Fraser Institute
Virtual care will break the Canada Health Act—and that’s a good thing
From the Fraser Institute
The leadership of the Canadian Medical Association (CMA) is facing sharp criticism for its recent proposal to effectively ban private payment for virtual care. In a clear example of putting politics before patients, this would only erect additional barriers for those seeking care.
Moreover, it’s a desperate bid to cling to an outdated—and failed—model of health care while underestimating modern-day innovations.
Virtual care—online video doctor consultations—is a private-sector innovation. In response to our government system’s inability to provide timely care, private companies such as Maple have been offering these services to Canadians for almost a decade. In fact, the public system only pushed meaningfully into the virtual space during COVID when it established partnerships with these private companies alongside setting up new fee codes for virtual consultations.
In return for improving access to physician consultations for thousands of Canadians, these virtual care companies have been rewarded with increased government scrutiny and red tape. The weapon of choice? The Canada Health Act (CHA).
Specifically, sections 18 to 21 of the CHA prohibit user fees and extra billing for “medically necessary” services. Further, the insurance plan of a province must be publicly administered and provide “reasonable access” to 100 per cent of insured services. Provinces found in violation are punished by the federal government, which withholds a portion (or all) of federal health-care transfer payments.
Until recently, there had been no obvious conflict between the CHA and privately paid-for virtual care—primarily because the provinces are free to determine what’s medically necessary. Until recently, many provinces did not even have billing codes for virtual care. As virtual services are increasingly provided by the public sector, however, the ability to innovatively provide care for paying patients (either out-of-pocket or through private insurance) becomes restricted further.
Within this context, the CMA recently recommended formally including virtual care services within the public system, alongside measures to ensure “equitable access.” At the same time, it reiterated its recommendation that private insurance to access medically necessary services covered by the CHA be prohibited.
See where this is going?
The kicker is an additional recommendation banning dual practice (i.e. physicians working in both the public and private sector) except under certain conditions. This means doctors in the public system who could otherwise allocate their spare hours to private appointments online would now have to choose to operate exclusively in either the public or private system.
The combined effect of these policies would ensure that innovative private options for virtual care—whether paid for out-of-pocket or though private insurance—will either be overtaken by bureaucracies or disappear entirely.
But what the CMA report fails to recognize is that virtual care has expanded access to services the government fails to provide—there’s little reason to suspect a government takeover of the virtual-care sector will make things better for patients. And even if governments could somehow prevent Canadian doctors and companies providing these services privately, virtual care is not beholden to Canada’s physical borders. Patients with a little bit of technical knowhow will simply bypass the Canadian system entirely by having virtual consultations with doctors abroad. If Canadians can figure out how to access their favourite show in another country, you can be sure they’ll find a way to get a consultation with a doctor in Mumbai instead of Montreal.
Instead of forcing physicians and patients to operate within the crumbling confines of government-run health care, the CMA’s leadership should be grateful for the pressure valve that the private sector has produced. We should celebrate the private innovators who have provided Canadians better access to health care, not finding ways to shut them down in favour of more government control.
Author:
Business
Residents in economically free states reap the rewards
From the Fraser Institute
A report published by the Fraser Institute reaffirms just how much more economically free some states are compared with others. These are places where citizens are allowed to make more of their economic choices. Their taxes are lighter, and their regulatory burdens are easier. The benefits for workers, consumers and businesses have been clear for a long time.
There’s another group of states to watch: “movers” that have become much freer in recent decades. These are states that may not be the freest, but they have been cutting taxes and red tape enough to make a big difference.
How do they fare?
I recently explored this question using 22 years of data from the same Economic Freedom of North America index. The index uses 10 variables encompassing government spending, taxation and labour regulation to assess the degree of economic freedom in each of the 50 states.
Some states, such as New Hampshire, have long topped the list. It’s been in the top five for three decades. With little room to grow, the Granite State’s level of economic freedom hasn’t budged much lately. Others, such as Alaska, have significantly improved economic freedom over the last two decades. Because it started so low, it remains relatively unfree at 43rd out of 50.
Three states—North Carolina, North Dakota and Idaho—have managed to markedly increase and rank highly on economic freedom.
In 2000, North Carolina was the 19th most economically free state in the union. Though its labour market was relatively unhindered by the state’s government, its top marginal income tax rate was America’s ninth-highest, and it spent more money than most states.
From 2013 to 2022, North Carolina reduced its top marginal income tax rate from 7.75 per cent to 4.99 per cent, reduced government employment and allowed the minimum wage to fall relative to per-capita income. By 2022, it had the second-freest labour market in the country and was ninth in overall economic freedom.
North Dakota took a similar path, reducing its 5.54 per cent top income tax rate to 2.9 per cent, scaling back government employment, and lowering its minimum wage to better reflect local incomes. It went from the 27th most economically free state in the union in 2000 to the 10th freest by 2022.
Idaho saw the most significant improvement. The Gem State has steadily improved spending, taxing and labour market freedom, allowing it to rise from the 28th most economically free state in 2000 to the eighth freest in 2022.
We can contrast these three states with a group that has achieved equal and opposite distinction: California, Delaware, New Jersey and Maryland have managed to decrease economic freedom and end up among the least free overall.
What was the result?
The economies of the three liberating states have enjoyed almost twice as much economic growth. Controlling for inflation, North Carolina, North Dakota and Idaho grew an average of 41 per cent since 2010. The four repressors grew by just 24 per cent.
Among liberators, statewide personal income grew 47 per cent from 2010 to 2022. Among repressors, it grew just 26 per cent.
In fact, when it comes to income growth per person, increases in economic freedom seem to matter even more than a state’s overall, long-term level of freedom. Meanwhile, when it comes to population growth, placing highly over longer periods of time matters more.
The liberators are not unique. There’s now a large body of international evidence documenting the freedom-prosperity connection. At the state level, high and growing levels of economic freedom go hand-in-hand with higher levels of income, entrepreneurship, in-migration and income mobility. In economically free states, incomes tend to grow faster at the top and bottom of the income ladder.
These states suffer less poverty, homelessness and food insecurity and may even have marginally happier, more philanthropic and more tolerant populations.
In short, liberation works. Repression doesn’t.
Alberta
Alberta Next Panel calls for less Ottawa—and it could pay off
From the Fraser Institute
By Tegan Hill
Last Friday, less than a week before Christmas, the Smith government quietly released the final report from its Alberta Next Panel, which assessed Alberta’s role in Canada. Among other things, the panel recommends that the federal government transfer some of its tax revenue to provincial governments so they can assume more control over the delivery of provincial services. Based on Canada’s experience in the 1990s, this plan could deliver real benefits for Albertans and all Canadians.
Federations such as Canada typically work best when governments stick to their constitutional lanes. Indeed, one of the benefits of being a federalist country is that different levels of government assume responsibility for programs they’re best suited to deliver. For example, it’s logical that the federal government handle national defence, while provincial governments are typically best positioned to understand and address the unique health-care and education needs of their citizens.
But there’s currently a mismatch between the share of taxes the provinces collect and the cost of delivering provincial responsibilities (e.g. health care, education, childcare, and social services). As such, Ottawa uses transfers—including the Canada Health Transfer (CHT)—to financially support the provinces in their areas of responsibility. But these funds come with conditions.
Consider health care. To receive CHT payments from Ottawa, provinces must abide by the Canada Health Act, which effectively prevents the provinces from experimenting with new ways of delivering and financing health care—including policies that are successful in other universal health-care countries. Given Canada’s health-care system is one of the developed world’s most expensive universal systems, yet Canadians face some of the longest wait times for physicians and worst access to medical technology (e.g. MRIs) and hospital beds, these restrictions limit badly needed innovation and hurt patients.
To give the provinces more flexibility, the Alberta Next Panel suggests the federal government shift tax points (and transfer GST) to the provinces to better align provincial revenues with provincial responsibilities while eliminating “strings” attached to such federal transfers. In other words, Ottawa would transfer a portion of its tax revenues from the federal income tax and federal sales tax to the provincial government so they have funds to experiment with what works best for their citizens, without conditions on how that money can be used.
According to the Alberta Next Panel poll, at least in Alberta, a majority of citizens support this type of provincial autonomy in delivering provincial programs—and again, it’s paid off before.
In the 1990s, amid a fiscal crisis (greater in scale, but not dissimilar to the one Ottawa faces today), the federal government reduced welfare and social assistance transfers to the provinces while simultaneously removing most of the “strings” attached to these dollars. These reforms allowed the provinces to introduce work incentives, for example, which would have previously triggered a reduction in federal transfers. The change to federal transfers sparked a wave of reforms as the provinces experimented with new ways to improve their welfare programs, and ultimately led to significant innovation that reduced welfare dependency from a high of 3.1 million in 1994 to a low of 1.6 million in 2008, while also reducing government spending on social assistance.
The Smith government’s Alberta Next Panel wants the federal government to transfer some of its tax revenues to the provinces and reduce restrictions on provincial program delivery. As Canada’s experience in the 1990s shows, this could spur real innovation that ultimately improves services for Albertans and all Canadians.
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