On March 4, 1996, Ontario health minister Elizabeth Witmer announced major reforms to the province’s health care system.
The old fee-for-service model, in which family doctors ran their own businesses, would be replaced by group practices with salaried physicians. Health records would be digitized and shareable. Wherever possible, home care would replace institutional care. Patients would be able to consult their doctors by phone.
The reforms were long overdue, said Duncan Sinclair, head of the province’s Health Services Restructuring Commission.
“I’m glad they’ve started,” he said, “but I’m very disappointed we don’t have the results, and we won’t have them by the time we need them,” which is “today, yesterday.”
Twenty-six years later, most doctors in Canada continue to work on a fee-for-service basis. People who could be treated at home are instead stuck in a hospital bed, creating backups in emergency rooms, some of which have been temporarily forced to close for lack of staff. One person in seven lacks a family doctor.
“The system is collapsing around us,” Dr. Katharine Smart, head of the Canadian Medical Association, warned in June.
All of this was true before COVID-19 arrived. “We didn’t have an excess of care providers prior to the pandemic,” says Rosalie Wyonch, a senior policy analyst at the C.D. Howe Institute, a think tank. But because of the stress of the past two years, and the resulting burnout, “the labour shortages are worse.”
Pandemic aside, there is a simple reason for the stressed state of health care: an unwillingness on all sides to make hard decisions.
Doctors resist giving up their practices and becoming part of a team at a clinic. Professional organizations resist allowing paramedics, nurse practitioners and others to provide more services. Doctors and nurses who were educated overseas have difficulty earning accreditation to practise in Canada.
Politicians would rather cut ribbons on new long-term care institutions than increase funding for home care, because that funding gets less attention. Privacy watchdogs resist the digitization of patient records.
In the end, it’s easier simply to shovel more money into the system, or for one level of government to blame another level for that system’s failures.
Other developed countries face similar challenges, says Carolyn Tuohy, a professor emeritus and fellow of the Munk School at the University of Toronto.
But “it’s also fair to say Canada has lagged behind its peer nations.” She cites, as one example, the difficulty that provincial medical associations have in representing all specialties and family physicians, leading to a lowest-common-denominator approach to bargaining with governments, which stifles reform.
Given the failing state of the health care system, it’s reasonable to ask how governments can afford to cut taxes, as Doug Ford has done in Ontario, or launch new programs, such as the Trudeau government’s child-care initiative.
But simply prioritizing health care over everything else is a false choice, Ms. Wyonch says.
“If we were to try to fix the health care system at the expense of everything else, we would likely end up in a worse spot in 10 or 20 years,” she said.
The solution is not to spend more, but to spend smarter, in part by implementing the reforms that analysts have been recommending since the 1990s.
There is a silver lining. The pandemic forced “collaboration across health care providers and provinces on a scale we have not seen before,” Prof. Tuohy says. “There is ferment, there are mistakes, but for the first time I think there may be potential for new coalitions and collaborations.”
“There was an explosion of virtual care during the pandemic,” said Jennifer Zelmer, chief executive of Healthcare Excellence Canada, a non-governmental organization that advocates for health care reform. That shift alone could help to reduce costs.
Ms. Zelmer believes the delays in reform offer an opportunity.
“We’ve now got the option to say, ‘What’s the right set of approaches for us now, and how do we mix those approaches, based on what we’ve learned?’ ” she says.
There is nothing like a collapsing health care system to finally get people’s attention.
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