Smith gets in the way of health reform
PREMIER’S HARSH WORDS DO THE DEBATE NO FAVOURS — TASHA KHEIRIDDIN
For political commentators, Alberta Premier Danielle Smith is the gift that keeps on giving. Whether it’s the war in Ukraine, the oppression of the unvaccinated, or the sacking of Alberta’s entire health services board, every time Smith takes the podium, she says or does something that prompts a slew of outrage — and makes the rest of Canada’s premiers look utterly rational by comparison.
In a video widely panned on social media, she described how Albertans should all have Health Care Savings Accounts to pay for care. These would be partly funded by the state, but also by individuals, their employers, their families, indeed, anyone who could spare a dime. The video built on a paper Smith published in 2021 for The School of Public Policy, in which she wrote that “My view is that the entire budget for family practitioners should be paid for from Health Care Savings Accounts … The fundamental rethink that has to happen in health care is to create a patient-centred system … It has to shift the burden away from taxpayers and toward private individuals, their employers and their insurance companies.”
Smith is not wrong when she says that the system needs to be more patient-centred. She is also correct when she says the system must find a different way of shouldering costs. But like a bull in the proverbial china shop, her blunt words and lack of empathy smashed any possibility of a rational discussion on the subject. The image people were left with was of patients begging their relatives for money so they could go to the emergency room once they had exhausted the $375 the government had put in their HCSA.
A patient-centred system isn’t about patients paying out of pocket for services: it’s about money following the patient through the system. Currently, most hospitals in Canada receive block funding, allocated according to the demographics of the population served by the institution. This means that every patient who comes through the door represents a cost, not a benefit. The more patients a hospital treats, the less money it can allocate to each of them from the pool of money available.
This leads to rationing and triage. It means capacity goes unused; for example, there may be a block of funding for only 10 surgeries a week, which take three days to perform. The other two days, the beds lie unused and the doctors, though they might be available, cannot be paid to perform more surgeries, as the funding has been exhausted. The result is underused capacity and overlong waitlists. A patient-centred system would have the money follow the patient; in other words, the hospital would be reimbursed for each patient it treats. This would incentivize hospitals to treat more patients, not fewer, and create competition between institutions, incentivizing innovation and higher quality care.
A patient-centred system would also empower patients to choose how they want to get their care delivered, by having both public and private options available to them for all services, not just those not covered by Medicare. Courts have already ruled that in Quebec, patients should have that choice for several operations, including hip surgery. Health Care Savings Accounts and private insurance can help pay for such choices; they currently exist in Canada to pay for things not funded by the public system, including a private room in a hospital, for example. But they should represent an option, or an add-on, not a requirement as Smith would have, for getting care. No one should be denied care based on ability to pay.
Health-care costs are not a burden, as Smith describes: they are a form of social contract necessary for a decent, functional society. Yes, we should make every effort to tame them, and there should be no sacred cows. But the premier’s harsh words do the debate no favours. And they are also highly ironic. If Smith really wants people to take personal responsibility for their care, she should be preaching prevention, like the public health officials she fired. Wear a mask in crowded spaces. Wash your hands often. Get vaccinated. Try not to infect others. But hey, that would be off-message in her brave new everyone-for-themselves healthcare universe.