A smarter public health care system

The Report: June 2011 vol.32 num.2

HSA invited Andre Picard, health reporter for the Globe and Mail, to deliver a keynote address on the future of public health care in Canada. His speech touched on several recommendations for improving the system.

Thank you for the kind introduction. But I recently changed my bio, courtesy of a politician who was angry with one of my columns. He said: -Picard, youre a hard man to ignore -- but its well worth the effort."

Unlike you, Im not a health professional. Im an observer. My job is to analyze health policy and translate the gobbledygook of politicians and policy-makers for the public.

Ill give you an example. Stephen Harper said this week: -I will not cut federal health transfers." Translation: -Transfers have been increasing at six per cent annually and Im going to make it zero. Expect a lot of pain and suffering."

Michael Ignatieff, for his part, said he would maintain federal health transfers at the current rate. While he didnt spell it out, that means they would increase from about $40-billion in 2014 to $75-billion annually in 2024. Translation: -Ignatieff believes he has no chance of winning so hes talking out his ass."

So, my task today is to speak to you about the future of healthcare. Ive been asked to say something upbeat and inspiring.

Those of you who read my columns in The Globe know that Im pretty bullish on medicare. I think we have a good publicly-funded health insurance plan and healthcare services that are as good as anything in the world.

You will know too that I think we can do better. I write critically about the system. But Im critical in the true sense of the word, meaning that I like to point out shortcomings and propose solutions.

The problem is that our political leaders like to use medicare as a whipping boy and dont really talk-up its benefits or propose improvements. Instead, they are largely silent. And, when they do talk, they tend to issue dire pronouncements and propose draconian -reforms."

All too often -reform" is a code word for slash-and-burn and privatizing willy-nilly. Its mindless dogmatism. I think that if were guided by values, by vision and by planning, we can actually strengthen and expand our medicare system and make it more sustainable and affordable.

As a result, some people think Im a fool. So be it. Maybe I have to be to survive. After all, Im a unionized worker at a newspaper, toiling in an industry many have given up for dead.

If youre down about triple zero contracts and the future of healthcare, think about my business. It will give you some perspective.

Heres a little slice ‘o life from the media world: I live in Montreal, where the largest, most profitable newspaper just settled a labour dispute. Workers at the Journal de Montréal were locked out for three years. The contract they finally accepted, however reluctantly, was a complete capitulation. It featured: Lower salaries, fewer benefits, less job security; and the unionized workforce was slashed by 75 per cent. They went from 100 reporters to 22.

Welcome to the brave new world of information. Relatively speaking, health workers are doing a damn sight better than newspaper workers - at least on paper. Where I think health workers fare worse is in their physical work environment, which can be toxic - mentally and physically. (Ill come back to this issue later.)

But fools like me hang on because we think what we do matters. Thankfully, there are many such fools in healthcare. Ive been writing about healthcare in Canada for 24 years. Ive seen a lot and learned a lot.

In our era of hyper-specialization, Im the ultimate generalist. Im one of the few people who flits about the system, from province-to-province, from safe injection sites to heart transplants, and from angio suites to labs.

As a result, I know more about Canadas health system than is healthy to know. I know that, for all its faults, our health system does a lot of good. Most of the time, the care is superb.

We deliver good care in spite of the system - because we have a superb healthcare workforce. We have a largely invisible army of 1.1 million people that keeps the care flowing 24 hours a day, seven days a week, 365 days a year. And the quality of that care rivals anything in the world.

All that to say that, generally, Im upbeat. Im a medicare booster. But I have to be honest: Its not easy to be optimistic in the current political and policy environment. We are in the midst in a federal election campaign and in B.C. there will soon be a provincial campaign.

There is little or no serious healthcare talk from our prospective leaders. The closest we have come to vision is the leaders saying they wont cut health transfers in 2014. The likely outcomes of these federal and provincial elections present us with a depressing prospect - regardless of your political stripes. We can expect, at best, more of the same-old-same-old.

Whats most troubling is that, in the larger policy environment, were seeing a disturbing wave of anti-worker sentiment. In the U.S., legislative attacks on public employees - unionized public employees - are unprecedented.

The economic downturn has become an excuse to implement reactionary policies like stripping public employees of the right to collective bargaining. Its anti-democratic and anti-social, in the true sense of the term.

You can bet there are some politicians and business leaders here in Canada rubbing their hands with glee at the prospect of opening up a can of Wisconsin whoopass on public employees. Hopefully we will resist that kind of short-sightedness. And I think the way to do that is to make yourselves more visible.

If people had an idea of the work you do on a daily basis, you would be in a position of power. When youre invisible, its easy to take you for granted and make you a scapegoat. I can come back to the visibility issue in the question period if you like.

Let me come back to the current policy environment. Aside from anti-labour nonsense, were also seeing a ratcheting up of the Chicken-Little-like rhetoric.

One of the leaders of the Alberta Medical Association has gotten a lot of attention for saying the health system -is on the verge of catastrophic collapse." And a couple of days ago we got the latest dire warning that healthcare spending is going to bankrupt us from none other than David Dodge. The former governor of the Bank of Canada said that we suffered from chronic healthcare spending disease. He warned that in 20 years we could be spending 15 per cent of our GDP on healthcare -- the same as the U.S. is doing now. That, apparently is a horrific prospect so he prescribed a cure - more privatization.

Wow, weve only been hearing those warnings and that proposed solution since about 1947, when Tommy Douglas introduced a public insurance program for hospitals. Doctors warned of the imminent catastrophic collapse of healthcare when medicare was introduced nationally in 1960. Half a century later its still going strong. And the greatest beneficiaries of publicly-funded health insurance have been doctors. Go figure.

And then there is Mr. Dodge. We really should be taking health advice from a banker. After all, bankers were so prescient and insightful in their own area of specialty, accurately predicting the stock market meltdown and recession. And, oh ya, he forgot to mention that health spending as a proportion of GDP has actually gone down the last two years.

Okay, how am doing so far on delivering upbeat and inspiring?

What I want to convey is this: Despite all the jibber jabber and the dire predictions, medicare has survived and it has thrived. Why?

Because it works. Public health insurance is fiscally sound and politically astute. It delivers a necessary service and does so cost-effectively and fairly. Even business recognizes that, when they are being honest. Spreading risk is smart - thats what insurance plans do.

Medicare is not unsustainable. Its as sustainable as we wish it to be. Its about priorities and values. But its a work in progress. So lets talk about what the system does well, and what it could (and should) do better in the future.

I have a few wishes to get us there.

My first wish is that we dispense with this nonsense that healthcare is a drain on the economy.Yes, we spend a lot on healthcare - $192-billion last year, including $135-billion from the public purse and $57-billion out-of-pocket. Health spending accounts for 11 per cent of our GDP in Canada - one in every nine dollars. The healthcare workforce is massive -- 1.1 million people.

Healthcare is an economic motor. Medicare is an enormous benefit for workers and for companies. There are politicians who claim their sound economic stewardship helped Canada weather the recession. What they neglect to mention is that medicare also helped us weather the recession. In the U.S., there were massive layoffs and cutbacks in the health sector and elsewhere. These job losses had a domino effect because people lost their health insurance.

The cost of health services is the leading cause of bankruptcy in the U.S., and one of the leading causes of home foreclosure. It wasnt just low-cost mortgages. In Canada have a sound, stable health insurance program. A stable health workforce. Medicare was our built-in stimulus package.

My second wish is that we stop saying that healthcare is too expensive and unsustainable -- as if these were incontrovertible facts. Too expensive compared to what?

Per capita health spending is $5,614. Thats $15-a-day. People spend more than that driving to work. We deliver universal medicare to 33 million people for 15 bucks a day. Thats actually amazing.

But we should be satisfied or self-satisfied. Medicare cannot be a static program; it has to be a living breathing one. Im not suggesting we ignore financial realities. Health spending has increased by 5, 7 or 10 per cent annually virtually every year since national record-keeping began in 1975. (The only exception was in the early 90s, when the provinces actually reduced health spending. Does anybody remember how that worked out?)

But lets assume for a moment we want to cut health spending - say, because we want to give tax breaks to the rich or buy some F-35 fighter jets. Or maybe we want to do something sensible like spending more on education and social programs, things that will actually make people healthier.

There are two principal ways we can cut health spending: 1) limit what medicare covers: but that doesnt really reduce health spending, it simply shifts it from the public domain to the private domain; you will pay for it from the right pocket instead of the left pocket; 2) to do things differently - invest and innovate - and actually spend less.

I think we should do a bit of both. I believe medicare should cover essential health needs, and its lost its way a bit. We do a little too much peripheral stuff.

What the proponents of cutting need to articulate clearly is what and how theyre going to cut. For example say clearly: Were not going to pay for PSA testing because the evidence shows it does not reduce mortality or; were not going to pay for Vioxx because it doesnt work any better than ibuprofen. You have to be strategic, not ham-fisted . We have to avoid the 1990s method of across-the-board cuts. Thats idiocy.

But we have to recognize too that the savings to be had are not enormous. Theres not a lot of fat in the system. Thats a figment of the imagination.

Medicare is not some socialist utopia where armies of bureaucrats toil away. There is a little bit of that in our ministries of health but we spend only 6.5 per cent of our health dollars on administration. If anything, thats too little.

The single payer system is efficient. In the U.S. administration costs account for more than one-third of health costs. Thats because they dont have a system. Competition results in duplication and tremendous bureaucracy. In the U.S., hospitals dedicate an entire floor to accounting and bill collection.

Delivering good healthcare costs money. The principal expense is labour. It accounts for about two-thirds of health spending.

The proponents of cutting speak in generalities. They need to be reminded that cutting health spending means cutting jobs and cutting services.

If healthcare was a business like widget-making, we would cut costs but laying people off and moving our business to a country with cheap labour. But its not widget-making. Getting rid a lot of health professionals would be a disaster. So what we have to do is get more out of the people we have.

That doesnt mean making you work more, it means making everyone work more efficiently. It means ensuring that every work to the full extent of their scope of practice. Creating safer and healthier work environments. And it means having goals and priorities.

We have too many doctors doing things that RNs and pharmacists and dieticians can do. We have too many RNs doing what LPNs can do and what occupational therapists and physical therapists should do. We dont have enough health aides and support staff. We dont need to cut our labour costs, we need to spend more smartly, to have a better mix.

Right now, we overspend at the top - on GPs and especially on specialists. Ophthalmologists, for example, earn more than $600,000 on average. They are grossly overpaid for doing cataract surgery.If you pay a reasonable amount for cataracts, you could buy some much-needed janitorial care and maybe prevent some eye patients from going home with hospital-acquired infections.

My third wish is that we stop saying that the grey tsunami is going to overwhelm the health system. Old people are not bankrupting medicare. The cost drivers in our system are new technologies and drugs and the increased provision of medical services to people of all ages.

If anything, seniors are victims. Our system, fashioned in the 1950s and 1960s, was designed to deal with acute episodic illness and injury. Get in and get out quickly. Its built for young people.

Today, two-thirds of costs come from caring for people with chronic illnesses. People who come into the system and never leave. So, I believe that if we can do some structural re-organization we can really make some major improvements in both delivery of care and its cost.

Right now, our system is top-heavy. We invest massively in tertiary care, in hospitals. We spent $55-billion on hospital care last year. We have to shift that focus to primary care, to keeping people well and to treating them before its a crisis. Instead of a massive number of hospitals - there are about 600 in Canada - we should have a clinic-based system of care, with healthcare teams.

Another thing that needs to be fixed urgently is the provision of drugs. We introduced medicare because people were suffering, physically and financially, from lack of access to essential healthcare. Today, we are seeing those same problems with drugs.

In Canada, there are thousands of people mortgaging their homes, draining their RRSPs and running up massive debt because they have to pay out-of-pocket for drugs. We need some form of pharmacare or catastrophic drug insurance to ensure the same fairness of access and quality care that we have for other forms of medical care.

A national drug plan -- and I did not say federal, I said national, meaning having some common standards - will not bankrupt us. But the absence of such a program is leaving us morally bankrupt. It offends the principles of medicare and our values as Canadians.

Now, Im not suggesting that we pay for all drugs. We need programs like the Therapeutics Initiative that tell us what is safe and cost-effective. We need the Common Drug Review to tell us what should be covered and bulk buying of the useful drugs. I think that its essential that there be cost controls.

The same is true of medicare. One of the major problems with todays health system is that it tries to be all things to all people. In our publicly-funded system, we need to focus on the essentials, to get back to basics.

We can and leave the frills to private enterprise and those expenses can be paid out-of-pocket or with private insurance.

I believe there is a place for private delivery of services. That may not be a popular thing to say in this venue, but I dont want to be a hypocrite like many of our political leaders.

We already have a lot of private healthcare spending in Canada. About $57-billion worth last year. The problem I have is that we are doing privatization by stealth. Its being done without any public discussion or debate. And personally, my support for allowing private delivery of some services comes with important provisos.

I think we have to ensure that the services delivered by private contractors - either not-for-profit or for-profit - must be held to the same standards. I think they have to compete on a level playing field. And I dont believe in a private parallel system that would decimate the public system and serve only the wealthy.

I think that essential care which is covered by medicare should be delivered by the public system. The peripheral stuff can be done elsewhere - at the Cambie Clinic, Wal-Mart or wherever. Anyhow, thats an aside.

The whole private-public debate is muddled because we dont state clearly what we mean. I hope I have done so.

There are two other major areas that require our urgent attention -- at least two that I have time to talk about. Technology is one of them - specifically electronic health records. Its really obscene that, in 2011, we are still largely dependent on paper records. They are really inefficient.

Poor record-keeping is a tremendous source of waste and one of the leading reasons for medical errors. In this room, you will know just how much duplication of tests there is because of our poor record-keeping and inability to access info easily. B.C., to its credit, has been a leader in using technology to deliver better care, especially in prescription drugs.

Again, technology is not just about saving money. Its about making care safer and about freeing up the time of healthcare workers to deliver care.

The final item on my wish list is teamwork. That has to be a guiding principle for the future of healthcare delivery. The modern patient needs interdisciplinary care, they need a team, and we have to re-tool the system to ensure they get it. But a team does not have to consist of a doctor and his or her subordinates.

We need to get the mix right based on the needs of the patient. Sure, some teams should be led by a doctor; but some should be led by a nurse, a pharmacist, a dietician, an OT or PT or an ortho tech.

I want to wrap-up soon to leave time for questions because I know you will be a dynamic group but I want to quickly say a few words one last issue - politics.

You hear a lot of people say: -Lets get the politics out of healthcare." Well theyre deluding themselves. Health is inherently political because its important and deeply personal.

If you want to change the system - if you want to improve care and ensure a future for medicare - you have to engage in politics. There is no point lamenting this. Your energy is better spent figuring out how to become more politically effective.

We have a system that is designed around the needs of physicians and hospitals. It needs to be designed around the needs of patients.

As healthcare workers you need to stand up for yourselves but, first and foremost, you need to be champions of patients. As I said at the outset, Im not a health professional. I dont know much. But I know this:

What matters is people. The difference between good care and bad care lies in the simple acts of individuals - taking a moment to listen, double-checking the chart, making sure the test results are delivered promptly, re-calibrating the oxygen flow of a patient with COPD, turning a hospital patient one more time to be sure shes comfortable, celebrating the small victories in physio, wiping a surface one more time to make sure its clean.

Anyone who has ever been a patient will tell you thats whats really important. We need to give healthcare workers the tools to care - chief among them time. And we need to give them the respect they deserve, respect that is reflected in contracts and work environments.

If we focus on whats important - people - the money stuff will work itself out. You are the future of medicare, and thats why I think the future is bright.

I want to stop there. Even if you disagree with some of what I said, I hope listening to me was worth the effort. And I welcome your questions.