What do we want our health-care system to do, and how much are we willing to pay?

OPINION: The argument for expanding Ontario’s hospital capacity was strong pre-COVID, and it’s even stronger now. But saying that is easy — making decisions is a whole lot harder
By John Michael McGrath - Published on Jan 11, 2022
Almost all Canadian provinces have relatively few beds per capita compared with other wealthy countries (A&J Fotos/iStock)

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An undeniable part of Ontario’s current COVID-19 crisis — and the previous ones, too — has been our long history of under-investing in health care, relative not just to other countries (Ontario has fewer hospital beds per capita than the United States and many other countries) but also to other provinces: rapid population growth hasn’t been matched by an investment in hospital capacity, meaning that we have hospital-bed shortages locally (in places like Brampton) and provincewide. This was obvious before COVID-19 hit: the Liberals lost the 2018 election for many reason, but the flu season the winter before and the news coverage of “hallway medicine” certainly didn’t help. 

In that sense, all COVID-19 has done is shine a spotlight on the results of choices that have been made not just by the Doug Ford government, but by several governments before his. To put it another way, if Ontario had wanted to be adequately prepared for the pandemic, the clairvoyant premier we’d have needed wouldn’t have been Ford or even Kathleen Wynne: given how long it takes to build hospitals, not to mention train doctors and nurses, our preparations would have needed to begin back when Dalton McGuinty was the occupant of the corner office on the second floor at Queen’s Park. Needless to say, wishing can’t make it so.

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Governments of all stripes had their reasons for underfunding health care — Wynne acknowledged to Maclean’s earlier this month that, during her tenure, hospital spending was constrained by the constant need to try to wrestle the deficit to the ground. “If I had to do it again, given what I know about COVID, I probably wouldn’t do that,” she told Paul Wells.

The past is written; what happens next is still up for debate. The argument for expanding Ontario’s hospital capacity was strong pre-COVID — a wealthy, advanced economy shouldn’t be facing the risk of hospital paralysis every flu season — and the pandemic has inarguably strengthened it. But saying this is the easy part; making the decisions that flow from that are more difficult.

For starters, if Ontario doesn’t have enough hospital beds right now, what’s the correct number? In late 2019, the Ontario Hospital Association published a report touting the sector’s history of efficiency while warning that the efficiencies had come at a cost. It noted that, if Ontario funded its hospital system just to the level of the Canadian average, that would cost another $4 billion annually. But almost all Canadian provinces have relatively few beds per capita compared with other wealthy countries — 1.4 acute care beds per 1,000 in Ontario, per the OHA report, compared with 2.0 on average Canada-wide, 2.4 for the U.S., 3.1 for France, and 6.0 in Germany.

This gives a sense of just how far behind Ontario is and how monumental a task it would be to expand our hospital system. Just bringing this province’s bed-per-capita number up to the Canadian average would mean a nearly 50 per cent increase in beds (before taking into account the population growth we’re planning on over the decade it would take to do it). And aiming for something more ambitious, like French or even German levels of hospital capacity, feels almost delusional.

Who, after all, would pay for it? The obvious first answer is the province, since health care is a provincial responsibility. But the health-care systems have been cash-strapped for years because of different provincial spending priorities under governments of all stripes. At least some of this is simply a structural part of Canadian politics: the provinces and the federal government have lots of taxing capacity, but the most expensive spending obligations — education and health care — are provincial, leaving a fiscal imbalance that was already pronounced before the pandemic and will surely get more lopsided in the decades to come: the provinces have lots of costs, but the feds have lots of cash.

Okay, so then let’s have the federal government fund hospital expansion, right? There’s no inherent reason why a prime minister couldn’t set a national target for hospital beds per capita as part of the federal share of health-care spending, though that would certainly mean a very large increase in that spending. But you can’t take the politics out of politics, and it’s a fair question whether Canada’s national discourse would actually sustain a policy shift whose effect would be, on average, the spending of more money in Ontario, British Columbia, and Alberta and less money in Quebec and the Maritimes.

Here, Canada’s conservative movement has an answer waiting: if neither level of government is willing to pony up the money to expand hospital care, let the private sector do it, and let individuals pay the added expense for health care when they need it. Needless to say, that’s not an argument that will find unanimous support across the electorate. But provinces have been allowing more and more private delivery of publicly funded health care for years now, and they’ve faced relatively little resistance from voters.

All of which simply means that the next provincial election in Ontario, and probably the next federal one, too — possibly the next several, of both — are going to be about this question, either explicitly or by default. What do we want our health-care system to do, and how much are we willing to pay for? Political parties will either have an answer for this question or prefer to talk about something else. There will be many different issues to talk about this year and in the future, but we should try not to forget about this one. 

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