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The health care time bomb

Our aging population will make unthinkable reforms inevitable


 
The health care time bomb

Jacques Boissinot/CP; Ryan Remiorz/CP

Experts who have been pleading for an urgent debate on fast-rising health costs might secretly have welcomed the appearance of irate demonstrators outside Raymond Bachand’s Montreal office last week, two days after the Quebec finance minister proposed a new health tax, and even user fees, in his March 30 budget. And when Montreal police in riot gear clashed with the protesters, those worried experts—doctors and economists who’ve long argued that Canadians must face up to the hugely expensive needs of a rapidly aging population—wouldn’t have been out of line if they thought, “Finally, this issue can’t be ignored any longer.”

Bachand’s daring budget, and the angry reaction to it, gave those who’ve been issuing warnings about the cost of care a flashpoint to talk about. Quebec faces relentless growth in hospital, drug and doctors’ bills, similar to most provinces. Health will devour 45 per cent of Quebec’s budget this year, up from 31 per cent in 1980, and on track to consume 67 per cent by 2030. So Bachand announced a health tax slated to rise from $25 per adult in 2010, to $100 in 2011, and $200 in 2012. Even more provocatively, he said Premier Jean Charest’s Liberal government will study the idea of imposing a so-called “health deductible,” perhaps $25 per medical visit, which would be incorporated into the income tax system. It took two days for anti-tax, anti-user-fee protests to erupt outside his office in Montreal’s old city. Bachand didn’t back down, succinctly summing up his motivation for making the cost of care more directly apparent to Quebecers: “Nothing is free.”

Of course, Canadians realize health care is expensive, when they think about it. But government insurance means they usually don’t. Anne Doig, the Saskatoon family physician who is also president of the Canadian Medical Association, said Quebec’s surprise move might signal the moment when politicians across the country finally begin to confront costs. “We are pointing out the problem, a stinking elephant in the middle of the room, that our governments have been able to sidestep up to now,” Doig told Maclean’s. “I think we’ve reached the tipping point where they can no longer sidestep it.”

Though she welcomes Quebec’s budget as a wake-up call, Doig doubts Bachand’s measures are the solution: “I think this is perhaps a short-term—I’m not even sure if they meant this as a fix, or as a trial balloon to see how people would react.” Doig said a user fee, even if it’s built into the tax system, rather than collected up front by doctors’ offices and hospitals, is likely to increase costs in the long run. “Anything that causes a person to delay attention in a potentially serious situation is not good,” she said.

That criticism is echoed by Irfan Dhalla, a doctor and health systems researcher at the University of Toronto who has studied user fees. “Patients don’t generally know in advance if they are seeking necessary care or unnecessary care,” Dhalla said. “So the research has shown, again and again, that if user fees are imposed, patients reduce the amount of unnecessary care, but also the amount of necessary care.” For instance, he said women who have to pay for part of a mammogram tend to go without the test, delaying cancer diagnosis, which is bad for their health and ultimately more costly for the system. The same is true when high blood pressure and diabetes aren’t caught early because cost-conscious patients don’t visit their doctors soon enough.

If user fees are controversial, the other options open to provinces aren’t any easier. David Dodge, the former Bank of Canada governor and also a former deputy minister of the federal Health Department, recently laid out what he called four “stark and unpalatable choices” at a Liberal policy conference in Montreal. Dodge said the options boil down to significant user fees or “co-payments”; dedicated health taxes; cutting back on the scope of publicly insured services, which would force Canadians to buy private insurance for what’s no longer covered; or allowing erosion of the quality of care, perhaps letting wait times lengthen, again while allowing those who can afford it to buy private care.

Dodge’s éminence grise stature meant his blunt warning caused a brief stir in public-policy circles. He predicted a more sustained clamour for change will come from ordinary retired Canadians. “We as citizens are not going to put up with being denied access to life-saving, health-enhancing services,” he said. “It’s especially true of the younger elderly, the 60- to 80-year-olds, because many of the new services are things that make their lives better.” Dodge said active seniors—who tend to vote—won’t put up with being told they can neither count on high-quality government-funded care, nor dip into their own savings to pay for services that are denied.

In fact, the impact of an aging population has barely begun to be felt: the first of the baby boomers are only just beginning to retire. Even before that demographic shift takes hold, health costs have risen more than seven per cent a year on average for the past decade. In 2009, health spending hit an all-time high of 11.9 per cent of Canada’s gross domestic product. That’s $183.1 billion, $9.5 billion more than in 2008, or $5,452 per person. Spending is skewed toward the old. In 2007, the latest data broken down by age group, total health spending on those under 64 averaged $1,966 per person. Between age 65 to 69, the average was $5,589. For those 80 and older, the cost soared to $17,469.

Whenever caring for seniors is considered, the costs of running hospitals, long-term care and home care tend to be highlighted. But drugs are emerging as arguably the toughest component to control. The Canadian Institute for Health Information reports that hospitals soaked up 27.8 per cent of health spending last year, down dramatically from 44.7 per cent in 1975. During the same period, drug costs nearly doubled to 16.4 per cent of all health spending. Among the elderly, prescription drugs are a way of life to a startling degree: CIHI recently studied Canadians 65 and older in six provinces, and found that two-thirds are using five or more classes of prescription drugs, and about one-fifth use 10 or more types of prescription drugs.

Despite such cost pressures, many provinces have lately predicted that they will be able to hold down health spending. For instance, Ontario projects a six per cent increase for 2010-11, but just three per cent by 2012-13. British Columbia plans for a 5.8 per cent boost this year, but only 2.7 per cent two years from now. How do they and other provinces plan to do it? Clamping down on pay hikes for health workers, using cheaper generic drugs more, and pushing hospital efficiency are all touted as cost-cutters. Dodge is skeptical. “What I’m afraid of, as you look at the provincial budgets,” he said, “is that they have assumed the problem away.” Doig isn’t convinced either. “I’d like to understand on what basis they make those projections,” she said.

If dramatic reforms don’t yet seem to underpin optimistic provincial forecasts, there’s no shortage of bold ideas in the field. Many experts are intrigued by the way Britain’s National Health Service was overhauled after the Labour government came to power in 1997. They doubled spending, but also boosted efficiency. Wait lists shrank. British patients now shop on websites that rate hospitals and clinics. Those that underperform lose, since the money follows consumer-patients wherever they choose to go for care.

It’s all still paid for by government. Wendy Thomson, director of the School of Social Work at McGill University in Montreal, was chief adviser on public service reform to former British prime minister Tony Blair when he was driving health reform. She thinks fear of U.S.-style care has made Canadian politicians afraid to promote reforms based on a “quasi-market” for medical services. “You want to clearly set a framework of standards and responsibilities, devolve to the level that’s responsible, and step back and reward the successful and punish the failures,” Thomson said. “You don’t see that here.” Maybe after Bachand’s budget, the time is ripe for that sort of new thinking.


 

The health care time bomb

  1. With Canada's rapidly aging demographic, we will have to be willing to make changes to how and what we pay for health care. The sooner we make changes, the longer our existing system will remain fiscally healthy. We can no longer rely on the status quo and expect that health care delivery will not suffer as more and more baby boomers enter the years when they will have to rely on fewer numbers of those who are younger than them to prop up the system.

    While it is unfortunate that health care costs will continue to become a larger and larger percentage of total provincial budgets, provincial treasuries also need to re-examine their own wasteful spending practices. In the case of Prince Edward Island, the government wasted $1 million on Atlantic Canada House at the 2010 Olympics in a misguided attempt to draw tourists to the Island. An expense of this magnitude for 140,000 people was unwarranted and its benefits are unmeasurable. In my opinion, this money would have been far better spent benefitting more Islanders through improved health care delivery. Provincial treasuries need to realize that they don't have access to an infinite supply of money and that sacrifices on certain projects that are not essential will have to be made for the good of all.
    http://viableopposition.blogspot.com/

  2. If you can afford to go to war, you can afford to help the sick.

  3. Two tier system!!
    About time people start seriously thinking about it!

    • Injection of market mechanisms to a public system don't necessarily mean jumping to a two-tier system.

      Besides, while a two-tier system might be consider more fair to those with the ability to pay for better care, and may even improve patient care (though because of other factors in the Canadian health care system, I wouldn't expect this to hold for the majority of people), there's little reason to suspect it would reduce overall costs.

      We absolutely need to inject more market mechanisms into the public health care system, so that institutions who can deliver better care for less are rewarded, jumping to a two-tier system would be a mistake, especially with the current numbers of health care professionals.

    • No. We do not want a private payer system, for the reasons laid out in the article above.

      When people have to pay for their own health care, they typically wait to seek treatment until things get severe at which point it costs much more to address the problems. (If anything, people wait too long *now* to get checkups, so if whatever system we come up with also provides incentives to do that, that'd be a good thing)

      That said, we can certainly have a public pay, privately provided system. Which is similar to what's been set up as the BNH. But it means we'll need to establish a system whereby individuals can quickly and easily access data about the health care providers to see who'd suit them best.

      • We already do have a public pay, privately provided system for the majority of our care.

        • Depends on your province, I think. Hospitals aren't privately operated in Alberta, for example.

          • Probably. Ontario doesn't have too many publicly owned hospitals and – to my complete surprise – Alberta seems to have the largest publicly owned health care system in the country, one that is surprisingly centralized in its power scheme. Well, you learn something every day I suppose…

          • Just to clarify…most or many hospitals in Ontario are privately owned facilities? I did not know that.

          • Yeah, most people don't – I didn't either 'til I started helping out at one. Don't get me wrong, they're not private enterprises the way we normally think of private enterprises, since the government controls most of their revenue and sets a lot of standards, but yeah, a fair number are privately owned.

      • Speak for yourself,who is this we?Some of us do wnat private payer,the same thing that that the guys you support have access to,but deny us the same thing.I find it strange that you guysleftists make up your minds and then claim everyone agrees with,what nonsense.

        • I don't claim everyone agrees, I'm saying "we don't want it" because it's a dumb idea. It's like saying, "We don't want cars that pour half their gasoline on the road". People are free to disagree if they want, but if they do, it's because they haven't thought it through.

          • Well, then, speaking of thinking things through: We HAVE a two-tier health care system. The second tier currently exists from Bellingham WA to Portland ME.

            What you are saying, incorrectly I would argue, is that "we" deliberately choose to keep this portion of our economic activity outside of our own borders. Now, indeed, most people have been brainwashed by Maude Barlow et al into thinking that way, but it's just because they themselves haven't thought it through.

          • No, we don't. We currently get to use their system, but we don't have it, any more than I have everything in the local Walmart because they allow me to purchase things from them.

            And yes, you are arguing incorrectly about what I am saying. I'm saying we are wise to avoid a private payer system for the reasons cited in the article above, among others. That some people choose to go out of their way to use a private payer system does not in any way affect my argument.

          • You did claim everyone agrees. I have never seen anyone say 'we' and then say 'i meant it`s dumb idea'.Actually they do think it through.It is just you,with your illusions who thinks everyone who disagrees with you is dumbass.Go ahead,deny that,even though you just wrote that in your post.

  4. Good piece.

    I wish I could say that it's nice to see the the media starting to clue in to the logical connection between provision of a "free" service and the inherent supply limits to which this leads. I also wish I could say that it's nice to see the media cluing in to the connection between the Western world's population trend and its inevitable economic impact.

    Unfortunately the fact that these realities are impinging on the public consciousness means that the tsunami is almost here, and we are woefully unprepared. Many are still blithely expecting that something can be had for nothing, and that social policy that defers costs to the future will never catch up with us.

    Hold on to your hankies folks – the next 40 years are going to be a wild ride.

    • In Canada, nobody starves, but not everybody has caviar on crackers served by tuxedoed servants before dinner. But when it comes to health care, everybody expects caviar & tuxedoes FOR FREE as a divine right of simply living here.

      Well, you got your single-payer public monopoly and the caviar and tuxedoes are an interminably long wait-list away — inevitable result of central planning, friends — but the prices continue to skyrocket as governments attempt to curry voter favour by dangling caviar and tuxedoes under our noses come election time.

      Continued…

      • The wait times in Canada are largely the result of inadequate numbers of personnel – far from being a problem with our health care system, it's a problem with our education system.

        We lack surgeons, nurses, MRI techs – for all the hang-wringing about our lack of MRI machines, what we really lack is people to run them (thanks in large part to a pointlessly complex and long path to become qualified as an MRI tech).

        A private sector doesn't solve that issue, since it can't make professionals come from nowhere.

        • Should you have a chance to experience the US medical system before it too gets socialized, you will find that there are no significant wait times. It's a remarkably clear example of how efficiently a private system runs in comparison to a public system….and that's the US medical system, which is hardly a hallmark of efficiency compared to any normal private-sector industry.

          • That's 'cuz it's not a normal private sector industry. It has been messed up by employer-sponsored benefits. It's no longer insurance compensating you for catastrophic costs. It's spiraling insanity of acupuncture and vitamins and health club memberships and "wellness coaches" and any number of nonsense that no longer fits any definition of shared-risk coverage of major losses.

            And you're right, it STILL manages to have no two-year wait-lists down there.

          • Tell you what, how about we address our wait times as they do — triple our GDP per capita spending on health care to start, then disallow about 15% of the people from getting health care at all, and putting about 1% of those who *do* access health care into bankruptcy.

            Hell, with disincentives like that and spending like that, I'd be surprised if we had any wait times either. Of course, we'd have a lot more sick people, and be spending a lot more on welfare, but hey.. as long as you can argue that even if you caught a disease from your neighbor, at least you didn't pay for him to get it treated early, right?

          • Tell you what — why don't you put that straw man down and have a look at some European models without a hysterical mob yelling AMERICANIZATION OF OUR BLESSED SYSTEM in everyone's ears.

          • Hey, Gaunilon was the one who touted out the US medical health-care industry. Why don't you go whine at him.

          • 1) The US has more physicians as a proportion of the total population. They also have more nurses. I can't find the stats, but I'm almost certain they have more MRI techs (actually, they'd have to unless their MRIs are run by robots).

            2) The US covers fewer people as a proportion of the total population. 1) and 2) alone explain the lower wait times.

            3) Free market health care is great when it comes to productivity, which is where we're lacking, but nowhere near as efficient as what we have. Administrative costs are significantly higher, the number of unnecessary procedures is significantly higher and let's not forget that profit, while a motivator to eliminate other inefficiencies, is an inefficiency in itself as higher profit means more cost for no better product. There are many other factors to explain the high costs of health care in the US, but they're the closest thing to a private system in the modern world and it's far less efficient than what we are – they put in a significantly higher percentage of their GDP, of government money and total funds and their results are no better than ours.

          • The real issue is why the US has more physicians, nurses, and MRI's as a proportion of the total population (coverage is virtually a non-issue: less than 10% are not covered by Medicaid or insurance, and of those many have the means to pay for their medical services but choose not to purchase insurance).

            The reason for their higher per capita healthcare providers (and equipment, and facilities, etc.) is the free market. When supply gets scarce, the price goes up, schools can charge more tuition, so they make more spots, more doctors/nurses are produced, etc. It's simple supply and demand.

            Up here, on the other hand, the prices are fixed by government. Therefore when the supply gets scarce it stays scarce.

            You miss the whole point by saying "yah, they have more doctors and MRI's per capita, that's why they have less of a problem". It's not some bizarre coincidence that they have more – it's because our system is socialized.

          • Health care economics are far different from regular market economics, it's not a simple matter of supply and demand.

            France, Germany, Sweden, Norway, and the UK, all with health care systems where the government pays a greater portion than ours and the US have many more doctors per capita. Australia, which has a similar system to ours, also has more doctors than Canada and the US. If this supply and demand idea held true, the US – with spectacularly higher costs and less government involvement in the education system – should be rolling in doctors. But it's not.

            We have fewer doctors and MRI techs because we train fewer and have too many barriers for foreign-trained doctors to practice in the country, it's as simple as that. That lower number leads to higher wait times.

            Besides, if that supply and demand in health care held true, and let's assume for a second that all those countries with socialized systems didn't have more doctors than the US, those extra American doctors – having increased the supply of health care – should begin pulling the price down, or at least slowing the rise compared to Canada where supply is more constrained. And yet that hasn't been happening either.

            The economics of health care are much, much different than the economics for a typical good or service. It's never as simple as supply, demand and price, and that's a major reason why we can't just assume the free market will do things better.

          • Health care economics in socialized systems are affected by many other factors – true. That's because supply and demand are replaced by government fiat. European countries therefore have more doctors per capita if their governments choose to pay for those doctors….of course that impacts their fiscal situation.

            ". If this supply and demand idea held true, the US – with spectacularly higher costs and less government involvement in the education system – should be rolling in doctors. But it's not. "

            Supply and demand doesn't make the number of doctors go up infinitely; the number of doctors rises to meet demand. There are negligible wait times in the US, yet doctors are still in enough demand that they make a wage sufficient to offset their years in training. That's the balance between supply and demand.

            It's true that costs are quite high in the US, but this is not because of a doctor or equipment shortage as it is here – supply and demand have taken care of that. The costs in the US are primarily due to two things: (1) out of control litigation, forcing up doctors' insurance premiums and encouraging them to perform every test/treatment they could possibly be sued for neglecting even when they know it's pointless, and (2) arcane regulations that prevent insurers from taking customers from out of state and make it difficult to start up competing insurance companies in-state, thus leaving monopolies or near-monopolies in some states.

            In short, regulation/socialization increases costs by severing the connection between supply and demand. It has other advantages, but cost-saving and access aren't among them.

          • Supply is higher in the US, there's no reason to suspect demand is higher, yet prices are much higher, obliterating the traditional trade-offs between the three. It's not just that there are other factors, supply and demand are very different beasts when it comes to health care – more supply doesn't necessarily decrease price.

            1) Litigations laws in the US aren't significantly different than they are here. Besides, reports indicate that tort reform in the US could save, at most, 2% of the cost – a far cry from the 4+ GDP point different between the cost of our two systems.

            2) California has as many people as Canada – why would an insurance company be able to start up and reduce costs in a pool 300 million people when it can't in a pool 30 million? Monopolies pop up due to lack of anti-trust laws in the US and the fact that insurance companies are most profitable when they're large. It has nothing to do with the lack of insurance across state lines (and, as insurance companies are regulated by the states, it would create some rather perverse incentives for individuals and insurance companies if that were to be allowed).

            These are the Republican talking points Gaunilon, and they're entirely unhinged from the economic realities. France pays less as a percentage of GDP for health care than the US, has roughly the same results, is heavily socialized and regulated, has more physicians and, amazing, spends less of their government revenue on health care than the US as a percentage (and about the same in terms of real dollars!). The free market, while fantastic for so many products and services, simply crumbles when it comes to health care.

          • I should have added one further point: a significant problem in the US is also the fact that insurance is generally provided by the employer and used for all health care, not just catastrophic events. This is insane; it both decouples the price from the consumer (thus foiling supply/demand…again) and also leads to people being dependent on their job for their family's health care.

            " Besides, reports indicate that tort reform in the US could save, at most, 2% of the cost…"
            Let's just say there are conflicting "reports" on that issue.

            "…why would an insurance company be able to start up and reduce costs in a pool 300 million people when it can't in a pool 30 million? "

            It's not a question of what an insurance company would do, it's a question of what consumers can do. People can pick car insurance from wherever, so car insurance is dirt cheap. Health insurance is severely regulated, there is less competition, and therefore it is artificially pricey.

            I'm sure France is wonderful in many and sundry ways, and I'm not familiar with the details of their situation. I do know, however, that medical insurance is a lot more expensive than, say, life insurance, car insurance, dental insurance, travel insurance, home insurance, and just about any other kind of insurance in the US. It's also harder to get and more regulated. If ordinary medical care is paid for up-front, supply and demand takes hold just as it does with other essential services like food provision. Catastrophic medical care requires insurance, just like catastrophic house fires do. There is no reason why the former would be more expensive than the latter if the former were as unregulated as the latter.

            "These are the Republican talking points Gaunilon, and they're entirely unhinged from the economic realities. "

            These are the points made when I talk to doctors about it. If you're going to let your politics colour your thinking we're not going to get any farther here, so I will merely wish you a good day and good luck on your exams.

        • Oh my, Craig. Can you consider that governments have so royally screwed up the health sciences post-secondary education system that the scarcity of high-priced professionals has long been considered a feature, not a bug? That much of the high-priced talent is presently fleeing this country (although, thank you Mr. President, you are working hard at slowing down that trend)? That if education was left to the market, and a demand was identified, the "system" would find a way (if not f*cked up by government) to satisfy that demand?

          • Try doing some research rather than relying on what your gut tells you.

            First, the brain drain stopped years ago, and has reversed in recent years, with ex-pat doctors returning to Canada.

            Second, education *is* left to the market. That's the problem. The market has decided it likes its monopoly and keeping the supply of doctors down so demand can outstrip supply and keep wages high. If you want to get into med school leading to a certification, you have to go through their process. Supposedly it's based on your grades, an interview, your personal submission, and sometimes an additional pre-med test, which are then all put onto a point scale. However, how these points are awarded, especially in the interview and personal submission phase is not disclosed to the applicant.. and if you talk to successful applicants, you'll find an awful lot of them already have doctors in the family.

          • Oh Thwim, I am disappointed in you. The "market" has made no such decision because the market has not been allowed to make any such decision. GOVERNMENTS subsidize all aspects of the situation and so they also control all aspects. A decade or so ago some bright light wrote a report that stated that the reason things cost so much was that you had all these expensive doctors and nurses. So let's buy 'em out with early retirement packages and let's restrict available slots in university, and, oh dear, all of a sudden everybody's overworked and so many patients cannot find a doctor. Quelle surprise.

            Your little story about HOW people get into training has precious little to do with what we're talking about here: HOW MANY people get into training.

          • Actually, it has everything to do with how many get into training, because they control the numbers. When they have "enough" people, everybody else doesn't score high enough. That's just how it is.

          • I can consider it, but generally speaking I don't give much credibility to conspiracy theories without evidence.

            I haven't been able to find much on the government's role in low med school admissions – while med schools in Canada are private, our post-secondary education system is intertwined with the government, so while I can't say the provincial governments are pointlessly constraining the number of med school positions, I can't say that they're not. However, you're the one making the accusations, burden of proof is on you.

            They are, however, royally screwing things on the side of immigration and foreign accreditation – we have a lot of students going abroad for med school who can't come back here to practice, as well as a number of immigrants who are having significant difficulty entering the field. There's no way for the private sector to get in there to fix that problem, but it's certainly a place the federal and provincial governments could be working to ease the strain on the system.

  5. Controlling health care costs is not an easy thing, for any country, especially one such as ours where demographics and health care innovations are conspiring to push those costs up regardless of what other measures we take. Generally speaking, there are three general things the country and the provinces need to do to manage our health care system.

    1) Recognize that health care is not health, but the two are intimately connected and we need to put more focus on the latter. Medicine can't make people healthy if they're fighting to make themselves unhealthy. Between nutrition, exercise and stress management, we may be doing better taking care of our own health than the average American, but we're not ahead by much. If we want lower health care costs, we may need a better health care system, but we need better health more.

    2) Continue the trend of introducing real market mechanisms into the public sector health care system. Contrary to popular belief, most health care providers in Canada are privately owned and operated, even if they are paid in large part by the government. We need to be careful, as not all market-style incentive schemes will be effective, but certainly efficiency could be improved substantially in our current system if people and institutions are given the right kick. I'm not sure this would reduce costs in any meaningful way, but it might constrain the rise and improve quality of care while doing so.

    3) Recognize that some costs just won't stop rising – but that we need to cover those costs anyway. Right now, the current workforce is barely covering the cost of the health care they're receiving right now, let alone the costs they will incur once they retire and age. That needs to change, fast. If baby boomers want the kind of health care they expect, they'd better start paying for it before they leave the workforce, because there simply aren't enough of us younger workers to pick up that bill for them.

    Each of these components is in itself a minefield of problems, where each potential solution has a downside that needs to be considered and weighed. But Geddes is right, this is a conversation that we need to have now, because we're rapidly approaching the point where it becomes too late for effective action.

    • Well Craig, if drastic measures are needed and the emphasis is on health, I will go further and stress one's personal responsibility for good health. I would implement the following changes if I had my way. It's drastic and even brutal but it will serve as a wake up call for the health idiots. Of course, some sensible reform of the system is still needed as discussed in the Maclean's article.
      1. If one is morbidly obese(BMI > 35), forgetaboutit. We will not replace your knees, hips or treat you if you have obesity related diseases like diabetes and heart disease. Get your BMI below 30 and then we will deal if in fact the weight loss does not clear up all your problems. Those just merely obese(BMI of 30 to35), we will treat you but only if you enter a weight loss program and achieve the desired results, say a target of a BMI less than 29.
      2. If one is a drug addict, take a hike. If you get diseases associated with dirty needles or the drugs themselves, just go to an alleyway and die. The only treatment you can get are in programs to beat drugs. You get one chance.
      To be continued

    • Shouldn't you be studying for the 441B exam?

    • public healthcare is cheapest, private involves BIG profit and leads to barbaric care. Never mind all your gab. It is that simple. Think about it!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1

  6. It is not hard to foresee the injustices that a two tier system can cause when money becomes a deciding factor in who gets treatment faster or where doctors choose to work. However, not all aspects of markets are inherently bad and competition in search of efficiencies is a highly reasonable approach provided that all citizens have the same opportunity to get care. Many hospitals are consistently over budget and in need of aggressive efforts to reduce their costs. My wife works as an intensive care nurse and is horrified by the waste she sees in performing her day to day job. Her hospital does not represent the worst of the worst by any means so there are obviously many opportunities to reduce such waste.

    Rather than simply raising taxes or adding new taxes while the costs rise, it is important to try to contain the increases through significant prevention efforts, limitations of care for the terminally ill, deterrent fees to prevent inappropriate emergency room use, etc. Assuming that the costs have to rise and that more money will solve the problem means that the inefficiencies of the system are left unaddressed.

  7. With an aging population, this problem will be with us for at least the next 20 years so let's budget accordingly. It may just be a matter of paying a couple of hundred bucks more a year in income tax if we address the problem early.

    Alberta recently eliminated the monthly health premiums charged to all Albertans. Why on earth would they eliminate this fee if health costs are going through the roof in coming years? Sure, no one enjoyed paying the premiums but we accepted them as a cost for having healthcare available on demand.
    Also in Alberta we pay 10% flat income tax. It's awesome, don't get me wrong. But could we, say, increase the flat tax to 11%? Could we manage to afford this?

    And on the federal level, why did the government decrease GST from 7% to 5%? If they know they have significant future costs, they should manage taxation income accordingly.

    Why would Quebecers get up in arms over paying $100 more in taxes? Really, seriously. Is it worth a hundred bucks to keep the system functioning?

    And no, I'm not a left wing high taxation advocate. I believe in fiscal prudence and that involves good taxation income forecasting and planning by governments.

    • "Why on earth would they eliminate this fee if health costs are going through the roof in coming years?"
      They are politicians and they were just buying votes. Typical shortsightness.

      I agree with everything you stated, good common sense stuff. But I doubt you would agree with my drastic suggestions
      I stated earlier and got spanked by Johh for it.

  8. They will be forced to stop providing certain things,private healthcare will be here sooner or later.You are just postponing the inevitable.I don`t think anyone is crazy enough to let healthcare go over more than 50% of your budget.And I certainly do not see anyone welcoming tax increases or new taxes in the future,people already pay more than enough.You will always run out of other people`s money.I find it amusing that the people who defend this system the most,never use it themselves.Their supporters just turn a blind eye and then praise and defend them for not using it,pure insanity.

    • John, surely you are not promoting the private healthcare that the US is abandoning. It actually eats up more of the GDP than our system does. Publicly provided healthcare is part of the Canadian experience, along with a publicly funded post secondary education. Unlike the US, we taxpayers subsidize post-secondary education in a BIG way. So John, if you benefitted from that education, you are paying us back with those taxes that you say are "more than enough". When you go in for treatment John, perhaps for cancer, you will be happy to know that you are not in the US so your treatment won't be cut off because you forgot to disclose that you had acne as a teenager or that you have reached the maximum financial amount of your benefits.

      • Way to beat that straw man!

      • I talked to someone today who has a shoulder problem. Needs surgery. No WCB, has to wait. He can't work full time.

        Two years.

        He is considering paying for it himself. Far cheaper than missing revenue.

        Tell me. How do waiting lists save money?

        • Don`t for one minute think he even gets what you are saying

      • I have used this healthcare system,my family too and there is absolutely nothing to be proud of here.Do you enjoy the wait times?How do waiting lists save money?If I get cancer in this country,i am walking dead man by the time they start chemo,if I even get there to begin with.It's so good,it`s defenders don`t want to use it themselves.

    • The Liberals under Chretien and Martin reduced taxes substantially and Harper further reduced taxes. So now after reducing government revenues for a decade or so, they are suprised to learn that health care, which increases each year, is making up a larger percentage or revenue. It would be like you starting to work only half time and then being surprised that it is harder to make the mortgage payment.

      If we want to live in a modern and civilized society, and I do, we need to recognise that it is in everyone's interest to make sure there are sufficient government revenues to pay for it. That means fair and equitable taxes, not necessarily lower one.

  9. You know what I love about these methods for reducing health costs? None of them actually reduce health costs! It's like offloading the price increases to individuals is some sort of inherent good.

  10. Given that pensions will also be in crisis along with the health care system most of us under generation apparently have to look forward to broken and broke parents moving in or more frightening the in-laws.
    Cheery thought.
    Guess it's back to home remedies.

  11. 3. Alcoholics, yes, please get it over with, drink yourselves to death. No treatment for you unless it is to give up booze. Again, you get one chance.

    4. Smokers, apparently you guys are not much cost to the health system over the long run because lung cancer is rarely beaten though we do spend a lot of money for 5 years trying to save your worthless lives, then you die. I say worthless because that is what you smokers think your life is worth by smoking. In your case, I mandate no treatment, just go and get your affairs in order.

    Yeah, this solution can be considered inhumane and cruel but it should come down to the survival of the reasonably fit.
    The bleeding hearts will scream bloody murder and freak out. However if these rules should ever come into play(hah, never will), then people will get the message and play attention to their personal habits.

    • Somebody forgot his meds today.You are joking right?When somebody told you that you were funny,they lied to you.It`s not about bleeding hearts,but people with common sense will freak out.Nobody with a functioning brain would even suggest this.You have any idea how many people drink alcohol,you have any idea how many?Of course not.As for somkers,again,many,many people.You need to get out more and meet people.Better yet,just say nothing about anything.Just leave people to die in some alley?As for that BMI thing,you just barred half the police force and half the population from healthcare.Really,don`t ever say anything about anything to anyone.

      • Dear John:
        Not joking though there is some hyperbole.
        I stand by the basic premise.
        Accept responsibility or stop whinning and accept the consequences.
        We can't be wasting money on treating preventable conditions caused by reckless disregard to personal bad habits.
        The system should gear up to aim for prevention through lifestyle changes.
        People either get on board for get tossed overboard adrift.

        • Just when I thought you were joking,go take your meds and I wonder who this 'we' is?None of what you said will ever be said by anyone wioth a brain,nor will ever see anyone implement that.

  12. "They doubled spending"

    'nuff said. Some miracle.

  13. It seems that many people think that if a portion of health care costs are privatized, the cost simply goes away. What really happens when ehalth care costs are privatized is that health care is reduced. You only have to look south of the border to figure that out. The focus of this article is that health care costs are increasing and taking a larger portion of government revenue. This should be no surprise since reducing taxes, and consequently revenue, has been the goal of most governments for the past decade or two. The prime example of this is the Harper government and the Campbel government in BC, who brag about reducing taxes, while at the same time increasing spending to historic levels. This allows them to now say the cupboard is bared and health care costs must be reduced. So this leaves us with the concept that there is money to bankroll General Motors but no money for heath care in future. I agree with David Dodge's position. It is time for politicians to champion the fact that we live in a very civilized society and what keeps it that way is fair and equitable taxes to pay for it.

  14. There are ne free lunches. All resources are scarce and require rationing. You can ration on price in a free market, or you can ration on access in a non-free market.

    Why can those three simple sentences not get through so many skulls?

    • Come on. Everyone knows the government has infinite resources. That's why it's such a smashing success when they pay for everything.

  15. So, here comes my prediction of options for your next forty years:

    (A) We go bankrupt and developed societies level out with developing societies, with perhaps an ugly war or two thrown in.

    (B) We realize that not every octogenarian should get a shiny new hip and then spend those five days in the ICU on the way to the morgue, all courtesy of the state.

    (C) We "freeze" all available (state funded) health care technology & pharmaceuticals to the current year "standard" for the next twenty years — if you want better, pay for it yourself.

    (D) We pull an Oregon in a very major way, with an explicit list of those procedures the state will pay for, and an explicit DE-listing of those procedures that no longer make the cut. Five million dollars for three quality-adjusted life years — poof!

    (E) We keep doing what we are doing — see (A).

    • I'm guessing the following, based on past experience (my own and historical):

      (A) Yes. Ugly War 3 starts just prior to bankruptcy, either because creditors with large armies try to foreclose or because no one has the balls/funds to take the preemptive steps required to prevent a Middle-East nuclear strike.
      (B) This morphs into "octagenarians are just taking up valuable resources better used on younger people". Then it morphs into "octagenarians aren't legally persons any more anyway, so we can terminate them when they're an inconvenience". Meanwhile a few people stand up for the octagenarians and are told not to interfere with youth rights and free choice.
      (C) No, it goes into reverse because there isn't the manpower to maintain it.
      (D) The whole state goes bankrupt, so the question of state-funded care goes the way of rotary phones.
      (E) Yes. This one is just about guaranteed until government employees getting IOU's (and consequently walking off the job) wakes people up to the fact that there really is no such thing as a free lunch.

  16. Not 'til next week – got a project report to finish first, plus 444 (which I'm dutifully ignoring). But thanks for keeping tabs!

  17. Ah yes, ye olde 437B report. Not to be taken lightly.

    • 437A actually, only did a one-term project.

      BTW, this is starting to get a bit creepy…

  18. Well the decision in the 90's was certainly a mistake, though they're right in saying that fewer doctors does save money – fewer benefits to pay out, usually higher productivity per doctor. Of course that reduces quality and speed of care to an unacceptable level, so it's a bad idea, but there it is.

    But you've just destroyed your own theory – far from overly constraining med school spots, universities are increasing spots at a fairly high rate, but it's just not enough. Even with the 10% cut in the 90s, a 50% rise meant our doctor-to-patient ratio should have gone up over that time, as our population growth is rather small.

    And you've also hit on the actual reason we're in the doctor bind – it's not so much that we have fewer doctors, but doctors working fewer hours. Since there's no expectation that they'll work more, we need even more.

    Don't get me wrong, provincial and federal governments are not doing what they're supposed to be doing and pumping out enough doctors, or letting enough doctors into the country, but there's little indication a free market system would help out here. The UK, much of Europe, even those countries where post secondary education is entirely subsidized, have more doctors as a proportion of population than the US, and well more than we do. We need more doctors and our government definitely has a hand in it, but doctor shortages are not a property of publicly funded education.

    • I point out that government royally screwed up last decade by restricting doctor numbers, through restrictions on class sizes. You ask for evidence of my wild conspiracy theory. I give you a link to rather undisputed historical fact. You acknowledge that governments are screwing things up and yet you still belt out a gem like " but doctor shortages are not a property of publicly funded education."

      I am at a loss as to how to help you any further. But I shall try.

  19. Liberal chickens coming home to roost. Canada is lumbered with an extreme reluctance to face reality because the nation has been conditioned over the years by big spending Liberal politicians to accept high taxes to pay for an exclusive system that even socialist UK has discarded. The flattering reference to UK practise is ludicrous and one can scarcely believe one is reading it in a "serious" publication. Of course, Canada must go to a 2-tier system and of course there must be user fees charged and of course people must be re-conditioned to think like free enterprisers when it comes to government services.

  20. Growing costs of the healthcare system in Canada as a result of our aging population is a common myth that has been debunked by CIHIhttp://www.chsrf.ca/mythbusters/html/myth5_e.php. Evidence shows that the impact of aging on costs will only amount to a one percent annual increase, which is entirely sustainable. Impact of aging on the healthcare system is not aging per se, but, rather, how older people use health care. Elderly people are utilizing health services more intensely compared to their counterparts twenty-five years ago. The Canadian Institute for Health Information provides much evidence for this argument as well.

  21. What happens in a free market when there is a shortage of any professional (doctor, lawyer, plumber, automotive transmission specialist…). Well, let's watch Supply (S) and Demand (D) meet at Price (P). P goes up if D>S. That will, in a free market undisturbed by meddlesome government restrictions, lead to any number of spontaneous attempts to equilibrate. A high P will cut back a bit on D, and will also entice more people to enter the business to boost S. Maybe even to compete to offer more attractive S (for health care: improved outcomes, better patient safety, convenient hours, better tasting hospital food, free in-room wi-fi, enough hygiene standards to prevent C-diff infections, Air Miles, whatever) and-or a lower P to the consumer. That competition forces other suppliers in the marketplace to improve or close down. But S, P & D will continue to dance about so that everythiong is balanced. In a free market.

    • So, what's the solution? If you want to treat health care separate from just about any other good or service in a free market, you are bound to have trouble. If you permit a second tier to exist in parallel (hello, public and private schools…), you can have taxpaying citizens choose to fester on wait lists or, get this, choose to freely apply their own resources towards privately available health care, outside of the waiting list infested, union-barnacled, wi-fi absent, Air Mile-devoid public system. The challenge will be to treat Thwim and many other Canadians who would suffer serious wheezing and hives if ever a second tier should arise within Canada.

    • And, getting back to the whole gummint messing with public education: the release valve in a free market in which, above, I describe that more suppliers may wish to get into the business, only works if government lets it happen. See what happened about a decade ago. Major market distortion FAIL on the part of provincial governments everywhere. We are still paying for it.

    • Except this doesn't work in the health care market. Supply and demand in the health care market are inelastic.

      When the price for heart surgeries goes up, do people decide, "Well.. maybe I'll just wait and buy it later."

      Conversely, when the price comes down, to people go, "Wow, I should get one now just in case!"

      No. The free market works very well for many things, but health care is a different beast because the demand for each particpant is either infinite (If I don't get this surgery, I'm gonna die!) or zero (I'm healthy. I don't need that surgery)

      • …continued.

        A flooded basement requiring a plumber right this very minute is "a different beast." Running out of gas on a highway is "a different beast." Standing outside a grocery store when you're starving is "a different beast." Suddenly remembering it's your anniversary and all you have is three minutes at the florist is "a different beast." Somehow the free market has managed in these "inelastic" situations. We have just all decided for some reason that we prefer the mess of central planning when it comes to healthcare, because at least there the mediocrity and suffering are evenly distributed (if you ignore the queue-jumpers).

        • Except those aren't different beasts. The choices aren't between "Do it or die". That's the fundamental difference you fail to take into account.

          Or do you seriously believe that a fully informed patient would, when looking at the options, choose *not* to have life-saving surgery because the price was too high? Really?

          • Odd, that. If I don't eat, I die. If I have nothing to show for an anniversary, I die.

            Failing to account for all costs means you are not truly informed. If I am twenty and in need of life-saving surgery, I go for it and enjoy surviving to pay the bill. If I am eighty-six and in need of life-saving surgery, maybe I should think twice before blowing my wife's rent and food money, for the rest of her days, or my grandchildren's college fund. But that's where the "fully informed" part is not allowed to take place. It's Medicare, I am blowing an unknown amount of the next generation's wealth, so what the heck… This, I believe we call a "moral" system.

            Continued…

          • …continued.

            And that's where catastrophic health insurance comes in. I can choose to share into a risk pool, and then enjoy its benefits, or, better yet, enjoy not needing its benefits. Just like life and home insurance. But we don't get that choice. Taxpayers pay through the nose so that everybody can expect the right to harrass a physician over antibiotics for a cold, or an MRI for a headache. Or to insist that a highly trained pediatrician is the only one good enough to measure the growth of, and vaccinate, my healthy little princess, when a nurse practitioner would be just fine. Since it's *cough* free *cough* anyways, may as well insist on the best. And here we are.

      • No. The free market works very well for many things, but health care is a different beast because the demand for each particpant is either infinite (If I don't get this surgery, I'm gonna die!) or zero (I'm healthy. I don't need that surgery)

        You're still off a bit. The free market would MOST CERTAINLY work most efficiently in this instance as well, but nobody wants it to. A fully informed patient COULD, in a free market, choose to purchase the service or not, depending on its price. Public AND private insurance distorts the market because price is no longer a factor.

        But even then, such decisions to opt (or not to opt) for a particular treatment / procedure happen all the time, taking into account other COSTS that are outside of price (risk of complications, risk of failure, prolonging suffering, etc…). "You say chemo might up my survival from six months to a year, but it will be a year from hell? Thanks but no thanks, doc. You can close my file, I'm gonna perfect my will and then go play with my grandkids for whatever time I've got."

        Continued…

  22. The USA does not have that, except for the millions of uninsured. The many more millions of insured are in some sort of bizarre bubble where they are almost creating their own brief tragedy of the commons by consuming like crazy because the costs are covered by the evil insurance companies, only to have premiums skyrocket to oblivion, companies finding ways to delist the high-cost users because the "i" was not dotted properly on the original application, and users scared to death about changing or losing jobs because they'll never get back on to the not-so-free-ride they've been enjoying all these years. It's insane.

  23. Canada does not have that. Central planners do their best to restrict Price by being the single-payer bulk purchaser, but they also find ways to restrict Supply to keep costs down. I cannot imagine a time when Supply would ever exceed Demand in Canadian health care, even though, like oil changes and hotel rooms and baked goods and airport firefighters and soldiers and Maytag repairmen, some ability of the market to have excess Supply to meet spikes in Demand would be an important feature. Does anybody see that situation arising in single-payer public-monopoly health care? Me neither.

  24. health care is not free it is paid for in taxes. There are not many visits that are truly unnecessary, some people go to walk in clinics for colds yes, but when you start with pay at the visit, you lead to red tape, forms, which worsens efficiency, and people avoid going until things are bad. In addition, many times you see the doctor and they want a follow up for (blood tests, blood pressure, management of chronic conditions, and to see if the problem is worsening / responding to care…) if you pay for those, preventive health is lost (and you end up sicker and in the emergency room- much more expensive on the system. Why is the system more expensive as we age? drugs, and hospitalizations- how can these be managed is the better question. Quebec is notorious for less of its population that has a family doctor than other provinces- costs go up when you let people get seen in ER, Walk in clinic and by a specialist that doesn't deal with that issue.

  25. The only reason health care is in trouble is because the governments that are running it did not invent it did not want it and do not know how to run it They may have implemented it because if they did not they would have lost power and we probably would have had an ndp government or official opposition and i think they have resented that for many years.Its kind of like watching the pharaohs take power. They start destroying every thing the last pharaoh built good or bad. it seems to be about egos nowadays….sooo sad.

  26. In the 1980’s the InternationalMonetary Fund advised the federal finance minister ( lib ) that Canada spends too much of it’s GDP on health and education,so Paul Martin promptly decreased federal monetary transfers for health and education to the Canadian provinces, resulting in higher education and health care costs…and it continues to this day (conservative govt) ,( read the book NOW FOR THE GOOD NEWS by David Suzuki and Dressel written in 1982) and discover that we are being run by the USA through our contractual NAFTA and GATT obligations,among others,that result in Canada not being allowed to use our taxes to properly manage our land and resources as well as our infrastructures.

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