Recommended Dose of Reality

When I agreed to become the executive director of the Royal Commission on the Future of Health Care in Canada, in 2001, I thought I knew what I was getting into. After all, I had dealt with difficult and high-­profile policy issues as a provincial deputy minister and cabinet secretary in Saskatchewan. I was wrong — so wrong. Those eighteen months of the Romanow Commission, as it’s better known, would prove to be the most punishing of my career. Under a media spotlight, we were bombarded daily by individuals and organizations, all wanting to convince us of the merits and demerits of specific reforms. Some even launched pre-­emptive strikes, attacking the commission for what they presumed we would (or wouldn’t) recommend. Others personally went after Roy J. Romanow, the former premier of Saskatchewan and head of the commission, in the hope of discrediting him before the report’s release in November 2002.

Before the Romanow Commission, numerous other groups had delivered reports on health care reform to their sponsoring governments, but calls for change had fallen, largely, on deaf ears. So why the barrage of opinions, on one hand, and a lack of interest in actual reform, on the other? Because we’re talking about big business.

In fact, health care represents the largest economic sector in all high-­income countries. According to William Nordhaus, the 2018 Nobel laureate in economics, it has been the fastest-­growing part of the U.S. economy since the Second World War, as it has been in almost all high-­income countries, including Canada. The truth is that every health care expenditure by a federal, provincial, or territorial government ends up as someone’s income, so every policy change creates winners and losers. A number of those who rail against medicare are actually less interested in getting the government out of the picture than in securing their own access to tax-­funded revenues — less concerned about protecting the public purse than about lining their own pockets. Also problematic: some of the more prominent pro-­medicare groups are in the business of protecting aspects of the status quo that directly benefit themselves at the expense of the broader public interest.

Beyond the self-­interest of stakeholders, there is a polarization in the general public, between a relatively quiet majority who favour medicare principles (though they are rightly concerned about the quality and timeliness of service delivery) and an increasingly vocal minority who want medicare dismantled. How do I know the quiet ones are, in fact, the majority? At the time of the Romanow Commission, we organized a citizens’ dialogue, in which nearly 500 randomly selected Canadians from across the country met in twelve day-long sessions to discuss the options and trade-offs involved in reform. Surprisingly, each citizen panel produced similar results, irrespective of region or language. Canadians wanted major changes in the organization and delivery of care, but they remained highly supportive of the basic values underpinning medicare — hence the final report’s title, Building on Values. There have been dozens of public opinion surveys conducted since, all of which confirm the consensus.

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Nearly two decades after the Romanow Commission, more than a few books aimed at the general reader have dished up doom and gloom for our medicare system. They differ on details, but the basic narrative always goes something like this: the majority of Canadians may still support the principles of medicare, but that’s only because they have been duped by politicians. Taxpayers spend far too much on health care and get services inferior to those in other countries. Medicare may have worked at first, but it is now hopelessly outdated and in need of a major — if not complete — overhaul.

This narrative is repeated in Stephen Skyvington’s new book, This May Hurt a Bit. A long-time consultant, lobbyist, and columnist in this contested arena, Skyvington writes with a lively, highly conversational style, speaking directly to those who share some of his concerns about the sustainability and quality of our health care system. He admits to being an opinionated guy, to holding provocative opinions against the current of conventional wisdom. He explains that his first act, after being born and spanked into life by a doctor, was “to piss all over everyone” — a portent of things to come. He considers himself a rebel with a cause, dedicated to a popular movement that would fix medicare by fundamentally altering its working principles.

In Skyvington’s view, our sixty-­year-old publicly funded, single-­payer system went off the rails long ago. According to him, politicians across the ideological spectrum have peddled snake oil for decades, saying they will protect and improve medicare, but with no sincere intention or ability to do so. In Skyvington’s words, the current batch of Canadian politicians couldn’t be worse: they “are nothing more than a bevy of blathering buffoons — talking heads who look good, sound good, and seem to make sense, all while talking nonsense.” Not surprisingly, the first of his ten “fixes” is to just stop lawmakers from lying to Canadians about medicare. In other words, This May Hurt a Bit is a breezy, occasionally entertaining polemic. At the same time, it is irritating in its inaccuracies. Perhaps most unhelpfully, the book seeks to resurrect previously discredited ideas, known among policy experts as health care zombies.

The first zombie Skyvington attempts to revive: the need for user fees. He believes that if fees are set modestly, with exemptions for very poor people, they would generate significant revenues for the government, while deterring unnecessary use of medical services. However, numerous studies have shown that due to the high administrative cost of collecting modest user fees, only a limited amount of revenue is actually generated. Of course, extremely high fees might produce more revenues for government, but even Skyvington admits that this would block access for too many people. As for their role in deterring people from seeking unnecessary care, it seems that modest user fees would hardly deter upper-­middle-­class Canadians, but they would discourage the working poor and even some middle-­class Canadians from seeking the medical care they need.

The second health care zombie promoted by Skyvington: a parallel private system that can reduce wait times in the public sector. Again, ­studies from around the world pour cold water on this approach. There is, for example, no evidence that Australia’s parallel private insurance system, along with private hospitals and clinics, has produced shorter wait times in the public system, even if Australians with private insurance have faster access to care. At the same time, the private tier is supported by public money through generous tax incentives and some penalties if individuals do not buy private insurance.

For someone so piqued by lying politicians, Skyvington offers his own share of falsehoods and half-truths. To reinforce his argument that ­physician extra-­billing and user fees should be permitted, for example, he claims that Tommy Douglas, the Saskatchewan premier and father of universal health care in Canada, actually favoured user fees. This is simply not true. Douglas fought his whole life against them. He did accept that, initially, individual and family premiums were needed to supplement general tax revenues. However, these premiums were prepaid, like taxes (indeed, they were eventually integrated into the regular tax system). Douglas held that there should never be a charge at the point of service, as any fee could deter individuals from getting needed care.

This May Hurt a Bit argues that the Canada Health Act, passed in 1984, prevents major reform. This, too, is untrue. As Skyvington himself admits, the act does not tell provinces how to administer and deliver care; it simply sets a floor along with a few national standards for provincial governments. They must, for example, provide universal access to hospital and medical services to all residents based on need rather than ability to pay, and they must ensure portability of coverage when their residents travel to other parts of the country. Constitutionally, however, the provinces are in the driver’s seat. It is up to them if they want to exceed the floor of hospital, diagnostic, and physician services and cover, for example, vision care and dental care (which Skyvington argues they should and could provide, if individuals covered more of their hospital and doctor costs). Moreover, provincial governments don’t even have to adhere to the Canada Health Act as long as they are willing to forgo their per capita share of the federal Canada Health Transfer, worth on average just over 20 percent of provincial spending on health. The Canada Health Act is hardly the iron cage described by Skyvington.

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Skyvington is at his best when describing his experiences as a health care consultant and lobbyist for the Ontario Medical Association in the 1990s and early 2000s. Provincial medical associations such as the OMA represent physicians throughout Canada and exert great influence. On occasion, provincial governments have confronted these powerful associations in the pursuit of reform, and they have paid a high price each time. The most famous confrontation — a twenty-­three-day doctors’ strike in Saskatchewan that the government allegedly won in 1962 when trying to implement universal medical care coverage — forced a compromise that preserved the existing model of physician practice and dramatically increased remuneration for doctors. The ceasefire agreement actually enhanced the power of medical organizations by creating what the policy scholar Carolyn Tuohy long ago described as a jointly organized duopoly between organized medicine and provincial governments.

The problem is that the decisions resulting from these confrontations have not been arrived at in a transparent way, and Skyvington lifts the veil on this shadowy world in his book. Something that has always puzzled me about the OMA is that, unlike similar organizations in other provinces, membership is mandatory. How did this happen? As part of a deal with doctors to contain budget costs (a laudable objective), Bob Rae’s NDP government passed the Ontario Medical Association Dues Act in 1991. The extra money from mandatory dues certainly helped the OMA, but it was of questionable value to Ontario residents and even rank-and-file doctors. It was also highly questionable public policy that has not, to my knowledge, been reconsidered.

Skyvington also tells us about the origins of Ontario’s primary care reform, and how the OMA initially drove care design. Little wonder the early models kept doctors in charge. Furthermore, he gives us the inside dope on the changes wrought by Progressive Conservatives with Mike Harris’s Common Sense Revolution of the late 1990s, while criticizing Harris for trying to strip the OMA of its right to represent all of its members and (even more) for missing an opportunity to introduce a parallel private health care system.

However, Skyvington’s contempt really leaps off the page when he reviews the tenure of the Ontario Liberals between 2003 and 2018. He describes the Commitment to the Future of Medicare Act (2003), which reinforces access based on medical need rather than ability to pay, as “abhorrent.” And he portrays Eric Hoskins as a traitor to the medical profession, calling him the worst provincial health minister ever for his role in the Patients First Act (2016) and the Protecting Patients Act (2017). Skyvington’s antipathy toward pro-­medicare doctors is clear, as he also brands Jane Philpott, Justin Trudeau’s former federal health minister, and Danielle Martin, the founder of Doctors for Medicare, as traitors. However, I would contend that these individuals are just as dissatisfied with the status quo as he is, but they disagree with him on the fundamental problems and, therefore, the reforms that are required.

What truly needs fixing in Canadian health care is much closer to the coal face: how we pay doctors, manage hospitals, and treat patients; how we use technology (we cling to fax machines and paper documents instead of electronic medical charts and health records); how we coordinate services. I could go on and on. Access to medicine based on need, rather than ability to pay, is not the problem, either. Nor is the fact that we publicly finance about 70 percent of all health care, a figure that is actually lower than the average for high-­income countries. We should instead be focused on improving quality, safety, and timeliness of service, even as we provide greater accountability to those we serve.

According to Skyvington, the heroes of reform in Canada include people like himself who regularly question the consensus that universal health coverage is beneficial, along with the many nameless and faceless doctors who struggle mightily every day, against almost insurmountable odds, to make a broken system work as well as it can for the patients they serve. At one point, he singles out Brian Day, who has been fighting for parallel private health care for decades. Love him or hate him, Day’s foreword to This May Hurt a Bit is worth reading, if only for the fact that, in three pages, you get a summary of Skyvington’s main arguments, pre-­empting the need to read the rest of the book.