The Health Care Crisis V: Privatization

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Jordan Heath-Rawlings I will start with an admission there have been times when I am on a waiting list to see a specialist or my child is ill, but not ill enough to be bumped to the front of the line, that I’ve wished I could just pay for some health care and be done with it. I think almost everyone lucky enough to have the means has thought that at one time or another, when you or really your child isn’t feeling well, there is a powerful urge to do anything possible to fix that. So have I wished for a private paediatric clinic where I can call and get an appointment and be seen in an hour? Of course, sometimes. Do I want that to be the reality in this country? No, I don’t. But that doesn’t mean it won’t happen first slowly and then all at once. And here is the troubling part as the problems that we’ve spent all week describing Mount as wait times get longer and doctors harder to find and the whole system just gets worse, the number of people thinking that they just like to pay and be done with it will increase. So how would a two tiered system work and why wouldn’t it solve some of our problems? How is Canada different from our peer countries? And if we do start adding more paid options, what happens to the services that are right now available to everyone, but also sometimes not? I’m Jordan Heath-Rawlings. This is The Big Story. Natalie Mehra is the executive director of the Ontario Health Coalition, an organization dedicated to preserving public health care. Hello, Natalie.

Natalie Mehra Hello. Thanks for having me.

Jordan No problem. Thank you for joining us. I want to start by just asking this question. I think many Canadians, including myself, are confused when we talk about public health care in this country because they pay for something. So do we currently have any private health care in Canada?

Natalie Mehra Oh, yes, of course we do. We have the Canada Health Act, which covers medically necessary hospital and physician services. And so that means that it’s sort of like a bill of rights for patients. And it means that you cannot be charged for medically needed hospital and physician services. They’re not allowed to extra bill, they’re not allowed to charge user fees to you. So you have the right to health care based on need, not based on how wealthy you are. That’s the difference between us and, say, the United States. But there are things that aren’t covered once you’re moved out of hospital. For example, long term care, people co-pay, most provinces provide some subsidies. Home care, again, you co-pay provinces provide some home care. But not all drugs we pay for, unless you’re under your elderly and under a drug plan provided by your province, things like that. So there are kind of a range of things that are partially covered because the provinces cover them, but not actually under the Canada Health Act. So the Canada Health Act covers all of our provinces, making sure that that kind of critical care is accessible to people, and then what other kind of subsidies are available for things not covered can vary from province to province, is that correct? That’s correct. So everything all like when you go to see your family doctor or your nurse practitioner, or your family health team, or family health clinic, that should be covered, completely covered if it’s medically necessary service. And when you go to the hospital, it should be completely covered. Other things are subsidized, but not completely covered, and they’re subject often to copayments or user fees.

Jordan I think we all intuitively understand this because most of us are very happy and proud that Canada is a bastion of public healthcare. But maybe you can quickly, because this is so key to your organization, explain the rationale for making sure that these parts of the system are not private.

Natalie Mehra Well, when the Canada Health Act came in, more care was provided in hospitals and by family physicians. Over the years, Canada as a whole has downsized its hospitals kind of to an extreme rate compared to other European peer countries, actually, compared to the entire OECD, that’s sort of all nations with developed economies. Canada is quite low in terms of the scale size of its hospitals, the number of hospital beds that we have, because we’ve downsized significantly in a number of provinces. Ontario is the lowest in the country, so patients are pushed out to other parts of the healthcare system that aren’t covered. So when the Canada Health Act came in, more care was provided in hospitals and by physicians. Today the ratio is different, but we haven’t modernized public Medicare to catch up. So those things like home care, where patients used to be in hospitals covered fully under the Canada Health Act, now patients are subject to user fees, and virtually everything in Ontario that is pushed out of hospitals is privatized in the sense that the ownership is no longer public. Across Canada, virtually all of our hospital care is provided by public, not for profit hospitals. So there are kind of two types of privatization. One is does the patient pay? So who pays for it? And the second is who delivers it? Is it a private for profit company or a public and offer profit entity? And we’re seeing privatization kind of on both sides of that.

Jordan So we’ve spent this entire week talking about the healthcare crisis in Canada from various aspects, including nursing, including emergency rooms, including the stunning lack of family physicians for millions of Canadians. So it’s very clear that the system is overburdened, and as many doctors have told us, close to collapsing. So I just want to poke at this a bit if I have the means to take some of that pressure off the system for everyone, else by paying somebody for it. Why shouldn’t I?

Natalie Mehra Well, because the load limiting factor right now especially, is staffing. It’s how many doctors there are, how many nurses, how many health professionals of various sorts. And the reason why people are saying that the system is close to collapsing is that we have the most profound staffing shortages we’ve ever seen. They started to emerge around 2015, actually, according to StatsCan data, and they were getting a little bit worse. It was the aging of the workforce and workloads were becoming a serious issue before the Pandemic. But the pandemic has been devastating on the healthcare workforce all across the board, from home care to long term care to hospitals. Now, to the point where we’re seeing emergency departments, even ICU’s intensive care units closing for days or weeks at a time because they don’t have enough staff. That is the most urgent kind of care that there is. To see them closing is absolutely a complete emergency and it’s due to staffing shortages. If one was to open up a private clinic, you don’t add in staff. You take staff out of your local public hospitals. The private clinics only serve the profitable patients. They’re in it to make profit. And so they take the easiest lightest care patients, the ones that are profitable out of our public hospitals. They take staff out of the public hospitals, MRI, text or CTeX or nurses, et cetera, leaving the heaviest care patients, the patients with diabetes and who are obese and have comorbidities, who might code on the operating room table, they are left behind with less staff and less resources to provide for them. I mean, that’s one problem, but it certainly is not taking a load off of the public system. It’s not an add on. It’s a takeaway from the public system and into a group of companies that are operated for profit. And that changes, fundamentally changes the type of care that people get and the behaviour of those clinics and hospitals.

Jordan That makes a lot of sense. I hadn’t thought of it from the perspective of staff being taken away as well. You mentioned we are very low in the OECD rankings in terms of hospital space and beds and all that kind of stuff. How do we compare with those other countries in terms of the amount of privatization that’s allowed? And I don’t want to talk about the US here. Obviously we are miles and miles ahead of them. But I know that even Britain, with the NHS, which is lauded worldwide, has a level of privatization available for people who want to pay. How do we compare to that?

Natalie Mehra Well, it’s kind of hard to measure exactly how much of hospital care different countries have privatized. The same pressures to privatize exist around the world, except for us. We sleep next to the elephant, right? We live next to the United States. It’s the largest private, for profit healthcare market, quote unquote in the world and they’re banging at our door. I mean, they want the profit that can be taken out of our public health care system too. So we have a lot of pressure in Canada. We will always have to fight for public Medicare here because of that. But that said, a lot of countries have experimented with privatization and it goes back and forth. And a lot of countries, our peer countries, have actually more coverage to start with. So they cover pharmacy, that is public access to drugs that are needed. When you think about it, it makes no sense that your diagnosis would be covered under OHIP, or your provincial drug plan freely. You pay ahead of time in your taxes, but it’s there when you’re sick and when you’re elderly and when you’re least able to pay. That’s the whole point. But you can’t get your drugs covered. So many countries have actually public pharmacare, and those of us who have been advocates for public health care have called for an expansion of public health care to cover pharmacare and also to cover seniors care. Many countries have more coverage of social care, like home care and seniors care, and better coverage of that. And we have kind of a hodgepodge of different programs and services across the country, lots of big gaps, but really have failed to plan for the aging of the population on purpose, actually to save money. But I mean, it’s not like if you need healthcare, you need health care. Someone has to pay. And today more of that burden is borne on the shoulders of the elderly and their families. There is a lot of suffering very similar to what we had before the beginning of public Medicare in Canada as a result of that and the reason why we should actually create new expanded public systems. So a lot of countries have less of a proportion, like our pure countries in Europe have less of a proportion of private health care. They have broader coverage than we do.

Jordan So how did we end up in this situation then, where we like to hold ourselves up as a country that really values public health care? We’re way behind a lot of these countries in terms of pharmacare and elder care, as you mentioned, also dental care, which is another one that’s been long promised and not yet delivered. How did we fall so far behind?

Natalie Mehra Well, I think a couple of things happened at the same time. Thankfully, we have a Canada Health Act that provides coverage for hospital and physician services and that’s what saves people from really terrible financial burden when they have serious illness or injury. But starting in around the into the 90s, government started to downsize the hospitals. There was a transition in the way that care was provided and at the same time liberalism hit in the 1990s. So this idea of privatizing everything, of so called free trade, which is really just kind of corporate dominance expanded around the world and a kind of new unfettered greed among the very wealthy that pushed for evermore tax cuts, which of course always benefit the wealthy because they’re the ones that pay the most taxes. And at the same time as care was being moved and so as new systems were developed, as we moved people out of hospitals into long term care, into home care, those new systems were privatized and we didn’t modernize health care to cover those services for people, sadly. And we just have installed I mean, successive governments have promised pharmacare forever. There is a huge, very dominant for profit pharmaceutical industry in the world. The reason they’re not in favor of public pharmacy because pharmacare would require controlling over prescription, controlling prescribing practices and also controlling which drugs are covered so that those ones that don’t actually provide any clinical efficacy or very little clinical like they don’t actually improve outcomes, don’t get covered. And of course, that’s not in the interest of the for profit pharmaceutical industry which has been very dominant. And actually, I don’t think people realize this, but they have really used trade agreements, so called trade agreements to their benefit more than almost any other industry. They’re very smart about it and they’ve used it to expand sort of deregulation and their profit taking quite successfully for them.

Jordan How so?

Natalie Mehra Oh boy, I need a pause here. It’s a whole other podcast, to be honest with you.

Jordan Okay, we will leave that one there because I really do want to laser focus on privatization and how it’s considered sort of the third wheel. And I want to poke at this a little bit because you’ve been giving such excellent answers in terms of why public care is so necessary since there are aspects of our system that are already privatized. And as the system becomes more and more backlogged and we look to make sure that everyone, because I think everybody listening, can agree that equal care should be a priority for all in this country. Is there a way to allow the less urgent, less immediate visits to a hospital? And we’ve heard this a lot this week, people without a family doctor, all of a sudden something goes wrong. They can’t get into a walking clinic, they end up in the ER, and that continues to stress our emergency rooms. Is there a way to privatize a part of the system to allow the less urgent medical issues to be cared for while focusing the public aspect on the people who really need care and aren’t getting it right now?

Natalie Mehra Well, I really think there’s a finite number of doctors, there’s a finite number of nurses, there are a finite number of MRI technologists and CT techs and so on. At the end of the day, we have a labor shortage and we’re in a North American market for labor. And the issue is that if you are to privatize parts of the system. What you’re taking is people who are trained as physicians and trained as nurses. These are highly trained people that have postsecondary education. And by the way, every minute of their education is vastly subsidized by the public. Every minute of it. So why would we pour all of those public resources into training people only to say, here, go join a private market where you go make profit and don’t actually contribute to the public health care system when they’re doing actually very well in the public system itself? One and two, we don’t have enough to start off with. I mean, it doesn’t make a lot of sense. What makes a lot of sense is to organize the public system to provide for people better. And that means that we have to address the staffing shortages and we have to take head on, challenge head on the idea that you can endlessly downsize your hospitals beyond all reason, beyond all evidence, and push patients out ever thicker, ever more complex into other parts of care that just have never been able to provide for them. I mean, getting real. Before the pandemic, it wasn’t like long term care was good in Canada, in a number of our provinces, it was hideous. Well, I mean, in Ontario we’ve had literally almost 5000 people now die just of covid alone in long term care. The majority of it is privatized to for profit companies. Those are chain operated, for profit companies that operate to take as much money out as they can. And as their residents were dying of COVID in numbers, that among the worst records in the world. They were taking tens of millions of dollars per month in profit as people died literally of starvation and dehydration. It honestly, it makes me emotional. It’s the worst thing I’ve ever seen people suffering in that way from just terrible negligence. And they took their profits, they took their profits first and didn’t address the staffing shortages that they had created by refusing to pay their staff decently, by imposing ever worse workloads on them. I mean, is that the model of care that we want? It’s not a solution, it’s a disaster. And it isn’t sort of the protection of public Medicare to do that, it’s the destruction of public Medicare to do that.

Jordan Let’s talk about other solutions then. We’ve spoken, as I mentioned, to doctors and nurses all this week, and asked for their solutions. One of the things that they kind of made clear is that we are so far behind now and the staffing shortages have become so urgent, that like, a massive influx of cash alone won’t fix this. And if a massive influx of cash won’t work, and we also can’t afford because of those shortages, to go down the road of using private clinics to take off some of the burden. Where’s the third path? What do we have to do?

Natalie Mehra Well, one, a massive influx of cash actually would help. I don’t really buy that saying that it wouldn’t.

Jordan Well, their points were just kind of like we’re so far behind on training and repopulating our staffing shortages that even if you gave them a million bucks tomorrow to staff up, they wouldn’t be able to find the people to work the jobs.

Natalie Mehra Yeah, I think we did have a model in Quebec. I’ll use a long term care example in Quebec, after the first wave of the pandemic, which in Quebec was the absolute worst in the country, the government led a mass recruitment strategy for personal support workers. They are equivalent in Quebec. They have a different name for them, but they’re kind of the equivalent of PSWs. And they aim to recruit 10,000 of them. They offered to pay them $21 an hour for training. They did an intensive three month training. Then they were going to put them into the homes, I think it was $24 an hour or something like that, to pay. So they increased the pay to a decent level. And they did, in the end, recruit more than 7000 of them, got them into the homes in time for the second wave. And they had a much better second wave. I mean, remember at that time, we didn’t have vaccines at all. Right. So the way that you would save people’s lives was by staffing up, by being able to isolate people from each other if they had COVID, having enough care for them, feeding, providing care. Right. And they did that successfully. So it depends on the type of worker. Like in long term care and home care, we could do a mass recruitment and intensive training and get people in. I don’t dispute that we’re in such a crisis that you need like a big initial bump up, because part of what’s going on is the workloads are so brutal that people don’t stay. Even when you train new people in, they leave within a month or they leave within days or weeks because it’s just impossible to do the work. That kind of bump up, we absolutely could do. It’s been done and it’s shown to be effective for nurses and they take longer to train. We need to bring back the ones that have retired out or left the field from burnout and from workload. And that means guaranteeing decent workloads. It again means the government has to put their shoulder to the wheel. Independent hospitals and health entities can’t do it on their own. It needs to be led by government. It needs to be a mass recruitment. It needs to deal with their concerns around pay. Yes, actually, pay does matter around workload. Yes, workload matters. But of course, if you get a big bump up in one go and you make it clear that you’re addressing the workload issues, then of course people have hope and they see a light at the end of the tunnel and they’re more willing to stay and they’re more willing to come. And then you need to do other things to clear the barriers. Like, I think, in the short term, pay for their licenses, because they’d have to pay to get their licenses back. And those sorts of things provide the incentives, the financial incentives to get them back. But of course, it could be done, but no one’s doing it. I mean, that’s the problem. They’re not doing it.

Jordan The last thing I want to ask you about then, is what happens over the next bunch of months and even years? And I don’t want to stick too much to the provincial level, because that can change all across Canada, and there will be elections in various provinces. But at the federal level, where the Canada Health Act comes from, we currently have, in theory, the Liberal government and the NDP working together on issues like this. Are you optimistic they can find something to get things done?

Natalie Mehra We’re talking about pharmacy and dental coverage. Those are two things they’ve talked about. I don’t know how much progress has been made watching what happened in long term care. I mean, I was horrified. I think most Canadians recoiled in horror when they saw the military expose of people sleeping on bear mattresses, on floors with homes infested with bugs and cockroaches and almost no care happening. And it’s not like conditions have improved dramatically. I mean, we’re out of the darkest days of the first two, three waves of the pandemic. But still, care is terrible, remains terrible. The federal government gave more than $10 billion to the provinces for long term care. It had an opportunity there to attach strings to ensure that at least a few standards were met, that all the homes are inspected, that those inspections are published openly, that there’s accountability for those who fail to provide care, like in Ontario, for example. Not one home. The power of the for profit industry is amazing. It’s just staggering. Not one home has been fined for its poor care. None have lost their licenses. They haven’t even re-instituted annual surprise inspections of the homes. The industry doesn’t like those. I mean, it’s really horrific, the power of the industry. The fact that that industry was able to influence the federal government to the point that they actually didn’t bring in any required standards but gave billions of dollars to the provinces, I thought was shocking, because in truth, what does the for profit long term care industry have to do with the federal government? I mean, sure, they have controlled provincial governments for many years, but not usually at the federal level. So I was really horrified and deeply disappointed that neither the NDP required that the federal government, in order to ensure its cooperation, would attach strings to that funding, nor did the Liberals lead in any way on that. I expected better of them, to be honest. And if you’ve got $10 billion, you’re going to give, surely you could buy change with that at the federal level, but they didn’t do it. And I realized we have a group of provincial Premiers who want money with no strings attached, but there’s no question the federal government could speak to Canadians over the heads of their Premiers. And I think Canadians would understand and support the idea that there be accountability. It’s our money for that kind of thing. So will they enforce the Canada Health Act better than they have and stop the for profit clinics from extra billing patients and charging thousands of dollars for procedures and tests and things that they do, which they are doing across the country now in violation of the Canada Health Act? I am not expecting better, but I think Canadians, if we push for it, I mean, this is why we have democracy. If we push them, things change. And we’ve done that in our lives and in the Ontario Health Coalition. I mean, we’ve amended every piece of healthcare legislation in the public interest. We’ve stopped privatization over and over and over again. So, yes, we could push and we could get more. It takes a Ginormous effort, but it could happen. But the better way to stop that kind of thing from happening, to stop patients from being charged user fees, and to stop the egregious exploitation of patients for profit, is to actually just not turn over those services to the for profit industries in the first place, which is what we’re fighting to do here in Ontario.

Jordan Natalie, thank you so much for this. Really appreciate it.

Natalie Mehra Oh, thank you for having me.

Jordan Natalie Mehra, executive director of the Ontario Health Coalition. And that was The Big Story, concluding our five-part series on the healthcare crisis. We would love to hear some feedback from you. You can find us on Twitter at thebigstoryFPN. You can write to us via email. Hello at thebigstorypodcast CA. We’ve gotten some great responses already, some really valuable feedback. And of course, if you want to just call and rant, you can do that by dialing 416-935-5935 and leaving us a voicemail. You can find the big story Wherever you get your podcasts, please give us a rating, a review. Let your friends know that you love the show. Thanks for listening. I’m Jordan Heath-Rawlings. We’ll talk tomorrow.