Illustration by Tim Boelaars
The Fixing Health Care series presents 10 common problems faced by patients in the public health system across Canada, which are based on scenarios the authors have encountered through their work in health care and social services. The authors offer 10 solutions to these problems that, with political will, might be achieved through publicly funded initiatives (and in some cases may be faster and less expensive) without having to resort to increased privatization. The essay below presents an introduction to the series, while each of the 10 problems and proposed solutions can be accessed via the table of contents.
More below • Full series: Table of contents • About the authors
Canadians are more polite than passionate, the stereotype goes. But as we all know, there are a few subjects that can really ruffle the feathers of any Canuck. Along with gas prices and the housing market, chief among this group of galvanizing topics is health care.
Publicly funded health care (also known as “medicare”) arrived in stages across Canada in the latter half of the 20th century, beginning with Saskatchewan’s decision to fund public insurance for hospital care in 1947. An expansion of provincial and federal funding for health care gradually followed, as Canadians increasingly supported the principle that health care should be available for all citizens based on need, rather than on the ability to pay. Arguably, public health care has become a cornerstone of Canadian national identity, providing us with a distinct line of cultural separation from our American neighbours. Political wisdom suggests that you cannot challenge medicare without provoking the Canadian electorate’s ire.
Throughout the pandemic, we have collectively evaluated the effectiveness of our public-health response to COVID-19 and the resilience of our health system in general. In comparing our performance to other wealthy countries, Canadian pandemic mortality has been lower than in the United States, Britain and most countries in Western Europe.
As a country, however, we were horrified by the high number of deaths occurring in Canada’s long-term care facilities, particularly before vaccines became available. In fact, Canada had a higher proportion of pandemic mortality in its care homes than any other wealthy country. The suffering of residents and families has been a national tragedy.
During the Omicron wave of the pandemic, political leaders reintroduced many public-health restrictions (including school closings, limits on indoor gatherings, and closings of gyms and restaurants) as a way to protect the capacity of provincial health care systems. As increasing numbers of health care staff were exposed to the Omicron variant, Canadian hospitals’ ability to provide care was limited, necessitating both shutdowns in the economy and restrictions in the provision of hospital services, including surgeries.
As the pandemic continues, an alarming number of health care workers have indicated their intention to quit or retire in the near future, citing unprecedented levels of burnout. A survey of health workers in British Columbia released in March indicated that a third of respondents were looking to leave their jobs in the next two years, while over half of the respondents to a similar survey of health workers in Ontario said the same in October. In both cases, workers cited inadequate wages and poor working conditions as reasons for leaving the profession.
The pandemic has made it clear that the Canadian health care system requires major reform and possibly radical solutions. Typically, one of the first structural changes proposed is the abandonment of universal, publicly funded hospital and physician care to allow for the introduction of a parallel, for-profit system – also known as a two-tiered health care system. A two-tiered system would spell the end of Canada’s single-payer provincial health care systems (wherein all hospital and physician services are only paid for by the government) and would initiate a second system funded by private investment, private pay and private insurance plans. This two-tiered system would enable for-profit care by physicians and hospitals, thereby allowing wealthier individuals to pay for quicker access if they can afford it.
Proponents for the introduction of for-profit hospital and physician care insist that COVID has exposed the weaknesses of a public system that has been failing for years. They suggest that backlogs in accessing surgery or diagnostics during the pandemic were entirely predictable based on the long wait times that have increasingly characterized Canadian health care over the past decade.
We strongly disagree with this premise for two key reasons. First, two-tiered health care, particularly in the United States, has routinely proven to be more expensive than universal health care and has led to poorer health outcomes for citizens. In 2019, the Organization for Economic Co-operation and Development reported that Canada spent $6,666 per person on health care, while the U.S. spent $13,590. The Commonwealth Fund research foundation found that, despite spending twice as much on health care than the average OECD country, the U.S. has the lowest life expectancy, highest suicide rate, largest chronic disease burden, and highest number of avoidable deaths compared to 10 of its wealthiest peers (including Canada).
Proponents of two-tiered health care make the false argument that allowing wealthier people to pay for faster access helps the public system by reducing demand. In reality, we have a limited number of health care professionals – attracting doctors and nurses to a private system inevitably reduces the quality of care in the public system. A 2018 analysis of surgical wait times in Australia, which has an extensive two-tiered, private-pay model, demonstrated that the country’s wait times for surgery in the public system were worse than in Canada.
Second, we believe that medicare’s health equity principles are among the strongest and most lustrous threads of our Canadian social tapestry. Medicare reflects what is best about Canada – that we believe in equality and the fundamental tenet that all citizens should have equal access to health services regardless of their age, income, gender, ethnicity or location. Our health care system isn’t perfect, but we should not forsake our commitment to it without working hard to improve it.
So where does that leave us? We have all heard stories about dissatisfaction and frustration with Canadian health care – it’s a frequent topic of conversation among family and friends, a phenomenon that predates the pandemic. Often, the frustration is tied to timely access to care, whether it be a months-long wait to see a specialist or the experience of sitting in an emergency room for hours at a time. But the pandemic has also drawn new levels of scrutiny to our care for Canadian seniors. Stories about neglected residents in nursing homes have amplified prepandemic concerns regarding long wait times as well as abusive or neglectful treatment in these residences. Providing appropriate care for the rapidly increasing number of Canadians over the age of 75 is undoubtedly the most formidable challenge to the future of our public-health system.
The complexity of health care delivery makes it difficult to understand how we can provide faster access to care or provide better treatment for seniors without spending a lot more money. Health care costs approach half of the expenditures for provincial governments, and the increased debt load we have taken on during the pandemic has led many Canadians to question how we can spend even more tax dollars on health services. The idea that Canada’s health system will require massive infusions of money to work better usually leads to the conclusion that we will need private dollars and for-profit facilities to respond to the challenges we are facing.
Although investment is undoubtedly needed to improve some deficiencies and expand health services, we strongly believe there are solutions that can improve the quality of Canadian health care while maintaining or even reducing the current cost. These interventions do not require a dramatic restructuring of our system, nor do they require for-profit care, and they are supported by strong evidence. In most cases, either inertia and general resistance to change, or powerful vested interests, are currently preventing the implementation of these initiatives.
In this 10-part series, we will present 10 major problems that commonly arise within the Canadian medicare system. The “patient problem” stories you will encounter are fictional, but they represent amalgamations of real stories we have heard from Canadian patients and their families. We will present solutions to each of these problems that can be implemented by sheer force of political will, and in many cases without major investment. Some of the solutions we have proposed could even save money.
The four authors of this project approach these problems and solutions from different perspectives, with experience gained in the private sector and philanthropy, as well as from leadership in social systems and health care. We agree that there is an opportunity to provide care that is better, faster and often more cost-effective by implementing changes that have been shown to work both in Canada and elsewhere.
Canadian medicare can often represent a convoluted and frustrating set of systems that don’t always work in harmony with one another. But despite the current challenges we face, substantial improvements in each province’s delivery of health care are achievable – right now. We hope that this series will challenge Canadians to ask elected officials, bureaucrats and health care providers: “Why aren’t we making these changes already?”
Full series: Table of contents
Illustration by Tim Boelaars
Canada’s specialist referral system needs to be boosted into the 21st century
Transitional-care facilities will stop Canada’s ERs from resorting to ‘hallway medicine’
Taking the pain out of one of the biggest challenges for patients – getting a diagnosis
It’s time for therapy to be included in Canada’s universal health care system
Seniors need communities that cater to their whole selves, not just their bodies
Nearly 15 per cent of Canadians don’t have a family doctor, but the solution isn’t hiring more
Four ways to make the universal pharmacare dream a reality
About the authors
Dr. Robert Bell is professor emeritus in the Department of Surgery at the University of Toronto, former deputy minister of health for Ontario, and former chief executive officer of the University Health Network. Anne Golden is past president of the United Way of Greater Toronto and the Conference Board of Canada. Paul Alofs is former CEO of the Princess Margaret Cancer Foundation. Lionel Robins is past chair of the Princess Margaret Cancer Foundation, and a board member for the United Jewish Appeal Federation and the Betel Senior Centre.
What’s a pain point you’ve experienced in Canada’s health care system? Our experts want to hear from you.
Email your story to comment@globeandmail.com and one of our experts may feature it in a follow-up article along with a potential systemic solution. If your story is chosen, we will identify you by your first name and last initial. Please use “Fixing Health Care Reader Story” in the subject line.
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