Fixing Medicare: What if the doctor was always in?

Canadians of a certain age can recall a time when, if you didn’t get your shopping or banking done during what were then very limited business hours, you were out of luck. Baby Boomers and Gen Xers remember it well.

Banks were only open mid-morning to mid-afternoon, and closed on weekends. To deposit a cheque or make a withdrawal, you had to go to the branch – in the middle of the work day – and wait in line for a teller. You’d fill out a paper slip, with one of those black pens attached to a silver chain. Didn’t get to the bank before 3 p.m.? Got no money in your pocket? Too bad.

Retail stores were at least open late on Thursday and Friday nights. But most were closed, by law, on Sundays.

Twenty-four hour supermarkets? Pharmacies open at midnight? Banks operating nights and weekends? Online banking and shopping, any time? Unheard of. Unimaginable.

Canada’s consumer economy has changed a lot since then. The structure of Canadian health care? Medical technology, from surgical procedures to drugs, has advanced tremendously over the past half century. But the architecture of the system into which all of this innovation and money flow hasn’t changed much since the 1960s.

Consider this common Canadian complaint: I needed to see my family doctor but it was evening, or the weekend, or a holiday, and they weren’t available. So I had to go to the emergency room. I was there all night.

Or this: I needed to see a family doctor – but I’m one of nearly 15 per cent of Canadians who don’t have one. So I also went to the emergency room. I was there all day.

Why is this? Because medicare is still operating on blueprints from the 1960s. And we’re still stuffing health care spending into silos from that decade, which instead of communicating with each other operate more like hermetically sealed worlds.

Now let’s look at how things work in a country with universal health insurance, just like Canada, but which offers better and easier access to family medicine.

According to the Commonwealth Fund’s most recent report on health care performance in 11 rich countries, the Netherlands has the second-best health care system. Canada is second-to-last (though well ahead of the perennial last-place finisher, the United States).

In terms of “access to care,” the Commonwealth Fund ranks the Netherlands as best in the world; Canada finishes 9th out of 11. In the Netherlands, 99 per cent of people say they have a “regular doctor or place of care,” 66 per cent said they were able to see a doctor or nurse on the same or next day, versus 38 per cent in Canada. In Canada, 57 per cent of people found it somewhat or very difficult to obtain after-hours care; the Dutch figure is 26 per cent.

And 90 per cent of Dutch people say that their primary care provider has arrangements for patients to see a doctor or nurse after hours, without going to the ER.

In the coming months and years, as Canadians debate how to improve medicare, a lot of heated arguments are going to be about whether to privatize parts of the system. It’s an important question – but maybe not the most important.

The Netherlands debated that in the early 2000s, and moved to an arrangement where health insurance remains universal – and in fact covers more than Canadian medicare, including drugs and children’s dental care – but where the insurers are competing non-profits whose premiums and performance are regulated by government.

The Dutch can buy additional private insurance, but only for the same things as Canadians, like physiotherapy and dentistry. There’s no buying your way to the head of the surgery queue. In other words, with the exception of where your universal insurance comes from, things don’t look so different from Canada.

But zoom in closer, and some small but important things are very different. It starts with what happens if someone needs to a see a family physician after hours.

Many Dutch family physicians have grouped together to offer after-hours services. They work in partnership with a hospital, and even make house calls. That frees up ERs for true emergency cases, rather than those of people who simply need to see an otherwise unavailable family doctor or nurse practitioner.

Why can’t Canada do this? We can.