A health care worker in the intensive care unit at Toronto’s Hospital for Sick Children, on Nov. 30, 2022.Chris Young/The Canadian Press
Andrew Boozary is a primary care physician, policy practitioner, researcher and founding executive director of the Gattuso Centre for Social Medicine at the University Health Network. He holds the Dalla Lana Professorship in Policy Innovation at the University of Toronto.
Crisis. Broken. Medicare on life support. These are the words we see all too often in headlines about the Canadian health care system. Patients and caregivers are forced to wait for more than 20 hours in emergency departments. Millions of people are without access to primary care. The moral distress of health workers is palpable.
It feels hopeless. But there are practical solutions and innovations in the public system that we are letting die.
Over the past few decades, we have seen major advances in medical therapeutics and basic science, including the Nobel Prize-winning effort to develop a COVID-19 vaccine. But with almost every scientific advance, we have failed to urgently deliver these groundbreaking therapies to those who need them most. This delivery gap has driven unconscionable health disparities, especially for illnesses such as diabetes, cardiovascular disease and cancer. This is the paradox of our universal health system – those who most need health care are the least likely to have access.
This has left patients, caregivers and health workers in impossible situations – and now, much of the public discourse is pointing to for-profits as the sole source of innovation. But the evidence is far less convincing. In studies from the United States and Britain, when private-equity firms acquired hospitals or when surgeries were outsourced to for-profit entities, there were significant increases in avoidable injuries and death. Here in Canada, the Alberta government recently chose to de-privatize lab services after their own reports showed private lab tests cost significantly more than public ones. And though Saskatchewan has been piloting privately paid MRIs since 2016, this experiment never put an end to long wait times.
So what delivery innovations have worked? Many success stories are from within the public system, and many during the pandemic. One was the delivery of COVID-19 vaccines to neighbourhoods that needed it most. The early vaccine rollout saw life-saving interventions sequestered in select pharmacies and other health care settings. Community leadership taught the health care system a lesson in delivery innovation when it set up vaccine clinics where people were: right inside apartment buildings or out in mobile clinics. Another innovation was equipping vaccine teams with community health workers – highly skilled individuals with shared experiences who can help people navigate the system. This ingenuity is not confined to public-health emergencies, as other countries have seen community health workers reduce the likelihood of patients being readmitted to hospitals by offering continued health and social supports once they are discharged.
Even more examples of public innovation come from Alberta, where an integrated approach to hip and knee surgeries resulted in an average wait time of just 37 working days from consultation to surgery; previously, it took 290 working days. Saskatchewan saw similar results in surgical access when it set up a central referral registry – basically a single queue ensuring that each patient is seen by the next available surgeon based on their acuity and need. The program saw an 89-per-cent reduction in the number of patients waiting more than three months for surgery. Neither of these programs required out-of-pocket payments or for-profit management – but both these programs have since ended.
That we have failed to scale or even preserve homegrown success is exactly why the late federal health minister Monique Bégin once described Canada as a “country of perpetual pilot projects.” Short political cycles don’t align with the longer timelines for returns on public-health investments, nor do isolated ministries that rarely get to collaborate on health initiatives that have siloed budgets. As an example, it may be obvious as to why a $400 air conditioner for a low-income household is a prudent investment when it can help prevent a $15,000 hospital admission for heart failure or heat stroke in the summer. But the incentives to do so are seriously misaligned when any cost savings that come from investing in housing or air conditioners are never shared across ministries.
Currently, Ottawa is negotiating with the provinces over health care funding – and part of that negotiation should include accountability on performance outcomes that matter to patients. We also need better data reporting to illustrate where we are falling short and in which communities, and to identify where we can make serious investments in the health work force or implement team-based care models from the hospital to the home, to most effectively address delivery gaps. How can we say we have a universal health system when millions are without access to primary care? Why are we left wondering why emergency departments are being pushed to the brink when we have some of the fewest hospital beds per capita amongst OECD countries?
Ottawa cannot continue to let successful pilot projects fall by the wayside. One public example at the federal level is the U.S. Center for Medicare and Medicaid Innovation. Its focus is to identify and evaluate delivery care models that work in local settings – such as more equitable ways to access primary care – and to then shape policies that will help them scale across the country.
Right now, patients, caregivers and health workers are desperate for real solutions. Policy makers across every level of government must respond by working together to deliver on the promise of medicare – a high-performing health system that prioritizes access on need, and not the ability to pay. Failing to do so would ultimately be a matter of life and death.