Tougher times ahead … for health care and Mr. Romanow

Although policy-makers and analysts are making a valiant effort to tutor the nation in the algebra of health care reform, the simple arithmetic of cutbacks becomes clearer with each passing headline. Ontario hospitals are handed a $200 million stop-gap. Health care workers in British Columbia are told that, illegal strike or no illegal strike, there's no more money to be had. Disgruntled physicians pull up stakes to earn a better living down south — or in Alberta. Despite the talk of cost-effectiveness, rationalization and doing-more-with-less, it's just not possible to persuade Canadians, who live next to the world's most lavish health care system (lavish, at least, for the 70% of the US population who can afford health insurance), to remain content as the 13th-ranked country in the world in health care spending per capita. The US–Canadian contrasts in technology, equipment, waiting times and labour relations are just too plainly in our face.

The federal government has been wringing its hands over medicare since the stillbirth of its happy but unfundable proposals for national pharmacare and home care,¹ but any hint of pleading makes most provinces less, not more, inclined to cooperate. Provinces with money — or, like Quebec, an ideologic grievance — are leery of federally promoted schemes that will force them to ante up. The others, poorer and looking for any handouts they can get, are still singing endless choruses to the Canada Health Act.

Can Mr. Romanow resolve this mainly political problem? We hope so, for the burden of coping with the current health care mess falls to physicians, who are forced to ration services either through waiting lists or simply by telling patients that the best available treatment is, well, not available.

As the public system crumbles, private health care costs increase. This won't be noticed by the CEO of Nortel, who in round figures earned an estimated $100 million last year. But it will be by the 30 000 former employees of Nortel who were laid off and by the average Canadian, who earns only $34 426. New medical graduates will also notice: in an economic recession, health care wages are easily controllable expenses. It's a matter of temperament, perhaps, what will discourage physicians more: poor remuneration, or the prospect of providing second-class service.

Mr. Romanow has a tough job. Unable to count on much federal–provincial cooperation, he will have to face the dissatisfaction of health care workers in grungy hospital corridors and patients on ever-lengthening waiting lists. Yet, there he will also find sensible people who realize that we shouldn't try to keep up with the US — Why ride off into the wrong sunset? — but that we need stable and predictable health care funding and primary health care reforms that encourage a prudent use of resources and more cooperation among the health care professions. And, now that the banks are noticing that a medical career is not the safe bet it used to be,² Mr. Romanow might recommend adequate support for public education to ensure that it is not just the sons and daughters of the wealthy who can contemplate a future in medicine. — CMAJ