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Fraser Institute

Australia’s universal health-care system outperforms Canada on key measures including wait times, costs less and includes large role for private hospitals

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The Role of Private Hospitals in Australia’s Universal Health Care System

From the Fraser Institute

by Mackenzie Moir and Bacchus Barua

In the wake of the COVID-19 pandemic, provincial governments across Canada relied on private
clinics in order to deliver a limited number of publicly funded surgeries in a bid to clear unprecedented
surgical backlogs. Subsequently, surveys indicated that 78% of Canadians support allowing more
surgeries and tests performed in private clinics while 40% only support this policy to clear the
surgical backlog. While a majority of Canadians are either supportive (or at the very least curious)
about these arrangements, the use of private clinics continues to be controversial and raise questions
around their compatibility with the provision of universal care.

The reality is that private hospitals play a key role in delivering care to patients in other countries with universal health care. Canada is only one of 30 high-income countries with universal care and many of these countries involve the private-sector in their health-care systems to a wide extent while performing better than Canada.

Australia is one of these countries and routinely outperforms Canada on key indicators of health-care performance while spending at a similar or lower level. Like Canada, Australia ranked
in the top ten for health-care spending (as a percentage of GDP and per capita) in 2020. However, after adjusting for the age of the population, it outperforms Canada on 33 (of 36) measures of performance.

Importantly, Australia outperformed Canada on a number of key measures such as the availability of physicians, nurses, hospital beds, CT scanners, and MRI machines. Australia also outperformed
Canada on every indicator of timely access to care, including ease of access to after-hours care, same-day primary care appointments, and, crucially, timely access to elective surgical care and specialist appointments.

Australia’s universal system is also characterized by a deep integration between the public and private sectors in the financing and delivery of care. Universal health-insurance coverage is provided through its public system known as Medicare. However, Australia also has a large private health-care sector that also finances and delivers medical services. Around half of the Australian population (55.2% in 2021/22) benefit from private health-insurance coverage provided by 33 registered not-for-profit and for-profit private insurance companies.

Private hospitals (for profit and not for profit) made up nearly half (48.5%) of all Australian hospitals in 2016 and contain a third of all care beds. These hospitals are a major partner in the delivery of care in Australia. For example, in 2021/22 41% of all recorded episodes of hospital care occurred in private hospitals. While delivering a small minority of emergency care (8.2%), private hospitals delivered the majority of recorded elective care (58.6%) and 70.3% of elective admissions involving surgery.

Private hospitals primarily deliver care to fully funded public patients in two ways. The first is contracted
care, either through ad hoc inter-hospital contracts or formal programs. Fully publicly funded episodes of care occurring in private hospitals made up 6.4% of all care in private hospitals, while representing 2.6% of all recorded care. The second way is privately delivered care paid for through the Department of Veterans’ Affairs. A full 73.5% of care paid for by the Department of Veterans’ Affairs occurred in private hospitals.

It would be easy, however, to underestimate the significance of this public-private partnership by examining only the delivery of care that is fully publicly funded. Privately insured care is also partially subsidized by the government, at a rate of 75% of the public fee. Therefore, in order to understand the full extent of publicly funded or subsidized care in private hospitals, it is helpful to examine private hospital expenditures by the source of funds. In 2019/20, 32.8% of private hospital expenditures came from government sources, 18.2% of which came from private health-insurance rebates. This means that a full
third of private hospital expenditure comes from a range of public sources, including the federal government.

Overall, private hospitals are important partners in the delivery of care within the Australian universal healthcare system. The Australian system outranks Canada’s on a range of performance indicators, while spending less as a percentage of GDP. Further, the integration of private hospitals into the delivery of care, including public care, occurs while maintaining universal access for residents.


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Economy

Ottawa’s homebuilding plans might discourage much-needed business investment

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From the Fraser Institute

By Steven Globerman

In the minds of most Canadians, there’s little connection between housing affordability and productivity growth, a somewhat wonky term used mainly by economists. But in fact, the connection is very real.

To improve affordability, the Trudeau government recently announced various financing programs to encourage more investment in residential housing including $6 billion for the Canada Housing Infrastructure Fund and $15 billion for an apartment construction loan program.

Meanwhile, Carolyn Rogers, senior deputy governor of the Bank of Canada, recently said weak business investment is contributing to Canada’s weak growth in productivity (essentially the value of economic output per hour of work). Therefore, business investment to promote productivity growth and income growth for workers is also an economic priority.

But here’s the problem. There’s only so much financial capital at reasonable interest rates to go around.

Because Canada is a small open economy, it might seem that Canadian investors have unlimited access to offshore financial capital, but this is not true. Foreign lenders and investors incur foreign exchange risk when investing in Canadian-dollar denominated assets, and the risk that Canadian asset values will decline in real value. Suppliers of financial capital expect to receive higher yields on their investments for taking on more risk. Hence, investment in residential housing (which the Trudeau government wants to promote) and investment in business assets (which the Bank of Canada warns is weak) compete against each other for scarce financial capital supplied by both domestic and foreign savers.

For perspective, investment in residential housing as a share of total investment increased from 22.4 per cent in 2000 to 41.3 per cent in 2021. Over the same period, investment in two asset categories critical to improving productivity—information and communications equipment and intellectual property products including computer software—decreased from 30.3 per cent of total domestic investment in 2000 to 22.7 per cent in 2021.
What are the potential solutions?

Of course, more financial capital might be available at existing interest rates for domestic investment in residential housing and productivity-enhancing business assets if investment growth declines in other asset categories such as transportation, roads and hospitals. But these assets also contribute to improved productivity and living standards.

Regulatory and legal pressures on Canadian pension funds to invest more in Canada and less abroad would also free up domestic savings for increased investments in residential housing, machinery and equipment and intellectual property products. But this amounts to an implicit tax on Canadians with domestic pension fund holdings to subsidize other investors.

Alternatively, to increase domestic savings, governments in Canada could increase consumption taxes (e.g. sales taxes) while reducing or even eliminating capital gains taxes, which reduce the after-tax expected returns to investing in businesses, particularly riskier new and emerging domestic companies. (Although according to the recent federal budget, the Trudeau government plans to increase capital gains taxes.)

Or governments could reduce the regulatory burden on private-sector businesses, especially small and medium-sized enterprises, so financial capital and other inputs used to comply with often duplicative or excessive regulation can be used to invest in productivity-enhancing assets. And governments could eliminate restrictions on foreign investment in large parts of the Canadian economy including telecommunications, banking and transportation. By increasing competition, governments can improve productivity.

Eliminating such restrictions would also arguably increase the supply of foreign financial capital flowing into Canada to the extent that large foreign investors would prefer to manage their Canadian assets rather than take portfolio investment positions in Canadian-owned companies.

Canadians would undoubtedly benefit from increases in housing construction (and subsequently, increased affordability) and improved productivity from increased business investment. However, government subsidies to home builders, including the billions recently announced by the Trudeau government, simply move available domestic savings from one set of investments to another. The policy goal should be to increase the availability of risk-taking financial capital so the costs of capital decrease for Canadian investors.

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Economy

Today’s federal government—massive spending growth and epic betting

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From the Fraser Institute

By Jock Finlayson

One can legitimately ask whether the federal government has simply grown too big, complex and unwieldy to be managed at all

The Trudeau government’s 2024 budget landed with a thud, evoking little enthusiasm and drawing spirited criticism from business leaders, investors, provincial premiers and (of course) the opposition parties. Several elements of the budget have garnered outsized attention, notably the pledge to run endless deficits, the imposition of higher capital gains taxes, and various new programs and policy initiatives intended to address Canada’s housing crisis.

But the budget includes a few eye-catching data points that have been downplayed in the subsequent political and media commentary.

One is the sheer size of the government. The just-completed fiscal year marked a milestone, as Ottawa’s total spending reached half a trillion dollars ($498 billion, to be exact, excluding “actuarial losses”). According to the budget, the government will spend $95 billion more in 2024-25 than it planned only three years ago, underscoring the torrid pace of spending growth under Prime Minister Trudeau.

One can legitimately ask whether the federal government has simply grown too big, complex and unwieldy to be managed at all, even if we assume the politicians in charge truly care about sound management. How many parliamentarians—or even cabinet ministers—have a sufficient understanding of the sprawling federal apparatus to provide meaningful oversight of the vast sums Ottawa is now spending?

The ArriveCAN scandal and chronic problems with defence procurement are well-known, but how good a job is the government doing with routine expenditure programs and the delivery of services to Canadians? The auditor general and the Parliamentary Budget Officer provide useful insights on these questions, but only in a selective way. Parliament itself tends to focus on things other than financial oversight, such as the daily theatre of Question Period and other topics conducive to quick hits on social media. Parliament isn’t particularly effective at holding the government to account for its overall expenditures, even though that ranks among its most important responsibilities.

A second data point from the budget concerns the fast-rising price tag for what the federal government classifies as “elderly benefits.” Consisting mainly of Old Age Security and the Guaranteed Income Supplement, these programs are set to absorb $81 billion of federal tax dollars this year and $90 billion by 2026-27, compared to $69 billion just two years ago. Ottawa now spends substantially more on income transfers to seniors than it collects in GST revenues. At some point, a future government may find it necessary to reform elderly benefit programs to slow the relentless cost escalation.

Finally, the budget provides additional details on the Trudeau government’s epic bet that massive taxpayer-financed subsidies will kickstart the establishment of a major, commercially successful battery and electric vehicle manufacturing “supply chain” in Canada. The government pledges to allocate “over $160 billion” to pay for its net-zero economic plan, including $93 billion in subsidies and incentives for battery, EV and other “clean” industries through 2034-35. This spending, the government insists, will “crowd in more private investment, securing Canada’s leadership” in the clean economy.

To say this is a high-risk industrial development strategy is an understatement. Canada is grappling with an economy-wide crisis of lagging business investment and stagnant productivity. Faced with this, the government has chosen to direct hitherto unimaginable sums to support industries that make up a relatively small slice of the economy. Even if the plan succeeds, it won’t do much to address the bigger problems of weak private-sector investment and slumping productivity growth.

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