Soaring temperatures, bigger storms, more lightning strikes hitting tinder-dry conditions. Wildfires in Canada, France, ad Spain. Could climate change possibly be to blame? Not according to US President Donald Trump. He seems pretty certain that the fires affecting North America are entirely Canada’s fault.
….. You know, we got to stop the fires up there…maybe they should pay us some damages or something, or we should do some tariffs. But it was terrible. I mean, you had businesses closing.
That’s one reason why Trump has just hit Canada with 50% tariffs on the $20 billion worth of goods and services that the US imports annually from its next-door neighbour. Basically, the fires have to be [Canadian PM] Mark Carney’s fault because they didn’t use to happen, right?
“I’ve never remembered this happening. Over the last four or five years you saw it starting to take place. I never remembered it happening before.”
Yep, it’s a real puzzler why those fires should be happening now when they didn’t use to happen then. Think about it, though. What do those fires in California, Canada, and Spain have in common? Socialist governments.
Public health goes American
The US health system is widely seen to be the most expensive and least efficient model for public health delivery in the world – yet our own health system is steadily being Americanised without much in the way of a public debate. This Americanisation trend is evident in at least three ways:
1.Health insurance, private sector delivery
The people who can afford it are being made increasingly reliant on health insurance for timely care, and on private sector health delivery. The coalition government has actively encouraged this trend by signing short and long term service contracts with private sector providers. Along the way, taxpayers have been denied access to the costing details that reveal how much of their money is being diverted into for-profit healthcare contracts.
In line with the profit incentive, these contracts readily enable the easier, more profitable treatments to be cherry-picked by the private sector providers, while patients with more serious conditions and costlier treatments are being left behind to rely on an underfunded, understaffed public health system. But at least the government can then brag about reductions in waiting lists, even if only for non-critical care.
As in the United States, a two -tier system of healthcare delivery is emerging here, as the direct consequence of government policy.
2.The investor takeover of primary care
For survival, chronically underfunded GP practices have been forced to hike their consultation fees. Research has shown that those fees (even when discounted) are already a significant barrier to healthcare access for those on low incomes. They are also serving to shift everyone else towards a reliance on private health insurance.
In a further sign of the adoption of the US model, GP practices are becoming an increasing target for takeovers mounted by private equity firms :
Kaitiaki Hauora chair and AUT chancellor Rob Campbell says private equity firms are investing in New Zealand’s healthcare sector expecting “mid-teen returns” and he’s convinced those returns will come at a cost.
“Investment in a sector like health, where you have companies expecting those returns, it will put pressure on staffing levels and costs. If you are going to achieve those outcomes, you will have to indulge in severe cost cutting and that’s as clear as night follows day.”
More on this trend here. It is picking up pace:
In March, US private equity firm TPG received Overseas Investment Office approval to buy Tāmaki Health, one of New Zealand’s largest general practice and urgent care health service providers.
Reportedly, that US takeover bid was worth $400 million. Some of the takeover/merger/concentration activity in primary healthcare is also being driven by local investors. Tend Health (in which Ngai Tahu is a shareholder) is in the final stages of completing its $270 million takeover bid for the medical division of Green Cross Health which (reportedly) operates 65 medical centres, and has 413,000 enrolled patients.
In response, Dr. Bryan Betty chair of General Practice New Zealand, has been calling for a wider public debate about the future of general practice. “I know a lot of my colleagues have concerns about this [takeover/merger trend] ” Dr Betty told NZ Doctor, given the potential that he sees for a small number of large corporates ending up owning New Zealand’s entire primary healthcare sector.
In the same NZ Doctor report, Otago University professor of public health Peter Crampton contrasted the life-long community orientation of owner -operated GP practices with the quite different approach taken in the US under private-equity ownership:
Greater private equity ownership increases the risk to the quality and access of healthcare services, he says…Such firms tend to follow a predictable pattern centred on maximising returns for shareholders, often at the expense of patient care, Professor Crampton says. This may lead to unnecessary profit-generating procedures, the use of less qualified staff, higher staff turnover, a preference for less complex patients, and the closure of unprofitable services.
3.The government’s faux “devolution” plan
Under the benign-sounding banner of shifting decision-making closer to patients, communities and hospitals, the coalition government is actively distancing itself from the consequences of the privatisation process.
Basically, the terms and conditions of Brown’s devolution plan will require regions and districts to be responsible for the workforce, resources and delivery of healthcare, while the government busies itself with devising strategy and setting goals and standards, and maintaining its control of the funding.
In effect, this will enable the government to blame the regions/districts for the inevitable future shortfalls in staffing and delivery as the private investors chase their profits. The worst aspects of the DHB model are being set up to be repeated, this time with a toxic admixture of free market ideology and practice. The government will continue to hold the purse strings, no anti-trust barriers will be erected to prevent market concentration, and there will be fewer ways of holding the state accountable for what will be happening on the frontlines of public health delivery.
When it comes to public health, the government apparent aim is to (increasingly) become an absentee landlord.
Footnote One: The dimly understood role of Public Health Organisations (PHOs) is also in flux. As Pegasus Health CEO Kim Sinclair-Morris recently told NZ Doctor magazine, local PHOs “play an important role in understanding the needs of their communities, supporting population health initiatives, enabling general practice, and integrating services across primary and community care. Those functions remain critical to delivering better health outcomes for New Zealanders.”
However, despite the key roles played by PHOs in assisting and integrating GP /community care (and helping to implement wider health initiatives) private investors are entering this space as well, and are cannibalising existing PHOs. Meanwhile, Heath Minister Simeon Brown continues to watch from the sidelines as this process of PHO fragmentation and mergers unfolds, in the absence of any nationwide policy on the role of PHOs.
Par for the course. Policy formation does not appear to be a priority for the current Health Minister, unless it can be made part and parcel of maximising the profit opportunities in healthcare for the private sector.
An alternative vision
In stark contrast, Dr Philip Bagshaw and a group of colleagues have proposed here and also more fully here a blueprint for what the genuine de-centralisation of public healthcare could look like. As Bagshaw and Co argue at the outset, neo-liberalism has sickened our national health, disability and welfare services.
This sickness has affected relationships between health professionals and patients, colleagues, managers and government. Neoliberalism has driven these services to the verge of collapse, and the Ministry of Health/Health New Zealand Te Whatu Ora is pursuing increasingly rapid privatisation as the solution.
Instead, the authors propose the establishment of a National Collaborative Network covering these services. While honouring the Treaty of Waitangi, this network would :
(1) provide services as close as possible to those who need them through a collaborating network of local and regional centres;
(2) assign governance to local communities who are best placed to identify their own needs;
(3) restore management to individuals who understand best how they function, eliminating generic management and halting the progressive centralisation and privatisation of services;
(4) judge performance by regular population surveys of unmet need, not by meaningless, self-fulfilling (or missed) targets;
(5) expunge narcissistic, hierarchical attitudes that belittle those working in peripheral centres;
(6) accept that adequate funding of is one of the best fiscal investments a government can make; and (
7) establish oversight of national health, disability and welfare services. by a functional Ministry of Health, Disability and Welfare that reports to the whole of government.
This proposed structure, the authors point out, is consistent with much of the direction and intent of the Pae Ora (Healthy Futures) Act 2022,. This initiative was quickly scrapped by the incoming coalition government.
Within the Election Mix
No doubt, the state of the public health system will feature prominently in this year’s election campaign. Unfortunately, much of the focus will be on the tragic consequences of health system failure rather on how and why the public health system is being set up to fail. Dire consequences need to be reported, but so do the structural causes that keep on generating them.
Currently, the decisions behind our adoption of the profit-driven American model of healthcare delivery are being quietly made in the Beehive, and in the boardrooms of the private equity firms.