Brian Lee CrowleyBrian Lee Crowley says Canada's dismal performance in the prestigious Commonwealth Fund health care rankings are the latest reason why we need to reform our system.

By Brian Lee Crowley, July 25, 2017

Canada’s public service unions gleefully embraced a recent international ranking by Oxford University and the Institute for Government that placed us number one in the world for “civil service effectiveness.” Perhaps understandably intoxicated with this success, those same unions were curiously silent when the prestigious Commonwealth Fund in the U.S. released its most recent update comparing health-care systems in the rich industrialized world. This showed our health-care system, run virtually in its entirety by these effective Canadian public servants, not just below average, but at the bottom of the heap, barely outperforming France and our health-care system’s arch-enemy, the U.S.

On measure after measure the data belie the boasts that medicare apologists tout as proof we have the best system in the world. When measuring the equity of our system against the others, we come a pitiful ninth out of 11, despite the fact that “fairness” is the argument most frequently trotted out to defend the status quo. Turns out Canadian health care isn’t all that fair.

On measure after measure the data belie the boasts that medicare apologists tout as proof we have the best system in the world.

Ditto for health-care outcomes. Despite being a fairly high spender, we are not able to turn that money into better outcomes for Canadians. Again, we rank ninth out of 11.

But in what must be the bitterest pill, we come 10th in access. That means that among the 11 systems studied, every one of them gives better access to health-care services except one: the United States. Gives a whole new meaning to the sentiment that we don’t want American-style health care here, doesn’t it? Of course we don’t, but it is a wonder why people think Canadian-style care is somehow overwhelmingly superior. It is better than the U.S., but then why compare yourself to those doing worse than you? Surely we should aspire to better.

The reason why the defenders of the status quo want to keep Canadians fixated on America’s failings is that the top performers in this survey put the lie to every one of the myths trotted out to defend the Canadian system.

Take the much-loved “single-payer” principle, whereby a public sector monopoly in each province determines what health services shall be insured, how much they will pay for it, how it will be delivered and whether the quality of the service is acceptable. In most cases private providers are forbidden by law to provide publicly insured services.

Yet none of the national systems that outperform Canada approaches health-care provision as we do. Look at the top three performers in the Commonwealth Fund rankings for proof. Second-place Australia offers both public sector insurance and competing private sector plans. Many hospitals are privately owned. Third-place Netherlands has competing social insurance funds.

Even first-place U.K., closest to the Canadian system, has a parallel private health-care system that allows people to opt out of the public system and purchase private insurance. When the Labour government of Tony Blair sought to shorten endemic queues in the system, it was able to contract with a flexible private sector to purchase services the government could not get the public system to provide. In Canada, Saskatchewan’s highly successful experiments with provision of services through private clinics has earned that province a tussle with Health Canada, which is trying to stamp out the practice.

Even the best civil service in the world cannot save a system whose design is flawed at its heart

While the U.K. doesn’t allow user fees for most health-care services, there are charges for some, while people using the private system must pay the full shot. User fees or co-payments are standard in both Australia and the Netherlands, not to mention the other countries with proud traditions of quality public health care who also outperform us in these rankings. In many cases, doctors and other health-care professionals practise outside the public system without that system being unable to recruit the professionals they need. Yet access, equity and outcomes in these systems is superior to what we enjoy here in Canada, disproving the oft-heard argument that any compromise on these “principles” would signal the end of our commitment to a fair, high-quality system in which no one suffered economic hardship through illness or disease.

In fact the reverse is true. Even the best civil service in the world cannot save a system whose design is flawed at its heart and which no other country committed to similar principles holds up as a model (despite Canada being seen internationally as having the “most positive influence globally” according to yet a third international ranking). In fact, it is the defenders of the status quo who are denying Canadians the kind of experimentation and reform that provide superior equity and outcomes in our peer countries every day.

Brian Lee Crowley is the managing director of the Macdonald-Laurier Institute, an independent non-partisan public policy think tank in Ottawa.