Mission creep in the Canadian health care system

When you don't have clear goals, you won't know when you've arrived!

“Mission creep is the gradual or incremental expansion of an intervention, project or mission, beyond its original scope, focus or goals, a ratchet effect spawned by initial success. Mission creep is usually considered undesirable due to how each success breeds more ambitious interventions until a final failure happens, stopping the intervention entirely.”

Wikipedia

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Anyone thinking seriously about fixing the Canadian health care system might want to start with the foundation, the Canada Health Act (hereinafter referred to as “the Act”).

For those of you unfamiliar with the history, here’s a quick summary:

“When Parliament passed the Canada Health Act in 1984, it was one of the few pieces of legislation ever unanimously approved by federal politicians. In the years since, the Act has grown to be regarded by many as a symbol of what it means to be Canadian. As a former auditor general once said, "To many Canadians, the Canada Health Act provides for a healthcare system that helps to define this country. The Act symbolizes the values that represent Canada; it articulates a social contract that defines healthcare as a basic right."

The Canada Health Act states that "continued access to quality healthcare without financial or other barriers will be critical to maintaining and improving the health and well-being of Canadians." To help ensure that access, it sets standards the provincial governments, including the territories, must meet to receive federal funding for healthcare.

The Act says that under their health-insurance plans the provinces must provide equal coverage to all residents, without financial barriers. They must pay for the medical care of their residents, even if they received that care somewhere else in Canada. And provincial health insurance plans must be run publicly and on a non-profit basis. For many years, these standards were assumed to be a sufficient guarantee that Canadians would have equal access to healthcare. Recently, however, questions have been raised as to whether the Act is still sufficient to protect medicare in a changing world.”

From an Issue/Survey Paper prepared for the Commission on the Future of Health Care in Canada (the “Romanow Commission”) in 2002.

In short, the Act has been in force for 40 years, having replaced the Hospital Insurance and Diagnostic Services Act of 1957 and the Medical Care Act of 1966. At the turn of the century, it was seen as nation-defining and part of the social contract. Even then, there were doubts about whether it was fit for purpose. The Act has since been amended three times (in December 2002, June 2012, and December 2017), but the questions remain.

As I see it, the fundamental problem is that we were never really clear about the ultimate purpose of our health care system. We laid the foundation six decades ago. We’ve been renovating and making additions ever since. The whole structure is getting wobbly; it could collapse at any moment.¹

Without having clearly stated what the final system should look like, we can never know whether (or when) we’ve succeeded, or if we’re even going in the right direction.

It’s a classic example of mission creep. Failure is inevitable.

Let me explain.

What were we trying to accomplish?

The Preamble of the Act² tells a story:

• Canadians, through their system of insured health services, have made outstanding progress in treating sickness and alleviating the consequences of disease and disability among all income groups.

• Canadians can achieve further improvements in their well-being through combining individual lifestyles that emphasize fitness, prevention of disease and health promotion with collective action against the social, environmental and occupational causes of disease.

• Canadians desire a system of health services that will promote physical and mental health and protection against disease.

• future improvements in health will require the cooperative partnership of governments, health professionals, voluntary organizations and individual Canadians.

• continued access to quality health care without financial or other barriers will be critical to maintaining and improving the health and well-being of Canadians.

• the Parliament of Canada wishes to encourage the development of health services throughout Canada by assisting the provinces in meeting the costs, without abrogating, derogating from or in any way impairing any of the powers, rights, privileges or authorities vested in the provinces.

The problem in a nutshell!

Buried within all that well-intentioned verbiage, the paradigm shifted and the mission crept.

We claimed “mission accomplished” for our pre-existing targeted and effective system of “insured health services” (meaning publicly funded hospital care and physician care), having made outstanding progress in “treating sickness and alleviating the consequences of disease and disability”.

We set a new objective, a much more ambitious and ambiguous “…system of health services that will promote physical and mental health and protection against disease”. Achieving this would involve “combining individual lifestyles that emphasize fitness, prevention of disease and health promotion with collective action against the social, environmental and occupational causes of disease”.

The new objective was definitely far-reaching!³ It wasn’t just about improving “health care”. It was about improving the health and well-being of Canadians, which wasn’t expected to be simple or cheap. It would require the cooperation of governments, health professionals, voluntary organizations and individual citizens. We would have to mobilize all the troops! Individual financial and other barriers would have to be eliminated, meaning added government costs. To make it happen, the federal government was generously offering to “assist” the provinces with those costs, subject to certain terms and conditions.⁴

To be clear…

The first clause of the Act seemed to be even more explicit, stating that “the primary objective of Canadian health care policy is to protect, promote and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health services without financial or other barriers.”

Even though it refers to a singular “primary objective”, there are actually two objectives in that statement:

1. to protect, promote and restore the physical and mental well-being of residents of Canada, and

2. to facilitate reasonable access to health services without financial or other barriers.

Perhaps those reasonably accessible “health services” were considered necessary to “protect, promote and restore the physical and mental well-being”? It talks about the objective of “health care policy”, not “health policy”. Would health care alone be sufficient to improve well-being, or would other health-related factors be involved? Was the objective even workable? It depends on what was meant.

Without definitions, things aren’t clear!

“Definitions matter not because they fulfill some fetish about semantics, but because they determine what type of work is done in service of them.”

Paul Golding, 2019

The preamble and the first clause of the Act contain a mishmash of nouns and verbs:

• we promote and improve health

• we emphasize fitness

• we protect, promote and restore well-being

• we treat sickness

• we treat disability and alleviate its consequences

• we prevent, protect against, and treat disease, and we take action against its causes.

Sadly, while the Act does define some things, it doesn’t define “well-being”, “disease”, “fitness”, “sickness”, “disability”, or “health” (even though the word “health” appears in the title). It also doesn’t define “health services”, ‘health care”, and “reasonable access”, even though they are each to form part of the solution.

When you don’t define things, people interpret them as befits their own purposes. If you can’t say what reasonable access, well-being or health looks like, how do you know whether you’ve made any progress toward your objective? You’ve laid the foundation without planning anything above it.

The cynical side of me says the politicians did this on purpose. In being vague, they could claim that the Act would accomplish all sorts of wonderful things, depending on who they were talking to.⁵

Our nation-defining health system is a chimera, an illusion, a fabrication of the mind, whatever you imagine it to be. Just don’t expect it to perform well when you need it - there’s plenty of evidence that it doesn’t!

Looking for clarity…

I’m not a huge fan of the World Health Organization, but they see themselves as world leaders in health matters, so I looked to their Health Promotion Glossary of Terms 2021 for some definitions.

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Well-being:

“…is a positive state experienced by individuals and societies. Similar to health, it is a resource for daily life and is determined by social, economic and environmental conditions. Well-being encompasses quality of life, as well as the ability of people and societies to contribute to the world in accordance with a sense of meaning and purpose. Focusing on well-being supports the tracking of the equitable distribution of resources, overall thriving, and sustainability. A society’s well-being can be observed by the extent to which they are resilient, build capacity for action, and are prepared to transcend challenges.

So, if Canadian health care policy, through the Act, aims to protect, promote and restore the physical and mental well-being of Canadians, then that sounds like a pretty tall order. It goes well beyond your basic health care services. Doctors can fix your broken leg, but what can they do to improve your quality of life or restore your sense of meaning and purpose? There’s more to quality of life than access to health care.

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According to the classic 1946 WHO definition, health means:

“A state of complete physical, social and mental well-being, and not merely the absence of disease or infirmity.”⁶

The WHO definition has been heavily criticized, in part because the requirement for “complete” well-being makes it unlikely that anyone, anywhere, will actually be “healthy” for any sustained period of time. Complete health for all is neither realistic nor achievable. You can be disease-free today but still have a headache, feel sad, or lack food. Completely healthy people occupy a tiny idyllic island of calm in an ocean of physical, social, and mental turmoil, and the population of that island changes hour by hour!

Nonetheless, if we’re aiming to “promote physical and mental health”, then we are, by the WHO definition, aiming towards complete physical and mental well-being, not merely treating diseases and infirmity. While the Act seems to leave “social well-being” out of the equation, the WHO obviously thinks it’s inextricable. To have healthy people, you’ll have to address housing, food supply, education, social justice, the environment, etc., all of which go well beyond basic health care services. Doctors can drain your abscess, but they don’t have the tools needed to put a roof over your head, improve your food supply, or eliminate the contaminants in your drinking water.

Sure enough, there are other ways to define health. Other than the “medical” definition (the one the WHO deems insufficient), most seem hard to operationalize.

FROM: The Conceptualization of Health, James Larson, 1999

No matter how you look at it, even though “health” seems to be something our health care system aims to promote and/or improve, it’s not clear how we’ll measure it or know that we are making progress. In most cases, what gets reported is the number of people with diseases, or the number who access health services.

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Interestingly, the WHO doesn’t define disease. I had to look elsewhere, only to find that defining disease involves something of a philosophical debate.⁷

At its most basic, you might think that a disease involves a disturbance of the structure and/or function of an organ or bodily system. However, there are plenty of things out there that we call diseases without having identified any structural or functional defect (like chronic fatigue syndrome). It gets even more confusing these days because of the WHO-induced tendency to define anything other than perfect health as some form of disease⁸ (age-related declines in bodily function, for example), coupled with the consumerist tendency to pursue “medical” treatments for personal goals unrelated to disease (contraception, or cosmetic surgery, as two examples).

While there are several possible criteria for disease, they each work for some situations and not for others. For example:

• undesirability (infertility, for example. However, the elective use of birth control implies that infertility is not always undesirable. Being ugly is undesirable, but not a disease.)

• pain, suffering and discomfort (like kidney stones. However, not all things experienced as painful are diseases, childbirth being one example.)

• structural abnormalities (like a congenital abnormality. However, some congenital abnormalities go unrecognized and cause no problems, while diseases like obsessive-compulsive disorder have no obvious structural basis.)

• dysfunction (like kidney failure. However, some risk factors that we label as diseases, like hypertension, are simply statistical variations of normal functional states.)

• disability (like a broken leg. However, some disabling conditions like pregnancy are not diseases, while other diseases are not disabling, like vitiligo).

• deviation from statistical normality (like obesity, although being overweight is becoming the statistical norm. Osteoporosis and dementia, on the other hand, are both quite common among people at an advanced age and are both considered diseases.)

• treatability (like bacterial pneumonia. However, these days we “treat” plenty of things that aren’t diseases, like facial wrinkles.)

• being beyond the control of the affected individual (like addictions, even though, in the end, addiction treatment involves some measure of “self-control”. Conversely, some situations beyond our control are clearly not diseases, like being the victim of an assault.)

So, even though being healthy means more than being disease-free, it’s obvious that the definition of disease is pretty amorphous. It’s possible to be diseased and believe that you are healthy, as with unrecognized hypertension or an as-yet-undiagnosed cancer. Conversely, you can feel unwell and have no disease (although, as noted, there’s a tendency these days to assign any state of being unwell a diagnostic label).

In the context of our health care system, while treating disease seems to an important activity, it’s not always clear what constitutes a disease that needs to be treated. For example, male pattern baldness, erectile dysfunction, drapetomania⁹, homosexuality, hysteria, and addictions have all been labelled as diseases at some points in time and not at others, depending on social, political, business, and other factors.

Defining our system

Where health is so hard to define, it’s not surprising that “health care” or “health services” are also hard to define. The bottom line is that they mean what you want them to mean, depending on how you define health and what services you think should be included. Things will vary from one place to another (health services seen as essential in one culture might be seen as dubious or unaffordable in another¹⁰) and from one year to the next (see, for example, A Decade of Reversal: An Analysis of 146 Contradicted Medical Practices, which showed that changes in established medical practice are common).

In defining health care and health services, there are a couple of things to consider.

First, health is not the same as health care. Some people find it hard to imagine, but you can be healthy without having access to health care. Conversely, almost by definition, the people who do access health care are more likely to be unhealthy¹¹. Health care is sometimes, but not always, necessary to restore health to those who are unwell (sometimes people get better without health care). And, because things other than health care influence health, health care alone is not always sufficient to restore or sustain health. The Act in places equates health care with health, and that’s a problem, because offering universal health care isn’t going to result in universal health.

Next, because biomedicine (or allopathic medicine) is the dominant model of health care in our society, there’s an unfortunate tendency to see the solution to every form of “unwellness” as being some form of biomedical health care, including medication, surgery, counselling, physiotherapy, radiation, etc. This ignores any social, cultural, or environmental factors that contribute to or influence the problem. It also means that, in many cases, solutions to problems are offered by individual health care providers to individual patients, even when the root cause of the problem lies elsewhere. As one example, the current obesity epidemic (which in turn contributes to higher rates of hypertension, diabetes, osteoarthritis, ischemic heart disease, etc.) may well be the result of society-wide changes in activity and eating patterns.¹² Rather than making corrections at the population level, however, we offer individual dietary counselling, bariatric surgery, joint surgery, and all sorts of medications, an approach which is expensive, ill-targeted and ultimately ineffective.

It’s possible that these considerations explain why the Act envisioned “combining individual lifestyles that emphasize fitness, prevention of disease and health promotion with collective action against the social, environmental and occupational causes of disease”. The trouble is that the Act claims that Canadians “…desire a system of health services that will promote physical and mental health and protection against disease”. Health services, not health policy, in other words. Health services are individual. Health policy would require the broad cooperation of governments, health professionals, voluntary organizations, and individual citizens, but there’s nothing in the Act to actually make this happen.

Allowing for that fundamental problem, the Act lays out five basic expectations for a barrier-free health care system:

1. Public Administration: Healthcare insurance plans must be operated on a non-profit basis by a public authority.

2. Comprehensiveness: The plans must cover all services provided by doctors and in hospitals, if they're medically necessary.

3. Universality: All of the residents of a province must be entitled to the benefits of the plan.

4. Portability: A province must continue to cover its residents when they are travelling elsewhere in Canada.

5. Accessibility: Provinces must provide reasonable access to insured health services on uniform terms and conditions, without financial and other barriers.

Fair enough, but which health care services are included as insured benefits? What’s in scope for public funding and what isn’t? Who decides?

Without describing the full spectrum of health care, the Act defines several types of individual services offered to individual patients:

• extended health care services (meaning things like nursing home care).

• hospital services (meaning care provided to in-patients or out-patients at a hospital, but only if the services are medically necessary for the purpose of maintaining health, preventing disease or diagnosing or treating an injury, illness or disability).

• insured health services (meaning hospital services, physician services and surgical-dental services provided to insured persons).

• physician services (meaning any medically required services rendered by medical practitioners).

• surgical-dental services (meaning any medically or dentally required surgical-dental procedures performed by a dentist in a hospital, where a hospital is required for the proper performance of the procedures).

Introducing “medical necessity”

The common thread in all of those services is that “medically necessary” services are more likely to be “insured”, and the insured services are the ones that the federal government helps to pay for.

But what’s “medically necessary”, and who decides? Again, it’s not clear!

That’s where we’ll start in the next post.

1. This year, for example, our minority Liberal federal government, under pressure from the NDP, has added a national dental program and a rudimentary national pharmacare program (which only covers drugs for diabetes and contraception). Meanwhile, we have millions of people without a family doctor, hospitals are full of patients waiting for nursing home beds, emergency departments are full of admitted patients with no inpatient bed to go to, and ambulance paramedics spend hours waiting at the door to offload their patients.

Looking provincially, we have frequent unplanned emergency department closures and massive wait lists for diagnostics, specialist consultations, and surgery, and yet our governing party is campaigning for re-election on a promise to set up a centre of excellence for menopause.

2. While I haven’t been able to find a copy of the original 1984 Act, these preamble clauses appear unaltered in every amendment. It’s interesting that they haven’t been altered, because in itself that suggests a lack of progress (i.e. what was true in 1984 remains true now, despite 40 years of effort!)

3. It might even have extended to “solving world hunger” (or at least Canadian hunger)!

4. Health is a provincial responsibility. In this case, the federal government was using their spending power to bribe the provinces to do things in a certain way. However, all tax dollars come from the same taxpayer.

5. Of course, politicians don’t really do this, in the real world. I’m just old and jaded!

6. In typical WHO fashion, they actually go a lot further, saying:

Health is regarded by WHO as a fundamental human right. Correspondingly, all people should have access to basic resources for health. Within the context of health promotion, health has been considered as a resource that permits people to lead individually, socially and economically productive lives.

The Ottawa Charter for Health Promotion identifies health is a resource for everyday life, not the object of living. It is a positive concept emphasizing social and personal resources as well as physical capabilities. In keeping with the concept of health as a fundamental human right, the Ottawa Charter emphasises certain pre-requisites for health, which include peace, adequate economic resources, food and shelter, education and social justice, and a stable ecosystem and sustainable resource use. Recognition of these pre-requisites highlights the inextricable links between social and economic conditions, the physical and social environment, individual health behaviours and skills and health. These links provide the key to a holistic understanding of health that is central to the definition of health promotion.”

7. See, for instance, A New Approach to Defining Disease, or Health, Disease, and Illness as Conceptual Tools.

8. If you aren’t “well”, then you are not “healthy”. If you aren’t healthy, then you need “health services”. In order to access those, you’ll need a “diagnosis”.

The net result is that every form of distress gets labelled as a disease, even if the distress is a “normal” response to life circumstances (i.e. being upset when a friend or family member dies, “grief” by any other name, can be reframed as an “Adjustment Disorder”).

9. Per Wikipedia, “…drapetomania was a proposed mental illness that, in 1851, American physician Samuel A. Cartwright hypothesized as the cause of enslaved Africans fleeing captivity. This hypothesis was based on the belief that slavery was such an improvement upon the lives of slaves that only those suffering from some form of mental illness would wish to escape.”

10. As one example, in Germany spa treatments and visits can be prescribed by a physician and are covered by the federal health care system.

11. Some are healthy but worried about their health. That worry, in itself, can be labelled as a disease, “hypochondria”, otherwise known as “illness anxiety disorder”.

12. Look at crowd pictures from the 1970’s and compare them to crowds today, and then tell me why all those people got fat. It’s unlikely that 1/3 of the people decided individually to do something different that would make them heavier. It’s far more likely that they all fell victim to a shared “pathogen”, perhaps something related to the food supply (processed foods, maybe?). There are, however, powerful forces that resist a societal solution. Food manufacturers, processors, and marketers all have a vested interest in keeping our food supply as it is. Big Pharma are happy with the profits they make supplying drugs to unhealthy people. Ozempic, anyone?