Rural Ontario towns are confronting a health-care emergency. It’s difficult enough to find a regular family doctor in Ontario these days, but the problem becomes even more acute in rural areas, which can struggle to hang on to whatever medical services they have. (The situation isn’t helped by provincial funding decisions that close existing care facilities.) In that context, it’s no surprise that some rural municipalities have decided that they’ll sweeten the pot however they can to attract new practitioners. As the Canadian Press reported this week, these sweeteners can be substantial.
Huntsville: “$80,000 signing bonus to any family physician who agrees to work in the town for at least five years.”
Dryden: “Doctors moving to Dryden could be given up to $155,000 for a four-year commitment.”
Marmora and Lake: “Doctors are being offered riverfront housing and clinic space at zero cost, among other incentives.”
Nobody should begrudge these communities these incentives, and I certainly don’t. There’s a line from Thucydides that comes to mind: the strong do what they will, and the weak suffer what they must. If municipalities are already weak in our system of government, small and rural municipalities are the weakest of all — and suffer what they must.
There are, however, at least two major problems with these incentives. The first is that there’s a real risk of a beggar-thy-neighbour cycle: Relatively wealthy municipalities use their greater fiscal resources to attract health-care providers, putting them at a greater advantage when it comes to attracting other talent and economic development relative to other towns. That, in turn, allows them to further sweeten their incentives, accelerating the divergence between the have and have-not places. It would be, on a smaller scale, a repeat of the same dynamic that’s already playing out between rural Ontario and the big cities of Ottawa and the GTA.
You may think that this is overstated: Is there that much difference in principle between this and, say, a school-district fundraiser? Maybe not, but it’s worth noting that Ontario actually has guidelines about what schools can and cannot fundraise for, specifically to avoid this problem arising in the education system — the same wisdom should apply at least as much to health care.
This concern is admittedly a bit speculative for now. But there’s something that’s not speculative at all, and that’s the fact that putting health-care costs on the municipal ledger is unsustainable and nuts and happens to be something that Ontario already does too much of — and more than other provinces do.
A report from the Rural Ontario Municipal Association earlier this year estimated that rural municipalities in Ontario pay nearly half a billion dollars annually in health-care costs for what’s understood by Canadians to be a provincial responsibility. That’s a rounding error in the provincial health-care budget of $85 billion. But, for rural municipalities, that burden falls on a much thinner tax base, which strains to carry the weight. Municipalities help pay for hospital construction, fundraise for MRI machines, and pay for more than half of the cost of EMS services. (Paramedics are health care, and while the province nominally pays half the costs of EMS calls, municipal advocates have said for years that the province’s grants aren’t covering its half of the bills.)
Municipalities are already paying for health-care costs — subsidizing the province’s relatively healthy fiscal state, in effect — and that’s before we take into account the need to woo doctors and other practitioners to set up shop in small towns. To be clear, there are provincial incentives as well to encourage rural service, and that’s good; that’s the appropriate level of government to fund these kinds of things. But the fact that municipalities are also coming to the table is evidence that the provincial program is insufficient.
Service delivery in rural Ontario is just inherently a thorny problem, and I won’t pretend that the answers are likely to be simple (or cheap). But the crisis in rural medicine is real and shows every indication of getting worse in the near future. The ROMA report estimates that, within five years, the need for new rural GPs will double due to retirements. If Ontario doesn’t get ahead of this problem, soon, the results could be grim.
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