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Fraser Institute

Dearth of medical resources harms Canadian patients

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5 minute read

From the Fraser Institute

By Mackenzie Moir

The imbalance between high spending and poor access to doctors, hospital beds and vital imaging technology, coupled with untimely access to services, can, and does, have a detrimental impact on patients.

Whether it’s a lack of family physicians or other health-care workers, Canadians know we have a serious health-care labour shortage on our hands. The implications of this shortage aren’t lost on patients (including Ellie O’Brien) who’ve possibly faced delays in accessing organ transplants because potential donors need a regular family doctor to screen them to begin the transplant process.

Given these access issues, coupled with some of the longest recorded wait times for medical procedures on record, is it any wonder that Canadians are dissatisfied with how their provincial governments handle health care?

While one instinct might be to demand governments spend more on health care, it’s not clear we’re getting good value in return for what’s already being spent. In fact, compared to 29 other high-income countries with universal health care, Canada spent the most on health care as a share of the economy at 12.6 per cent in 2021, the latest year of available comparable data (after adjusting for differences in the age structure of each country’s population).

But what do we get in return for this spending?

As far as medical resources go, not a whole lot. In 2021, Canadians had some of the fewest medical resources in the developed world. Out of 30 high-income countries with universal health care, Canada ranked 28th on physician availability at 2.8 per 1,000 people, far behind countries such as seventh-ranked Switzerland (4.5 physicians per 1,000) and tenth-ranked Australia (at 4.3 physicians per 1,000).

But doctors are just one part of the puzzle. Canada also ranked low on available hospital beds (23rd of 29 countries), meaning patients often face delays for hospital care. It can also mean that patients end up being treated for their illness outside a traditional patient room—such as a hospital hallway, a phenomenon that has spread to many provinces.

We also see a low availability of other key medical resources including diagnostic equipment. In 2019, Canada ranked 25th of 29 comparable countries with universal health care on the number of MRIs (10.3 units per million people) compared to top-ranked Japan, which had four times as many MRIs as Canada. And we ranked 26th out of 30 countries on CT scanners (14.9 scanners per million people) compared to second-ranked Australia, which had five times as many CT scanners. It’s also worth noting that a large a portion of Canada’s diagnostic machines are remarkably old.

It’s no accident that countries such as Australia, which actually spend less of its economy on health care compared to Canada, perform better than Canada on measures of resource availability and timeliness of care. Unlike Canada, Australia embraces its private sector as an integral part of its universal health-care system. With 41 per cent of all hospital care in Australia occurring in private hospitals in 2021/22, private hospitals can act as a pressure valve for the entire system, particularly in times of crisis. Indeed, the country outperforms Canada on measures of timely access to family doctor appointments, specialist care and non-emergency surgery, and has done so regularly for years.

The imbalance between high spending and poor access to doctors, hospital beds and vital imaging technology, coupled with untimely access to services, can, and does, have a detrimental impact on patients. For some, this problem can be life threatening. Without genuine reform based on real world lessons from higher performing universal health-care countries including Australia, it’s impossible to reasonably expect our health-care system to improve despite its hefty price tag.

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Business

Broken ‘equalization’ program bad for all provinces

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From the Fraser Institute

By Alex Whalen  and Tegan Hill

Back in the summer at a meeting in Halifax, several provincial premiers discussed a lawsuit meant to force the federal government to make changes to Canada’s equalization program. The suit—filed by Newfoundland and Labrador and backed by British Columbia, Saskatchewan and Alberta—effectively argues that the current formula isn’t fair. But while the question of “fairness” can be subjective, its clear the equalization program is broken.

In theory, the program equalizes the ability of provinces to deliver reasonably comparable services at a reasonably comparable level of taxation. Any province’s ability to pay is based on its “fiscal capacity”—that is, its ability to raise revenue.

This year, equalization payments will total a projected $25.3 billion with all provinces except B.C., Alberta and Saskatchewan to receive some money. Whether due to higher incomes, higher employment or other factors, these three provinces have a greater ability to collect government revenue so they will not receive equalization.

However, contrary to the intent of the program, as recently as 2021, equalization program costs increased despite a decline in the fiscal capacity of oil-producing provinces such as Alberta, Saskatchewan, and Newfoundland and Labrador. In other words, the fiscal capacity gap among provinces was shrinking, yet recipient provinces still received a larger equalization payment.

Why? Because a “fixed-growth rule,” introduced by the Harper government in 2009, ensures that payments grow roughly in line with the economy—even if the gap between richer and poorer provinces shrinks. The result? Total equalization payments (before adjusting for inflation) increased by 19 per cent between 2015/16 and 2020/21 despite the gap in fiscal capacities between provinces shrinking during this time.

Moreover, the structure of the equalization program is also causing problems, even for recipient provinces, because it generates strong disincentives to natural resource development and the resulting economic growth because the program “claws back” equalization dollars when provinces raise revenue from natural resource development. Despite some changes to reduce this problem, one study estimated that a recipient province wishing to increase its natural resource revenues by a modest 10 per cent could face up to a 97 per cent claw back in equalization payments.

Put simply, provinces that generally do not receive equalization such as Alberta, B.C. and Saskatchewan have been punished for developing their resources, whereas recipient provinces such as Quebec and in the Maritimes have been rewarded for not developing theirs.

Finally, the current program design also encourages recipient provinces to maintain high personal and business income tax rates. While higher tax rates can reduce the incentive to work, invest and be productive, they also raise the national standard average tax rate, which is used in the equalization allocation formula. Therefore, provinces are incentivized to maintain high and economically damaging tax rates to maximize equalization payments.

Unless premiers push for reforms that will improve economic incentives and contain program costs, all provinces—recipient and non-recipient—will suffer the consequences.

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Alberta

Alberta’s fiscal update projects budget surplus, but fiscal fortunes could quickly turn

Published on

From the Fraser Institute

By Tegan Hill

According to the recent mid-year update tabled Thursday, the Smith government projects a $4.6 billion surplus in 2024/25, up from the $2.9 billion surplus projected just a few months ago. Despite the good news, Premier Smith must reduce spending to avoid budget deficits.

The fiscal update projects resource revenue of $20.3 billion in 2024/25. Today’s relatively high—but very volatile—resource revenue (including oil and gas royalties) is helping finance today’s spending and maintain a balanced budget. But it will not last forever.

For perspective, in just the last decade the Alberta government’s annual resource revenue has been as low as $2.8 billion (2015/16) and as high as $25.2 billion (2022/23).

And while the resource revenue rollercoaster is currently in Alberta’s favor, Finance Minister Nate Horner acknowledges that “risks are on the rise” as oil prices have dropped considerably and forecasters are projecting downward pressure on prices—all of which impacts resource revenue.

In fact, the government’s own estimates show a $1 change in oil prices results in an estimated $630 million revenue swing. So while the Smith government plans to maintain a surplus in 2024/25, a small change in oil prices could quickly plunge Alberta back into deficit. Premier Smith has warned that her government may fall into a budget deficit this fiscal year.

This should come as no surprise. Alberta’s been on the resource revenue rollercoaster for decades. Successive governments have increased spending during the good times of high resource revenue, but failed to rein in spending when resource revenues fell.

Previous research has shown that, in Alberta, a $1 increase in resource revenue is associated with an estimated 56-cent increase in program spending the following fiscal year (on a per-person, inflation-adjusted basis). However, a decline in resource revenue is not similarly associated with a reduction in program spending. This pattern has led to historically high levels of government spending—and budget deficits—even in more recent years.

Consider this: If this fiscal year the Smith government received an average level of resource revenue (based on levels over the last 10 years), it would receive approximately $13,000 per Albertan. Yet the government plans to spend nearly $15,000 per Albertan this fiscal year (after adjusting for inflation). That’s a huge gap of roughly $2,000—and it means the government is continuing to take big risks with the provincial budget.

Of course, if the government falls back into deficit there are implications for everyday Albertans.

When the government runs a deficit, it accumulates debt, which Albertans must pay to service. In 2024/25, the government’s debt interest payments will cost each Albertan nearly $650. That’s largely because, despite running surpluses over the last few years, Albertans are still paying for debt accumulated during the most recent string of deficits from 2008/09 to 2020/21 (excluding 2014/15), which only ended when the government enjoyed an unexpected windfall in resource revenue in 2021/22.

According to Thursday’s mid-year fiscal update, Alberta’s finances continue to be at risk. To avoid deficits, the Smith government should meaningfully reduce spending so that it’s aligned with more reliable, stable levels of revenue.

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