The Future of Health Care

Medicare must be preserved and made truly comprehensive
February 1, 2012

There are two fundamentally competing visions that seek to shape the next stage of health care in Canada.

One view, based on the premise that health care is a commodity, believes that markets should determine who gets care, when, and how. This view may sound reasonable or even innocuous, but don’t be fooled: the end game is always the same: to withdraw public funding for Medicare and shift costs onto individuals.

The other vision – one that I adhere to – believes that health care is a “public good,” grounded on the Canadian values of fairness, equity, compassion, and collective action. As I said in my final report as Commissioner on the Future of Health Care in Canada, Canadians view Medicare as a moral enterprise, not a business venture. We see it as a right of citizenship, not a privilege of status or wealth.

If anything, that point of view is even stronger today than it was when I released my report. A recent poll by Nanos Research found that support for public health care had risen to a record-high 94%.

“There are two issues at play here,” said Nanos President Nik Nanos. “First, health care continues to be a top issue of national concern for Canadians. The second point is that right across the board, regardless of political affiliation or other demographics, support for public solutions in health care has increased over the past three years.”

* * *

I see the choice that we as Canadians make about Medicare as one which is fundamentally intertwined with our nation’s values and its future. Every day, Canada faces new challenges that ask questions about what kind of people we are and what kind of future we wish to shape.

Today we are wrestling with renewing and securing the future of Medicare. But we could, just as easily, be discussing the integrity of our environment, our role in Afghanistan and the world at large, or our domestic choices with respect to other social and economic policies.

There is something that these debates all have in common. They all return to a fundamental question: what are the shared values that underpin our society and how can we make decisions and follow through with actions to build a more progressive and united nation?

In confronting these important questions, we should never act as if we are starting from scratch. In fact, the exact opposite is true.

Every nation has a narrative. Canada’s history offers a strong and rich legacy of success that has forged our nation. It is this legacy of a “shared destiny” that is key to understanding our young but dynamic history. And it is this same legacy of “shared destiny” that remains the road-map to our future, both at home and abroad.

For those like me, who came of age in our Prairie communities, or know our history, the notion of “shared destiny” was key to our existence. The harsh, often snow-blown conditions, droughts, distance and isolation, and small population, forced us together, like poplar trees huddled on a windswept plain.

And so it is with other regions in Canada, where geography and demographics may vary, but where we all learned to see survival and progress as a test of our ongoing ability to organize collectively and to remain united around shared values.

Through the years, as we lived together, worked together, and built together, this notion of “shared destiny” was transformed into the foundation of a nation. Generation after generation of Canadians have seized on the cornerstone idea that our future and our society is best shaped through community action -- that the sum of Canada is often greater than its remarkably diverse parts.

John Whyte, in making the Saskatchewan government’s argument to the Supreme Court of Canada in the post-1995 Quebec Secession reference case, best summed up this notion of “shared destiny” when he said: “A nation is built when the communities that comprise it make commitments to it, when they forgo choices and opportunities on behalf of a nation… when the communities that comprise it make compromises, when they offer each other guarantees, when they make transfers, and perhaps most pointedly, when they receive from others the benefits of national solidarity. The threads of a thousand acts of accommodation are the fabric of a nation.”

This, then, is our nation’s narrative and it resides in our collective DNA. In recent years, however, the soil has been tilled for the sprouting of views at odds with this narrative. We now feel a palpable momentum toward individualism, decentralization, and privatization. Indeed, under the guise of “individual accountability,” all sorts of dubious and unfair policies are being inflicted on Canadians -- policies that deliberately, often maliciously, ignore the difference between equality and equity; policies that pretend there is a level playing field in Canada in terms of access to opportunity, and that those who are disadvantaged, or whose lives have taken a bad turn, are solely responsible for their own fate. As though living on the margins, or suffering from poor health, mental illness or addiction is somehow a conscious lifestyle choice.

There is a meanness of spirit in this approach that advocates punishment over rehabilitation, that imposes mandatory sentencing without taking account of context, that somehow finds the money to buy defibrillators for hockey arenas, but drags its feet about providing potable water to First Nations communities.

All of these individualistic views are described as the “new ways” to deal with today’s world. But, in truth, they represent an abandonment of our accomplishments and a parting of the ways with the belief in our collective capacity to meet our future challenges.

Medicare, which is the product of this history, is also now caught up in this so-called “new thinking.” And, just like with today’s other major issues, how we choose to inform our way forward, and the set of values that we draw upon to shape our progress, will ultimately become an expression of who we are as a nation.

That is why the debate over Medicare is not just about effectiveness and efficiency. It is not simply about the irrefutable evidence showing that our single-payer, public system delivers excellent outcomes, which it does. The Medicare debate is not even just about basic Canadian values like equity and fairness for all citizens. Yes, it is about all these things, but it is also about much more.

Medicare holds such a central role in our narrative of “shared destiny” that how we deal with our social programs may determine the future progress of our nation – or whether, in fact, we do make progress.

So, keeping this view of history in mind, what is the road to progress on Medicare? The good news is that there are solutions at hand, ready to be seized by our policy-makers, just as soon as they muster the political will to act.

Let me simply to outline five enduring lessons that I believe remain central to the Canadian debate about health care reform:

1. The universal single-payer advantage

My first point is that a universal, single-payer, public insurance model is both less costly and produces better population health outcomes than multi-payer systems like the one they have in the United States. This has been proven time and time again, by study after study.

Take pharmaceuticals, for example, which for most Canadians are outside of the public insurance system. Since 1990, the cost of prescription drugs, as a percentage of total health expenditures, has increased from 8% to about 15%. Canada’s private spending on prescription drugs now outpaces that of most other OECD countries.

Our task is clear, if not without difficulties. We must lay the groundwork now for including catastrophic drug costs, at least, and bringing aspects of home care, long-term care, and access to advanced diagnostic services – the areas of fastest rising costs – under the umbrella of public funding.

Otherwise, costs will continue to escalate – without restraint and with relentless abandonment of those in need.

2. Keeping the focus on total costs

We must avoid shuffling expenditures between the public and private sectors of the health care system. Until the mid-1990s, some provincial governments, including my own in Saskatchewan, were successful in restraining the growth of public health care costs. We rationalized our services and improved efficiencies, while trying to preserve access to quality services. Our fiscal position obligated us to do this.

It turned out, however, that we pushed some of these costs out of our own provincial budgets, and onto the personal budgets of the residents. It was, in other words, a false economy. Because, in the end, the total bill for health care is paid by all citizens, whether through their taxes, their premiums on insurance policies, or out of their own pockets, through direct payment.

3. Tackling wait times

We must improve timely access to quality services. While the vast majority of Canadians who have used the system find it highly satisfactory, there continues to be a significant proportion who are waiting an unacceptably long time for care. A recent OECD survey of 11 countries showed Canada as having the longest wait times for care.

Moreover, our policy responses, concentrating on only five areas of care, seem misplaced. They are incomplete and have negative effects on other needs. We need a more comprehensive strategy. After all, we are not fighting to preserve a 1960s style of health care; we are fighting to build a modern and sustainable health care system that meets today’s needs.

Here are a couple of things we could do. We could invest more in advanced diagnostic services and efficient information systems. We could also increase the supply of skilled health care providers to alleviate unnecessary blockages and provide the impetus for a more integrated approach to health care delivery, which remains one of our biggest impediments to reform.

There is still much to do to make the current system more efficient and sustainable

4. Addressing the determinants of health

We have to pay more attention to preventing illness and disease, especially chronic disease, which arguably is the greatest health challenge of the 21st century.

The Canada Health Act, which sets out the principles of Medicare, states that the primary objective of Canadian health care policy “is to protect, promote, and restore the physical and mental wellbeing of residents of Canada.” Yet we continue in this country to focus on restoring wellbeing, while largely ignoring promoting and protecting it. We shrink from tackling the fundamental social, economic, and environmental factors that shape our wellbeing.

Over the past several years, I’ve been working with a group of exceptionally dedicated and talented national and international experts on the important task of creating a Canadian Index of Wellbeing, the CIW.

To date, we’ve released reports on each of eight categories that shape our wellbeing. A few months ago, we released the first CIW composite index, tracking 64 wellbeing indicators over a 15-year period.

Our goal is to re-define wellbeing as the presence of the highest possible quality of life in its full breadth of expression; to track where we’re making progress in this country and where we’re falling behind; and to identify policy changes that will ensure that Canadians enjoy the best possible state of wellbeing.

Improving our wellbeing -- especially for our growing population of seniors -- is one of the key ingredients for maintaining a viable health care system into the future. We need to start paying as much attention to the demand side of our health care system as we have to the supply side -- and the CIW is one of the tools for doing this

5. Transformative change

It is vitally important that governments show the will and leadership to achieve what is truly transformative change.

Modernizing and transforming the health care system involves the evolution of primary care – people’s first point of contact with the health-care system. We must tackle the continuing “silos” mentality, which separates general practitioners from other professionals, and a broad range of frontline illness, wellness, and diagnostic health services essential to preventing or mitigating downstream acute and institutional care.

Simply stated, we need to break down traditional barriers among health care providers and reform the local delivery of health care through more efficient and effective integration.

One approach would to adopt a national strategy for expanding Community Health Centres across the country, with new federal dollars targeted specifically for that purpose. Another is to finally implement a national home care strategy – one that will relieve pressure on our hospitals and allow more Canadians to be treated at home, rather than in expensive hospital beds.

* * *

Health care in Canada is a work continuously in progress. The system as we know it today is by no means a done deal. Former Minister of Health Monique Bégin, author of the Canada Health Act, often reminds me that the true guardians of Medicare – this most cherished expression of what it means to be Canadian – are the people of Canada.

An overwhelming majority of Canadians believe in a vision of Medicare that is rooted in our narrative as a nation – a vision that sees health care as a “public good” and a right of Canadian citizenship. But there are others with a different vision – one that sees health care as a commodity; one that believes that markets should determine who gets care, when, and how.

That’s why, now more than ever, we need to engage and mobilize Canadians in the fight to secure and expand Medicare.

Now, more than ever, we need to reaffirm the original vision of a truly comprehensive public health care system that provides a continuum of services and includes a universal program of home care, long-term care, and Pharmacare.

Now, more than ever, we need to embrace comprehensive policy solutions that tackle root causes instead of surface symptoms; that bring about systemic changes instead of quick fixes; that promote long-term benefits instead of short-lived gains.

Now, more than ever, we need to root ourselves and our work in the values that have shaped this great country: fairness, diversity, equity, inclusion, health, safety, economic security, democracy, and sustainability.

Now, more than ever, is the time to recapture the moral and political strength to see ourselves in our own place, in our own time, informed by our own values, and within our own actual narrative, as an independent nation, worthy of the respect of a world that needs an even better Canada.

In doing so, we shall once again put our nation’s policies on track and resume the task of building an even greater Canada.

Let us dare to have that vision. And let us dare to make it come true – for ourselves and for future generations that are depending on us.

(Roy Romanow, former Premier of Saskatchewan and Commissioner on the Future of Health Care in Canada, chairs the advisory board of the Canadian Index of Wellbeing. This article was adapted from a speech he made to a recent meeting of the Canadian Health Coalition in Ottawa.)