Monday, August 17, 2009

A Health Care Challenge for Canada?

Canadians watch the health care debate in the US with mixed emotions. The Americans, who spend more per capita on healthcare than any other nation in the world, clearly have many challenges. Some forty six million are not covered by health insurance, seniors pay for prescriptions after the first $2,500 and life expectancy is amongst the lowest in the developed world. Clearly, a lot needs to be changed.

The trouble is debating change in a health system is always very emotional, as we can see from coverage of the town hall meetings taking place across the United States. We each have stories of good and poor experience of health, of family members who struggled through the system and of things going terribly wrong. Serious discussion about change becomes clouded in emotional conversations about pain, disease and problems.

Many Canadians appear satisfied with the basics of Canada’s health care system, despite the rising costs of securing universal health care coverage and the growing waiting list for a range of basic procedures. Yet an OECD study, just published, uses poll data to show that sixty per cent of Canadians are seeking fundamental change in the way Canada’s publicly funded health care system operates. More people in Canada seek such change than in Britain, the US, Germany or Australia. A further twelve per cent think that our health care system needs to be completely rebuilt. Put simply: most Canadians don’t think the current health care system is sustainable.

There are several issues. The first is that the costs of the system are growing faster than Provincial governments can afford. When health care reaches half of all Provincial spending, as it will within the next decade in British Columbia and Alberta, what cuts to other government services will be made to permit this cost to be covered?

The second challenge is our over-reliance on professional health care workers to help us manage such things as diet, exercise and minor health issues – cuts, bruises, and colds. Self-reliance and personal responsibility has been ceded to an ever growing list of professional workers seeking to manage more aspects of our daily life.

The third major problem is the growing cost of technology for health. Expensive equipment can now produce powerful images and deep understanding of physical conditions and doctors and patients rely on expensive technology to make decisions. Technology changes and improves frequently at great cost to us all.

Linked to the growing costs of technology is the growth of sustaining the prescription drug culture – “there’s a pill for that”. A diabetic with hypertension will spend close to $5,000 a year on prescription drugs, only seventy per cent of which is recoverable through most insurance policies. It is this that drives up the costs of insurance.

Finally, the accountants are taking over. While some of them used to health care workers – doctors and nurses – their preoccupations are now costs. Whether it is staff costs or the cost of procedures, cost not outcomes are driving key decisions in the health system.

Whenever discussions of health care occur in Canada, the passions engendered are similar to those seen in town hall meetings in Wyoming or Chicago. Emotion replaces rational conversation about options.

One option is for Canada to retain a single payer, but to permit private companies to offer health care and health insurance from which the single payer can purchase services. The private providers would focus on high volume, profitable activities – hip and knee replacements, treatments for diabetics and obesity, rehabilitation services, chiropractic - and sell their services to local health authorities. Competitive private insurers would provide coverage which “filled the gaps” of the provincial system, including drug and dental coverage.

A second option is to require every citizen to hold a health insurance policy for which they pay their provider (the provincial government or a private insurer), with rates depending on life-style. Smokers pay more. People who are obese pay more. These policies may cover more than the “approved list of services” under the Canada Health Act, depending on the premium paid. Connecting health to cost for the end-user would be a major change.

Whatever happens, Canada needs to have a serious discussion about health care. Most Canadians think we need a significant change. They are right.

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