Exiting management of health care and focusing only on governance is key to achieving reform

Shawn WhatleyAlbertans re-elected Danielle Smith’s United Conservative Party with a majority last week. Smith now offers a chance to change how we think about health care – a radically conservative vision. What might that include?

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

One month before the election, Smith took out-of-pocket payments off her campaign table.

“I believe actions speak louder than anything,” said Smith. “One of the first things I’ve done as premier is sign a 10-year, $24-billion health-care agreement with the federal government, where we jointly agree to uphold the principles of the Canada Health Act.

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“One of those main principles is no one pays out-of-pocket for a family doctor, and no one pays for hospital services. That’s in writing.”

Smith’s pledge of allegiance to the Act sounds like other conservatives who have caved before her. True, Smith might govern health care like other “conservative” governments, but her pledge need not bind her. A big opportunity lies at the heart of her pledge, if she has the courage to chase it.

The “accessibility” principle of the Canada Health Act bans out-of-pocket payments: “charges made to insured persons.” Out-of-pocket charges disqualify provinces from federal health transfer payments.

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

Many conservatives bristle at the Canada Health Act precisely because of its ban on patient out-of-pocket payments. That is partly right but mostly wrong. Yes, the CHA prohibits federal transfer payments to provinces which allow user fees for medical services. But no, that is not why Canadian medicare suffers.

Conservatives bristle at the wrong end of the bill. While fuming at federal overreach on access, they forget the CHA’s first principle: public administration.

Public administration, not payment, is the key to Canadian health care. Medicare does not pivot on whether patients pay for care with their Visa card or their health-care card. Payment irritates voters, which matters to politicians. But payment for services matters far less to health care than management of care itself.

Herein lies the opportunity.

The Canada Health Act does not say services must be managed by government. It says provincial governments must manage a “health care insurance plan.” Provincial governments must manage payment for services, but they could stay out of managing the services themselves.

A health insurance company is not the same as a health management organization. The federal Medical Care Act of 1966 nationalized Canada’s health insurance companies. Governments took control of the health insurance industry, and insurance companies left the insurance business. The insurance companies never were in the managed care business.

Over the last 50 years, provincial governments have morphed from health insurance companies into managed care organizations. Each province closely manages medical services and seeks ways to manage even more.

Most conservative governments seem to ignore this by intention. Having been beaten in the out-of-pocket fight, conservatives shrug and get on with managing like a Liberal or an NDP. They tweak and twiddle the levers of control, adjusting regulations, programming, and funding allocations. Conservatives avoid (most) obvious progressive social policies, but it can be impossible to tell the difference in the clinic or at the bedside.

Conservatives could be (radically) different by refocusing on good government. Good government means good governance. And good governance means “noses in fingers out.”

Governments, like boards of directors, need to know what is going on (noses in), but they cause chaos when they meddle (fingers out). Keeping “noses in fingers out” of health care has been hard for Conservative governments – impossible for Liberals and NDP.

Smith has the opportunity to change Canadian health care. She could refocus government on governing and find all the ways to get government out of management.

Perhaps this asks for too much.

Currently, provinces control which medical services Canadians can access. Governments control the price, volume, quality, and management of services. Provinces fund and oversee the training of health-care workers and shape labour relations. Doctors retain the privilege of managing the lease and upkeep of their clinics.

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

Smith faces a stark choice. She can take a conservative approach and do what most Conservative parties have done. Or she can chart a new course to rediscover what good governance means. The question is, will Smith try?

Shawn Whatley is a physician, past president of the Ontario Medical Association, and a Munk senior fellow at MLI. He is the author of  When Politics Comes Before Patients – Why and How Canadian Medicare is Failing.

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