Medicare in Canada is a government-funded universal health insurance program established by legislation passed in 1957, 1966 and 1984. The Canada Health Act does not cover prescription drugs, home care or long-term care or dental care, which means most Canadians rely on private insurance from their employers or the government to pay for those costs. Provinces do, however, provide partial coverage for children, those living in poverty and seniors. This article will provide a brief overview of the challenges that face medicare in today’s economic climate as well as into future. We will also identify ways we can prepare for future challenges by identifying areas of improvement within our healthcare system to meet the challenges of tomorrow.
Saskatchewan Leads the Way
Making of Medicare: the History of Healthcare in Canada found on the Canadian Museum of History‘s website it lists Saskatchewan in leading the way. Tommy Douglas and the Co-operative Commonwealth Federation (CCF) had been in power since 1944, but the promise made then to provide comprehensive health care coverage to all citizens had been stymied by lack of funds. When Saskatchewan began to receive federal funding under the Hospital Insurance and Diagnostic Services Act, the government was able to move to the next component: medical services insurance. As Douglas pointed out to voters during a provincial by-election in 1959:
“The Government of Saskatchewan is convinced that the time has arrived when we can establish a prepaid medical care plan in our march toward a comprehensive health insurance program that will cover all our people, and will ensure a high standard of medical care to every citizen of Saskatchewan . . . If we can do this — then I would like to hazard a prophecy that, before 1970, almost every other province in Canada will have followed the lead of Saskatchewan, and we shall have a national health insurance program from the Atlantic to the Pacific. Once more Saskatchewan has an opportunity to lead the way. Let us therefore have the vision and the courage to take this forward step believing that it is another advance toward a more just and humane society. (Thomas H. McLeod and Ian McLeod, Tommy Douglas: The Road to Jerusalem[Edmonton: Hurtig Publishers, 1987], p. 195)
Fast forward:2019 – Saskatchewan is still leading the way….
The World is Watching, Canada: What to do about Medicare?
Canada used to be a global leader, a good example, in providing health care to its citizens. The services that we provide to handle those who are in need of care through medicare quickly became a defining feature of our national identity. However, especially in recent years our reputation of being good health providers has been at risk as we are no longer counted among the countries that do provide a comprehensive health program and other countries are taking notice. Washington post reported on the British survey and presented an expose on what ails our system on the “journal’s first series on Canada and its release was timed to coincide with the beginning of the country’s G-7 presidency and the 150th anniversary of Confederation.” Had we progressed with electoral reform, this story would have been a positive one focused on how we are furthering to improve our national identity through proposed electoral changes as a “birthday gift” to our country. Instead we now have an reports from other countries pointing to a weaker aspect of our national identity, one that we have been proud of that seems to have lost its luster over the years.
Unfortunately we have so many issues outside of health care that are pressing in nature, in which areas do we first put our full focus? And since it is difficult to spread our attention and resources to all of them at the same time – we’d be perpetuating the problem rather than finding a solution. At present we seemed to have flip flopped from taxes, to creating jobs in the energy sector, medicare and a pharmacare plan, mental health and the opioid crisis, housing and now the most pressing, it seems, is creating a new “green deal” for the environment. With an up coming federal election I wonder which major campaign issue(s) will take front and center and if I may make a prediction or at least a suggestion, that it should be focusing on medicare that would also include establishing a national pharma-care drug plan.
Collectively we need healthy people collectively making healthy decisions in the future direction for our country. We need healthy people to re-entering the work force and in their participation improving our GDP and tax system that needs their contributions to have the monetary resources to answer the call on most pressing issues such as the environment. We need healthy people to demand and help change our electoral system, to one that allows innovative leaders to take their place and respond to our immediate needs. If you are a person who’s living with an illness, it’s hard to think about pressing issues such as our looming environmental crisis when you’re mind is occupied with thoughts about having enough pharmaceuticals to last you for the rest of the week. If people feel that their lives will be shortened because of what ails them they won’t be as receptive to pressing issues such as the environment because, in their minds, they’ll already be dead before any environmental catastrophe will occur. And that simply is not the case. Strengthening medicare and providing a national pharmacare program will do what it was meant to do and what Douglas envisioned it to do: to provide security in that everyone is looking after each other through our medicare program – it’s based on equality so that no one, regardless of status and financial capabilities, is left behind; and that everyone is treated equally and given equal treatment.
“The Canadian system gets batted around as either an example of a socialist disaster or a utopian dream,” said Danielle Martin, one of the authors of the study and a Toronto-based physician and professor. “It is a good time for Canadians to set the record straight about who we are and how our health care-system does and doesn’t work.”
According to a new series of papers and commentaries published in the Lancet, a British medical journal, Canada spends less per capita on health-care than the United States (for example) and most European countries; it also performs better on a wide range of indicators like life expectancy, obesity rates, infant mortality and “amenable mortality”— deaths that theoretically could have been avoided by timely and effective medical care — according to the series. But its authors note that these glowing statistics conceal abysmal health outcomes for Canada’s 1.7 million indigenous people, who face disproportionately higher rates of suicide, infant mortality and chronic disease. Canada’s Inuit people have a life expectancy that is as much as 15 years shorter than non-indigenous Canadians, and tuberculosis rates that are 270 times higher than those of the Canadian-born, non-indigenous population.”
Canada’s status as the only country in the developed world with universal health-care that does not cover prescription drugs is panned, too. In almost one-quarter of Canadian households, someone is not taking medications because of an inability to pay, according to the Angus Reid Institute, a polling organization. The Lancet series faults Canada’s incrementalist approach to health-care changes for Medicare’s status as “a system in stasis”. “Incrementalism only works if you take one step, and then immediately take the next, and then immediately take the next,” Martin said. “The concern always is that you will take one step and then spend all of your time defending the one step”. (W. Post)
They are partially right. Tommy Douglas reflected on the continuing need for health system reform at a conference in Ottawa in 1979. He noted that those involved in the original development of what became Medicare saw health system reform as a two-phase incremental process with removing financial barriers being the first phase:
“Phase number two would be the much more difficult one. That was to alter our delivery system, so as to reduce costs, so as to place the emphasis on preventive medicine….What we have to apply ourselves to now is that we have not yet grappled seriously with the second phase. We must now move increasingly to group practice….to make possible the practice of preventive medicine. Only in that way we are going to be able to keep the costs from becoming so excessive that the public will decide that Medicare is not in the best interests of the people of this country.” (Douglas, 1979)
The point is, Douglas knew that medicare wasn’t a complete delivery system for healthcare, that more had to be done and with each incremental step he recognized that it would get progressively more difficult. One of those difficult aspects would be implementing a national drug plan which was the NDP’s position and one that they have been advocating since the implementation since its founding convention in 1961. Jean Chretien would later try to do so but did not succeed.
And so, my fellow Canadians, it’s time to step up to the plate, what are we going to do about Medicare?
First, let us identify some of its problems and throw some ideas into the mix for possible avenues for solutions.
Role of the Government of Canada
The federal government’s roles in health care include setting and administering national principles for the system under the Canada Health Act; financial support to the provinces and territories; and several other functions, including funding and/or delivery of primary and supplementary services to certain groups of people. These groups include: First Nations people living on reserves; Inuit; serving members of the Canadian Forces; eligible veterans; inmates in federal penitentiaries; and some groups of refugee claimants.
The Canada Health Act establishes criteria and conditions for health insurance plans that must be met by provinces and territories in order for them to receive full federal cash transfers in support of health. Provinces and territories are required to provide reasonable access to medically necessary hospital and doctors’ services. The Act also discourages extra-billing and user fees. Extra-billing is the billing of an insured health service by a medical practitioner in an amount greater than the amount paid or to be paid for that service by the provincial or territorial health insurance plan. A user charge is any charge for an insured health service other than extra-billing that is permitted by a provincial or territorial health insurance plan and is not payable by the plan.
The federal government provides cash and tax transfers to the provinces and territories in support of health through the Canada Health Transfer. To support the costs of publicly funded services, including health care, the federal government also provides Equalization payments to less prosperous provinces and territorial financing to the territories.
The federal government’s roles in health care include setting and administering national principles for the system under the Canada Health Act; financial support to the provinces and territories; and several other functions, including funding and/or delivery of primary and supplementary services to certain groups of people. These groups include: First Nations people living on reserves; Inuit; serving members of the Canadian Forces; eligible veterans; inmates in federal penitentiaries; and some groups of refugee claimants.
First Nations and Inuit
Direct federal delivery of services to First Nations people and Inuit includes primary care and emergency services on remote and isolated reserves where no provincial or territorial services are readily available; community-based health programs both on reserves and in Inuit communities; and a non-insured health benefits program (drug, dental and ancillary health services) for First Nations people and Inuit no matter where they live in Canada. In general, these services are provided at nursing stations, health centres, in-patient treatment centres, and through community health promotion programs. Increasingly, both orders of government and Aboriginal organizations are working together to integrate the delivery of these services with the provincial and territorial systems.
In 2003, the first ministers agreed on the Accord on Health Care Renewal, which provided for structural change to the health care system to support access, quality and long-term sustainability. The Accord committed governments to work toward targeted reforms in areas such as accelerated primary health care renewal; supporting information technology (e.g., electronic health records, tele-health); coverage for certain home care services and drugs; enhanced access to diagnostic and medical equipment; and better accountability from governments.
Role of the Provinces and Territories
The provinces and territories accept transfer payments from the federal government, which in turn gets dispersed through its various channels within the healthcare systems to the hospitals and clinics. Therefore, the roles of the provincial and territorial governments in health care are the following:
- administration of their health insurance plans;
- planning and funding of care in hospitals and other health facilities;
- services provided by doctors and other health professionals;
- planning and implementation of health promotion and public health initiatives; and
- negotiation of fee schedules with health professionals.
That would mean we have fourteen ministries of health currently operating in Canada: ten provincial, three territorial and one federal. each of these ministries has a minister of health for the province and with that a body of civil servants to support the minister of health through its offices within the province. For starters, I wonder if we were to examine how each of these provincial and territorial bodies operate, set them up side-by-side, I bet they all operate exactly the same way using the same channels for delivery with a few minor differences in support of a few unique challenges experienced only by the province. I don’t know about you but right there I am beginning to see some funding overlap, wasted dollars and an opportunity re-think how we deliver our health care services and divert some funds to areas that would make the program more robust.
Stephen Skyvington, a political pundit and author of “This May Hurt a Bit: Reinventing Canada’s Health Care System“ articulates this point by suggesting a solution, one to me, that would make a lot of sense as I am sure anyone reading the statistics would draw the same conclusion. Skyvington suggests to create, as he calls it a “”super ministry” with one health minister and one bureaucracy – all located in Ottawa”. By doing this think of the enormous savings we could create by diverting funds back in to areas within the health system that is in real need of support or to expand our services.
The idea of a”super ministry” in itself shouldn’t be intimidating. According to various news outlets ,including Dr. Eric Hoskin’s report, they are already calling for a centuralized national formulary – a National Drug Agency they call it- why can’t we make that formulary a component of the centuralized “super ministry”. For a national drug plan we would have to increase taxes by at least $15 billion a year because the cost of prescription drugs will continue to rise inexorably, from $30 billion in 2017 to almost $52 billion in 2027. I wonder, if we were to additionally create this “super ministry” how much money would we be saving that in turn could go towards the increase of drug costs with the aim to minimize the impact of raising taxes.
Author: Stephen Skyvington, Publisher: Dundurn (Feb. 2 2019), ISBN-10 : 1459742435, ISBN-13 : 978-1459742437, Paperback : 248 pages
In terms of the provinces, “most provincial and territorial governments offer and fund supplementary benefits for certain groups (e.g., low-income residents and seniors), such as drugs prescribed outside hospitals, ambulance costs, and hearing, vision and dental care, that are not covered under the Canada Health Act. Although the provinces and territories provide these additional benefits for certain groups of people, supplementary health services are largely financed privately. Individuals and families who do not qualify for publicly funded coverage may pay these costs directly (out-of-pocket), be covered under an employment-based group insurance plan or buy private insurance. Under most provincial and territorial laws, private insurers are restricted from offering coverage that duplicates that of the publicly funded plans, but they can compete in the supplementary coverage market.” These supplemental services could all be covered and should be covered. The provinces, well I know for sure Ontario, are already pushing for an all encompassing coverage, both NDP Andrea Horwath and Wynn (Liberals) were calling for these services to be covered in the last provincial election. NDP had a more comprehensive plan with realistic deliverable and timelines.
What we are attempting to change is the structure of healthcare where the federal government’s role will no longer be the money masters but act as the headquarters to the provinces for medicare. As enticing the idea of a “super ministry” might be, a word of caution; we would have to re-open our constitution to make the necessary adjustments. That in itself shouldn’t scare you – it’s about time that we do; we’re already hearing constitutional talks for example, Doug Ford using the notwithstanding clause, Jason Kenney arguing with Trudeau about Bill C69 crisis and the threat to National unity reporting that 50 percent of Albertans are so angry that they would consider secession (See: National Post Matt Gurney), reconciliation points with First Nations and aboriginal communities, finally including Quebec etc . Point is constitutional talk is slowly creeping into our national conversations – creating a national pharamcare program and expanding medicare coverage to accept services such as dental, senior care, drug costs, emergency services (etc.) is also an issue of ‘national unity‘ – let’s be prepared. With the recent tabling of Dr. Eric Hoskin’s National Pharmacare report and conflicting points on how best to accomplish our goals – this just might also be an election issue.
Economic Stability vs Financial Sustainability
Economic sustainability focus on whether a good return is being made on investments in healthcare specifically whether the return on health investments exceeds their opportunity costs. Financial sustainability looks at the level of health spending that can be “afforded” at prevailing or desired levels of taxation.
We are entering a “dependency burden” phase. That means those who need to be taken care of under the age of 15 and 65 plus are in the dependency bracket as they rely on the taxpaying working populations that pay for various facets of our systems (i.e. education, home and hospital care etc. ) Fertility rates are down meaning over time there will be less individuals entering the workforce and with the advent of robotics taking over human jobs, well that too will soon become more of a reality and a concern. Robots do not pay taxes.
Another area for concern in terms of runaway costs is the rising prices of pharmaceutical drugs and new technologies. The data shows time and time again we have enough funding through our tax system to fund medicare as it stands. Our problems with medicare mainly stems form the fact that we’re not using best practices, employing innovative ideas and taking risks to try out new systems to streamline services. Even with the reporting mechanisms a common comment is a lack of meaningful transference of knowledge in that there is difficulty in extracting meaningful information from the data provided to determine action items to move forward on for improving services and information exchange of best practices; as well as, outdated administrative practices and ineffective use of human capital within the system.
The size of government (and the tax structure to support the desired range and level of public services) is the result of political choices. Political parties (and political commentators) have different predispositions to support public provision, public subsidies to private provision, or personal private responsibility for aspects of health care. Their positions reflect, in part, different emphasis on values of welfare, equity and liability and their place on the left/right spectrum of Canadian politics. It should come at no surprise that questioning of the sustainability of Medicare is often accompanied by calls for a greater role for private funding.
Saskatchewan was leading the way as early as 1944; “to develop the provincial plan, Douglas outlined five principles that would provide the foundation for provincial funding: prepayment, universal coverage, high quality of service, public administration and a plan that was “acceptable both to those providing the service and those receiving it.” And therein lies the problem.
The sustainability of provincial governments (not just their health portfolios) requires long-run alignment of spending revenue. Therefore, in addition to pursuing efficiency strategies including increases in general taxation or “earmarked” health taxes, to meet future increases in health expenditure requirements. Different types of taxes impact differently on equity and have different political impacts with less visible taxes (natural resources revenue, corporate taxes) eliciting smaller negative voter impact.
We can be accommodating without raising taxes.
Centralizing health coverage under one “super ministry”, is one option of doing so by adjusting how the federal government deliver its transfer payments to the provinces which could eliminate duplicated services and delivery costs. It would also be wise to aggressively pursue those who have unpaid taxes, tax cheaters and those who have hidden their fortunes off-shore. We need that money back and we need it now. What we don’t need or I should say we can use less of is funding of charities through donations by the rich, if they [all] properly paid their taxes we probably won’t need as many charities that we already have. There’s nothing wrong in charitable giving (and it’s strongly encouraged and rewarded through our tax system) – just do it after you have paid your taxes. The government is capable and can provide what is needed to various low income and marginalized groups that charities currently provide for today. We have the number of charities that we do because of shrinking funding of government services and oddly enough government grants that these charities in most part rely on. The children of tomorrow are counting on us to set systems in place, in which they can improve upon according to meet the challenges inherent from what we have done, lets do our best to set them on a path of longevity for the generations that come after them.
“What’s up Doc?”
Much of what plagues our medicare system is nothing new, we’ve been managing these problems for years going back to end of World War II and beyond. What is new however, is the increasing size of the problem, new technology that is poorly integrated into the system, and a fear of trying new and innovative ideas to improve the system – which speaks to lack of leadership and of course costs; rising drug costs; cost of new technology, chronic diseases, and a shortage of doctors and nurses.
That said, healthcare is still sustainable. Stephen Duckett wrote a two comprehensive books on Canada’s health care system and provided some excellent ideas on ways in which we can answer the call to our ever changing times and demographics. I like this one, for example from his book “Where to from here? Keeping Medicare Sustainable“, he says: ” But most of the change that is necessary will be in terms of the health systems, particularly how chronic care is managed and in terms of improving efficiency. He provides a little mantra we should all get to know and think about how we can follow its guideline in all aspects of healthcare, he says:
“The right person enables the person enables the right care in the right setting, on time every time.”
Duckett provides a comprehensive breakdown of the sentence:
Right Person: to ensure that the full potential of all health workers is used, that all work to their full scope of practice, doctors do what doctors do, nurses do what nurses do, aides are used to full potential and so on. Benefit: from perspective of job satisfaction and economic perspective (I would add “safety” too).
Enables: health utilization is increasingly about managing chronic diseases. The health care discourse should recognize “co-production” the person with the disease is an important partner in care, therefore, the strategy should be about informed demand. What changes is the language of the role of the health care provider who is an “enabler” of care supporting the person (caregiver and family) with managing their chronic disease.
Right Care: This is about knowledge exchange about what is the best care as it is not always implemented in a clinical practice until about a decade or so after its first established. identify best care, develop protocols to facilitate us in practice and benchmark the outcomes. “”Right Care” also implies that the care is provided efficiently.”
Right Setting: Sometimes getting the right care imposes travel and dislocation costs on patients and their families. An important concept here is the “least restrictive alternative” with an emphasis on maintaining independence as much as possible for patient/resident seniors’ accommodation perhaps care at home , via telephone consults and in local and community settings. that would mean an emphasis on primary care rather than secondary care, ambulatory care rather than inpatient care and an emphasis on getting patients home as quickly as possible.
On time: Duckett says the phrasing of the Canada Health Act criterion of “reasonable access” explicitly addresses financial barriers to access, but long waits also impede access. For example, waits for a small list of elective procedures and diagnostic services, but the access agenda needs to be broadened to include waits to see a specialist, and waits in an emergency. Timeliness of access across the whole continuum of care thus needs to be assured and demonstrated.
Every time: Consistency, consistency, consistency! In terms of right care (in the right setting) and on time, thus linking to both timely access and good quality. Safety and quality of care is equally important. “Every time” also connotes “for everybody,” emphasizing the importance of equity in access and provision.
Let’s break it down a bit more to describe our present day challenges within our health care system.
Hospital Wait Times
There is a great deal of variation in the total waiting time faced by patients across the provinces. A report authored by the Fraser Institute lists”Saskatchewan report[ing] the shortest total wait (15.4 weeks), while New Brunswick reports the longest (45.1 weeks). There is also a great deal of variation among specialties. Patients wait longest between a GP referral and orthopaedic surgery (39.0 weeks), while those waiting for medical oncology begin treatment in 3.8 weeks.
The total wait time that patients face can be examined in two consecutive segments.  From referral by a general practitioner to consultation with a specialist. The waiting time in this segment decreased from 10.2 weeks in 2017 to 8.7 weeks this year. This wait time is 136% longer than in 1993, when it was 3.7 weeks. The shortest waits for specialist consultations are in Saskatchewan (6.3 weeks) while the longest occur in New Brunswick (28.5 weeks).  From the consultation with a specialist to the point at which the patient receives treatment. The waiting time in this segment increased from 10.9 weeks in 2017 to 11.0 weeks this year.
This wait time is 97% longer than in 1993 when it was 5.6 weeks, and more than three weeks longer than what physicians consider to be clinically “reasonable” (7.7 weeks). The shortest specialist-to-treatment waits are found in Ontario (8.3 weeks), while the longest are in Manitoba (19.7 weeks). It is estimated that, across the 10 provinces, the total number of procedures for which people are waiting in 2018 is 1,082,541. This means that, assuming that each person waits for only one procedure, 2.9% of Canadians are waiting for treatment in 2018. The proportion of the population waiting for treatment varies from a low of 1.7% in Quebec to a high of 6.2% in Nova Scotia. It is important to note that physicians report that only about 12.1% of their patients are on a waiting list because they requested a delay or postponement.
Patients also experience significant waiting times for various diagnostic technologies across the provinces. This year,Canadians could expect to wait 4.3 weeks for a computed tomography (CT) scan, 10.6 weeks for a magnetic resonance imaging (MRI) scan, and 3.9 weeks for an ultrasound.
Wait times can, and do, have serious consequences such as increased pain, suffering, and mental anguish. In certain instances, they can also result in poorer medical outcomes—transforming potentially reversible illnesses or injuries into chronic, irreversible conditions, or even permanent disabilities. In many instances, patients may also have to forgo their wages while they wait for treatment, resulting in an economic cost to the individuals themselves and the economy in general.
Oxford Dictionary defines Chronic as: (of an illness) persisting for a long time or constantly reoccurring. With the rise in life expectancy, there has been an out-of-control growth in chronic illnesses in the last few years; today it eats up more than 70% of health care costs in Canada. Care for chronic conditions is not a new problem, it has plagued hospitals and medical facilities as far back as 1973 even further. What is different this time around, however, is the rise in the number of individuals suffering from chronic illnesses. As such, the common pattern of care now is no longer those with acute episodes but those visiting their doctor for chronic illnesses “that are now seen in every day practice, with no corresponding evolution of the payment model.” Out of the list of chronic illnesses, obesity, dementia and diabetes are considered the tsunamis of our time and we are ill prepared to handle the sheer volume of those who are suffering (or would be) from these conditions. In fact, the more chronic conditions a person has, the greater his or her health care use, meaning: a person with three or more chronic conditions will have about three times the number of health care visits per year. The Ontario chronic Disease Prevention Alliance and Ontario Public Health Association estimated the total direct and indirect health care costs for selected chronic diseases in Canada at over $112 billion dollars (2005). About two thirds of that total was attributable to indirect costs (short and long-term disability and premature mortality).
Expenditure growth is driven by two key factors- a rise in the prevalence of treated disease and an increase in the cost of each treated case – but the relative importance of the two factors is a subject of academic contention. Change in treated prevalence is driven only in part by population factors that include aging but also other causes of increased prevalence of disease, such as stress and increased obesity. It is also affected by changed treatment thresholds (sometimes driven by innovation, such as new drugs, sometimes by professional advice to consumers or consumer expectations). In other words, the increased prevalence of treated disease is due to both external and internal factors: population factors external to the health system, and policy and practice changes internal to the system. Even the exogenous factor of population effects could be impacted by policy choices, inside or outside the health system, for example the prevalence of obesity.
At this point, I would like us to consider the possibility of combining solutions for senior’s care with those who are suffering from chronic care. Many seniors are suffering from chronic illnesses and would require similar long-term solutions. In both cases a team is assembled to assist with the patient’s management needs. The emphasis now is on “self-management” and more support for home care due to high costs for in-hospital stays and most patients would rather be treated and manage their illnesses insider the comforts of their home environment. Stephen Duckett outlines some areas where attention is needed with those who are suffering from chronic illnesses, he begins by quoting, “Wagner et al. (1999) have advanced a comprehensive and multifaceted approach to system redesign appropriate for management of chronic illnesses that has its focus on “productive interaction” between an “informed, activated patient” and a “prepared, proactive practice team”; both sides of this interaction require support to be effected. Support comes both from the community (in terms of resources, policies, an self-management support) and from the health system, it involves improvements to the organization of healthcare, the delivery system design, decision support and clinical information systems.”
A patient with chronic illness lives with it 24/7 so does the patient’s partner, family and caregivers. And here’s, for example, where that mantra comes in about our goal for the health system: the right person enables the right care in the right setting, on time, every time. Most care needs of a person with chronic illnesses (and/or senior’s care) are met within the family/caregiver home environment. The role of the partner/family/caregiver is to provide a supportive environment for the person with chronic illnesses: making the home safe for walking around other activities of daily living (eating, showering) to assist with medication management and health monitoring. For community services system they could potentially assist by supporting home modifications or providing assistance to the caregivers, including respite care.
There is a greater emphasis on “enabling” or supporting role for the federal government to play in the health system, rather than just simply a “providing” role, which is also more sustainable into the long term. As the prevalence of chronic illnesses increases, without changes to the service model, workforce requirements will increase as will costs of employment. As such, an emphasis in supporting self-management and creating supportive environments will allow each health professional to manager a greater number of patients. Because of the increased number of patients, management of the ongoing care needs of people with chronic illnesses will be met by people with a narrower skill set such as health care aides, allowing other health professionals to manage an increase number of patients. These shifts in patient care needs requires action and support. The health system can’t just off-load these responsibilities onto [unskilled] partners, families or even caregivers, without training in self-management and without support to caregivers, this new approach will fail, with resultant additional downstream costs in terms of health care utilization.
Seniors – The Aging Effect on Health Care
We are in the midst of a demographic shift where the Baby-Boomer generation are now reaching threshold of retirement age and beyond. Now this is a catch-22 in that while it’s true seniors require more care as they get older, however, the Baby-Boomer generation are living longer because they are taking better care of themselves putting more emphasis on preventative care. This attitude in turn has a trickle-down effect providing a trend in self-care management for generations that come after them. Additionally, since the life expectancy of the Baby Boomer generation is healthier and longer that also affects our GDP per capita, as many work well past the age of retirement or start a business once they have retired (meaning more money is going into our tax system). That being said, we do age and with it comes mobility issues vs independence, and other costs associated with aging. For example, there is an increasing need for home care (i.e. costs associated with retrofitting a home to meet on-going needs) as many seniors prefer to be treated at home than staying in group/senor’s home or medical setting.
The Health Council of Canada noted that, in 2005, 3–4 percent of seniors reported that they need home care but do not receive it and that estimates that in 2005, 2–3 percent of Canadians received government-subsidized home care and 2–5 percent paid privately for home care services. The proportion of private versus public services varies by province. In a 2003 Statistics Canada survey, for example, 65 percent of home care recipients in Manitoba indicated that they had some or all of their care covered by public funding, compared to 42 percent in British Columbia.47 Total expenditures on home care exceed what is reported.
“Elderly people, however, are more likely to experience chronic and medically complex conditions, which require a different kind of care — one that provides an ongoing relationship with an integrated care team. 5 out of 6 seniors use a disproportionate amount of hospital services. Although they make up 17% of the population, they represent 34% of hospital cases and 58% of the hospital days.” (See: Seniors in Transition Exploring Pathways Across the Care Continuum)
Actual spending on home care identified by CIHI may be twice the $3.4 billion identified. Why? First, more formal care is delivered privately than publicly. Second, the bulk of care is delivered by informal caregivers. If one were to calculate a minimum wage for all the volunteer hours devoted to care, estimated to be at least $6 billion, the total amount devoted to home care in Canada could approximate $13 billion.
- The number of people receiving home care has risen and is expected to continue to do so.
- The people who are receiving subsidized home care generally require a higher level of care.
- In looking at the health care budget as a whole, home care remains a small component.
- Of the component dedicated to home care, the emphasis, or priority, is on post–acute care rather than long-term care that is focused on maintenance of skills and preventive care.
- The provision of home care appears to be shifting from the public to the private sector, and, in cases where clients are unable to pay for private care or it is unavailable, the informal caregiver must shoulder more responsibility for care.
To meet the increasing needs of this aging demographic we need to ensure that there is predictable and sustainable funding for home care. The 1984 Canada Health Act applies only to insured health services that cover hospital care (acute, rehabilitation and chronic) and medical services. Home care remains an uninsured service under the Act, listed only as an extended service to which the five principles of the Act do not apply. It therefore has no protection under the Act. The Health Council of Canada has stated that two weeks of publicly funded home care services to eligible patients is too modest of an investment. It therefore urges jurisdictions to expand their home care coverage. This can be accomplished through a variety of methods, proposed by Wanless:
• universal entitlement to social care that is government-supported and not means-tested;
• a social insurance model in which the government acts as the insurer and provides a package of care;
• shared costs between state and individual;
• the capping of individuals’ liability after they have paid a certain amount or received services for a certain length of time; and
• a pension-linked savings plan.
In a series of pre-Budget briefs, CHA recommends as a start, a $1 billion investment over three years to support a home care program with ongoing/chronic care services linked to pan Canadian objectives while respecting provincial/territorial jurisdiction regarding the delivery of care.
Pharmacare – National Drug Plan
The World Health Organization has declared that all nations are obligated to ensure equitable access to necessary medicines through pharmaceutical policies that work in conjunction with broader systems of universal health coverage. To that end, every developed country with a universal health care system provides universal coverage of prescription drugs—except Canada. Pharmacare 2020: The Future of Drug Coverage in Canada is a research-based report that presents a clear and coherent vision of Pharmacare for Canada: A Public Drug Plan that is universal, comprehensive, evidence-based, and sustainable. I am also providing a link to Dr. Hoskin’s report about implementing a national pharmacare program and another report, “A Dose of Reality“, by Sean Speer writing for Macdonald-Laurier Institute, which provides another alternative to single-payer program that is offered by Dr. Hoskin’s report.
A Dose of Reality argues that a single-payer program is not the most effective way to serve those who are in need. They maintain that our present system works well and that we need to focus on filling in the gaps that currently exist. Those gaps are individuals who are uninsured and under-insured. These individuals have a job working; in the temporary industry, under precarious employment, the “gig” economy, self-employed or working for small companies that cannot afford private insurance for its workers. They represent 3.6 million to 4.1 million of the population with 2.8 million of what’s quoted representing un-insured self employed workers, however this number is expected to exponentially grow with an ever-changing workforce and lesser job security in the coming years to decades. If the government currently has programs that could cover these individuals, Speer suggests that government(s) perhaps aren’t doing a very good job in promoting the services they offer and to step up their efforts to promote their services so these individuals can take advantage of what’s offered – thus closing this gap. If the government doesn’t have a satisfactory program to offer to this segment of the market, they suggest to create a program that entirely focuses on these individuals.
Speer maintains that the way our current system is set up in terms of satisfying the needs of those who rely on prescription drugs is working just fine – we do not need to reinvent the system. Creating a single-payer program is costly. A single-payer program can fiscally cost us $20 billion and that number is expected to grow by more than 3% annually. Second, the formulary for a single-payer program will have a narrower inventory of drugs to offer than most private plans. The government’s judgement about utility and costs may render a drug or a certain sets of drugs to be absent from the inventory that one would normally have easy access to under a private plan. Additionally, a public plan may not be able to adequately and efficiently answer the call to new and approved drugs that would normally be accessible under a private plan and that’s IF the public plan agrees to carry the product. Third, is the disruptive component in implementing a single-payer program. The vast majority of Canadians are happy with the current plan and the services they currently receive. They are happy, probably because they don’t know any better in that they could receive better options through a national single-payer program. Speer offers the example of unions who have collectively bargained for the programs employees currently receive, putting in a new system will disrupt their agreements potentially sending them back to the bargaining table, all this in order to better service the poorer populations which amounts to roughly 3.5 million individuals. The final concern Speer offers would be the potential, or I should probably say, eventual interference by government in public health care policies. Based on historical data top-down policy making tends to be associated with higher costs with poor results.
Those are all good points that should be taken well into consideration. However, despite Speer’s objections to the single-payer option, with a little foresight and flexibility, can minimize some of these impacts and still adequately meet the needs of Canadians. Rome wasn’t built in a day, nor should fixing healthcare be taken as such. To mitigate immediate and short term needs, one option could be to implement Speer’s suggestion in creating a healthcare program that specifically targets the uninsured and under-insured population in an effort to fill in the gap. Create that program to specifically satisfy this segment of the market. View it as plugging a hole by providing a short-term solution, ensuring everyone’s needs are met, with the intention of revisiting the project to implement an all encompassing universal program at a future date.
Medicare is built on the principle of “equality“, which is also one of the pillars of our Canadian democracy that is enshrined in our Charter of Rights and Freedom. If there is no equal access to healthcare and our present system is leaving people behind- then it’s not a good system and as such, it needs to be fixed. In the meantime and in keeping with the WHO’s mandate in having a single-payer drug plan “that works with a broader system of universal health coverage”, go back to medicare and fix it. Develop and implement the “Super Ministry” first, adding more services to be covered by the program and slim down current needless, costly and excessive practices. Once that is implemented and working satisfactory, proceed to study and create a single-payer national drug program that uniquely fits within the parameters and/or work in unison with the delivery channels of the “super ministry”. After identifying a satisfactory delivery program implement the system and transfer everyone over at the same time. When speaking of transferring people over to a new system, we’re not looking for a two-tier or even three-tier disruption phase – just ONE disruption that is needed. Additionally, whatever “it” is that we do and however we are going to do “it” – these programs and delivery services should be ones that put the needs of the individual first, policies after – meaning it should first fit the patient’s needs rather than making policies that’s best administration and then try to weave the individual’s needs in and around those policies. Putting patients needs first would also include how we can effortlessly transfer the population over to a new systems once it is in place.
Pharmacare 2020 has provided the following principles for a national drug plan that provides a good starting point when determining what our system should be focused on delivering:
Principle #1: All Canadians should have equitable access to medically necessary prescription drugs.
Principle #1 – Access: Provide universal coverage of selected medicines at little or no direct cost to patients through Pharmacare. Equitable access to medically necessary prescription drugs does not require that every drug be covered for every use. It requires that all patients be able to access, without barriers, medicines selected with due regard to public health relevance, evidence on efficacy and safety, and comparative cost-effectiveness. This is not achieved through drug programs for select populations or the protection of all people against only “catastrophic” costs. Even small patient charges can deter patients of all income levels from filling necessary prescriptions, particularly preventive treatments that must be taken regularly to manage asymptomatic chronic diseases.
“Principle #2: No individual or group should be financially disadvantaged by their health needs”
Principle #2 – Fairness: Select and finance medically necessary prescription drugs at a population level without needs-based charges—such as deductibles, coinsurance, or risk-rated premiums—on individuals or other plan sponsors (e.g., businesses). All Canadians should have financial protection from the costs of medically necessary care. Needs-based means of paying for prescription drug costs— including deductibles, co-payments, and risk-rated premiums—are borne disproportionately by those with significant and/or ongoing health needs. Protecting individuals and groups from the cost of necessary prescription drugs, requires that the cost be shared fairly across the entire population. It also requires that decisions about what drugs to cover be taken at a population level to avoid inequities in financial protection based on age, occupation, or other characteristics
“Principle #3: Prescription drugs should be funded, prescribed, and used only in accordance with the best available evidence concerning risks and benefits.”
Principle#3 – Safety: Establish a publicly accountable body to manage Pharmacare, one that integrates the best available data
and evidence into decisions concerning drug coverage, drug prescribing, and patient follow-up. The safety of medicines as used by Canadians is of primary importance. Increased drug coverage by itself may address problems of under use of needed therapies but may also exacerbate existing problems of overuse and misuse of prescription drugs in Canada. Pharmaceutical coverage therefore needs to be based on the best available evidence and integrated into the health care system in ways that increase the appropriateness of prescribing. A single, evidence-based formulary should be developed in a fair and transparent fashion by an accountable and representative body, and program implementation should foster the routine use of evidence and data for decision support and safety surveillance.
Principle #4: The cost of medicines should be managed to achieve maximum value for Canadian society
Principle #4 – Value for Money: Establish Pharmacare as a single-payer system with a publicly accountable management agency to secure the best health outcomes for Canadians from a transparent drug budget. All Canadians should have access to a health care system that is efficient and sustainable. This requires careful management of administrative costs, drug prices, and treatments selected to meet health needs. It also requires attention to the fact that money spent on pharmaceuticals cannot be spent on other things—including other investments in health and health care. A single-payer system for covered medicines would lower administrative costs, increase purchasing power, and enable the program budget to be set in the context of broader health system management. An accountable management agency should apply best practices in procurement policy and contracting to ensure a safe and secure supply of covered medicines.
In 2010 the Mental Health Commission of Canada commissioned a study to fill a gap in pan–Canadian information about the number of people living with mental health problems and illness today and the associated costs. The study built a unique model based on a wide range of existing studies in Canada and internationally. Its findings, combined with existing evidence of effective interventions, offer
some key reasons for why it is important to invest smartly in mental health.
In any given year, one in five people in Canada experiences a mental health problem or illness and it affects almost everyone in some way.
- More than 6.7 million people in Canada are living with a mental health problem or illness today. By comparison 2.2 million people in Canada have type 2 diabetes.
- Mental health problems and illnesses hit early in people’s lives. More than 28% of people aged 20-29 experience a mental illness in a given year. By the time people reach 40 years of age, 1 in 2 people in Canada will have had or have a mental illness.
“Our universal health-care system is a point of pride for Canadians, but the reality is, we don’t have a universal health-care system, but a universal medical system that doesn’t guarantee access to some of the most basic mental health services and supports.” ~Dr. Patrick Smith, National CEO, CMHA.
Over half of Canadians (53%) consider anxiety and depression to be ‘epidemic’ in Canada, with that perception spiking amongst younger people, according to a new survey commissioned by the Canadian Mental Health Association (CMHA). Fifty-nine per cent of 18 to 34-year-olds consider anxiety and depression to be ‘epidemic’ in Canada, followed closely by addiction (56%) and ahead of physical illnesses such as cancer (50%), heart disease and stroke (34%), diabetes (31%) and HIV/AIDS (13%). The survey accompanies a national CMHA policy paper, Mental Health in the Balance: Ending the Health Care Disparity in Canada, released today, which calls for new legislation to address unmet mental health needs and bring mental health care into balance with physical health care.
Eighty-five per cent of Canadians say mental health services are among the most underfunded services in our health-care system—and the majority agree (86%) that the Government of Canada should fund mental health at the same level as physical health.
“What we outline in our policy paper is that righting this balance is about more than just the balance sheet,” explains Dr. Smith. “The Mental Health Parity Act we are advocating for is not just about increasing funding for mental health services, but also improving coordination, treatment, research and access and making better choices about how best to spend health-care dollars effectively.”
“Canada dedicates only 7.2 per cent of its health-care budget to mental health.”
Many people with complex or chronic mental health problems do not receive the full scope of care they need and end up cycling through the acute care system. A more integrated continuum of care provided through community mental health services can meet the needs of as many people with mental health problems as possible by including early intervention and prevention, enhanced treatment for those who need it, and longer-term follow-up and supervision for those with severe and persistent illness.
“By 2020, depression will be the leading cause of disease in Canada.”
“Canadians are suffering from health conditions that are preventable or manageable with the right supports,” says Dr. Smith. “By adopting and promoting a ‘stepped-care approach’ to mental health service delivery that matches people to the right services and supports to meet their needs, Canadians will have better access to the right care at the right time.”
The topic of mental health blends into other conversations I’ve posted regarding medical intuition and energy healing as preventative practice that bares positive results. The good news is that you’re never too old to start learning its language. (See: Anatomy, Ensler, Unction)I believe we’ve been witnessing a trend in Western medicine where mind, body and soul are no longer viewed and treated separately – that there is a correlation between the three that influences one another thus welcoming Eastern influences an philosophies blended with Western medicine. Whether its turning to the Hindus to learn about your chakras, there’s Yoga and Tai chi, practice mediation and movement through breathing, calming the mind with a Buddhist monk, venturing on a native vision quest in the wilderness or sweating out your “issues”, with the grandmothers [or grandfathers] in a sweat lodge; turning to other cultures to broaden your ability to protect and to heal yourself is becoming more than just a trend. More studies are connecting the emotional and psychological history of a patient when diagnosing physical wounds, there is even more tolerance among medical professionals for those who seek holistic alternatives, that is no longer thought of as “new age”, “hokus-pokus” and that there is a science behind some disciplines that leads to our benefit. For those who wish to pursue the alternative market to combine with what they are doing in their medical treatments, there must be communication with your physician about what you are doing. This is emphatically stressed and is excellent news for it goes to show how far we’ve progressed in accepting Eastern medicine in a Western world.
The total cost from mental health problems and illnesses to the Canadian economy is significant:
- The study commissioned by the MHCC makes it clear that the economic cost to Canada is at least $50 billion per year. This represents 2.8% of Canada’s 2011 gross domestic product.
- Health care, social services and income support costs make up the biggest proportion of these costs. But it also cost business more than $6 billion in lost productivity (from absenteeism, presenteeism and turnover) in 2011.
- Over the next 30 years the total cost to the economy will have added up to more than 2.5 trillion.
Nadine Burke Harris in the above TEDtalk video drives home the point of how early in child development the seeds of mental illness can be planted. Spoken in such blunt terms, I am sure it sent each and everyone of us to think about the environments we were exposed to vs the challenges we had faced and are able to make our connections about past and present day mental health challenges and healing. Indirectly Harris has pointed to a larger issues in terms of present day child care and development needs in effort to advert the pitfalls of tomorrow. To attach the mythic proportions or mental illness and chronic illnesses much of which can be managed to mitigate or to completely circumvent are healthy environments for children to grow.
Growing healthy children, mind-body and soul into healthy adults starts in the home and progress to day cares, at church, elementary and high schools (remember participACTION), university, in the workplace and in all the spaces we occupy in between. Tommy Douglas new the second step to medicare was to focus on preventative measures because if we take better care of ourselves we would thus be less reliant on the system and in turn we wouldn’t have to spend so much of our tax dollars in healthcare. Personally I’d rather see less funding in healthcare and more funding in education – but we can’t and the problem we are currently facing today are growing expenditures, in many sectors including education that is competing with a growing healthcare budget. Of course there are legitimate circumstances in which we seek medical assistance but in many conditions we can see that if we only took better care of ourselves (mind-soul and body) we wouldn’t be so reliant on the system. “Self-Management” is the new catch phrase in those who are facing challenges with chronic illnesses to senior’s care. How do we the help them help themselves = savings in healthcare dollars and healthcare human capital.
We have many pressing issues facing us outside of the health care sector, for example the environment, that requires our attention and participation in civic engagement. I personally enjoyed what Harris said in the video above about a Dr. who sees 100 children drink from the same well and 98 of those children get diarrhea and the Dr. writes 98 prescriptions for diarrhea, instead of just going over to the well to fix the drinking water. This is the attitude we must have when solving the problems – of a capitalist society – that face us in not only healthcare – but everywhere. We are focused on the money that the 98 prescriptions provides for us instead of fixing our root problems that is brought up and gushing forth from the well. This is mindset in which we all need to possess in fixing what ails our society today – let us all become not doctors, writing prescriptions that just treat the symptoms but a fixer of wells to eliminate the problem.