Friday, January 13, 2023

Public vs. private - two perspectives

Two separate articles in today's paper have me wondering about the hoary old public-private dichotomy.

First, the god-forsaken eastern Ukrainain town of Soledar is being pounded into oblivion, not by the Russian army, but by Yevgeny Prigozhin's Wagner Group, a private army of mercenaries. Despite taking heavy losses in the campaign for this small town, which boasts little more than a network of salt mines (and a reasonaly strategic position, to be fair), the mercenaries have dug in and are coming close to taking what's left of the town.

But I had to stop and wonder what was the difference between the Wagner Group fighting and the Russian army fighting? The mercenary organization has a reputation for extreme violence and a readiness to commit illegal atrocities, but hell, so does the Russian army. Yes, they are paid for their efforts, but so is the army of Russian conscripts (although presumably much less). They are loyal to their employer (at least while they are still being paid), and not to Mother Russia, but very few Russian conscripts have warm fuzzy feelings for Vladimir Putin by now.

Which leads me to wonder: has anyone tried to buy off the Wagner Group? Maybe Prigozhin himself can't be bought (although maybe he can?), but the individual fighters? Might it be a cheaper option for the Ukraine-supporting West to bribe the Wagner Group force with some big money than the huge amounts of cash being pumped into military equipment and ammunition? Could the Wagner Group even be persuaded to work AGAINST Russia? Idle musings, nothing more, but food for thought nonetheless.

The very next article in the paper is also about a very different public-private argument. The Conservative Ontario government has made no secret of its love for private healthcare. As the healthcare system creaks and groans in what feels like its final death rattle, the government is in the process of bringing in a law allowing what it calls "independent health facilities" (basically for-profit private health clinics) to take up some of the slack. Doug Ford has made it very clear that Ontario residents will not have to break out their credit cards in order to receive healthcare, and that, whatever changes are made, they will all be covered by the current OHIP system.

So, private doctors will be paid by the government to treat patients for free. But isn't that effectively what already happens? Doctors and specialists in the public system are essentially self-employed business people underwritten by the public health insurance system. How is the idea of publicly-paid private clinics any different, if patients are still receiving their treatments for free (which after all is the basic tenet of socialized medicine)? 

There has been the predictable outcry and claims that we are heading pell-mell towards the despicable American system. But it does raise the question of what actually constitutes public healthcare. Is the important part that residents do not have to pay direct for the care they receive? Or is the salient point that the organizations providing the care not make a profit? Equal and universal access to care, funded by progressive taxes paid to governments, is the usual definition of medicare, and that may not actually change under the proposed changes.

Presumably, though, the private sector will charge even higher rates than the doctors currently in the public system, and so tax-payers will ultimately be on the hook for higher taxes to cover it (which the government does not seem to be talking about), but the underlying principal is surely the same. So, why not just pay current public sector doctors and nurses more money to retain their services, and to encourage new entrants into the field, and to discourage new graduating doctors from heading straight down the higher-paying specialist route, especially given the acute need for regular family doctors, particularly in rural and northern areas? Wouldn't this achieve the same end, more cheaply, and with a lot less controversy?

Public solutions do exist. For example, one other proposed solution within the current public system might be "community surgery centres" (also known as "ambulatory surgery centres"), which are designed to handle large volumes of low-complexity surgeries. These community surgeries can apparently deal with about 30%  more operations than a hospital on any given day at a similar cost. What's not to like?

Either way, it seems clear that the status quo is failing Ontarians, and some drastic re-think is needed. Mr. Ford is determined to bring his dream of more private medicine to fruition, following in the footsteps of other provinces like Alberta, Saskatchewan and British Columbia, starting with procedures like cataract surgeries, MRI and CT scans, and hip and knee surgeries. So, it will be interesting to see how it all transpires, and how much push-back there will be from the strongly-unionized public sector (and whether there is a mass exodus of doctors and nurses from the public system to the better-paid private sector - potential poaching of public hospital staff by private clinics is probably the top concern of hospitals when considering Ford's plans). 

And finally, here is one other relevant consideration: although Mr. Ford credits BC as a big inspiration of his own plans, it turns out that BC is actually heading in the opposite direction currently, as it is in the process of bringing private clinics back into the public system, and clamping down on private operators accused of underusing operating rooms. Hmm.

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