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Fraser Institute

Australia’s universal health-care system outperforms Canada on key measures including wait times, costs less and includes large role for private hospitals

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The Role of Private Hospitals in Australia’s Universal Health Care System

From the Fraser Institute

by Mackenzie Moir and Bacchus Barua

In the wake of the COVID-19 pandemic, provincial governments across Canada relied on private
clinics in order to deliver a limited number of publicly funded surgeries in a bid to clear unprecedented
surgical backlogs. Subsequently, surveys indicated that 78% of Canadians support allowing more
surgeries and tests performed in private clinics while 40% only support this policy to clear the
surgical backlog. While a majority of Canadians are either supportive (or at the very least curious)
about these arrangements, the use of private clinics continues to be controversial and raise questions
around their compatibility with the provision of universal care.

The reality is that private hospitals play a key role in delivering care to patients in other countries with universal health care. Canada is only one of 30 high-income countries with universal care and many of these countries involve the private-sector in their health-care systems to a wide extent while performing better than Canada.

Australia is one of these countries and routinely outperforms Canada on key indicators of health-care performance while spending at a similar or lower level. Like Canada, Australia ranked
in the top ten for health-care spending (as a percentage of GDP and per capita) in 2020. However, after adjusting for the age of the population, it outperforms Canada on 33 (of 36) measures of performance.

Importantly, Australia outperformed Canada on a number of key measures such as the availability of physicians, nurses, hospital beds, CT scanners, and MRI machines. Australia also outperformed
Canada on every indicator of timely access to care, including ease of access to after-hours care, same-day primary care appointments, and, crucially, timely access to elective surgical care and specialist appointments.

Australia’s universal system is also characterized by a deep integration between the public and private sectors in the financing and delivery of care. Universal health-insurance coverage is provided through its public system known as Medicare. However, Australia also has a large private health-care sector that also finances and delivers medical services. Around half of the Australian population (55.2% in 2021/22) benefit from private health-insurance coverage provided by 33 registered not-for-profit and for-profit private insurance companies.

Private hospitals (for profit and not for profit) made up nearly half (48.5%) of all Australian hospitals in 2016 and contain a third of all care beds. These hospitals are a major partner in the delivery of care in Australia. For example, in 2021/22 41% of all recorded episodes of hospital care occurred in private hospitals. While delivering a small minority of emergency care (8.2%), private hospitals delivered the majority of recorded elective care (58.6%) and 70.3% of elective admissions involving surgery.

Private hospitals primarily deliver care to fully funded public patients in two ways. The first is contracted
care, either through ad hoc inter-hospital contracts or formal programs. Fully publicly funded episodes of care occurring in private hospitals made up 6.4% of all care in private hospitals, while representing 2.6% of all recorded care. The second way is privately delivered care paid for through the Department of Veterans’ Affairs. A full 73.5% of care paid for by the Department of Veterans’ Affairs occurred in private hospitals.

It would be easy, however, to underestimate the significance of this public-private partnership by examining only the delivery of care that is fully publicly funded. Privately insured care is also partially subsidized by the government, at a rate of 75% of the public fee. Therefore, in order to understand the full extent of publicly funded or subsidized care in private hospitals, it is helpful to examine private hospital expenditures by the source of funds. In 2019/20, 32.8% of private hospital expenditures came from government sources, 18.2% of which came from private health-insurance rebates. This means that a full
third of private hospital expenditure comes from a range of public sources, including the federal government.

Overall, private hospitals are important partners in the delivery of care within the Australian universal healthcare system. The Australian system outranks Canada’s on a range of performance indicators, while spending less as a percentage of GDP. Further, the integration of private hospitals into the delivery of care, including public care, occurs while maintaining universal access for residents.


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Alberta

A Memorandum of Understanding that no Canadian can understand

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From the Fraser Institute

By Niels Veldhuis

The federal and Alberta governments recently released their much-anticipated Memorandum of Understanding (MOU) outlining what it will take to build a pipeline from Alberta, through British Columbia, to tidewater to get more of our oil to markets beyond the United States.

This was great news, according to most in the media: “Ottawa-Alberta deal clears hurdles for West Coast pipeline,” was the top headline on the Globe and Mail’s website, “Carney inks new energy deal with Alberta, paving way to new pipeline” according to the National Post.

And the reaction from the political class? Well, former federal environment minister Steven Guilbeault resigned from Prime Minister Carney’s cabinet, perhaps positively indicating that this agreement might actually produce a new pipeline. Jason Kenney, a former Alberta premier and Harper government cabinet minister, congratulated Prime Minister Carney and Premier Smith on an “historic agreement.” Even Alberta NDP Leader Naheed Nenshi called the MOU “a positive step for our energy future.”

Finally, as Prime Minister Carney promised, Canada might build critical infrastructure “at a speed and scale not seen in generations.”

Given this seemingly great news, I eagerly read the six-page Memorandum of Understanding. Then I read it again and again. Each time, my enthusiasm and understanding diminished rapidly. By the fourth reading, the only objective conclusion I could reach was not that a pipeline would finally be built, but rather that only governments could write an MOU that no Canadian could understand.

The MOU is utterly incoherent. Go ahead, read it for yourself online. It’s only six pages. Here are a few examples.

The agreement states that, “Canada and Alberta agree that the approval, commencement and continued construction of the bitumen pipeline is a prerequisite to the Pathways project.” Then on the next line, “Canada and Alberta agree that the Pathways Project is also a prerequisite to the approval, commencement and continued construction of the bitumen pipeline.”

Two things, of course, cannot logically be prerequisites for each other.

But worry not, under the MOU, Alberta and Ottawa will appoint an “Implementation Committee” to deliver “outcomes” (this is from a federal government that just created the “Major Project Office” to get major projects approved and constructed) including “Determining the means by which Alberta can submit its pipeline application to the Major Projects Office on or before July 1, 2026.”

What does “Determining the means” even mean?

What’s worse is that under the MOU, the application for this pipeline project must be “ready to submit to the Major Projects Office on or before July 1, 2026.” Then it could be another two years (or until 2028) before Ottawa approves the pipeline project. But the MOU states the Pathways Project is to be built in stages, starting in 2027. And that takes us back to the circular reasoning of the prerequisites noted above.

Other conditions needed to move forward include:

The private sector must construct and finance the pipeline. Serious question: which private-sector firm would take this risk? And does the Alberta government plan to indemnify the company against these risks?

Indigenous Peoples must co-own the pipeline project.

Alberta must collaborate with B.C. to ensure British Columbians get a cut or “share substantial economic and financial benefits of the proposed pipeline” in MOU speak.

None of this, of course, addresses the major issue in our country—that is, investors lack clarity on timelines and certainty about project approvals. The Carney government established the Major Project Office to fast-track project approvals and provide greater certainty. Of the 11 project “winners” the federal government has already picked, most either already had approvals or are already at an advanced stage in the process. And one of the most important nation-building projects—a pipeline to get our oil to tidewater—hasn’t even been referred to the Major Project Office.

What message does all this send to the investment community? Have we made it easier to get projects approved? No. Have we made things clearer? No. Business investment in Canada has fallen off a cliff and is down 25 per cent per worker since 2014. We’ve seen a massive outflow of capital from the country, more than $388 billion since 2014.

To change this, Canada needs clear rules and certain timelines for project approvals. Not an opaque Memorandum of Understanding.

Niels Veldhuis

President, Fraser Institute
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Business

Carney government should privatize airports—then open airline industry to competition

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From the Fraser Institute

By Alex Whalen and Jake Fuss

This holiday season, many Canadians will fly to spend time to with family and friends. But air travellers in Canada consistently report  frustration with service, cost and choice. In its recent budget, the Carney government announced it will consider “options for the privatization of airports.” What does this mean for Canadians?

Up until the 1990s, the federal government served as both the owner and operator of Canada’s major airports. The Chrétien government partially privatized and transferred the operation of major airports to not-for-profit airport authorities, while the federal government remained the owner of the land. Since then, the federal government has effectively been the landlord for Canada’s airports, collecting rent each year from the not-for-profit operating authorities.

What would full privatization of airports look like?

If the government allows private for-profit businesses to own Canada’s major airports, their incentives would be to operate as efficiently as possible, serve customers and generate profits. Currently, there’s little incentive to compete as the operating authorities are largely unaccountable because they only report to government officials in a limited form, rather than reporting directly to shareholders as they would under privatization. Private for-profit airports exist in many other countries, and research has shown they are often less costly for passengers and more innovative.

Yet, privatization of airports should be only the first step in a broader package of reforms to improve air travel in Canada. The federal government should also open up competition by creating the conditions for new airports, new airlines and new investment. Currently, Canada restricts foreign ownership of Canadian airlines, while also restricting foreign airlines from flying within Canada. Consequently, Canadians are left with little choice when booking air travel. Opening up the industry by reversing these policies would force incumbent airlines to compete with a greater number of airlines, generating greater choice and likely lower costs for consumers.

Moreover, the federal government should reduce the taxes and fees on air travel that contribute to the cost of airline tickets. Indeed, according to our recent research, among peer countries, Canada has among the most expensive air travel taxes and fees. These costs get passed on to consumers, so it’s no surprise that Canada consistently ranks as a very expensive country for air travel.

If the Carney government actually privatizes Canada’s airports, this would be a good first step to introducing greater competition in an industry where it’s badly needed. But to truly deliver for Canadians, the government must go much further and overhaul the numerous policies, taxes and fees that limit competition and drive up costs.

Alex Whalen

Director, Atlantic Canada Prosperity, Fraser Institute

Jake Fuss

Director, Fiscal Studies, Fraser Institute
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