To understand the long-simmering dispute between the province of Ontario and its physicians – who have been without a contract for two years, and who recently voted down an agreement reached between the government and their union – it's important to keep a few numbers in mind.
$51.8-billion: That's how much Ontario will spend this year on health care. Health is the largest part of every province's budget – by a long shot. It consumes more than 40 cents of every dollar Queen's Park spends. The envelope is so big that even small changes could end up saving, or costing, billions of dollars.
1.8 per cent: That's how much Ontario plans to increase health spending, each year between 2015 and 2019. That little number, laid out in last spring's budget, has big consequences.
In real terms – taking inflation and population growth into account – an annual 1.8-per-cent spending increase is actually a per-capita spending cut. That's because inflation is around 2 per cent a year, and the province's population grows by 1 per cent a year. If Ontario wanted to flat-line real per-capita spending, it would be increasing by the sum of those two figures, or about 3 per cent a year.
But the Ontario Liberal government is aiming lower – and to some extent, it has no other choice.
Negative 0.6 per cent: That's how much real health spending in Canada has declined, each year from 2011 to 2015, according to the Canadian Institute for Health Information (CIHI).
In the early years of medicare, health spending grew much faster than the economy. Between 1975 and 1992, public and private expenditure on health had grown from 7 per cent of GDP to almost 10 per cent. Exploding health costs were threatening to eat provincial budgets.
As a result, Canada went through its first period of health care austerity in the mid-1990s. Whether it was Progressive Conservative premier Mike Harris in Ontario or NDP premier Roy Romanow in Saskatchewan, governments set about trying to wrestle health costs down. By 1997, Canadian health spending had fallen to 8.7 per cent of GDP.
In the years following, however, health spending once again rapidly increased, as voters decided that austerity had gone too far. By 2010, health expenditure had risen to a record level, 10.6 per cent of GDP. In response, the past few years have been a kind of replay of the mid-1990s.
In real per-capita terms, Ontario is aiming to reduce health spending by about 1 per cent a year. This may be necessary. Countries such as Australia spend less than Canada on health, while achieving comparable or better health outcomes. But bending back the cost curve, even slightly, means finding savings. And those savings have to come from somewhere. Or somebody.
$368,000: That was the average gross compensation for an Ontario physician in 2014, according to the CIHI. The figure doesn't include the considerable costs that many doctors have to bear, such as office space, equipment and staff. Nevertheless, Ontario physicians are, on average, the highest paid in Canada.
And while MDs are only one part of the health system, they are the most highly trained part, and the most highly compensated.
15 per cent: That's how much the number of physicians in Canada increased, between 2010 and 2014. Over the same period, Canada's population grew by just 4.1 per cent. In Ontario, the physician growth rate was even faster, with the number of doctors in the province up nearly 16 per cent between 2009 and 2014.
Canada has more physicians per person than ever before. There's nothing wrong with that, and rather a lot that's right about it. Back in the early 1990s, provincial governments decided to cut health-care costs by slashing medical school enrolments, thereby reducing the supply of doctors. It was a terrible idea, but the wrong choice was motivated by a real issue: Physicians are expensive.
Two out of three: There are three major drivers of health-care costs – hospitals, drugs and physicians. As part of the reforms of the last few years, savings have actually been found in two out of three, according to CIHI's most recent annual report on health spending trends.
But "the third major cost driver, physician spending, has outpaced that of hospitals or drugs since 2007," says CIHI, "due in part to more rapid growth in the supply of physicians and the increase in physician fees."
Those numbers underpin the conflict between Ontario and its doctors. Physicians want to be paid more, but the province can't do that unless it either reduces the number of doctors (bad idea), cuts spending elsewhere (which means picking fights with other constituencies), or reforms the health system to reduce demand for physician services (no easy trick). Prognosis? Don't expect Ontario and its doctors to agree on a course of treatment any time soon.