The Canadian Supreme Court ruling on private health insurance has alerted us that individual rights do matter and now they matter in health care, more than people had thought. Perhaps the greater impact of this ruling may be the emergence of legal or rights-based challenges to health policy, something the European Court of Justice has shown global leadership on.
Traditionally, health care decisions revolve around money, how much who gets and how; Canadian health politics is littered with the wrangles between the federal government and the provinces, and where has it got us? Years of polemic perhaps about fiscal priorities, but perhaps little mileage on how to ensure Canadians get the health service they are paying for. Other countries have been rudely awakened from this complacent slumber and found themselves faced with a steep challenge; in the UK, government spending on their National Health Service is being virtually doubled, to bring average UK spending in line with average spending in the other European countries. Indeed, it used to be a hallmark of the venerable NHS that is was parsimonious in delivering health care, but the social costs in waiting times and waiting lists became politically unacceptable when compared with the rest of Europe. Canadians of course compare Medicare to that the US system, and thank heaven that we don’t do that here! But reality is of course much different, and we are learning daily now that there are things our mother never told us about Canadian Medicare, and finally perhaps the public is asking, “so, remind me again, what is we have been paying for all along?”
How do we know if we are getting a decent health system for our money? The answer is not easy, but there are some clues. Unfortunately, waiting lists and waiting times are indicators of resource shortages, not necessarily whether the health system is working well. It’s a bit like heading into Home Depot to buy some paint, they may have lots of paint, great variety in the catalogues, but you need to line up to discuss the colour with one person, line up to get the cans from someone else, and third person to mix them for you, and you still haven’t paid for the paint! Canadian health care is fascinated with hospitals, the most expensive, inefficient and labour intensive institutions known to modern society. Not noted for being particularly safe, people get sick there while they’re recuperating from being sick.
One way to make sense of how well as health system works is to look at how well it treats new entrants, i.e. babies. Infant mortality is a measure of the deaths of newborns, up to 1 year of age, and measured as a death rate per 1000 live births, so a number of 5 means 5 infants died in year for every 1000 babies born alive (i.e. not still births). High death rates pick up on problems associated with access to health care facilities, medicines, as well as maternal knowledge of child-rearing, diet and hygiene. Low rates suggest the opposite.
In 1996, Newfoundland had a rate of 6.6, compared to the Canadian average of 5.8. Nova Scotia had a rate of 4.9, while Nunavik Region in Quebec had a rate of 22.9. In Ontario, Quinte area, rated by some as one of the best places in Ontario to live, had a rate of 6.8, Northwestern Ontario at 8.6 with the lowest being Halton/Brant at 3.9. As we head west, Manitoba sits at 7.3, Saskatchewan, the birth place of socialized medicine at 8.7, Alberta, the new driver of health system reform at 6.1 and BC at 5.3. Nunavuk is 17.9 and the Yukon 8.7. Quite a spread. To put it into a different perspective, the infant mortality rate in 2003 in Austria is 4, Finland 3, Romania and Argentina 17 and Colombia at 21.
So, once we survive that first year, how long will we live? In Canada it is about 78.3 years of disability free life (1996 data). But the best place to live if you’re a woman is BC with 81.8 years, and the worst place is Nunavut for men at 69.8. Does the health system have any impact on how long we live? Probably not, as most people’s encounters with the health system are around accidents and child birth, and the regrettable tenure we endure in our final days when the system’s heroic efforts to keep us alive gradually fail. Most health system expenditure is incurred within the last 6 months of life, we just know when those last 6 months are.
Does money matter? Well, you’d think it did, but there isn’t really any accepted correlation with how much a country spends on health care and the results it gets for its spending. Canada spends a lot of money percapita (per person). Newfoundland is the biggest spender, at $2151 per person along with BC at $2157, and PEI the smallest at $1718 and Quebec at $1760. This money is being used to buy the same sorts of things in all these provinces, with varying degrees of success in meeting public expectations and service standards. But it is how we organize those resources, well or badly, that determines whether we get good value for our spending. The case may be building that the problems with Medicare are problems with design, the choices we’re made on how to organize it. The main problem in my view being this fascination with hospitals and the bottlenecks created through them in accessing diagnostic tests for example. Most countries trying to reform their health system, believing it will improve the statistics mentioned above, are trying to reduce expenditure and use of hospitals, and move resources into the community where the focus is on greater real-time engagement with people to help them maintain their health, rather than respond with a ‘sickness service’.