On April 27, Maclean’s hosts “Health Care in Canada: Time to Rebuild Medicare,” a town hall discussion at the Marriott Pinnacle Downtown Hotel in Vancouver. The public forum is held in conjunction with the Canadian Medical Association and broadcast by CPAC.
Numerous polls put health care as the top priority in the federal election campaign, yet until recent days there was little debate about the failures of a health system that is a middling performer among most wealthy nations in its scope, cost and outcomes.
There’s an alarming lack of new ideas among national leaders on ways to either help provinces improve delivery of public health services or to rein in what a new report by the C.D. Howe Institute calls “chronic health care spending disease.”
Prime Minister Stephen Harper has committed to maintaining the six per cent annual federal funding increase contained in the current health accord (as have the Liberals) but he’s ruled out “radical” changes in health care. That seems to preclude expanding the Canada Health Act beyond its current focus of insuring doctor and hospital care when the current health accord expires in 2014. Last Sunday, Liberal Leader Michael Ignatieff pledged to convene a first ministers’ meeting should he win the election to begin early negotiations on a new health funding accord. That may have been prompted by a similar call days earlier by Ontario’s Liberal Premier Dalton McGuinty. “This campaign provides an opportunity for federal parties to share their vision for the future of medicare,” McGuinty said. “Right now, that vision is lacking.” The next accord will set the financing and design of health care delivery for 10 years. Without change, there will be no publicly funded drug plan, or initiatives to help an aging population live independently. More to the point, many fear the status quo is unsustainable.
Canadian Medical Association (CMA) president Dr. Jeff Turnbull said the Canada Health Act has to shift its focus from the decades-old model of hospital care of short-term illness to one that enables health teams to provide long-term chronic care. “Preparations for the next accord represent the last, best chance we have to hold a thoughtful discussion about how that money will be used, how it will transform health care for future generations,” he said in a speech days after the election call.
The challenge was outlined in stark terms in the C.D. Howe report, co-authored by economist Richard Dion and David Dodge, a former governor of the Bank of Canada and one-time deputy minister of health. In even its most optimistic scenario, the amount spent on public and private health care jumps to almost 16 per cent of GDP from 12 per cent today.
The report’s prognosis: increased spending for uninsured services, delisting or “some form of co-payment” for some services currently publicly funded, a cut in other public services and a tax hike to finance health spending. Added to this, “a major degradation of publicly insured health care standards—longer queues, services of poorer quality—and development of a privately funded system to provide better-quality care for those willing to pay for it.” It’s a rat’s nest of issues politicians are keen to avoid.
So, what to do? Well, for one thing, Canadians can take a greater personal responsibility for their health, and for advocating for policies that let them do so. Between 85 and 93 per cent of those responding to a series of Health Care in Canada surveys agreed it was their responsibility “to take care of their own health through prevention of illnesses and injuries and by leading a healthy lifestyle.” Eight in 10 wanted a role in managing their health care. Half said those with healthy lifestyles deserve tax incentives or other rewards.
It sounds very motherhood, but the role of personal responsibility is among the most complex and ethically charged issues in health. It extends to end-of-life treatment options. And if health prevention and wellness incentives are on the table, what about penalties for self-inflicted illnesses? There are initiatives, some more palatable than others, to foster more personal control, including:
DISCOURAGE BAD BEHAVIOUR
Arizona’s often controversial Gov. Jan Brewer has used more stick than carrot in her attempt to tame health care costs. Her proposed budget would cut 138,000 people from cash-strapped Medicaid, the publicly funded health care program for low-income residents. The issue that generated the greatest buzz, however, was her recommendation to impose a $50 fee on childless Medicaid recipients who lead unhealthy lives: smokers, the obese, those with illnesses who don’t follow doctors’ orders. “If you’re not going to manage those things and take some personal responsibility,” said Monica Coury, assistant director of state Medicaid, “then you need to have some skin in the game.” It’s unlikely Canada’s politicians, or its citizens, have the stomach for an Arizona-style “fat tax” or a “loser fee,” as some have dubbed Brewer’s idea. Lecturing Canadians about taking personal responsibility for their health is an unlikely campaign tactic. Yet a reminder we all have skin in the game is an essential ingredient in sustaining and renewing universal health care.
PREVENTION AND WELLNESS
Last September, Canada’s health ministers issued a substance-free statement saying disease prevention and health promotion were key priorities, “and necessary to the sustainability of the health system.” Harper, in a modest nod to fitness promotion, pledged to double the tax credit for children’s sports and recreation fees while instituting a similar credit for adults. It will pay a maximum $150 for children and $75 for adults—but not until the budget is balanced.
Australia, New Zealand, the Netherlands and Switzerland are among the countries using incentives to promote healthy behaviour. The result: “improved health outcomes and responsible utilization of health care services,” notes a paper by the American College of Physicians.
Prevention was a priority at the first three town hall meetings Maclean’s has staged with the CMA. “We need to focus more on some of the health quality improvement activities,” panellist and emergency specialist Dr. John Ross told the Halifax forum, “as opposed to…putting more and more dollars toward expensive [acute] health care.”
MANAGE YOUR HEALTH
Policies that make patients active participants in their treatment are showing excellent results, and savings. A case in point: the Sherwood Park Primary Care Network, one of 40 in Alberta. Once a family doctor makes the initial diagnosis, patients are referred to the centre, a one-stop shop for specialized care. Someone with a chronic illness like diabetes would see a nurse, a dietitian, a pharmacist. They’d get an exercise plan, and, if necessary, mental health counselling. It is delivered at half the cost of using a doctor as the only care provider, says Dave Ludwick, general manager of the Sherwood Park network.
Administrative staff work with patients to ensure they keep appointments and stay engaged in their care. “That motivational element, the educational element and the management element, that’s what a primary care network does well,” says Ludwick. The initial studies show improved health outcomes, shorter wait times and a high patient satisfaction rate. “If they’re happier,” he says, “they’re more likely to engage in the management of their own care, which means they end up being healthier.”
When Bart Mindszenthy’s elderly father, Bart Sr., was still vibrant and in control, he did his family a huge favour. He showed them the book he and Bart’s mother, Lenke, had prepared. “ ‘We call it our death book,’ ” he’d said. “I thought, oh, great,” recalls the 64-year-old son, a specialist, ironically, in crisis communications. Inside were essential family documents, insurance papers, care instructions, even receipts for their prepaid burial and headstone. “I thank him to this day,” says Mindszenthy, a Toronto resident.
The book, and the resulting difficult conversations about his final wishes, allowed him to control his destiny, ease the burden on family and, incidentally, save health costs.
Bart Sr. lived to almost 99. “He just stopped eating one day. He’d had it,” his son said. Doctors wanted to take him to hospital where his life could be prolonged with technology and tube feeding. “It was a gut-wrenching decision because I love my father dearly,” he says. “But I feel the right decision was to have him stay in his home and let him live his last days in dignity.”
Mindszenthy has become an advocate for better elder care. He’s the author of a bestselling book, Parenting Your Parents, and founder of the mycarejourney.com website. Families have a responsibility to have those difficult talks about end-of-life care, he says. Governments would reap rewards if they created better supports to let the frail and elderly maintain their independence and health outside of institutions and hospitals, he says.
At the Edmonton town hall, a nurse spoke about the death of her husband in hospital. “I’ll probably for the rest of my days be sorry that I didn’t keep him at home with me,” she said. “I couldn’t take him home when he begged me to take him home because I couldn’t look after him at home alone. And the [assistance] for care at home is the pits.”
One of the great failures of personal responsibility is the mute acceptance of the status quo in health care—another point driven home repeatedly at the Maclean’s/CMA forums. “We need to get angry, we need to say, you know what, this is goddamn not good enough,” Dr. Patrick White, president of the Alberta Medical Association, told the crowd in Edmonton. “That anger has to translate into action,” he said. “Government will not listen and will not make the appropriate changes until they get the advice—and they’re pushed to act on the advice.”