Ontario health-care reforms good first step in right direction

The Ford government recently passed Bill 60 in a bid to reduce wait times for surgeries in Ontario. Also known as Your Health Act, the bill will expand the use of private for-profit and not-for-profit clinics to provide select publicly funded procedures (such as cataract surgeries and diagnostic imaging). The move is bold, and good news for Ontarians in need of relief. However, further steps are needed for long-lasting reform.

Wait times in Ontario (and Canada at large) have been growing for decades. In 2022, Ontarians could expect to wait 20.3 weeks for elective treatment—the longest wait recorded in more than 30 years of measurement, 11.2 weeks longer than the 9.1-week wait Ontarians faced in 1993, and about four weeks longer than the 16.0-week wait in 2019, before the pandemic and ensuing scale-back of elective (a.k.a. scheduled) medically necessary procedures.

By expanding the use of private clinics for publicly funded care, Ontario can rapidly expand health-care capacity without necessarily investing in expensive capital infrastructure, while reducing the burden on the government-run system and potentially improving timely access to care.

Although full details of the recent move by the Ford government are yet to emerge, this strategy appears to closely mirror the Saskatchewan Surgical Initiative (SSI), which helped that province reduce wait times and per-procedure costs more than a decade ago.

In 2010, the median wait time for a surgical procedure in Saskatchewan was 26.5 weeks, the longest in the country outside the Atlantic provinces. That same year the Saskatchewan government introduced the SSI, an innovative four-year multipronged approach to deal with wait times. Perhaps the most controversial aspect of the SSI was the contracting of private for-profit clinics to deliver publicly funded surgical care.

By 2014, the final year of the SSI, wait times in the province had dropped to 14.2 weeks, the second-shortest in Canada that year. Furthermore, procedures were found to (on average) cost 26 per cent less in the contracted private facilities compared to their public-sector counterparts.

While there’s clearly much to learn from previous experience, it also serves as a cautionary tale. The positive results only lasted as long as the province was willing to pay for them—and wait times have since crept back up. One key lesson for policymakers is that limiting private-sector involvement to the confines of the public-sector framework is a temporary, but not permanent, solution to reducing wait times for care.

Other more successful universal systems such as Germany, Switzerland, France and Australia routinely outperform the Canadian system on several fronts, including on the timeliness of specialist and surgical care, while spending similar (or lower) amounts on health care (as share of their economy). What’s common among these three high performers?

These countries more fully embrace their private sectors as a partner or pressure valve. For example, Swiss residents must purchase health insurance from private insurers in a regulated market. In Australia, public hospitals routinely contract services to private clinics to deliver publicly funded care. And more than 40 per cent of hospitals in Germany operate on a for-profit basis. Contrary to Canada, each of these countries also expect patients to share the cost of care, and generally fund hospitals based on activity, which incentivizes them to treat patients in a timely fashion.

Notably, only 62 per cent of Canadians received non-emergency surgery in less than four months once advised they needed it, far less than patients in Germany (99 per cent), Switzerland (94 per cent) and France (90 per cent).

The lessons from Saskatchewan and universal health-care systems abroad suggest that the Ford government’s plan to expand capacity through publicly funded contracts with private clinics may be successful in the short term, but must be followed by more significant reform in the future. While this is a bold necessary step forward, the government should also look to other examples of success and emulate proven solutions for long-term improvement in timely access to care.