Pandemic Stress Test Reveals Fragile Future for Canada’s Health Care

Canada’s exposure to the COVID pandemic was modest compared to that felt by most other developed nations, but its impact revealed a health-care system already overburdened and unprepared for a repeat event any time soon.

After undergoing a serious wake-up call during the 2002/2003 SARS epidemic that killed 10 per cent of infected victims (44 in Canada, mostly in Toronto); and then the H1N1 (swine flu) that originated in North America in 2008 (killing more than 400 Canadians through 2010), Canada mobilized its public health officials to fast-track a defence against any repetitions.

But a decade later, as COVID-19 swept in, the nation’s public health system appeared to have been caught flat-footed, its initial responses delayed and indecisive; in the opinion of Canada’s auditor general: “not as well-prepared as it could have been.”

What the pandemic stress test also exposed was a fragile health-care system that, even during “normal” times, often operates at 100 per cent of hospital-bed capacity, has an inadequate number and distribution of family physicians to serve a growing population, and has the longest average wait times for necessary medical services among developed countries throughout the world.

According to the U.S.-based Commonwealth Fund, a respected monitor of international health system trends, a 2016 survey showed that Canada performed below average in providing timely access to patient care compared to Australia, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the U.K. and the U.S. It was rated the worst of those countries in providing same-day or next-day appointments for sick patients, waiting for treatment in emergency departments, waiting to see a specialist or waiting for elective surgery. In receiving after-hours care without resorting to an ER, it was the second worst. CIHI Accessibility report by Commonwealth Fund 2016.

How can this be, for a country that spends more than $265 billion (11.5 per cent of its Gross Domestic Product) on health care, more than almost any other with a UHS − universal health-care system − CAD$7,064. per every resident in the country?

Despite this formidable spending, in a grading of countries with universal health-care systems, Canada ranks 26 out of 28 (28 being the worst) for its number of doctors (2.8 per 1,000 people); 25 out of 26 for its number of acute-care hospital beds (2.1 per 1,000 people); 22 out of 26 for availability of MRIs (10.5 per million people); and 21 out of 27 countries for CT scanners (16 per million people). Data from OECD and Fraser Institute 2020.

Almost all developed high-income countries (except for the U.S.) have universal health-care systems, which means that all of their residents have (or are required to have) access to comprehensive medical care coverage funded or administered publicly or through taxes or premiums, or by a combination of public and private insurance.

Canada’s “single-pay” model doesn’t travel well.

In Canada, which has a single-payer form of UHS, all such coverage is administered and funded through taxes or premiums or both, but private insurance is prohibited from covering medical goods or services that are covered by the provincial plans. Although a handful of private clinics have fought to provide such options (Quebec and B.C., for example), they have been aggressively challenged in the courts on the premise that such competition might erode the public program.

Most other universal systems eschew the single-payer model, preferring blends of public/private funding and administration.

The U.K., for example, supplements its publicly funded National Health Service with a robust private health insurance system that allows an additional layer of optional services − private hospitals, shorter or no queues, enhanced personal care options for patients who choose to pay privately. And providers often work interchangeably in many areas.

Germany, which initiated universal health care in 1883 (a system that has served as a model for many European countries) provides high-quality, comprehensive service through a system of more than 100 non-governmental private insurers known as sickness funds, with high earners, civil servants and self -employed persons able to opt out and buy private insurance. The government sets regulations and fees for the sickness funds, but plays no role in direct health delivery. Virtually no waiting lists, very high public satisfaction and a very limited bureaucracy.

The equally highly rated Netherlands UHC is administered by private, competitive health insurers and health-care providers. Virtually all health insurance companies in the Netherlands are not-for-profit co-operatives that allocate any profits that they make to the reserves which they are required to maintain, or return them in the form of lower premiums.

Among high-income developed countries, Canada’s single-payer model is a rarity in that it relies solely on annual global budgets or block grants. A block grant is, in reality, a “do the best with what you’ve got” ticket. It tends to generate access problems and waiting times, encourages fewer patient admissions, fewer costly treatment interventions, longer retention of lower-cost patients and early discharging of high-cost patients. The money doesn’t follow the patient.

Conversely, virtually all other universal health-care countries have long since discarded block funding or global budgets in favour of activity-based funding which pays hospitals predetermined amounts of money for the care which they receive, largely following the Diagnosis Related Group (DRG) model developed in the U.S. in the 1980s which was designed to pay according to the specific services required for treatment of that patient.

Writing in a June 2021 survey of international hospital payment patterns, Nadeem Ismael, senior fellow at the Fraser Institute concludes: “It is noteworthy that Canada’s provincial health-care systems are in a distinct minority in the developed world for not having adopted activity-based funding for hospital care in a meaningful way. Decades after reforms were undertaken in other developed nations with universal access health-care systems, and at a time when some nations are embracing even more sophisticated approaches to money following patients, no Canadian province has embraced a wholehearted shift to activity-based funding.”

Ismael concludes: “Canada’s health-care system provides remarkably poor value for money to taxpayers and leaves patients with relatively poor access to medical services, despite its high price tag. Part of the reason for that poor performance is likely Canada’s commitment to an outdated method of paying for universally accessible hospital care.”

No shortage of bureaucrats

There is, however, one grading in which the Canadian single-payer system excels: the proliferation of public service administrators (bureaucrats), involved in the micromanagement of provincial health services, all absorbing their fair share of sparse health-care dollars.

Matthew Lister, a Canadian health-care analyst, surveyed health systems in several developed countries and discovered that Canada in 2015 had 32,000 health-care bureaucrats (government-appointed managers, directors of local and regional boards, evaluators, etc.) organizing, adjusting and fine-tuning health care as it was being delivered. That number, wrote Lister, represented 0.9 health-care bureaucrats per 1,000 Canadians and compared to only 0.06 per 1,000 people in Germany and 0.23 per 1,000 Japanese. From a different perspective, Japan had 30,000 health-care bureaucrats for 130 million people; Canada had 32,000 for 35 million people.

Another interesting comparative study was prepared for Jeff Yurek, former environmental minister for Ontario who wrote that in 2017, the Ontario College of family physicians listed some 10,500 family physicians available to serve the entire province, and 13,000 health ministry and affiliated agencies, consultancies and partnerships to “administer” the system.

From 50-50 to not so much.

In 1966, when the original Medical Care Act (medicare) was enacted, the funding deal offered to provinces was a 50-50 federal/provincial split. But in 1984, the Canada Health Act supplanted the original funding deal and replaced it with federal grants “at sustainable levels.” All vestige of private funding gave way to the current single-payer system and monopoly government control. Along with it, a chronic concern regarding underfunding has only grown.

In 1984, Dr. Everett Coffin, president of the Canadian Medical Association wrote a lead article in the association’s journal in which he predicted that the newly imposed Canada Health Act would “radically change Canada’s 10 diversified provincial health insurance programs into state medicine − into a medical service that is completely controlled by government.” He also asserted that “What health care services are available, their quality, who will get them and where, will be determined entirely by government through complete control of health-care financing and the medical profession.”

Added Dr. Coffin, “Health care of the future is too important to be sacrificed to political expediency, a provincial-federal power struggle or the dogmatic thrashings of any government seeking a way to get re-elected.”

Thirty-seven years later, this message resounds even more forcefully.

By Milan Korcok