Many spectres are haunting what the Globe and Mail’s André Picard (@picardonhealth) has just described as the crumbling edifice that is the Canadian healthcare system.
Perhaps the biggest and scariest – many would describe it alternately as a zombie that refuses to stay dead – is that of privatization and two-tiered medicine. Those in government who deny the existence of this particular ghost would say what we are seeing in provinces such as Ontario and Quebec are only the increased use of private companies in the provision of publicly funded health care.
The lack of funds to support the increasingly costly public system and loud calls for those who can afford it to deal with growing access issues by allowing them to pay for services makes the next step and allowing private companies to offer care in a parallel system for those who can afford it almost irresistible. This has already become widespread for diagnostic imaging services such as CTs and MRIs. The growth of personalized or precision medicine where new treatments and drugs can be better tailored to individual patients for better outcomes but usually at a significantly increased cost can also feed into this.
The spectre of privatization now appears to be roaming all the spaces that make up the Canadian medicare system. It is so pervasive now that the Canadian Medical Association has announced it will be launching a series of consultations this fall to look at the balance between public and private healthcare delivery “and what role, if any, increased private care should play in a publicly funded health system.”
Howling around the crumbling infrastructure of medicare is the banshee of public health. The recent COVID-19 pandemic showed just how far governments and the public were willing to go to sacrifice individual rights for the greater public good and equitable health for all. The answer was, only so far. Prior to COVID-19 public health budgets in some jurisdictions were being slashed and with many saying the pandemic is over there seems a palatable desire to reduce public health initiatives that may or may not be needed in the future.
A more recent spectre in the healthcare house, portrayed by many Casper, the friendly ghost, is that of artificial intelligence (AI). Generative AI models hold huge promise in augmenting and relieving the pressures on healthcare providers in both clinical care and for administrative duties. But AI algorithms fed by massive amounts of patient data also provide the opportunity for Canadian jurisdictions to cut out the middleman (i.e., the physician) and offer medical advice to the public and patients at a far lower cost. One health policy commentator has characterized this as a spectre where those using the public system have access to AI-supported chatbots while those who can afford it can access real human physicians.
On the “I’m not dead yet” list of spectres is that of patient and caregiver engagement/partnership. The pandemic showed how quickly direct patient/caregiver involvement in care can be jettisoned to serve what many within the system see as the greater good of infection control or a more streamlined top-down management system. Many patient advocates in Canada and abroad have noted patient involvement in what should be a “patient-centred” system have still not returned to pre-pandemic levels. A just-published paper by many leading Canadian patient advocates has shown just how challenging it can be to do patient engagement right. With growing pressures on the Canadian healthcare system and challenges on just getting access to any care it is not hard to imagine a future where the principles of patient partnership are sacrificed to maintain whatever limited levels of care the public system can afford.
Affordability raises another terrifying spectre in the Canadian context and that is the use of medical assistance in dying (MAiD) to meet economic goals. Whether apocryphal or not, cases have already been made public of people being offered MAiD for reasons other than intractable suffering.
Many ghosts haunting our healthcare system. But as we enter summer (albeit a hazy one with that other scary spectre climate change threatening us all), a feel-good ghost-busters movie seems to be just what we need.
(Photo by Ján Jakub Naništa)
Days of Past Futures 