PHP fellow Gilbert Benavidez and Dr. Michael Stein sat down to speak with Dr. Danielle Martin at Boston University School of Public Health, where she was giving a talk to dispel some of the myths about the Canadian healthcare system and provide some lessons that can be utilized in the U.S. healthcare debate that is currently underway.
PHP: What do you think about a financing system in which expenses related to the social determinants of health are covered?
DM: The separation between healthcare expenditures and expenditures on social determinants of health has always been a false dichotomy. I believe in the principle of looking upstream to try to deal with poor health before it becomes an issue. One of the ideas that I talk about in my book is the concept of universal basic income guarantee as one example of a way to get at health issues from the side of the social determinants. In Ontario where I’m from we’re actually launching a basic income pilot. The Ontario government has specifically articulated that a primary purpose of this pilot is to understand how to structure poverty reduction programs in ways that will improve health outcomes and reduce strain on publicly-funded health care systems.
PHP: How do you drum up the political motivation needed to achieve something like a basic income guarantee?
The reality in all developed countries is we have and will continue to have poverty reduction programs and strategies. But are we going to structure those in ways that pile on rules and eligibility criteria such that being poor effectively becomes a full time job by the time you finish with the caseworkers and people who want to make sure that you’re adhering to every single eligibility criteria? Or are we going to trust people to do what all the evidence suggests that they do? Which is when you put money in their hands they spend it on things that will improve their welfare and allow them to become contributing members to society.
PHP: A right to healthcare is fantastic, but there must be practical limits right?
Of course. The limits should fall along the lines of evidence. Where there is strong evidence that a test or an intervention, prescription, health care interaction is likely to significantly improve the health of the individual, I think it should be universally accessible based on need. But where there’s no good evidence or perhaps even could cause harm, I think that’s where we need to draw the line. It is worth saying that there is an asymmetric obligation on the part of the health care community to help structure our systems in ways that will protect patients. Because in fact many of the most harmful, unnecessary things that get done to people in healthcare systems are not at the request of patients, they are at the advice of health care providers.
I do not believe that having a single payer publicly financed system means that you just have to put up with waits.
PHP: At a surface level, what is the biggest shortcoming of the Canadian healthcare system?
The Achilles heel of the Canadian health care system is wait times for elective services. I say this knowing that there is a myth that gets propagated about the Canadian health care system in some American media where people are sort of clutching their chest and dying while waiting for care. That’s not the case! Access to urgent and emergent care in the Canadian health care system is excellent. But when it comes to elective or non-urgent or planned care of a variety of sorts, Canadians do wait. And while those things don’t cost people their lives they certainly contribute to a sense among the Canadian public that the system is not working.
But I don’t buy this rhetoric that every system rations care where in the U.S. there’s ration based on wealth and in Canada it’s ration based on need. I do not believe that having a single payer publicly financed system means that you just have to put up with waits. And if you look at the way our delivery mechanisms are structured, there is a tremendous amount that we could be doing in the Canadian system to reduce our waits without having to invest a lot more money.
PHP: What are the policies you think follow from that?
One of the examples that I use very frequently is the example of centralized intake for specialty care and inter-professional teams for specialty services of a variety of different kinds. We have tremendously successful examples of projects across the country but our implementation is spotty. If you happen to live in Vancouver where the orthopedic surgeons partnered with the family doctors, you’re not waiting for Dr. so and so, but are seen by the next available provider. Patients are initially seen by an inter-professional team with a physiotherapist, etc. so that the ones who are seeing surgeons are the people who are actually surgical candidates. They brought the wait times down from eighteen months to three months for surgery without spending more money and without investing any additional resources.
PHP: As it pertains to challenging perceptions — even when you have all the facts, you don’t always win the debate. What’s the strategy?
I think it’s critically important to have people who are actively involved in delivering care getting engaged in the conversations about system design. As much as evidence is critically important, narrative is also important in this conversation and I do think that being able to speak from experience around some of these questions about wait times or electronic medical records makes a difference.
I think it’s critically important to have people who are actively involved in delivering care getting engaged in the conversations about system design.
PHP: So currently prescription drugs are not covered under Medicare. You propose publicly financing medications (pharmacare) is both an ethical and economic argument?
Interestingly I think in the U.S., Canada sometimes gets held up as a model where people can purchase their prescription medicines less expensively as compared to the U.S., but in fact Canadians pay thirty percent over the O.E.C.D. average. If we were to have an evidence-based national formulary in Canada and publicly purchase essential medicines for everyone who needs them in the country, we would save our private sector billions of dollars. The Canadian model for insurance for prescription drugs almost exactly mirrors the American model for health insurance more broadly. And so we have all of the things that you would expect that we would have, which is very high costs, high rates of over utilization and inappropriate prescribing in the private plans, and a whole lot of people who aren’t taking their medicine because they can’t afford it.
PHP: In your Stouffville Ted Talk you gave the quote: “My barn having burned down, I can now see the moon.” What does that mean in light of the ACA repeal and replace effort and conservatives calling it a “failure”?
So I approach this question with some trepidation because you never want to be the outsider coming in and telling people what to think or feel about their own situation. But it seems to me that it is entirely possible that things get really bad in the United States with respect to insurance. So my question would be “is this the barn burning down?” Is this the moment where, if things get as difficult as it appears they may well get, some more fundamental questions might be asked about whether the structure of the U.S. insurance is really set up to work for people? And if it’s not, might this open up the opportunity for that bigger conversation? I understand fully that that is a conversation that’s been tried a few times. But I would not underestimate the impact of having had insurance and losing it on people’s desire to get engaged in these conversations.
The public engagement to me is the most important thing about this whole experience and process of writing a book and traveling across Canada. I’ve got an e-mail box full of messages from people I’ve never met saying, “how can I help?” People see that there are problems and they want to participate in the solutions. So what I would ask is: are you about to hit that moment here? Where people get disenchanted enough that they are willing to really participate in a way that they have not participated in the past. Might that be the moon?
Photo of Danielle Martin courtesy of Women’s College Hospital.