Republican California Governor today announced his plan to achieve universal healthcare in California. The plan would:

– require employers with 10 workers or more to buy insurance for their workers or pay a fee of 4% of their payroll into a program to help provide coverage for the uninsured.
– tax doctors 2% of their gross revenue and place a 4% tax on hospitals.
– ban insurers from refusing to offer coverage to some individuals because of their prior medical conditions.
– require insurers to spend at least 85% of their premium revenues on patient care, a move that would limit the amount companies spend on administrative costs and profits.
– provide insurance (through the state’s Health Families program) to children whose parents make less than three times the poverty level. That works out to about $60,000 for a family of four.
– require every Californian to have health insurance. As Schwartenegger said, “If you can’t afford it, the state will help you buy it,” he said, “but you must be insured.”

This is an ambitious plan to reform California’s healthcare system. It will be interesting to see how this plays out. Stay tuned.

Ezra Klein wrote an interesting piece in the L.A. Times (“Going Universal”) on the U.S. Healthcare System.

The American health system, put simply, is a mess. An expensive one. Indeed, in 2002, we spent $5,267 per capita on healthcare — $1,821 more than Switzerland, the nearest runner-up. And yet we had higher infant mortality, lower life expectancy, more price inflation and an actual uninsured population, a phenomenon virtually unknown in the rest of the developed world, where universal healthcare is, well, universal.

Indeed, with 47 million people uninsured and an 81% increase in premiums since 2000, the U.S. system is quite simply unsustainable. As Klein concludes:

“The realization that our illogical, mistaken healthcare system can’t go on forever has dawned, and so it will end.”

Alberta’s Third-Way Health Framework: An Independent Look
By Gregory D. Morrow

This week, Alberta announced a new health policy framework that, in part, experiments with more private-sector involvement in the delivery of health services. Predictably, many (mostly on the right) who have long extolled the benefits of private healthcare have applauded Alberta’s plan, while those who oppose any involvement of private-sector in healthcare (mostly on the left) have condemned the plan. Between the rhetoric of both ideological positions, it is hard for level-headed Canadians to get a real sense of whether Alberta’s plan is workable or not. So, in what follows, I attempt to analyze Alberta’s health plan from an independent perspective. I will assess the Alberta framework according to its 10 points (Note: the Alberta plan is only a policy framework, so full details are often lacking):

1) Putting Patients at the Center
I can’t imagine anyone arguing against this policy objective. As such, it is largely symbolic. It reminds health professionals to treat people with respect, but also asks patients to take responsibility for their health. This is a feel-good statement with few tangible policy implications.
Assessment: Good, but largely symbolic

2) Promoting Flexibility in Scope of Practice of Health Professionals
This policy objective means giving nurses, pharmacists and other non-physicians more authority to make decisions about your health, freeing physicians to deal with more complex cases. The goal is to make healthcare more “team-oriented”. Collaboration is good — and can be facilitated by instantly-retrievable electronic medical records — but it cannot come at the expense of someone (a primary-care physician) taking responsibility for a patient.
Assessment: Good, so long as primary care physician remains responsible for patient

3) Implementing New Compensation Models
This policy objective moves physicians’ fee-for-service compensation to alternative structures that provide incentives for quality. I agree that the fee-for-service system typically rewards volume, not quality. However, the policy brief does not detail alternative models, noting only the possibility of bundling services. It is not clear what the policy implication here will be until more details of the alternatives are laid out.
Assessment: Potentially good, but no way to know since alternatives not laid out.

4) Strengthening Inter-regional Collaboration
This means better communication and collaboration between the regional health authorities. This one should go without saying; obviously, different sub-units of the healthcare system should collaborate. No-brainer here (but easier said than done).
Assessment: Good, but self-evident.

5) Reshaping the Role of Hospitals
This means using hospitals less for primary care and more for emergency care. The problem here is that urban hospitals are overburdened, and rural ones are often under-utilized. The goal is for regional health authorities to shift services to community-based facilities, or to rural hospitals (in the case of rehab or post-acute care). This could be a good thing, but only if those secondary facilities have the personnel and equipment to deal with the additional load — the brief does not acknowledge that community or rural facilities may not be able to take additional capacity without more resources. More gravely, however, it fails to recognize the central cause of overcrowded hospitals: the lack of primary care physicians!
Assessment: Good, but only if additional primary care physicians are trained.

6) Establishing Parameters for Publicly Funded Health Services
This is a policy meant to limit what the public system pays for. Alberta wants to pay for only “essential” services. Non-essential services — discretionary, experimental or unproven procedures or drugs — would need to be covered by private insurance. This is at the crux of the matter. Yet, it received the least attention in the policy brief. The cursory treatment of this objective is unacceptable. If the health framework is to mean anything, this policy objective needs much more detail to be useful. As it stands, it is code for de-listing public services without a comprehensive plan for those who cannot afford to pay for them privately.
Assessment: unacceptable. This is a central question, but there is no way to know since the question of what is and is not covered is avoided.

7) Creating Long-Term Sustainability and Flexible Funding Options
Much like 6), this policy objective is meant to shift payment for services to non-government sources. The brief mentions the problem of the rich buying access to better services, with the poor being treated differently, but it does not effectively address this central question. Possible alternatives include co-payments, long-term savings accounts, and various private insurance options. However, it is important to examine what, precisely, those alternatives look like. Unfortunately, there are two negatives to creating a private insurance market: 1) Canada, let alone Alberta, is too small to have enough competition to make it work and 2) if private insurance is tied to employment — the most effective way to make private insurance affordable — then patients don’t have choice without changing jobs. The use of co-payments could be useful, if only to ensure that people think twice about going to the hospital (but it needs to be low enough not to be barrier). Long-term savings accounts are also helpful to save for healthcare that might be needed later in life. This could just as easily be a change in RRSP rules to allow people to use them for medical services not covered by Medicare. Overall, this policy objective needs further explanation.
Assessment: Co-payments and long-term savings (or using RRSP funds) is probably wise in the long-term, but creating a private market with the assumption that competition will increase quality has proven neither realistic in the Canadian context nor effective in the U.S. context. With no details provided, it is not possible to evaluate alternative funding schemes.

8) Expanding System Capacity
This is another policy meant to increase private-sector healthcare, both for- and non-profit. No details are provided here. Only a vague suggestion of increasing personnel by collaboration between teaching institutions and healthcare facilities is mentioned. This should be done regardless of expanding capacity. The absence of a commitment on the public sector’s part to train more doctors, nurses, technicians and other health professionals is a glaring omission here. Also missing is a commitment to work with the professional associations to recognize the credentials of foreign-trained medical personnel, and to establish intensive touch-up courses to ensure they have the same level of training as domestic-trained professionals. It is also unclear how additional technology (MRIs, for example) will be financed in order to increase capacity.
Assessment: Unacceptable. No details are provided on private-sector involvement, and obvious means of expanding capacity are not mentioned.

9) Paying for Choice and Access while Protecting the Public System
This policy objective essentially allows the rich to buy quicker access to non-essential services or to pay for a higher quality of care. Ostensibly, the additional revenues will be used to fund essential services and to act as an incentive to build additional capacity. This policy allows physicians to double-dip — to operate both within and outside of the public system. There are long-debated reasons to avoid double-dipping, the most obvious is that a doctor’s patients who pay privately (i.e. pay more), will have preferential treatment. This policy is framed under the rhetoric of ‘consumer choice’. If you have money, you have choice. If you can’t pay for a service, it is not really a choice.
Assessment: Unacceptable as outlined. There may well be a role for elite medical services but for these not to negatively impact the public system, they would have to be priced so as to be used only by a tiny fraction of people (i.e. the very wealthy) — that is, they need to cost the same as similar services offered in the U.S. And this can only be effective if doctors do not double-dip, otherwise they will give preferential treatment to the rich. For this policy to genuinely improve the public system, the proceeds must be channeled back into the regular system.

10) Deriving Economic Benefits from Health Services and Research
This isn’t really a policy so much as touting Alberta’s success in attracting top people. It basically says that improving health and research is good for Alberta’s economy. It’s not clear why this is part of the framework other than as a feel-good conclusion. The only implication is the desire to market Alberta’s achievements.
Assessment: irrelevant since there are no policy implications.

Overall: there are surprisingly few innovations here. There are several commitments that are worthwhile — expanding the role of nurses, pharmacists and other health professionals (so long as physician accountability is maintained); shifting non-emergency care to secondary facilities instead of hospitals (only possible if they have the people and equipment to receive them, and there are more primary care physicians); possibly introducing small co-payments, or allowing RRSPs for uncovered medical services. There are some policies that are self-evident, like greater cooperation between regional health authorities, and making the system patient-centered. However, on the key questions, the brief is curiously silent. Exactly how would an expanded private health sector work? What services would and would not be covered by the public system? How would elite services help the public delivery of health services? And on other key items, the brief is dead-wrong: allowing doctors to double-dip in elite and regular health services, a blind faith that a private insurance market will be competitive or be patient-centered, or be affordable without being tied to employment (which would limit choice, not expand it). Moreover, other obvious reforms are absent: training more doctors, nurses, and technicians, expanding the capacity for diagnostic equipment within the public system, getting foreign-trained health professionals into the workforce. Overall, this policy framework is disappointing. It picks up the low-hanging fruit, misses obvious reforms and avoids the tough questions. For this to be a solution to health reform, it must provide details. It is in the details we will discover whether the reforms are workable or not.

It is Time that Canadians Get Off Their High Horse of Healthcare
By Gregory D. Morrow

Marilyn Churley’s parroting of the NDP party line on healthcare illustrates the problem with the level of discourse on health in Canada. She recently said:

“But seeing no action coming from the federal government, the NDP made the decision that it is time for Canadians to decide who can best protect and improve public health care. I am proud of the first-ever NDP budget passed in the House of Commons that, while balanced, provided more for people and less for big corporations. Now Layton and the NDP are determined to fight for medicare and with more New Democrats elected to the House of Commons, we will in fact do just that.”

Marilyn Churley,
NDP candidate,
Beaches-East York, Toronto

I hate to say it, but if this is the party line on healthcare then the NDP will not significantly improve its totals. This is the same recycled message they have played since 1993 and it has fallen on deaf ears because it is rhetoric, not a plan of action.

It is a laudable goal to ensure that Canada’s healthcare system be universal and publicly funded. However, the NDP needs to have a specific plan, one which operates within the reality of federal and provincial budgets. It is not enough to simply say they will “protect public healthcare”. We’ve heard it before, and it wasn’t enough to sway people to the NDP. The issue is money. Private spending accounts for $36 billion or 30% out of total health spending of $125 billion. If the NDP wants to eliminate that private spending, how will it make up the difference? You can’t raise taxes to cover that difference — it amounts to a 20% tax increase.

The Romanow Report is not credible - his “solution” hinges on more federal dollars. Yet, Canada spends more on health (per capita) than any other country than the United States. For far too long Canadians have sat on their high horse comparing themselves to the U.S. and feeling proud that their health indicators are better and for only 2/3 the cost. But that’s not the right benchmark - the U.S. is a country nine times the population and has a structurally flawed healthcare system. Of course Canada outperforms the U.S. on health! Instead, we should be comparing ourselves to France, the UK, Italy, Spain, Japan - all of which perform better than Canada’s system and cost less per capita. Take a look at the numbers below. We should be looking to these countries for innovative solutions. Every country is facing rising costs but some perform better - it is time to look beyond merely the goal of protecting a system that ranks 30th in the world to a plan that will see Canada rise to the top 10 in the world. On other indicators - education, wealth, quality of life, etc - Canada is one of the best. Why shouldn’t we expect the same for our healthcare system?

FRANCE
WHO health ranking: 1
population: 60 million
GDP per capita: $28,700
Per capita health spending: $2,903
% of GDP on health: 10.1%

ITALY
WHO health ranking: 2
population: 58 million
GDP per capita: $27,700
Per capita health spending: $2,258
Per capita health spending: 8.4%

SPAIN
WHO health ranking: 7
population: 40 million
GDP per capita: $23,300
Per capita health spending: $2,258
Per capita health spending: 7.7%

JAPAN
WHO health ranking: 10
population: 127 million
GDP per capita: $29,400
Per capita health spending: n/a
Per capita health spending: 7.9%

UNITED KINGDOM
WHO health ranking: 18
population: 60 million
GDP per capita: $29,600
Per capita health spending: $2,231
% of GDP on health: 7.7%

CANADA
WHO health ranking: 30
population: 33 million
GDP per capita: $31,500
Per capita health spending: $3,003
% of GDP on health: 9.9%

UNITED STATES
WHO health ranking: 37
population: 296 million
GDP per capita: $40,100
Per capita health spending: $5,635
% of GDP on health: 15.0%

There was an interesting editorial on Healthcare in today’s Toronto Star. The authors, who are not “Stephen Harper groupies”, urge Canadians to not dismiss economic tools (such as incentives and disincentives) as part of a larger strategy of health care renewal. They argue that failure to view healthcare renewal with an open mind amounts to a ‘national delusion’.

“The national delusion is the feeling in Canada that any breach of the public monopoly on “medically necessary” health care constitutes not only a threat to our public system, but to the very fabric of Canada.”

Articles such as these are necessary to dispel the many myths that exist in Canada about more innovative tools of government action (i.e. anything other than simply direct government ownership & operation and regulation, which Canadians rely heavily upon). Essentially, the authors simply ask readers to open their minds, to focus on the goals of improving healthcare and less on the methods of achieving those goals.

Suppose we were to look at additional economic tools, test them through research to ensure that they actually work — would we then be able to sustain and even enhance our health-care system? Would we dare to implement it? Are we too burdened by ideology even to try?

I have said this time and time again. Canadian governments only use half of the tools available to them; it is time we look at best practices around the world to see if more innovative solutions are worth adopting. Canadian healthcare has a good foundation, and we can be proud of the values it promotes, but like all things, it needs to be constantly improved. We are indeed deluding ourselves, for example, if we don’t think that private healthcare already exists in Canada – it does – 30% of all healthcare expenditures in Canada are private. We are deluding ourselves if we don’t think ‘two-pier’ healthcare already exists – people who do not have private health insurance through employers to cover dental, eye-care and out-of-hospital prescription drugs, must bear the burden. Clearly, professionals typically get these benefits, while low-income Canadians do not. Given these facts, we first need to ask whether we are OK with the present situation. I would hope that most Canadians are not.

So, if we agree that equal access to equal healthcare is important – and I think it is – then we must actually chart a course to ensure we get there rather than simply screaming up-and-down about how this problem was created by past Liberal spending cuts. Yes, spending cuts exacerbated the cash crunch, but when costs are rising at 10% or more each year, and the economy and wages are riding at only 3% (at best), there is a serious sustainability question with healthcare. And if the only course of action is to “throw more money at it”, then we are hopelessly deluding ourselves as to the sustainability of that solution. Canada spends more than every other developed country (other than the U.S., whose system is more fundamentally problematic). The solution isn’t more money per se, but more utility for the money already spent.

We must remain focused on the goals, and less on the methods to achieve those goals i.e. to improve the quality of care available to Canadians, to ensure it is widely and equally available, in a timely manner, regardless of a person’s ability to pay. Access to healthcare is not only socially necessary, but it is also economically necessary, since public healthcare gives Canada a competitive advantage over the United States. While keeping our eye on our goals, we cannot be blind to looking at new ways of tackling the systemic problems of the system. In Canada, just to accept this premise is a difficult task. The sooner we accept it, the sooner we can begin a more serious debate on its necessary improvement.

Another week, another disturbing flip-flop by Ontario Premier Dalton McGuinty – this time on the issue of P3 hospitals (public private partnerships). McGuinty specifically campaigned on reversing the Tory move towards P3s for hospital construction (stopping the “Americanization of our hospitals” he said), but like so many campaign promises, McGuinty is unrepentant in his willingness to break them. (In fairness, he is in a bind given that the previous Tory government claimed the deficit would be only half of the $5.6 billion it turned out to be).

So what’s all the fuss about P3 hospitals? Well, it boils down to the same old debate — privatization vs. more government spending. P3 advocates say it is the only way to meet the infrastructure demands for the Province — that it provides cheap (in the short term), fast and efficient construction of hospitals. Anti-privatization forces reject it on ideological grounds — i.e. private companies should have no involvement in healthcare — period.

Given my inclination to be skeptical of those extolling magical benefits of privatization — and equally skeptical of those driven by rhetoric not facts — I set out to learn more about the P3 arrangements being proposed by the Ontario government. One of the first things I learned was that there is wide variety of arrangements that fall under the broad P3 category, each with vast differences as to the level of private involvement and thus each with vastly different consequences for retaining public sector control of services. There are many arrangements out there - but there seem to be three basic categories of P3s:

1) Privately Built and Operated: this is the most privatized form of P3 and one that critics fear the most. Under these arrangements the private sector finances, builds and operates the hospital — doctors, nurses and technicians would be employed by the private entity. It is easy to see how this could lead quite quickly to private healthcare, since the hospital would likely be able to charge fees for certain procedures. Allowing these kind of facilities is, in effect, allowing full privately delivered healthcare. As such, this is not a good option for Ontario and critics are right to oppose this kind of privatization.

2) Privately Built and Leased to the Public Sector: this is a fairly standard practice in the private sector - essentially like an office building, that has a tenant signed up from the beginning (so they can dictate to the developer how they want their spaces to work). Under this arrangement, the private entity simply provides the facilities, but employees are brought in by the public sector (or, like many university hospitals, a non-profit board). The public sector or board makes annual payments to the private entity. In most cases, the private entity owns the land and hospital, but it is also possible for the pubic sector to do a ‘land lease’. In this case, the public sector retains ownership of the land, but leases it to the private entity for a lengthy period (99-years is common) who develops it, and, in turn, leases the finish product to the public sector or hospital board. This is a common arrangement with various kinds of real estate in London (UK) or New York. In these cases, after the 99-year lease is up, the property, together with its improvements (i.e. the hospital) reverts to the original owner (i.e. the public sector). Typically, it is the private entity’s responsibility to ensure the building is adequately mantained and arrangements can be made to cancel the lease if they do not perform.

3) Privately Built, Leased to the Public Sector, but with the Public Sector Building Equity in the Property: While details are sketchy, it appears this is the kind of private-sector involvement that Ontario envisions. This is effectively like #2, where the public sector finances and leases the hospital, but whereby the lease also includes an equity payment. In effect, it’s like mortgage - they are paying part of the principle cost slowly over time. This results in the hospital reverting to the public sector much more quickly than in #2, say, in 20 years instead of 100. The advantage is obvious: instead of paying the entire cost of a couple hospitals up-front, you can building scores of hospitals up-front and pay for them slowly over time. It should be noted that all medical services will continue to be provided by the public sector or hospital boards as per usual (I believe Ontario is playing with the ideal of allowing the public sector to look after maintenance of the building — janitorial staff, etc — this is consistent with the way typical real estate deals like this work — but it need not be the case — the contract could easily be written to allow the tenant — the public sector — to look after such services, thus ensuring those jobs stay unionized).

In all cases, the private sector finances and builds the hospital. They differ, however, in that in case #2, the hospital reverts back to the public sector after a lengthy period. In case #3, the hospital reverts back to the public sector in a shorter period. Critic say that, since private companies are only interested in profit, they will cut corners and the building will be sub-standard. In my experience as an architect, institutions (universities, museums, etc) hire construction managers to constantly monitor construction to ensure the contractor is meeting the specifications outlined by the client. There is no reason to believe the public sector, as the client, would not follow suit. The key — and this would be true with or without private sector involvement - is to have very detailed plans and specifications for the project (otherwise, the constractor will say it is an extra), and to minimize changes along the way.

Critics also warn that fully privatized hospitals means private jobs, often resulting in lower wages or fewer benefits or worse working conditions (longer hours, fewer holidays, etc). This is a justified critique, but it only applies to case #1.

Critics also say that, since the public sector can borrow money at lower interest rates (since they typically have much better credit ratings, or can issue tax-exempt bonds), the cost of any private sector involvement will be higher. This is probably true, but the question at hand is whether the marginally higher interest charge is offset by the advantage of paying for a large amount of infrastructure over time. The analogy is a mortgage — if you put more down up-front, your interest charges will be lower, but you either not be able to afford as nice a place or your other finances will be heavilty burdened.

Critics also suggest that, in the long run, the government will end up paying more than if it had just built the hospital itself. I think this is also a valid argument, but it doesn’t accurately reflect the situation. It’s like the different between owning vs. leasing a car. Leasing a car results in significantly lower monthly payments, allowing you to buy a car that you couldn’t normally afford, or simply lowering your auto costs so you can spend the extra money on other things (or save it!). In Ontario’s case, the choice is whether to build the 66 hospitals it needs now and pay for them over the next 20 years, or whether to build 4 now paying for them up-front.

So, as with most things, when you do some digging, you learn new things. What I learned was that some kinds of privatization are very bad, particularly for key public services such as healthcare. However, in other cases — and in fact, if I understand correctly, in the arrangements the Ontario government is pursuing — the private sector involvement has nothing to do with the delivery of healthcare. It is purely a real estate deal, to allow the province to build the hospitals it needs now and pay for it over a longer period of time. This allows it to spread its infrastructure investment out over the long haul (of course, one could criticize all the previous Ontario governments for so badly neglecting the need for so many years — why, for example, didn’t we gradually build new hospitals over time?).

If the delivery of health services remains public and the public sector is simply leasing the building (and eventually acquiring ownership of it after 20 years), then there is no reason to fear. If you add up the cost of the payments over the long haul, it might cost the government more money than paying up-front for the hospitals, but any reasonable person can understand that you can’t make up for years of neglect all at once. So the choice is building the hospitals we need now using the leasing strategy or building what we can afford to by paying the whole cost up-front as we go. And given the neglect over the past couple decades, it seems more important that we reinvest now rather than wait. Once the facility shortfall has been met (i.e. the 66 hospitals are built), if politicians are willing to make the planned investments going forward - to not neglect them for 40 years — we can return to building public facilities in the usual way.

The Supreme Court ruling earlier this summer, Alberta’s ‘third way’ healthcare proposals, new polls on Canadians’ changing attitudes towards healthcare and recent declarations by the Canadian Medical Association have all put healthcare reform back into the political spotlight.

Most reasonable people in Canada recognize that while its foundation is solid, changes to Medicare are necessary to improve care and ensure its sustainability. Universal health (along with universal education) is a pillar of Canadian society and identity, but we cannot be afraid to fine-tune the system to meet the changing needs of our society. Unfortunately, most want a quick fix. Right-wingers think the answer is expanding private care (under the banner of “choice”). Left-wingers think the answer is more government spending (under the banner of “equality”). Such “solutions” are merely accounting moves – shifting the burden from either individuals or the government rather than acknowledging systemic problems of the system. Canada spends 9.9% of its GDP on healthcare – comparable to most developed countries (for 2003, Australia = 9.5%, France = 9.5%, and the OECD average is 8.6%; the U.S. is the highest at 15.3%). Instead of simply moving money around, reforms must focus on increasing the utility of the money already spent while, of course, increasing the quality of care. So what reforms would increase utility and care? Here are some that I have found to be the most plausible:

1) Electronic Medical Records: This would allow doctors and nurses to instantly see a patient’s medical history, allergies, prescriptions (past and present), likely cutting the time taken to take a medical history, eliminate duplicate tests and avoid harmful drug interactions.

2) Recognize Foreign Credentials: More doctors, nurses and technicians in under-served regions would cut down wait times, which often exacerbate health problems. We might also see fewer Canadian-trained doctors leaving for the U.S., since more doctors means less workloads for each (many doctors leave not because of they are attracted by higher salaries but because they are over-worked).

3) Wait Times Database: an electronic database of wait times at hospitals and institutions nation-wide would enable patients and doctors to see if nearby (or even in other provinces) could accommodate their surgery more quickly than those in their immediate vicinity. This would ensure immediate care for those most in need and would even out wait lists across the country (thus bringing down maximum wait times). Moreover, as recommended by the Canadian Medical Association, we need to establish reasonable wait times (though it needs to be expanded beyond the five areas they studied). If space cannot be found within the public system across the country, Medicare should pay for that patient’s care at a private institution. Given the other measures recommended here, I would hope this would be a rare circumstance.

4) Medical Technology Fund: Instead of simply paying capital costs for new MRI and CT machines, a portion of health spending could be diverted to a technology fund that would be invested and grow over time. This would establish a sustainable pool of funds from which the government could tap periodically to purchase (or rent) the latest medical technology.

5) Drug Purchasing and Patent Reform: using the collective buying power of the federal government to buy drugs results in lower overall average costs. While easier said than done (due to the WTO and TRIPS, the Trade Related Aspects of Intellectual Property Rights agreement), we need to lower the 20-year protection of patents. That’s a very long time to have a monopoly of research.

6) Sustainable Funding: like most countries, Canada is facing an unsustainable situation with a declining workforce and an aging population. This means that more people are tapping a system that is funded by fewer and fewer people. Health funding in Canada could be set up to mirror the Canadian Pension Plan – which a dedicated (but progressive) payroll tax into which current workers pay (as opposed to come out of general revenues), a portion of which would be invested and grow over time. This would give the system a ‘cushion’ for the upcoming wave of baby-boomers who are due to retire.

7) More Spaces in Canadian Medical Schools: Canada needs more doctors, nurses and specialists – we have only about 2 doctors per 1000 people, while the OECD average is about 3. Many people have suggested that we need in the neighborhood of 3000 new doctors each year in order to replace those leaving practice. Currently there are only 2200 spaces in Canadian med schools (and about 2000 remain in Canada). The ‘gap’ between 3000 and 2000 is roughly the same as the gap between the OECD average of 3 and 2 doctors per 1000. Adding 800 new spaces at med schools across the country would close this gap. There is no shortage of bright young people who currently can’t get into med school because of a lack of positions.

8) Non-Profit Community Care: most Medicare supporters use the terms private and for-profit interchangeably. This is not entirely true. It is entirely possible to deliver care privately through the non-profit sector. This need not be the horror that is suggested. We should embrace the growth of local non-profit community-centered clinics that adhere to the principles of the Canada Health Act and can provide specific services at no cost.

None of the above recommendations are particularly revolutionary. They aim to increase the effectiveness of the current system without cutting services and without increasing spending (it is easy to make dollars go further if you cut covered services, and it is equally easy to increase services by simply spending more). I believe Medicare is fundamentally sound, but needs several systemic adjustments in order to ensure its sustainability for the future and to increase its responsiveness in the present. If we could move beyond the politicized “more spending” vs. “more privatization” debate that has produced deadlock, we might actually be able to improve upon the existing system.

On June 9, the Supreme Court of Canada ruled that Quebec cannot prevent people from paying for private insurance to cover health-care procedures that would be covered under medicare. Most people in Canada don’t want private healthcare at all since it is more costly and less equitable. But they especially don’t want a private system of healthcare running parallel to the public system. So, this ruling is something of a wake-up call for the public system – it basically says get your act together or private insurance will be allowed to take over.

A few facts that many Canadians may not realize (or want to accept): Canada’s healthcare system is 70% public and 30% private. The U.S. healthcare system is 45% public and 55% private (these are the dollars spent on all healthcare for both countries). Numerous studies have shown that private healthcare is more costly, largely due to high administration costs (and lawsuits). I buy that. But, cost is not the only factor. Timely access to care is also important – and unfortunately, Canada performs poorly for some procedures (usually not medically urgent). Equality of care regardless of income is also important. And despite the common perception, this is no longer a strong point of Canada’s system – certainly, it is better than the U.S. on this point, no question (44 million Americans have no health insurance – i.e. 1.5 times Canada’s entire population!). Many things in Canada are not covered by the public system: drugs (outside of hospitals), eyecare, dental, among others. That means you need private insurance to cover them – and usually those with good jobs (and/or unions) get these benefits. Those that don’t have good benefits, don’t get them. Sounds like two-tier health to me, no? The point is, we Canadians have a fundamentally solid foundation for health, but we need to be more intelligent about recognizing where the system is weak and how to go about making change without the debate being dumb-ed down into juvenile language (two-tier health! Privatization! – those may be undesirables, but let’s work towards solutions not just state the same thing over and over).