The Decibel - Is $200 billion enough to fix health care?

Episode Date: February 9, 2023

Ottawa announced Tuesday a proposed $46.2-billion injection in new federal health care funding for the provinces and territories.For years, there have been calls to reform Canada’s health care system. People have died in emergency rooms waiting for care, 15 percent of Canadians don’t have a regular health care provider and there are ongoing issues facing long term care.Will this new money help fix these systemic problems?Health reporter Kelly Grant asked leaders in health care what they make of the deal, and she’ll detangle what this money can and can’t do for our ailing healthcare system.Questions? Comments? Ideas? Email us at [e-mail]

Canada's health care system is struggling. So in a deal announced on Tuesday, Ottawa proposed $196 billion over 10 years to the provinces and territories to try and fix things. But what impact will this money actually have? The Globe's national health reporter, Kelly Grant, is here to break down what this deal means and what the experts think about it. I'm Mainika Raman-Wilms, and this is The Decibel from The Globe and Mail.

Kelly, thank you so much for joining me today. Thanks for having me. So you spoke to healthcare leaders about this deal. What was their reaction to the news? I'd say it was mixed. Well, it seems like a really game-changing amount of money, which is good because I think for the first time, certainly in my 20-year career in Canadian health care,

I am now firmly convinced that an investment is required to get us through the situation we find ourselves in. I mean, here's the good news, right? A few months ago, we weren't even agreeing to come to the same table, right? A lot of nice words, but I'm very worried that nurses are not going to see themselves in anything that's being proposed and are going to be more discouraged than they are today. My main thing is the money, you know, whatever we get is helpful.

And, you know, the majority of the work to transform the health care system is going to be on the provinces. So let's get into the numbers here. That $196 billion sounds like a lot of money, but of that, there's actually $46 billion in new funding. Can you break that down for us? What does that mean? Yeah, I think the idea that that sort of nearly $200 billion number is a touch misleading. Like that is all money that is going from the federal government to the provinces and territories earmarked for health care. But about three quarters of that was already anticipated, baked in increases to something called the Canada Health Transfer. And that is the main pot of money that Ottawa gives to the provinces and territories to help with the cost of running their health care system.

It's the largest transfer that the feds make to the provinces. It's bigger than the social transfer, bigger than equalization. So it's always a lot of money. But what's new is about $46 billion in spending. Some of that is an increase to the Canada health transfer. And a fairly significant portion of it is $25 billion over 10 years for bilateral health care deals. Okay. Okay. So there's $25 billion in bilateral deals. I believe it's $17 billion. That's kind of to bump up the Canada health transfer. And where does the rest of that,

that doesn't quite add up to $46. So what else do we have there? So there are a few other things. There's $2 billion in immediate relief that is supposed to go to shoring up emergency rooms and pediatric workers. And then there's sort of a list of other previously announced or previously promised bits of money for mental health and substance abuse, home and community care and long term care. So let's break down this a little bit more because there's there's a lot of big numbers here. There's a lot of terms I want to focus in on the bilateral deals that you mentioned because you also talked about Canada Health Transfer and then bilateral deals. What exactly are those two, Kelly? Like what's the difference between those two?

Okay. So think about the Canada Health Transfer as like the steady partial operating fund for your organization. That's kind of like your base funding. Then the bilateral deals will be sort of project-specific funding, if you want to think about it that way. Each province and territory will sit down with their federal counterparts and figure out what are their specific needs. And once those are defined, they'll use that to get these sort of more targeted bilateral deals. The federal ministers have talked about having those deals in place in time for the coming budget. Which is in April then probably. Likely, yes. And the Canada health transfer,

so this is money that provinces have to use on health care then? Is it stipulated specifically for that? That's the idea. And the provinces will always say that, yes, this is how they spend the money. They spend it on health. However, it does just go into general revenues and there is no real way to track exactly how it is spent and to guarantee that it is spent on health. It seems like a little bit of a lack of accountability here. Like, I guess, shouldn't there be something in place so that Canadians can see this kind of the big numbers, the big money that's actually going out here that we're actually

seeing a benefit from this? So one of the things the federal government wanted was that all of the provinces and territories would agree to some common data sharing so that we can as a country do a better job of tracking whether the money that is being put into health care is actually giving patients the results that they want and need. You know, the provinces, as a general rule, have said, like, yes, they're okay with more tracking and more data sharing. What did health experts say about the amount of money, like in terms of what it can do? What did you hear on that front, Kelly?

So again, I'd say that the reaction was mixed, and it depends a lot on where they're coming from in the system. So one example is I spoke with Dr. Michael Gardam, who is the CEO of Health PEI, which is that province's health authority. And he looked at the numbers for his province and thought, you know, that this is enough to make a pretty substantial difference for the quality of health care that they offer in PEI. He said, you know, more would certainly help, but that this would be enough to make a difference. Then when I spoke with Kevin Smith, who's the president of the University Health Network, which is the largest research hospital network in the country, he looked at this amount and said, it's a good amount of money, but they're already facing such pressure with inflation for the goods they purchase and planned wages for staff that this might help them get past the inflationary bump, but that it's not going to be enough to buy real fundamental change.

So it really depends on where you are and the number of patients that you're treating. It all depends on those factors in terms of if this is a significant amount of money then. And it also depends ultimately on how the money is spent, right? And we really just don't know that at this point. All right. Let's get into some of the specifics of actually where we might see a difference in our health care system here. So we're talking about cash injections into a system that we've seen across the country really struggle, especially in emergency rooms. People have literally died waiting in ERs,

including a 37-year-old woman in December in Nova Scotia. I think people might remember that because it was shocking. She had waited six hours to see a doctor and ended up dying there. So what is this money going to do to help the situation, specifically in emergency rooms right now? So all that's really targeted in this package for ERs is this $2 billion top up that the federal government is trying to push out before the end of this fiscal year. That is dedicated to ERs. The problem of ER wait times are really complicated. They have a lot to do with staffing. And that is, I should say, another thing that this deal is supposed to be targeting. And that is that improving our health human resources situation.

So that's more doctors, more nurses, essentially, that kind of thing? That's what the hope is, yeah. But, you know, there's an international competition now for more doctors and more nurses. One of the first people I spoke to yesterday was Linda Silas, who is the president of the Canadian Federation of Nurses Unions. And, you know, she was very unimpressed. She said she didn't see anything here that would give nurses in particular confidence that their working conditions were going to get any better. And I do think nursing is a really important thing to talk about because nurses are the backbone of the system. Her major concern is retention. So even though there is a lot we need to do to recruit and bring more people into the nursing profession and make it easier for nurses from overseas to come in and get licensed here in Canada, probably the most important thing we can do in the short term is to keep the nurses that we have now from leaving or dropping down to part-time or retiring early. So she didn't see

anything in this deal that would improve either the pay or the working conditions or the work-life balance for nurses, and that was a big concern for her. And so what would she have liked to see? You mentioned those three things. Are those specific things that she would have liked to see in this deal to actually improve the situation? Well, I'm not sure she was expecting anything as specific as all that. But in general, she feels like nurses and she's the head of a nursing union. So like, obviously, that's a big part of her job is advocating for this sort of thing. But, you know, she thinks nurses need to be paid better, that the workload is a huge problem. That's really what burns people out.

So you have to think about how to structure their work days and their workloads differently to make it something that people can do for 30, 40 years without getting burnt out. And that they have more flexibility and more work-life balance. You know, one of the things that came up a ton with nurses during the pandemic was how often they were in some provinces being asked to work mandatory overtime. So, you know, try to imagine, especially if you have a family that, you know, you finish your 12-hour shift and you're told, I'm sorry, you need to stay for another eight hours or another 10 hours, or you think you can make a plan on a weekend and are told you have to work. Like this makes the work, can make the work unappealing. I think in a lot of other professions, like people wouldn't really put up with that. We don't give nurses a choice because it's such an essential job.

But those are pretty rough working conditions. And so when we're talking about funding, again, just to bring it back to the money, like where exactly would we see that go? Is that to increase salary? Is that to hire new people? Where would that money end up? So this is, I mean, a federal offer like this is pretty disconnected from like what a nurse gets paid at a hospital, because that's up to the negotiations between nursing unions and, you know, their hospital employers and ultimately the provinces who set the budgets and who are responsible for delivering health care. So the kinds of things that the federal

government can do and the kinds of things that the prime minister mentioned in his announcement yesterday is, you know, they can work on helping encourage a pan-Canadian license that would make it easier for nurses to move from province to province. They can work on streamlining the immigration process to bring in more nurses from overseas. That's the kind of stuff that the federal government can have a bit of a hand in. You know, the day-to-day working conditions and pay of nurses is, at the end of the day, going to come down to hospitals and nursing homes and other employers and the policies of their provincial government that they live in. We'll be right back.

Let's talk about a third thing here, which is family doctors, primary health care. This is a huge issue across the country. We know that 15% of Canadians don't have a primary care provider right now. And in some provinces like Quebec, that number goes up to 27%. And that's according to StatsCan in 2019. Kelly, did we learn anything more about how the federal government plans to tackle this issue of primary care? So yes and no. I would say yes in the sense that they made access to family health teams a priority. So it's one of the lists of things they said like, hey, this is the kind of thing that we would like to see this money go to and to produce some improvements on the ground.

I would say no in the sense that they didn't really talk in specifics about how they intended to improve access to team-based family health care. So we might see a little bit more of that when the bilateral deals are actually hammered out. But it's one thing to say, yes, we want to see better primary care, and that's part of what we want this money to go to. But then we don't really have an answer to the question of, well, how are we going to improve primary care? And have the experts that you've talked to, have they said anything about that? How? Like, what are the things that we should be doing here in order to improve the situation? Well, there's all kinds of different proposals on the table, not necessarily through this deal. I

mean, just in general, what sort of like various health system researchers talk about when they say, how could we improve this? And, you know, one of the ideas that I find the most interesting is something that I talked to Dr. Daniel Martin at U of T about yesterday. And this is the idea that every Canadian should have access to a local health team the same way that they have access to a spot in a public school. So you move to a neighborhood, you sign up, you can register, your kid's got a spot in the school regardless. There are some people who advocate the idea of doing something similar with a local health team that would be made up of doctors, nurse practitioners, nurses, pharmacists, other kinds of healthcare providers, and that that would sort of eliminate the kind of hunger game scramble that so many people go through trying to find a local family doctor. This is an example of something that would count as truly transformative change.

I mean, right now doctors are essentially independent contractors and small business owners. And if you move into a neighborhood where no doctor has chosen to set up shop or the local doctor is full and has no more room for you, you're just out of luck. Something else I want to ask you about here is we hear about private care a lot. Is there any possibility that these funds could go towards private care or is this specifically publicly funded stuff? So I always want to be careful when we use the word private in the context of the Canadian healthcare system, because something I think people don't broadly understand, there is a lot of private involvement in the Canadian healthcare system.

Very often, if you go to get something like a blood test, or an MRI scan, or a CT, or an MRI scan or a CT or an ultrasound, you may go to a private for-profit clinic. But when you show up, you use your provincial health card, you don't use your credit card. So the only talk really about the idea of quote-unquote privatization that came up in this announcement was simply the prime minister saying that they will continue to uphold the principle that healthcare should be provided on the basis of need and not the basis of the ability to pay. There's been a lot of pressure on governments to do something to fix the issues in the healthcare system. So, and this deal is coming after kind of two years of provinces pushing for more money from the federal government, wanting a little bit more from them. I wonder if we've seen anything similar like this before, you know, where the federal government has responded with a bunch of money 30 years, the two things that stick out the most are that in

2004, when Paul Martin was the prime minister, he did a big 10-year healthcare deal with the provinces that was supposed to be a sort of fix for a generation, that really this latest deal is in a lot of ways an echo of that. That involved an increase to the Canada health transfer and had a list of priorities that the federal government wanted to see the provinces meet. And then in 2017, the Trudeau Liberals negotiated bilateral health care funding deals with all the provinces and territories

to improve mental health care and home care. So we've seen in the last a little over 20 years a sort of big 10-year increase to the Canada health transfer in terms of the Martin deal. And we've seen this concept of bilateral deals that happened in 2017. This latest proposal combines both. And those previous deals, like, did we actually see a benefit from them? Did they help fix things? So it's interesting you ask that because CHIHI, which is the Canadian Institute for Health Information, has been trying to track some shared indicators from those 2017 deals. And this is no knock on CHIHI, which does really good work. But it's very hard to determine whether some of these improvements actually

happened. So let me give you one example. And that's that I know they were trying to see whether youth with mental health issues were able to get early access to treatment for those issues, right? So they did try to measure that. But you know, they did a survey, right? And when you go out and survey people, you always run the risk that there's all kinds of people you don't reach, and those might be the very people who are not getting the care they need. So some of these things are, in fact, hard to measure. Doesn't mean we shouldn't be trying to measure them and continuing to improve how we measure them. But I don't think anybody would look around at our system after the pandemic and say that access to mental health or home care is better now than it was five or six years ago.

Yeah. We don't have the clear, I guess, the proof that throwing money at the system has necessarily worked before. I guess, why are we trying this again? Like, do we have a, is there something different this time around where we might get a different result? Was that sigh audible enough for you? I mean, after covering the healthcare system for a lot of years now, I don't want to try to let people off the hook,

but I mean, a lot of years now, I don't want to try to let people off the hook. But, I mean, a lot of these problems are just really hard and really complicated. And I think the big picture that we are all missing and maybe not talking about as much as we should is that our population is getting older and our population is getting larger. And it's very hard to imagine a scenario where you can care for more people in their 80s and 90s with more complex chronic illnesses with less money. That's not to say that there doesn't need to be lots of innovation. That doesn't mean to say that there doesn't mean to be different ways of providing that care. Everybody needs to think about that. But like the fact of the matter is, is caring for an 85-year-old with multiple chronic illnesses in a long-term care home is always going to be an expensive proposition. And it's going to be more expensive if they're cared for in hospital because you don't have enough space for them in long-term care.

So, I mean, it sounds like there's a lot of ideas around here, but everything is kind of vague. It doesn't seem like we have really kind of concrete things that are coming out of this deal. No, I don't think we do at this point. I think there is hope that there will be a lot more concrete detail in the bilateral deals when they come together. Kelly, thank you so much for taking the time to speak to me today and walk me through all of this. Okay, thanks again for having me. That's it for today. I'm Mainika Raman-Wilms. Our producers are Madeline White, Cheryl Sutherland, and Rachel Levy-McLaughlin. David Crosby edits the show. Kasia Mihailovic is our senior producer,

and Angela Pichenza is our executive editor. Thanks so much for listening, and I'll talk to you tomorrow.