A Healthcare Solution Brief
a)The “private insurance” solution
The five sacred pillars of Canadian healthcare are, and always have been, unaffordable in a “completely controlled from the top” system basically because human needs are infinite, and money, despite what the modern money printing economists say, is finite.
The five pillars are:
1)Comprehensive
The government’s insurance covers every healthcare need that is medically necessary or needed. Yeah,right. What about dental? What about a facelift? Oh. That’s cosmetic. Well, one can make a pretty good argument for a hernia or a cataract being cosmetic too! We can argue a mighty big word salad about what the word comprehensive actually is. But let’s just say true comprehensive insurance is bullshit.
2)Universal
This means all thirty five millions Canadians in the country get coverage paid for by the government. Okay. What about people with Canadian passports who don’t live in Canada. What about patients who aren’t Canadian who just show up? Gotta call balderdash on universality also.
3)Accessible
This means healthcare is available in a timely fashion with no financial barriers or extra fees. OK. Then. Ask the politicians who go to the best private clinics paying extra to jump the line.. Ask people who can’t find a family doctor. Ask patients who fork out $4000 extra for a special lens for their cataract procedure. Ask people about waiting in a line that snakes out of a hospital’s emergency room for some ailment that a decent family doctor could have taken care of easily.
4)Portability
Oh yeah. Right. Find me any BC doctor who has ever been paid by Quebec for taking care of someone in BC who is visiting from Quebec. Hint: There aren’t any. Sorry for the Quebec bashing. I know. Things are different there.
5)Government administered
This may be the one exception. Administration costs are probably lower in Canada (even considering the malignant growth of bureaucracy in this country) than in the USA where: 1) private insurance companies jerk doctors and patients around making for a huge bureaucratic costly system, 2)where the number one reason for personal bankruptcy is a medical bill and, 3) where the number one user of collection services is a local hospital.
Maybe health insurance in BC should be a little more..well, private? There is no question that the market (private) is a better information gatherer than the government (public) so that error correction can be applied to experimentation. [1]
Maybe healthcare insurance should be more like insurance for your house or your car…if the house burns or if the car gets wrecked then insurance will take care of it….if the front door of the house squeaks or there’s a scratch in the paint of the car then forget it….the more you raise a deductible the less it costs you.
This means a citizen should be able to pay to get some healthcare (that’s now illegal..sort of) After all, in Canada right now one-third of healthcare is paid for privately. The BC Government does not like two tiered and they have good reasons for this. Basically it has to do with concerns about people who are sick getting ripped off and, more importantly, governments maintaining total control. This is an old argument about collective vs. individual responsibility dating back to Plato. But two tiers exist now in BC in very hypocritical ways. [2]
From a government funded healthcare system point of view we keep pouring money into the top of the stack. With more money dumped in at the top the waste/stupidity of the system keeps getting bigger…let’s not get into a big bun fight about how “waste/stupidity” is defined. [3] Might it not be better to put money into the bottom of the stack at the individual level with private pay or insurance?
Probability of this happening? Almost zilch!
[1]Example.Here’s how the government likes to measure healthcare. NUMBER of operations. Let’s not even talk about how this is gamed by doing 5 minute operations vs 5 hour operations. Suffice it to say that Goodhart’s Law rules….when a measure becomes a target it ceases to become a good measurement.
[2]Like, an individual can drive 45 minutes to the USA from Vancouver and pay. But if that individual does have a complication of medical treatment they are right back in BC being collectively paid for. Ditto for showing up here with a complication from a new kidney transplanted after being harvested from some political prisoner. Intent of the rules is one thing but the rules are always there to game.
Canadian governments say they hate this private insurance thingy because rich people will jump the line. These rich people/patients counter that by saying they are now off the waiting list. Both have a point. Of course let’s not talk about provincial governments that have had programs to attract “rich” foreigners paying privately into Canada.
If you go to a “private” clinic and get a battery of lab tests ordered, where do you go for said lab tests? Well…to the government lab of course. I won’t rave on.
[3]Is there lots of waste and stupidity? Of course there is! But the real question is, like…. waste and stupidity for who? The taxpayer sees fifty workers (thrilled to be employed with nice benefits) in yellow vests who take all day to repair a pothole in the road and shakes her head. She is less likely to see seventeen vice presidents pulling in anywhere from three to six hundred a year plus benefits at a VGH and get upset. In hospitals managerial/human resource technology has definitely not kept up with surgical/anesthesia/ drug technology as “correction” really gets tyranny of the status quo unions upset. Waste and stupidity should at least be up for discussion though.
b) The “financial crisis” solution
Thermodynamics says that you get useful work out of something (all the molecules together are moving in one direction) if you keep shoving energy into it. But eventually this energy is taken up by the vibration of individual molecules to give you heat which in the thermodynamic sense is useless for doing work [1]
Think of healthcare from this angle. It is like any other bureaucracy…think of the city’s garbage collection, or road repair, or whatever. It 1) provides a service and 2) employs people. Like any other bureaucracy it tends to evolve more and more to employ people while not doing its stated function so well.
Given the fact that healthcare is the largest business in any western liberal democracy it is easy to see how the “2)employs people” is where the big money is. It is also easy to see how this workforce is of more than passing interest to those trying to get elected especially considering the need for union votes. It is almost like patients have become secondary to government management/employment. [2]
And these bureaucracies….administrations…whatever you want to call them….more and more are able to control the behavior of their employees with more and more strength including what doctors say in public. Unless of course, the doctor is a billionaire like J. K. Rowling who can just tell her detractors to FOAD knowing full well that no publisher in the universe is going to “cancel” her next book. This type of control of a system by a managerial class regardless of whether the system is top down (communist, fascist) or bottom up (democracy, supposedly) is not a new concept. [3]
Pretty hopeless situation? Yeah, maybe. Let’s switch to another field (biology) to give us a metaphor of what might be…possible….like…maybe some error correction? The Cambrian explosion 500 million years ago was a real phase shift….that’s physics….or perhaps better to say paradigm change…that’s sociology. All sorts of new things happened really quickly in that brief period of evolutionary time. This error correction (novelty) probably had something to do with predators arriving on the scene which require a fundamental evolutionary change to survive.
So what “crisis” could possibly happen in healthcare? Maybe. A PROVINCIAL BOND MARKET COLLAPSE? Yeah, I know…. impossible in rich British Columbia (that btw, can’t print money like the Feds). Yeah, I guess..whatever. But if a government wakes up one morning and is told by some bean counters somewhere (usually on an “east coast”) that there is no more money then things change….almost instantly…like the collapse of a Schrodinger wave function….well, not really, but you get my point? And a government will then say to its citizens that this is how we are going to run things now. And people will say that you can’t do that…And the government with no money will say “IT’S ALREADY DONE” ….so basically read em and weep boys. [4]
Probability of this happening? Not zilch!
[1] This is a bit of a fib as the “thermodynamic” reasoning has to do with whether the system is closed or open to the “outside world”. There is also a big argument among physicists about the “mammoth in the room” paradox of order vs chaos at the heart of this mathematical science….like if the start of the universe was zero entropy why was it soooooo, “maximum entropy” uniformly smooth? But let’s ignore all this for now in the name of the metaphor.
[2]Shawn Whatley wrote a whole book about it.
The same thing happens in education, which is the second biggest ticket item in Canadian provinces’ budgets. At universities the big spending has been for non-teaching administrative staff which means post secondary education, like healthcare, has increased in price faster than inflation for decades.
[3]The Managerial Revolution by Barnham 1941…or perhaps Orwell’s Animal Farm (1945) or Nineteen Eighty Four (1949)
[4] Dornbusch's Law says that the inevitable crisis takes longer to come than you can imagine, but when it does come it happens faster than you can imagine. You could also think of this solution as the SimCity solution where you just clear everything away and start over.
c)The “put doctors on salary” solution
There are only three ways of paying doctors….fee-for-service, sessional, or salary. They are all terrible. [1] They are terrible because humans do what is in their best interest.
In BC at the present moment [2] under fee-for-service there is a very small percentage [3] of doctors that really mint it. This is due to either, to doctors gaming a high volume practice or fees that have not changed as technology has advanced, like turning a surgical procedure of 3 hours 30 years ago into 3 minutes when done today.
A true professional, in any field is someone who is paid well and therefore is relatively content. They can easily give up a few shekels by not doing something if it is in the best interest of their patient. However, when one looks at the debt levels of medical graduates one can see how this is easily subverted…and…all that public opinion stuff about people generally liking their doctor and not liking their politician starts shifting.
In many areas of medicine now it is impossible to do good medicine and make a good living. There are other systems where docs (like everybody else in the system) are salaried.
Probability of this happening? Probably not zilch!
[1] Well known BCMA expression. Actually you could just say there are two ways. Fee-for-service is piecework. More pieces, more money. The other two are based on time….sessional is per day and salary is per year…for argument's sake. More time, more money.
[2]It has actually been this way forever….at least decades.
https://bcmj.org/blog/physicians-income-inequality
[3]It is just the way finance/capitalism/whatever works. For instance, there are eleven million creators on Spotify but only eleven thousand, or so, hit $50K a year.
d) The “individuals stop self inflicting illness” solution
The second biggest “healthcare” problem is addiction [1]. People generally eat, smoke, and do stupid things [2] way too much which medicine then puts a bandaid on. The Homo Sapien operating system runs on dopamine [3] which modern society provides to the brainstem intravenously. Just walk into any drug store and you will see two aisles where the shelves are filled with food in tin foil bags (basically highly concentrated sugar and fat) followed by an aisle of treatments for diabetes. Wtf? I guess it’s capitalism at its best. Governments, even the most socialist, are not going to protect its citizens from this.
Western medicine is really good at saving your life in an acute trauma situation. If you get run over by a truck and get to an operating room with a heart still beating chances are really high that you will make it, unlike many other places on this planet. But this amazing science ain’t gonna “solve” any “societal” issues.
What generally happens now is that many people screw themselves up and start going downhill earlier than they should. Let's say at sixty. Then there’s this slowish decline filled with all sorts of medical/surgical stuff before the patient dies. Let's say at eighty. Now if that patient doesn’t start killing herself early with food, booze, etc then she will probably go along a pretty even road until there is a quick demise. Let’s say at ninety.
My hope is that in a new world that evolves there will be an extraordinary bottom up change where citizens act so they don’t become patients prematurely who are then subjected to lots of expensive medical interventions, few of which will cure them and some of which will kill them.
Probability of this happening. Ask my kids. LOL
[1]The biggest problem, of course, is an unwanted pregnancy, which is basically the reason for another gigantic system called prisons in addition to the large subset of medicine known as mental health.
[2]There’s lots of self-inflicting damage you can do to yourself. Where this crosses the stupid line is up for debate. If you get the whites of your eyes tattooed blue (yep, it has happened) and wind up with a perforated eye and blindness, well, you could make the case for stupid. If you skydive? I dunno. Put your baby to bed sucking on sugary apple juice? OK. I’ll stop.
[3]It is the same neurological operating system that was there when we were cavemen. We still live by the pleasure of microgram doses of dopamine (mostly provided from the energy from barrels of oil) that society is able to provide in spades by burning all that unoxidized carbon/stored sunlight that was shoved in the ground on this planet over the last 4B years
z)Thee “solution”
The real power in our system lies with the government. Politicians react to incentives like anybody else. We like to bitch about our politicians. But they are NOT stupid people. You don’t get to be an elected representative without being really smart in one way or another. They know that making a massive change in a massive system means massive responsibility and really massive pushback from vested interests.