Shawn Whatley: Noses in fingers out How Danielle Smith could transform healthcare

A trailer for more space outside the emergency room at Alberta Children's Hospital.

Governments, like boards of directors, need to know what’s going on, but when they get in the way, they wreak havoc

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Albertans re-elected Danielle Smith’s United Conservative Party with a majority last week. Smith now offers a chance to change the way we think about health care, a radically conservative view. What could it include?

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Many conservatives trumpet out-of-pocket payments as the embodiment of conservative health care policy. Critics of Danielle Smith have inflamed central patient payment fears in their campaign attacks.

A month before the election, Smith took out-of-pocket payments from his campaign table.

I think stocks speak louder than anything else, Smith said. One of the first things I did as premier was sign a $24 billion, 10-year health deal with the federal government, in which we jointly agree to uphold the principles of the Canada Health Act.

One of these basic principles is that no one pays out of pocket for a family doctor and no one pays for hospital services. This is in writing.

Smith’s pledge of allegiance to the law sounds like other conservatives who have given in before her. True, Smith could govern health care like other conservative governments. But his commitment shouldn’t bind her. A great opportunity is at the heart of his commitment to him, if he has the courage to pursue it.

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The accessibility principle of the Canada Health Act prohibits direct payments: charges made to policyholders. Out-of-pocket expenses disqualify provinces for federal healthcare transfer payments.

The principle of accessibility is the only reason why the CHA exists. The first four principles of public administration, completeness, universality and portability derive from the Medical Care Act of 1966.

Many Conservatives oppose the Canada Health Act precisely because of its ban on direct payments to patients. This is partly right but mostly wrong. Yes, CHA prohibits federal transfer payments to provinces that allow fees for medical services. But no, that’s not why Canadian medical care suffers.

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Conservatives chafe on the wrong side of the bill. Conservatives rage about the federal override of access, but forget the first tenet of the CHA, public administration.

Government, not payment, is the key to Canadian healthcare. Medicare does not depend on patients paying for their care with their Visa card or their OHIP card. Payment irritates voters, which is important for politicians. But paying for services is far less important to healthcare than managing the care itself.

Herein lies the opportunity.

The Canada Health Act does not say that services must be managed by the government. He says provincial governments must manage a health insurance plan. Provincial governments have to manage the payment of services, but may remain outside the management of the services themselves.

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A health insurance company is not the same as a health management organization. The Federal Medical Care Act (1966) nationalized Canadian health insurance companies. Governments took over the health insurance industry and insurance companies exited the insurance industry. Insurance companies have never been in the managed care business.

Over the past 50 years, provincial governments have transformed from health insurance companies to managed care organizations. Each province manages medical services closely and looks for ways to manage even more.

Most Conservative governments seem to intentionally ignore this. After being defeated in the outright brawl, the Conservatives shrug and continue to run like a Liberal or an NDP. They change and manipulate the levers of control, adjusting regulations, scheduling and funding allocations. Conservatives shun the (more) obvious progressive social policies, but it can be impossible to tell the difference in the clinic or at the bedside.

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Conservatives could be (radically) different by refocusing on good governance. Good governance means good governance. And good governance means nose in, fingers out.

Governments, like boards of directors, need to know what’s going on (snoop), but they wreak havoc when they get in the way (fingers out). Keeping your nose in your fingers off healthcare has been difficult for Conservative governments, impossible for Liberals and the NDP.

Premier Smith has an opportunity to change Canadian healthcare. He could refocus government on government and find all sorts of ways to get government out of management.

Perhaps this takes too much.

Currently, provinces control which medical services Canadians can access. Governments control the price, volume, quality and management of services. The Provinces finance and take care of the training of health professionals. Provinces shape labor relations. Doctors retain the privilege of managing the rental and maintenance of their clinics.

The government has its fingers in so many things that it will be hard to imagine anything different.

Smith faces a difficult choice. He can take a conservative approach and do what most conservative parties have done. Or he can chart a new course in rediscovering what good governance means. The question is, will Smith try?

Shawn Whatley is a practicing physician in Mount Albert, Ontario, and a fellow of the Macdonald-Laurier Institute. He is the author of When Politics Come Before Patients: Why and How Canadian Medicare is Failing.


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