Looking at other countries with public systems, one is struck by how little Canadian medicare has changed, compared with what is happening elsewhere.
In Sweden, a country with a deep social-democratic tradition, health care has been blown open so that private and public providers compete for patients, with the state paying. In Britain, hospitals and other health-care institutions pay directly for doctors’ and nurses’ services. In Australia, a private system runs parallel to the universal public one, and people who make more than a certain income are penalized with additional taxes if they do not purchase private insurance.
None of these places, or other countries, has found the holy grail, but they have been willing to experiment and change beyond what has been tried in Canada.
Here, medicare has Cadillac costs but Chevrolet results. It’s a system unique in the world – not for its excellence (although elements of it are indeed excellent, especially for acute care) but for its gaps: Medicare covers costs associated with hospitals and physicians; beyond that, we have a patchwork of private and public coverage. As the Organization for Economic Co-operation and Development unkindly but pertinently observed, in many respects Canadians have U.S.-style medicine.
Other public systems provide some or complete coverage for drugs, eyeglasses, dentistry, home care, nursing homes, long-term care. Canada does not. At 70 per cent, this country stands at the low end internationally of what share of health care is covered by the state.
We are told that medicare incarnates Canadian values. It does not, because every country with a public system agrees with risk-sharing and equity of access.
What is Canadian is the way we give effect to those values. No other country organizes and finances health care the Canadian way, and for good reason.
We have a system plagued by inefficiencies in too many areas, especially wait times that are the longest over all in the Western world.
Canadians also pay among the highest costs in the world for pharmaceuticals, and do not receive appropriate research investments in return from brand-name drug companies. Provinces, with Ontario and British Columbia in the lead, are trying to scale back drug-cost increases by ending rebates to pharmacists and lowering generic drug prices.
Still, Canada has the worst method for purchasing drugs among all countries with largely public health care: Provinces set their own formularies, then negotiate their own deals. Instead, there should be one national buyer and formulary, as in countries such as Australia, to take advantage of bulk purchasing on behalf of the largest number of consumers.
Also, each province has a seniors drug plan. These, predictably, are a hodgepodge, and costs are rising everywhere as the population ages. As the premiers suggested in 2004, there should be a national seniors plan – paid for in the same way as the Canada Pension Plan and attached to it, with contributions from Canadians, their employers and governments, in exchange for drug coverage (with deductibles) when they turn 67. Pay now, benefit later.
Otherwise, we will continue to put costs unfairly on the shoulders of the next generation. Medicare is based on fairness across society; it also needs to be based on fairness between generations.
Canada pays doctors and nurses handsomely by world standards. According to a 2010 OECD report, Canadian specialists had the highest ratio of remuneration to the average wage of 33 countries; family practitioners had the fifth. Some provinces are – and other provinces will be – in tough negotiations to scale back remuneration increases. And why not, given how well health-care professionals and hospital administrative staff have done?
How well is that? From 1998 to 2008, the cost of physicians’ services jumped 6.8 per cent a year; half from higher fee schedules, half from higher volume of demand. Payments to physicians increased on average 9.6 per cent in 2008-09, ranging from 3.9 per cent in British Columbia to 13.4 per cent in Quebec. Nurses’ incomes from 2000 to 2009 rose twice as fast (2.3 per cent after inflation) as the average wage of all workers (1.1 per cent).
The most dramatic surge came after governments followed the recommendations of the Romanow commission and, starting in 2005, poured vast additional sums into medicare: $41-billion.