Jeffrey Simpson has been the national affairs columnist for the Toronto Globe and Mail for almost three decades. Since the turn of the new century, Simpson has written numerous critical columns on the state of health care in Canada. He has not only been a reliable weathervane for the changing critique of medicare but, as a leading mainstream journalistic voice in English Canada, he also shapes the views of his readers. It is not surprising, therefore, that considerable attention has been lavished on his latest book, Chronic Condition.
The good news is that the book goes beyond simply rehashing Simpson's past critiques. More space is devoted to the facts--the statistics and individual stories on which Simpson builds an argument for major change. The bad news is that on the basis of these facts Simpson ends up drawing some very questionable if not erroneous linkages, and this puts into serious question both his diagnosis and his policy cure for what ails Canadian medicare.
Since the 1990s, a stream of books and think tank essays have criticized the Canadian model of universal, tax-financed medicare. At first the critics argued for more private delivery of government-financed medicare services. This was always a red herring given that in Canada the vast majority of doctors and their clinics are private for-profit operators. And while it is historically true that most hospitals in Canada were owned by religious orders, charities and municipalities and hence were not-for-profit, they were not owned by provincial governments. This has changed somewhat with the introduction of regional health authorities in the 1990s, but in some provinces, such as Ontario, hospitals remain private not-for-profit organizations separate from government. In any event, there is nothing in the Canada Health Act that prevents provincial governments from allowing the private delivery--for-profit or not-for-profit --of medicare services
By the 2000s, the brief against medicare had shifted to the single-payer model of funding. This became most obvious in the 2005 Chaouilli decision by the Supreme Court of Canada. A slim majority held that the government of Quebec could not hold a "monopoly" on funding health services if it permitted wait times for surgery that might put patients at risk. In such situations, provincial residents should have the right to purchase private health insurance permitting them to obtain more timely health services. Although Cbaoulli was not the killer punch to medicare that proponents had hoped, other cases have been launched that strike at the heart of the Canadian model of medicare.
In fact, the antimedicare coalition has become ever more vocal since Cbaoulli. And its activists are willing to back up their beliefs with hard cash: they conduct expensive litigation and fund think tanks such as the Fraser Institute, which has led the charge in favour of private delivery and private health insurance. Recently, Dr. Brian Day--the medical profession's most outspoken critic of medicare --and his Cambie Surgeries Corporation in Vancouver have sued the government of British Columbia on the grounds that its single-payer administration of medicare (and therefore all provincial and territorial models of medicare) is a violation of sections 7 (individual right to life, liberty and security) and 15 (individual right to equal protection and equal benefit) of the Canadian Charter of Rights and Freedoms. The case will he winding its way through the B.C. courts to the Supreme Court over the next two to three years and will no doubt trigger further debate on the Canadian model.
I have no argument with Simpson's basic contention that Canada has slipped on a number of health and system performance indicators in the last two decades. At the same time, other facts demonstrate the situation to be not nearly as dire as Simpson has presented. This is not to defend the status quo--far from it. In almost everything I have written in the past decade, I have argued that we can and should do better, but we have got some things right, and we should build from these strengths. At the same time, we need to identify the institutional impediments to progress and be prepared to make major changes irrespective of those interests that are vested in the status quo.
Is the system fiscally sustainable?
Let me start with the issue of fiscal sustainability. Simpson is correct that health care has been eating up an increasing proportion of provincial government budgets in the years following the fiscal retrenchment in the mid-1990s. This has put considerable fiscal strain on the provinces.
However, since 2000, governments have chosen to reduce taxes and, at least in the case of the federal government, increase tax expenditure subsidies. In other words, they have reduced the denominator even as the numerator needed to increase--after a half decade in the mid-1990s during which Canadian governments drastically restricted health spending. Putting the revenue issue aside, where does Canada sit, comparatively speaking, on the expenditure side of the equation? Is Canadian spending on health care truly unsustainable relative to similar OECD countries?
Figure 1 plots per capita growth in public health expenditure against per capita growth in GDP for all OECD...