I actually think that Dr. Martin and I might have a lot in common. We are both passionate about healthcare. We both believe that Canada’s public health care system could do a lot better when it comes to serving the needs of Canadians who rely on it. We both believe that timely access to medical care should not be reliant on a person’s wealth. We both believe that social determinants of health (things like income, education and housing) drive health outcomes and the use of the healthcare system – and that by addressing those issues significant improvements in the health and well-being of Canadians could be realized. We are both young women with well-informed opinions (hers developed in the context of being a physician and my own developed as a result of being a health economist and first hand experiences as a patient) and a willingness to debate those opinions publicly.
Dr. Martin believes that a single-payer system that has a monopoly on medically necessary care is critical. Further, she believes the system could be salvaged if just 3 big ideas were implemented – National Public Drug Coverage, Less is More, and a Guaranteed Income Supplement.
In contrast – I have come to the conclusion that the single-payer system and how it is structured is a very big part of the problems that seem endemic to our system and that no idea is “Big Enough” to salvage it, and absent structural change that the most promising “Big Ideas” are simply not feasible. I believe there’s a reason why every other first-world country in the world with a universal public health system that out performs Canada’s also has a parallel private system that also provides medically necessary care. Single-payer is simply one of those ideas (like communism) that is nice in theory, but in practice and in the context of a complex reality fails to deliver the best outcomes and leaves many suffering the very real consequences of the system’s inadequacies.
Dr. Danielle’s first “Big Idea” is National Public Drug Coverage for the top 20 drugs used to treat chronic conditions in Canada. It is nothing short of shameful that Canada does not include pharmaceuticals as part of its public health system – particularly given that pharmaceutical therapy has become the cornerstone of effective medical care for many conditions. It is also shameful that the approach to pharmaceutical policy in Canada is a provincial/federal/territorial patchwork quilt. It is true that bulk buying the most common drugs would save the system money, and that providing access to those drugs would likely improve adherence among those for whom cost is the primary reason for lack of treatment adherence. National coverage of the top 20 pharmaceuticals would be a good start.
However, that is all this particular “Big Idea” is; a start. It is nowhere near big enough to actually remedy the larger problems and the larger reality that Canada’s health system is a patchwork quilt of practice and policy that is far from comprehensive. The fact that Canada runs more than a dozen different health systems (each province and territory effectively administering its own system, plus the systems run to address the needs of first nations, prisoners, members of the military, etc.) – is a massive waste of resources in and of itself. Further, while the lack of pharmaceutical coverage is lamentable, other big voids include the absence of coverage for dentistry and the services of many para-health professionals (psychologists, chiropractors, massage therapists, physiotherapists, etc.) and the absence of comprehensive coverage for long-term care. If we want a public health care system that is truly functional and comprehensive – the multitude of public systems would be collapsed into a single federal entity, and the system would be expanded to be truly comprehensive in nature to include pharmaceuticals, the services of para-professionals, and long-term care.
Dr. Danielle Martin’s second “Big Idea” is less is more. This idea is aimed at limiting the number of tests and procedures that are of questionable value or duplicative in nature. In retrospect there are a lot of things that happen in the health system that prove to be of little value, in retrospect there are things that are done that perhaps should not be done. In a perfect world – and even in this imperfect world, it is hard not to say that doing some things less would save the system money and not result in worse outcomes, in some cases, doing less might even result in better outcomes (for example the prescription of unnecessary antibiotics that lead to resistant strains of bacteria). This idea is alluring in its simplicity and echoes the environmental movement to reduce, reuse, and recycle in order to stretch what is available to the limit of its potential.
However, the idea of “Less is More” is deserving of scrutiny, particularly in healthcare. Born out of “Less is More”, are care protocols that exhaust conservative options first, denial or delay of access to diagnostic testing and denial or delay of access to treatment. The first thing to understand, is that healthcare decisions are not made retrospectively. There is no “way-back” machine to turn back time and make a different choice if the choice made proves to have been the wrong one – and for some the “less is more” will exact a terrible human toll. Further, patients are a diverse group of individuals with a diverse range of preferences and a diverse tolerance of risk. Not all patients want to wander through the conservative options first. Not all patients are going to be satisfied with denial and delay of access diagnostics or treatment. “Less is More” as a philosophy has the potential to deprive patients of informed choice and decision making with respect to their own bodies and has the potential of moving the system further away from being patient centred. Too many patients in Canada have already borne the brunt of “Less is More”, of having doctors put the needs of the system ahead of the needs of the patient – and absent any alternative route for patients to access, seems like an unjust infringement of rights that should be contested.
Dr. Danielle’s third big idea is a guaranteed income supplement. Poverty is highly correlated with levels of poor health. If you do not have an adequate income, you may not eat an adequate diet, you may not have access to adequate housing, you may not be able to make investments in your own skills to improve your chances in the labour market. Dr. Danielle’s answer is a straight-up hand out to the poor. She proposes that the tax system be used to directly transfer wealth, and that doing so will address the ills that poverty causes. Doing so will make the problems of inadequate housing, inadequate education and inadequate nutrition simply disappear.
However, this is another idea that is deserving of scrutiny and more than cursory thought. Simply giving money to the poor is attractive in its simplicity. It is what is done every time you walk down the street and give the panhandlers change. However, it neglects the reality that poverty is a symptom of underlying problems, many of which are not solved by a hand-out and for some, money may make those problems worse (in the case of addictions). It is also a bit of a “cop-out”, instead of trying to understand and address the causes of poverty and impacts on those impoverished, society buys itself out of the responsibility to be compassionate, the responsibility to give the impoverished a hand-up rather than a mere-hand out. Further, doing so would negatively distort individual decisions with respect to the development of skills, participation in the labour force, and other life choices. If the cost of making poor decisions is lowered, inevitably more poor decisions may be made. Further, it may generate even greater levels of disdain for those who are impoverished – particularly as significant tax increases on those who have made “good decisions” would be used to subsidize a share of the poor who are poor as a direct result of “bad decisions”. Merely giving money does not translate into better housing, better nutrition, better education and social integration. Canada needs to do the hard work in this area and truly get a handle on understanding poverty and its underlying causes as the solution is unlikely to be a mere hand-out. After all, it’d be a shame to spend all that money, and still have to contend with the results of inadequate nutrition, inadequate housing, inadequate education, and inadequate social integration – when that money could have been used to provide better nutrition, better housing, better education, and better social support. Good medicine is treating the underlying causes of disease and disorder, rather than ameliorating only the symptoms.
Big ideas are most definitely needed if we are going to get to a place where a truly comprehensive, universal public health system that meets the needs of Canadians is to be achieved, the biggest of which is the acceptance of the idea that it does not need to be a single-payer monopoly on medically necessary care.