Morris Barer and Bob Evans first coined the term “health care zombies” in 1998. A health care zombie is a terrible idea about health care that refuses to die. No matter how many times you drive an evidence-based stake through its heart, it rises from the (un)dead to confront you in the newspapers of the nation, ruining a perfectly good morning cup of coffee.
These ideas have often been proposed as solutions to the pressures on our health care system. But they’ve all been shown, time and time again, to weaken health care quality and sustainability. They also undermine our shared values.
User fees are a classic example. This zombie is resurrected year after year as a suggestion to deter inappropriate care and raise money. The idea behind user fees is that if people are required to pay either a fee (a copayment)—even a small one like $5 or $10—or a percentage of the total cost (co-insurance), they’ll think twice before making an appointment for something “silly.” They’ll thus curb unnecessary use, and contribute some money out of pocket to help finance services. It’s the “skin in the game” argument.
As an abundance of evidence shows, this is a bad idea for two reasons. First, user fees at the point of care indeed make patients think twice before seeking treatment. The problem is that these fees deter both unnecessary and necessary care. One U.S. study looked at how employees reacted when their employers switched them from a full-coverage plan to a high-deductible plan, in which employees had to pay a large sum out of pocket before their insurance kicked in. The employer saved money on the order of 15 percent, but the employees reduced the number of services they received to cut their own costs by much more: around 40 percent. They didn’t shop around for better deals. Instead, all they did was get less care, risking their health or the health of their loved ones to save money.
This has been confirmed right here in Canada, in the birthplace of medicare. In the late 1960s the Saskatchewan government authorized physicians to charge patients $1.50 per clinic visit and $2.00 for outpatient services, including home, emergency, and hospital outpatient visits. The result was a drop in the use of those services—a drop most marked among people who could least afford to pay for health care and yet likely needed it most.
Do we really want a woman to think twice before coming in for her Pap test? Or a patient with chronic heart failure to put off her appointment with her cardiologist because she’s already spent this month’s income on other priorities? Do we want to burden parents with deciding whether their child’s sudden stiff neck and cranky mood is due to a bad pillow or to meningitis? Especially among lower income people, user fees reduce usage of the kind of health care we want people to get. And in most cases, seeking reassurance from a health care provider doesn’t constitute “abuse” of the system.
User fees are very blunt instruments for controlling usage. Beyond the human tragedies of these missed opportunities, care for advanced-stage illness is usually more expensive than the savings experienced by deterring preventive care. User fees are, as the saying goes, penny-wise and pound-foolish.
Second, user fees are a bad idea because they don’t actually raise much money. If you set a user fee low enough to be affordable for everyone, it has to be pretty low. By the time you pay the administrators who have to collect and account for the copayments and co-insurance, you’ve created a costly bureaucracy that charges patients in order to support itself. In 2010, the Government of Quebec made waves by suggesting a “new” approach to dealing with increasing health care costs: a fee of $25 charged to the patient for every visit to a physician, to be paid in a lump sum at the end of the year when tax time rolled around. (Very low income people would not have to pay the fee.) Careful analysis of the proposal showed that it would fail to produce significant revenues for government. In order to raise enough money to make them “worth” the bureaucratic effort, user fees need to be pretty high. And once you start setting fees at the level needed to really raise revenue, you begin to block access for those with low incomes who may be quite sick. Alternatively, a significant part of the population would need to be exempted. So few people would be able to pay high fees that the policy would not generate considerable revenue.
In the parade of the undead, close behind the user-fee zombie we can usually find the private-pay zombie. The myth is that allowing wealthy patients to jump the queue will “take pressure off the public system.”
I understand why this argument is intuitive. One might think that pulling one person out of the public queue would make the queue that much shorter, so that the private-pay tier functions as a safety valve of sorts for the public system. It’s not true.
A study was conducted in Australia before and after that country moved from single-tier publicly funded care to two tiers, allowing privately funded care. It found that in those parts of the country that had more privately funded care, waits in the public system became longer. We saw the same results here in Canada when Manitoba experimented briefly with parallel private funding for cataract surgery, only to return to a fully public system when public wait lists got longer rather than shorter.
Why is this the case? Because the doctors, nurses, and others providing care in a privately funded system have to come from somewhere. What people forget is that when a patient jumps the queue, a physician does too. The physician isn’t available to treat the next person in the public queue, because she’s busy treating the patient who just paid privately to jump that queue. The drain on the public system by providers exiting to the privately funded sector creates longer waiting lists in public health care.
In theory you could train enough doctors to staff both. But a health care system isn’t just made up of doctors. You need nurses, nurse practitioners, physiotherapists, technologists, and an alphabet soup of other health care professionals. You need qualified administrators. You need a regulatory system to ensure quality and inspectors and accreditors to monitor it. Imagine the cost and time required to train the people and build the private tier in a way that wouldn’t siphon resources from the public tier.
And in practice, a privately funded tier even provides an incentive to make wait times in the public system longer. A colleague once told me that in New Zealand, surgeons talk about “farming” in their practices: tilling the soil by keeping their public wait times long and then harvesting the benefits of high-paying patients in their private practices.
In 2006, the Canadian Medical Association reviewed all the evidence about two-tier and single-tier systems. Its report concluded that private health insurance does not improve access to services in the public system. It also concluded that private insurance does not lower costs or improve quality in the public system. In other words, access may improve for the small minority who can afford to pay; but patients in the public system can’t expect anything good to happen for them if some people exit to a private tier.
So private financing won’t reduce wait times for everyone, or help improve quality in our public system. Next in line comes the zombie of for-profit delivery. A clinic or hospital or facility might be owned by a group of investors rather than a couple of doctors, and those facilities have an obligation to bring profit back to their shareholders. Does it matter who delivers the service if the patient isn’t being asked to pay out of pocket for it? Some argue that as long as patients use their health cards to pay for the service, it shouldn’t matter whether those services are delivered by for-profit (more often called “private”) clinics.
It does matter. As we move more services out of hospital and into the community, the number of private clinics inside the public system is growing. There are ardent supporters of such clinics, who believe that because they’re driven by profit they’ll be more efficient in their service delivery models.
But if we’re to embrace for-profit hospitals and clinics in Canada, the quality of care has to be at least as good as it is in not-for-profit hospitals and clinics. And so far, that doesn’t seem to be the case.
Instead, the evidence on for-profit hospitals, clinics, and long-term care facilities suggests that the care provided in them is inferior. In the United States, being admitted to a for-profit hospital instead of a not-for-profit hospital is associated with a statistically significant higher risk of dying. Having dialysis in a for-profit instead of a not-for-profit facility is also associated with an increased risk of death, even if the care is still publicly funded.
The evidence here in Canada points in the same direction. For example, a 2015 study looked at the rates of hospitalization and death among fifty thousand people newly admitted to Ontario long-term care homes (also known as nursing homes). Six months following admission, patients in for-profit homes were 16 percent more likely to have died, and almost 36 percent more likely to have been hospitalized, than those in not-for-profit homes.
Even if we figure out a way to regulate quality in for-profit facilities, the business models of the for-profit sector often involve upselling services and products that patients have to pay for. I think of my husband’s friend who needed a colonoscopy, a service that was medically necessary and covered by OHIP. He was referred by his family doctor to a specialist who had hospital privileges but also worked in an out-of-hospital for-profit clinic. He was quoted a price and advised that he could jump the hospital queue and have the colonoscopy done in the private clinic a number of months earlier. It wasn’t urgent, so he chose to wait for an opening in the hospital. He was subsequently contacted by the specialist’s office and offered an appointment for the colonoscopy in the private clinic, but when he raised the question of fees, he was told that the procedure would be covered by OHIP. When he arrived he was seen by a dietitian, who counselled him on the importance of a high-fibre diet for his bowel health. He then had the procedure. On his way out the door, sedated, he was handed a bill for $300—the cost of the non-insured dietitian consultation that he’d never requested.
From orthopaedic surgery centres to colonoscopy clinics to boutique primary care offices, too many of these clinics find some way to charge patients for something. The core service is covered by taxpapers, but people leave having been upsold—whether it’s a fancier lens when they get their cataract removed, or some sort of assessment that’s only marginally related to the issue at hand. And in many cases, they aren’t clearly offered the option not to pay for those extras, meaning that the for-profit delivery model ends up leading to compulsory private payment. So I remain unconvinced by claims that for-profit delivery can be incorporated into the Canadian health care system in ways that will help us achieve the Triple Aim of better health and a better patient experience at lower cost. Maybe it’s possible, but I haven’t yet seen the proof.
The zombies of user fees, private pay, and for-profit clinics all converge in one of the worst zombies of them all: the “Look at Europe” argument. European nations have models of health care that incorporate some aspects of private payment and for-profit medicine, say the supporters of this argument. Of course we don’t want American-style health care, they concede, but why are we so afraid to follow the European model?
There is no such thing as the “European model” of health care. Each country in Europe has its own set of health and social services that have evolved in a very particular cultural, historical, and economic context.
Most European nations invest more public money in their health care systems than we do. They also tend to have much broader coverage and more generous social safety nets, and the higher tax rates to support them. Proponents of the so-called European model don’t seem to argue for European tax rates or European child care policies, though. They pick the one thing they like about the French or the German or the Italian system and talk only about that specific policy, as if it existed in isolation. But we can’t import French user fees and claim to have a French health care system any more than you can throw a Big Mac patty into a baguette and call it French cuisine.
In France, having private insurance does not let you jump the queue. It’s voluntary and used primarily to cover the copayments charged in the public system. And, owing to concerns about fairness, regulations are increasingly aimed at preventing physicians from charging more money privately than they do publicly.
In Germany, only 10 percent of the population has private health insurance, and those who do must leave the publicly funded system entirely. I think it’s unlikely that Canadians would be interested in such a model.
Another important consideration when comparing Canada to Europe is the border we share with the United States. Canadian doctors earn more money than doctors in many European countries—and one of the market forces that drive the price of physician labour in Canada is the fact that we’re in competition with the United States for our health care workforce. It’s something that France, for example, doesn’t really have to contend with.
That shared border has another important effect. Our trade agreements with the United States, including NAFTA, contain clauses that preserve the ability of Canadian governments to maintain single-tier medicare by regulating private investment in the health care sector, including by American firms. But if we were to move to private payment and for-profit delivery, medicare would no longer have those protections. We can’t switch to “European style” health care and not end up with American health care corporations surging into our system. To claim that we could is to fundamentally misunderstand our political, economic, and geographic reality.
The suggestion that a magical “European model” will solve all our problems usually stems from a desire to allow some people to pay privately to jump the queue and some doctors to charge more for their services. It’s nearly always made with a dogmatic belief in the “free market,” despite all the evidence of its inefficiency in the health care sector.
That said, it’s always worth learning how other countries organize their services so that we might improve care in our own. In many European countries, for example, home and community care are much better integrated with other health and social services. We can certainly take the best of those care delivery models and adapt them for the Canadian context.
When I asked my mother to write down her parents’ story for me to include in this book, she finished her message with a reference to the Canada Health Act. “We rejoiced when Monique Bégin and the federal government of the day passed the Canada Health Act in 1984,” she wrote. “It was far too late for our family, but it signalled the dawn of new hope for all Canadians.”
Many Canadians who remember life before medicare still feel this way. But in the context of an aging population, new technologies, increasing utilization of services of questionable value, and concerns about system sustainability, medicare needs new approaches.
Having dispensed with the zombies, let’s explore those new approaches. In this book, with gratitude to the innovators who think about how to improve our system, I’m pulling together the six Big Ideas I believe can best improve the health of Canadians. They aren’t my ideas. But they’re well formulated, they’re grounded in good evidence, and they meet the two tests for delivering on the promise of medicare. They would improve the Triple Aim of our health care system, delivering accessible, high-quality services in an equitable way. And they’re worthy of an iconic program.
These Big Ideas would help us get better—much better. Now. And each idea is dedicated to a particular Canadian patient, because it’s important to remember who we’re in this for.