The Sustainability of Medicare
In the past few months several politicians, journalists, and private sector organizations have claimed that Medicare is unsustainable. Too often the allegation of runaway healthcare costs is swiftly accompanied by a replay of the fifty-year old Medicare debate. “User fees are the answer.” “The public sector can’t do anything right.” And, recently, “If you think things aren’t bad yet, wait until the Silver Tsunami of baby boomers hits Medicare beaches. It won’t last the first wave!”
However, we need to be constantly on guard for those who claim the sky is falling and then rush us to their claimed pet remedy. In fact, a closer examination of the numbers reveals that apocalyptic future forecasts for Medicare are seriously flawed. Furthermore, the best cost-control options focus on improved public-sector management not privatizing costs or delivery of care.
Healthcare costs are not out of control
Healthcare’s share of the GDP has always waxed and waned. This reflects different rates of increase in spending and different periods of economic growth and slowdown. Healthcare’s GDP share was quite stable during the 1980s around eight per cent of GDP. However, when the economy fell in 1990, healthcare’s share of GDP rose to ten per cent by 1992. Starting in 1992, governments greatly reduced their spending for five years during which time health costs fell to less than nine per cent of GDP. Canadians became alarmed about problems in the healthcare system which resulted in political pressure to increase funding starting in 1997. Further concern led to the creation of the Commission on the Future of Health Care in Canada chaired by former Saskatchewan Premier Roy Romanow.
After the commission delivered its report, two rounds of Federal Provincial Territorial negotiations led to the 2003 and then the 2004 Health Accords which raised federal health spending by six per cent per year for ten years. Even in good years, the economy only grows at three per cent so the Accord reflected the political choice of Canadians to invest in their health system by deliberately spending a larger proportion of government resources on healthcare.
Over the next five years, as planned, overall healthcare costs increased slowly as a share of the economy, from 10.2 to 10.8 per cent of GDP. In 2009 overall healthcare spending only increased by 4.3 per cent but Canada began a very serious recession, the rest of the economy shrank rapidly, and there was a large jump in health’s share of GDP to 11.9 per cent. Almost all of this sharp increase was due to the economic downturn. If the economy had grown at the same rate in 2009 as 2008, overall health spending would have only been 10.9 per cent of GDP.
Healthcare spending is a summary measure capturing spending from both the public and private sectors. So what happened to public spending over this period? Public spending on healthcare was relatively stable through most of the 1980s at 6.3% of GDP but jumped up to 7.4% in 1992 following the recession. Following the tight budgets of the mid 1990s, public sector health spending returned to 6.5% in 1997. After the 2003 and 2004 health accords which committed to increased public spending, public health spending increased to 7.6% of GDP by 2008. Public sector health spending increased to 8.4% of GDP in 2009 almost entirely because of the recession. If the economy had grown at the same rate in 2009 as 2008, public sector healthcare costs would have been only 7.6% of GDP, identical to the year before. In 2010 public sector healthcare costs were estimated to have held steady at 8.3% of GDP.
Government spending is under pressure from tax cuts
Even though publicly funded healthcare has not markedly increased its share of the economy, it has received an increased share of government spending in recent years. However, part of the explanation are the major tax cuts which governments have made in the past decade. In total the three levels of government cut their revenues by 5.3% of GDP from 2000 to 2008 which amounted to roughly $85 Billion in foregone annual revenue (Federal Department of Finance, 2009). Since over this same period public sector health budgets increased by $52.6 billion, there has been a decrease in the amount of money available for public programs. Additional decreases in government revenue through the scheduled corporate tax cuts will continue to pressure government spending.
Finally, Canada’s healthcare costs are similar though at the high end of other wealthy countries (and much lower than those of the United States) (OECD, 2010). According to the latest data from the Organization for Economic Cooperation and Development (OECD), Canada spent slightly more than 10% of its GDP on healthcare which was slightly less than Belgium, Germany, Switzerland, and France and slightly more than about ten other countries including Sweden and the Netherlands. The United States leads the pack by a long way, spending 16% of its GDP on health in 2007.
The Silver Tsunami that isn’t
Canada’s population is aging. The proportion of the population aged 65 and older will almost double during the next 20 years (at an average growth rate of 2.3% annually). This demographic shift has been triggered mostly because baby boomers—who were born between 1946 and 1962 and make up a substantial proportion of the population—are aging (Thompson, 2010). Fertility rates also play a part. Since the baby boom generation, the number of children born per 1000 people dropped from 28 to 10.5 in 2004 (Statistics Canada, as cited in Thompson, 2010).
Many political commentators have speculated that population aging threatens the financial sustainability of Canada’s healthcare systems (e.g., Robson, 2001; Siegel, 1994). This speculation is based on several real facts. Population aging reduces the amount of personal income tax revenue, which accounts for approximately 30% of government income. Per capita healthcare costs increase with age (see more in section 2.0). As well, an aging population increases demand for (potentially expensive) health services such as long-term care (Ronald et al. 2008).
Based on these facts it may seem as though aging will break the health system’s bank; however a plethora of research evidence indicates that aging does not pose a major threat to the financial sustainability of Canada’s healthcare systems (e.g., Barer et al., 1995; CHSRF, 2002; Denton & Spencer, 1999; MacKenzie & Rachlis, 2010; Evans, 2010).
How could this be? In part, it’s a question of numbers. The aged are only a small part of the Canadian population: in 2006 only 13% of Canadians were 65 years or older. So if this 13% increases by 2% that year, this translates into a very small (0.3%) increase in the number of elderly relative to the total number of Canadians that year. People have always gotten older, and have always needed more healthcare as they have got older. But it is only the relative size of the increase in the older population that will directly affect healthcare needs and that increase is a small percentage of a small percentage―i.e. a relatively small number.
Holding factors such as inflation constant, recent projections estimate population aging will increase healthcare costs in Canada by about 1% annually from 2010 to 2036 (OECD, 2010). This result replicates many others demonstrating that population aging accounts for only a small proportion of increased cost for particular services (e.g., hospital services, physician services, drugs; e.g., Health council of Canada, 2009). Although a 1% increase in healthcare costs due to aging is still a significant increase, factors such tax revenue on pension and RSP withdrawals, and cost savings from the reduced need for public funding related to services for the younger and working age population such as education and workers compensation, are predicted to be able to offset some of the added expense (Denton & Spencer, 1999; Infrastructure Canada, 2008).
As indicated by the figure below, the financial impact of population aging will be more pronounced in some provinces than others, from a low of 0.7% in Manitoba to a high of 1.9% in Newfoundland and Labrador, with well-above-average impacts in all three of the territories (MacKenzie & Rachlis, 2010). Thus, some provincial governments are faced with stronger pressure to prepare for the aging demographic (Robson, 2001).
Mackenzie and Rachlis 2010. P43. Sources: Projected population by age group and sex according to three projection scenarios for 2010,2011,2016,2021,2016,2031and 2036, at July 1, Statistics Canada, Cat. No 91-520-X, June 2010, projection M4. National Health Expenditure Trends, 1975 to 2009, Canadian Institute for Health Information, Ottawa, Ont.: CIHI, 2009. Note: CIHI data gets updated on a regular basis. For the latest available information please visit website (www.cihi.ca) or contact their media team at firstname.lastname@example.org.
Canadians don’t have to pay a lot more to get better access to care
Public opinion polls tell us that Canadians’ big concerns with the healthcare system are waiting times and access to care. While sometimes more resources (e.g., more staff) reduce wait times, evidence suggests that many issues contribute to wait times and several approaches exist for solving them. For instance, accurately recording wait times is an important first step in reducing wait times, while ensuring appropriateness of care (is this MRI necessary?) is another. Further, many long wait times are due to a failure to use appropriate management tools rather than insufficient resources. Work that has been done changing management practices in Alberta and Ontario has rapidly reduced wait times without increased resources. Sometimes of course, more resources do help. In addition, all waits are not equal – in Canada, studies demonstrate that people generally have rapid access to emergency and essential care.
The Saskatoon Community Clinic implemented its Advanced Access model of booking patients with its family doctors and nurse practitioners in 2004. Now most patients are seen the day they want to be seen and many are seen the same day. The community clinic has assisted the Saskatchewan Health Quality Council attempt to implement advanced access throughout the province.
We could also eliminate most delays for specialty care. In Hamilton, the Mental Health and Nutrition Program integrates the practices of over 100 family doctors, with 17 psychiatrists, 80 counselors (most of whom are social workers), and 20 dietitians. In the mental health component, the counselors are based with family doctors (Kates, 2002; Kates, 2006). As a result of the program, 1100 per cent more patients have been seen with mental health problems in primary health care while referrals to the psychiatry specialty clinic have simultaneously dropped by 70 per cent. All patients are given standardized assessments and the program has documented improvements in depression scores as well as general health and functioning.
We can even decrease wait times for elective surgery. The Ontario Wait Times Strategy has been an effective provincial wait time initiative. It has demonstrated significant reductions in wait times for joint replacements, cataract surgery, and other elective procedures. The Alberta Bone and Joint Health Demonstration project used a variety of different processes to reduce waiting times (Alberta Bone and Joint Institute, 2005). The evaluation revealed:
- Wait times from first referral from family doctor to first visit with orthopedic surgeon dropped 80 per cent, from 35 weeks to six weeks.
- Wait times from first visit with orthopedic surgeon to surgery plummeted 90 per cent, from 47 weeks to 4.7 weeks
- Length of stay in hospital fell 30 per cent, from six days to four days
- Patients surveyed expressed increased satisfaction.
In the management of waiting times for surgical services, it is also necessary to consider the different thresholds for surgery that exist among and between surgeons. Tools are available to help deal with this issue and with the priorization of patients when a decision for surgery has been reached, but they are not yet widely used in practice.
For profit options have lots of risks and few benefits
Although it may be counter intuitive, private, for profit alternatives don’t seem to work very well in healthcare.
Privatizing finance tends to increase overhead costs. Each health insurance company needs actuaries, managers, clerks, computer systems and lots of marketing and sales people. That’s one of the main reasons why public insurance costs so much less to administer than a system of private insurance. There’s less overhead. In fact, that’s one of the main reasons Supreme Court Justice Emmett Hall recommended public medical insurance in his 1964 Royal Commission.
And, a single purchaser can negotiate lower prices with suppliers than many small purchasers. That’s one of the main reasons why Canadian health care costs are lower than US costs (Anderson et al, 2003).
Some claim that as long as the public pays, it doesn’t matter who delivers a medical service. Why shouldn’t governments put the delivery of health care (cataract surgery, MRI clinics etc) up for bidding? This option sounds intuitively appealing because competitive bidding does lead to efficiencies in some other sectors. However, the evidence is clear that this policy doesn’t work in healthcare.
In the US, kidney dialysis has been run for many years using a competitive model. The US Medicare program, which provides coverage for people over 65, also covers all Americans with kidney failure regardless of their age. The Medicare program decides which dialysis centres to fund by using a competitive bidding process. Roughly three-quarters of dialysis is conducted in for-profit facilities and one-quarter in non-profits.
In 2002, a large Canadian group collated the evidence on the quality of dialysis care in the United States (Devereaux et al, 2002a). They found that patients attending for-profit dialysis clinics had eight per cent higher death rates than those who got their care at non-profits. For-profit clinics had fewer staff and less well trained staff. They also dialyzed patients for less time and used lower doses of key medications. These results suggest that in the US there are 2,000 premature deaths every year among people on dialysis because their care is being provided by for-profit clinics.
In another study, Dr. P.J. Devereaux’s group found that adults have two per cent higher death rates in for-profit hospitals, while the newborn mortality rate was ten per cent higher (Devereaux et al, 2002b). The investigators found that for-profit hospitals tended to have fewer staff and less well trained staff. These factors have been found to be associated with higher death rates in other studies of quality care in hospitals. Dr. Devereaux’s group also found that American for-profit hospitals are 20 per cent more expensive than non-profit facilities on a case-adjusted basis (Devereaux et al, 2004).
Finally, studies from both BC and Manitoba have found better patient outcomes in not-for-profit long term care facilities than in for-profit homes (McGrail et al., 2007). For-profit facilities in BC and Ontario have lower levels of staffing despite the same funding. Because of the tremendous needs for physical assistance for residents, staffing levels have been found to be strongly related to care outcomes (McGregor et al., 2005).
Making Patients Pay won’t make the System more Affordable.
Some people think that charging patients when they use the health system would help control health care costs and ensure that people were getting the care they need and not overusing the system. Others believe that user fees would bring in much-needed revenue.
Research to date suggests user charges for patients discourage patients from seeking both necessary and unnecessary care. When preventive care is discouraged and effective drug prescriptions are not filled, user charges can promote higher costs and poorer health.
But this doesn’t mean that money is saved. Nature abhors a vacuum, and the health care system detests unused capacity. As a result, any beds or doctors freed up because the sick are discouraged by charges, end up being used by the healthy for care they may not need.
Some claim that user fees are benign because they discourage only frivolous use. However, a US study involving fairly healthy adults showed that user fees led to a 20 per cent increase in risk of death for people with high blood pressure because they were less likely to see a doctor and get their blood pressure under control (Brook et al, 1983). The same study showed that user fees were just as likely to discourage appropriate care as inappropriate care (Siu et al, 1987; Foxman et al, 1987).
And, that’s a big problem with user fees. The average person doesn’t know whether their symptom warrants medical attention. When a child has a fever, most parents don’t know whether it’s the flu or the onset of meningitis. Do we really want them to make the decision about whether to seek health care on the basis of whether that will leave enough money to pay the rent?
The scientific evidence supporting publicly financed care is long and strong. So why do discredited ideas like user fees keep coming back? Dr. Bob Evans and his colleagues (Evans et al, 1995) have repeatedly examined this issue and refer to user fees and related ideas as “zombies.” That’s because they have been killed off repeatedly by the scientific evidence, but, just like zombies, they keep bouncing back to life to wreak havoc with our public policy.
More Care is Not always Better
We don’t know for sure if we had a perfect health care system that always delivered appropriate care if we would spend more or less, but there are many examples of waste and harm within our system. It is easy to assume that the real problem with the health care system is “not enough”—not enough physicians, not enough MRIs, not enough money in the system. But the evidence suggests something different. More health care is not always better and the more expensive drug is not necessarily the right choice.
So what is the “right amount” of care? Getting the “right amount” of health care means that you are getting as much care as you need, but no unnecessary care. Unnecessary care is care that you don’t really need. Here are some examples: Getting antibiotics for an infection that is helped by antibiotics is the “right amount” of care. Getting antibiotics for an infection that is not helped by antibiotics—such as the common cold—would be unnecessary care. Staying on schedule with the preventive care and screening tests that are recommended for your age and health condition is the “right amount” of care. Having preventive care and screening tests more often than recommended would be unnecessary care.
Often there is an assumption that more health care and the more expensive option in health care means better outcomes. However, there is huge variation in the amount of healthcare that similar patients receive that depends largely on where they live. For more than 20 years, the Dartmouth Atlas Project has tracked the distribution and use of healthcare resources in the US. Studies consistently show that deploying more resources—specifically, specialist visits, diagnostic tests and hospital care, for similar patients—does not necessarily lead to better care; in fact, sometimes it leads to harm. By safely adopting more conservative practices, the evidence suggests that savings of about 30 percent of Medicare costs or almost $40 billion, could be realized, with care that could be at least as good.
In Canada, large regional variations have been documented in the provision of healthcare for patients with conditions such as cardiac disease, stroke, arthritis, asthma and diabetes, despite the availability of evidence-based clinical guidelines.
A variety of factors, such as patient illness severity and physician clinical judgment, determine whether a patient receives more health services. But non-medical factors, including patient demand, a medical culture that promotes testing and interventions regardless of necessity, fee-for-service structures that reward volume rather than quality, and availability of healthcare resources, such as hospital beds and specialists, also play a role.
There are limits to the amount we can spend on health care, and there is a need to determine whether we are getting good value for our health care dollar (cost vs. benefit).
Health is More than Healthcare
Canada spent over $180 billion dollars on health care in 2009. So why don’t all Canadians have similar chances of having a long healthy life?
Health starts in our homes, schools and communities. It is critical than everyone can see a doctor when they are sick and everyone needs to be able to access preventive care easily―things like screening for cancer and heart disease. But we also need to stop thinking of health as something we get at the doctor’s office. Health starts in our families, in our schools and workplaces, in our playgrounds and parks, and in the air we breathe and the water we drink. The more you see the problem of health this way, the more opportunities you have to improve it. The evidence shows the conditions in which we live and work have a big impact on our health, long before we see a doctor. It’s time we expand the way we think about health to include how to keep it, not just how to get it back
Simply put, the brain is an environmentally sensitive organ. It requires specific sensory input at particular times in order to develop pathways, and the richer the stimulation, the richer the resulting connections. Children in nurturing environments develop more neural pathways, synapses and dendrites. Further, the stress hormone cortisol, produced in situations of neglect, fear, and deprivation, damages several parts of the brain, including the major site of memory and learning. The wiring of bad pathways can, without intervention, stay with a child throughout life.
Not being able to afford the basics, cycles of violence and abuse, and poor education take their toll on young bodies and young minds. The effects of stressful adverse experiences can take years to show themselves, but when they do they often show up as disease. At risk children become at risk adults who carry mental illness, disability, and premature death with them into adulthood.
Current models of health promotion, disease prevention, and health policy focus on promoting healthy behaviours and trying to change damaging behaviours in adults. Mounting scientific evidence suggests the effects of these strategies may be limited. It’s time to expand the way we think about health to include how to keep it, not just how to get it back.
Medicare is as sustainable as we want it to be
Canadian healthcare costs are increasing. But, on closer examination the recent increase in healthcare’s share of the economic pie is due to the recession shrinking the economy rather than massively increased costs. Health care is also increasing its share of government spending, but this is largely due to reduced government spending on other portfolios. And, Canada’s spending is similar to other wealthy countries while being much less than the US.
Aging of the population by itself is increasing healthcare costs but at a very slow rate. Rather, the utilization of healthcare is increasing for all age groups and this is affecting the elderly the most. However, there is abundant evidence that at least some of this increased servicing is dubious and even outright dangerous. Of course, some needs are unmet now. But, it may be that improving the overall quality of care might reduce costs.
Private for-profit options may be intuitively appealing, but evidence shows that for-profit finance increases administrative costs and dilutes the ability of a single purchaser to get a better price (think of Walmart). Under most circumstances corporate for-profit delivery of healthcare produces few benefits to the patient or to the health care system. Potential ‘win-win’ situations exist if savings result from strong economies of scale or better management. However, savings frequently arise from more contentious measures, including freedom from labour agreements (and different wage levels and skill mixes), risk selection/cream skimming, or even dubious practices. In theory, these problems can be minimized if performance is monitored, but this adds additional costs, and may be difficult where outcomes are not easy to measure. If performance cannot easily be monitored, not for profit delivery is more likely to provide high quality outcomes than is for profit delivery, with corporate for profit delivery being the most vulnerable to poor outcomes. Finally, user charges for patients discourage patients from seeking both necessary and unnecessary care. When preventive care is discouraged and effective drug prescriptions are not filled, user charges can promote higher costs and poorer health. Medical savings accounts, another approach to making the patient pay, don’t work. They don’t work for services that the sick need and they don’t work for the services that the healthy need.
The key to controlling costs and improving quality in the health care system, as unexciting as it sounds, is better management of the system in the public interest.
 Federal spending amounts to 20-40% of overall health spending depending upon definitions.
 Public-sector Health Expenditure in current dollars found in table B3.1 page 145 of report. See http://secure.cihi.ca/cihiweb/products/NHEX_Trends_Report_2010_final_ENG_web.pdf “GDP figures for 2010 found in Appendix A.1, titled “Gross Domestic Product at Market Prices, 1975 to 2010 — Current Dollars ” from CIHI’s National Health Expenditure Trends, 1975-2010 report. To access a copy of this appendix please contact email@example.com.”
 “Hence, the decision which Canadians have to make…is whether they wish to pay $1.020 million…in 1971 for a programme administered by the insurance industry, or $837 million for a programme administered by government agencies” “In our opinion it would be…uneconomic…to spend an extra $193 million. We must choose the most frugal method.” Royal Commission on Health Services. 1964.
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