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Self-interest to blame for meager health-care reform

health_reform.jpgAlmost continuously since the second half of the 1990s, Canadians have pointed to health care as their largest national concern and the issue that should receive the greatest attention from Canada’s leaders. Polls taken over the last decade or so have found that health care is typically the highest priority among voters. It is also the policy area in which governments often score most poorly. This sentiment has become so commonplace across the political spectrum of voters that we take it for granted that it was always so.

July 24, 2014  By Harvey Lazar

Yet, in the 1980s, worries about health care barely registered in public
opinion data. In fact, up to that point and since the introduction of
countrywide hospital insurance in the 1950s, Canadians had been smitten
by their universal, publicly financed hospital and medical services. So
what’s changed?

It’s not a lack of money. Health spending continues to be a spending priority.

it’s not the performance of individual healthcare providers, especially
when there is an urgent and acute need. Canadians are generally
satisfied with quality and the timeliness of the care they receive in
critical situations.

But on other health-related matters, the
reviews are less impressive. The slow response to the growing need for
chronic care has been apparent for some time despite its predictability.
The Commonwealth Fund International Health Policy Survey (2010) found
that of 11 OECD countries surveyed, Canada fared worst or second worst
on several access-related matters, including accessing health care in
the evenings and on weekends. Wait times were the worst for appointments
with medical specialists and for certain kinds of diagnostic tests. On
access to prescription drugs, we scored second worst.


This is a
stingingly familiar list of concerns — documented in the 2002 Romanow
and Kirby Reports and, before them, in the reports of the many task
forces, advisory committees and commissions — appointed by both left-
and right-leaning governments. Here we are, decades later, and these
issues have still not been adequately addressed.

Why is it so
hard to reform health care policy in Canada? This is the question my
colleagues and I posed in an examination of 30 health reform case
studies (published in Paradigm Freeze, McGill-Queen’s University Press).
The answers we found are not heartening.

Our study indicates
that, by and large, self-interest among vested parties has led to mostly
meagre health reform across the country. Specifically, provincial
medical associations have been able to protect physician interests, in
some cases, by keeping the health reform window shut. In others, by
persuading governments to advance their goals through incentives rather
than through regulation.

This is a legacy from the foundations of
medicare. When provinces first enacted medicare, they adopted a
fee-for-service method of compensating physicians that seemed to make
sense at the time. However, the logic of fee-for-service led, over time,
to a close and growing relationship between provincial health
ministries and provincial medical associations. This influence continues
today in the complex and opaque “master agreements” between provincial
health ministries and provincial medical associations that are rarely
subject to public discourse.

The end result is that provincial
medical associations have veto or near-veto powers in respect of the
many policy related issues that affect physician compensation.

and unionized hospital workers, on the other hand, have been part of
the great Canadian coalition that has successfully protected medicare at
all costs. This has afforded them a substantial political voice in
safeguarding the not-for-profit hospital sector against proposals to
encourage competition from privately-owned hospital corporations. But
along with left-leaning civil society groups, and support from the
general public, this has had the effect of halting discussion of any
possible real reform outside the current model.

There were a few
exceptions to these broad findings. In cases of newly elected first-time
governments, there were some instances of significant reforms but these
were largely within the existing medicare framework.

It appears
that supporters of medicare fear that once the medicare genie is out of
the bottle, all bets are off. The fear of going backward has created a
fear of debating the future — and may be part of what has prevented us
from moving forward.

In a nutshell: Provincial medical
associations, other health care provider bodies, the labour movement,
and the general public all prefer the arrangements that we created a
half-century ago than to undertake reforms with an uncertain outcome.

What does that mean for health reform going forward?

means that the chances of reform on a very large scale — the proverbial
big bang — are slim at best. It took the Great Depression and the
Second World War to create the political climate in Canada that enabled a
new innovative postwar social contract among Canadians in the form of
medicare. Without some sort of insurmountable disruptive force, either a
major shift in medical science or technology or a catastrophic economic
or political crisis, fundamental health policy reform in Canada in the
future remains unlikely.

Harvey Lazar is adjunct
professor at the School of Public Administration, University of
Victoria. His co-edited book, Paradigm Freeze: Why it is so Hard to
Reform Health-care Policy in Canada, was published by McGill-Queen’s
University Press. He is an advisor with

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