In the prologue of her new book, Better Now: Six Big Ideas To Improve Health Care For All Canadians, Dr. Danielle Martin tells the story of her grandfather, Jacques Elie Shilton, a hard-working Egyptian immigrant who, months after arriving in Montreal with 10 family members, suffered a devastating heart attack.
At the time, the early 1950s, doctors' visits, drugs and surgery all had to be paid out-of-pocket. The combination of failing health, unaffordable care, and crippling debt destroyed the family and left Shilton dead at 54. It was an all-too-common story in the days before medicare, and it's the reason Canada has a publicly funded health insurance system.
The strength of Better Now is that it takes complex policy questions such as "why do we have single-payer public insurance system?" and makes them personal and relateable, not abstract and academic.
While it goes without saying that Martin, one of the founders of Canadian Doctors for Medicare, is a staunch believer in medicare, she is not a blind supporter of the status quo. She acknowledges that the promise of medicare – to deliver accessible, high-quality care in an equitable manner – is no longer being met, but cautions against throwing out the baby with the bath water.
"Health care isn't perfect," she writes. "But I grew up believing, as most Canadians do, that the values on which our system is built are sound. That being sick is bad enough without worrying about having to pay for your care." In other words, all the challenges we face can be solved within a publicly funded system.
Martin proposes "six big ideas" as the starting point for fixing the health-care system and improving the health of the population: Ensure relationship-based primary health care for every Canadian; bring prescription drugs under medicare; reduce unnecessary tests and interventions; reorganize health care to reduce wait times and improve quality; implement a basic-income guarantee; and scale up successful solutions across the country.
There is, of course, nothing new here – and that doesn't matter. In the 60 years since medicare began, there have been countless royal commissions, learned studies and earnest books that proposed fixes.
Martin's proposals are intriguing because they do what few others have – place as much emphasis on improving care for the individual patient as on reforming the larger health system. This "bifocal vision" is refreshing. So too is her breezy, readable writing style.
To illustrate the primordial importance of good primary care, Martin tells the story of Abida, a "complex patient" – meaning many medical problems, and as many social and economic challenges – she has been caring for since 2006. "I've slowly learned how to be there for her without always trying to fix her," she writes. And later: "The secret sauce of primary care is the relationship."
Imagine if all care was delivered with such insight and compassion – with as much head as heart? In fact, one of the recurring themes of Better Now is the need to practise medicine differently. Martin argues that overtreatment is rampant, that there is too much CYA (cover your ass) medicine, that there is too little accountability and that physicians are too often impediments to change.
As both a front-line clinician, an administrator (vice-president of medical affairs and health-systems solutions at Women's College Hospital in Toronto) and an activist, she has a unique perspective, and uncommon insight.
Some of the strongest material in the book is the "big idea" that implementing a form of guaranteed income would improve the health of Canadians. "Like medicare, a basic-income guarantee is a form of insurance against hard times, a policy that is both simple and fair," Martin writes, "… a right of citizenship rather than an act of charity."
Her call for medically necessary prescription drugs to be covered under medicare – often referred to as pharmacare – is equally passionate and convincing.
There is no doubt that implementing the "six big ideas" (or even a couple of them) would make health care better. But if there is a shortcoming in Better Now, it is that there is too little discussion of how to do it.
There is no lack of good ideas on how to fix medicare. Better yet, many of the necessary fixes have been implemented – in pilot projects or locally. But the plea to "spread and scale" innovations that Martin makes, like many before her, never seems to be heeded.
How do we get over that hump? That's the missing piece of the puzzle. Martin argues that reform can't be the job of government alone, that every Canadian has to do their part.
But one has to wonder if there is the collective will to do so or if, as in her grandfather's era, it will take a crisis of immense proportion to finally trigger bold action.
One thing is certain: As Martin concludes, we need "less talk about whether medicare is good, more talk about how to make it better."
André Picard is a health reporter and columnist at The Globe and Mail. His new book, Matters of Life and Death: Public Health Issues in Canada, will be published in April.