The Ontario government recently announced another 1.3% cut to physician OHIP billings applied across the board, following cuts that happened in January of this year. I’m happy to see this has been hotly discussed in the news, and online. Dr. Ming Yu’s article in the Huffington Post, for example, has gone viral (according to the OMA). Most of the current debate, as far as I can tell, centers on the plight of doctors – are we are being undervalued and disrespected, or maybe we are too wealthy and entitled?

There doesn’t seem to be much argument about the discrepancy between projected growth in health expenses and the increases in funding to health care in the budget. Whoever is making the estimate, the consistent point seems to be that anticipated growth in healthcare expenses will exceed increases in government funding of health care. We can spend a lot of time talking about how much doctors get paid, but it made me wonder, if the government is willing to make this potentially very unpopular move (if comments on Kathleen Wynne’s Facebook page are a reliable indicator) what does that say about their other options – and the current state of our health system and economy?

I couldn’t sleep the other night, and here is what I found out: the Fraser Institute published “Ontario’s Debt Balloon: Source and Sustainability” in February 2015. To sum it up, it says the source of Ontario’s debt balloon, which reportedly expanded from 28% of the provincial economy in 2008/09 to an expected 40% in 2014/15, is mostly due to high operating expenses, and that without significant changes, the level of debt is unsustainable, i.e. the province will default on its debt at the rate it’s going. Ontario’s credit rating was downgraded in 2012. The Council of Canadians published “A Difficult Road Ahead: Canada’s Economic and Fiscal Prospects” in 2014. It concluded: “If spending on health care increases at rates close to the pace recorded over the past decade, Canada’s provinces and territories will have to raise taxes to avoid deficits growing even larger.” “If Canadians don’t want to pay higher taxes to cover surging expenditures on health care, the only other option will be to cut spending on social programs and education”. Blame our current woes on mismanagement by our government, but it seems to be a nationwide issue.

This is a selected representation of sources; maybe other authors have reached different conclusions about our state of affairs. However, working with very basic assumptions it seems possible to reach similar conclusions. In a big-picture sense – and I think these observations would be accepted by a casual observer – the population is aging and health care costs are therefore rising. For the same reason, revenue (and future revenue) is shrinking. Furthermore, economic growth on a worldwide level cannot continue indefinitely as it involves extracting finite resources from the planet. The idea that the province is in massive debt is another extra detail. Therefore, we are going to have major problems sustaining our current way of delivering health care regardless of whose fault it is (and maybe it isn’t anybody’s fault), and maybe what is happening now to physicians is a sign that we finally can’t keep throwing more money at the problem, because the credit line is maxed out.

To the doctors posting in online forums that they feel undervalued and they are thinking about moving elsewhere, so the government should pay us more – I think we need to grieve, and then we also need to move on, for our own good. To put it another way, if you see steam coming out of your faucets you should wonder if maybe your house is burning down instead of worrying about what is wrong with the tap. We could diversify our income streams, cut expenses, reduce our lifestyle, even look at overseas options, however one wants to cope in the short term. Then, we can move on to deciding if we should be advocating for cuts to other social services, convincing the public they need to pay more taxes, abandoning the idea of universal healthcare,  coming up with our own proposal for rationing health care, or some other plan of action to dramatically increase efficiency. Unilateral cuts aside, we’re all citizens and we’re going to need health care someday.

Even if I don’t agree with the Health Minister’s actions, I can certainly thank him for getting me (and other physicians all across the province, and the public) more engaged in thinking about the situation of health care in Ontario. If not for the repeated pay cuts I probably wouldn’t have turned onto the fact that big problems have been brewing for quite some time and that we really need to do something about it.

To be fair, I think doctors and the public are thinking about the bigger picture. The public discourse seems to be focusing mostly on the (relatively) smaller issue of physician compensation, but I imagine people are thinking about the larger context. We are likely to face some difficult questions as a society – are we going to spend proportionally more on health care, or are we going to accept that health care needs to look different than it does now, and different in what ways? How much can we gain by making health care delivery more efficient? If we can’t make up the difference by increasing efficiency, what do we cut? How little we can get away with paying our professionals before we really start hurting from it? Which ones can we really do without? If we have to start cutting services, how will we decide which ones? Can we go further down the road of the two-tier health, shifting more services into the private sector for those who can pay for them?

I haven’t heard anybody saying that universal public health care is unsustainable and dying a slow, inevitable death, and I hope it’s because that’s not true. The conspiracy theory loving part of me can’t help but wonder if all the hand-waving about cuts to physicians is a distraction from the larger issue, because the political will to confront the difficult questions doesn’t exist and whoever brings it to the attention of the public is going to look bad. On the other hand, to echo Dr. Gail Beck’s sentiment – it is a good time to be a doctor in Ontario. I would add, maybe there hasn’t been a better time in a long while. There’s nothing like a crisis to put into perspective what really matters.