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Shawn Whatley: Health care’s iron triangle is hindering innovation


The Honorable Monique Begin (et al.) wrote in 2009, “When it comes to moving health care practices forward efficiently, Canada is a country of perpetual pilot projects.” Governments need “financial control” and remain “leery” of committing to programs. Pilot programs are easy to shut down “to avoid criticism” or if “budget priorities shift.”A country of perpetual pilot projects

At first glance, we might blame voters. Canadians rank health care as a top priority in most elections over the last several decades. Voters like Medicare; politicians are loath to change it. The last federal election stood out for (almost) hinging on a debate about health policy. As Sean Speer put it in August, “We are having a Section 92 election in a Section 91 moment.”Trudeau, Singh seem more interested in running for premier than head of a national government Most of the time, politicians from all parties work hard to avoid saying anything meaningful about health care—especially during an election—aside from pledging support for more of the same.

But we cannot blame health care stasis on politicians or the voters they need to woo. Medicare cannot change because it is locked in an iron triangle consisting of government, the medical profession, and public-sector unions.

Veto Power

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

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

De facto veto power often gets constitutionalized into law. Consider two examples. In 2012, the Ontario Medical Association won a major battle with the government over labour dispute resolution and representation rights. The government agreed to abide by a binding resolution process with doctors. The government also granted the OMA exclusive “representation rights” agreeing to negotiate with the OMA and no one else. Or consider also that in 1991, the government gave the OMA power to collect dues from all Ontario doctors, whether or not doctors were members or even supportive of OMA policy. Ostensibly, The Ontario Medical Association Dues Act, 1991 empowered the OMA to fund its negotiations with the government, but the bulk of every OMA budget has funded issues unrelated to negotiations for decades.

This is not to pick on physicians; nor is it an attempt to reopen the debate about “rep rights”, arbitration, or dues. We could multiply examples of constitutionalized privilege for the regulatory colleges, universities, public-sector unions, and government itself.

The issue is constitutionalized privilege—the iron triangle between government, the medical profession, and public-sector unions. (Note: the medical profession includes medical associations, licencing bodies, and training programs, not individual doctors.)

Iron Lady Breaks Iron Triangle

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

Thatcher set to work smashing the relationship. However, she left the welfare state “comparatively intact… the political thrust of early Thatcherism was in the direction of the dismantlement of the corporatist policies of the 1960s and early 1970s.”Enlightenment’s Wake: Politics and Culture at the Close of the Modern Age

Canada needs something similar: break the health care iron triangle while leaving the welfare state comparatively intact. The (once) friendly relationship between government, doctors, and unions has ossified and become hard, brittle, and inflexible: unable to manage stress or major change.

Institutions, like young trees, become weak and spindly shielded from the pressure and strain of social competition. Secure in the functional monopoly afforded by corporatist-style policy, institutions come to see themselves as existing to mitigate frictions between the other parties within the triangle instead of shaping the individuals inside the institutions themselves. As Yuval Levin, an American author, often says, “Institutions become performative instead of formative.”A Time to Build: From Family and Community to Congress and the Campus, How Recommitting to Our Institutions Can Revive the American Dream

We have no shortage of ideas to improve health care quality and efficiency, such as funding reform, integration of health services, public-private partnerships, and so on. 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 do not lack ideas; we lack strategic vision.

The pandemic exposed the lack of resilience in our health system and the desperate need for substantial growth. All parties in the iron triangle agree the system needs change. But the parties cannot agree to any solution which does not benefit their own weight and influence inside the arrangement.

Health care’s iron triangle rests on the concentration of power—a tripartite monopoly. The best way to undermine a monopoly is to invite new parties into the relationship. Break concentrations of power into multiple smaller units. It can be done: Thatcher found a way to do it in Britain. It starts by addressing the iron triangle as the root of resistance to change. If we do not, Canada will remain forever a “country of perpetual pilot projects.”

Mark Johnson: Canada has too many MPs


The Conservative leadership race is still in its early days. Battle lines are being drawn. Forces are being marshalled. General themes are being developed. Dinnertime robocalls have started. (Lucky me.) And we’ve heard some early gunfire. All standard stuff. But the race needs more than just the same old debates between the same old wings of the party. And so far, the race is quickly becoming nothing but a party referendum on the carbon tax.

Those debates are both needed and important but it’s time for some bold new ideas to bring to Canada. Here’s one that’s overdue for serious debate. Reduce the number of MPs.

You read that right. Yes, it’s coming from someone who wanted to be an MP. Does Canada really need 338 MPs?“Each member of Parliament is elected to represent a constituency in the House. There are currently 338 members in office in the 44th Parliament.” And that number is set to go to 342.“Put forward in October 2021 as the years-long process kicked off, the independent elections agency calculated that to account for Canada’s population changes, the House of Commons’ seat count would in the coming years be increasing from 338 to 342. To adjust for this, new ridings will be added, requiring the redrawing of current electoral district boundaries.” That’s one MP for every 112,000 of us. The U.S. has one Congressional representative for every 760,000 people thereabouts. We have so many MPs now that they barely fit into the House of Commons.

Raising this may get me into trouble with my political friends but it needs to be said. Let’s have a serious debate about whether Canada needs all these MPs. Don’t get me wrong. I’m not knocking the MPs themselves. They’re hardworking folks. I’m pro-politician. I tried hard to become one. Yet in the grand scheme of things, does Canada need that many MPs? Can we be just as well governed with fewer? We can.

If Conservatives are sincere about reducing the size of government, then let’s start at the top with the number of politicians.

What’s the connection between the size of our legislature and the quality of a national policy or a decision that’s national in scope? Does Canada today with 38 million people need more MPs formulating defence or economic policy than the Canada of 32 million? Would our Covid response have been worse if we had forty fewer politicians in Ottawa? Was it better because we had forty more?

More MPs means more salaries at $189,000 per head, plus more staffers, other costs, more people to mess around in things, and more projects to justify their existence.Indemnities, Salaries and Allowances The Devil makes work for idle hands. Idle MPs make for bigger government.

Some will argue that more populous ridings will only lead to politically underserviced citizens. Companies regularly downsize their workforces but achieve the same outputs. So why not the House of Commons. Ontario significantly cut its number of legislators in the late nineties. It can be done.

What’s a good number? That would be up for debate. Downsizing the House to 295 or 300 seats from 338 would return it to the size it was between 1988 and 2000, roughly speaking.

Here’s the sticky wicket. If we reduce the number, then it must only happen if we fairly allocate the remaining MPs across the provinces based on their relative populations. There’s not enough space here to describe the formula for allocating MPs to each province. It’s convoluted, outdated, and leads to enormous provincial disparities.

In the 2021 election, I ran in the suburban Toronto riding of Scarborough-Agincourt. Its population is 105,000. The PEI riding of Malpeque has 36,000. According to Elections Canada, Ontario had one MP per 122,000 people on average. PEI had one MP per 41,000. Therefore, Islanders have three times the political power of Ontarians. Put another way, Canadians who live in Malpeque had three votes per person while those in my riding had one. I’ve got nothing against the good people of PEI but that’s manifestly unfair.

The equality of Canadians is violated. People’s voices aren’t heard. Regional grievances are fueled. Politics becomes distorted. Negative outcomes are more likely.

Let’s be honest. A reallocation of MPs based on the principle of political equality will lead to Atlantic Canada, Manitoba, and Saskatchewan having less clout than they have right now. But they won’t be getting any less than anyone else.

This will be a thorny debate, perhaps even an unpleasant one. Let’s not be afraid. Modernizing the formula requires a constitutional amendment.“An amendment that only ‘applies to one or more, but not all, provinces’ requires approval from the Canadian parliament and the governments of any affected provinces. An amendment that affects all provinces, by contrast, requires the approval of at least seven of the provincial governments representing at least 50 per cent of the Canadian population (sometimes called the 7-50 formula). On a handful of really important matters, such as changing the amending formula itself, unanimous provincial consent is necessary. The very high bar for passing substantial amendments is probably the main reason Canada’s Constitution has not been significantly modified since 1982, though there have been a few minor amendments passed, usually only involving one province (see sidebar). These are known as Constitution Amendment Proclamations.”

It risks dredging up regional tensions, old grudges, and provincial demands. Managing it to ensure a positive outcome will require leadership, compromise, discipline, and forbearance on the part of our leaders. It also requires hard boundaries to be placed on the scope. Just because we’re debating the number of MPs doesn’t mean we’ll re-open Senate reform or the distinct society clause.

Maybe it’ll be political suicide. Maybe, just maybe, it will succeed and Canada will be better for it.

Canada needs fewer, better politicians. We’re not better governed today because we have forty more MPs than we did twenty-five years ago. The ever-increasing number of MPs is not written in stone. It’s written in our law. We can change it. It’s past time we did so.