A commentary by a previous deputy provincial health officer
Ken Fyke’s June 30 commentary is an admirable summary of the development of health care in Canada, and he includes all its present woes. His plea for primary care reform is described in the hopeful prescription advocated for by Dr. Jane Philpott, previous federal health minister, in her book Health for All.
This prescription raises, however, several questions. Will it create an add-on health care cost? Will it enable better access to care? Will it result in better outcomes for individuals, particularly for seniors?
We need to think about how health care is delivered in Canada, and what levels of government are responsible compared to other countries.
A recent publication from the Canadian College of Health Leaders compares the performance of the Canadian and Australian health care systems.
In five major indicators — access, care process, administrative efficiency, health care outcomes and equity, Australia outperforms Canada by at least five points. The data come from Commonwealth Fund reports and the Organisation for Economic Co-operation and Development (OECD).
The most important difference between the two countries has been the role of the national government.
In Australia that was established in 1946. It gave the national government authority for the development of health care such as a national pharmacare program in 1950 and a national long-term care program in 1963. Even though private insurance is available in Australia, the authors of the recent report did not consider it was a critical factor. It likely, though, played a part in the performance of the health-care system.
As Fyke references, Canada has a dysfunctional health care system due to the federal-provincial relationship that is defined by the Canadian Constitution Act of 1982. In Canada the provinces are responsible for the delivery of almost all health care.
The political action that is needed is to change the Constitution Act to give the federal government more power and authority over health care. This will be difficult to achieve. It requires two-thirds of the provinces containing at least 50% of the population to change this act.
The other political action that is needed is to modify the Canada Health Act to recognize there is a place for private insurance and private pay. This act is “to protect, promote and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health services without financial or other barriers.”
Reasonable access is sadly lacking at this time for many residents.
British Columbians are getting access to private care though such insurance as WorkSafeBC, ICBC and increasingly by private payment. Members of Parliament have access to a private public health-care plan that covers more services than available to all Canadians.
The reason there is no easy fix to Canadian health-care delivery is that the Canada Health Act does not allow any private pay in provincial health care delivery, otherwise the federal government will reduce the transfer payments to the provinces, who are responsible under the Constitution Act to provide these services to most Canadians.
The federal government has the provinces in a firm financial grip (Philpott continues to advocate for this mechanism) but paradoxically does not have the authority under the Constitution Act to deliver health-care services as in Australia.
Because of the insatiable demand on health-care services due to continued advances in medical care, as well as public expectations, there must be some form of private pay or co-payment in the future.
No-one wants to talk about private pay or private insurance, because they fear a U.S. type of for-profit health-care industry.
The U.S. has an uncontrolled for-profit health-care industry. However, if you review the health care delivery in many other western countries — such as Australia, France, the U.K. and Switzerland — you will find there are different, albeit government-controlled legislated, mechanisms for private pay or co-payments.
Is changing these Canadian acts achievable? It needs action by our federally elected politicians.
For many years Canadians’ belief in the present system has supported the present legal arrangements for delivery of health care. It is time for a change.
Australia has a national primary care strategy, as do other countries. Here in B.C. there is already some primary care reform with the increasing role of pharmacists, recognition of the role of nurse practitioners and possibly physician assistants.
It will improve access to care particularly for minor ailments. Will it improve outcomes, though?
Seniors often have multiple medical issues that still need a primary care physician to coordinate the care that may be provided by several organ-specific specialists.
Primary care reform is a nice banner for federal and provincial governments to support together, but it should be questioned whether it can be implemented, and more importantly will it improve the outcomes that matter to all Canadians, particularly seniors.
Only changing the federal acts to be more in line with Australia’s system of care will achieve this.
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