Shifting some of the money saved by these measures into public support for
pharmaceuticals and home care, perhaps through income-tax credits.
are other recommendations the committee has suggested it might make, such as encouraging
the provinces to buy pharmaceuticals jointly for their publicly subsidized drug plans
(usually aimed at the elderly and poor).
But the committee is unlikely to recommend that Ottawa and the provinces expand
the current medicare system, which is virtually 100 per cent publicly funded, into new
areas such as home care and pharmaceuticals.
In itself, that is curious, since Kirby and his 14 fellow senators also
concluded medicare's so-called single-payer system in which a public monopoly, like the
Ontario Health Insurance Plan, funds physician and hospital care is more efficient than a
mixed private-public system.
Kirby is asked about this in an interview. While it might be costlier for
governments, wouldn't it be cheaper overall for Canadians if home care and drugs were
fully covered by medicare? After all, Canadians already pay for extras either
out-of-pocket or through employer-financed drug plans.
"I wouldn't argue with that," Kirby says. "But how do you get
there from here?"
Politically, he says, expanding public medicare into areas that are currently
the preserve of the private sector would be tricky. Too many oxen would be gored. Some
might be better off, but others might lose. "It's the problem of the distributional
effects," says Kirby.
He notes the National Forum on Health, the last body appointed by Prime
Minister Jean Chrétien's federal Liberal government to investigate medicare, did
recommend expanding public health insurance into new fields such as home care and drugs
precisely because this would be cheaper overall.
What he doesn't need to say is that the forum's 1997 report was resolutely
ignored by the government that commissioned it.
When Kirby released the first of his five-volume report in March, he promised
recommendations that would avoid ideology and be based firmly on demonstrable evidence.
Since then, the Kirby committee has been surrounded by controversy. The
Canadian Health Coalition, a pro-medicare group associated with the Canadian Labour
Congress, has demanded Kirby resign as head of the committee, citing what it calls his
conflict of interest as a director of Extendicare.
(Kirby, in turn, asked for and received a clean bill of health from Chrétien's
hand-picked ethics counsellor, Howard Wilson. Wilson said, since the Senate committee is
only making recommendations about health care, Kirby is not in conflict.)
Perhaps more serious, however, were the charges levelled during hearings in
Winnipeg in October. Noralou Roos, head of the Manitoba Centre for Health Policy and
Evaluation at the University of Manitoba, calmly eviscerated the committee's fourth
volume, labelling it ideological and non-factual.
The committee's most striking omission, she said, was that it had produced no
evidence for its most basic starting points that more money is needed for health care and
that more private involvement is the obvious solution.
Kirby responded with what he called "teasing" rebuttals. But,
clearly, Roos had hit a sore point.
Indeed, a careful reading of Volume 4 shows there is little evidence cited for
most of the committee's observations. any appear to be based on common wisdom what people
believe to be true rather than verifiable fact. References to sources are virtually
For example, the report says Canadian medicare "is not nearly as one-tier
as most Canadians believe or as most government spokespersons claim," noting
"people who can afford it can, and do, already go out of Canada (usually to the
United States) to receive the medical services they require if their only alternative is a
long waiting line in Canada."
This claim is widely believed. But is it true? Do those who can afford it get
their medical care in the U.S.? The report offers no evidence to back up its claim.
Indeed, there is evidence to the contrary.
A study published in the Journal Of Health Affairs in 1998 that looked
at Ontario found the practice of crossing the border to obtain medical care, while widely
reported, was relatively rare, usually representing less than 1 per cent of health
Noting most Ontarians treated in the U.S. did so because they suffered a
medical emergency while travelling, the authors of that 1998 study concluded: "These
occurrences represent a tip without an iceberg."
As further evidence for what it calls Canada's existing two-tier health system,
the Kirby committee points out provincial workers' compensation systems already operate
outside of medicare. And the committee is correct; they do as do health systems for the
military, the RCMP, status Indians and federal prisoners.
But does the existence of these parallel systems matter? Do industrial accident
victims or federal prisoners receive, on average, faster health care than other Canadians?
Kirby says the committee doesn't know and never tried to find out.
The report cites what it calls "anecdotal evidence" to conclude that
people with money and connections routinely jump the medicare queue.
Again, this is what many people believe. But is it true? If true, how
widespread is the practice? Is queue-jumping by the wealthy and powerful more endemic in
Canada than in nations with explicit two-tier health systems, such as Australia?
The report doesn't answer these questions. "There's no way we can quantify
that," says Kirby.
On it goes. The options report notes approvingly that Sweden, "which is
generally recognized as being among the most socialized of the European countries,"
levies user fees on those who visit doctors and hospitals and concludes these fees
"are not perceived as impeding access (to care)."
Again, no evidence is given for this conclusion. And again, the committee seems
unaware of research that contradicts its claim. A 1998 article in the academic journal Social
Science And Medicine, for instance, says even Sweden's relatively small user fees have
discouraged poor people from seeking necessary medical care.
Part of the Kirby committee's problem stems from the fact that Volumes 2 and 3
of the report, which are said to contain the evidence used to justify its suggested
options in Volume 4, are not yet published even though they were signed off by the
committee in August.
Kirby cites translation problems for the delay. An aide says the committee
clerk fell ill. Whatever the reason, the lack of substance makes it difficult to evaluate
the Senate committee's claims.
Take, for instance, the committee's almost casual suggestion that Ottawa
consider scrapping one of the principles of the Canada Health Act, that of public
administration. This is the principle requiring provincial governments to offer medically
necessary services through a monopoly health insurance plan.
It does not prevent private-sector players from operating inside medicare; most
physicians are private. But it does prevent private insurance firms from covering
medically necessary services. You can't buy private insurance to cover, say, a hip
operation in Canada.
Tom Kent, a key adviser to then-prime minister Lester Pearson when national
medicare was implemented, points out that the principle of public administration was
crucial to the scheme, because it made universal health insurance affordable. That's
because a monopoly insurer, a so-called single payer, offers economies of scale that allow
it to operate far more cheaply than a host of private companies.
In fact, even the committee itself makes that point. In its first volume,
published in March, it cites a New England Journal Of Medicine study that says the
principle of public administration saves Canadians fully $10 billion a year.
Yet, by Volume 4, the committee is suggesting scrapping the idea.
"I do not know what to make of that," Kevin Taft, a Liberal member in
Alberta's legislature and his party's health critic, told the committee during hearings in
Edmonton. "The research is clear that a publicly administered system has enormous
gains in efficiency over a (private) market-driven system."
Kirby himself is not much help here. In an interview, he says he is firmly
wedded to the notion of maintaining a government-run, single-payer monopoly over health
insurance, no matter what his report says.
As for the committee's suggestion that the government consider letting private
insurers operate across the whole range of health-care services, even if this might lead
to an explicit two-tier system, Kirby says he was just trying to be controversial.
"I did that as much to be provocative as anything," he says.
"What troubles us is a situation in which we have such an essential service being
deliberately rationed by public policy-makers with the population cut off from any other
avenues of supply."
(In fact, the Canada Health Act does not prevent physicians from operating
outside medicare. But few do. Even in Alberta, where those who opt out are allowed to
charge whatever they wish, only one physician has opted out.)
Perhaps the strangest element of the Kirby report is its internal
inconsistency. At times, it is as if the committee hadn't even read its own work before
listing the options it thinks the government should examine.
In Volume 4, for instance, the committee suggests Canadians should look at
two-tier medicine as one way to curb lengthy waiting lists. But Volume 1 points out that
in countries that permit two-tier medicine, such as Britain and New Zealand, waiting lists
are longer than in Canada. It uses the word "myth" to describe the notion that
"a free-market system would solve the problem of waiting lists." It even
Whether the health system is one-or two-tier, Volume 1 notes, there is only one
set of doctors. If physicians are attracted to a lucrative private tier, they have less
time to work in the less-remunerative public tier. Adding a private tier to Canadian
medicare, it concludes, "would in turn create longer public-sector waiting
Similarly, the committee suggests in one part of Volume 4 that user fees
charging patients up front each time they seek a medical service are worth looking at. It
seems particularly amenable to targeted user fees (such as charging those who want to see
a doctor instead of a nurse), saying they could reduce frivolous use of the health-care
But the committee also says in another part of the same volume that user fees
don't work; that when they are low they don't produce enough revenue to cover the cost of
administering them, and when they are high they deny "access to the less well-off who
have the misfortune to require expensive services."
And in Volume 1, it dismisses as "myth" the notion that user fees of
any kind would deter frivolous use of the health system.
None of these contradictions may matter. In Ottawa terms, Kirby's committee is
a minor powerhouse. Deputy chair Marjory LeBreton is a well-connected Tory who served as
prime minister Brian Mulroney's chief patronage adviser. LeBreton has made no secret of
her feelings, calling the rival Romanow commission a waste of money.
Adding weight to the commission are Dr. Wilbert Keon, a respected Ottawa heart
surgeon, and Dr. Yves Morin, a former dean at Laval University's faculty of medicine who
acts as a special adviser to Health Minister Allan Rock.
Kirby himself is indefatigable. Unlike the chronically cautious Romanow, he
thrives on controversy. He is scrupulous about returning media phone calls and has made a
point of traipsing to editorial boards across the country to sell his committee's take on
Moreover, the committee's not-so-hidden leaning toward more private involvement
in medicare strikes a chord with powerful forces across the country.
Alberta Premier Ralph Klein is already chafing under what he considers to be
the onerous restrictions of the Canada Health Act. Ontario's Tory government wants more
private funding, as does the Ontario Hospital Association. The British Columbia Medical
Association is calling for private medical savings accounts, a kind of RRSP for health.
Perhaps most important, the Kirby committee's not-quite recommendations, even
those based on flimsy or non-existent evidence, fit a certain common wisdom.
"I believe in user fees," Senator Gerry St. Germain declared at
committee hearings in Vancouver. St. Germain, who is not a member of the Kirby committee
and who almost certainly has not read any of its reports, nonetheless had firm views that
day as he expounded his catechism, one probably held by many Canadians.
"I believe as well in competition in the private clinics. Competition
drives everything in our system. That is proven. The U.S.S.R. tried a system without
competition and that did not work. Our system is based on competition, so why not in the
private hospital side?...I just cannot believe that user fees would not work."