Public healthcare is unfair.

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Might as well say it up front: our public healthcare system is not fair. Yes I know, you’re going to try and throw the Canada Health Act in my face, quoting the infamous “…insured persons must have reasonable and uniform access to insured health services, free of financial or other barriers. No one may be discriminated against on the basis of such factors as income, age, and health status.” – Canada Health Act, 1984

Much like many things in life, reality falls way shorter than the intended idealistic goal. It’s our own fault really; many Canadians probably interpreted that Act as an all-you-can-eat healthcare buffet. Now, even all-you-can-eat buffet restaurants need to make enough money in order to be sustainable. They do so only because a small percentage of their customers actually manage to eat extraordinary amounts of food…the rest have to wait in line and settle for leftovers.

At the end of a recent ER shift, I realized I was working at a buffet restaurant.

Many of you have probably heard of the term “frequent flyer”, a title that frontline ER workers bestow (often with an accompanying eye-roll) upon patients who visit the hospital more often than they do their own basements. While it is within their right as stipulated in the Act to utilize such resources as often as needed, each visit costs the public health budget tremendously – even if those visits turn out to be completely unnecessary and wasteful. It is not uncommon in a single ER shift to see several drunk homeless patients brought to the ER simply because they are intoxicated; a couple of adolescent teenagers with bruised cheeks after a bar fight; and scores of healthy individuals with runny noses who can’t wait a day to see their family doctors.

The most recent statistics published in the Drummond report are eye-opening. “About 1% of Ontario’s population accounts for 49% of hospital and home care costs, and 10% of the population accounts for 95% of such costs, according to a 2010 study by the Canadian Health Services Research Group (CHSRG). The Institute for Clinical Evaluative Sciences (ICES) looked at system-wide health care costs (excluding inpatient mental health and non-fee-for-service physician costs) and found a similar trend: 1% cent of the population accounts for 34% of costs and 10% accounts for 79% of system-wide costs.”

The killer question is, should that really be surprising? Public healthcare, in essence, is a publicly administered health insurance policy that we all pay into. And like any other insurance business, the premise is that the majority of payers will remain relatively healthy to fund the minority of payees requiring exhaustive usage of the insurance services. Thus, we cannot all expect to get the same health services all the time – by definition we’ve set the system up that way.

What makes the Canada Health Act truly “unfair” is not its vision of trying to provide equal care to all, but its failure to address the other side of the health-illness equation: health prevention and determinants of health. The person who chooses to smoke like a chimney, drinks his/her liver to cirrhosis, and pays less taxes, will receive the same healthcare as the person who exercises everyday, eats well, and pays higher income taxes. There is simply no accountability on individuals to take care of themselves; and it is my experience that many frequent flyers exhibit a “I’m here, fix me” attitude. Resources are thus eaten up rapidly with no feedback/regulation, and someone in the system will end up suffering as a consequence.

As an example, on a recent ER shift I spent a disproportionate amount of time on a number of so-called frequent flyers to our department, with the wait times creeping up. I finally saw a new patient who had been waiting patiently for a truly urgent medical issue … but what struck me most was that the patient was extremely apologetic for having “taken up my time” – even though I should be the one apologizing for the significant time delays in treating this legitimate medical problem. One of the unforeseen effects of the all-you-can-eat model catering the top 10% of users is the inevitable negative consequences on other 90%.

But perhaps that’s better than other funding alternatives. People aren’t going bankrupt because of medical bills. They aren’t having to choose between their houses and organ transplants. Sure, we have our share of wait times and other problems – but I think I can live with those…for now.

Maybe we just need to suck it up and finally realize that our healthcare system was created to be unfair.

Edmund Kwok

Edmund Kwok

Emergency Medicine. Quality Improvement. Patient Safety. Change Management. Healthcare Administration.

Frontdoor 2 Healthcare

Frontdoor2Healthcare, founded by Dr. Edmund Kwok in 2012, provides editorial and commentary on issues affecting Canadian healthcare from the emergency department’s “front door” perspective. Frontdoor posts allow for open sharing of the diverse opinions and perspectives of emergency physicians from across the country.

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