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Code Blue: Reviving Canada's Health Care System


The introduction to David Gratzer's book Code Blue: Reviving Canada's Health Care System, winner of the Donnor Prize as an outstanding book on public policy.


David Gratzer

 Author Notes

Student at the Faculty of Medicine, University of Manitoba, where he served on the university's Board of Governors for four years. Author of a weekly column for the Halifax Herald and contributor to over a dozen newspapers and magazines including the National Post, the Calgary Herald, the Ottawa Citizen, and the Toronto Star. Author of Code Blue (1999), winner of the Donnor Prize for outstanding books on public policy.

Book by David Gratzer
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Code Blue: Reviving Canada's Health Care System
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 Essay - 11/1/1999

Early in 1999, the surgery of a 46-year-old man was cancelled.

Such an event isn’t unusual in any health care system, but this was no ordinary operation. Daniel Smith suffers from cystic fibrosis. February 3 was the day he was to receive two donated lungs, an urgently needed transplant that could literally breathe new life into his body.

But it didn’t work out that way. It wasn’t that lungs couldn’t be found for the surgery (miraculously, they were) or that the procedure was too difficult or dangerous for doctors to perform. Administrators cancelled the double-lung transplant because no ICU bed could be found for the patient.

Modern medicine wasn’t the problem. Medicare was.

It would be easy to dismiss this example as an exception—a tragic and unacceptable shortcoming, but an isolated example. Except that, while Smith was losing his opportunity for life-saving surgery, patients across Canada were having problems getting proper medical care. Here are other examples from February 1999:

The Ontario government was desperately trying to arrange medical treatment for cancer patients—in the United States. And with good reason. Waiting times far exceeded the clinically recommended four-week period between diagnosis and the start of radiation therapy.

Emergency rooms were severely overcrowded for a second year in a row, not only in Ontario but also across Canada. At Cité de la Santé, the largest hospital in suburban Laval, Quebec, staff took the unusual step of issuing a press release early in the month. The sick were asked to delay any visit to the hospital.

In Montreal, nurses at Sacré-Coeur staged a wildcat strike to protest the overcrowding, a problem experienced by every hospital in the city. For instance, at Maisonneuve-Rosemont—a hospital that had drawn national attention the year before because an elderly patient had died while waiting to be seen in its overcrowded emergency room—79 patients jammed into a room designed to accommodate only 34.

In Nelson, British Columbia, a 74-year-old ER patient was placed in a hospital storage area. No other room could be found for him at a time when patients were routinely placed in hallways and linen closets. And, in Victoria, facilities were running at 110% capacity—since the summer before.

The above incidents all occurred during a two-week period that was by no means unusual. It’s not difficult to find newspaper articles throughout 1999 about physician shortages, long waiting times for treatments, and a lack of high-tech equipment. It doesn’t matter which daily newspaper you pick. The problems in Halifax are similar to those in Montreal, Saskatoon, and Vancouver.

Of course, you needn’t open a newspaper if you want to hear about the problems with the health care system. Friends and family can relate their own stories.

When such stories come to light, they are almost always underplayed by the so-called experts. A health care consultant told a CBC Newsworld panel that Canadians are far too negative. On the topic of the missed lung transplant, he observed that it’s a “miracle” doctors can perform lung transplants at all. “Two out of three [lung transplants in a day] isn’t bad,” he noted, based on the fact that the Toronto Hospital had performed two lung transplants the morning Smith was scheduled to have his surgery.

Such views are common. Even those who openly criticize the health care system—opposition politicians, union spokespeople, physicians—typically have grievances with the way a provincial government manages the system but not with the basic organization of the system. When medicare is discussed, two opinions are usually expressed. The magicians believe that, with just the right combination of government regulations, medicare will magically work. The spendthrifts argue that more government money would solve every problem—from the attitude of the grumpiest hospital orderly to the lengthiest waiting list for radiation therapy.

Magicians and spendthrifts dominate the health care debate in Canada. And, on the surface, they seem to have little in common. That they attack each other with great contempt in public debates no doubt fosters this view. John Ralston Saul, a writer, explained at the Canadian Medical Association conference The Future of Health Care that “anyone who doesn’t think that putting billions of dollars back into the health care system is a good idea is crazy or either in the business of caskets.”

Both magicians and spendthrifts, however, believe in a government-run health care system. And, while they don’t agree on the best way to reform medicare, they basically agree that government action, whether more spending or better management, will provide a solution.

Provincial governments have been busy implementing the ideas from these two camps. Health care has never been managed more than it is today. For all the talk of “using money better” and “coordinating and integrating,” provincial governments have spent the past two decades feverishly implementing one management idea after another: regional health boards, bed closures, and now community care.

Despite the widespread view that health care spending has declined in recent years, it hasn’t. In 1990, in the easy deficit-spending days, total health care expenditures amounted to $61 billion. In 1998, after federal Minister of Finance Paul “the Axe” Martin supposedly chopped down the health care budget, more than $80 billion was spent, an increase of about 33% (roughly 20%, factoring in inflation).

Yet medicare is worse than it has ever been. What’s going on?

Code Blue attempts to answer this question. On the great debate of our time—more money or better management—this book rejects both ideas. Magicians and spendthrifts are persuasive and well spoken, but the ideas they champion are about as useful as rearranging the deck chairs on the Titanic. This book challenges many of the widely accepted “truths” about medicare, including the most important one: medicare is fundamentally sound and is merely in a time of transition.

Chapter 1 details the state of the health care system. Although many Canadians are familiar with polls suggesting widespread public concern (and with the anecdotal evidence behind this concern), the first chapter looks at specific indicators: studies on waiting times for treatments, statistics on high-tech equipment, and physician migration. From the American practice of a frustrated Canadian surgeon to the struggle over Vancouver Island’s MRI scanner, the chapter gauges the real state of medicare—and soundly rejects the “don’t worry, be happy” attitude of so many health care experts.

Chapter 2 follows the political debate over medicare, offering a careful critique of Reform and Liberal positions. The chapter takes a serious look at the cherished Canada Health Act, promises of pharmacare, and the bidding war over increasing health care funding. It also notes that, while both the government and the opposition are eager to attack one another, their public pronouncements are generally hollow and eerily similar.

Because so much of the health care discussion in Canada focuses on the American system, chapter 3 takes a careful look across the border. It explodes commonly held beliefs: that U.S. health care is free market, that government noninvolvement has resulted in millions of citizens without insurance, and that high administrative costs are inherently wasteful. It also observes, perhaps surprisingly, that the trend in U.S. health care—away from individual choice and toward bureaucratic management—parallels that in medicare.

Chapter 4 looks at the economic problem at the heart of medicare’s woes. With no direct cost to the patient, and the physician billing the government, the basic doctor-patient relationship gets distorted. An expensive system full of perverse incentives is the result. To combat these incentives, governments have worked feverishly to save money—largely by restricting patients’ access to the care they want and need.

Demographics has become a hot topic in discussions about public policy (e.g., pensions) but not about health care. Chapter 5 explains why health care analysts need to look at demographics. Indeed, Canada’s aging population coupled with the rising costs of medical technology is sure to increase pressures on the health care system. Time, it seems, will make medicare’s problems much worse, not better.

Chapter 6 takes the observations of previous chapters and weaves them into a series of principles for a good health care system: quality, cost effectiveness, timeliness, consumer orientation, and efficiency. It then looks at alternative proposals—user fees, more money, two-tiered health care, internal markets—and explains why they fall short. The failings of these ideas, however, contrast with the success of society’s ability to address other basic needs, such as food, clothing, and shelter.

Chapter 7 outlines a health care system that doesn’t fall short on these principles. It’s possible not only to preserve universality and accessibility but also to avoid waiting lists and declining standards. Such a system is built on the simple idea that it should be run not by the government but by the people who use it. This chapter details the concept of medical savings accounts and discusses experiments with them in other countries.

The epilogue describes how such a system might work in the future for three generations of a fictional family.

This book, in short, breaks from the typical discussion of health care, which increasingly resembles a tiger chasing its own tail. It’s a book written in plain English, free of complicated technical language. And it’s an invitation for those in the health care field, patients, and concerned citizens to do what nearly no politician or expert is willing to do: take an honest look at our health care system.

[Code Blue is available in bookstores now, and is also available from Chapters.ca through the links provided here on conservativeforum.org.]

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