Reforming Canadian Healthcare

The provinces are responsible for administering and delivering healthcare in Canada and while provincial jurisdiction may appear odd, it was not of major concern when the Fathers of Confederation ratified the British North America Act in 1867. Following several years of debate, however, the Judicial Committee of the Privy Council declared the provinces responsible for administering and provisioning healthcare. The federal government is responsible for public health, in addition to providing healthcare to certain groups, including First Nations, Inuit, military personnel, and federal inmates. It does provide funding to the provinces via the Canada Health Transfer, which is supposed to assist them with costs and ensure some degree of equivalency between provincial healthcare systems.

Former Saskatchewan Premier Tommy Douglas, widely recognized to be the “Father of Medicare,” fought ardently for the implementation of a publicly funded healthcare system. In 1962, one year after his departure from provincial politics, Saskatchewan began providing public healthcare and, shortly thereafter, so too did Alberta. Former Prime Minister John Diefenbaker, in 1958, announced the federal government would fund 50 per cent of provincial healthcare, and eight years later, then Prime Minister Lester B. Pearson ratified this motion.

As a result, Ottawa’s role in healthcare funding is controversial and has been a major policy issue in Canada. Indeed, without federal funding, there would be significant disparities among the provinces in terms of quality, yet, despite these concerns, healthcare innovation is provincial jurisdiction.

The debate over federal funding remerged following the expiration of the Canada Health Accord, established in 2004 under Paul Martin’s tenure as Prime Minister of Canada. It guaranteed six per cent annual increases in funding for healthcare and was supposed to help with deficiencies, such as high wait times. Stephen Harper’s government recently committed to a six per cent increase until 2017, after which the government will fund based on inflation-adjusted economic growth (although the level of funding will not fall below 3 per cent). This development has prompted critics to demand the government return to guaranteeing the six per cent increase, arguing that underfunding issues could worsen the system, and more worrying, allow new issues to emerge.

However, despite funding increases, very little has changed in terms of quality. Kelly McParland of the National Post, for instance, notes the lack of progress in reducing wait times. Moreover, citing the Health Council, he noted that homecare services for seniors are inadequate, primary care is insufficient, and prescription drugs are unaffordable. For example, as reported by the National Post, the federal government has given $41 billion in extra healthcare funding since 2004, yet in 2010 Canada ranked last of 11 countries in wait times.

McParland is not the sole critic. Indeed, there are several reports revealing the shortcomings of Canada’s healthcare system given the amount of money spent on it. Funding, therefore, is not necessarily the issue. There needs to be real reform of the Canadian healthcare system: Ottawa should retain its role, however, the provinces must consider new healthcare models as a means of strengthening their programs. Perhaps the first step ought to be reforming the Canada Health Act to be less restrictive in terms of delivery requirements. The Act requires that healthcare be publicly administered, greatly restricting any partnership with private entities. France, on the other hand, embraces a two-tier system, which typically performs highly in comparison to healthcare systems administered by other rich, democratic countries, in terms of both cost and outcome.

Randy Kaye is a 2013-2014 Atlantic Institute for Market Studies’ Student Fellow. The views expressed are the opinion of the author and not necessarily the Institute

Applying “Do No Harm” to Politics

The Hippocratic Oath requires medical professionals to uphold certain ethical standards, the most famous of which is the mantra, “Primum, Non Nocere,” translated as “First, Do No Harm.” Because definitive diagnoses are rare, and since doctors can never really be sure what medical intervention is the best choice, this principle applies naturally in the face of uncertainty. Thus, the primary concern of all medical professionals is to ensure that they do not harm the patient.

“First, Do No Harm” parallels closely with the approval process for new medical interventions: they must be both safe (not harmful) and effective (clearly helpful). The treatment, therefore, must meet certain standards before use. However angelic the intentions of pharmaceutical companies may appear, for instance, it is clear that mistakes, bias, and even outright fraud are common and can be both injurious and fatal. As such, despite a drug representative’s best pitch, a new drug must still be tested.

In politics, however, the same standard is nowhere to be seen. When judging an intervention – that is, a policy proposal – too often good intentions are deemed a sufficient reason for adoption, regardless of whether the policy works, or harms. Needless to say, I deeply wish that politicians and bureaucrats would take a page from medical ethics and biomedical research.

The debate about ethicality in the political sphere raises important questions about public policy, chiefly concerning research integrity. Modern government, for example, is more expansive and comprehensive than its ancient counterpart. Because of this enlargement, lobbying the government for special treatment has become extremely profitable. This attracts all levels of “evidence” from lobbyists seeking to convince politicians of their view.

Consequently, legislation often features concentrated benefits for a defined group. However, the costs are dispersed to such an extent that it doesn’t pay anyone to fight against their fraction of a per cent of the harm. In this way, various interests can dominate the “evidence” landscape.

As the legendary economist, Ronald Coase, once quipped, “If you torture the data long enough, it will confess to anything.”

In this light, I have become skeptical over the years about whether truly unbiased research exists. Even randomized, controlled trials, in addition to systematic reviews, which are the highest levels of evidence, can be fraught with methodological problems, funding biases, personal ego, and other deformities. Thus, it remains unknown how to ensure “safe and effective” research in the public policy realm. Identifying the problem, however, brings it to the forefront.

Beginning at home, New Brunswickers may do well to pay careful attention to environmentally sensitive discussions. It is possible that both shale gas and a transnational pipeline could be very good, or indeed very bad. The important question is this: either way, how can we ever be sure? Other local issues that could use some solid evidence include the recent discussion around awarding the municipal policing contract to the RCMP.

Such shaky policies can also be found all around us. Here in Canada, I immediately think of the last vestiges of trade protectionism that serve special interests, including the so-called supply management of the dairy industry. Furthermore, on the environmental front, rhetoric from vested interests on both sides has clouded the discussion about such promising policies as carbon taxation. Further abroad, some public policies are either tragic, or laughable. Particularly, the United States has a history of interventionist agricultural policy that includes both paying non-farm landowners huge annual sums to avoid farming their land, as well as the outright burning of excess crops in accordance with production quota violations. Harkening back to the medical analogy, this seems akin to the old practice of  “bleeding” a patient in the vain hope of a cure.

When considering political intervention, the basic guideline of “First, Do No Harm” should be used to ensure interventions are both safe and effective. Government, however, has lagged consistently behind medicine, industry, and other fields in regards to evidential value, which seems irresponsible. I hope that the tide can turn before the trend continues for much longer.

Mike Craig is studying medicine at Dalhousie University and is a 2013-2014 Atlantic Institute for Market Studies’ Student Fellow. The views expressed are the opinion of the author and not necessarily the Institute

*This piece appeared in the 27 January 2014 edition of the Telegraph-Journal