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THE STRAIGHT GOODS
(CAB-10),
Anchor/Reporters: DR JOHN GILLIS
HEALTH CARE IN
DR. JOHN GILLIS (CAB-10): Welcome, (inaudible)
viewers, to this episode of Doc Talk
as part of the Straight Goods series in (inaudible)
television. Today's topic,
Medicare in
My name is Dr. John Gillis. I'm your host in this second episode of the season. The goal
of our show, Doc Talk, is to bring common medical issues and issues that are in the news
about medicine to you, the public, so that you can be informed and so that you can make
better decisions about your own health care and when it comes time to make decisions
politically and personally.
Our goal today is to talk about all the issues surrounding Medicare: how Medicare started,
how it's evolved, and how it's come to a point of crisis that we hear so much about every
day in the media.
To talk about these issues, I've been joined today by three guests who all bring a
different perspective about the Medicare system. First, to my far left is Dr. David
Zitner.
DR. DAVID ZITNER (General Practitioner; Professor of Medicine,
GILLIS: (Inaudible)
ZITNER: Thank you.
GILLIS: David is a general practitioner, professor of medicine at
Next to David is Mr. Ian Johnson. Ian is the Vice-Chair of the Nova Scotia Citizens Health
Care Network. Thanks for being here, Ian.
IAN JOHNSON (Vice-Chair, Nova Scotia Citizens Health Care Network): Thank you, John.
GILLIS: And closest to me is Dr. Ben Hoyt. Ben is an ear, nose and throat surgeon in
training, and the immediate past president of the Canadian Association of Interns and
Residents.
Gentlemen, we have a big topic today. Clearly Medicare is something that affects us all.
There's a lot of issues. Before we get into some of the specifics, maybe you could tell us
a little bit briefly about yourselves and about what your role in this debate has been.
Start with you, David.
ZITNER: Good day. I'm David Zitner. I'm a family doctor and Director of Medical
Informatics at Dalhousie. As a family doctor, I was impressed and in fact quite depressed
by the appalling deterioration in health
health care in
Although we have a single-tier system for price, where nobody can pay for publicly insured
services, people get different qualities of care depending on the whims of government.
I came to realize that Canadians lacked the information needed to manage, monitor and
evaluate our health system. Working with the Atlantic Institute, we created a paper called
Operating in the Dark: The Gathering Crisis in
Section 19 of the Nova Scotia Health Authorities Act says that the role of a district is
to govern, to plan, to manage, to monitor, to evaluate, and to deliver health care
services. What other group in society is encouraged to evaluate the services they deliver?
No wonder, by and large, we've only heard good things about health care in
We've been arguing that in order to overcome this conflict of interest, and one of the
necessary conditions to improve care in
GILLIS: OK, that
that apparent conflict in the system is something we're going to
get into later. I think it's very interesting. Thanks for those comments. Ian, could you
tell us a little bit about your role in the health care debate?
JOHNSON: Sure. Thank you very much, John. My name is Ian Johnson (inaudible)
(SPEAKERS OVERLAP)
GILLIS:
very excited, so we'll
we'll carry on.
JOHNSON:
(inaudible)
I'm here as Vice-Chair of the
I guess I'm here as a Medicare advocate. I'm not, at the same time though, here to say
everything's perfect. No one
none of the people I'm associated with say we need to
stay where we are. We have a vision going back to 1964 (inaudible) reviewed in terms of
moving ahead to make sure that all the fruits of health sciences are available to
everyone, regardless of their situation.
So we want to move ahead and
in a publicly funded system, which isn't a monopoly. I
disagree with that. It's
it's a whole range of providers, most of whom are
non-profit private actually. So
and yet the role
there's a very important role
for the public and for non
for front line workers in all of this.
GILLIS: OK. Well, thank you very much for those comments. I think it is very important to
highlight the ultimate point of Medicare is to take care of everybody. And I
I also
like the point that we often get hung up on physicians. The health care system is not just
about physicians; it's about a lot of different people.
GILLIS: Ben Hoyt, Dr. Ben Hoyt, could you tell us about what your experience has been and
your role in this
this debate?
HOYT: Well, sure, John. Thanks. As the president of the Canadian Association of Interns
and Residents last year, my role was pretty straightforward. I represented more than 5000
doctors in training. We are the future of the profession in terms of the
medicine
specifically, not of the allied health professionals, obviously.
And we have a very vested interest in
in this debate and the direction that it takes
because we're going to be using the system for
for years to come. So we wanted to
make sure that
that the physicians of tomorrow had a voice in the debate. I was
fortunate enough to be that voice over the last year.
GILLIS: That's great. I think it's important to realize, as we make any changes in our
system, the physicians that are out there right now, a lot of them are on the verge of
retirement, and without the
the viewpoint of the new generation, you know
(inaudible)
HOYT: For sure.
GILLIS: Talk about a number of goals today. We're going to talk about who the major
players are; how did public health care evolve; why is it under duress; what options for
change have been suggested; and what are the pros and cons of some of these options. And I
guess we're going to move into that right now.
So just to give us a bit of an overview, Ben, maybe you could tell us who the major
players in the health system are today.
HOYT: Sure. Often (inaudible)
people sort of think of the major player as being the
patients who receive the care
GILLIS: Of course.
HOYT:
and the physicians, nurses, allied health professionals who provide it. Those,
in my mind, are the two key major players, but we can't forget the governments as well
because, as has already been mentioned, and my opinion is somewhat different, but
governments certainly do play a role in managing, evaluating and funding health care, both
federally and provincially. So really there are four players: the feds, the provincial
governments, us who provide care, and those who receive care.
GILLIS: David, maybe you could help clarify for us
I think this is often an area of
confusion, that both the federal and provincial governments are involved. How is the
federal government involved? What is their responsibility?
ZITNER: The federal government's involvement largely has been termed a system of
(inaudible)
People probably are aware of the Canada Health Act. The Canada Health
Act has five principles: portability, accessibility, universality, comprehensiveness.
Those are the four that are most important to patients. The one that we hear mainly about
is public administration.
And under the Canada Health Act, the federal government is meant to withhold transfer
payments to the provinces for failing to comply with elements of the Canada Health Act. I
haven't heard of any province being penalized for not providing comprehensive, universal,
portable and comprehensive services. But there are ways
we often hear discussions
about penalizing the provinces for not maintaining a system that's solely publicly
administered.
And that doesn't surprise (inaudible)
because the role of government is to do public
administration. So just like any other monopoly trying to maintain its monopoly, that's
what you would expect them to (inaudible)
GILLIS: So I guess, Ian, we've heard about the Canada Health Act (inaudible)
a
little bit more. We have a bit of a conflict in the sense that the provincial government
has the constitutional jurisdiction for health care. Could you tell us a little bit about
that?
JOHNSON: Yeah, sure. Essentially the (inaudible)
experience has been the provincial
government is really responsible for the administration and delivery of health care
services in
in their jurisdiction. That doesn't mean they actually have to deliver
it, but they have to organize it.
They're the
the ones that are on call and accountable, even with a regionalized
health system, for how health care is delivered within the province and also for dealing
with issues around, for example, health
health human resources, funding
(inaudible)
and the whole strategies that we're hearing about in terms of the
possible flus or, you know, pandemics. So it's a whole range of responsibilities that fall
under provincial jurisdiction.
GILLIS: Absolutely. So to summarize what you three gentlemen just said, you have the
federal government with a set of rules and the
and the chequebook, in
in many
ways, and you have the provincial government, who's in charge of running it, but they have
to
they have to talk and
and agree on it. If they don't you reach a potential
conflict.
UNIDENTIFIED: The federal government has some responsibility for delivery too
GILLIS: Right.
UNIDENTIFIED:
for certain groups
(SPEAKERS OVERLAP)
ZITNER: It's interesting that Ian said that the provincial government has responsibility
but they don't have to actually deliver. And I know in my clinical practice, many of my
patients feel they're doing a great job of not delivering the care that
that the
public really needs.
GILLIS: OK. So I think we've done a good job of sort of setting up the
how it is
governed, and you
you already see some of this conflict emerging. Maybe we could
just take a step back for a few minutes to talk about how we came to this system.
We haven't always had universal health care, as we know it. And maybe Ian, you
you
lived in
JOHNSON: Sure. I'll try and do that. I think one thing that's important to recognize is
Medicare wasn't given to us on a silver platter. It was something that took a lot of
public and front line health care worker and organizational support to achieve.
In the case of
So we had many parts of it, but in terms of what we now call Medicare, it was Saskatchewan
that led the way, first with pre-paid hospital insurance in
in '57 and then
and then later, in '62, with the pre-paid medical care insurance.
But those things didn't happen accidentally (inaudible)
it took a lot of effort,
especially with medical care insurance, what we call Medicare, because the
the
established medical profession at the time opposed it, actively opposed it, so did the
insurance industry. So
so did the provincial Liberal Party (inaudible).
So
and it took three weeks of a doctors' strike and vigorous effort by citizens to
organize (inaudible)
of medical care services to ensure we now have what we call
Medicare (inaudible)
then went to the federal government to look seriously
when
when John Deifenbaker from Saskatchewan was Prime Minister, he appointed
(inaudible)
who was also from Saskatchewan, a Chief Justice, to look at the whole
health care system. And that opened the door for
for what we now call Medicare
(inaudible)
provincial systems.
So it was
it wasn't something that just happened, absolutely. It was very much
the public played a major
even in this province, we had Medicare Now committees with
church people, labour, community leaders pushing for Medicare. So it wasn't a given, even
when they had it in
GILLIS: Ben, who's Tommy Douglas? We hear his name around a lot in the media. Who was this
person?
HOYT: The media likes to refer to him as the father of Medicare.
GILLIS: Mm-hmm.
HOYT: Tommy was the Premier of Saskatchewan back when a lot of the
GILLIS: OK. So I guess to take us forward, Ian has given us a little history about how
Medicare came to be. It did start in
What are the issues, and maybe David, you can comment on this for us, as sort of how
things started to change, is that initially when the federal government contributed under
Diefenbaker, the federal government committed to spending 50 cents on the dollar towards
health services. That has changed significantly. How has that affected us, David?
ZITNER: It's affected us in the sense that Canadians now are in a system that may not
actually be meeting their needs. The
the goals of the Canada Health Act are to
improve the health of Canadians.
We don't cover, for example, drugs. We don't provide the comprehensive catastrophic drug
coverage that Romanow, Kirby and our own (inaudible)
the Romanow report suggested.
We have a system that has a depth of coverage for the few things that it covers, like
hospitals and doctors, but not a wide scope.
It was very interesting that Mr. Romanow suggested that patients should pay something for
drugs, but they shouldn't be harmed catastrophically. For doctor care patients don't pay
anything.
And it's odd to me that we don't even pay attention to what Tommy Douglas, the founder of
Medicare, said. He said in the Legislature I think there's value in having every family
and every individual make some individual contribution to the costs of their coverage
under Medicare. I think it has psychological value. I think it keeps the public aware of
the costs, and it gives people a sense of personal responsibility.
And after all, if those of us who could pay paid something for the small costs of care,
then government could use their money to subsidize people so that they get their
catastrophic needs met so that they didn't have to wait a long time for necessary,
important surgeries.
(SPEAKERS OVERLAP)
GILLIS: We're going to
we're going to go to break briefly. We're going to come back
with an analysis of Tommy Douglas.
UNIDENTIFIED: That's really a misrepresentation
GILLIS: OK.
UNIDENTIFIED:
of Tommy Douglas.
GILLIS: We'll start with that. Thank you.
(BREAK)
GILLIS: Hi there in (inaudible)
television land. I'm Dr. John Gillis. We're back on
Doc Talk, talking about Medicare in
We'll come back to Mr. Ian Johnson, who was talking about the role of Tommy Douglas in our
health care system, and some of his comments about how Canadians should be. Evidently
money has become the biggest issue. Ian, what are your thoughts on the quote that Dr.
Zitner just referred to?
JOHNSON: Well, I think it's taken out of context. I think that, first of all, again, what
I tried to say earlier was that Medicare was done in stages, and one of the stages was to
allow for moving (inaudible)
private system. And
But he was very strongly against what David then went on to talk about, in terms of user
fees or extra billing or health premiums, and was very concerned in the
in the early
eighties when a number of us (inaudible)
shift to the system based on that kind of
so-called patient participation (inaudible)
just to speak a little bit about the
funding arrangements, you're right. It was earlier 50/50. But in the mid-seventies, the
federal government decided it was too costly and shifted to what they called established
program financing.
But the worst thing, I think, that's happened in terms of funding was the Canada Health
and Social Transfer under Paul Martin as Finance Minister, which represented a devastating
blow to publicly funded services and created some of the problems. I agree with David,
there are some serious problems that still exist today because of that substantial
cutback.
GILLIS: OK. I'm going to come ahead to the era of Paul Martin in a few minutes. Ben, maybe
you could tell us about sort of what happened. We talked about Diefenbaker spending 50
cents on the dollar. That started to get cut back. How did provinces respond when they
were told they were no longer getting 50 cents on the dollar? Where were they going to get
the money?
HOYT: Well, I totally
any government funding comes from the public. So provinces had
to find new ways to get the funding. And because health care delivery is a provincial
jurisdiction, each province went about it their own way
GILLIS: Right.
HOYT:
to find the best way to provide care for
for their citizens. Some
provinces just sucked it up out of tax dollars, they increased their taxes, while other
provinces have gone recently as far as health premiums and
and user fees.
Earlier on, it was (inaudible)
just cutting other problems so that they could fund
costly health care. There's no doubt it's costly. The money's got to come from somewhere,
so the tax base was the obvious
the obvious source, the provincial tax base.
GILLIS: And David, you alluded
alluded earlier to the Canada Health Act. As Ben
indicates, as
as funding was cut back, provincial governments, who are the ones that
are administering the services, had to find the money. User fees happened, hospital fees
happened. And clearly, as Ian alluded to, this was sort of against the fundamental
principle of Medicare.
So in 1984 the federal government passed the Canada Health Act. But that didn't happen on
its own. There was at least
I was part of it
a two- or three-year struggle
across the country to make that issue front and centre and to force the federal government
to act. So it didn't happen just because (inaudible)
was a nice thing to do.
JOHNSON: Absolutely. I'm not sure if it's against the principles. It's against one
principle: public administration. The fact that people don't have access to care, they
have long waits for surgery, they have long waits in emergency departments, they have long
waits for specialists, we don't have a universal system. People who work for the federal
government, some categories, get preferred rapid access, workers compensation patients,
and a whole group of other people are committed to pay.
If a patient says that they have foot pain and is disabled, they're allowed to pay for it,
but if they say what bothers them is that it's a cosmetic problem and that it's not
medically necessary. So how bizarre is it that if you have a severe, serious medical
problem you can't get the care you need; if you have a trivial one you can pay for it?
And comprehensiveness
in Nova Scotia the provincial government (inaudible)
it
sounds trivial, but in Canada if your ears are plugged and you're deaf because you have
wax in your ears, largely only a doctor can take it out. It seems to me that this is
medically necessary.
GILLIS: OK. Let's break
let's break down these five principles, shall we? Ben, what
does public administration mean?
HOYT: That one's probably the most straightforward of the principles. It is exactly how it
sounds. The
the governments, rather than private industry, are going to be
responsible for administering health care. That's
the reason that is in there is to
ensure that we don't have for-profit companies coming in and trying to make money off
health care. The government has decided that health care is a basic service in life for
all
for all Canadians. They shouldn't have to
to pay for it, and somebody
shouldn't have to make profit off of it. So public administration was the first and
foremost principle (inaudible)
governments are going to run it and not private
industry.
GILLIS: Now, just briefly, Ian, we already deviated from this.
JOHNSON: Yes, absolutely, and
and in many ways. David's talked about some of them.
And
and I think the general problem we have with the Canada Health Act is not what
it says but its enforcement. It is not being enforced.
GILLIS: Absolutely.
JOHNSON: The federal government has allowed
UNIDENTIFIED: So (inaudible)
JOHNSON: In
in
in fact, public administrators are (inaudible)
so the
heads of
some CEOs of some hospitals, large hospitals, are earning in the range of
two, three, four hundred, and even 500,000 isn't unheard of, what does the meaning of
profit mean when the individuals who are publicly administering our health system are
earning large (inaudible)
GILLIS: Well, that
that is a general problem with commercialization, actually.
UNIDENTIFIED: (Inaudible)
health systems, when (inaudible)
government had
taken up the whole idea of being like a business, whether it's a business plan
(SPEAKERS OVERLAP)
GILLIS:
they're a business but they're not a business.
UNIDENTIFIED: That's right.
GILLIS: Could we talk
Ian, maybe you could talk about comprehensiveness. David has
alluded to this a little bit.
JOHNSON: Sure.
GILLIS: It's interesting that comprehensive isn't always comprehensive.
JOHNSON: Yeah, absolutely not. I
I agree with David (inaudible)
But again,
going back to (inaudible)
'64 and '79, the whole vision was that we would move to a
point to expand that coverage.
Now, everybody recognizes you can't move in one step to have universal drug coverage,
technical aids covered, a whole range of other home care, long-term care. But there
there should be provision back again to expand into a whole range of services that
would
that people need.
Again, I mean, I was part of helping to set up a dental service at a community health
centre. Unfortunately, we had to close that service after a few years because
not
because it wasn't needed, but it because it was
it was just too costly for a small
facility to operate it. So
GILLIS: Ben, one of the comments that
that I've heard is that comprehensiveness is
both arbitrary and it varies from province to province, you know, meaning eye exams used
to be covered but now they're not, and it varies from province to province. What are your
thoughts on that?
HOYT: That's
that's totally fact, for sure. Because we're set up where the provinces
administer and manage and deliver health care, the provinces have the right to choose what
will be covered and what will not. Whether that's just or not, whether it's right or not
is debatable.
There have been movements lately afoot from groups like the Canadian Medical Association
and the Wait Times Alliance, which stem from the Canadian Medical Association and other
groups, to try to get some sort of standardization from province to province. If eye exams
are deemed medically necessary in one province, it doesn't make a whole lot of sense that
they wouldn't be in another.
So yeah, there's a lot of variety. It'd be nice if we could tighten that up. But provinces
are reluctant to let go of their jurisdictional authority, so it's
it's a bit of a
pipe dream.
UNIDENTIFIED: We even have a problem, I think, with the so-called division between insured
service and so-called uninsured services. That's what David was talking about. And it's
got to the point
I mean, I was part of the effort to get rid of extra billing in
this province because it was a real barrier for a lot of people, who wouldn't get service
or didn't feel they could ask the doctor not to pay.
Now, since '84 (inaudible)
Canada Health Act, and
UNIDENTIFIED: (Inaudible)
Canadian Medical Association said privatization was
necessary, but not necessarily privatization. And what they meant is that in a developed
economy, it's tragic if people don't get the care they need. And intelligent,
enthusiastic, energetic people will find ways to get the
the care they need,
independent of what government says they can or can't (inaudible)
Even in the
GILLIS: But the people that are suffering now are women primarily, low income people,
people of visible minorities?
UNIDENTIFIED: (Inaudible)
at the moment. I mean, these are the people who use the
system, who would benefit
have benefited the most from
UNIDENTIFIED: Which
UNIDENTIFIED:
Medicare.
UNIDENTIFIED:
which is why we say that governments should be subsidizing those
people directly, at the same time as they charge people like the folks on this panel for
the services that they can afford to pay for.
UNIDENTIFIED: No, the best way to do it is a universal system.
(SPEAKERS OVERLAP)
GILLIS: Universal and portable sort of speak for themselves. It's available to everybody,
and
and if you're in
Let's talk about accessibility. OK? And I think this is one of the biggest issues. We hear
people talking all the time: I can't get my hip done, I can't get my cataracts fixed. Ben,
you're a surgeon in training. What do you see on a day-to-day basis (inaudible)
accessibility to, say, surgical services?
HOYT: You see unfortunately what the media portrays on a day-to-day basis, and it's wait
times. People have to wait unfortunately (inaudible)
where the wait times are
ridiculously long. There are plenty of patients out there who are waiting for hip
replacements for more than a year, waiting for cataract surgery for more than a year.
These are people who can't see or can't walk, and they have to do so for a year before
they can get access to service.
The Canada Health Act says that everybody should have access to insured services. It
doesn't define what that access is. It doesn't define what a reasonable wait time should
be. And that's a big gap that needs to be addressed. We have to figure out how long is too
long and make sure this
that people are getting this access that they need.
GILLIS: I think we have some different opinions on this panel, but I think we could
probably all agree that accessibility is a problem. I think where we might differ is how
we fix it. Ian, just briefly, what are your thoughts on accessibility right now
(inaudible)
?
JOHNSON: Well, I agree, it is a problem. No question that wait time is a major issue. I
guess I may differ from others in terms of how to approach that. I think we've seen, and I
think there is some evidence to suggest this, that progress can be made within the public
system to address it because, for example, Saskatchewan in one year (inaudible)
capacity by getting more information, as David said. They've actually made a major advance
in terms of reducing surgical wait times. So
and the western
the whole Western
Wait List Management Strategy shows that the
that it can be done.
And then the other big problem of course is health human resources. We don't have enough
people
GILLIS: (Inaudible)
JOHNSON:
to
and that
that clearly has to be addressed. What I think is a
non-solution
I mean
I mean, you
you go back to
in the history of
Medicare (inaudible)
is to assume that private, for-profit health care can help
address it, when the evidence is, from internationally as well as within Canada, that it
doesn't. It actually makes the problem worse.
And that's because it's
it doesn't exist on its own. It draws from the public
system, takes resources away.
GILLIS: OK. We have about a minute to go before we go to break. But David, maybe you could
give us a comment on your thoughts on accessibility.
ZITNER: Well, we hear quite often this comment about
Ian, and maybe after the break
talk about accessibility. But this paper we did (inaudible)
definitely not the
Romanow Report, actually looked at the literature around private and the hospital sector,
what the literature really does say.
And there's no question, and my opinion is when the private sector should be delivering
services and when the public. And perhaps after the break we can discuss that.
GILLIS: Absolutely. I think we (inaudible)
a good history. I think we've talked a
good deal about where the conflicts lie in both the money being taken out of the system,
and the fact that the Canada Health Act, even though it's a nice set of principles, is not
being applied universally to people all over the country, and perhaps is not being
enforced. So I think after the break, gentlemen, we'll get into those topics.
(BREAK)
GILLIS: Welcome back to Doc Talk on the Straight Goods series on (inaudible)
television. I'm Dr. John Gillis, your host. Today's topic, with my guests Dr. David
Zitner, Ian Johnson and Dr. Ben Hoyt, is Medicare: A System in Crisis.
Before the break, we gave a good history of Medicare. We talked about how we've come to
where we are today. The extension right up to 2005 is that the Canada Health Act came in,
money continued to be an issue, in the nineties the Chretien government had to make some
budget cuts, the system lurched further toward crisis. Drug costs went up, technology
costs went up, Canadians live longer, and we've reached a point I think that we would all
agree was a crisis point.
What I think we want to talk about now is where do we go from there. How do we fix the
system? We know where we are. Where do we go? OK? (Inaudible)
talk about
accessibility, I'm just going to read
read a comment that actually Dr. Zitner
provided to me, and I'll ask Ian to respond to it.
In the past, before, people shouldn't be denied health care because they can't or won't
pay for the health services they need. Now, people must be denied health care because
their neighbour can't or won't pay for necessary health services, or because
governments
governments can't organize the system properly.
Your thoughts on that, Ian, and then David, we'll hear you as well.
JOHNSON: I find that very confusing. And I think
I guess what we're trying to deal
with in terms of accessibility is
and as I said, in terms of why we have Medicare,
is to ensure that those
that insured services or really medically necessary services
are provided without barriers. So whether those are financial, geographic, linguistic, a
whole range of barriers, that's what want to move towards.
So we
I hear that Ben, he
Ben had this
this clear set of indicators of
what that
how that should operate. But clearly, we have the Canada Health Act,
because of financial barriers, from user fees and
and extra billing by physicians.
And that
that's very clear. There is research that shows that is a barrier,
especially for persons on low or fixed income. There's no question about that.
GILLIS: (Inaudible)
respond, David, just the flip side of this. And this is
something that I think is interesting. The system is set up to
to allow
accessibility to all Canadians, as it should be. This is a fundamental component. David,
if the system is preventing somebody with the money from getting a better care, is that
also a problem? Should
should
is there a problem when you're just offering
better care for certain people? What do you think?
ZITNER: I guess it depends on who you ask and which political walk of life they come from.
I
I tend to lean right towards the Medicare system. But at the same time, I have a
hard time justifying telling somebody that they can't spend their own hard-earned money to
make themselves better, when they can spend it on anything else they want in this country.
The ideal situation would be let's make it so they don't have to spend that money. Let's
make the public system that gives care to everybody good enough that you shouldn't want or
need to spend your own money on it because the government's providing it fully and
and
(SPEAKERS OVERLAP)
UNIDENTIFIED: Exactly.
UNIDENTIFIED: I think the fundamental difference maybe we share in this table and in
and in the public generally is
is health
whether health care is a business, a
commodity, or something that should be a universal public service provided through
collective responsibility. And that
that's a fundamental difference. And again and
again, that's why we have Medicare, because before we had privatization, like some people
are still advocating, that didn't work.
GILLIS: Let's have David jump in.
ZITNER: I
I don't think that's the fundamental difference. The fundamental
difference is between people who think that everyone should have adequate care or a system
where things that nobody should be allowed to pay and we should all suffer equally. I
think the real issue is that many of us feel that government's role is to subsidize those
who aren't able to pay so
UNIDENTIFIED: But you know, David
(SPEAKERS OVERLAP)
ZITNER:
that they can get the care equal to their neighbours. We have car insurance
that doesn't pay topped up first dollar coverage. Many of us are afraid that as
governments pour more money
more money into health care, and we've seen care has
gotten continually worse despite this $41 billion, which is hardly pocket change, even for
government, despite this infusion of money, many people aren't getting the care they need.
Let's let people pay for the care that they can afford (inaudible)
Let's do what
Romanow said and allow people to pay, so that they have a broad scope of coverage, and let
government subsidize poor people so that they can get equal care.
GILLIS: Yeah, I think it's
it's tough, and
and I think you brought up a good
point about
or maybe I guess it was Ben, about buying what you want. I think in the
eyes of a lot of Canadians, and
and I'll share my bias is from this point, if you're
rich and you want to buy a Lexus, then go for it. You can do that. But your
your
heart surgery and your life, I think in the minds of many Canadians, should be equal.
Everybody has that right because they were born in this country and they're a Canadian
citizen.
I think most of us agree on that; it's just a
a real difficulty in how to get there.
UNIDENTIFIED: We all agree (inaudible)
UNIDENTIFIED: Yeah, and I just wanted to basically make a similar comment. And the
comparison being drawn by Dr. Zitner to
to car insurance, yeah, there's differences
in car insurance, but driving is a privilege, not a right. Buying a car is a privilege,
not a right. We all seem to agree that health care is a right, so we shouldn't be drawing
comparisons to our health insurance.
You also made the comment that people who believe in Medicare feel that we should all
suffer equally. We don't feel that anybody should suffer. We feel that we should have a
thriving public system in which nobody has to suffer. And that's
that's our goal.
It's not so that we can all suffer together; it's so that nobody has to suffer.
The problem with allowing people to purchase certain services is that it
it takes
away
it undermines the public system, either in the short term or in the long term.
And we've seen that now across
you know, in
in the
And clearly that
and research has been going (inaudible)
that shows if we ever
had, like Dr. (Inaudible)
and others, in that analysis, if we ever had a for-profit
hospital system, there would be at least 2000 more deaths in the country a year. And
that's pretty stark. And similarly, about 2500 deaths if we had a for-profit
(inaudible)
UNIDENTIFIED: (Inaudible)
between one and ten percent
UNIDENTIFIED: (Inaudible)
UNIDENTIFIED:
between one and three percent of people admitted to Canadian
hospitals.
UNIDENTIFIED: But the point is
the fact
the fact is that the number that he
quotes, other health systems have far fewer preventable deaths.
GILLIS: OK. Well, gentlemen, it sounds like we agree that it doesn't work.
UNIDENTIFIED: OK.
GILLIS: So one of the reasons why we're here, despite different opinions, where do we go
from here?
Some general comments in terms of provisions for change, and my guests are going to expand
on this. How do you fix it? Keep the present system the same but make it work better,
number one. Number two, push beyond (inaudible)
the current system, user fees,
etcetera. Number three, introduce, and we'll use that in quotation marks, a two-tiered
health system. We already have it, to some extent.
What I'd like, I guess, to hear from my guests, and maybe we'll start with you, Ian, along
the lines of keeping the system the same, what has been done by people like Roy Romanow,
and what more can we do to keep the system as it is and make it function?
JOHNSON: I
I should be clear. I'm not here to say that we want to keep the system as
it is.
GILLIS: Right.
JOHNSON: We want to keep the publicly funded
GILLIS: Yes.
JOHNSON:
and the publicly controlled system.
GILLIS: Absolutely.
JOHNSON: What we want to do is expand, though, and to make sure that
that there is a
much better comprehensive range of services that would deal with the wait times. I mean,
these things are fixable, you know.
We need a strong preventive health care system, a primary health care system. That's what
I'm part of (inaudible)
The problem is governments and their eyes in different
forums, whether it's think tanks or other groups, suggest that there
that we need
private sector participation in order for this to work.
GILLIS: What are
what are those ways to make it work under the current universal
system?
JOHNSON: Well
GILLIS: Give us
give us some examples.
JOHNSON: Sure. Well, as I said, in terms of primary health care, I've been part of a
community health centre. There is evidence to show that we have high
we have
inappropriate (inaudible)
in hospitals, in tertiary care, for
for things that
can be done in a community health centre setting, at a
at the local level. And I
don't just mean solo practice; I mean group practice with other health disciplines and
consumer and publicly controlled. Those
there is research to clearly show that
the
the costs can be reduced.
And we
we now have a situation where (inaudible)
information is that over half
the visits to emergency departments shouldn't happen. People shouldn't go. It's not their
fault, but that's the way the system is structured. We need to change the structure of the
system so that it allows for an emphasis on primary health care and prevention
(inaudible)
along with providing adequate human and health resources to perform the
services (inaudible)
wait list management strategy.
Those to me are three major changes that are
that are needed.
GILLIS: Going to (inaudible)
Ben, who's been around (inaudible)
What can you
tell us about the future of
of Medicare?
HOYT: Well, Mr. Romanow was
was our
our Health Commissioner. I think it was
Mr. Chretien who appointed Roy Romanow as
as the guy who was going to go coast to
coast, city to city, town to town, every nook and cranny, and find out what Canadians
really feel about health care, get to the people out in the hospitals and in the clinics
and in the doctors' offices to see how the system is currently running and what needs to
be done to fix it.
At the end of the day, his report stated that the current public system is sustainable; it
just needs a lot more money and it needs a lot of improvements in terms of what is
covered, what isn't covered, and how it's covered.
But realistically, he's
he's
he (inaudible)
government appointed
individual who really did a thorough
thorough review of the health care system in
GILLIS: OK. David, what do you think about the comments from Ian and Ben about sort of
keeping it the same versus moving (inaudible)
ZITNER: I
I agree
agree with Ian's comment that we need to change the
structure. And Romanow and Kirby
in particular Kirby said that we need to separate
government's role as an administrator from its role as an insurer and evaluator. But I
think we need to strengthen the role in evaluation and regulation.
I'm quite (inaudible)
Ian's quite correct that the clinics provide excellent care.
They also cost substantially more.
UNIDENTIFIED: (Inaudible)
ZITNER: Well, the evidence is that they cost about $180 to $200 per patient.
UNIDENTIFIED: (Inaudible)
ZITNER: Compared
compared with other clinics, but
but they have a broader
range of coverage, which is how governments in
GILLIS: David
David, let me ask you to be point blank what you think. Do you think
we
that Canadians should be able to pay for private insurance and that physicians
should be able to provide
provide services for fees outside of Medicare?
ZITNER: I agree with Kirby and Romanow, who say that people should be able to pay for
services that are necessary and important and that governments aren't delivering. And I
think that it's horrendous to have people dying, disabled and uncomfortable because
somebody says their neighbour won't pay for the care that they desperately need.
UNIDENTIFIED: I
I find that very appalling. I mean
(SPEAKERS OVERLAP)
UNIDENTIFIED: We're talking about a public system. We all contribute through tax dollars.
I guess one of the points I have about this is why should people have to pay twice. Why
should they pay when they haven't received the service or need a service? That
that's the fundamental barrier that's
it's contrary to the accessibility principle.
And
and again, I say that the evidence seems to be that once you get into that
system, that you undermine the public system.
UNIDENTIFIED: Forty-five percent of government spending
program spending goes into
health care. If we take
(SPEAKERS OVERLAP)
UNIDENTIFIED:
sixty, 70, 80 percent, we won't have the other public service
(SPEAKERS OVERLAP)
GILLIS: How do you respond
how do you respond to the
to the statement that
people that are rich can pay for services, that that's less money that has to come out of
the public pot, and that's better for everybody else?
UNIDENTIFIED: It doesn't work that way.
(SPEAKERS OVERLAP)
UNIDENTIFIED: (Inaudible)
When you get into that arrangement, as other countries
have, and that's the problem with private insurance, is you have this
you try to
move to a separate system, and it
and
at least outside of the public system.
And when you do that, that's taking money and resources out of the public
it's
taking health care workers often, who will go over and work in those systems. So the
then the waiting list problem (inaudible)
I mean,
So when you move to (inaudible)
we need to focus the resources in the public system.
When you move to separate it, it takes away from it. It makes the problem worse in terms
of wait times and in terms of quality care, frankly.
GILLIS: And let
let's (inaudible)
gentlemen, on the
on the problems we
face and on some of the issues with our public and private financing. After this break I
think we're going to get a little more into some of the
some of the options and some
of the pitfalls of public and private. And I look forward to your comments on those
issues.
(BREAK)
GILLIS: Welcome back to Doc Talk on (inaudible)
television. I'm Dr. John Gillis.
Today's topic, Medicare: A System in Crisis. Back with Dr. David Zitner and Dr. Ben Hoyt
and Mr. Ian Johnson.
Before the break, we were discussing public
pardon me, private financing, and how
that helps or hinders the system. The next question I have for you, Ian, is the concept of
user fees. We often hear about (inaudible)
you just charge people ten dollars every
time they go to the doctor, they won't go as much, and there's this great wealth of money
for the system. Everybody's happy. Is that true, or is that a false statement?
JOHNSON: Well, no, everybody isn't happy. And again, as I tried to say earlier, the
research suggest that it is a major barrier. It's contrary to the sensibility. That's one
of the reasons we have a Canada Health Act, is so people don't have to pay those fees.
Unfortunately, governments have chosen, especially with funding cutbacks, to
to
instigate those or
or expand those that exist.
So it's a
it's a real problem, especially for persons or low or fixed income who
just
because then it sets up a barrier in terms of their participation and they have
to come forward and say I'm not able to pay this, and it doesn't work. So the best
response to that is to make the service universally available so that people don't have to
do that.
And it's the best way in terms of costs too because when you get into separate systems,
then you're getting into administrative costs and
and it's
it's inefficient
and ineffective.
GILLIS: OK. Let me ask Ben a quick question, and then David, I'd like to hear your
thoughts on government accountability. One of the comments that you hear from people who
advocate private medicine is that if there's competition and if there's more providers,
that
as in many aspects of business, that competition will lead to more efficiency
and will drive costs down, in turn putting more money into the system. Do you buy that
argument?
HOYT: I think the argument has some merit, but not in this setting. Clearly in the
business setting competition improves the marketplace, without a doubt. We're not talking
about a business. We're talking about a system in which the resources are already strapped
to the very dear limits.
Creating a parallel private system might work if we had an unlimited number of doctors and
nurses and hospital beds and all of the things that you need to provide care. The public
system is using all that we have right now. If we add another system, a parallel system,
the only way that it could work would be to draw the resources away from a public system.
That wouldn't improve the public system. It wouldn't
it wouldn't drive better
competition; it would simply deteriorate the public system because it needs those
resources.
GILLIS: One of the
one of the concerning things we read that
some articles in
the paper, hospitals in
David, you alluded earlier to something that I think is very important. As much as we may
or may not believe in a public system, I think many of us would agree that there are
there are issues surrounding accountability if one body is both the purse
purse
keeper and the administrator. What are your thoughts on government accountability and how
we can improve (inaudible)
?
ZITNER: I strongly support universal public insurance where everybody gets care according
to clinical need, not ability to pay. (Inaudible)
The current environment is
untenable, and in fact only two other countries have systems like ours:
I think the way to do this is to separate, as Kirby suggested, government's role as a
regulator and evaluator from its role as service deliverer. We have other public services
where governments pay for the service, they're universally available, for example roads,
yet we don't have government people building the roads necessarily. They contract out with
performance (inaudible)
One
one of the interesting things, and people may want to go to the web
the
Pennsylvania Health Care Cost Containment Council, www.phc4.org, has information about the
costs and the outcomes for every health organization in
So I think that until we have a system where government can fulfil its proper role as a
regulator, Canadians will be in difficulty because they can't make the personal and
political choices that are necessary to even decide between positions such as Ian and I
have.
GILLIS: When we talk about separating the regulator from the deliverer, you know, are we
talking about private hospitals that have to take their money from a government pot? Is
that
is that one of those options?
ZITNER: I think there are a number of models. In the States (inaudible)
most health
organizations are not for profit but independent of government. In
I think there are other clinics that are private, and the people working in them make
profit, as do all the people who the
Most primary care offices, family doctors' offices in
GILLIS: Ian, do you think public funding for a private hospital works?
JOHNSON: No, I don't.
GILLIS: Why not?
JOHNSON: Well, as I tried to say earlier on, I think they
it costs more to provide
(inaudible)
I cited the research that Devereaux (ph) and others had done to show
that it actually leads unfortunately to more deaths and the quality of care suffers.
I mean, the private system
if we had
if we had private clinics in
But it's not just
I think it's a misnomer to think it's all under government. It
isn't. I mean, we have regional health services, we have private non-profit providers, we
have individual practitioners. We have a whole range of
if we need to strengthen it,
and I think we do, we need more information and the right kind of information. We also
need to democratize the system. We need to make it more open and accountable to the people
who (inaudible)
and work and
and provide the service.
GILLIS: Quick comment here.
UNIDENTIFIED: In support of democracy, people might want to look on the web at this paper
by Brian Ferguson (ph), Profits in the Hospital Sector, which (inaudible)
literature, and they can make their own choices.
GILLIS: But when you get into private, I mean, I
I have some experience with the
Freedom of Information Act in
UNIDENTIFIED: We
we haven't been able to get current information on the number of
preventable deaths in Canadian hospitals. We have a set of journalism students trying to
get the
the two sectors (inaudible)
GILLIS: You
both of you alluded to different systems. I'd like maybe Ben to
to
change tack for us. As much as we bemoan our beloved health care system, we have to
remember that it still is one of the best in the world. And you know, if we look at our
neighbours to the south, Ben, you know, how does the American system stack up compared to
ours?
HOYT: Well, I mean, it depends on who you ask. If you ask the person with really deep
pockets and a huge bank account, they'd say it's great because there are centres in the
They spend upwards of 14 percent of their gross domestic product on health care; we spend
nine and a half. Everybody says that health care is expensive in
But the other interesting thing is the costs of the
of the private sector,
for-profit administration (inaudible)
that if you took all that money that was spent
on administration by the private sector and put it into a public system, you could finance
a universal public system.
So that is another example where private for-profit health care is inefficient. It's
bureaucratic. And it's ineffective.
UNIDENTIFIED: The
the World Health Organization doesn't rank the Canadian health
system highly, for fairness. I'm not sure why we continue to compare ourselves to a bad
health system. Why not compare ourselves to some of the European systems that the World
Health Organization ranks more highly?
UNIDENTIFIED: I guess we do for two reasons: one, they're on the same continent, so
obviously the fact that we're not isolated from the
(SPEAKERS OVERLAP)
UNIDENTIFIED:
of GDP, and then it's changed significantly.
UNIDENTIFIED: (Inaudible)
we do have a good thing with our health care system. It's
a good system. People come from all over the world to train in our system. People who work
in our system are highly qualified, highly skilled, no matter where you go in the country.
Our system isn't all bad; it just needs a lot of work to fix it and make it more cost
effective and efficient.
UNIDENTIFIED: (Inaudible)
GILLIS: Well, gentlemen, we are largely out of time. I think
for our viewers out
there, I think we've seen that this is a very complicated issue. I think it's an issue
that affects us all every day. It's an issue of money, and it's an issue of planning.
I think as we all go forward, I think it's important that, regardless of what your
personal beliefs are, that we all take an active interest in this because it is only
through our participation in the public system that we as individual citizens will be able
to make change. If we all make health care reform first and foremost on our agenda when we
talk to our community leaders and our politicians, we can effect change.
Whether it's a strictly universal health care model, whether it's a model that
incorporates some aspects of other systems, including private systems, that's not for me
to say today. We've heard some very strong and informed opinions from our guests. I'd like
to thank them very much for being here. Clearly this is a big topic and not an easy one,
guys, and I
I appreciate your
your candour and your ability to share your
opinions.
I hope this has been informative for everyone out there, and thank you very much. We'll
see you next week.