“Health Care for All” Policies Will HURT Physicians and Patients

Recently, physicians leaders have been in the media promoting the right to primary care. I generally refer to this as a “Health care for All” policy, as it is reflective of one of the tenets of former Health Minister (and current Dean of Queens Medical School) Dr Jane Philpott’s new book. Dr. Tara Kiran has also promoted the same through her “Our Care” project. These proposals seek to guarantee a family physician for everyone in a certain geographic area, just like children in an area are guaranteed a school.

While these policies sound nice (for reasons I’ll go over later) – they are doomed to failure. To understand why, let’s look at just two other situations – The Barer Stoddart Report and the move toward safe injection sites and decriminalization of illicit drugs. I appreciate my three loyal readers (I actually gained one!) might be wondering what this has to do with primary care. Bear with me, it hopefully will make sense later.

The Barer-Stoddart report is infamous in Ontario medical politics. It’s the report that is widely viewed as suggesting Ontario had too many (!) doctors in 1990s and led to the reduction of the number of medical school positions. However, what is not commonly appreciated is that was the last recommendation in the report. The first recommendations were to support the current supply of physicians by adding a large number of allied health professionals and making many health systems modifications. If and only if all those recommendations were carried out, then medical school enrolments could be cut. The bureaucrats and politicians looked at that, went through the report, decided that all the other recommendations were too expensive or complicated, and just cut med school enrolment. “The report told us to.”

Similarly, when it comes to drug decriminalization, the idea is best implemented in Portugal. The top line read is “addiction rates fall 40%” after Portugal introduced this policy. BUT a deep dive shows that before decriminalizing drugs, Portugal made a number of legislative changes, ensured that the court systems were educated, ensured that addiction therapy and counselling was available for addicts, and then implemented the decriminalization policy.

In Canada, our bureaucrats looked at Portugal, and figured all the rest of the changes were too complicated. But hey, maybe just decriminalizing will be enough without the other stuff! The result is a disaster when it comes to safe injection sites and an obviously failed policy.

So let’s look at the right to primary care that Drs. Philpott/Kiran and others propose. At their heart, ideas like this are reasonable, make sense and will help improve health care for the general population (I bet you didn’t think I’d say that did you?). They speak to a fairness that just isn’t apparent in the current system. One of the reasons that people pay taxes is so that those taxes can fund health care. How is it fair then, that one taxpayer has a family doctor, and another does not? How is it fair that one quarter of Ontarians can access team based health care, but the rest cannot? And so on.

Well then, what’s the problem and why do I think “Health Care for All” type policies will hurt physicians and patients?

Because I simply don’t believe that our politicians/health care bureaucrats will be able to implement all the work necessary to support this, prior to implementing this change.

Look at the other items I mentioned. Do you really think that the bureaucrats who mucked up so badly will get it right this time? Do you really believe that those bureaucrats are going to provide the admin support, the additional allied health workers, the organizational and structural backing first, before just writing out “everyone gets a family doctor” in the funding contracts?

Not a chance. Zilch. Zero. They will look at the need to invest in teams and say “too expensive.” They will look at the need to add administrative support first and decide that’s not feasible. They will look at the need to build healthcare infrastructure and be confused as to how to do it properly.  They will be aghast when they come to the part that says for teams to be successful, they must be physician led.  “But I’m the aide to the executive secretary of the assistant to the assistant deputy minister’s attache for the chief regional officer of the Primary Care Branch of the Ministry!  I should run the team!”

Then they will come to the part of the policy that says ensure every patient in a geographic area has a family doctor. And those bureaucrats will say “oh that’s easy to do with just some changes and regulation”. And they’ll do just that without any of structural changes needed.

I did some rough calculations for my neck of the woods. Each family doctor in my area would have to take on 200 unattached patients to make this work. The problem is we’re all working at 110% capacity right now. There’s no way we can do that.

So, once “health care for all” comes in what’s going to happen? Physicians will stop doing comprehensive family medicine, myself included.  You can only ask a person to work so hard before they get frustrated and quit.  Which increases the burden on the remaining physicians, which will cause more of them to quit.  And so on.

What’s worse, presenting these policies now deflects from the main issue. Basically, family medicine is no longer economically feasible. Without some immediate stabilization funding, family medicine will collapse.  By the time people figure out how to implement “Health Care for All” and reduce admin burden, you won’t have any family physicians left.  By introducing the “right to primary care” now, the laser like focus on just what is needed to make family practice economically viable is lost and this hurts everyone, patients included.

I genuinely have a great deal of respect for Dr. Kiran and Dr. Philpott in particular (she was the one who sacrificed her political career to warn us that our Prime Minister was an effete, vacuous ninny who for the sake of all Canadians needs to go back and teach drama classes).  But as well intentioned and well thought out as “Health Care for All” may be, now is not the time to talk about it.  

Economically stabilize and support family medicine first.  Then let’s talk.