Plus ça change

On Monday I asked, "Will Tuesday's election change anything in healthcare?" Now we have our answer: nope.

Yesterday's federal election changes very little in Parliament, yielding yet another Conservative minority -- albeit a larger one, with a decimated Liberal opposition. No majority for Stephen Harper's Tories. No hope for the rumoured Liberal-NDP coalition. No change in the balance of power in Ottawa despite a total of cost of some $300 million of taxpayers' money on the whole affair, right in the middle of what all the party leaders agree is the worst global economic crisis in decades. No wonder turnout was the lowest in Canadian history.

For health policy, a second Conservative minority likely means more of the same. There's scuttlebutt that Tony Clement, who has served as health minister since the Tories came to power in 2006, may not stay in that portfolio. ("In a sense," Mr Clement told me earlier this year, "everyone who's a health minister usually has a very difficult, complex portfolio that has been the frequent graveyard of political aspirations in the past." And there's no doubt he has aspirations.) Who might replace Mr Clement if he gets moved? Leona Aglukkaq, the freshman MP in Nunavut who served as the territory's health minister until last month when she stepped down to run for the Conservatives, has been mentioned as a possible junior cabinet minister but a more experienced hand is likely required to guide Health Canada. Minister of Industry Jim Prentice's name often emerges in cabinet rumours, but he may be the one destined to replace David Emerson in Foreign Affairs.

But, really, it may not matter who becomes health minister. Stephen Harper's government has been reluctant to even speak about -- much less create new policy on -- the healthcare system. His first term began with an ambitious plan for "wait times guarantees" that he and Mr Clement touted for some time, but those guarantees haven't had much of an effect on wait times in practice. Critics pointed out that the provinces were eager to take the federal government's wait-times incentives, but simply chose to guarantee low wait times in a field in which they were already doing well; the provinces were essentially offered money for nothing, the National Review of Medicine reported last year in an article titled, "The PM's $600 million wait times shell game." I asked Mr Clement about this in my interview with him earlier this year, which it seems appropriate now to excerpt:

SAM SOLOMON: Wait times are high on your agenda.

TONY CLEMENT: Yeah. I see the federal health portfolio in perhaps a fundamentally different way than some of my predecessors. We had a campaign commitment to establish, with the provinces and territories, patient wait times guarantees. That was a first year promise and we delivered it early last year.

SAM SOLOMON: But how do you know the guarantees will work?

TONY CLEMENT: Well, we don't. So my approach is to try some things out. I rail against those prophets of healthcare reform who want to change the system radically overnight. That's a very high risk enterprise. What if it doesn't work? We could in fact make things worse.

SAM SOLOMON: When will we know if it's working?

TONY CLEMENT: I think it's going to take a couple of years.

SAM SOLOMON: And how much money are we going to throw at it before we know?

TONY CLEMENT: We've committed over $600 million from the last budget. But my point is — look, the idea is worthwhile. It's a new idea for Canada, but it's not a new idea in the world. In fact, many countries have gone past their first generation of wait times guarantees. In Sweden, for instance, they went from a flat 90-day guarantee, every procedure available within 90 days, and bumped it down to 60 days. We're still at the earlier stage, but we can learn from that.

SAM SOLOMON: One of the loudest criticisms against the guarantees is that the provinces are just picking the easiest targets to meet.

TONY CLEMENT: Yeah, the low-hanging fruit.

SAM SOLOMON: Do you think it's a problem?

TONY CLEMENT: I don't think so. The provinces were saying, 'You know what, we are doing so well all we need is to shave off a week here or a few days there and we can say for every single person in the system this guarantee is there so you will get the care you need.' Whether it's in cataracts or joint replacements or cardiac, access to diagnostics, for cancer, I think that's actually the right way to approach it rather than empty, half-baked promises that don't help anyone.

SAM SOLOMON: But doesn't that mean we're not actually guaranteeing a reduction in wait times but rather guaranteeing to maintain the status quo? Or even making things worse — in one case, radiation oncology, the benchmark ended up being longer than the one set by the radiation oncologists themselves.

TONY CLEMENT: You're going to get folks, specialists, that they think it should be 90 days rather than 60 or 60 rather than 90. That's a healthy clinical dialogue to have. The way other countries have approached this is entirely different. They've set a flat guarantee across the whole system. Maybe at some point we'll be ready for that — we're not right now.

SAM SOLOMON: Wouldn't it be easier to have one federal set of wait times guarantees?

TONY CLEMENT: Here's the advantage and the disadvantage of the Canadian healthcare system: everybody wrings their hands because you've got 14 systems, you've got 13 provinces and territories and the federal government. 'Gosh, wouldn't it be easier, wouldn't it better if we had one system, run at the federal level?' That's like wishing the sky were purple.

SAM SOLOMON: Do you wish the sky were purple?

TONY CLEMENT: No, I like to wish for things that are realistic. That isn't the way the country was put together, so stop pining over something that will never happen.

Although Mr Clement and Mr Harper had reputations as private-healthcare zealots before they arrived in Ottawa, neither has even mentioned the possibility of a legislative reform. Their tenure hasn't been entirely impotent, however. In the October issue of Parkhurst Exchange, I reported:

Across the country, in the past two and a half years of Conservative minority government, Canadians have experienced the fastest rise of uninsured health costs since the drafting of the Canada Health Act; average out-of-pocket health expenses grew about 2.5 times faster since Stephen Harper's election than they did in the previous 22 years. (1)

The Liberals and New Democrats attempted to get healthcare some airtime during this year's campaign, speaking about catastrophic drug coverage plans, national pharmacare and remedying the shortage of doctors and nurses across the country. Tony Clement sounded open to discussing a national pharmacare program -- especially after the most recent Council of the Federation meetings, where the provinces pushed the idea -- so it's possible there may be some progress on that front within the next few years.

Frustrated at the lack of attention healthcare received during the election campaign, the Canadian Medical Association (CMA) has pledged it will do its best to keep healthcare reform front and centre in the new minority government. My interview with CMA President Robert Ouellet about what the election results mean for doctors and patients will appear in the next issue of Parkhurst Exchange.

(1) Osberg L, Sharpe A. Measuring Sustainable Development (PDF). GPI Atlantic 2008.

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