Medicare's Condition Critical
With mounting concern, Dr. Joel Carter studied the situation in the Winnipeg Health Sciences Centre emergency ward. In one resuscitation bed, an elderly heart patient lay dying, the family gathered around her. Doctors had revived her heart, and were maintaining her on life-support systems, but death was only a matter of hours away. Then, as Carter anxiously watched, a second cardiac-arrest victim was wheeled in, occupying another resuscitation unit. In a perfect world, he thought, the dying woman's family could have sat with her indefinitely, a necessary part of the grieving process. But in the mid-1990s, the world of Canadian medicine seemed anything but perfect. A strike had closed emergency wards at other area hospitals. In the entire city, Carter knew, there were, at most, two other resuscitation beds available. The longer his first patient remained on life support, the more likely it was that another cardiac case would arrive and have nowhere to be put. The choice was inescapable: the woman's life-support system would have to be turned off in order that another patient might have her bed - and a chance to live. It fell to Carter to inform the family.
That happened in September. Today, Carter, 34, is practising emergency medicine in Duluth, Minn. - one of three Health Sciences Centre doctors who have recently left Winnipeg and accepted primary-care positions in the United States. It is true, Carter concedes, that money had something to do with his decision. In the United States, he will roughly double his annual income - to about $180,000. But equally important, he insists, were standard-of-care issues - the constant frustration of bed shortages and delays for surgical procedures. "It's sad," Carter says, "but we didn't have the resources or the time to care properly for that family in a time of crisis." And that, he says, is beginning to happen everywhere. "There are no reserves left. It's time for the politicians to call a spade a spade. The system isn't working any more."
Among Canada's 55,000 physicians - and Canadians at large - Carter's sentiment seems to be striking an increasingly responsive chord. Indeed, according to the results of a Maclean's/Medical Post/Angus Reid health-care survey of both doctors and the public, the country's confidence in the decades-old structure of universal medical care is starting to crack. Conducted in late September, the poll of 1,500 Canadians shows that slightly more than half the population still regards the current system as either very good (33 per cent) or excellent (19 per cent).
But the numbers are in decline, indicating a clear and steady erosion of consumer faith in the system. And an absolute majority - 58 per cent of Canadians and fully three-quarters of the physicians - now believe the future of health care is likely to be worse a decade from now than at present.
"The entire system is teetering," insists Rufus Turpin, 44, an Ottawa quality controller, who has been studying the health-care industry for years. "The services provided are excellent, but the pressures are causing it to slip, and the ability to deliver services is threatened." And the poll, according to Angus Reid vice-president Andrew Grenville, is an early warning of the conflict that looms in the health-care arena. "That's where we're headed," Grenville says. "And it will raise fundamental questions about Canada and who we are as a people."
Yet despite those danger signals, there are high levels of satisfaction with the service doctors are providing. As well, there is an abiding conviction that the Canadian health-care system is superior to the American. "I still say we have the best medicare system in the world, and doctors as well," maintains Bob DeMarsh, 52, an Alberta civil servant living in Calgary. Like most of those surveyed, DeMarsh says he would prefer to be treated for a serious illness in Canada, "where you don't have to mortgage your house to pay for it." Interestingly, in an earlier poll of 1,700 doctors, about one in five said they would rather be treated in the United States. The Maclean's poll also reveals that, on a variety of ethical issues, including support for assisted reproduction and physician-assisted suicide, the public tends to be far more liberal than the practitioners. Overall, concludes Angus Reid's Grenville, "health-care concerns are occupying an increasingly prominent place in the minds of Canadians."
Prominent and uncertain. In fact, the Maclean's poll suggests there is a growing sense among both patients and doctors that medicare's once impregnable fortress is under siege. Across the country, health-care delivery is being squeezed by revenue-starved governments. Long waiting lists have formed for certain procedures, including cardiac and cataract surgery, and hip and knee-joint replacements. With their fees reduced, many physicians are apparently pumping up the volume - maintaining income levels by seeing more patients. In fact, fully 70 per cent of all doctors think some of their colleagues are encouraging more patient visits in order to maintain income levels. And almost 40 per cent of physicians say that is "the only reasonable response" to the revenue shortfall. It is logical, says Toronto family practitioner Dr. Mark Doidge, but it puts the profession on a vicious treadmill. "Many doctors are running like crazy," says Doidge. "It's exhausting, so they become resentful. Then their morale sinks, and that's bad for the public."
Some members of the medical fraternity are even more pessimistic. "We all know the country is broke," says Dr. David Cram, one of three general practitioners in Souris, Man. (population 1,800). "The government is trying to cut, which is appropriate. But then they tell the public everything's fine. And that's not the truth, because everything is not as available as before. Access will be restricted in some way. You can't tell me closing 12 hospitals in Toronto, as has been proposed, won't affect services." Indeed, as the doctors' survey suggests, the professionals think budget austerity and government policies are having a clear and negative effect on health care. Some 62 per cent say their ability to practise medicine that is best for their patients has been unreasonably restricted. And 40 per cent say they now hesitate to book follow-up appointments out of concern for medicare resources.
"The system is limping along," agrees Dr. Louise Cloutier, a family physician in Dartmouth, N.S. "There are longer waiting periods for services, even those now considered essential. This requires an adjustment in people's attitudes." Quoting The Rolling Stones, Cloutier adds: "You can't always get what you want."
The irony, of course, is that from the knowledge and technological point of view, medical science has never been more capable. "We can now do more and more, but we have less and less to do it with," says Dr. David Walker, an emergency physician in Kingston, Ont., and president of Ontario's College of Physicians and Surgeons. "So the real question is, how do we continue to meet expectations and needs with unlimited capabilities but limited resources?"
Inevitably, perhaps, the perceived crisis of funding is generating sharp debate about the merits of what is known as two-tier medicine - a system in which the existing public apparatus would be paralleled by some privately funded architecture, under which consumers would pay for the medical services they used. That battleground, says Angus Reid's Grenville, is now being formed. A dress rehearsal for the larger, systemic dramas that lie ahead is the current federal-provincial controversy over private health clinics in Alberta.
And on this issue, the gap between ordinary Canadians and the medical community is striking. Only 42 per cent of the public at large support development of a second tier - compared with 69 per cent of the nation's doctors. Support for two-tier is strongest in Quebec (55 per cent) and Alberta (47 per cent), but significantly weaker in other regions. "It's going to be an ugly, difficult, long drawn-out battle," Grenville predicts. "When Canadians wake up to the implications - the cost of paying for dad's long-term care and mom's heart attack, the need to save funds for catastrophic illness - they will scream. And it may be too late then." It is a fundamental question, says Grenville, adding: "Do we stand for a kind of soft socialism that's compassionate and caring? Or do we desire excellence - a first-rate medical system that has to be paid for? Either we have to change our expectations of what constitutes normal medical care or we have to start paying."
Grenville, among many others, believes Canadians are not ready to abandon these entitlements. Medicare, after all, has long been one of the defining characteristics of contemporary Canada - that sense of collective responsibility to look after each other in a hostile climate. Such totems are not easily surrendered. "No doubt there are changes we can make to the system," says Kingston's Ernest Steele, 75. "But I'm a great believer in the universal medicare approach. I would not like to see us backtrack into a private system of any kind."
Still, a majority of doctors (56 per cent) say Canada should never have adopted medicare, while more than one-third of the public (37 per cent) say the quality of health care would be better today if Canada had opted for private insurance or co-payment. Among those more sympathetic to a two-tier concept, there is concern that private facilities would tend to impoverish the public system. "I don't have a problem with the principle," says Calgary engineering technologist Connie Sydorchuk, 35, "as long as they are offering the same quality of service. The danger, of course, is that the additional dollars in the private pool would attract 'the doctors with expertise.' "
Many doctors, on the other hand, think some form of two-tier arrangement is probably inevitable. "There isn't any way around it," says Souris's Cram. "Why should I wait nine months for a cataract operation when, by going to a private clinic, I'd only have to wait a month?"
Some experts consider the issue itself moot. "Two-tier is here already," says Dr. Martin Barkin, a former deputy minister of health in Ontario. "Coverage has never been entirely universal. People pay for vision care, dental care, long-term care." Barkin, now CEO of Mississauga-based Draxis Health Inc., a pharmaceutical firm, says the question is not whether two-tier is coming, but "what its extent will be."
Yet, many health industry analysts share the prevailing public perception that the system is not suffering as much as headlines may suggest. "The anecdotal evidence is more anecdote than evidence," says Toronto's Dr. Michael Rachlis, a former general practitioner now heavily involved in consulting. In fact, according to Evelyn Shapiro, senior researcher at the University of Manitoba's Centre for Health Policy and Evaluation, studies show that, even after the closure of almost 20 per cent of Winnipeg's hospital beds, there has been no measurable decline in access, quality of care, or the general health of Manitobans.
"The real crisis," argues Rachlis, co-author of the 1994 book Strong Medicine: How to Save Canada's Health-Care System, "is whether we continue with public financing; delivery has always been more or less private - private hospitals and private practitioners." And the public method, he insists, is "far more efficient than the private financing system. I know it's counter-intuitive in the '90s that public could actually be more efficient than private. But the single-payer system actually gives the government power at the bargaining table, with more leverage to control costs, negotiate with doctors, etc. The fact that the system is not perfect is no reason to blow it up." Yet that, Rachlis maintains, is precisely what groups that support privatization, powerful alliances of hospitals and doctors, are trying to do. "Some doctors are trying to ruin the public system, or prevent it from being fixed."
Other observers think the current fiscal squeeze may actually have a salutary effect. "Often people don't change behavior unless there's a crisis," says John Ronson, president of Toronto-based Quantum Solutions, a health-care consulting firm. "There's more than enough money in the existing system to provide medically necessary services to all Canadians. But we have to get at the enormous amount of duplication, the unnecessary testing. The problem is, we really have no system. What we have is a very fragmented structure, with hospitals here and family practitioners there, and public health there, and long-term health care over there. And they're not at all integrated. Which means the patient suffers."
As the Maclean's poll results indicate, Canadians are clearly conscious of medicare's decline in quality. Today, only 19 per cent of respondents still regard the system as excellent - seven percentage points less than in 1991. "We've been flying first-class for many years," says Dr. Robert Wedel, a family physician in Taber, Alta. (population 6,000), 60 km east of Lethbridge. "Now we're flying economy. But withdrawal of funds without planning will sooner or later lead to a crash. Some rebuilding and restructuring is necessary."
Indeed, many health-care analysts believe that with major reform, the system is capable of being more adequately financed - even in a climate of government penury. "Our problems have less to do with money than with management," says University of British Columbia health economist Bob Evans. What's needed, he says, is more careful oversight, throughout the system. One example: the large percentage of vaccines ordered by doctors that become stale-dated and are eventually thrown out. "Physicians have no training in inventory control," notes Toronto practitioner Doidge, "and those kinds of losses represent millions of dollars."
There is waste, too, at the institutional level. Although the fight over hospital closures across the country is just beginning, most health-care experts acknowledge that the move is long overdue. "The system is frozen in time," says Quantum's Ronson. "So many resources are swallowed up by these hospitals. There's enormous duplication - of services, human resources, administration, maintenance, support. In Toronto, for example, many people think the district health council's recommendations did not go far enough." In short, as Evans notes, "there's no one, single magic bullet" for eliminating waste and duplication.
Another area that clearly needs addressing is doctor distribution. Although the Maclean's survey shows that more than six out of 10 Canadians believe physicians should have the right to practise where they choose, a significant minority (38 per cent) disagree. But there is no consensus on how to service the many remote and rural communities now lacking access to either general practitioners or specialists. Civil servant DeMarsh suggests that doctors be required to do six months' or a year's stretch in places like northern Alberta - "not just get their education, have it paid for, and then go to the States."
But would such a policy really benefit underserved areas? "I'm not sure you're doing the community a favor," says Dr. Alan Katz, an assistant professor of family medicine at the University of Manitoba. Katz, who spent two years working in rural Saskatchewan, points out that under such a regimen, communities would, every year or two, welcome "a new doctor who did not really want to be there. There would be no continuity of care, no long-term relationships, and no investment in the community emotionally. So that's not the answer."
Still, Katz concedes that the concern is legitimate. Other possible answers, he suggests, include accepting more rural candidates into medical schools or moving training sites to those areas. Another solution now actively being explored is providing patient care via two-way television and other telecommunications technologies. Several American jurisdictions are already using such systems.
But as Grenville notes, the debate over solutions to medicare's crisis is just beginning. And as the poll data suggests, many Canadians are largely pessimistic. "It's going to require cutting down the empires," says Rufus Turpin, "and that takes leadership." General practitioner Cram predicts that in five years, there will be "more professional discontent, more doctors leaving, more caps on income and more government control." For his part, Quantum's Ronson fears that governments will be tempted to avoid restructuring, by doing "less of the same. And that will put us in difficulty. We have to do things differently. The massive fragmentation has to come to an end." What medicare really needs, says Dr. Ed Brown, an emergency physician at Peel Memorial Hospital in Brampton, Ont., is a new mission statement, one that reflects broad consensus and long-term planning. "It's a big ship," Brown says, "and it has to be steered with great care."
Maclean's November 13, 1995