Health care crisis: looking beyond the obvious

Case

You start your day with Luke, a 62-year-old patient without a regular family physician, who is facing housing insecurity and poverty. He explains he has been unable to work for years due to a back herniation. He requests renewals for his hydromorphone and pregabalin prescriptions and asks for a referral for injections to treat back pain. Despite his chronic pain, Luke has never had physiotherapy, as he cannot afford it. You decide to order appropriate preventive screening tests, which Luke has not received in more than a decade.

A week later, you receive Luke’s blood test results, revealing a hemoglobin A_1c level of 11.7% and an estimated glomerular filtration rate of 33 mL/min/1.73 m². Concerned, you try to schedule a follow-up appointment to discuss his tests, but your next available appointment is not until the following month. Tragically, the following week, as you review paperwork, you come across a hospitalization summary informing you that Luke died of a massive myocardial infarction.

In the first article of this 3-part series, we identified the health care performance paradox as a central driver of the ongoing crisis.¹ As health care becomes more effective—reducing mortality and prolonging life with chronic disease—it simultaneously generates a growing population reliant on extended medical care, straining the system’s human, financial, and ecological resources. Compounding this challenge is a societal denial of death, which distorts expectations and further contributes to the unsustainability of the system.

As worrisome, and parallel to this phenomenon, is the exacerbation of health inequalities, which undermines the principles of universality and equity that form the foundation of our health care system.² This reality confirms the 50-year-old inverse care law, which states that those who need care the most are the least likely to receive it.³

Confronting the forces at play

To resolve the health care crisis, we must confront the forces at play in a courageous societal dialogue. We must do so by reframing the overall goal of our health care system, rebalancing equity with outcomes within the Quintuple Aim,⁴ and introducing limits.

Outsmarting the overall goal of our health care system: the unreachable goal. To truly transition out of the crisis, it is essential to question the very goals our health system pursues. At the federal level, Health Canada’s mission is “to help Canadians maintain and improve their health.”⁵

While this goal sounds reasonable, it requires closer scrutiny. To properly interpret it, we must first define health. The World Health Organization provides the following definition:

Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.

The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.⁶

At first glance, these definitions seem aspirational. But, as many authors have rightly pointed out, the broad, holistic definition of health makes every aspect of individual and collective life a potential health problem.⁷ One may ask, how can we maintain and improve health while we are all aging and eventually dying?

Combined with the “need trap” described in the first article,¹ this unattainable goal of “perfect health” ensures perpetual failure and systemic crises.

Developing a specific, measurable, achievable, relevant, and time-bound health care goal. To address these challenges, we advocate for the development of a specific, measurable, achievable, relevant, and time-bound (SMART) overarching goal for our health care system to have reasonable and achievable outcomes. We argue that there are 2 key features that should be incorporated into this goal:

    1) a recognition that equity needs to be included in our goal, and

    2) an acceptance that aging and death are inevitable parts of life, not necessarily a health system failure.

In the interest of sparking dialogue, we invite readers to consider the following potential SMART goal which incorporates the desired 2 features named above: “Ensure an equitable chance at a healthy natural life span and a peaceful aging, end of life, and dying process for all Canadians.”

The concept of a healthy natural life span has been defined as the life span that allows everyone to accomplish the ordinary scope of possibilities that life affords.⁸ This idea connects to the “fair innings” argument, first advanced by John Harris in 1995, asserting that everyone is entitled to a “normal” span of health.⁹ This concept has value insofar as it gives a general common-sense description or approach to what a social contract could equitably offer in terms of health. However, the “fair innings” concept has received pushback from some scholars, ethicists, and clinicians. The capabilities approach, a framework for evaluating well-being and justice that focuses on individuals’ abilities or freedom to live the kind of life they value,¹⁰ has been proposed as an alternative.

Without trying to define strict delineation, both concepts can guide the identification of consensus outliers—situations where individuals are dying considerably earlier or later than typical life expectancy—as situations requiring systemic attention in priority.

The second half of the proposed goal emphasizes achieving a peaceful process of aging, end of life, and dying. While alternative wording is possible, peaceful conveys essential values: gentleness, dignity, humanity, and even joy.

Currently, this remains an unmet aspiration: more than 22.7% of people older than 85 years report feeling lonely¹¹ and while 69% of Canadians say they would like to die at home, 80% will die in hospital or long-term care.¹²

Achieving while challenging the Quintuple Aim. The Quintuple Aim extends the well-established Triple Aim framework, which sought to improve population health, enhance the patient experience, and reduce per capita costs.⁴ It adds 2 crucial and interdependent dimensions: ensuring the well-being of health care providers and advancing health equity.

While progress toward achieving the original Triple Aim is increasingly well integrated into system-level initiatives, the addition of equity and provider well-being creates new tensions, particularly when balancing equity with high-quality outcomes.

The Quintuple Aim also sheds light on the systemic factors that contribute to inequity:

• The phagocytosis of social spending: Health spending has grown 10 times faster than social spending since 1981.¹³ As health budgets expand, they consume funds crucial to social determinants of health—income, housing, education, and food security—which account for 50% of population health outcomes, compared to only 25% attributable to health care.^14,15

• The double jeopardy effect: Material and social disadvantages correlate with earlier deaths and less access to health resources. Disadvantaged people tend to be additionally disadvantaged by a shorter life.¹⁶

• The outcome traps: In the context of an aging population increasingly burdened by multiple concurrent chronic conditions, system-level and disease-specific metrics are often misaligned with what matters most to older adults—quality of life, functional independence, and dignity¹⁷—hence reducing precious resources for this subgroup of the population more in need.

By protecting social spending and primary care while integrating appropriate interventions and their metrics for the late phase of life, we could imagine a system that promotes both equity and high quality. Hence, we need to focus on complementary metrics such as perceived health, health-adjusted life expectancy, and rates of premature mortality.¹⁷

Introducing a planetary boundaries–inspired health care model: defining the floor and ceiling. Building upon the imperative to balance outcomes with equity, it is essential to recognize that health care systems operate with finite resources and capacities. Drawing inspiration from the planetary boundaries framework (Figure 1)^18-20 and its derived social adaptation (Figure 2)^21-23—which together delineate the limits within which humanity can safely operate—we propose a health care boundaries model (Figure 3), bounded by the following:

• a “floor” that ensures a baseline of equitable access to essential health services, guaranteeing that all individuals receive the necessary care to prevent premature mortality and maintain a basic quality of life; and

• a “ceiling” that represents the maximum sustainable capacity of the system, beyond which additional interventions may yield diminishing returns, contribute to over-medicalization, and strain the system’s sustainability.

Here, safety refers to sustainability; exceeding these interdependent boundaries risks triggering nonlinear, abrupt changes with potentially catastrophic consequences.²⁴

This framework aligns with new international recommendations like the Swiss roadmap for sustainable health services, which identifies 3 critical challenges: overuse of resources, underuse of essential services, and inequities in access and quality of care.²⁵

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Figure 1.

The 2023 update to the 9 planetary boundaries and their status

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Figure 2.

The doughnut of social and planetary boundaries

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Figure 3.

The health care boundaries model for a sustainable and equitable system

Call to action: leadership for a sustainable future

Integrating the concepts of a health care floor and ceiling invites policy-makers, providers, and Canadians alike to have a collective conceptual awakening, bold conversations, and courageous leadership to make difficult resource allocation decisions.

In the final article of this series, we will explore how these concepts can be operationalized to forge a more equitable, sustainable, and human-centred health care system.