Canadians hate ‘populism’—but love populist policies: The Weekly Wrap

But the claim that dual practice cannot increase total surgical volume rests on a static view of the system—one in which physician hours stay fixed, no new doctors arrive, universities don’t adjust medical-school seats, no new capital enters the system, and providers don’t reorganize their practices in response to new incentives. That’s not how any real labour market or complex service-delivery system operates. Consider physician workloads. Data show that average physician hours have actually declined by about 13 percent over the past three decades. If physician hours can fall in response to changing conditions, they can rise in response to better incentives and more flexible operating environments. The fact that workloads aren’t fixed undermines the critics’ central claim. In the near term, dual practice will almost certainly mean some surgeons work more—particularly if private clinics offer extended hours, additional operating-room access, and better compensation. That alone will increase surgical throughput. Over the medium term, the policy will ostensibly encourage supply-side adjustments. Alberta, on the one hand, will become more attractive to physicians from other provinces. And, on the other hand, fewer doctors will leave. The government will now have a greater incentive (and indeed should) expand medical-school seats at the University of Alberta and the University of Calgary. And, over the longer horizon, dual practice will spur private investment in operating suites, technologies, and even new business models that should boost system-wide capacity. Although it’s true that supply constraints will limit how much dual practice can deliver in the short term, it’s wrong to claim that they’ll fully nullify the benefits. This perspective underestimates the policy’s dynamic effects on physicians, policymakers, and other players. But it’s also true that realizing the full benefits from the government’s reforms will require complementary reforms—including expanding training capacity, improving recruitment and retention, and encouraging new capital and delivery models. Here’s the virtue of the Smith government’s approach. Without dual practice, neither government nor system actors would face the same pressure or incentives to pursue these broader changes. The legislation, in other words, shouldn’t be viewed as the end point of supply so much as a catalyst that makes a more ambitious expansion agenda both necessary and achievable. The dual-purpose model, therefore, should be understood as a meaningful reform that will increase surgical capacity in the short term and set the stage for even gains over time. Far from being inconsequential, it marks a fundamental step toward a more capacious and responsive health-care system. What other “settled issues” aren’t so settled with Canadian voters? The muted response to Alberta’s health-care legislation raises an intriguing question: What if private health care, which has long been perceived as the so-called “third rail” of Canadian politics, was never as untouchable as we assumed? At a minimum, the lack of sustained opposition to the Smith government’s injection of market forces into the province’s single-payer model is a challenge to one of the long-standing axioms that has governed how politicians, journalists, and policy commentators think about the country’s political boundaries. Canadian politics is full of these perceived truths. Assertions about public opinion or political risk get repeated enough that they become self-enforcing: Politicians fear crossing imaginary red lines, pundits warn them not to, and journalists describe these constraints as immutable features of our political culture. Before long, we’re left with a set of counterfactuals about what Canadians supposedly believe. Alberta’s experience with health-care reform is a direct threat to one of these axiomatic assumptions. If so-called “two-tier” health care was as radioactive as we’ve been led to believe, we’d be seeing a strong public backlash, a coordinated opposition campaign, and signs of political retreat. Yet, notwithstanding an elite campaign of opposition from single-payer activists, the issue has received far less bottom-up attention than conventional wisdom would have dictated. That suggests the old axiom was wrong—or at least overstated. The more interesting question in hindsight is whether reform could have (and should have) happened years earlier had political leaders not been so beholden to untested assumptions about voter preferences. It seems rather clear now that politicians and those who advise them vastly overstated popular opposition to market-oriented reforms. This problem of false narratives and political counterfactuals extends far beyond health care, of course. There’s a range of issues where we presume to know that certain issues are settled and ideas are verboten. The political class (and those adjacent to it) come to accept a narrower and narrower Overton window. We end up with a politics between the 40-yard lines of accepted debate. None of this means political risk is a fiction. Politicians must be prudent. But Alberta’s recent experience should make us more cautious about accepting received wisdom about which issues are “settled” and which boundaries cannot be crossed. Sometimes the electorate is ahead of the political class. Sometimes it takes a government willing to test an assumption to reveal that the assumption was unfounded. The lesson isn’t that everything is up for grabs, but that our politics is too often constrained by inherited caution rather than democratic forces. Every so often, a government exposes that what we thought was a political truth was merely an untested belief.