Canadians keep being told that we have one of the best health-care systems in the world. And we want desperately to believe that we do.
Since public health insurance came to Saskatchewan 50 years ago under the Co-operative Commonwealth Federation (and became fully national 10 years later), medicare has become a Canadian icon.
According to a 2010 Environics survey, 85 per cent of us ranked it as our most important national symbol, and myriad polls identify health care as our most important issue. In other countries, public health-care systems are important social programs; in Canada, medicare is who we are.
But medicare is like any 50-year-old – it is showing signs of wear and tear. The principles of risk-sharing and public organization remain sound, but the application of those principles is creaky. Talking about change, however, is difficult when it is wrapped up with the nation’s self-definition.
Medicare is the third rail of Canadian politics: Touch it and you die. Political survival demands avoiding a serious debate. Instead, election campaigns usually consist of bidding wars among political parties promising to spend more on health care.
Deeper discussions get snuffed out immediately by accusations that critics harbour secret plans to bring “two-tier” U.S.-style health care to Canada. “Down there,” former prime minister Jean Chrétien liked to quip, “they check your wallet before your pulse.”
The U.S. comparison is a bogeyman – no Canadian public figure since medicare began has ever argued for U.S.-style health care. Why would anyone want it? The United States spends 50 per cent more of its national economy on health care than Canada, without getting 50 per cent better outcomes.
Put the U.S. example aside and instead compare Canadian medicare with other largely public health-care systems in the world: Alas, Canada’s performance is only average at best when judged by money spent versus results.
Today, health care consumes 11.7 per cent of the gross domestic product and eats up 42 to 46 per cent of provincial budgets. In most years, health-care costs grow faster than provincial revenues, faster than population growth plus inflation and faster than economic output.
From 1998 to 2010, health-care spending in Canada rose by 4.7 per cent a year after inflation. No other program’s spending increased remotely that fast.
Post-2008 recession, deficit-laden provinces are trying to keep spending increases much lower. Some, notably Ontario, are succeeding temporarily.
History suggests that periods of restraint are followed by explosive growth as pent-up demand for higher wages, more beds, more tests – more of everything – puts pressure on budgets.
Something has to give.
That something is almost everything else (except education) that provincial governments do. Though no politician would admit it, health care is stealthily forcing governments to reduce spending on everything from roads to justice, social welfare to the environment, child care to recreation. Cash-desperate provinces now earmark most of their gambling revenues for health care.
Meanwhile, the population is aging. More seniors will bring more financial demands – not some kind of “grey tsunami,” but at least an additional 1 to 1.5 percentage points in cost increases per year. As well, Canada, like other Western countries, has entered an extended period of slower economic growth, meaning slower provincial-revenue growth. And the Stephen Harper government has announced that it will reduce the index for federal health transfer payments to the provinces from 6 per cent to 4 per cent three fiscal years from now.
No right amount exists to spend on health. Rich countries always spend more on it than poor ones, and Canada is rich. We could spend even more than we do – if we were prepared to tax ourselves and/or to continue to cut spending. But we need to debate the options, to have what some call an “adult conversation” about health care.
Among countries with public systems, Canada is in the top five spenders per capita from public and private sources. But it is far from being in the top five on any international survey on results, whether you measure outcomes, quality of care, wait times, patient satisfaction or other factors.
At best, international surveys show the Canadian system in the middle of the pack or lower – a 2010 study by the Commonwealth Fund, a U.S.-based health-policy research group, ranked Canada sixth out of seven countries, ahead of only the United States.