Build health care back better
For nearly a year the COVID-19 pandemic has played havoc with our already dysfunctional health-care system. Shawn Whatley has written an erudite and informative book, When Politics Comes Before Patients, about how the health-care system ended up in this morass and how it can get out. A doctor and former head of the Ontario Medical Association, Whatley’s command of both medicine and management uniquely qualifies him to diagnose what ails our health-care system.
The flaw at the heart of Canada’s socialized medicine, Whatley argues, is the focus on planning and distributional issues instead of results and patient care. The expansion of bureaucracy and government control of health care has led to a deterioration of outcomes, notably the steady growth of costs for taxpayers and wait times for patients. Canada has become the poster boy for Gammon’s Law, which states, based on a British study of the National Health Service, that increases in health-care spending will be matched by lower production: spend more, get less.
Canada’s health-care system is now best known around the world for its waiting lists. This is ironic for several reasons. despite its obsession with planning, Canada’s health-care bureaucracy never planned that waiting lists would be the outcome of its policies and actions. And “access to waiting lists is not access to health care,” as one Supreme Court justice trenchantly observed. Moreover, waiting lists open the door for inequality in access to health care, when greater equality was the main justification for Medicare.
Waiting lists lead to both unequal access to health care and queue-jumping, facilitated by personal contacts in the health-care system, celebrity or political or other influence: preferential access is a prime motivation for donating to hospital foundations, as TV star and NBA owner Mark Cuban once said after being treated in a Toronto hospital. Queue-jumping is so common that in 2004 Ontario passed a law forbidding it, though it has never been enforced.
Of course, the ultimate form of queue-jumping is to go outside Canada’s public health care for treatment, including to the united States, following the well-trodden path of our political leaders, including former prime minister Jean Chrétien, and former premiers robert Bourassa and danny Williams. Or it may mean going private within Canada, as renowned socialist and equality advocate Jack Layton did for hernia treatment. Bypassing wait lists in Canada for treatment in the u.s. foreshadowed the current wave of politicians and senior health-care bureaucrats ignoring COVID travel advisories and vacationing in the sunny south. Whether in “confinement-jumping” of this sort or in queue-jumping in health care, elites clearly do not hold themselves to the same standards as ordinary people. As Orwell wrote in Animal Farm, “All animals are equal but some animals are more equal than others” — which is roughly what equality means in government today in Canada.
Waiting is not an unavoidable result of our health-care system. Maternity wards always have enough capacity, because the optics of a mother in labour arriving at a hospital with no open beds are too gruesome for politicians to imagine, so every hospital ensures enough resources are always available.
Whatley says there is no doubt that “socialism” is the right word to describe Canada’s health-care system. Some argue our system is a hybrid of public payment and private provision, with doctors’ offices and even hospitals nominally in private hands. But governments took control of essentially everything when they shifted from passively funding health care to actively managing it in the 1990s. They dictate who doctors can see, what care is offered, what prices are to be charged, which technology can be used and what data is to be reported and how. Such complete control is socialism even if government does not own all the means of production outright.
That data plays an increasing role in the healthcare system is one symptom of how bureaucratic planning has taken over. doctors know that their relationship with patients cannot be reduced to numbers, yet bureaucrats insist on collecting irrelevant data so they can devise the procedures and regulations that both dictate patient care and pretend to measure outcomes. Whatley describes how form-filling also serves the purpose of reducing the time doctors have for medical procedures, thus lowering billings to government.
The fundamental problem with planning was evident from the outset of Medicare. In the words of political scientist James C. Scott, planners “regarded themselves as far smarter and far-seeing than they really were and, at the same time, regarded their subjects as far more stupid and incompetent than they really were.” The result of planning in the health-care system is bureaucrats dictating to doctors because, as Whatley bluntly puts it, regulation “replaces knowledge with power.”
Whatley wants to restart a national dialogue on health care and sees the COVID crisis as the opportunity to do this without ideologically-motivated experts shouting down any questioning of our current system. It should now be obvious to all that the chaos in health care created by the pandemic’s delaying or cancelling millions of medical tests and procedures and driving some practitioners out of business will require the system to reform itself if patient care is to return to an acceptable level. Patient care and not phoney bureaucratic metrics or political grandstanding about equality has to be the focus for everyone as we pursue what should be our overriding goal for the post-pandemic health-care system: yes, building it back better.
HEALTH-CARE SYSTEM IS NOW BEST KNOWN AROUND THE WORLD FOR ITS WAITING LISTS.