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THE STRAIGHT GOODS (CAB-10), HALIFAX, 26 Oct 05, Reach: 3,000, Time: 20:00, Length: 01:00:00, Ref# 555761-1
Anchor/Reporters: DR JOHN GILLIS

HEALTH CARE IN CANADA

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 Today's topic, Medicare in Canada: Canadian institution or an outdated dream?
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, Dalhousie University; Director, Medical Research, Dalhousie University): (Inaudible)…
GILLIS: (Inaudible)…
ZITNER: Thank you.
GILLIS: David is a general practitioner, professor of medicine at Dalhousie University, and the Director of Medical Informatics at Dalhousie University.
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 Canada. I saw patients who didn't have access to a full range of comprehensive services, and I saw that we'd set up a system in Canada where people have different qualities of care.
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 Canada's Publicly Funded Health Care System. And as part of that work, we came to realize that Canadians had put governments in an unsustainable conflict of interest.
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 Canada, at the same time as many people are waiting too long for care in emergency departments, too… too long for operations that are necessary to save lives and promote health.
We've been arguing that in order to overcome this conflict of interest, and one of the necessary conditions to improve care in Canada, is to encourage government to assume their normal role as a regulator. In the Canadian system right now, if government slaps the hand of those who are administering and delivering care, they themselves have to say 'ouch' because they're slapping their own hands. No wonder we rarely hear public statements about the deteriorating quality of care in Canada.
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 Nova Scotia Citizens Health Care Network. I've also been involved with the Canadian Health Coalition and really the Nova Scotia Citizens Health Coalition as well. I've been active at community health centres in Saskatchewan and Nova Scotia, here at the North End Community Health Centre, and I work now as a researcher (inaudible)… analyst with the Nova Scotia (inaudible)… So I have regular contact with front line health care workers (inaudible)… approximately half our membership are… are health care workers, from nurses through to a whole variety of health professionals, technologists, cleaning staff, dietary, the whole range of (inaudible)… delivery of health care services.
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 Saskatchewan, which is the birthplace of Medicare in many people's minds. Could you give us a little more… little sketch of how we came to be where we are?
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 Saskatchewan, I'm sure it goes back to the… to the early twenties and thirties with municipal health systems of various sorts. But (inaudible)… other provinces. Even in Glace Bay, for example, there was a worker check-off system that established a health care system.
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 Saskatchewan, that we'd have it here in Nova Scotia.
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 Saskatchewan change was happening. And he was later elected as an MP and sort of brought the… brought the Medicare fight to the federal level and tried to get every province on board. So he is often termed the father of Medicare. Whether it's right or wrong, he certainly had a major role as a political player in trying to make Medicare a national issue.
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 Saskatchewan. Through the years, from 1950 through 1970, it went from being a hospital service and then a doctors service in Saskatchewan to a nation-wide services.
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. Canada, I believe (inaudible)… although we always pat ourselves on the back, saying we have a wonderful health care system, has among the narrowest scopes of coverage of… of developed countries with universal care.
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 Canada today.
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 Douglas said earlier on, as… in the early development (inaudible)… what he was quoting from. He was talking about an earlier stage.
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 Alberta, for example, to go wholesale in terms of privatization. But… and… and other provinces as well. I mean, it is not properly administering the Act.
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 Nova Scotia was the first province to get rid of extra billing. We have a whole range of other services, which even the Medical Society at that time said people should not have to pay. That covers a whole range of things from administration to having (inaudible)… Those things should be… should not be charged to individual patients. And that's a… that's a serious problem that… that is not being addressed by government. They're… they're hiding under this and saying well, we can't do it when it's uninsured. Yes, they can.
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 Soviet Union, black markets developed and people got the goods and services that they needed.
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 Nova Scotia and you get served in BC, even though the menu of services may be different.
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 US certainly, but also in countries that… that allow a so-called parallel system.
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 Canada and where it stands.
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 Canada have supported a two-tiered system for (inaudible)…
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, Manitoba and Alberta both had private clinics for a period of time. Alberta still does. The private clinics were… where the situation was for eye exams, for example, the private facilities had longer waiting lists than… than the public facilities.
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 California deliberately doing unnecessary tests to drive their profit margins. So competition can clearly work both ways.
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: Cuba and North Korea. And I don't see other developed countries jumping on the band wagon to copy us.
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 Pennsylvania. Government has insisted that these results be made public.
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 Canada the Health Act (inaudible)… example was run by the (inaudible)… They were a not-for-profit organization independent of government.
I think there are other clinics that are private, and the people working in them make profit, as do all the people who the Nova Scotia government employs. They are profit because they're paid for their work that they do. One thinks of the… there's a clinic in Toronto that does hernias, that's a private clinic.
Most primary care offices, family doctors' offices in Canada, are private clinics. They're not owned or operated by government, and government's role is to insure people, to pay the bills for the services that government has decided to pay the bills for.
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 Nova Scotia now, there are no regulations and controls. It's buyer beware. I mean, at least in the public system, and I agree with David, there's… there's questions of our quality of information, but at least we have some mechanisms to hold those services and facilities accountable.
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 Nova Scotia. When you get into private operators, like EMC, for example, for ambulance services, it's much harder to get information from those private… because they don't feel that they're accountable.
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 US where you can get some of the best quality care in the world at a price. If you're talking about the general health of the population, the state of the health care system for the country, I don't think it compares to ours at all.
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 Canada. Well, clearly it's a lot more expensive in the US. So that model doesn't necessarily answer all the problems.
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 US; and the other is we have what the US… I mean, when we got Medicare, roughly, we were spending about the same amount…
(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.