As outraged Americans confront Republican representatives over planned repeal of the Affordable Care Act, it's easy to forget the quiet turmoil in Canada's own public health care system.

In recent weeks, the federal government reached bilateral deals for federal health transfer payments with all territories - Nunavut, Northwest Territories and Yukon - as well as five of ten provinces: New Brunswick, Newfoundland and Labrador, PEI, Nova Scotia and Saskatchewan. The five other provinces are holding out for higher increases in annual transfers.

Last December, the Liberals made clear they would stick with the previous Conservative government’s plan to reduce the annual increase in federal health care spending from six per cent to three per cent in 2017-18, which provinces initially rejected before New Brunswick signed a separate agreement in late December. Ontario, for example, asked for a 5.2 per cent annual increase. In all, the numbers revealed that Ottawa intended to provide $37.15 billion in health transfers for the year 2017-18, up from almost $36.1 billion in 2016-17.

To top it off, a landmark lawsuit by a B.C. doctor advocating for more private health care may create an important precedent that could unravel the public health care system.

What better time, suggests Toronto family doctor and author Danielle Martin, for Canadians to reflect on their public health care system and ways to strengthen it. Martin is a strong champion of public health care, who became prominent by appearing before a U.S. Senate committee to bust popular myths about Canada's health care system in March 2014. Shared on social networks by popular Vermont Senator Bernie Sanders, a video of her testimony was viewed almost 1.5 million times, and resulted in a torrent of phone calls and emails to her office from people across the United States.

When Canadians had no public health insurance

“A new generation of Canadians is being sensitized to the fact that universal health care is not a given,” Dr. Martin said, in a recent interview with National Observer. “It's not that the Obamacare debate is directly relevant to whether or not we get to keep medicare here, but it's hard for newer generations of Canadians to even believe that life could ever be like that. That 20 million people can wake up every morning without health insurance. It's important to always remember and honour what we've built, while of course still also looking to improve it. Those two things are not incompatible.”

Dr. Danielle Martin speaks about Canada's public health care system at a U.S. Senate subcommittee on health and aging in Washington, D.C. on March 11, 2014

In the two years since her appearance in the Senate, Martin — who also has a masters degree in public policy — contemplated what works in Canada’s health care system and what needs to improve. She recently wrote a book, Better Now: Six Big Ideas to Improve Health Care for All Canadians. While conversations around improving Canada's health care system often include proposals for some level of privatization, Martin staunchly favours Canada's current single-payer system, giving health insurance coverage for the poor as well as the wealthy. Based on her own family's struggle with health care, she wants the government, patients and the medical community to work toward fixing the kinks in Canada's health care while honouring the principle of universal coverage.

In Better Now, Martin vividly details how her Jewish immigrant grandfather Jacques Elie Shilton and grandmother, Sarah, suffered when he had a major heart attack in 1953 - long before Canada's health care system was in place. The opening pages reveal her grandfather's pain and the psychological strain on the whole family as they borrowed money to finance his care. Important decisions, including surgery, were based on affordability, and the stress of mounting medical bills had a profound impact on her grandmother's mental health, resulting in her own hospitalization.

“My mother’s view is that the struggle to deal with financial hardships — along with health problems — destroyed her family,” Dr. Martin writes candidly.

Basic minimum income: an unlikely cure?

One of the arguments Dr. Martin makes is that health care doesn’t exist in a vacuum — that social, economical and environmental issues have a significant impact on public health costs. In her view, poverty, above all other factors, has enormous ramifications that can’t be ignored in any conversations about improving health care in Canada.

“It’s impossible to talk about health care in Canada and not address the impact of poverty. It’s the number one thing,” she said. “It’s more important than anything else we do in the medical system.”

She said the negative impacts of poverty tend to pile up on the same kind of people, often marginalized individuals, such as low-income earners and First Nations communities. “Poverty leads to isolation, isolation is linked to poor nutrition, etc. The same people are hit from all sides by that convergence of factors.”

A key solution to this problem, in her view, is creation of a basic minimum income. She said there’s evidence this works. In the 1970s, the Canadian government experimented with a basic minimum income program in a small Manitoba town, and its effect on health were surprising, she said.

“They found that hospitalizations in the community decreased by 8.5 per cent during the period of the experiment. I would say if we could find a drug that cut all hospitalizations by 8.5 per cent, we'd be putting it in our water supply. Almost nothing we do in health care has an impact of this magnitude,” she said.

“Poverty is stressful,” she said. With minimum income (or "mincome," as it was called in the 1970s experiment), she said there was less smoking and drinking, among other stress-coping behaviours which ultimately affect public health care spending.

Writing about the correlation between poverty and sickness, Martin recounts the experience of a single mother in Toronto with asthma whose health deteriorated because of the mould in her social housing unit, which she stayed in because she couldn't afford to leave. Another example is people who can't afford basic dental work and eventually end up costing the healthcare system when they are rushed in to emergency hospitals with painful dental abscess.

She said the impact on public health care of a minimum income pilot program in Ontario will be worth watching for potential national implications.

“We can keep pouring money into the downstream fix-up shop, or we can look at root causes,” she said. "With Ontario's pilot program, I know they will be tracking health system utilization and I think it will be very informative for the government to see."

Not just about money

In her book, Martin emphasizes that improving Canada's health care system isn't about pouring more money into the system. She believes there aren’t any quick fixes, but multi-faceted solutions such as:

  • Ensuring every Canadian has regular access to a family doctor

  • Reorganizing health care delivery to reduce wait times and improve quality

  • Bringing prescription drugs under medicare

Martin says it’s unlikely a mere funding increase from Ottawa alone will fix the shortcomings of Canadian health care. The issues had to be worked on collectively by hospitals and patients.

“Of course, it would be wonderful to have agreement on the number,” Dr. Martin said, referring to funding. “The money matters. But what's interesting and energizing in the conversations about health care reform is not about whether [the annual increase] going to be 3.5 per cent or 4.2 per cent. We’re not going to get a very different result whether we increase the escalator or decrease it in the opposite direction.”

She said one of the changes she feels will have significant impact is having prescriptions covered by medicare. Even though roughly 60 per cent of Canadans have coverage for private drug insurance, the remainder don't, notably young people in precarious entry-level jobs, people working part-time or in small businesses.

As a family doctor, she says she sees patients who are well aware of their health problems, yet so squeezed by financial pressures they have to choose between paying rent and buying necessary medication to preserve their health. For example, a patient on a $20,000 annual income may choose not to buy prescription drugs at $800 because of other priorities, such as paying bills or university fees for their children. In Dr. Martin's eyes, it's a choice Canadians shouldn't be forced to make. In fact, publicly funding essential medicines could save taxpayers $3 billion per year, according to new research, led by Steve Morgan of the University of British Columbia and Dr. Nav Persaud of St. Michael’s Hospital in Toronto, published in the Canadian Medical Association Journal.

Coverage of basic medicines would save Canadian taxpayers billions a year, according to a new study by Steve Morgan at the University of British Columbia and Nev Persaud at St. Michael's Hospital in Toronto .

Brian Day's private health care battle

Dr. Martin said the hotly debated lawsuit by Dr. Brian Day, who advocates for patients to have the option to pay privately for medically necessary procedures (and for doctors to charge patients accordingly) will be an important battle to watch, with potentially long-lasting impacts on Canada's national health care system.

Doctors in the Canadian health care system are currently are not allowed to "extra bill" patients, the practice of charging more than what the government pays doctors for necessary services. File photo of a C-section delivery at Oakville-Trafalgar Memorial Hospital by the Canadian Press

"I think it has the potential to destabilize the (public health care) model," she said. "The effects on the system more generally can potentially be very profound."

"I think there's a misconception that somehow allowing few people to buy their way to the front of the line isn't going to affect anyone else. But all evidence suggests that wait times get longer in public health care system when we pull doctors and surgeons and technologists out of the (public) system to serve the private system."

She said a clear example of this was in Australia, which introduced a parallel private-pay system in 1999, and saw wait times increase for patients dependent on public health care. Although everyone in the Australian system pays for medicare, the federal government provides taxpayer-funded rebates to encourage people to use private health insurance.

"When Australia went to two-tier (private-public insurance), a lot of people purchased private insurance and they saw wait times increase which should be completely unsurprising to anyone who thinks about it. When the patient jumps the queue, the doctor jumps the queue with them. Australia is undergoing a massive review of their private insurance now actually because in order to incentivize people to buy private insurance in Australia, the government had to offer massive tax rebates to people or employers to purchase private insurance to employees."

Although Day's years-long fight for private health care highlights agonizing long wait times for some medical procedures in Canada, Martin believes the way forward is to fix the existing system, rather than providing an alternative through private health insurance. She said what gives her hope for Canada's future is that a large number of average citizens are becoming energized to improve public health care, rather than abandon it in favour of privatization.

"We've had so many negative conversations about health care, which can be incredibly de-energizing for people. But now, we're finally trying to change the channel and say something positive," she said.

"What we've built is good, but it's not perfect, and it can be better....None of these solutions can be dictated from on high. They require physicians to practice medicine differently, for patients to have a different understanding about their own role in health care. We all need our oars in the water to fix this."

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Being old enough to remember the bad old days before healthcare as well as working for the last 3 decades in health care I think there are important variables this doctor is overlooking as well as vastly different social conditions. A system that was once designed to prevent catastrophic financial failure for individuals has now become an enabler of poor health and expensive chronic health conditions. There is no incentive for people to look after their own health when they can just go to the doctor for "free" and get "fixed." People have no idea the true costs of their illnesses. As a result our system is clogged with people with preventable disease who would rather spend their money going to Disneyland than investing in their health. I saw this first hand working in disability management where fully 6% of the employees where on employer sponsored long term disability. (The insurance company rep agreed possibly 50% of these cases were for preventable lifestyle related issues.) Renal units have expanded 300% over the past decade in order to handle the ever expanding cohort with organ failure due to uncontrolled type II diabetes--a very preventable and even reversible condition that is now striking at almost a decade younger than previously. Also, a large part of what drives poverty is drug and alcohol addiction--often compounded with cigarettes. The excellent Knowledge TV series on life in the ER at VGH showed that if problems related to addiction were removed, our ERs would not be crammed full. More enabling. The only thing that is going to "fix" this crushing load on the system, is a massive public health campaign and getting people to accept some financial responsibility for their conditions. As well, the huge numbers of teenage women having and keeping their babies when they are least equipped to either raise a child or use the system to get out of poverty--since there is often addiction issues--should also be the target of a public health campaign. Personally, I've save a nest egg in the event I find myself caught on a waiting list and have to go elsewhere for timely treatment. I'm not rich and instead of taking foreign vacations over the years I've invested in my own health care fund. I shouldn't have to but this is what we've come to. Walking through the park on family day I observed two young women, probably early 20s, who were horribly morbidly obese, as where the two young children. These moms were smoking a very potent joint and their children were eating a massive cheap pizza. All I could think is these folks are crushing their vascular system as well as their kidneys and it won't be long before they are in the system for a very long time. This was once a very rare scene and is now becoming the norm. We should all be very worried.

Dear "StoriesHaveTwoSides":
I too have worked in healthcare for over three decades, and have seen the effects of privatization. Dr. Brian Day trained at my hospital! My father's career in medicine began in the years before national medicare, and he accepted "payment" from grateful patients in the form of corn on the cob, which he loved. As well, I attended Dr. Martin's talk in Vancouver.
You say "a massive public health campaign and getting people to accept some financial responsibility for their conditions" will serve to decrease the load on the system. In theory this looks like a good solution, until people living in poverty are unable to pay. As Dr. Martin states, poverty is the most significant determinant of poor health.
Instead, as she recommends, better education of the public in self-care, along with education of family doctors in improving their relationships with their patients, will go a long way to improving outcomes, and reducing pressure on the system. Of course, instituting a universal minimum wage wouldn't hurt!
All this and more has already been studied and reported on - see the Romanow report, among others. Of great value as well is the Leap Manifesto.
It's all in Dr. Martin's book.

Thanks very much for taking time to comment, Penny.