Issues in the News
So how about the health care system in Manitoba and throughout Canada? Should it be saved? Can it be saved? If so, what needs to be done?
These are big questions that have been nagging Canadians for the past several decades and several elections have been won on the basis of hallway medicine and emergency waiting times, not to mention the political debate over private versus public health care.
We are constantly reminded by the NDP that the public system is sacrosanct, that any incursion of private practice is the death knell of universal care. But is it?
In truth, we currently have a public/private system. Think about it. At least 25% of health care delivery is private and that number grows if you count the fact that doctors are essentially private practitioner who are forced to bill the public purse instead of you. Many things are not covered by public health care. That is why we have private medical insurance plans, although not everyone is covered. And we have some stupid ways of handling that gap. For example, prescription drugs, expensive, critical to life but not accessible to all. Some years ago, when the NDP were still in power, I had a very good salesperson who kept missing work, sometimes for a day or two, sometimes longer. I asked him what was happening, and his story made me very angry with the system.
The fellow had been working for another firm until he had a heart attack in the fall of the year before he came to me. His earnings had been reasonably high, certainly more that the benchmark $30,000 that put him in the predicament he was in at the time. Hospitalized for some time, he lost his job, so by the time he came to work for me he was in trouble because he couldn’t afford the expensive medications that kept him alive. Why? Because he had earned too much the previous year and the deductible for drugs on the government plan was tied to his earnings of the previous year. He could not come up with the $1,500 required to be spent before he qualified.
His answer was to go to the hospital every time he ran out of meds. They would keep for observation for a day or two and send him home with a limited supply of pills. Looking into this and writing about it at the time, we discovered that there was a program to bridge this gap – it is financed through Manitoba Hydro of all things. Your monthly Pharmacare bills must be at least 20% of your monthly income and the money is withdrawn automatically from your bank account.
This shows the kind of limited thinking that has gone into bolstering the system, band aiding here and there with poorly engineered strategies that always break down and in so doing continue to build a heap of bureaucratic detritus that is overwhelming the system.
Currently, we have a knowledgeable and committed health care minister, Audrey Gordon, who understands the system and continues to probe at the base levels to see what can be done to fix it. She recognizes the patchwork of fixes that are no longer working, and she is much more forgiving than I would be. And I am not convinced that she is being supported by all the bureaucrats in the system who should be supporting her reforms. But that is another article.
What I want to examine here is what can be or must be done from a high level perspective to deal with a benefit all Canadians would like to be able to rely on and for which, by the way, we all pay for through the nose.
Let us start with looking at the facts:
- Provinces spend between 30% and 40% of their total budget on health care. This varies according to the size of the province. Manitoba, with a lower GDP, is at the lower end. The Feds, on the other hand, spend only 12.2% of the total GDP on health care. (2022 figures but the increase with the recent deal is about 2%).
- 25% of all healthcare expenditures are out-of-pocket costs paid for by individuals to private health insurance to cover private health services for everything from prescription drugs to dental care, eye care, long term care and in-home care. That is just a fraction of the procedures paid by individuals.
- Nationally, hospitals on average eat up just over 24% of the total health care costs of the spending. In Manitoba that amount is 39.7%.
- Nationally docs get 13.6% of the budget on average. In Manitoba, docs get 24.4%.
No matter how you parse the numbers, it is clear that we already have a public/private system in Canada. According to “Healthy Debate”, a journal on healthcare in Canada, “Privatization, in numerous forms, is part of Canada health care. Private health care has been described as “anything beyond what the public system will pay for.” For example, if you’re in hospital, public insurance will pay for the cost of your bed in a shared room, but if you have private insurance, or want to pay out of pocket, you can upgrade to a private room, for a price.
“Private clinics have also opened in many provinces across Canada, offering services such as imaging, diagnostic tests and low risk surgeries, for a fee. Another significant area of private spending is on outpatient prescription drugs. Although some patients are covered by provincial governments, many are not, and pay for medications through private insurance, out of pocket payments, or a combination of the two.”
Across Canada, the private system fills about 30% of our needs. We pay out of pocket or buy private health insurance to cover this, often through our workplace and occasionally, privately.
So how do private/public systems work when that fact is understood and exploited? Does the private system drain away health care providers from the public system? Not according to Australian experience. A study by the Australian Human Resources for Health reported, “Physicians prefer to work in the public sector, though the value of working in the public sector is very small at 0.14% of their annual earnings to work an additional hour per week. Those with relatively low earnings prefer public sector work and those with high earnings prefer private sector work, though these effects are small.”
In examining the outcome of having a public/private system where physicians can work in with public or private medicine or a combination of both, the report found that “48% of medical specialists combined public and private sector work, 19% worked in the private sector only, and 33% worked in the public sector only.” Those that worked only in the public sector tended to be young international students.
Public/private combinations work and are already part of our health system. They should be studied with an open mind to find out the best way to deploy better care for our community.
Health Care in other jurisdictions
Excerpted from News, Medical and Life, “Health care systems around the world” by by Dr. Liji Thomas, MD
The UK National Health Service provides free healthcare for all and higher life expectancy than in the USA, at half the cost. Patient satisfaction is relatively high, at 61%, compared to 29% in the US.
The UK has public, private profit and non-profit hospitals. The first type is operated as hospital trusts or foundation trusts, in three tiers: community hospitals, district hospitals, and regional-level hospitals. Dedicated hospitals offer specialized treatment.
Patients may opt for supplemental private insurance, to get services not supplied within the public health service, or to see doctors not employed by this service. Patients in the NHS can choose a hospital and specialist. Currently, 12% of the population also opts for private health insurance, mainly to avoid the waiting period for elective care, to have a choice of specialists, and better facilities.
France, cited by some as having among the best healthcare systems in the world, has a significant private healthcare system as well as statutory health insurance, offering a wide choice of coverage.
In Switzerland and the Netherlands, health insurance is mandatory and provided exclusively by private providers. The government subsidizes the premiums through taxes, making it possible for even low-earning citizens to afford health insurance. All insurers are legally required to accept any applicant.
China has almost universal publicly funded medical insurance, with urban employees enrolled in employment-based programs. Others enroll voluntarily, for basic subsidized medical insurance. Comprehensive healthcare is covered, but deductibles and copayments apply. There is also a ceiling on reimbursement.
For-profit private insurance is also available for services not covered by public insurance. Patients share costs for physician visits, inpatient care and prescription drugs, which are uncapped.
China spends about 6.6% of its GDP on healthcare, with 28% being funded by central and local governments, 28% out-of-pocket, and 44% by public or private insurance, and social health donations. These form part of a medical assistance program for the poor.
Australia has a tax-funded universal free public health insurance program. All citizens get free care for public and many physician services and drugs at public hospitals.
About 50% of Australian citizens also take out private insurance to pay for private hospital care or dental care. This is encouraged by the government, and high-income families pay a tax penalty for not buying private insurance.
The total expenditure on healthcare is about 10% of GDP, with 67% being from the public sector. It is jointly run by federal, state and territorial governments, and is among the best in the world.
There is no perfect system, but the top runners (including Taiwan Denmark, and South Korea) all have one thing in common – they are a combination of public and private insurance and care.
Want to know how doctors are paid in Manitoba? Check out this 147-page payment schedule, then ask yourself, what is wrong with the system.
As for administrative burden, doctors say up to 70 percent of their time in seeing a patient is taken up with administration. Many of the questions on patient care forms are redundant or unnecessary. For example, docs are required to re-submit info every year for folks who will need the same treatment for the rest of their lives. They say if this work was reduced, they would have much more time to actually deal with caring for patients. In Manitoba, this is being taken seriously and the government is working Doctors Manitoba to set up a mixed experience task force that will look for ways to reduce paper burden. The report is to be released this year.