Western Standard - August 08, 2022


Bacchus Barua of the Fraser Institute on health care reform

Topics
universal health care wait times and healthcare reform
Mentioned
COVID-19 Brian Day Baskin-Robbins Canby
Mark Milke of the Aristotle Foundation how the right has to stop acting like the left Triggered： A provincial police force is worth the investment

Episode Stats


Length

14 minutes

Words per minute

201.04

Word count

2,925

Sentence count

176

Harmful content

Misogyny

2

sentences flagged

Toxicity

1

sentences flagged


Summary

Summaries generated with gmurro/bart-large-finetuned-filtered-spotify-podcast-summ .

In this episode of the podcast, we speak with health care researcher and CEO of the Commonwealth Fund, Dr. Robert Lustig, about the state of Canada's health care system. Dr. Lustig joins us to discuss the challenges facing Canadian health care, and what needs to be done to fix them.

Transcript

Transcript generated with Whisper (turbo).
Misogyny classifications generated with MilaNLProc/bert-base-uncased-ear-misogyny .
Toxicity classifications generated with s-nlp/roberta_toxicity_classifier .
Topics generated with Qwen2.5-3B-Instruct.
Hosts, guests, and mentioned names generated with spaCy (en_core_web_sm), reconciled against Wikidata.
00:00:00.000 Our health care resources just seem to be incapable of keeping up.
00:00:03.880 We've got in Calgary, an urgent care center that's been reducing its hours, one in north of the city that's shut down for weekends.
00:00:11.700 I believe in the East Coast, we're seeing, again, hospitals and such that just don't have the staff or the ability to keep up.
00:00:18.540 But still, we aren't hearing discussion on the system.
00:00:22.180 And that's where I get concerned.
00:00:23.860 You know, we're in a very, very difficult situation right now.
00:00:26.800 As you said, you know, there are years closing across the country.
00:00:30.880 We have many physicians who are leaving the system.
00:00:35.880 There are situations where nurses are burnt out. 1.00
00:00:38.280 And, of course, none of it is really their fault.
00:00:40.440 They've had an incredibly difficult two years.
00:00:43.400 But it is a tough situation right now that should not be taken lightly.
00:00:49.040 It's probably, you know, the first reaction would be to kind of put all of the blame or the onus on COVID-19.
00:00:55.220 And certainly COVID has pushed the system to its limits and exacerbated a lot of the problems.
00:01:00.760 But to really understand what's going on, we actually need to roll back the clock a little bit to 2019 before COVID was there.
00:01:06.980 Because then we can start to disentangle what's due to COVID and what's actually due to our system.
00:01:12.380 And one of the things that we can do is look at one of our studies, actually quite a few of our studies in 2019 that look at data for Canada compared to other countries in the OECD, specifically countries with universal health care.
00:01:25.620 And what we find is that Canada, for the longest time, is routinely ranked amongst the top spenders.
00:01:31.680 But we aren't seeing value coming out of that spending, at least not to a commensurate level.
00:01:37.240 We routinely rank, you know, either second highest as a percentage of GDP after adjusting for age or eighth highest in terms of per capita.
00:01:46.820 Again, that's out of 28 universal health care systems are really amongst the top.
00:01:50.860 But when we look at the numbers for physicians, we were, you know, right at the bottom, we were ranked 26th out of 28th for physicians.
00:01:57.300 We were ranked 14th out of 28th for nurses.
00:01:59.480 And we were ranked 25th out of 26th for beds.
00:02:02.320 So even in 2019, this is the picture of the system that was already pushed to the limits.
00:02:07.880 And we experienced those limits during COVID-19.
00:02:11.480 And it seems like we're starting to fall off that precipice.
00:02:15.220 Yeah, and it's unfortunate that, yeah, you know, COVID's kind of exacerbated a problem we already knew we had.
00:02:20.860 Or at least those of us watching the system knew.
00:02:23.420 But I mean, so if we're going to look at systemic reform, hopefully some people are ready to start, you know, at least poking into it.
00:02:28.900 Because we turned it into a bit of a sacred cow and people don't discuss it.
00:02:31.680 But we've got to accept that there's got to be some changes.
00:02:34.160 But that key word that a lot of people miss is universal.
00:02:37.060 I mean, that's the value everybody wants, I believe, in Canada.
00:02:40.620 They don't want to move away from that.
00:02:41.840 They're fearful that we can move into a system where they wouldn't be covered any longer.
00:02:45.580 But that's not what anybody's proposing at any point.
00:02:47.720 No, and, you know, one of the things we've done very purposefully in our report is only looking at countries with universal health care.
00:02:55.040 And I think it's a little sad that the discussion in both Canada and the United States tends to focus on each other a lot of the time.
00:03:04.240 You know, the United States loves to, you know, well, I'm not saying the United States in general.
00:03:07.660 But a lot of defenders of their system seem to, you know, want to reel against Canada's wait times very specifically and say, well, that's how all universal health care systems look.
00:03:16.880 And in Canada, you say, you look out at the border and say, oh, you know, we don't want to import the problems that we've seen in the United States.
00:03:21.880 And really, we're just putting blinders on ourselves.
00:03:24.360 I mean, there are countries like Switzerland, Netherlands, Germany, France.
00:03:28.520 All of these countries have universal health care.
00:03:30.220 They're spending about the same as we do.
00:03:31.820 But they have remarkably more doctors.
00:03:33.660 They have more nurses. 1.00
00:03:34.860 They have more beds.
00:03:35.860 And, of course, all of them had the same struggles with COVID-19, maybe to some varying degree.
00:03:41.480 But they were starting at a very different baseline.
00:03:43.580 You know, I have some interesting numbers when we're looking at wait times for elective surgery.
00:03:49.100 This is from the Commonwealth Fund.
00:03:50.400 And it reported that in 2020, 62% of Canadians were able to get surgery within four months for elective surgery.
00:03:58.060 By contrast, in Switzerland, 94% of patients were able to get treatment within that time frame.
00:04:04.260 And in Germany, 99%.
00:04:06.180 And before even then, you know, 2020 is, again, getting into COVID territory.
00:04:10.760 But if you look at 2016, the numbers were basically almost the same.
00:04:13.660 In fact, in 2016, 0% of German patients were waiting longer than four weeks for elective surgery.
00:04:20.620 So these are all countries with universal health care that don't seem to have the long wait times that we do.
00:04:27.120 And in some cases, they're actually spending the same or lower than Canada is.
00:04:30.920 So the key really is not about spending, which is unfortunately what a lot of the, not a lot,
00:04:36.900 well, all of the current premiers are advocating for with their increased CHG transfers.
00:04:42.500 But it's really about what is happening to that spending.
00:04:44.880 Why aren't, why is it not translating into more doctors?
00:04:47.640 Why is it not translating into shorter wait times?
00:04:50.820 And what can we change in our policies?
00:04:52.860 And what's stopping us from changing those policies right now?
00:04:56.800 Yeah, well, I imagine the answer to the question of what's stopping us is the Canada Health Act.
00:05:00.820 It needs some changes to allow the flexibility to make some policy changes.
00:05:04.440 But let's say, assuming, you know, the government's receptive to opening the act
00:05:09.100 and changing some of these things, what sort of changes could we implement then
00:05:13.300 that would help us move more towards those sorts of outcomes like Germany, you know, in a universal system?
00:05:18.240 Well, when we look at the basket of countries that generally perform better than Canada,
00:05:23.460 there are three things that they do very differently.
00:05:26.400 The first is their general attitude towards the private sector.
00:05:29.540 And that is looking at the private sector as a tool, either as a partner to deliver on the universal health care promise
00:05:36.740 or as a pressure valve to kind of, you know, serve as a way out once the public system is overburdened.
00:05:43.420 The second thing that they do differently is that they generally expect patients to share in the cost of treatment.
00:05:48.540 Now, this is, you know, something like maybe a $300 to $400 deductible.
00:05:52.880 It could be 10% of the cost of treatment.
00:05:55.080 Of course, they understand that there need to be limits so that there's never a financial burden.
00:05:59.160 So there's an annual cap on payments.
00:06:01.180 There are exemptions for vulnerable populations.
00:06:03.880 And the third thing that they do differently is they fund their hospitals based on activity.
00:06:07.660 And what that does is that ensures that money is actually following the patients with the system.
00:06:11.980 In Canada, because we have this sort of, you know, for lack of a better word,
00:06:15.780 a government monopoly over the financing and delivery of care,
00:06:18.240 we have these global budgets, which the incentive structure is such that patients are treated as a cost to the system.
00:06:25.860 Because every time a patient comes in, they're eating into that budget.
00:06:28.540 Contrast that with activity based funding and money is following the patients.
00:06:32.200 The problem is that, you know, you can't implement any one of these and expect healthcare to be magically fixed.
00:06:38.800 It's probably a palette of these options because each of them temper each other.
00:06:42.020 The cost sharing sort of tempers demand, the activity based funding ensures that supply is reacting dynamically.
00:06:48.380 But the thing is, right now, we're in such a risk averse environment because of the Canada Health Act that, you know,
00:06:54.220 if provinces even try to do something, you know, the federal government usually is coming down and clamping on them and saying,
00:07:01.520 hey, we're violating the act or you may violate the act and we're going to penalize you for it.
00:07:06.220 And that's very unfortunate because one of the, one of the most successful experiments was in Saskatchewan with the Saskatchewan Surgical Initiative,
00:07:13.280 where they partnered with private clinics to deliver third-party day surgeries within the public system.
00:07:20.960 They also had a pooled patient referral system where, you know, patients go into a central pool and they're referred to the physician with the shortest wait time.
00:07:29.300 And they had a number of other changes.
00:07:30.940 And that actually resulted in Saskatchewan going from a province with one of the longest wait times
00:07:34.980 to one of the shortest by 2014 or 15.
00:07:37.880 But ultimately, it started to, their wait times started to go up again after that because they couldn't do any more reforms
00:07:44.260 because governments, the federal government started to say, hey, if you try anything now,
00:07:48.780 we're going to actually penalize you by, by building the Canada Health Act.
00:07:52.900 And that's not the sort of, you know, incentive structure that you want.
00:07:55.340 You want provinces to try the best that they can to experiment with different policies,
00:08:00.840 to try and see what they can do because they really have the interest of their residents
00:08:04.620 at heart.
00:08:05.860 So, you know, don't stop them.
00:08:07.640 Encourage them to try things that will result in better or quicker treatment.
00:08:12.800 Yeah, well, it's unfortunate the way our country's kind of laid out, I guess, with jurisdiction.
00:08:18.060 The federal government is the regulator with the Canada Health Act.
00:08:21.240 They sort of impose the rules, but then they dump it on the provinces.
00:08:23.980 It's okay, but it's up to you guys to deal with everything else.
00:08:26.200 You've got to deliver it.
00:08:27.260 You've got to set up the infrastructure.
00:08:29.100 You've got to recruit the staff.
00:08:31.760 And it's just sort of a catch-22 as it sits there.
00:08:34.760 Each can kind of deny responsibility.
00:08:36.820 I mean, likewise, a province can also say, well, it's not my fault.
00:08:39.580 It's the Health Act.
00:08:41.000 And the federal government say, well, it's not our problem.
00:08:42.780 It's the province.
00:08:43.760 But, of course, it's the consumers who always lose in the end.
00:08:46.540 You're right.
00:08:47.160 You know, I mean, there's actually a lot that provinces can do within the confines of the CHA as well.
00:08:51.480 Some of the things like activity-based funding, it says no problem.
00:08:55.200 And there are provincial legislations that actually sometimes go far beyond the Canada Health Act.
00:09:00.360 But I would go back to it because the thing is, ultimately, the Canada Health Act is so vague
00:09:04.380 that it can be interpreted by the federal government of the day to be contributing any aspect of it,
00:09:09.220 particularly with the section about reasonable access.
00:09:12.600 So it's just, you know, you don't want a risk-averse environment when you're talking about policy.
00:09:17.060 You want a policy where you say, look, what we care about is the patient.
00:09:20.980 And the system comes secondary.
00:09:22.840 Unfortunately, we're in a situation where the system is given priority and the patients come secondary.
00:09:27.760 It's backwards.
00:09:29.680 So, I mean, you know, I know this gets you work more into the policy and the alternatives.
00:09:34.000 But, I mean, I believe, you know, politicians are typically driven by demand from the people.
00:09:38.040 They want to get reelected.
00:09:39.400 I mean, if we could see more public will, people saying, hey, we want to see some systematic reform,
00:09:44.880 the politicians are going to act on it.
00:09:46.440 But that's a really, there's some really entrenched mythologies, I guess, about our current system
00:09:50.960 and a few things that have to be chipped away at before enough people are ready to say, yeah,
00:09:55.180 let's try some different stuff out.
00:09:57.900 Yeah, you know, I'm not a political funder at all.
00:10:00.300 And, you know, I often am reminded of those New Yorker cartoons where politicians are leading
00:10:06.080 from behind and saying, hey, you know, I see where the crowd's going.
00:10:09.260 And let me please lead you there now.
00:10:11.300 But I do think that there is a lot of reform coming from the ground up.
00:10:15.220 Because the thing is, at a fundamental point, once Canadians have information,
00:10:20.060 once they understand that there are other ways to do it,
00:10:21.900 once they understand what's happening with the system,
00:10:24.360 they start to demand change.
00:10:26.520 And you see this happening in a variety of different ways.
00:10:28.700 You see it happening, you know, with things like the Canby court case in British Columbia,
00:10:33.200 where Dr. Brian Day, who is the former head of the Canadian Medical Association,
00:10:38.000 is fighting alongside a number of patients to simply get the right to treat them
00:10:43.700 within his hospital.
00:10:45.940 You know, and you see it, you've seen it already in Quebec with the 2005 Chevrolet decision.
00:10:51.420 And then you also see it happening at a real, you know,
00:10:55.580 just a normal reactionary level with, you know, Canadians starting to look towards
00:11:01.060 things like virtual care and video appointments,
00:11:05.560 which in many ways really circumvents the entire restrictions of the CHE.
00:11:09.560 And you're starting to see, I would say, a lot of defenders of the status quo
00:11:15.420 are now starting to clamp down on virtual care and private care,
00:11:20.080 which really had been quite a lot, a huge help during COVID-19.
00:11:24.640 But the thing is, I think that that will be a futile fight,
00:11:28.000 because the thing is, you can perhaps try and clamp down on these appointments
00:11:32.840 within a doctor and a patient within Canada,
00:11:35.320 but there's nothing that's going to stop a patient in Canada
00:11:38.020 trying to get an appointment with a doctor in South Africa
00:11:40.440 if that's the only way that they're going to get that consultation,
00:11:43.320 unless you build, you know, some sort of a firewall,
00:11:46.560 which would be an entirely different story.
00:11:48.280 So, yes, I'm a firm believer in Canadians
00:11:51.080 and their ability to embrace and process information
00:11:54.040 and demand change, because, you know, fundamentally this is about their healthcare
00:11:58.680 and they are the peers for it.
00:12:01.320 Well, that's it.
00:12:01.780 When times get tough enough, well, people suddenly can become more receptive
00:12:05.340 to changing anyways.
00:12:06.440 This is unfortunate that it has to go down before it can come up,
00:12:09.000 but when you realize you can't get yourself a physician
00:12:11.420 or can't get treatment in a timely manner
00:12:13.900 and, you know, start looking at things and realize,
00:12:17.040 well, it's not for lack of expenditure. 0.75
00:12:18.600 I mean, you know, Canadians aren't fools.
00:12:20.040 They'll start pressuring the right way, hopefully.
00:12:22.000 So I guess more conversations we can have
00:12:24.220 and showing people like there's, again, it's not that polarized thing.
00:12:27.260 There's much more than a Canadian-American world out there.
00:12:30.240 We could start getting our policymakers examining
00:12:32.260 some more innovative options soon, I hope.
00:12:35.220 Absolutely.
00:12:35.920 You know, this is really about, you know, universal healthcare
00:12:39.460 that is trying to ensure that there's timely access to treatment
00:12:45.280 regardless of financial ability to pay.
00:12:47.480 And there are at least, you know, it's sort of like Baskin-Robbins.
00:12:49.540 There's just like at least 27 other flavors of universal healthcare.
00:12:52.980 And we're just, we have the blinders on.
00:12:54.380 We're focused on Canada versus the United States.
00:12:56.900 It's, you know, betting on the two horses that are coming last in the race
00:13:00.340 and forgetting about, you know, the top three or top four of the performances.
00:13:04.200 Unfortunately, you're right.
00:13:05.100 We're in a situation where we're now being forced to make these changes
00:13:08.640 because our healthcare system isn't, you know, able to keep up with it.
00:13:14.940 And we've been talking about this for 10 years.
00:13:16.780 And unfortunately, there's a situation that's brought it to the fore.
00:13:21.160 But, you know, again, we have an ability to work on it right now.
00:13:25.940 And I would say, start doing it right now before wait times go even further
00:13:30.080 than what we're, you know, our loss measure of wait times is 25.6 weeks
00:13:34.080 between referral from a GP to getting treatment, according to our national survey.
00:13:39.280 We've been doing that since 1993.
00:13:40.760 And at that time, that wait time was 9.3 weeks.
00:13:43.560 That's an increase of 175%.
00:13:45.420 If you want to take out COVID from that, the wait time in 2019 was 20.6 weeks.
00:13:51.060 This is a fundamental systemic issue that has been really pushed
00:13:55.040 and exacerbated by COVID-19.
00:13:56.880 And we've got to tackle it before it really becomes, you know,
00:13:59.840 a dangerous situation in the future.
00:14:02.020 It's not going to get better without some effort.
00:14:04.300 Well, thank you very much for the work you do and, you know,
00:14:07.620 putting those studies out there and such and for speaking to us today.
00:14:10.440 So before I let you go, where can people find more information
00:14:13.340 on the work you've done and, you know, see some of those alternatives
00:14:16.060 for healthcare provision out there?
00:14:17.280 All of our information is free and publicly available
00:14:20.220 at freezerinstitute.org.
00:14:23.100 Great.
00:14:23.620 Well, I thank you again.
00:14:25.120 And well, hopefully we'll start seeing some positive changes soon.
00:14:27.840 I really do appreciate your work.
00:14:29.380 And hopefully we can talk again down the road.
00:14:31.720 Thanks so much for having me on the show.