Book Review: Chronic Condition: Why Canada's Health Care System Needs to be Dragged into the 21st Century by Jeffrey Simpson (Penguin, 2012).
It took two world wars and approximately forty years for the earliest stages of Canada's universal health-care plan to see the light of day. In Chronic Condition, Jeffrey Simpson lays out our health system's tumultuous history. His central concern is that health-care costs will continue to rise as a share of the national economy, without returning the value for dollars spent by Canadian taxpayers.
The discussion is grounded in the clinical "trenches" of medicine, as Simpson shadows past Canadian Medical Association president Dr. Jeffrey Turnbull in the national capital. The text quickly jumps into the complexities of social and political change across the first three quarters of the twentieth century.
Simpson frequently attempts to level with his reader and draw critical eyes to the rhetoric that fogs discussions of health system reform. He does some literary eye-rolling as he discusses the recent propensity of politicians and organizations to use the term "patient-centred," noting that "to have to repeat the obvious—the health-care system must be 'patient centred'—must mean that it is not. . . . What seems to have happened is that a system supposed to be designed for patients has become one designed for and by providers."
The Story so Far
Canadians can, and must, learn from Medicare's long and somewhat volatile gestational period. Simpson details the volleying of responsibility that took place "pre-Medicare" between agencies and jurisdictions over the nature and administration of health care coverage. The discussion quickly disposes of any assumptions that Medicare was easily delivered, or about the inception of the now-celebrated Canada Health Act (CHA). Saskatchewan is often thought to have been the willing incubator for state health insurance, when, in fact, the issue "produced the most bruising fight in the history of health care in Canada" and was, due to a number of standoffs between powerful interest groups (including physicians) and the state, "a near-run thing."
Even in the early 1980s a number of associations (including the Canadian Medical Association) and other "pockets of resistance" were still waging war on the Act and the universal care plan that it protected. They asserted that the Act was unconstitutional, Medicare fiscally unsustainable, and that together they posed a threat to autonomous medical practice. In the end, the will of a "silent majority" of supportive Canadians ruled. Certainly, key organizations and individuals (such as Tommy Douglas and Monique Begin) championed Medicare and, later, stick-handled the Canada Health Act into being. Simpson demonstrates, however, that the sustained force behind the implementation of universal coverage was the will of the Canadian people, who politicians across party lines and several decades were careful to listen to in order to hold onto their offices.
The Equity Lens
Medicare was intended to foster equity—to create good long-term health outcomes for all Canadians, regardless of their background or income. Exploring this principle in detail, Simpson argues that "rule one of healthcare cost sustainability is . . . to produce a more equal society," acting on the social determinants, the factors beyond individual behaviour that impact health. He draws from the Lalonde Report in 1974 and the 1986 Mulroney Report, Achieving Health for All, both of which demonstrated that "people's health remains directly related to their economic status," and that gains in equality equalled reductions in demand for health services.
Despite strong arguments for investments in prevention, Simpson does not include in his final proposals any action on the factors that might reduce inequalities and socio-economic disparities. This is understandable, given the pragmatism with which he is attempting to address the immediate threats to health care. Simpson's analysis is a kind of triage; he recommends treatment for the most pressing and urgent issues, while arguing that political discourse cannot remain stalled on the equally pressing issue of inequalities. "The logic," he argues, "points to a longer-term horizon."
Subject to Triage
We are now faced with a system that cannot keep up with the magnitude of fiscal and demographic change upon us, with data showing that the demand for and cost of health services will continue to increase. While we spend more on health than most countries and perform well on various aggregate measures such as life expectancy, we are not seeing adequate returns for dollars spent and are slipping down the international health-measurement charts. There are many factors—including over-use of hospitals, inadequate community and long-term care, and the need for supplementary insurance—that culminate in a generally sicker population. Finding efficiencies, Simpson argues, will not be enough to treat the advanced chronic condition of health care in Canada. Cost savings must be found, and improving efficiency will only, maybe, yield savings in the very long-term.
Based on a number of public opinion surveys, the fiscal reality he has laid out in his earlier arguments, and a general consideration of the value that Canadians continue to place in their universal health system, Simpson offers a number of solutions. These are a reasonable effort to identify cost-effective actions that will curb spending, build modest efficiencies, and indirectly uphold equity across the system user population.
Simpson meets the issue of privatisation head-on, emphasizing that it is allowed under the CHA, and is one way to "de-hospitalize" health care, though "the single-payer remains the state." He offers a compelling argument for this mode of delivery, with the admission that the discussion itself is likely to raise the ire of those married to the idea of publicly provided care. Simpson includes in his prescription for the immediate course-correction of the health system a comprehensive drug plan, increased "restraint" in compensation, and the reduction of public dependence on hospitals for care that can, and should, be provided elsewhere.
Those in power are implored to be candid with the Canadian public, to express the "unpalatable truths" that will hasten needed conversations. There remains a disconnect between Canadians' understanding of the situation and the realities that health policy leaders have long faced; according to opinion-surveyor David Herle, "all that is assumed by the policy elites is unknown to most of the public."
As a deeply personal and politicised issue from its very beginnings in the early twentieth century, health care can win and lose elections—politicians don't want to touch it and "risk committing political suicide." By setting up a political and historic foundation in the dense beginnings of his discussion, Simpson demonstrates why our elected officials must lead the conversation about how to facilitate lasting change and bring our system back to its full potential. Chronic Condition makes it clear that the same population that, not so long ago, inspired and fought for a comprehensive health care system, now needs to share in the sacrifices to drive forward the modernization of that early vision.