Privatization where necessary, but not necessarily privatization.

by: Charles Cirtwill

I recently attended a lecture in Halifax delivered by Andre Picard entitled “Medicare: can it survive 25 more years”.  To a large extent, I got exactly what I expected from a “Canadian intellectual”. There was the jingoistic anti-Americanism, the snide jibes at republicans, a euro-centric love-in, repeated references to Canadian history and core Canadian values, and, of course, the de-rigeur slams of Prime Minister Harper and “this” federal government. The crowd ate it up (note to self, need to hate on Americans more when speaking in Canada).

But I also heard some very interesting things about evidence based decision making in health care and the fundamental instability of our current 1950’s approach. I heard a clear condemnation of the Canada Health Act as a barrier to needed reform. I heard a call to stop talking about two-tier health care because we, like everyone else around the globe, already have multi-tiered health care. I heard a litany of what we should add to publicly funded services in Canada but it was accompanied by an equal, if not longer, list of what we should remove from that publicly covered pool.

Consider Mr. Picard’s observations on health care’s administrative costs. They have risen some 50% over the last 25 years, but in his view they are still too low and he used private sector administrative practice as his justification for that assessment. For example, he argued that electronic health records are not a tool to control spending, but to increase value from that spending. But he repeatedly emphasized that administration should be done by administrators, not doctors or nurses. At the same time, he defended high wages for ALL health professionals, provided they are practising their professions and not counting bedpans. In Picard’s view it seems, if we improve how we spend we will get more for what we spend, and over the long term will likely then need to spend less.

Central to this thesis was a surprising point (at least for me).  Picard offered a strong endorsement of mixed public-private delivery, a relatively strong approval of at least mixed private management where appropriate, and an unequivocal endorsement of private insurance as a means to enhance services available through public funding: “it has always been there and always will be”. Picard cited not only global evidence that it works everywhere, but he went for the heartstrings too, highlighting that Tommy Douglas held similar views of the private sector’s needed role in sustainable universal health delivery.

Of course, these positive remarks about the necessity to blend private and public delivery and finance of health services were followed a few minutes later by a blanket condemnation of “calls for total privatization”. Given the applause after the latter remark and the silence following the former, I suspect the audience missed the nuance of Mr. Picard’s presentation. A nuance that sounded to me like it fell into the category of what I believe the Canadian Medical Association once described as privatization where necessary but not necessarily privatization.

It was as if Mr. Picard’s better evidence based angels were warring with his socialist collectivist ideological demons (feel free to reverse that sentence structure depending on your own personal world-view). After all, while slamming “this” federal government for “disengaging’ on health reform, he made the very case the federal government is making for what the upside of that disengagement might be – provincial action. Too long the provinces have waited for Ottawa to lead the way, with Ottawa holding out this time, provincial leadership becomes not only possible but necessary, and he urged them to step up (just as Mr. Harper has done).

Similarly, while unilaterally dismissing out of hand some views he considers too hard line (on both the left and the right), he called for a more respectful national debate. One where leaders are free to lead, not just to follow, where diverse views are tolerated and the right to hold them is accepted without question. Where the merits of the idea and not the morals of the individual are what we discuss. Mr. Picard is a double morality tale on this front – showing us not only why it should be done, but how hard it will be to do it.

With talks like this one it is no wonder that Mr. Picard prefaced his remarks by highlighting he gets attacked from both left and right. If you attack both left and right, neither are likely to love you all the time. Fortunately, it also increases your odds of being right, as, on this evening, Mr. Picard largely was.

Charles Cirtwill is President of the Atlantic Institute for Market Studies, an independent social and economic policy think tank based in Atlantic Canada.