Health Policy and the Distribution of Risk in Canada
In the effort to develop case studies on the state of democracy in Canada, this blog focuses on the problem of justice and the management of risk when tied to health care. I argue that the Harper government has developed a gingerly approach to what is considered by most Canadians to be a sacred right as they are very proud of the system they have developed whatever its relatively minor flaws. The Harper Conservatives in the pursuit of reducing the federal government has tackled costs only on the margins and demonstrated a Hobbesian liberal approach to the management of risk in this area by, on the one hand, denying benefits o refugee claimant for relatively very minor savings but also in an anti-Hobbesian approach and by downloading future increases in health costs to the provinces thereby undermining the social contract as Canadian citizens of a sovereign state and fracturing even further the sense of sovereign and shared membership.
My informant on this issue was Kelly Crowe, the Kierans Janigan Fellow in Journalism at Massey College. After stints in journalism all over the world on various beats, since 2009 she has covered the health beat at CBC. She expressed her greatest interest in health care policy particularly with respect to the movement towards a two-tiered system, the increasing costs of drugs and those new drugs introduced, especially in the treatment of cancer, that cost a great deal, the big gap in public health policy with respect to dental care and other issues such as “who you know” determining access to quality care, duplication in services and the role of methodone treatment in addiction. I can only deal with some of these issues, especially since I want also to deal with health policy issues with respect to the training and deployment of health professionals which Kelly has not researched.
Equality of Opportunity and of Distribution
Let us begin with the undisputed difference between the American assertion of rights and the Canadian version. Section 15 of the Canadian Charter of Rights and Freedoms guarantees equality rights and prohibits specific types of discrimination by governments, but notably exempts affirmative action programs. Those equal rights accrue to natural individuals and apply to physical and mental disabilities with equality expanded from equality before the law to equality under the law thereby referring to outcomes and not just opportunities, to equal benefits and not just equal access. Laws deal with practices if discrimination can be shown to result for one group compared to another group related to a group’s actual needs, circumstances and capacities.
The most notable difference in this regard has been the single-payer system and the distribution of risk for health care matters through the government. As a number of panellists on this issue said on CNN last night, Obamacare, whatever the flaws in the plan, at least has finally introduced a policy whereby people with previous health problems can soon get access to reasonably cost health insurance, a situation which Canadians take for granted. Access to health care has undeniably become a defining Canadian value and, in election after election, in one commission after another, equal access as the core defining feature of the Canadian health system has been a dominant public policy issue. Even the Supreme Court’s interpretation has evolved from its 1990 Stoffman v. Vancouver General Hospital in which health delivery was considered a private matter to 1997 Eldridge v. British Columbia wherein Justice Laforest on behalf of a unanimous court ruled that governments are required to take special measures to ensure that disadvantaged groups are able to benefit equally from the delivery of health services.
A key, and perhaps the key most important variable in guaranteeing equality of access, has been the distribution of human professional resources. The law may guarantee anything, but unless there are enough doctors, nurses and medical facilities in an area, the guarantee is empty. We have seen how this applies to aboriginal peoples when their equality was discussed with respect to education. It applies even more so to access to health care services. However, in this blog, before I deal with the issue of the provision and distribution of health care professionals, I want to focus on taking away access to health care for uninsured refugee claimants and then deal with the impact of Canadian policy on exacerbating inequalities around the world. Before that, however, I want to take up the issue that Kelly Crowe raised of weakening the equality of access and, in particular, moving more towards a two-tiered health care delivery system.
But first a bit on distribution of risk and political theory.
Hobbes, Liberal Theory and the Distribution of Risk
There are four different basic liberal theories with variations to each that deal with justice and the management of risk. The most basic one is that of Thomas Hobbes on whom Brian Bitar, a Senior Resident at Massey for 2013-14, is researching in his work on political psychology and the resulting distribution of power. Without going into the various nuances and debates, a Hobbesian political theory views the social contract as a way of overcoming the outcome of individuals pursuing their own interests to the detriment not only of others but the commonwealth as a whole. In Hobbes’ mechanistic psychology of human motivation, people pursue self-preservation. The most important ingredient of self-preservation, absent the threat of significant external threats, is the pursuit of individual health and access to health services when one’s health begins to falter as we are driven by the fear of death and the desire to avoid pain. (A development of a Hobbesian basis for a health care system requires parsing the tensions between the two.) This fear and aversion leads to our rational self-interest to develop precepts of prudential reasoning in developing a political system to minimize suffering and maximize our life chances. The distribution of power is the mechanism through which this is achieved as a form of justice and through which the various endowments of bodily and mental health, intelligence and strength are adjudicated to overcome what would otherwise be a war of all against all as each person has an equal right to seek self-preservation and minimal suffering. Government becomes the necessary mechanism for overcoming such conflicts, minimizing risks and maximizing outcomes in terms of reduced suffering and increased prospects for longer and better survival. So we transfer the right to pursue our own survival and minimize our suffering to the jurisdiction of the sovereign state, not to maximize our chances for the best outcome but to minimize our risk at encountering the worst outcome.
Compare this premise with a deontological liberal doctrine rooted in the nature of duty and the obligation to develop practices of proportionality, consistency and fairness to all irrespective of their differential endowments or circumstantial differences. A doctrine of public health provision dictated by duty versus the individual quest for self-preservation and the avoidance of suffering is inherently universal and puts the obligations to each and every one on earth on an equal par with one’s fellow citizens, whereas the social contract developed by Hobbes restricts obligations to those who are part of the social contract and assigns the obligations for insurance to the state rather than to a charitable sense of duty in each individual.
A utilitarian liberal theory ignores abstractions like duty and an individual psychology in favour of outcomes and comprehending whether the system is operating best to maximize the self-preservation and minimizing the suffering of the greatest number. Finally, a neo-teleological ethical vision such as that of John Rawls discard the state of nature premises of each individual simply pursuing their own self=preservation in favour of an imagined original position in which an ideal system of justice and the distribution of health services can be created by bracketing information of each individual’s religion, ethnicity, gender and other differential traits in favour of abstracting everyone from their contexts and treating each as an individual with equal rights regardless of background and predetermined conditions.
Each doctrine will yield a single payer public health system with somewhat different emphases though a privatized multi-payer system is not ruled out if that is the only way to deliver a fairer system of health care given those ideologically opposed to a larger government role in delivering justice. But there will be different results. A utilitarian and ontological theory will be inherently universal whereas a Hobbesian one and even a Rawlsian theory, quite aside from its original intentions, will inevitably be state centric. On the other hand, a Hobbesian and utilitarian approach will be permissive about assisted decisions to end life which are not likely to be supported by ontological premises or a Rawlsian approach that endorses choices that produce the most benefits for those in the least advantaged position in accordance with the difference principle and maximin rules. The variations and combinations multiply in spinning out differences since the foundations begins with minimizing risk and a risk averse approach.
Since a Hobbesian approach to the provision of health care and the just distribution of risk best characterizes the Harper government, I will focus on how that liberal theory in the provision of health care plays out in Harper government policies.
Harper, Justice and Health Care; Denying Refugee Claimants Coverage
Stephen Harper has been very cautious about any effort that would threaten public support for the government by intervening in Canada’s sacred belief in its health care system. 99% of expenditures for physician services, and 90% of expenditures for hospital care, come from public sector sources. What he did do is make cuts in the future after the next election and cut benefits to those who are non-citizens. In a Hobbesian social contract, ostensibly there are no obligations to provide security for those among us who are not citizens or on route to becoming citizens. Economic and family class immigrants are included because, having been selected for membership, they are proto-members of the polity. Self-selected refugees are not. Nor for that matter are temporary residents such as tourists, foreign students and temporary workers.
Even in the case of selected immigrants, the prospective cost to the health care system becomes an issue in selection. Further, the shift in weight given to economic as contrasted with family-class immigrants is not only intended to enhance productivity but to further reduce stresses and strains on the costs of the health system. But the greatest sufferers are those who come to Canada and make refugee claims but are not covered by health care under the Harper government policies introduced last year. Research has shown that while immigrantsunderuse the health care system in general, refugees show patterns of increased use relative to Canadian citizens, either because of what they experienced and the conditions they were exposed to or other factors. (Cf. Sarah McDermott et al, “Health Services Use Among Immigrants and Refugees in Canada”) To save $20 million dollars a year, Bill C31, referred to as The Refugee Exclusion Bill, became law on 30 June 2012 and denied access to government-paid health care, medications or medical visits. Canadian Doctors for Refugee Care with the Canadian Association of Refugee Lawyers have led a court fight to challenge the government and is seeking a court ruling declaring refugee claimants to be covered by the Charter with rights to access health care as well as already won rights to legal representation in advancing their refugee claims. In honour of refugee rights on June 17th on Refugee Rights Day they released the following examples of refugees denied necessary health care because of the federal cuts:
- a woman with severe Post Traumatic Stress Disorder as a result of sexual violence in her country of origin who could not be treated because she had to wait for her Interim Federal Health Program (IFHP) coverage to be initiated
- a man with a mass in his liver after an Emergency room visit who lacks insurance because he is from a Designated Country of Origin (DCO) and does not have the funds to pay for follow-up procedures himself
- a woman who fled the sex trade and is in the late stages of pregnancy but cannot get testing as she awaits her IFHP coverage
- a six year old child again awaiting IFHP coverage who cannot get an investigation underway for a possible urinary tract infection as she awaits her IFHP coverage and the family lacks the funds to pay for the procedures
- a woman with a biopsied mass in her neck who actually has coverage under IFHP but cannot get a follow up appointment to get her results
- a woman with a large mass in her pelvis who cannot get diagnostic or curative surgery because she was denied refugee status
- a woman in labour asked to pay for the cost of her epidural when the anaesthetist is unable to understand her IFHP insurance coverage and is forced to deliver her baby without pain control
- a woman requiring treatment for fibroids and heavy vaginal bleeding denied coverage for a necessary pelvic ultrasound.
The government would reply that refugee claimants, especially those who have already been rejected or deemed ineligible, should no more be entitled to health care than any other temporary resident in Canada. Further, if access were granted, Canada would be flooded with claimants simply to take advantage of our health care system. Blips in the administration of the IFHP are not grounds for undermining the general problem addressed by the policy. The results of the Court challenge will not only have practical consequences but is bound to set important precedents for the breadth of application of the Charter.
The savings in this field are relatively minor and a question can be raised with respect to costs and the management of risk and why more has not be done with respect to other issues of risk with respect to health care – climate change and health risks; food safety and inspection given the reduction in the numbers of food inspectors; aboriginal health; nutritional risks to both children and the elderly where poor socio-economic circumstances are so closely related to the enhancement to such risks; methodone treatment and safe needle programs. For example, On 4 June 2012, the federal government announced an initiative for pathogen reduction for meat and poultry as a response to several food poisoning scares and the recall of meat products. The initiative was ostensibly intended to decrease health risks and the economic impact of food-borne pathogens such as Listeria and Salmonella, an initiative that involved not only a current assessment of risk, setting targets for reduction but also an enhanced strategy of monitoring. However, on 5 May 2013, less than one year later, The Globe and Mail in a story revealed that the Harper government had made significant cuts to the Food Inspection Agency undercutting its monitoring goals.
Shifting Costs to the Provinces
However, the more extensive implications of cuts for Canadian citizens and permanent residents has been left until after the next election when the guarantee of holding federal increases in health care support to 6% will end and the federal government shifts more of the responsibility for financing health care to the provinces which are faced with that other costs that historically increase beyond the rate of inflation – education and particularly post-secondary education. Yet in 2011, Prime Minister Stephen Harper declared that it would be up to the provinces to find “solutions” for a better and more economical health-care system. The long-term funding plan for health care was declared non-negotiable and Harper declared that provinces have been given plenty of time to get their houses in this field in order. Until 2016-17, the federal government will increase federal health care transfers by 6% and, after that, increases will be tied to economic growth including inflation but with a floor of 3%. Harper is simply obeying the “first law of cost containment” by opting for the easiest way to control costs through shifting those costs to others, in this case, the provincial governments and, likely down the line, increasingly to individual citizens.
In other words, while access and quality of health care in Canada remains relatively high and while there is an overwhelming majority support for the idea of health care as a public good, the federal government has avoided any effort to expand a two-tired system by transferring the burden for determining incentives, structures, procedures and policy decisions about comprehensiveness to reduce costs that historically increase well above the rates of inflation to the provincial governments. Efforts to foster rostered group practices where physicians are paid on a capitation rather than a fee-for-service basis have had only a very marginal impact. In the hospital sector, provinces have either pushed more central planning and integration or gone to the other end of the spectrum and privatised the delivery of some services to enhance competition in the belief that competition will lead to efficiencies. What it seems to have led to is reduced wages to skilled health workers and lowering the quality of the mix of those professionals.
Thus, although the provincial governments are constitutionally burdened with the health portfolio, and precedent has been set for the federal government to set the standards across the country, when the government responsible for those standards refuses to pay the price for maintaining them, then the stage has been set for further power struggles with health care destined to be the perennial loser. While the principle of public administration is unlikely to be undermined, while universality will be attacked only on the extreme and relatively minor though humanly important fringes, such as excluding refugee claimants from the system and increased rationing, while principles of portability and accessibility will be maintained, the weak link will be comprehensiveness as well as rationing leading to extended waiting times for increasingly less and less service.
There is little likelihood of expanding the system to include chronic care, drug costs or dental care, two obvious large gaps in the health care system. Yet there is also little indication that, given the uniqueness of health care as a vital service for survival, market forces will be able to play a significant role in reducing costs. As experience in the USA has demonstrated, voluntary risk pooling within a competitive financial market has not worked since insurers have avoided the high costs of insuring the minority who need expensive services. If anything, it the American system is any guideline, market forces have contributed to significantly higher costs for health care overall so that the proportion Americans have spent on health care uses up 50% more of their GDP that the equivalent percentage in Canada. However, given increased costs and the prospect of reduced funding, one can envision a further deterioration in the health system and increased pressures to expand the nascent two-tier system thereby further undermining the principle of “single-tier” publicly funded medicine for “medically necessary” services on both grounds of equity and the economic efficiency of a single-payer system. Thus far, no one has designed a suitable answer for overcoming this conundrum though some answers appear in small initiatives.
Education and the Distribution of Health Professionals to Reduce Risk
The final issue I want to raise about the distribution of risk relates to the import of health workers from abroad and their distribution within Canada. Basically, Canada like the United States, Britain, Australia and New Zealand import approximately 25% of their doctors, nurses, and health technicians from abroad where other countries carry the economic burden of training those health professionals and Canada gains the benefits. Further, within Canada, those professionals educated in Canada tend to congregate in large population centres leaving the outlying provinces and territories underserviced. So it should be no surprise that 17% of health professionals working in Saskatchewan in 2001 originated in South Africa. Efforts to develop ethical standards to avoid exploitation of the countries exporting health care workers, even where remittances transferred back home make up for some of those costs, have been abject failures. (Cf. Tom McIntosh, Renée Torgerson and Nathan Klassen (2007) “The Ethical Recruitment of Internationally Educated Health Professionals: Lessons from Abroad and Options for Canada,’ Research Report H|11 Health Network, January.)
Proposals have been made to develop a positive sum game by developing health schools abroad funded by developed countries where professionals can be educated at 5-10 cents on the dollar and when, then, even if Canada skims off even the top 10% of graduates, the country developing those skills will also benefit significantly. Foreign aid comes nowhere near to making up for these losses to the developing country. But lacking any international agency for enforcing or even developing such a system on a voluntary level – the World Health Organization has been unable to step into this gap – exploitation and the mal-distribution of health professionals around the world will continue at enormous costs to the health of citizens in developing countries.
If access to health care is considered a democratic right, the Harper government has demonstrated a gingerly approach to this issue, advancing its privatization agenda and breaking off support on the margins and relegating the problem to the future. The federal government has used refugee claimants as a token sacrifice with the legal basis yet to be adjudicated. Instead of privatization, the government has pursued provincialization of the carrying costs with serious implications to the Hobbesian social contract and the distribution of risks. Further, no initiative has been made to the global problem of the distribution of risks as Canada has acted as a Hobbesian state in the war of all against all to grab health professionals at the cost of territories who suffer a serious health professional outflow while bearing the training costs for those health workers.
1. Ontario Health Quality Council, 2006 First Yearly Report]; Paul Caulford & Yasmin Vali, “Providing
Health Care to Medically Uninsured Immigrant and Refugees” (2006) 174 Canadian Medical Association Journal 1253 at 1253-54, online: CMAJ <http://www.cmaj.ca/cgi/content/full/174/9/1253>.Shelley Phipps, The Impact of Povertyon Health: A Scan of Research Literature, Commission on the Future of Health Care in Canada, Building on Values: TheFuture of Health Care in Canada – Final Report (Saskatoon: Commission on the Future of Health Care in Canada, 2002) at xvi (Chair: Roy Romanow), online: Commission on the Future of Health Care in Canada <http://www.hc-sc.gc.ca/english/care/romanow/hcc0086.html> [Romanow Commission]; Standing Senate Committee on Social Affairs, Science and Technology, The Health of Canadians – The Federal Role, Interim Report on the State of the Health Care System in Canada: The Story So Far, vol. 1 (Ottawa: Senate of Canada, 2002) (Chair: Michael Kirby), online: Parliament of Canada <http://www.parl.gc.ca/37/1/parlbus/commbus/
senate/com-e/soci-e/rep-e/repintmar01-e.htm>; Standing Senate Committee on Social Affairs, Science and Technology, The Health of Canadians – The Federal Role: Final Report on the State of the Health Care System in Canada: Recommendations for Reform, vol. 6 (Ottawa: Senate of Canada, 2002) at 38 (Chair: Michael Kirby), online: Parliament of Canada <http://www.parl.gc.ca/37/2/parlbus/commbus/senate/Com-e/SOCI-E/rep-e/repoct02vol6-e.htm> [Kirby Committee, Final Report]; Commission on the Future of Health Care in Canada,National Values, Institutions and Health Policies: What Do They Imply for Medicare Reform, Discussion Paper No. 5 by Theodore R. Marmor, Kieke G.H. Okma & Stephen R. Latham (Saskatoon: Commission on the Future of Health Care in Canada, 2002) at 15-16, online: Commission on the Future of Health Care in Canada <http://www.hcsc.gc.ca/english/pdf/romanow/pdfs/5_Marmor_E.pdf>; Conference Board of Canada, Canadians’ Values and Attitudes on Canada’s Health Care System: A Synthesis of Survey Results (Ottawa: Conference Board of Canada, 2000) at 11, Cf. Shelley Phipps, The Impact of Poverty on Health: A Scan of Research Literature.
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