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The Honorable Monique Bégin wrote in 2009: “When it comes to effectively advancing health care practice, Canada is a country of perpetual pilot projects. Governments need “financial control” and remain “wary” about committing to programs. Pilot programs are easy to stop “to avoid criticism” or if “budget priorities change”.

At first glance, one could blame the voters. Canadians have ranked health care as their top priority in most elections in recent decades. Voters love Medicare; politicians are loath to change it. The last federal election stood out for being (almost) centered around a health policy debate. Most of the time, however, politicians from all parties work hard to avoid saying anything meaningful about health care — especially during an election — other than pledging to support more of the same.

But we can’t blame the stagnation in health care on the politicians or the voters they need to woo. Medicare cannot change because it is locked in an iron triangle of government, health professionals and public sector unions.

The health care triangle is stronger than any party within it; each party holds de facto veto power over important decisions. Each party seeks to improve its position and power within the triangle relative to the other parties. When a government attempts to change from within the triangle, it can only manage minor adjustments or overhaul. For example, regionalizing services, then centralizing them, then regionalizing them again.

Veto guarantees that modern Medicare shares more similarities with its 1960s design than any evidence of significant innovation since then.

De facto the right of veto is often entrenched in law. Let’s take two examples.

In 2012, the Ontario Medical Association (OMA) won a major battle against the government over labor dispute resolution and representation rights. The government has agreed to a binding resolution process with doctors. The government has also granted the OMA the exclusivity “performance rights,agreeing to negotiate with the OMA and no one else.

In 1991, the government gave the OMA the power to collect dues from all physicians in Ontario, whether or not they were members or even supported OMA policy. Apparently, the Ontario Medical Association Dues Act of 1991 authorized the OMA to fund its negotiations with the government, but the bulk of every OMA budget has funded matters unrelated to the negotiations for decades.

I am not attacking doctors, nor am I trying to reopen the debate on “representation rights”, arbitration or dues. We could multiply the examples of constitutionalized privilege for regulatory colleges, universities, public sector unions and the government itself.

The issue is one of constitutionalized privilege – the iron triangle between government, the medical profession and public sector unions. (Note: The medical profession includes medical associations, regulatory bodies, and training programs, not individual physicians.)

In the early 1980s, British Prime Minister Margaret Thatcher took on a similar rigid coalition. John Gray, a political philosopher, described it as “the triangular relationship between government, business and trade unions”.

Thatcher went to work to break up the relationship. However, it left the welfare state “relatively intact…the political thrust of early Thatcherism was in line with the dismantling of the corporatist policies of the 1960s and early 1970s”.

Canada needs something similar: breaking the iron triangle of health care while leaving the welfare state relatively intact. The (once) friendly relationship between government, doctors and unions has frozen and has become hard, snappy and inflexible, unable to handle stress or major change.

Institutions, like saplings, become weak and immune to the pressure and strain of social competition. Secure in the functional monopoly offered by corporatist-style politics, institutions come to see themselves as existing to lessen friction between other parties within the triangle instead of shaping individuals within the institutions themselves. . As Yuval Levin, an American author, often says, “institutions become performative instead of formative”.

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We have no shortage of ideas to improve the quality and efficiency of health care, such as financing reform, integration of health services, public-private partnerships, etc. But these ideas do not even reach the level of tactics to implement change. They are the outcome we hope to see after change has been allowed to occur. We are not short of ideas; we lack strategic vision.

The pandemic has revealed the lack of resilience in our healthcare system and the desperate need for substantial growth. All parties in the iron triangle agree that the system must change. But the parties cannot agree to any solution that does not benefit their own weight and influence within the arrangement.

The iron triangle of health care is based on the concentration of power – a three-way monopoly. The best way to undermine a monopoly is to invite new parties into the relationship. Divide power concentrations into several smaller units. It can be done: Thatcher found a way to do it. It begins by addressing the iron triangle as the root of resistance to change. If we don’t, Canada will forever be a “country of perpetual pilot projects”.

Shawn Whatley is a physician, past president of the Ontario Medical Association and Munk Senior Fellow at the Macdonald-Laurier Institute. He is the author of When Politics Comes Before Patients – Why and How Canadian Medicare is Failing.

Shawn is a thought leader at Troy Media. For interview requests, click here.


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