Apart from idealists, there are only two reasons people change from the status quo, you’re better off if you do and worse off if you don’t (carrots and sticks). And so it is for the fourteen provincial, territorial, and federal programs collectively referred to as the Canadian healthcare ‘system’, now 50 years old. Despite widespread recognition of the need for and recommendations on what should be changed and how, healthcare remains in 2017 much as Tommy Douglas described it in a speech in 1982, 21 years after it began in Saskatchewan:
“… we pointed out that (Medicare) would be in two phases. The first phase would be to remove the financial barrier between those giving the service and those receiving it. The second phase would be to reorganize and revamp the delivery system—and of course, that’s the big item. It’s the big thing we haven’t done yet.”
Why it is taking so long to “reorganize and revamp” healthcare? A major reason is the lack of leadership both by governments and the providers of health and healthcare services. The latter, particularly acute care hospitals, their employees, and some physicians, fear being worse off, that reform of healthcare will dilute and weaken their long-standing financial advantages. Provincial governments are intimidated by the well-tested capacity of medical, nursing, and other provider organizations to generate negative public reaction to proposals for change by “death in the streets” rhetoric. But the principal reason continues to be that Canada’s provinces and territories have not faced a crisis sufficiently severe and prolonged as to overwhelm resistance to change or to shake the public’s passive acceptance of paying high costs for a relatively narrow range of services of mediocre quality at best.
Are we approaching such a crisis now? Barrie McKenna thinks we are and that it is fiscal in nature. Our so-called ‘system’ continues deep in its rut with failure of the provincial/territorial Ministers of Finance and Health to shift focus from the shared financing of Medicare to systemic changes to incorporate more, better, and more available and appropriate services for people living with mental illnesses and addictions and those in need of care and support in their own homes and communities, particularly the vulnerable elderly with their multiple chronic conditions. Ironically the provision of primary, home and community care is much less expensive than is care in hospital and offers a route to alleviation if not solution of the impending fiscal crisis the results of which would surely make Canadians much worse off.
What’s to be done to make Canadians better off?
Devolution offers promise, the distribution of authority from central governments to regional or even local groups to make fundamental changes in the distribution of resources and to the provision of policy direction to the several elements that together deliver healthcare services to the people of a particular area. It is the fundamental principle articulated in Ontario’s Patients First Act although, sadly, it is unaccompanied there by clear policy statements on how it is to be accomplished. To paraphrase The Economist’s comment about a different but equally aspirational long-term plan, it is like a balloon riding high over Ontario’s cities, farms, lakes and forests offering beautiful views of a far distant horizon, powered by hot air.
A relatively recent but increasingly well-tested innovation in the United States that should be considered is the Accountable Care Organization. ACOs are groups typically composed of hospitals, physicians, and other providers willing to work with governments to provide less expensively the wide range of services needed to optimize the health and care of members of a defined population. To do this they are each given a consolidated annual budget based on the aggregate cost of funding separately all the involved providers, hospitals, physicians, nurses, home and community care workers, etc., together with authority to assign those revenues as each thinks best to meet the needs of the served population. The “carrot” for the ACO is agreement with the government to share equally any savings it is able to achieve in that budget. Its accountability both to government and to the people it serves is discharged by measures made by government of the health outcomes and status of the served population, including of patient and family satisfaction both with those outcomes and the processes by which they are achieved.
Over the past 50 years the iconic character of Canadian healthcare has made its renovation really difficult. But it needs to be freshened up, improved both by enhancing the quality of the services and outcomes provided for patients and their families and making it more affordable for taxpayers. Lets not wait for that crisis before making providers directly accountable to those patients, their families, and taxpayers through devolution to local or regional Accountable Care Organizations. It’s a renovation whose time has come.
 Decter, Michael B. 1994. Healing Medicare. McGilligan Books, p. 14.
 The Globe and Mail, 25 December, 2016
Authored by members of the Queen’s Health Policy Council: