While Canadians are understandably preoccupied with issues of national security and safety, it is also wise to heed the advice of President Bush and Prime Minister Chretien and get back to living our lives.

So it is instructive to remember that health care is the number one social policy challenge for the next decade. But so far Canadians have suffered through a debate that has seen its inherent complexity diminished down to facile bi-polar country comparisons and simplistic left/right ideological disputes.

Canada spends $95 billion - 9.3% of its GDP - for public and private health care. With health costs consuming 62% of all new budget expenditures in the provinces over the last three years, it is clear that health care is a taxpayer issue.

The Canadian Taxpayers Federation (CTF) has authored a research and discussion paper entitled The Patient, The Condition, The Treatment. The CTF believes that:

Health care is in a state of crisis;

Canadians are ahead of their politicians on the need for reforms;

Health care is a shared jurisdiction between Ottawa and the provinces;

The Canada Health Act is not the Bible;

It is impossible to measure health systems by numbers alone;

The present debate is too continental, it must become global; and

Quality and excellence must be the primary focus, not cost containment.

The development of health care policy in Canada over the past century reveals that we can handle exhaustive and sometimes painful debate. We must now build on this history and consider all options for reform without needless rhetoric and hyperbole.

The logical starting point is with a review of the Canada Health Act (CHA). Scholars and medical practitioners agree that the CHA constrains provincial initiatives and its core principles are often in conflict with each other. Public opinion reveals a thirst for fundamental changes, even if these changes sometimes contravene the CHA's existing principles.

While the fight between Ottawa and the provinces over health funding levels is partly inherent to our federal system, it is clear that this tension is now counterproductive.

Spending growth in health care is unsustainable and provincial health ministers have stated as much.

Yet these same ministers abandon economic reality in favour of good politics as health care spending continues to ramp up at rates that double or even triple annual revenue growth in budget after provincial budget.

If this spending continues unabated, today's tax cuts vs. more spending debate will quickly give way to tomorrow's MRIs vs. school books dilemma. And tomorrow will come as 2007 for provinces like B.C. and Newfoundland when health care is projected to consume 50% of all provincial spending. Similar fates await Alberta, Manitoba and Saskatchewan in 2012, 2014 and 2019 respectively.

At the root of this problem is medicare itself with its flawed economics. Funding flows from taxpayers though a variety of intermediaries (governments to insurers to other governments to service providers) and insulates patients (read: consumers) from the financial ramifications of their consumption decisions.

As a result, we are left with a patchwork system of perverse incentives for patients, doctors, bureaucrats and politicians. This perversion vaccinates the health care system against options that could improve quality and health outcomes.


Even more damaging is the blunt assessment by the World Health Organization which rated the health care systems of 191 countries: Canada ranked 30th. As a WHO official put it, "Canada does not have the best health care system in the world." Yet, as a country, we are still loathe to embrace or adapt the best practices (financing, organization and/or service delivery) of those countries that finished ahead of us.
Demographic pressures are already upon us and by 2020, almost 60% of health care expenditures will be consumed by those aged 65 or older compared to 45% today. Moreover, technological advances - while welcome - usually just improve upon existing technology instead of replacing it (i.e.: x-ray, CT scanner, and MRIs), thereby driving costs further in an upward spiral.

Pharmaceuticals consume more resources than physician billings. With new and aggressive drug therapies around the corner, costs will only escalate. Amidst these pressures, patient demands and expectations for "right here, right now" services will also magnify.

Taken together, demographic, technological, pharmaceutical and patient expectation pressures can be termed as the "gang of four."

To date, reforms in Canadian health care have been supply side driven, from regionalization of service delivery to province-wide disease networks to cost containment to structural integration. While some economies have been found, patient demand, patient responsibility and perverse incentives have been ignored as focal points for reform.

Health care is complex and it is clear that there are no magic bullet solutions. However, key principles do exist that should be employed both in legislation and in restructuring service delivery which would put Canada on the proper road toward patient-focused, sustainable reforms.

At the legislative level, a modernization of the Canada Health Act is long overdue. Its current five principles should be replaced in with the following six principles:

Public governance;

Universality;

Quality;

Accountability;

Choice; and

Sustainability.

At the structural level, guiding principles for reform include:

Individual accountability and responsibility (this could include co-payment);

Intergenerational fairness (pre-funding of health care is key which could include health care savings allowances or accounts); and an

Embrace of innovative approaches (including flexible and workable public-private partnerships in capital construction, service provision and technology renewal as well as provincial experimentation in financing and service delivery).

The principal and laudable aim of medicare was to provide health services without hindrance.

Now, the greatest hindrance to reform is the intransigence of those who refuse to accept that the problem with health care is the system itself.

Its present global funding configuration is unsustainable and its orientation must change to place the patient at the centre of every interaction. An honest, open and thorough debate on the future of health care is needed.

This debate must go beyond the hearings of the Romanow royal commission or the deliberations of the Kirby Senate Committee, it's time for citizens and taxpayers to take ownership of this debate.