The health system reform plan presented by Minister Christian Dubé puts forward several relevant policies to improve the quality of health care in Quebec. Although they involve significant costs, most of these reforms are desirable. However, the government does not tell us how it intends to finance them.
In normal times, health spending grows more than other public spending and often grows more than the size of the economy. Innovation in medical technologies, the aging of the population and the influence of certain interest groups are driving strong growth. In addition, public demand for massive investments in the network has never been stronger, while the pandemic has revealed the vulnerabilities of the healthcare system.
The government is talking about two ways of financing both the increase in recurring costs and the new investments it is proposing. First, it aims for medium-term efficiency gains in order to be able to reinvest in the network. Investing in home care for the elderly or facilitating the digital shift of the network could indeed reduce future growth in health care, but it may not be enough.
Then, Quebec turns to Ottawa and calls for an increase in federal health transfers, arguing, with reason, that they are insufficient to support the rising costs.
However, federal politicians are reluctant to significantly increase transfers, which would entail significant fiscal costs forcing Ottawa to increase deficits, taxes or reduce other expenditures. Federal politicians would pay the price, while provincial governments would benefit from this financial windfall. Ottawa therefore prefers conditional transfers to provincial investments in specific areas, to influence how the funds are spent and hope to derive political gain.
Incompatibility
Even if Ottawa increases its transfers, these will have to be financed by Quebec and Canadian taxpayers. Thus, it seems obvious to me that any significant investment in the health network is incompatible with the CAQ’s objective of never increasing the tax burden on citizens. An increase in capital gains taxation, by Quebec and Ottawa, could represent an important first step.
The alternative is worse. If the government does not increase its revenues, the increase in investments in health will occur to the detriment of the other missions of the State. By reducing our investments in policies that reduce social inequalities in health and that influence the social determinants of health, we risk harming the health of the population. However, the Quebec government’s plan aims precisely to prevent the disease upstream by fighting against social inequalities in health, in particular with the help of social policies.
The report implicitly suggests that Quebec already spends a lot on health and that a reorganization of spending will suffice to allow reinvestment. However, the level of public health spending in Canada, at 7.6% of GDP in 2019, is 12and rank of Western countries, far from countries like France, Germany or the Netherlands. Moreover, Quebec is, year after year, the province that spends the least per capita on health. It is therefore perfectly legitimate to choose to increase health spending, but we must agree to pay the price.
Counterintuitively, it is the health care expenses paid by private insurance or by the taxpayers themselves that remain particularly high in Quebec and Canada. Only 70% of total health expenditure is publicly funded in Canada, compared to nearly 85% in Western European countries. In our country, home care for people with loss of autonomy, dental care, psychological care and, to a lesser extent, medication are largely paid for by citizens or by their own insurance. However, several studies show that this private financing is more expensive and less equitable. It is perhaps by reducing the share of the private sector in the financing of the health network that we would obtain the efficiency gains so much sought after.