1. Wait times: the good and the bad
This item is written by Jennifer Henderson.
The length of time continues to grow for people waiting for a total hip or knee replacement.
Surgeons are not able to estimate when patients may get a date for the procedure now that elective or non-urgent surgeries have been cancelled for a third week in a row. Hospital admissions are rising due to the latest wave of COVID (72 new patients last week), which puts additional pressure on facilities that were already filled to capacity with an estimated 200+ patients waiting for a place in nursing home.
There are roughly 7,200 people waiting for orthopedic surgery across the province. In the Central Zone, where the QEII Health Sciences Centre and Dartmouth General Hospital do the majority of those operations, 4,500 people are waiting for operations and about half that list — 2,200 — waiting for hip and knee replacements.
There is hope, according to Dr. Bill Oxner, the Chief of Orthopedics for the Central Zone. Oxner says that backlog of patients waiting for new knees and hips could be eliminated in a year’s time if there were beds (and nurses) available to care for patients who require overnight stays.
Oxner notes that when COVID emerged two years ago, wait times for people requiring hip and knee replacements was hovering in the six to nine month range, finally approaching the national benchmark of six months.
“So we were on our way to solving this wait list problem and then the pandemic hit,” says Oxner. “So, I believe we have the tools, outside of the beds, to clear this backlog in a year.”
In the two years prior to the pandemic, steady progress had been made following the hiring of four new surgeons and the establishment of five Orthopedic Assessment Clinics located in Sydney, New Glasgow, Kentville, Dartmouth, and Halifax. In-patient stays were averaging two days instead of four days as a result of better pre-op and post-op programs provided through the clinics.
Then COVID hit and suddenly the 30 beds in the Central Zone designated for ortho patients — who needed to stay overnight for spine, knee, or hip surgery — were cut to 12 beds. Essentially the Orthopedic Unit at the Infirmary became the COVID Care Unit. Those beds have not been released, and two weeks ago the remaining 12 beds were needed for COVID patients. Last week, the Central Zone made available 10 beds to surgeons from several disciplines. This week, most elective surgeries will not take place, according to this email received yesterday from Jaimee Dobson with Nova Scotia Health:
Surgical services across the province are being closely managed and expanding/reducing capacity as required with staff being redeployed to areas of greatest need… We recognize this is incredibly frustrating and challenging for our patients and for our staff and physicians in the surgical program who have seen their services affected repeatedly throughout the pandemic. However surgical reductions are necessary to ensure sufficient inpatient bed capacity.
Maintaining emergency services at our regional sites is a top priority and people requiring emergency care should not hesitate to visit, although waits may be long.
Last week, there were 577 health care workers across the system absent due to COVID.
Hip replacement as outpatient surgery
When there are no beds, surgeons can’t operate on people who may require more care after an operation. People with underlying medical conditions or patients who don’t have a family doctor are considered too high-risk to have a hip or a knee replacement as an outpatient or day surgery.
That said, the lack of beds has forced changes to the way surgeons work. Oxner said where surgeons once did 100 joint replacements a year on out-patients, that number ballooned to 800 over the past 18 months. Surgeons have generally been able to keep pace with knee scopes and shoulder procedures that do not require an overnight stay.
Tim Houston made an election promise to expand the hours that operating rooms are open to try to reduce the surgical backlog built up during COVID. That hasn’t happened since he became premier, and it won’t happen unless more in-patient beds can be freed up.
That may require finding new homes for patients waiting months in hospital for long-term care. When surgery does resume and patients can be booked again, Oxner predicts it won’t be on a “first come, first serve” basis.
“Coming out of the pandemic, we are just starting to do some surgery and, shockingly for the poor patients, we can’t just pick up where we left off,” explains Oxner. “For example, if you were scheduled to have your hip replaced in March 2021 and you were cancelled (and some people have been cancelled more than once), we may not be able to operate right now because in the interim, unfortunately, someone with a higher level of acuity — whether it’s an implant that’s about to fail or an infection — will need to be seen first.”
Oxner encourages patients whose pain or condition is much worse than the last time they saw a surgeon to call the nearest Orthopedic Assessment Clinic and request an appointment for a re-assessment. There is a working group of orthopedic surgeons across the four zones who meet regularly.
This year’s health budget does include $27 million for 28 new beds and staff to provide more orthopedic surgeries at the Dartmouth General Hospital. The first operations are tentatively scheduled for later this spring, when two surgeons will move from Halifax as part of the QEII re-development project to replace services at the Victoria General Hospital, which is slated for closure. A third surgeon will move sometime in the fall. Health Minister Michelle Thompson has indicated her department is also looking to find “capacity as soon as possible” at hospitals across the province and at the Glace Bay General.
Thompson said she is “exploring” the idea of a central registry that might attempt to match patients waiting for surgery with doctors in neighbouring zones who have shorter wait lists. While that may work for some categories of patients, Oxner is doubtful it would provide much benefit to orthopedic patients who need both pre-op and post-op care close to home to reduce the length of their hospital stay.
“I am optimistic that the government is trying to do the right thing,” says Oxner. “Our message is where we added surgeons and we have a well-oiled machine, once it gets going again we will be able make serious gains on these wait times — without having to dip into night times and weekends. Not that we are against doing that but we need the resources to work in the daytime.”
Orthopedic patients represent one in four people estimated by the province to be waiting for surgery. The total number on the wait list is approximately 27,000.
2. What gaps are there in dementia care in Nova Scotia?
While we’re on the subject of health care…
There are about 12,000 people living with dementia in this province and, since our population is aging, that number is expected to rise. In preparation for the care that increase will require, a group of researchers want to know how dementia care can be better around Nova Scotia.
To do that, they’ve created a province-wide survey, supported by Nova Scotia Health, Research Nova Scotia, QEII Health Sciences Centre Foundation, and the Alzheimer Society, where they hope to get input from people living at home with dementia, as well as their family members, caregivers, and health care professionals. Since our population is older than average, and spread out across rural areas, the survey is looking at the needs of people living with dementia outside of long term care facilities.
“I think a lot of people are wanting to stay within the community as long as possible,” Nova Scotia Health neuropsychologist Dr. Paula McLaughlin told the Examiner. “We want to be able to set it up so that people have access to the support that they need to live in their home for as long as possible, if that’s what makes sense for them.”
“We want to be meeting those needs, and we know that they’re going to be unique by individual community. But without this information, we can’t really change anything or improve that access to services without really knowing truly where the gaps are.”
In her full article this morning, Yvette d’Entremont looks at how the survey is being conducted, what unique challenges Nova Scotia has with this type of care, how the pandemic and telehealth have changed things, and what this new research could mean for the future of dementia care in the province.
3. Northern Pulp says it’s ‘insolvent’ and can’t pay pensions; yet somehow, it’s able to pay for litigation
Joan Baxter continues her reporting on the never-ending Northern Pulp saga this morning. The latest: the company says it can pay for legal attacks, but it apparently has no money to make pension payments:
Northern Pulp declared itself “insolvent” in June 2020, and since then has been enjoying creditor protection in the B.C. Supreme Court.
Insolvent it may be, but Northern Pulp still seems to have no shortage of cash to bankroll legal assaults on Nova Scotia’s government and laws.
Northern Pulp also has some “friends” who seem equally flush and able to finance expensive PR campaigns — a “woo and sue strategy” on which the Halifax Examiner has reported extensively.
It helps the Northern Pulp companies’ finances, of course, that they have been granted a holiday of any repayments on more than $85 million they owe the province, can save money by short-changing on pension payments. In October 2021, Nova Scotia’s Superintendent of Pensions filed an affidavit with the BC Court expressing “significant concerns” about Northern Pulp’s “failure to make contributions” of special pension payments after 2020.
It also helps Northern Pulp and its affiliates — known in legalese as the “petitioners” — that in October 2021, the B.C. Supreme Court allowed them to use $450,000 from the “Interim Financing Facility” to fund litigation expenses for their and their owners’ lawsuit against the province of Nova Scotia.
The lenders for that financing facility are none other than Northern Pulp’s parent Paper Excellence Canada Holdings, and the related Pacific Harbor North American Resources Limited, a private company incorporated in Hong Kong in March 2020.
To quote Baxter a little further, “There is much that is perplexing about this complex and convoluted corporate puzzle, and this creditor protection case.” But that just means there’s a lot for Baxter to dig into and relay to the Nova Scotians whose money Northern Pulp is after. This is a comprehensive story worth checking out in full.
Click here to read the full article.
4. The Coast has been sold
The Coast is no longer in local hands.
As Zane Woodford reports, Halifax’s long-time alt-weekly newspaper (though they’ve moved online through the pandemic) was bought by Overstory Media Group. The company owns several media outlets, or brands, in Western Canada, including Capital Daily in Victoria, Vancouver Tech Journal, and Fraser Valley Current. Woodford writes:
In a note to readers on Wednesday, Coast cofounders Christine Oreskovich and Kyle Shaw wrote that they “struggled to consistently produce an online version of The Coast that achieves the high standards we set for the print edition:”
We knew we needed expert guidance and we felt we owed it to our team and readers to find a partner that could coach and mentor The Coast into being a stronger digital media outlet. Overstory is that partner.
We believe being a part of Overstory’s larger community will help us build up The Coast. During the last two years, we met with many media groups, owners and entrepreneurs learning what makes a small local media brand thrive. We believe Overstory understands the challenges of local media like no other and is committed to hyperlocal digital storytelling as much as we are.
Woodford tells us how the (now digital) paper that started almost 30 years ago changed hands, and what it could look like going forward.
What happens to a surgery deferred
I got a phone call from the office of a medical specialist a few weeks back. I’d been waitlisted for a minor surgery in late 2018 — I won’t go into detail, but I will say the return of my love life depended on this operation — and the receptionist wanted to know if I’d since moved and could be taken off the queue.
I had moved, I said, but only to Halifax. I’d left to go back to school, where I completed my degree, then worked multiple jobs, changed apartments after a year, watched my cousin learn how to talk, and ultimately moved back to the Valley. A long way of saying I was still around. Still, I told her to take me off the list.
I’d already had the operation. After a year of waiting, I’d paid to have it done at a private clinic out of province. I’d used a whole paycheque to drive across a border ready to close at any moment, get an operation, and stay three days in an Airbnb until I was fit enough for travel.
I’m glad I did. And fortunate I could. Although I’d still be alive and able, my physical and mental health would be deteriorating fast if I was still waiting for care. And I would still be waiting. Before I got off the phone with the doctor’s office, I asked when my surgery would have been expected if I’d stayed in the queue. Still too far away to know, they said.
If you’re one of the 27,000-odd Nova Scotians still waiting for a so-called “non-urgent, elective” surgery, you can likely relate.
My neighbour in Wolfville can. He’s one of the people waiting for total knee or hip replacement that Jennifer Henderson wrote about at the top of today’s Morning File. An avid tennis player and gardener, he’s been waiting nearly three years for an operation that would let him walk without pain again, let alone resume his favourite activities. He doesn’t share the same optimism Dr. Brian Oxner has about potentially clearing up the backlog with more beds and staff. Like me, he’s decided to pay for the surgery outside Nova Scotia.
These delays have been a recurring problem through the pandemic.
In January, Aly Thomson at CBC spoke with Tonya Porter, a Halifax woman who’d been diagnosed with spondylolisthesis years ago. A slipped vertebrae was putting pressure on nerves in her lower back and she had two surgeries cancelled after waiting months for an MRI. The condition made it painful to walk and move, and it was damaging her bladder. Yet hospital staff shortages were forcing her to live with the pain.
She later told John McPhee at Saltwire that she had to lie down most of the day and couldn’t do household chores or physical activity anymore. That article reported she was rescheduled for surgery at the end of January and would be in recovery for six months.
I mention all this to show how difficult it can be to live in this limbo — the first circle of hell, might I remind you — for so long, to show how urgent “non-urgent” surgeries can be. Delaying these operations force people to live with unnecessary pain, discomfort, and debilitations each day, and can eventually turn minor problems into major ones. A person doesn’t have to be on death’s door to need surgery urgently.
So what’s to be done?
Henderson’s report this morning is reason for cautious optimism. More beds and staff could clear up the backlog of hip and knee replacement surgeries by year’s end. And the new provincial budget is heavy on health care spending, including the $27 million Henderson noted for new beds and staff to provide more orthopedic surgeries at the Dartmouth General Hospital.
Tim Houston promised to focus on fixing health care in last year’s provincial election. Part of that promise was to extend operating room hours to reduce the surgery backlog. Of course, keeping those rooms open longer means nothing if there’s no one to staff them after hours. The premier had also promised a multi-year plan to fix health care would be ready at the end of March. Just like that list of 27,000, we’re still waiting. The federal government’s put aside $2 billion to help reduce wait times. About $51 million of will go to Nova Scotia, but we’re still waiting on details. (Deputy Health Minister Jeannine LaGassé is attending meetings at the end of this month to find out more).
As I said before, I was lucky to have the money and the option to pay for my surgery elsewhere. And I understand my neighbour’s choice to do the same with his hip. Like justice, health care delayed is health care denied.
That doesn’t mean I want to see more private health care options to make. It was a costly, short-term solution to a problem the public system was unable to address with timeliness. But it’s being considered as a solution.
Late last month, Jennifer Henderson reported the province’s Health System Leadership Team — which replaced the former Nova Scotia Health Authority CEO and board of directors — was “looking at every possible option, including the increased use of private clinics, to ‘blitz’ the backlog of 27,000 people waiting for surgeries.” It’s something Alberta’s premier has been pushing since COVID had the same affect on that province’s surgery backlog. Ontario, too, has considered offloading surgeries to private care.
Beware the creep of privatization. Perhaps it would alleviate some immediate problems, but it would be difficult to return health care to the public’s hands. And that’s whose hands it belongs in. Underfunding public services — as we’ve done with health care for decades — doesn’t mean they don’t work. It means they don’t work without spending time and money to maintain them. It isn’t an argument for privatization. It’s an argument for reform. If it’s broke, fix it. Don’t sell it. We shouldn’t set a precedent by allowing private interests to gain more control when times get tough.
Look at Nova Scotia Power, our province’s most infamous instance of privatization. Right now, the province is trying (poorly, some would say) to introduce legislation that would make Nova Scotia Power more accountable to ratepayers. Elected officials are accountable to ratepayers, but our power company isn’t our power company anymore. If we privatize, we could make the role of CEO of Nova Scotia Health a lot more appealing. Instead of paying her $244,000 a year, we could give her over $8 million in compensation to deliver an essential service and hope she doesn’t ignore the public interest and try to squeeze us for all we’ve got.
Making the public private is easy enough. Making the private public is near-impossible. And it could mean short-term gain for long-term pain.
What about housing? Residential property is almost all privately owned. And it always has been here. I’m not saying we should make property state-owned. I’m just saying, look what happens when you leave a basic human right like shelter to run wild with the market.
If health care is a problem we need to fix, then it’s a problem we need to fix.
To the well-wired mind, the newspaper might seem intolerably limiting. A screen is many things all at once or in quick succession: The New York Times, Netflix, an auction house, a video of last summer’s vacation, a box of recipes, a text from a friend. The newspaper contains multitudes, but in the end, it is only itself. The well-wired mind knows that the screen, as a medium for news, is truer to real life because it brings us life in what we insist on calling “real time.”
As if there is such a thing! Time’s relativity (thanks, Einstein) means we should have some control over the pace with which the world, and the news, comes at us, since neither screen nor paper will ever do better than offer a simulacrum of real life. My daily paper at the curb brings its own simulacrum in its unique way, its own fantasy of what the world is like. I relish reacquainting myself with it each morning, at least for as long as I can. Of course, when my day really begins and I peek at my phone or flip open my laptop, the illusion is destroyed and replaced by another, much more frenetic one — until it returns the next morning with the steaming cup and the plumped-up chair, with the world held in place so I can get a good look at it.
That short passage from Andrew Ferguson, published in the Atlantic a few years ago, came to mind when I first heard The Coast was moving online at the start of the pandemic.
Ferguson was writing about his renewed subscription to the print version of the Wall Street Journal, and how he enjoyed the medium as much as the message. It was a welcome break from screens and a comforting ritual he’d forgotten when he’d switched to all online subscriptions some years before.
The Coast, for me, may be the only modern publication I can personally think of that lost some of its relevance by moving online. The paper still produced great work, including Victoria Walton’s outstanding coverage of housing and homelessness in the city.
The community contributions, features on HRM gems (here’s a personal favourite), culture reviews, and Readers’ Choice Awards sandwiched between ads for drink specials, Neptune productions, and student deals made it feel like I was truly taking in Halifax, one week at a time.
I miss sitting on the bus with The Coast and having copies scattered around everywhere, using old editions to start campfires or throw away compost. I miss scouring the ads — something I’ve never done for any online publication — for exciting events, new stores, and sweet deals. I loved how quickly you could take in one week of Halifax life without the endless distractions of a phone. Like Ferguson said about the daily paper, I relished re-acquainting myself with it each week.
And it wasn’t just arts, culture, and Freeman’s ads.
When I first moved to Halifax back in the day, one of the pieces I read on my bus commute was from my future boss, Tim Bousquet, exposing the estate scandal that would lead then-Mayor Peter Kelly to decide against running for re-election.
Now that the Coast is not only online, but out of the hands of Kyle Shaw and Christine Oreskovich, I wonder how relevant it can remain. It still has great writers like Walton and Morgan Mullin, and it produced great work after it lost its regular print edition, so we’ll see.
One of my favourite segments of the old Coast was the Love the Way we Bitch/Love column. I’d read it on the bus to school and snap photos of my favourites to archive on my phone. As far as I can tell, they haven’t done them since they switched to the online model.
In honour of that hilarious section, and the changing of the guard, here are four Love/Hate entries from an anthology The Coast published in 2019. Submitted by readers, I think they truly encapsulate Halifax.
March 2012 – Build Something
Enough with the empty pits in the city, construct something. A fucking nuclear survival facility, a few yurts, anything!!! Make some decisions and we’ll try to carry on.
July 2015 – It’s Dartmouth
Dartmouth is not Halifax
—sick of HRM propaganda
December 2015 – To Garlic Fingers
Thanks for always being there, old friend.
—See you next weekend
March 2006 – Alberta Sucks
I know Metro Transit SUCKS. I know the bouncers SUCK. I know the weather SUCKS. I know how much it SUCKS to see your favourite bar/ restaurant/ hair salon/ cafe/ grocery store/ florist/ book store etc shut down for whatever reason. I know servers SUCK, taxi drivers SUCK, taxi companies SUCK, stinky people SUCK, students SUCK, non-students SUCK and just about everything and everyone else SUCKS… But do you know what REALLY sucks? Reading The Coast ONLINE from F%&$ing ALBERTA, wishing with everything I have that I could spend just 10 MINUTES in Halifax.
Audit and Finance Standing Committee (Wednesday, 10am) — virtual meeting
Harbour East Marine Drive Community Council (Wednesday, 6pm, HEMDCC Meeting Space, Alderney Gate) — agenda
Public Information Meeting – Case 23724 (Wednesday, 6:30pm, Tallahassee Community Centre, Eastern Passage) — application by Happy City Lab Inc. for a rezoning and development agreement to allow a 87-unit residential development on the lands at 1818 Shore Road, Eastern Passage
Community Planning and Economic Development Standing Committee (Thursday, 10am, City Hall) — also virtual
Active Transportation Advisory Committee (Thursday, 4:30pm) — virtual meeting
Youth Advisory Committee (Thursday, 5pm) — virtual meeting
Public Accounts (Wednesday, 9am, Province House) — Virtual Care Nova Scotia; with representatives from Department of Health and Wellness, Doctors Nova Scotia, and NSHA
Legislature sits (Wednesday, 1pm, Province House)
Legislature sits (Thursday, 1pm, Province House)
Kinase-independent synthesis of 3-phosphorylated phosphoinositides by a phosphotransferase: Implications for Salmonella infection and gallbladder cancer (Wednesday, 4pm, Theatre A, Tupper Building) — Gregory Fairn will talk
Optogenetic engineering of calcium channels and immune cells with tailored function (Thursday, 11am, Room 3H1, Tupper Building) — also online; Yubin Zhou from Texas A&M Institute of Biosciences and Technology will talk
3 Minute Thesis finals (Thursday, 6pm) — online competition for research-based master’s and doctoral students competing for $4,000 in prizes and a place in the regional version of the competition; register in advance
In the harbour
05:00: Atlantic Sail, ro-ro container, arrives at Fairview Cove from Liverpool, England
07:00: NYK Nebula, container ship, sails from Fairview Cove for Port Everglades, Florida
11:00: MSC Tianjin, container ship, arrives at Berth TBD from Sines, Portugal
15:30: Atlantic Sail sails for New York
16:30: CSL Kajika, bulker, arrives at Coal Pier (Sydney) from Halifax
- Some wet out there.
- For those still waiting endlessly for a much-needed operation, hang in there. I sympathize.
- At 4:20 this afternoon I’ll be in the middle of a cat nap.
- I see there’s now coffee-flavoured Coca-Cola: “Sips like a Coke. Finishes like a coffee.” Progress continues its relentless march.
- Health System Leadership Team is a government-named body if I’ve ever heard one.
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As a surgeon who keeps having all their lists cancelled this is driving me bonkers. It’s never been this bad.
Glad that you aren’t buying into the argument that the health care system is broken but rather that it is underfunded and not just NS but Canada and for decades. We spend less than OECD countries with similar GDPs-the UK, Germany, Sweden, France and New Zealand. And we are well below on hospital spending per capita when compared to Australia, France, Germany, Netherlands, Sweden, the UK.
At the same time, for decades Canada has cut taxes that could go towards increasing funding for health care; since 1980 corporate taxes have decreased from 36% to 15%; the income tax rate for highest income earners has decreased from 43 to 33%; and prior to 1990 capital gains was 75% but after 1990 was lowered to 50%
Dollars and numbers are confusing so to put the $51 million of federal dollars that will go to Nova Scotia to help address wait times in context- that’s ~half of the $100 million that will be spent on the two parking garages for 1500 private cars for the QEII re-development on the Halifax Common. That money could have gone to real and ready better options- park & ride, carshare, active transportation, shuttle services, transit passes, electric buses, or even a cheaper more compact efficient robotic parking garage on an existing parking lot by the Veteran’s Hospital.
This decision to ‘induce capacity’ for private cars comes at a time when many cities in the world are doing their utmost to get people out of their cars by providing real transportation options. Building parking garages ignores the cost to human health on several counts; increasing GHGs in a time of climate crisis; increasing the impact of transportation emissions & pollution and increasing motor vehicle accidents. Most importantly is the loss of public open space at a time when we know access to it is critical for mental and physical health and for dealing with the impact of the climate crisis. ~ three thousand citizens signed a petition against the parkades. You can remind the Premier to make better use of our too few health care dollars by writing email@example.com
Many people attend the QE II for an appointment and they travel from well outside the central peninsula. The notion that the hospital does not need a parking garage is absurd. A neighbour travelled from Dartmouth to Bridgewater for a 7:30 a.m.day surgery appointment – how was he supposed to get there ?
Shouldn’t we have a health care system that allows you to get treated close to home? Local clinics and hospitals are critical infrastructure. And for specialist appointments that require travel – yet another rationale for a provincial public transit system.
No matter where you live on Nova Scotia, or the Atlantic region you will or may be required to travel quite a distance for treatment. A provincial public transit system will not get you from Dartmouth/Halifax to Bridgewater for a early morning surgical appointment. The surgery begins at the time I noted and you have to be there at least 45/60 minutes before the time stated. HRM residents often travel to Kentville/Windsor for day surgery and the doors open at 6 a.m.
Couldn’t agree more about the old joys of The Coast, paper edition, which really helped me get to know and understand Halifax when I moved here in 2009. Once I had a pair of students analyze a year’s worth of Love the Way we Love/Bitch columns for a final paper in an urban studies class. It was great.
The healthcare situation makes me want to leave the country. While I’m still (kinda) young and healthy, I face an enormous tax burden but do not benefit from the free healthcare that a lot of the taxes go to pay for. Sure, I’ve gotten blood work done and gotten stitches a couple times for free, but realistically these services would have amounted to a couple thousand dollars if I did them in the US without insurance. If things don’t seriously change, how can I count on the health care system to be there for me if I need a hip replacement or a tumor removed when I’m older?
Asset-rich elderly people should be paying for this stuff, not asset-poor working people. Once again, I submit a (mildly NSFW, mild gore warning) proposal for a new national flag: https://upload.wikimedia.org/wikipedia/commons/8/82/Francisco_de_Goya%2C_Saturno_devorando_a_su_hijo_%281819-1823%29.jpg
Taxes. We all want the benefits but who wants to pay, eh.
“All right, but apart from the sanitation, the medicine, education, wine, public order, irrigation, roads, a fresh water system, and public health, what have the Romans ever done for us?”
Close to half of our provincial budget is for health care, and a quarter of the federal budget gets spent on health care. I don’t have a problem with high taxes as long as the services actually get delivered. I don’t think that rich people should have better access to medical care than poor people and a single payer system like we have is one way to implement that. My problem is that I pay taxes *now* for services that I am not confident I’ll receive in the *future*.