levels.

First in order to participate I guess you would need to have a credit card and your taxes up to date-- otherwise no care?

Secondly, you are ignoring the fact that direct fee for service is inefficient and the collection process would eat up substantial parts of the revenues. This is especially so of a means tested system as you describe.

Thirdly, people who pay taxes to support the system ought to expect something from it.If they are supporting healthcare through taxes they should be able to call on it when they need it.

Fourthly, means-tested systems never do well because effectively you deny the people who have the means to defend the system from any benefit from it and ultimately create a two-tier system.

Fourthly, the insurance aspect of the system is not just for low income people. This is not just a question of facing individual medical expenses but also cumulative expenses so the means test would need to track not only what you earn but also what you paid already. For fairness would we account for certain hardships for additional expenses? If so then essentially what you are proposing is to break medical expenses from the rest of our income tax system and effectively pay two income taxes. I can't follow an argument that this is either fairer or more efficient.

Fifth, from the last comment we are lead back to the question of why duplicate what we have? We have a tax system that means tests people, provides some exceptions and additional credits looks at what they make and then has them pay in to a fund to cover all our collective expenses. It is efficient because it manages in a single collection all of those public goods be they for education or health or whatever else. The main purpose to not use the tax system is to punish users to discourage use which is problematic when ti comes to health spending because ignored needs tend to get more expensive as well as add to misery and inequity. Another purpose to not use the tax system is to ration use to assume only those with the money should receive the service (a point you do not concede it seems). Another is to hide accountability for taxes paid so that payers cannot know what they are spending -- however when it comes to hiding taxes paid to government for political purposes we already have consumption taxes which while inefficient are already perfect for obfuscating the exact amount you pay so even that political objective is covered.

So what is being proposed here is a massively expensive collection scheme that would need to be borne by health care users without any actual benefit.

Indeed this is why this system is not popular anywhere. User fees work if you want to punish the poor, help insurance companies make money but then there is no point having them means tested.

The only value I can see with your proposal is if the objective is eventually to ease people in to paying their own medicare and ease society in to abandoning those who cannot pay and eventually allow the less efficient private system to manage it all for the purpose of its own profit. So in that sense it could have a purpose for a while as a transition to a Darwinian health care system. Of course if you think the cost to move to electronic health care records in Ontario has been expensive, this will be much more and of course someone somewhere will make a pot of money. But then if that is the objective why not just say so?

Fri, 2010-06-18 10:56

#11

INP

The intent wasn't to punish the poor. The intent was to make the rich pay and financially bolster the system with the money collected. You make a compelling case as to why this particular approach may not achieve that end. I do believe, however, that some alternative to a system funded 100% from general tax revenues may be necessary to ensure the contunied viability of the system as a whole. Wait, let me rephrase. My desire is not to ensure the contiuned viability of the system, it is to enhance, improve and enlarge the system so everyone gets cadillac care. And I still believe that it is obscene for someone driving a mercedes to get cost-free care. Thanks for your thoughtful rebuttal.

Fri, 2010-06-18 11:00

#12

Sean in Ottawa

BTW, I avoided the argument that health care is a public good because while I believe in this strongly, I suspect that INP is a little too far to the right to be reached by such an argument. Instead I went to the efficiency arguments.

Let's not forget that user fees are not only bad medicine. They are medicine for a disease that does not exist. The point is public spending on health care is actually quite sustainable.

Private spending in fact is not. It is private spending that is out of control, has unintended consequences (the only intended ones being profit), and threatens not only health and equity but indirect damage to every other aspect of society.

Now can we not recognize the disconnect between a belief in collective protection that is at the core of the concept of insurance and the idea that we cannot do this at a national scale? Here we have insurance companies selling private insurance under the same premise that we provide national health care, yet they pretend that somehow by making the beneficiaries more exclusive and hauling out profit, it is somehow better. The only real difference apart from inefficiencies that the private insurers can offer is the creation of profit which as I say is the end in itself. Otherwise the mechanism is the same it is just a question of whether we do this on an efficient and equitable universal national scale or an exclusive members only one.

Let me emphasize if private insurance can even claim to be sustainable, a national insurance plan is more so because of the advantages it brings in universality, efficiency and sustained social purpose. There is simply no possible argument that can be made to suggest otherwise. And even the most rabid privatizer (privateer?) would never argue against the concept of collective insurance of some form (and they all personally carry it when they can) -- they just pretend that exclusive for profit has some kind of benefit other than their own profit.

Fri, 2010-06-18 11:10

#13

INP

"I suspect that INP is a little too far to the right to be reached by such an argument. Instead I went to the efficiency arguments"

The ability to reach me in the centre is dependent on how many miles you are to the left of centre. Never once did I suggest that any services should be provided outside the public system. If you think that exploring alternative funding mechanisms for public care is "right wing" well, it is you who is far from the middle, not me.

Fri, 2010-06-18 11:56

#14

thorin_bane

All I know is the CMA came out in early 90s to say we had too many doctors. The provinces then cut enrollment acceptance to medical deegrees. Then 5 years later we began the CRISIS in medicare with too few doctors, which meant wait lines...umm is there any correlation ...not according to our media there isn't.

Problem is when you have lots of docs available it is harder for them under the current funding formula to make thier 'Quota' to max out income every year, mostly cause each of them is a private businees. No wonder when I go in for 2 things I always have to come back to discuss the other on a different day.

Whatever happen to the romanow report, thanks paul martin.

Fri, 2010-06-18 13:09

#15

Sean in Ottawa

INP- I must apologize for my sloppy overly personal conclusion. I should not have suggested you were anywhere in particular on the left-right spectrum. User fees are indeed a right wing solution discredited as a means to supporting the system and only presented from an ideological purpose for the most part.

Another left-right perspective surrounds taxes and it is that perspective that lead me to suspect you were right wing. Taxes are in fact collective purchases of public goods and so long as they are sufficiently progressive we have no cause to worry about the person in the Mercedes not getting another bill on receiving care.

I have long understood that we are each individually in the centre as that is where we see things as to the left or right of ourselves. I have no doubt therefore that you are at the centre of your vision. However, inasmuch as there is a common vision in a given context or place you may not be at the centre of that.

There are of course two concerns here: the first surrounds who is paying, access and equity and that can be best satisfied through the ultimate means test: a progressive tax system.

The second is efficiency which is best managed through a single payer system. There are other reasons for this in health care. Health is interdependent and the act of pricing individual procedures leads to a form of inefficient competition not for efficiency but for cost transfer. Individual rather than overall accountability can lead to unintended consequences-- you can save some money in one silo by transferring a cost at greater expense to another. This is one of the reasons why privatization and the pricing of medical care (including activity based funding models) are so dangerous.

Over the last number of years Primary Health Care has increasingly been seen by experts as requiring a holistic vision that is not compatible with localized bean counters. As well we should not underestimate the administrative burden of determining what each individual procedure or element costs. Such analysis can be important if you are getting different people to pay for something or if there are choices but at times it is extremely wasteful and distorting if we are speaking about a necessary procedure being provided at the expense of a single payer.

Fri, 2010-06-18 13:12

#16

Sean in Ottawa

There is a strong argument that we do not have an overall doctor's shortage. Rather we have too many in some fields competing to create the maximum number of income-generating procedures and too few in others such as GPs, some specialties and in rural locations creating lineups. The market alone does not determine the correct numbers.

Fri, 2010-06-18 13:31

#17

INP

Thank you Sean in our Nations Capital. I appreciate your thoughtful comments on this issue.

Let me pitch this to you then. I am a skeptic by nature. I suspect our (relatively) unaccountable centrally administered health care payment system is rife with abuse and manipulation. It wouldn't surprise me ifs a fair number of doctors cheat. They are human and humans are exceptionally falable, especially when it comes to money That's why I would like to see a detailed invoice sent to all users semi-annually or annually. It could include the amounts paid to the provider if only to drive home to the user how much the system is paying for given services. Primarily, though, it would list the services provided the dates and the service providers. Under the current system the user has no idea what service is being billed in their names and the system has no proof that the service was even provided. It astounds me that health systems involving over 180 billion dollars a year could run with such little oversight and such few checks and balances. It is a testament to our trusting nature (read, gullability).

I expect your agrument against this will centre around the logistical difficulties and cost of implementing and administering such a system.

Fri, 2010-06-18 13:36

#18

Unionist

Health care costs in single-government-payer Canada are 9.4% of GDP, vs. 13.9% in the U.S, where most billing is totally transparent (either to the user or to the insurers, both of which are easily verifiable by the user). It takes a peculiar world view to suspect that "cheating" is rife in Canada.

Fri, 2010-06-18 13:40

#19

Fidel

I read somewhere that health care fraud in the US is worth $30 billion a year. They've got all kinds of problems with everything from billing the taxpayers for ghost operations to outright theft. All those insurance companies represent dozens and dozens of duplications of health care bureaucracy in the US. It's way inefficient.

Fri, 2010-06-18 13:50

#20

INP

Unionist, I don't see anything pecular about wanting to ensure that Canadian health care providers are held to as high a level of accountability as possible. It also takes a pecular mind to take my argument in favour of more accountability in our system and, in rebuttal, offer some off-the-wall comparison with the American system (which I would never defend, by the way).

Fri, 2010-06-18 14:29

#21

Unionist

Furthermore, the notion that a doctor (one who hasn't lost his marbles) would risk submitting a phoney bill - even once - is worthy only of U.S. evangelical talking points. If caught, the doctor would lose their licence to practise and face criminal charges for theft/fraud. The other underlying assumption is that individuals can be trusted to monitor medical fraud, but the government bodies mandated for this purpose can't.

For someone not defending the Amerikan way of life and thought, you're not doing a half-bad job.

Fri, 2010-06-18 14:29

#22

Boom Boom

Here on the Lower North Shore of Quebec, we are seen by a GP that travels the coast every few weeks. No resident GP in any but two of these communities, and any time there's a medical emergency, we rely on helicopter evacuations to an air ambulance in a larger population centre. We all have community clinics staffed by a resident nurse. No access to a pharmacy either - we fax our orders to a pharmacy at the hospital, and our prescriptions are sent once a week, usually a Friday. No resident dentists, either - the health service sends a dentist from Montreal to the coast every two months for a week. For specialists, we are airlifted out to Sept-Iles to an appointment at the hospital. I'm being sent back to Sept-Iles next week for a follow-up to my eye surgery a few weeks ago. More money in the public system would have more frequent visits to the Coast by GP's, dentists, and medical specialists.

Fri, 2010-06-18 14:31

#23

Sean in Ottawa

INP- there are a couple ways of looking at this.

I don't like the idea of a "bill" because of both the need to quantify and secondly the philosophy behind the person being billed.

I also feel that there are so many urgent priorities and opportunities that I worry what does not get done while we do that.

I am not against accountability, however.

As we move to electronic medical records that may end up on your medical card on a chip, I think that personal access to medical records is important and people should review them.

Still the fee for service model may not be the best for Doctors either. It may be preferable to place most on salary. Of course then you need others to do case management which may not be a bad thing.

Fri, 2010-06-18 14:51

#24

Unionist

With drug companies raking in uncontrolled billions, and with chronic doctor (especially the lowest-paid) and nurse shortages, I find the notion that we should start cracking down on lazy cheating doctors particularly misguided and regressive.

Fri, 2010-06-18 15:30

#25

INP

Great, you figure out how to solve the drug and service issues and I'll deal with the accountability issue. Fair?

Fri, 2010-06-18 18:21

#26

Sean in Ottawa

INP- I think Unionist may be more categorical than I would but the point being made is one of proportion. When there is so much money to be saved through better management of resources (supporting homecare rather than having it back up into uneeded long term care and from there in to acute care or supporting pharmacare), why would we be spending resources going after the few Docs that are cheating costing the system relatively tiny amounts?

As well, once medical records are fully electronic this problem will disappear.

Fri, 2010-06-18 18:22

#27

Sean in Ottawa

If you want to look at the accountability issue -- the big bucks are in policy and management choices not individual fraud.

Fri, 2010-06-18 18:27

#28

Unionist

Thank you for putting it more rationally than I was inclined at the time to do, Sean.

Sat, 2010-06-19 11:18

#29

edmundoconnor

I quite frankly find it amazing that right-wingers put forward the private system as efficient and cheap, as compared to the inefficient, bureaucratic and expensive public system. Funny that they never notice the most inefficient, paperwork-riddled and plain old expensive system is the private one!

Thu, 2010-06-24 03:39

#30

leftypopulist

So true, Edmund.

If one were only concerned with a quarterly profits perspective, one might very well indeed refuse to upgrade to the 21st century, because "ya gotta cut overhead and expenses to out-compete the opposition... and the 4th yacht for the CEO is an absolute *must* !".

We see the same cost-cutting obsession with massive oil companies refusing to spend a relatively small amount on the necessary equipment to help quickly counter an emergency spill or malfunction.

Sometimes, only mandatory regulations will snap people out of the regressive, wreckless obsession with quarterly profits.

Fri, 2010-06-25 10:57

#31

Uncle John

One thing I won't back down on is universal medicare.

We could afford medicare when Canada's economy was $600 billion. Now it's $1.2 trillion and we suddenly can`t afford it?

I don't think so.

Sun, 2011-08-07 13:21

#32

Boom Boom

My main beef is that there's a lack of specialists in the more isolated communities - as I found out this summer with my ENT crisis. It gets worse as you go north. Much more funding in the Canada Health Plan might help to recruit more specialists - but is that the problem? Maybe medical folks don't want to live in tiny far off communities? Comments welcome.

Sun, 2011-08-07 15:20

#33

abnormal

Boom Boom wrote:

My main beef is that there's a lack of specialists in the more isolated communities - as I found out this summer with my ENT crisis. It gets worse as you go north. Much more funding in the Canada Health Plan might help to recruit more specialists - but is that the problem? Maybe medical folks don't want to live in tiny far off communities? Comments welcome.

That's been an issue as long as I can remember (and it's not just specialists). Thirty plus years ago when I was a student med-school applicants automatically got interviews if they were from "remote" areas - forget where the cutoff points were but the areas in question were truly in the booneys.

Problem was that after spending several years in "the big city" going to university and med school after that most of the new doctors I knew didn't want to go "home". They'd been in Southern Ontario for so long that that was home, not the small town they grew up in. And in a lot of cases they were married, or at least in long term relationships, with people they'd met at school who were simply not willing to move to small town nowhere.

Sun, 2011-08-07 16:15

#34

Boom Boom

We get a nursing rotation here - we were lucky to have the same nurse for about three years, then she left. This year it's been one nurse after another, most just stay on a month or two. Our community is just 100 people, and no road connection to the mainland, and nothing to really attract someone to remain here for the duration - other than a good income and really nice accomodations. Our physician usually flies in for a few days every two or three weeks. The dentist is here for a couple days every two months, and the ENT specialist is here for just two hours twice a year - total of four hours in the year.

A hearing aid specialist is here one afternoon twice a year, and an optometrist is here for an afternoon four times a year. The opthamalogist (eye doctor) is here one afternoon in the year.

If there are difficult or extreme cases (such as kidney stones) requiring hospital care we get airlifted out on a regular passenger flight. If it's a life-threatening situation (heart attack), we have a helicopter medevac on standby in the next community 44 km away that responds quickly if the weather is good for flying - and makes the connection to an air ambulance that flies in from either Blanc Sablon or Sept-Iles (both over 400 km away so it takes well over an hour before boarding).

Sun, 2011-08-07 19:47

#35

Sineed

Trouble is, I don't think even a properly-funded health care system would be able to provide local care to all people living in remote areas. Canada is just too spread out, its tax base too sparse, to support the availability of specialists everywhere. And depending on the speciality, you wouldn't want that. For more sophisticated medical procedures, you'd want your provider to be doing a certain minimum number of them per year to stay practiced up.

Under the Canada Health Act, we all have the right to accessibility to care. But practically speaking, there can't be tertiary care centres in every remote area. It's too expensive, and there's also the problem of your high-end providers not getting enough practice on the lower frequency higher skill requiring procedures, like I mentioned in the 1st paragraph.

That said, a proactive approach could be taken by ministries of health, defining a certain level of care depending on population, so that we can determine where the needs are, and allocate health care workers there rather than waiting until there's a crisis of no care in some communities.

Sun, 2011-08-07 22:14

#36

Boom Boom

Instead of just one specialist to cover that speciality spread out in a huge territory, why not two?

Sun, 2011-08-07 23:54

#37

deb93

Rich people all over the world, including rich Canadians too, will go and pay for speedy service or reknowned experts anywhere in the world. They don't need more private services here. Means testing is expensive bureaucracy.

Mon, 2011-08-08 18:57

#38

abnormal

Boom Boom wrote:

Instead of just one specialist to cover that speciality spread out in a huge territory, why not two?

First you've got to find that other specialist that's willing to visit the territory in question. Using Ontario as an example, there really is a shortage of doctors which is why there are so many "Urgent Care" centres scattered around the province.

Mon, 2011-08-08 20:17

#39

Boom Boom

I guess the only solution to providing adequate medicare to the entire population - scattered as we are across this huge country - is a large influx of funding to encourage more medical personnel, then. Dumping these idiotic neocon F35s, mega-prisons, massive corporate tax breaks, and other wasteful stuff would provide funding for a while. It's a matter of prioritizing.

Tue, 2011-08-09 08:39

#40

Boom Boom

from: Canada's Medicare System: It's all about equality for Canadians with disabilities (.pdf format)

The problem with respect to inadequate access to health support services in the community has existed for decades but reached a crisis point in the mid-1990’s when provincial governments began to restructure health care in Canada. The health care buzz words of ‘closer to home’ health care and the ‘continuing care model’ of health care were to be heard in every jurisdiction across the country giving rise to the closure of close to 300 hospitals and the elimination of thousands of acute care beds in the last decade. Unfortunately when it came to implementing a community-based health care model, our politicians failed to provide an adequate infrastructure and resources to community care – the less expensive preventative side of our health care system. The result has created an overburden Medicare system that provides less equal access for persons with disabilities and seniors.

Canada’s ability to promote equality should be measured by the degree to which our most vulnerable citizens can fully participate in all aspects of society. An important vehicle to achieve this is through the provision of a range of public services that supports the integration and participation of our disadvantaged citizens. Most of these services support and form a community-based health care system.

Around the time that health care was being restructured across the country towards a community-based model of health care, our federal government, through their war of the deficit, cut back on its funding of health care and eliminated its funding for the many support services that support a community-based health care system. The biggest single factor in this regard was the 1995 federal budget of former Finance Minister Paul Martin, which reduced federal funding for health care and eliminated an important public policy instrument that promoted greater equality in Canada – the Canada Assistance Plan (CAP). CAP would have also gone a long way in providing financial resources to support a community care model of health within Canada. CAP was a federal/provincial fiscal arrangement dating back to 1966 whereby the federal government provided provincial governments with fifty cents for every dollar they spent on community-based health and social services. These federal ‘50¢ dollars‘ provided provincial governments with a significant incentive to expand services and programs to allow our more vulnerable citizens like people with disabilities to fully participate in the lives of their communities. The elimination of CAP has affected the lives of persons with disabilities disproportionately to other Canadians since the national standards of CAP ensured that they had access to many of the vital services that relied on for independent living in their communities. CAP ensured that the sharing and caring values of Canadians formed a part of our country’s overall prosperity. CAP also provided a strong signal that the state had a collective responsibility for the associated costs related to an individual’s disabilities. Since the elimination of CAP, provincial governments have failed to provide adequate funding for the necessary support services to sustain a community-based health care system. Although spending on community-based services has increased by over 200%, most of that spending has come from private sources. The increased demand for health support services has greatly outstripped the increases in public spending.

- snip -

This instability in funding for these vital support services has greatly attracted 'for-profit' interests and thus spread the growth a two-tier health care. The growth of 'for profit' private services in community health will always hit hardest at those with the lowest incomes resulting in less access to health care services for them compared to those who can afford to pay directly for health care. People with disabilities are disproportionately poor, and as a result their access to health services will decrease as a result of increased fees and privatization.

Tue, 2011-08-09 09:50

#41

Boom Boom

Boom Boom wrote:

from: Canada's Medicare System: It's all about equality for Canadians with disabilities (.pdf format)

The biggest single factor in this regard was the 1995 federal budget of former Finance Minister Paul Martin, which reduced federal funding for health care and eliminated an important public policy instrument that promoted greater equality in Canada – the Canada Assistance Plan (CAP).

Conservative MP Shelley Glover on P&P to Rosemary Barton said the Harper Conservatives would never cut health care like the Liberals did.

Tue, 2011-08-09 10:42

#42

Sean in Ottawa

How many medical helicopters could we buy for the price of one F35 jet?

Rural and remote areas health policy is about access-- not just putting more people in -- and that can be done in part with high bonuses as there are people that might find that a good way to pay of tuition fees etc...

But also there is infrastructure access to make the best out of available staffing which means transportation and facilities.

Transportation is a fact of life in remote communities. But it takes investments.

Tue, 2011-08-09 10:50

#43

Boom Boom

Here on the Lower North Shore of Quebec the air transport infrastructure is actually in place, but we're using antiquated DH Twin Otters from the 1960s and 1970s as our primary aircraft in the smaller communities along with more recent small helicopters - the larger (paved) airstrips in the bigger communities are served by more modern Beech Craft turboprops. Our air ambulance is actually a turboprop, but it can not land in the smaller communities such as mine (Kegaska). A constant refrain here on the LNS is the lack of finances to do all the things that need to get done - and medical transport is a priority; but even so, there's still not enough money in the system.

Wed, 2011-08-10 10:32

#44

thorin_bane

Boom boom, though I doubt its as bad here, Windsor is less than half the average for doctors and we are a metropolitan area. OUr average doctor patient load is approx 4,300, ontario average is 2,200 and in toronto its about 1,300 we are only 3 hours from Toronto and just across the river from detroit. We are lacking in so many specialists and even though we had the numbers to jusitify a 1 million angioplasty(sp) care center it took 15 years and an addition of a medical school to our university to get one. We use to send over 100 people a year to beaumont hospital in detroit at 100,000 a pop but they couldn't justify the 1,000,000 required for our own center. Bad economics and the wait at the border could kill a person if we had to rely on detroit solely for cardiac care. Our medical professional also are not interested in more doctors being trained-if it means it cuts into their pay)

I would like to see doctors with a salary instead of per customer billing as we currently have. Better care and reduced cost(per doc) are likely to happen(Oh I know the docs would fight it same as they are leading the charge against universal healthcare) . Nurse practitioners could help too.

Wed, 2011-08-10 12:05

#45

Sean in Ottawa

Border areas are especially hard hit because doctors cross over and stay there. People in a border area get used to crossing and are more familiar with the other side...

Wed, 2011-08-10 19:12

#46

abnormal

Sean in Ottawa wrote:

Border areas are especially hard hit because doctors cross over and stay there. People in a border area get used to crossing and are more familiar with the other side...

That says something about the "other side". Why do doctors cross over and stay there? And why do patients get used to crossing over so they become familiar with the "other side"? It would suggest that there's something appealing to both doctors and patients "over here". What is it?

thorin_bane wrote:
I would like to see doctors with a salary instead of per customer billing as we currently have. Better care and reduced cost(per doc) are likely to happen(Oh I know the docs would fight it same as they are leading the charge against universal healthcare) . Nurse practitioners could help too.

I agree on the topic of nurse practioners but have to disagree on the question of doctor's salaries. First and foremost, they do not work for the government. The vast majority are self employed and simply bill the relevant medicare program [and that includes most doctors whose offices are actually in a hospital, not just those that work out of their own offices or private clinics].

Wed, 2011-08-10 20:10

#47

Boom Boom

I think I've read many times that Canadian doctors are attracted to higher salaries on the American side. The reason Canadian patients go over is lower wait times for some procedures - and those are all either reimbursed or paid directly by the medicare system here. I think the phenomenon of border town health service whereby Canadians flock to the American side will continue until such time that the Canadian system is fully funded.

Wed, 2011-08-10 21:12

#48

Sineed

boom boom wrote:
Conservative MP Shelley Glover on P&P to Rosemary Barton said the Harper Conservatives would never cut health care like the Liberals did.

Well, they don't have to, because the Liberals already did it for them.

And yeah; doctors potentially can make a lot more money state-side, though for the average doc it doesn't net out to massively higher, because their administrative costs are substantially more because it's more complex and time consuming to bill to many insurers rather than the government provider in our single-payor system.

Thu, 2011-08-11 13:02

#49

Sean in Ottawa

Actually I don't think it is the income alone that is the attraction to the US. Some of the attractions come from some negative influences with some positive side effects. By the way I have talked to doctors in the Brockville area who were thinking about going.

Some docs go over for the high pay but not all. Many people on the other side don't have access to healthcare and overall they have more doctors which makes the system less efficient and costly.What this means is the number of patients to a doctor are lower. They also get paid more for a consult and can afford to spend more time with each patient. That is the upside I guess for a system that leaves millions with no access to medical care. A system that intends to treat everyone based on need will be more pressured, more crowded. There are also docs who leave the US because they don't want to turn people away who don't have coverage or manage the beastly MOs. Some docs go there because they feel they can make the same money but spend more time with each patient and work in better conditions.

On balance I prefer a system that treats everyone based on need but I can see why a doctor might like the less pressurized approach with more time that can be spent on individual patients which happens in a system where the care is delivered to fewer people by more practitioners. The docs office however might spend a lot more money dealing with insurance companies but if the doc is making enough another person can be paid to do that.

Back in Canada in an office where a couple docs have left already, you have an overloaded-high-pressure working environment-- you can't take holidays easily because there is no replacement, work days can be longer and more frustrating and leaving people behind at the end of the day is hard. Docs often speak of the frustration with wait times themselves-- they don't like to refer people to see a doc right away only to have them go in a 2 year waiting list.

Our system is better but wasteful. The lack of investment in homecare, pharmacare, Long term care together with a public hospital care system leads to inefficient use of resources as backlogs and lack of affordable access in the private areas backs people up in to overuse of the public areas. With the proper investments in our system we could avoid this but right now these are realities doctors face and some vote with their feet -- and it is not all greed related.

A similar point-- this happens with nurses as well. When nurses are underpaid in a province, fewer people go in to the profession there. Those who want to leave to make more money do so. The remaining nurses face working conditions that become dangerous and stressful -- low nurse-patient ratios lead to more violent frustrated patients, stressed and tired nurses, more on-the-job injuries, inability to have functional schedules, refused vacation, unpaid and excessive overtime.... The morale drops and more nurses leave because of conditions. No they are not leaving because of low pay even though that was a factor in causing the snowballing cycle.

A lot of attention must be paid to retention of both nurses and doctors. Assuming they are motivated by greed is one way to blow the system up. Recognizing how the system works and how individuals get influenced to leave is critical. There is a lot that can be done to fix those problems. Some of it is competitive pay but that alone won't do it.

Better management of resources (such as building and staffing 24-hour clinics rather than having people all get treated in an ER after 5 pm each day-- and to staff them you need to pay more after hours), better management of referrals is part of the solution (they did this with regional rather than individual physician wait lists in pilots here). A recognition that modest cuts at the front end can produce huge costs at the back end once they have filtered through the system is a realization health care provider organizations are beginning to realize and governments somewhat slower.

Fortunately this works in reverse as well placed investments could save the system from the pressures it has now. People in Canada are talking about an approach to the continuum of care that if fully implemented would improve our system making US docs want to come here... In Canada we are looking at skills upgrading while people are on the job in a more sophisticated way than there. Problem is you need leadership from government at the federal as well as provincial levels. Political leadership is lacking frustrating the institutional leadership that is struggling with a lower public commitment than they should have.

Put bluntly with the right investments we can make our system work way better than the US one because it is on a better foundation but starved for resources we will fail to compete with the working conditions you get when you only have to care for a better off segment of the population and therefore lose people.

Hope this helps clear up some things because just blaming the people that leave is no way to respond to the challenges and opportunities we face.

Sun, 2011-08-14 12:16

#50

Boom Boom

This has been a great conversation. I hope it continues.

Sun, 2011-08-14 13:09

#51

Sineed

Boom Boom wrote:

This has been a great conversation. I hope it continues.

Indeed

Good points, Sean! Our system can certainly use improvement, like more coordination in the health care system, and maybe more rational allocation of resources rather than just hoping a specialist would choose to live in a remote area. Perhaps partnerships with professional colleges to determine need...

Though we have to be wary of criticism from people who would tear down our health care system; conservatives who speak of improvements but really want to privatize. Change must be motivated by allies of our system, not enemies.

Leading Economist Shatters Myth That Public Health Care is 'Unsustainable'; Pins Blame for Soaring Costs on Private Health Care

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