Health-care reform deserves 'adult conversation'

New Brunswickers are attached to their health-care system and are understandably wary of change. Health care consistently rates at or near the top of public policy priorities voters identify in election campaigns. While so many policy fields are remote and unimportant to them, they take health care very seriously indeed.

They have reason to favour the system. Comparatively speaking, Canada has a reasonably successful system that works well in cases of urgent, emergency need. It generally conforms to the principle that care is available based on need rather than ability to pay. And polls indicate that while Canadians complain about their system in general, they have higher opinions of their particular experiences. It may take some time to get into the system, but once in, New Brunswickers are well served.

But we voters can be quite myopic. We tend to see the health-care system in terms of acute care: hospitals, heroic interventions, lots of impressive technology. We also tend measure the performance of the system in terms of how much money is poured into it.

Politicians are listening. They happily play the vote auction game; after all, it’s our money they spend on programs to attract our votes. As Globe and Mail columnist Jeffrey Simpson writes in his book on health care, Chronic Condition, health care is the “third rail” in Canadian politics – the issue a politicians touches at his or her peril. The winning political formula has been to promise more money, more hospitals, more doctors. Otherwise, say nothing or you will lose the election.

This form of health-care politics is no longer affordable. Annual increases in public spending on health care in recent years have exceeded economic growth, inflation and population increase. In other words, massive infusions of money into health care are impossible.

The New Brunswick provincial government has made steps in the direction of restraint by holding the line on spending on health care. A lot of this restraint has been achieved through wage restraint and attrition.

There is reason to think that this form of restraint cannot last forever. Similar declines in funding occurred in the 1990s as the federal government drastically reduced transfers to the provinces, some of them for health care.

When economic and fiscal conditions improved, pent up demand for wage increases caused spending to return to former rates of growth and savings in the system were erased. We can expect similar pressures to build in favour of new spending in this province.

In addition, short term savings, without deeper change, will probably increase costs down the road. In an excellent new book, Over the Cliff? Acting Now to Avoid New Brunswick’s Bankruptcy, the University of Moncton’s Richard Saillant argues that we should not assume that New Brunswick can “unilaterally put on the brakes on health spending for long without major changes to how things are done.”

Fiscal pressures

“Perhaps we can grow the economy and raise more money to pay for health,” say some critics. This is unlikely. Canada and the advanced democracies are just now coming out of a unique, halcyon period in which economies grew consistently at two to three per cent annually. This cannot be expected to continue.

Most of that growth was by means of one-time phenomena, such as increases in female labour force participation, a post-war population boom and certain critical technological advances. Realistic growth projections for the future are in the 0.5 to one per cent range. Government revenue increases will be similarly modest.

Our revenue problem is joined by a spending problem. New Brunswick’s net debt approaches $12 billion and the annual cost of interest on that debt is more than $600 million, about eight per cent of provincial spending. And this is in a period of unusually low interest rates.

New Brunswick can expect, in the absence of serious action on the fiscal front, to receive a credit rating downgrade and thus higher charges on the debt, which will make the overall picture still worse.

Per capita indebtedness is not as bad in this province as in others, such as Quebec and Ontario. But New Brunswick faces acute challenges.

Population growth is a key economic growth driver but this province has always lagged behind the rest of Canada. Few immigrants come to New Brunswick and about half of those who do come then leave for other provinces. Thousands born here are leaving for economic opportunity in western Canada. Those who remain are not having children to maintain the population.

This all means restrained growth but also increased pressure on the health system since an aging population puts disproportionate pressure on health care. Right now about one in six New Brunswickers is a senior citizen. If present trends continue, in 20 years that fraction goes to one in three.

Clearly a new provincial government will have to attend to the difficult fiscal picture, doing so requires attending go the health system. Health-care spending already consumes 40 per cent of the provincial budget. Some estimates are that by 2035, if recent spending trends continue, health care will consume 80 per cent of provincial spending. This, of course, is simply not tenable. Shall we close schools and ignore roads to keep hospitals open?

Simpson argues that, compared to leading countries in Europe, such as Norway, Germany, and Holland, Canada has a Chevy system at Cadillac prices. Unfortunately, we delude ourselves on this score because we compare ourselves only to the United States whose complicated system consumes 15 per cent of that country’s GDP. Canada is at about 10 per cent by contrast, but the real issue is not how much we are putting in; it is what we are getting in return.

New Brunswick has more doctors per unit population than the rest of Canada. The same is true for nurses and most other health-care professionals, MRIs and acute care beds. We spend more per capita on health than the Canadian average. We will have to do better with less money in future.

It is time for an honest, adult conversation about the design and performance of the health-care system in this province and the country as a whole. There is wide consensus on the principle that every person is entitled to care regardless of his or her economic status. Let’s move beyond this and get into the details about system redesign for sustainability into a difficult and challenging future.

4 health policy ideas

Here are a few ideas to start the discussion.

First, New Brunswickers need to take more responsibility for their own health. This province performs terribly on rates of smoking, obesity, diabetes and inactivity. Personal neglect of health clogs the health-care system and adds to its costs. Some analysts say people need to be “nudged” to live more responsibly. Perhaps soft drinks should be made more expensive or labels made more vivid. Cultural change with respect to smoking indicates that change can occur. Whatever the policy instrument, a significant culture change has to take place and voters should not expect politicians to solve all their health problems. We should not call a politician or a doctor every time we get a headache.

Second, we need to stop examining health care in terms of how much money government should inject into the system. We can no longer afford such fruitless auctions for our votes. Instead we have to talk a lot more about efficiency, what value we actually get for what is spent. If the government injected $200 million into health care tomorrow, exactly what health outcome should we expect one year from now? Or will we see the lion’s share of that money folded into compensation for those already working in the system, but with no change in health outcomes?

Third, get out of the single-minded attention to hospitals and acute care. People have diverse health needs and only a small portion require the very expensive attention that is available in a hospital. Right now, acute care beds are occupied by people who really need to be in a nursing home at a fraction of the cost. In addition, people need to be able to have good access to primary care in the first instance and largely avoid hospitals and emergency rooms. In a recent study the New Brunswick Health Council reports that some regions in this province with extensive acute care facilities nonetheless do badly on mortality rates. More hospitals and MRIs do not necessarily add up to better health. Let’s keep our eye on the ball: the goal of the system should be the health of New Brunswickers, not the number of hospitals, doctors and MRIs.

Fourth, match resources to population. Population shifts in New Brunswick proceed apace. Rural and northern areas are depopulating. Yet while people move to other places, the expensive infrastructure – hospitals, schools, and so on – remains. Politicians lack the courage to close or re-purpose under-utilized facilities and so the system drones on, racking up costs with little health benefit.

This election will test the realism and courage of the candidates of all parties, since the challenges transcend partisan divisions. Will they be willing to face the difficult truths? Will they entertain different ways of organizing health care? And will the voters themselves muster the realism and courage to vote for change? We’ll see.