Double-dipping and wait times

Doctors are to blame for double-dipping but not for the long wait times in B.C.

image: Global news

Rosalia Guthrie of Salmon Arm found out the hard way about double-dipping. After waiting for 16 months, her surgeon’s secretary gave her the number of another clinic. To her surprise, she discovered that the other clinic was run by the same surgeon –and that she would have to pay.

Guthrie paid $500 to get in the door of the private clinic and another $3,850 for a written report. She didn’t have to pay for the actual surgery. That was covered by health care and only one-tenth of what she paid. The surgeon was paid $410.67 for the surgery done in a public hospital at UBC.

The surgeon did a number of things wrong. Double-dipping is illegal. That’s where doctors bill both the patient and the province for different aspects of the same treatment. And doctors are forbidden from charging patients for reports while advising patients on publicly-insured treatment. Also, the B.C. College of Physicians and Surgeons dictates that before referring patients to clinics, doctors must disclose if they have a financial interest. The surgeon did have a share in the clinic where Guthrie was treated and that wasn’t disclosed.

Doctors are not to blame for long wait times. That blame for that lies squarely at the feet of the government of British Columbia. The BC Liberals have failed to provide access to operating rooms for surgeons says Judy Darcy, the NDP spokesperson for health:

There are operating rooms that sit idle, MRIs that sit idle for many hours of the day. We need to invest in innovation to use our capacity to the maximum.”

If hospitals can’t provide operating room times for doctors, the province should build public clinics I argued earlier. There is no shortage of doctors; there is a shortage of operating rooms for them to work. In a survey done by the Royal College of Physicians and Surgeons, 208 fully trained specialists -16 per cent of those surveyed- were under-employed because “. . .there aren’t enough ORs.”

Some doctors contend that, while they may be doing something illegal, they are relieving patient suffering. Patients may lose their jobs while waiting or they may become addicted to pain-killing opioids.

Private clinics are expensive. Doctors can’t run them without charging patients. Dr. Ross Outerbridge, The founder of the Kamloops Surgical Centre, explains: “We factored in all the cost and a reasonable profit margin and that is what we charge the private patients.” But the whole realm of private clinics is unregulated. “I know that at other clinics, they overcharge,” says Dr. Outerbridge. ” I don’t personally agree with that – but it is very difficult, because nothing is being done about it.”

The BC Liberals have balanced the provincial budget by underfunding health care. British Columbia has the largest number of private clinics in Canada. While we are paying fewer taxes, we are likely paying more for health care when the cost of private clinics is factored in.

Yes, taxes would be higher but public clinics would be better than the illegal, unregulated, Wild West of bootleg medicine sold on the side of public medical practice.

 

 

The problem is doctor distribution, not shortage

The number of doctors in Canada is increasing faster than population growth says Dr. Michael Rachlis on CBC Radio’s The Current:

  photo: Nancy Bepple

“We’ve been increasing the number of physicians at about three per cent per year for the last 10 years and the population is only going up at one per cent per year.”

Another of the panellists on the program, Dr. Danielle Martin, author and VP at Women’s College Hospital, warns of a surplus of doctors:

“In fact you know in some parts of the healthcare system, people are worried about a glut and you hear stories of people coming out [of medical schools] and being unable to find a job.”

That’s certainly not the view from the streets of Kamloops. NDP candidate Nancy Bepple regularly visited lines of people lined up at a clinic to see a doctor. An estimated 30,000 Kamloopsians don’t have a family doctor (one-third of the population). In B.C. overall, it’s 15 per cent.

Why can’t people find doctors if there’s so many of them? Are they hiding?

Well, some of them have chosen to work for a salary rather than billing for each patient. They work exclusively in hospitals says Dr. Chris Pengilly of Victoria, another of the panellists. He calls them “hospitalists.”

They prefer to work only 40 hours a week. Who can blame them? And they are paid better. At $150 an hour, a hospitalist makes $300,000 a year with no overhead. After paying staff and rent, a family doctor would have to earn $400,000 a year, to take home that much; and work longer hours with less support.

The choice is obvious says Dr. Pengilly:

“So anybody coming out of medical school with a big student loan, which do you think they’re going to go for? A family physician [with] no time in hours a week or a hospitalist 40 hours a week and $300,000 with minimal expenses?”

Furthermore, hospitalists don’t want to work alone says Dr. Rachlis “Well, I say good for them that they’re looking to work in teams with other groups, with other physicians.”

One-half of Canada’s physicians focus on sports medicine or palliative care, says Dr. Martin:

“. . .they’re not practicing what we would think of as full scope full service cradle-to-grave primary care family medicine, and that is what those people who are lining up at Dr. Pengilly’s clinic and asking [for a primary caregiver].”

The current model is not working because doctors no longer want to work in the silos of a fee-for-service practice.

It’s ironic that the provincial government has created a hospital environment which doctors prefer to work but one that removes them from the general public.

The solution is obvious but the BC Liberals have been slow to implement it: Build walk-in clinics and hire doctors on a salary basis. Everyone, doctors and patients alike, will be happier.

It’s going to cost more because the government will own the clinics. But the alternative, privately-built clinics, is a failure. The reason that two walk-in clinics in North Kamloops closed their doors is because doctors don’t want to work for less in an environment where they don’t have the same support that hospitalists enjoy.

It’s too late to decriminalize pot

Decriminalization of marijuana should have happened decades ago. Now it would only add to the confusion.

Marijuana users are caught in a legal limbo. The government intends to legalize marijuana before Canada Day, 2018, but until then it’s illegal. Then, like a light being switched on, what was once a criminal offence will not be.

Alberta Legalization of Cannabis Committee

Government intentions aside, police are going about their business. They arrested activists Mark Emery (the “Prince of Pot”) and his wife Jodie as reported by CFJC Today.

The Liberals have been dithering over decriminalization for decades and this Trudeau is no different. Pierre Trudeau could have decriminalized marijuana in 1979. Then Justice Minister Marc Lalonde was playing politics when he said that he would decriminalize it before the upcoming election if opposition parties would just fast track the legislation. He was doubtful that they would. “I’m not optimistic,” Lalonde said (Calgary Herald, Feb. 22, 1979).

The opposition parties took Lalonde up on his challenge, agreeing to fast tracking.  Both opposition leaders Joe Clark and Ed Broadbent sent me letters of approval for decriminalization. They were responding to letters I sent on behalf of the Alberta Legalization of Cannabis Committee. I helped organize the group in 1977.

Prime Minister Pierre Trudeau wrote me to explain how his government was trying to decriminalize marijuana. His government had initiated a bill in the Senate, Bill S-19, in 1974.”The Commons, however, was unable to find the time to give the bill further attention; so it died on the order paper when the last session of Parliament ended (January 17, 1978),” Trudeau explained.

In my letter to the Calgary Herald, I complained about Lalonde’s tardy pace: “Why does the government seem so reluctant to do what all agree must be done? If Lalonde wants us to believe that this is a demonstration of his government in haste, then it’s time to see what a new government in action; a government that will not fiddle while Canadians get burned (April 14, 1979).”

Lalonde had teased Canadians long enough with his promises of decriminalization. His government was defeated by Joe Clark’s Progressive Conservative Party in June 11, 1979.

Executive Assistant to Clark’s Minister of Justice wrote me: “Mr. Clark’s government is currently reviewing this and other issues with a view to formulating policies and setting priorities.” “Be assured, Mr. Charbonneau, that your comments will be given serious consideration by the Government as it continues its study of this important matter (Aug. 3, 1979).” However, Clark’s government didn’t last long enough to decriminalize marijuana.

A Globe and Mail editorial argues that the government should decriminalize marijuana before legalizing it because users are in legal purgatory: “Besides, there is no viable interim regulatory regime that could accommodate a quasi-legal retail market. But there is when it comes to personal possession. It’s called decriminalization.”

It’s too late for decriminalization. More legislation would only add to confusion. There is a simple solution –what the Dutch call “gedogen.” Police simply don’t enforce marijuana laws. Unlike the Netherlands, where the law has been ignored for 30 years, police only have to turn a blind eye for another year.

Tax loopholes –the good, bad and ugly

What’s the difference between a tax break and a tax loophole? Tax breaks are legitimate deductions that I make and loopholes are shady tax dodges that others use. Seriously, they’re all what economists call tax expenditures. The only difference between them is whether they progressive or regressive, and how much they improve equality.

Some tax expenditures benefit low and middle-income families such as deductions for union dues and post-secondary education. Others benefit wealthy Canadians such the mineral exploration deduction and the capital gains allowance.

Regardless, they are all uncollected taxes. And it’s a lot says David MacDonald, senior economist for the Canadian Centre for Policy Alternatives (Monitor, Jan/Feb, 2017). The government of Canada gives up almost as much in tax expenditures as it collects in taxes. In 2011, tax expenditures were $103 billion while collected taxes were $121 billion.

Tax expenditures serve a useful purpose if they improve equality. Equality is an indicator of how happy citizens are, be they rich or poor, as I argued in an earlier column (Conservatives can increase chances by decreasing happiness, Dec. 14, 2016).

The question is whether tax expenditures increase equality or reduce it. Are they progressive or regressive? MacDonald has analysed tax revenues and found that of 64 tax expenditures, only five are progressive and go to the lower half of income earners. The remaining 59 tax expenditures go to the top half. The tax benefit for low-income earners is a paltry $130 while for the richest it’s $15,000. Is it any wonder that “tax loopholes” seem shady? Low income earners see it for what it is –a benefit that only the rich receive.

With the feds in the fiscal hole, and with almost as many taxes uncollected as collected, I would have thought that Finance Minister Morneau would have use the last budget to reform taxes. But he didn’t according to Kevin Milligan, professor of economics at UBC.

“In the budget, the government did make some good moves with the tax measures it tackled, but it did not tackle enough. That is, Mr. Morneu may have grabbed some of the low-hanging fruit, but he left a lot of fruit further up the tree untouched, (Why Morneau got cold feet over eliminating Canada’s bloated tax-credit system, Globe and Mail, Mar. 24, 2016.)”

On the plus side, the feds are still committed to reviewing corporate tax shelters that allow income to be split with partners and lower taxes. And they simplified the Canada Caregiver Credit for those caring for an elderly or infirm family member.

It’s OK to eliminate tax breaks but not my tax break. Milligan elaborates:

“For every tax expenditure, there is a particular constituency that benefits, while costs are dispersed across all taxpayers. Firefighters like their volunteer-fighter tax credit; teachers like their teacher-school-supply credit and first-time home buyers like their home-buyer tax credit.”

The solution, adds Milligan, is to eliminate entire bundles of tax breaks. That way no particular group feels targeted by tax reform.

Tax reforms may be painful but they’re necessary to improve equality. We’ll all be happier for it.

By the time the trekkers got to Kamloops

In April of 1935 they left their miserable camps and made their way to Vancouver. The camps had been set up in the middle of nowhere. Young men worked in the military-run camps for 20 cents a day under deplorable conditions in dead-end jobs with no end in sight.

Canada’s History Magazine

The camps were designed to harsh. Prime Minister Bennett had reluctantly set them up as a concession to the unemployed victims of the Great Depression. He was opposed to anything that looked like a handout, including even the appalling camps. He told a labour delegation in 1930: “Never will I or any government of which I am part put a premium on idles or put our people on the dole (Canada’s History magazine, August-September, 2016).”

The camps didn’t have to be that way, says historian Bill Waiser of the University of Saskatchewan. “In contrast to the American Civil Conservation Corps, a popular federal work-for-relief program across the border, the make-work projects and isolating conditions of the Canadian relief camps aggravated the gloom of the men who were in them.”

About fifteen hundred desperate men arrived in Vancouver and were warmly received. Huge public rallies and parades were held. On Mother’s Day in Stanley Park, three hundred women circled the men in the shape of a heart.

As is typical, provincial and federal governments wrangled over who was responsible for the men. Finally the men decided to take matters into their own hands and trek to Ottawa aboard boxcars. About one thousand left Vancouver in June of 1935. Governments made no attempt to stop them –convinced that the trekker’s tenacity would dissolve in the cold trip through the mountains.

By the time the trekkers got to Kamloops they were cold, hungry and dispirited. Unlike Vancouver, no warm reception awaited them. Nothing had been done to prepare for their arrival: Mayor W. J. Moffatt and the chief of police flatly refused requests for help.

Kamloops had problems of its own with hordes of desperate, unemployed men in formal camps and informal “hobo jungles” says Mary Balf, former curator of the Kamloops Museum, in her book Kamloops 1914-1945. In one case, on May 1, 1931, men flocked into the city to complain about the poor conditions in these camps. Police closed the bridge from North Kamloops to limit the numbers.

“The work camps continued rather haphazardly until the summer of 1936,” says Balf, “but never really worked well. . . frequently they were so badly managed that even the promised wages were not forthcoming.”

After 300 men joined the trekkers from Kamloops, they were revitalized. As word of the trekkers spread, they were soon regarded as folk heroes. Washtubs of stew awaited them when they arrived in Golden in June. Calgary citizens were struck by the youthful innocence of the men.

More men joined the trek in Alberta but not my father. He was in a camp in Jasper at the time building the national park. He never told me about the camp conditions in Jasper. Perhaps he preferred to forget the depression and the stigma of unemployment. Perhaps, like some of the projects in the U.S., the building of parks gave purpose to his work.

As the popularity of the heroic trekkers grew, the federal government began to worry that they might actually get to Ottawa. By the time they got to Regina, the feds decided they would go no further. On Dominion Day in 1935, Regina police and RCMP raided a rally attended by thousands of trekkers and supporters. A riot ensued with hundreds of injuries and two deaths.

The trek ended but not without a cost to the feds. In October of 1935, Bennett’s government was defeated. A year later the camps were closed down.

Electoral reform disappointment #3

I was disappointed but not surprised when Prime Minister Trudeau abandoned his plans for electoral reform. I’ve been let down before.

fairvote.ca

fairvote.ca

The first time was in 2005 when a Citizens’ Assembly was created to study models of reform. After much deliberation, they recommended a made-in-BC type of Single Transferable Vote called BC-STV.

The referendum was coincident with the provincial vote. Only weeks away from the vote, an Angus Reid poll showed that two-thirds of respondents knew “nothing” or “very little” about BC-STV.

Then to everyone’s surprise and my delight, BC-STV almost passed despite the high threshold: 60 per cent of voters had to be in favour as well as 60 per cent of the provincial districts.

The threshold for districts easily passed with 76 of 79 districts in favour. The popular vote came within a hair`s breadth of passing: 57.7 per cent. Support in Kamloops was the lowest in the province at 49 per cent in both districts (Elections B.C.). Bud Smith, the popular Social Credit MLA from 1986 to 1991, led the no vote in Kamloops.

The popularity of BC-STV seemed baffling given the lack of understanding of just what voters were supporting. But not so baffling in light of a recent referenda, such as Brexit. British voters were as much against immigrants as they were for leaving the European Union. Clearly, voters don’t necessarily answer the question on the ballot.

BC-STV was on the ballot but not on voter’s minds; rather, it was dissatisfaction with Gordon Campbell’s BC Liberals. The BC Liberals lost 31 seats, down from their record win of 77 out of 79 in 2001.

My second disappointment was the defeat of the BC-STV referendum again in 2009. With the earlier referendum being so close, I hoped, against discouraging opinion polls, that earlier support was not a fluke. This time, even in Kamloops, electoral reform would prevail. I joined city Councilor Arjun Singh, Gisela Ruckert, and others in Fair Voting BC. In a column for the Kamloops Daily News (May, 2005), I implored:

“This is a limited time offer.  The chance to change our electoral system comes once in a lifetime, . . . Don’t let this chance to make history pass you by.”

It was not to be. A disinterested electorate, 51 per cent of eligible voters, returned the BC Liberals for a third term, defeated BC-STV by 61 per cent and buried electoral reform for decades.

Trudeau raised my hope federally by proposing unilateral legislation. But Canadians want a referendum (73 per cent in an Ipsos poll).

A referendum would doom electoral reform to failure. Voters like the idea of proportional representation but have trouble understanding the voting systems that would accomplish it. The outcomes of referenda in B.C., P.E.I and Ontario made that clear. The same would be true of a federal referendum says pollster Environics. The vote would be split between three alternatives –the current system and two types of proportional representation:

“In a referendum, not one of these three alternatives would achieve majority support — leaving the reform project to die, along with virtually every other proposal ever put to a referendum in this risk-averse country.”

And that assumes they vote on the ballot question.

Canada is a young country. Or I’m old.

Canada is 150 years old this year. Since I’m one-half that age, Canada must be a young country. Or I’m old. It must be the former.

canada-150-horizontal-colour

We had humble beginnings, Canada and I. I was born in Jasper Place, now part of Edmonton but in 1941 it was a rudimentary town. We had no water or sewer. The bucket in the indoor toilet had to be emptied regularly to the outhouse in the back. The honey wagon would clean it out once in a while. Water was delivered by a truck to a cistern in the basement. A hand-operated pump supplied water to the kitchen. Milk was delivered by a horse-drawn cart.

Canada was born with only four provinces at confederation. Like Jasper Place, it lay outside the huge territory it would eventually encompass.

Canada was rebranded as much as it was born in 1876. John Ralston Saul, author of A Fair Nation, argues that Canada had already been a federation for 250 years before that. We are a Métis nation, comprised of indigenous people, English and French. Before 1876 our federation comprised mostly of indigenous people, numbering one-half million.

By 1947 we moved to a suburb of Edmonton called Bonnie Doon, Scottish for “pleasant, rolling countryside.” We lived only one block away from Saint-Jean College where Catholic priests taught students who were about to enter the clergy. Now it’s the only francophone University west of Manitoba, a campus of the University of Alberta. The college allowed neighbourhood kids to use their outdoor rink when they weren’t playing hockey. That’s where I learned to skate.

The broken hockey sticks made fine bows as long as they had a straight grain. We carved them with a draw knife and used them to hunt rabbits with bows and arrows in the nearby Mill Creek. The rabbits didn’t have much to worry about because of the thick bush and our poor aim. I wore horsehide moccasins in the winter which warm even on the coldest days. We would often spend entire winter days sledding on the hills in the ravine.

By the time Canada was officially born, our indigenous people had been decimated by disease which they had no resistance to, and by conflict with their European guests.

However, the 250 years of gestation of Canada left its imprint on the fledgling nation. Canada is not just a collection of its people; it is a product of our collective consciousness. John Belshaw, former Thompson Rivers University professor, puts it this way:

“Scholars draw a distinction between historical consciousness and collective memory. The former is something on which we reflect but often forget. History as a discipline consists of facts – – objective and recitable. Collective memory, on the other hand, is an ongoing process that builds a shared and more nuanced understanding of the past, (Walrus magazine).”

While not exactly a Baby Boomer, I identified with the Hippy Movement. I smoked my first joint in the Haight-Ashbury district of San Francisco, the birthplace of the counterculture movement. I naively believed John Lennon when he implored the world to “give peace a chance.”

We have done OK, Canada and I, but we’re still young and have a lot to learn. Happy sesquicentennial, Canada!