Health care crisis: looking beyond the obvious

Case

You open your news application before a long clinic day and glance at the headlines: Emergency departments (EDs) have reached capacity in your area; many of your fellow Canadians are without a family physician or other primary care provider; a northern Indigenous community is lacking adequate housing and clean water; your local hospital has a massive nurse shortage; and the drug toxicity crisis, once limited to opioids, has intensified. You take a deep breath. Nothing here is new. You have been reading the same news for at least 30 years. While reflecting on this thought, you realize you have become numb to this and are on the verge of cynicism. You open your emails. A medical journal headline informs you that a single prostate serum antigen screening can lower the mortality rate from prostate cancer, but when you read the abstract, you realize that the absolute mortality reduction is minuscule. Your clinic manager informs you that a secretary has resigned, too stressed with the volume of telephone calls and increasing patient expectations. An email from your local health authority is asking for volunteers for their winter clinics aimed at offloading the pressure in the ED. You hesitate. You often find yourself working late into the evening, checking laboratory test results and making telephone calls. Your family members have been noting how exhausted you are and that you are less interested in doing things with them. You start your clinic telling yourself you will think about it later.

Understanding the forces at play: the perfect storm

Over the past 5 decades, health care spending in Canada has skyrocketed, increasing by nearly 500%.⁵ Between 1980 and 2022, the percentage of gross domestic product dedicated to health care rose from 6.5% to 11.2%.⁶ Despite these investments, health care still finds itself in crisis.

While this growth appears to reflect improvements in care, it masks a more complex reality: Behind the rising costs lies a redefinition of needs, growing societal expectations, and structural challenges posed by medical advancements.

Needs trap

Unlike other forms of distributive justice, which may be based on egalitarian justice or equitable access, our health care system allocates resources according to what are termed needs.

However, a need is a non-standardized concept that has evolved considerably in recent decades. Defining the concept of needs and then prioritizing them has been an unending task. Easterlin’s paradox provides insight⁷: Increased material wealth does not necessarily lead to greater happiness because societal expectations adjust. As more people gain access to certain goods such as cars, air conditioning, or smartphones, these goods transition from luxuries to perceived necessities or needs.

Health care needs follow similar logic. With technological and medical progress, there is a corresponding expanded perception of what the health care system should offer. What was once considered an inevitable part of human life—aging, discomfort, anxiety, and death—are now perceived as unacceptable medical problems requiring medical solutions. This has led to increasing societal demands, overdiagnosis, and overtreatment, as well as the medicalization of aging and dying, among other domains.

Impact of technological and pharmaceutical advances

Scientific and technical progress has revolutionized medicine, offering unprecedented solutions for treating previously incurable diseases. However, these advances are not merely scientific and technical, they are also intimately social and have amplified economic and structural challenges within health care systems.

Cutting-edge technologies such as magnetic resonance imaging deliver remarkable diagnostic gains at rapidly escalating cost. Their use is frequently driven by availability rather than clinical necessity. This dynamic reflects a principle in health economics, often referred to as Roemer’s Law, whereby expanding medical supply—initially observed for hospital beds—tends to generate its own demand across health systems worldwide today.^11,12

Another example is that the use of intensive care units (ICUs), which costs 3 times more, uses far more human resources, and is growing faster than the number of acute care hospitalizations in general.¹³ Furthermore, a retrospective cohort study showed that increasing the number of ICU beds in a hospital increased the odds that a patient with advanced dementia would receive mechanical ventilation, doubling the rate of mechanical ventilation without improving survival.¹⁴

Similarly, advances in treatments for conditions such as diabetes, kidney failure, or heart failure have allowed millions to live longer. However, this increased longevity contributes to expansion of life with disease, which leads to increased pressure on the system.¹⁵ This cycle is exacerbated by a culture that values technical interventions and expensive innovations, often at the expense of preventive measures or primary care.¹⁶

Denial of death: a burden on health care systems

Modernity has profoundly altered our relationship with death. Dying is no longer seen as an inevitable stage of life but as a failure of the medical system. The goal of reducing mortality, applied indiscriminately, means that we are collectively missing the chance of what is deemed a good death, as noted in numerous reports on missed opportunities for palliative care.¹⁷

Furthermore, Canada is among the highest-ranking countries in terms of medical expenses at end of life.¹⁸ The statistics are striking, with nearly 25% of health care spending devoted to the final months of patients’ lives, often for invasive treatments with minimal impact on longevity and major negative impact on quality of life. This high financial cost reflects a systemic and societal misalignment.¹⁸

Our health care system’s decision to push toward more aggressive medical management, while motivated by a certain form of hope, reflects our inability to initiate courageous discussions about goals of care, particularly at end of life.

Dr Iona Heath, an English family physician, expands on this:

Nowadays, doctors are driven by a sense of guilt and discomfort at fighting more and more for the prolongation of life, often at the expense of its quality. Once again, the hubris and ambition of biomedical science are largely responsible for the dangerous and damaging denial of death in contemporary society.¹⁹

Performance paradox: a system that fuels its own crisis

The above analysis reveals a less frequently discussed aspect of the crisis, that is, the role of the health care system itself in increasing demand. The more effective the health care system becomes in reducing mortality and extending life, the more it creates a population in need of prolonged care (Figure 2). This phenomenon illustrates the health care system performance paradox in which the health care system’s successes threaten its own sustainability.²⁰

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Figure 2.

The health care performance paradox

To address this crisis, we must consider how demand, generated by both patients and professionals, feeds the crisis; and we need to confront these forces with a new way of thinking about what being healthy means and what aging, dying, and death can and should look like. The next article in the series borrows from concepts on planetary limits to propose a reframing of the health care system.