Bilodeau: Traditional thinking isn’t going to fix Canada’s health care

The Canada Health Act was a good solution for its time, but hanging on to it with a kind of religious fervour will just make things worse. No policy is good forever.

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If there were easy solutions to the current crisis in our health-care system, they would likely have been found by now. Playing every few years with the structure, like most provinces do — centralizing-decentralizing-recentralizing — has produced no observable improvement.

Our system has been deteriorating for a number of years, and repairing what has been broken will also take a long time. So I am not proposing a solution but rather a series of ideas that may, over a decade or so, lead to significant improvement.

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First, we should stop bickering over “private” versus “public.” At 30 per cent of GDP, our private expenses on health care are already higher than in most European countries whose systems are better than ours. The issue is not who provides what, but rather who pays for what and what is covered by the public purse.

Second, we know that just throwing more public money into the system does not work. We already spend more than most developed countries, just to get poorer results.

Third, rather than comparing ourselves with the United States, let us look closely at those countries that have the best outcomes, not to copy them but to understand the common features that make these systems efficient and design a long-term plan that draws on them.

Fourth, we know that we have many fewer physicians per population than successful countries. The reason we have fewer is that they are all paid from the public purse and provincial governments need to control the budget allocated to physician remuneration. Therefore, they limit the number of spaces in faculties of medicine. This creates an inflationary pressure on physician remuneration, which increases the problem.

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How can this be changed? The first step is to determine the number of publicly paid physicians the society can afford and to create “positions,” both in hospitals and in the community. Next, increase the number of places in faculties of medicine, accepting as many students as there are qualified candidates. When they start getting their diploma, there will be a limited number of “positions” available in the public system. The others will be in private practice, or in a mix of public and private practices. Once we have a more acceptable number of physicians, the inflationary pressure on their remuneration will be reduced.

Fifth, to reduce wait times in the ER, ER nurses (and sometimes physiotherapists) should be allowed to prescribe lab and X-ray tests, and to discharge some patients even if they have not been seen by a physician. ER pharmacists should be allowed to prescribe some medications. Social workers and/or psychologists could treat some mental-health problems and discharge patients without the involvement of a physician.

Sixth, insurance companies should be allowed to cover services provided by the public system. This is a common feature of successful countries, but currently prohibited in Canada. One possible approach is to decide that since people are funding the public system through their taxes, those who chose to go to a private physician or hospital would get reimbursed by the state for what the government would have paid if that patient had gone to the public system. The difference would then be paid by the patient or his insurance.

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Seventh, develop and expand primary care and home care to reduce the pressure on hospitals.

The Canada Health Act was a good solution for its time, but what worked well at first now needs to be reviewed to better serve Canadians. Hanging on to it with a kind of religious fervour will just make things worse. No policy is good forever.

I know that any federal government that would propose such an approach would face strong opposition. But like Brian Mulroney’s bravery in promoting unpopular measures such as the GST and free trade, now lauded by so many people, will some politicians have the courage to admit openly that the Canada Health Act is no longer sacred and that we have to explore other options?

Michel Bilodeau is currently vice-president of Public Governance International (www.pgionline.com). He is a former CEO of Bruyère Continuing Care and CHEO.

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