Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 54 - Evidence
OTTAWA, Wednesday, May 8, 2002
The Standing Senate Committee on Social Affairs, Science and Technology met this day at 3:40 p.m. to examine the state of the health care system in Canada.
Senator Michael Kirby (Chairman) in the Chair.
[English]
The Chairman: Senators, I see a quorum. We are delighted to have back with us today the Honourable Monique Bégin, the former Minister of National Health and Welfare. As many of you know, since leaving public life, Mme Bégin has gone on to be an academic health administrator and a professor in the school of health administration at the University of Ottawa.
We are delighted to have you with us again, Mme Bégin. It is great to hear from you and hear your views on the issues you wrestled with for the best part of a decade.
The Honourable Monique Bégin, P.C.: Mr. Chairman, I need guidance because I prepared a short brief as requested. This morning, I was bold enough to send a short addendum to my brief, which I believe all senators have. I distributed at the end of February a text of a public conference that also gives my position on the Canada Health Act.
Do you want me to read what I have sent you, Mr. Chairman, or can it be taken as read?
The Chairman: It can be taken as read. To begin the debate, it would be useful if you hit the highlights and the issues on which we can then get into a detailed discussion with you.
Ms Bégin: Thank you. I will make the point that not knowing exactly what is meant by reforms the way your committee understands it — we must clarify words — the Canada Health Act can accommodate many reforms of the health care system. This is the case certainly as the five basic principles are concerned, although some regulations have to be written — to my knowledge, they may not have been written — and reviewed and updated. Perhaps the five conditions can be kept, but their definition in the act might need to be revised.
I think the time is right for modernizing, shall we say, or updating the Canada Health Act. I believe that the other expression, which somewhere in the legislation that defines medicare by hospitals and doctors, should be changed and enlarged to capture the modern way of giving health care.
This being said, two conditions, in my opinion, should be worked on. First is the condition of comprehensiveness, which is defined by what is medically necessary; the words ``medically necessary'' call for the judgment of the treating physician. I have always supported that definition. However, we need to modify that definition — if we can find a better way — by an approach that would make what is included under medicare based on evidence of what works and what does not.
Procedures and drugs are delisted or added to the list in a totally secretive manner in the 10 provinces — at times on phoney moralizing grounds — when the process should be transparent, on the one hand, and completely and only evidenced-based, on the other hand. That is to say, what works and what does not work.
The other condition is public administration, which you have very rightly pointed out is totally misunderstood by the vast majority of Canadians — public and experts included — as well as politicians. This needs some work. I mean that right now, the payer has to be a single payer government and each province has a medicare plan.
We decided not to change that at all in 1984 because we could not see that there would ever be a market in Canada — because of our numbers — for the private sector. Since provincial legislation always permitted doctors and patients to opt out entirely from the system, we saw no problem.
Times have changed. I think that the boundaries between private and public should be spelled out. I am not satisfied that I have seen anything to date suggesting an interesting new rule of the game, for there are no rules now. Hospital food, laundry and labs went private, however we do not know if they were more efficient because they have never been evaluated. One thing is certain: We intuitively know it was not an erosion of medicare.
When is it that the privatization of elements of the system becomes serious erosions or threats to a public universal system? I would like to see that articulated. To my knowledge, that has never been done.
With regard to sustainability, I may or may not differ in opinion with the committee. On home care and pharmacare, my opinion is that ideal medicare in Canada should include, of course, the spectrum from primary care outside of hospitals to chronic care, rehabilitation services, home care and pharmacare.
That is an ideal dream of what medicare should be. I have no particular intelligence on costs for home care and pharmacare. I know, however, that the private sector is already, because of the vacuum of government legislation, programs and funding, made of public and private for-profit as well as private not-for-profit components. Therefore, the rules of the game will have to be devised differently for medicare purposes.
I do not know. I am simply acknowledging that we cannot treat home care and pharmacare with insurers the same way we treat the general medicare. In my addendum, I point out that there is some urgency for the federal government to establish with the provinces, in respect of the intent and requirements of the Canada Health Act, that all drugs and home care services that are direct substitutes to hospital care must be accessible free of charge to discharged patients.
I will address three points, after which I will stop.
Two major reforms are needed in the info-way system at the level of infrastructure. One is, we say in French, ``l'informatisation complète du système.'' Reforms are needed in the integrated info-structure from electronic patient dossiers and health surveillance data analysis. Those changes are great urgency, and I am very interested in them.
One element has puzzled me for years. We know changes in the system are needed, but nothing is happening. We witnessed downsizing. Beds in hospitals were reduced and hospitals were closed. Except in isolated cases, we did not witness true reform.
I am interested in engineering change; I am also interested in engines of change. In addition to being an essential element in a modern health care system, the current info-structure is also a major possible engine of change. The outside world should force change on the system. I recognize that as a dimension for info-structure.
We are talking about billions of dollars. I do not know how many billions, Mr. Chairman. We lost an occasion, federally, to do that about five years ago. At a similar cost is the need to update the medical equipment in the country both for diagnostic and treatment purposes. That is also very important. It is also a priority for me.
However, the more urgent of the two is the integration of the info-structure in the system, which should permit an optimum utilization — better than today — of the medical equipment, even if it is not what it should be. Of course, the medical equipment must be changed also.
Human resources looks like an urgent brand new problem. I refer you to a 1991 Ontario Premier's Council on Health Strategy report in which this question was discussed. Today, people speak of the problem of human resources planning in health care only in terms of more nurses and more doctors. Another dimension of the question is the distribution and flexible arrangements of these human resources. That is the priority.
In the last decade, I have referred to that as a new division of labour. To use an old concept of labour studies, there needs to be a redivision of labour among GPs, nurse practitioners and nurses of every level of competency. There may be room for more redivision of labour, but I am not a specialist with regard to the details.
Today's human resources in the health care system are wasted and badly used. Patients, family and friends see that. We should address that issue.
HRDC and Health Canada gave the Royal College of Physicians and Surgeons $4.7 million over three years to study human resources. I sit on the policy committee of the Royal College, but I did not find the mandate of the study before coming here.
The problem with a redivision of labour is that we may not have a tool to do it. I do not know. We do not want to do that province-by-province because many parts of Canada lose their manpower to the next province. We have to do it nationally. I do not think that we have a proper tool. Perhaps that huge study by the Royal College could be the vehicle to do that.
Those are my points, Mr. Chairman. My major point is how can we engineer a change that is so obviously necessary but is not taking place in the system.
The Chairman: Before turning to Senator Pépin, I will ask you two questions. One is a follow-up to what you just said. I am trying to get a handle on the primary obstacles to change.
It is clear from all the hearings that we have had that the resistance to change is amazing even among very smart people. Is the resistance to change essentially a federal-provincial issue? Is it a primarily federal-provincial issue or primarily the attitudes of various groups of professionals who do not want to change scope of practice rules or do not want to change the way service is delivered?
The second question relates to your addendum. In the first piece you sent to us, you talked about the importance of home care in general. Am I right that you are saying categorically in the addendum is that in cases where the home care is really being used as a direct substitute for the patient being in an acute care hospital, that expense should not be thought of as home care expense although it is delivered at home? It should be thought of as a publicly insured service under the Canada Health Act, for example.
In some sense, there are two different types of home care. There is the home care that follows immediately after being in the hospital for acute care during effective convalescence. There is also the other form of home care, which we usually call long-term care, for people who need care on a long-term ongoing basis.
Although both services are delivered at home, they are really two different programs. One is long term and the other is merely an alternative delivery system for what we think of as a medicare service.
Ms Bégin: Yes, that is what I think, but I added drugs. In the same way that my drugs today can be reimbursed partly by my employer's insurer or my personal coverage, they should not be paying for the drugs that I received free of charge when in hospital. All the hospitals of Canada have passed on directly to the patients in the last seven years an enormous sum of money as new patient fees or costs through drugs and home care.
The Chairman: In the drug case, to emphasize your point, in my own family, I had a case in the last few years in which oxygen was delivered in the hospital, obviously free of charge. When oxygen was delivered at home, we paid for it. It is hard to think of something less medically necessary than oxygen.
Ms Bégin: Your first question was about change. I hope we can discuss federal-provincial relations later. Everyone knows how strongly I feel on what I call governance. Federal-provincial relations are totally dysfunctional, and they will not change. Right now, they work when you put $23 billion on the table. They work for maybe a few weeks. I will say that ironically, sarcastically or caustically even — choose the word.
Having said that, there must be a constraint to change and reforms. Within each province, corporatism is big. Basically, it is the fear of physicians, the OMA, the provincial associations. When the questions of moving from fee- for-service to another system, or moving from solo to group medical practice, the response is fear. It is the fear of losing income, which is a very human and very legitimate fear. That should be addressed first.
For nurses, I do not know the constraints in change in scope of practice from within organized nursing. However, from what I understand of the whole health care system, their constraint is the medical profession. It is not each physician who resists change so much as the medical profession or organized medicine, which is very different from individual practitioners. Yet, everyone knows that sooner or later it must be done.
The Chairman: Let us say that the income issue was resolved — none of the members of the medical professions felt they were losing income — would the overall problem be resolved? Is income the big problem, or do status or loss power also factor in? A number of us around the table would be quite confused as to the extent to which a fair bit of the issue was not status — not arguing money. Money in theory ought to be a solvable problem, but status may not be.
Ms Bégin: I would have to say at every level of experience that I had, both in my past incarnation and now, I would single out money for physicians as a very important ingredient. If GPs do 30 per cent less of what they do now when they see us, they will do more people. They will be capable of doing more complex procedures according to their training. They will still have gone through a faculty of medicine. I do not think status is at stake at all.
[Translation]
Senator Pépin: I greatly appreciated your presentation which highlighted a number of very important points. Last January, you spoke at a conference about governance and about users. At the time, you stated the following, and I quote:
[English]
Knowing behind the curtain the invisible driving force of the whole system is, of course, high-tech medicine, and finally, somewhere is the public as patient, as citizen or as taxpayer.
[Translation]
You went on to say this:
[English]
Nowhere in this hierarchy is the citizen as patient considered seriously except as passive recipient of health care services.
[Translation]
After talking at some length about relations between various governments and what needs to be done to assist the restructuring process, you make the following observation:
[English]
Finally, those who should be at the centre of the equation, the patient and the public in general, have no voice in the role.
[Translation]
Many of the speakers talked about the role of governments, about spending and so forth, but we need to be concerned about system users. If we want to go ahead with a restructuring of the system, we need to consider the users who make up the different patient categories.
The majority of users will be 65 years of age. However, we must not forget the baby boomers and younger people as well. When we talk about consumers, we are really talking about patients. We need to give some serious thought to all aspects of reform.
What problems are we likely to encounter in trying to help patients accept some restructuring of the system? They do not speak out as loudly as the experts. How should we broach the issue with them?
Ms Bégin: I would like to draw a distinction between patient and public participation in the reform process — and we anticipate that there will be numerous reforms — and their involvement on a regular, ongoing basis in system governance.
I have never approached the subject from this angle, but practically speaking, I see no need to separate the two issues. I would not want to hear only from patients. I am also interested in hearing from taxpayers who, over the course of their lifetime, will have been patients at some point in time. I want to see them involved in system governance at all levels, including the federal-provincial relations level.
As a federal committee, you are making recommendations at all levels. I congratulate you on choosing this approach. You have the power to exert some influence on the entire system directly at the federal level.
I foresee a problem with devising a new way for the provinces and the federal government to work together, other than the tried and true federal-provincial conferences, health ministers' meetings and so forth.
According to existing federal legislation, the Parliament of Canada is responsible for health care. I want to uphold this principle. Some argue that health care should not be a political issue, to which I always respond that health and education will forever be political issues because they represent the cornerstones of society. There are choices to be made. What these individuals are saying is that health care has become too politicized and they are absolutely right about that. Therefore, what kind of new relationship can be forged to repair the damage?
Personally, I do not have the answer to that question, but I would be curious to know what kind of approach the European Union came up with to work with other member countries. The European Union and its member countries share some similarities with the federal and provincial governments. I have been told that they are very innovative in many areas. I would like to know what kind of conflict resolution and governance mechanisms they have adopted.
Whether we like it or not, it would seem that we are prisoners of our own past. I stepped down from cabinet in 1984 and even back then, there had been calls for a citizens health council which would play an advisory role. I did not support the idea at the time.
During the 1990s, I discussed at considerable length the idea of a citizens council comprised solely of members of the public and patients. Such a council would report on the health of Canadians and groups at risk, not on the status of institutions and the work force. No one was doing performance reports at the time.
Now I have started to believe that the federal-provincial conference formula should be completely revised. What kind of changes would be needed to ensure the input of citizens and perhaps even that of experts? I do not have the answer to that question. It is something we need to consider further.
Senator Pépin: Do we definitely need to include these groups?
Ms Bégin: Yes.
[English]
Senator Keon: Thank you, Madam Bégin, for coming here again. I would like the record to reflect the truly enormous contribution you have made to the health of Canadians over the years. I fully appreciate how busy you have been and the time it takes from your agenda to prepare briefs and come and testify before us.
One of the things that I have been testing with some of the witnesses before us is the concept of regional health authorities as it relates to health manpower reform. There is much resistance to regional health authorities on the part of some provincial bureaucrats at the level of deputy minister and assistant deputy minister. My feeling is that we are never going to come to grips with person-power reform in health until we can establish regional health authorities so we can provide health care teams to fit the environment in which they work.
Our current methods for gathering information and assessing the needs of health care professionals are seriously flawed. The medical associations come in at the national level and tell us how many doctors they need, which is the same for nurses, technicians and so forth. We do not have someone telling us what kind of health care team would be best to serve the area of Timmins, Ontario, for example. I would like to have your comments on this.
Ms Bégin: Dr. Keon, on the general question of health authorities, which exist in nine of the 10 provinces under one name or another — the exception being one-third of Canada, Ontario — I would observe there is no panacea. However, in a country as vast and diverse as ours they become an important consideration just because the delivery of health care should have multiple facets that could accommodate that. We are not sure that is it is a panacea, but I find them an interesting idea as an agent of change. By analogy, in the same way, I spoke of a massive investment in the info-structure. That is where I situate them.
To answer your specific question of bringing in reform in human resources planning, they could accommodate local diverse needs a million times better than Queen's Park or any provincial government can. Health economists, as well as students of health administration, will share with your committee the fact that for a long time — I will borrow this from my former colleague Judy Erola — provincial ministries in Canada have been like huge HMOs — badly run. In general, the system is micromanaged by our provincial ministries of health. I should not say that to those who have created the gem of an institute in which staff suffer from knowing their budget six months after the year has started.
It is everywhere, even in Alberta. With the CLSCs and the Régies Régionales, Quebec has been the innovator. The CEO of one of the biggest Régie régionale in Montreal, whom I saw recently at a McGill conference, told me that every decision of any importance is entirely second-guessed and restudied by the Quebec ministry. What is the point? That is not decentralization.
Therefore, I think it would be an interesting tool of change to go to regional authorities provided there is complete devolution of budgets, including global budgets for salaries and drugs. I know your committee refers to that in volume 5 in terms of what Claude Forget promotes — is internal markets. I find that interesting. It is the U.K. approach. However, I cannot speak to that. I will let experts discuss the pros and cons.
I see it in terms of addressing the diversity of a huge country and adapting locally at a manageable level to what is needed there. Timmins would therefore get what they need. I already know that it will be francophone and totally different than fancy Toronto. I apologize to those who come from Toronto.
The Chairman: I wish to ask a supplementary question based on your comments on the micromanagement of institutions by provincial health departments. The committee is really of the view that that is generated, not because they think they know a lot about the management of institutions but because they are trying to save money. In other words, what has driven micromanagement from the provincial government level has been a fiscal constraint in general, not a belief that they necessarily understand a lot about managing institutions. One of the reasons for arguing strongly for separating the issue of the insurer, or the payer, from the provider, which is to say the institution, is to get provincial governments out of the micromanagement role.
My question is: Do you agree that the micromanagement role has been driven primarily for fiscal reasons and does our separation get them out of it successfully?
Ms Bégin: I suppose you are right. Since I am not a health economist but a sociologist, and by practice a political scientist, I will tell you that my view is that it is about turfs, territories, control and power.
What you describe is a beautiful justification — my biased views against your biased views. It is really about power and control. The Quebec provincial ministry of health is extraordinary. When it created all these CLSCs and then the additional layer, it did not fire one single bureaucrat in Quebec City. You have doubled the numbers and you have not saved. That is for sure.
The provinces should be in charge of defining the rules of the game for accountability. The regional authorities operate the system and must be accountable to the province. Therefore, the provinces should have very few top bureaucrats in the ministries of health who do the planning: They divide the same pie but they give it to regional authorities. Perhaps they would oversee common functions such as public health. I am no specialist. A few functions of health care should probably remain central. I am thinking of public health and surveillance, for example. That must be discussed. Some functions might be better performed and more efficient if they remain central.
However, what we call health care delivery, in the sense of doctors, hospitals and primary care, should be regional.
Senator Morin: I would like, first, to say that since you introduced the Canada Health Act, you are considered as the guardian angel of medicare. That is why we follow your comments so closely. That is not a question but a reflection on the comment you made at a speech about a month ago, where you stated, if I understood correctly, that you had no objection to private providers in the system, private in the sense of for-profit providers. I think that was a very important statement.
My question deals with another issue. In your statement, you dealt with the necessity of reforming and restructuring our health care delivery system with the objective of improving quality, accessibility and efficiency. I think we all agree with this.
Some of these restructuring operations will have to be done at the provincial level. Some of these issues are intensely provincial, while others can be initiated at the federal level.
If you were at the federal level — which is where we are working — what would be, in your view, the federal role in this restructuring? In other words, what would be the federal initiatives? If there were supplementary federal funding — limited, of course — and realizing that we cannot exert influence without funding some of the provincial activities, where would you start at the federal level?
I realize this is not an easy question. This is the sort of question we are dealing with right now.
Ms Bégin: For me, it is so easy that I will have to repeat myself. I apologize. I think that is what I am addressing, in the sense that the X number of billions needed for info-structure refers to the feds having a role of facilitator and enabler for the provinces. I agree with Terry Sullivan and Pat Baranek in their last book, First Do No Harm, that the strength of medicare is the notion of equity built into transfer payments. We live right now physically in Ontario. We should not forget the rest of the country.
There is a role of enabler or facilitator. I do not mean the feds should decide on how the info-structure is done, what company is chosen and all of that. They should pay the bill. I am sorry, I feel very strongly about that. It should be targeted money, of course. I find that an urgency.
Senator Morin: That would be your priority?
Ms Bégin: No, I will not give you the pleasure of a linear list. My notion of social change has always been of parallel avenues and the sum total does the trick. In parallel, other people — not the same people — must work on defining what ``public administration'' means, meaning what is a good rule of the game to articulate the interface of private and public players in hospital care and medical care. That has not been done. Health Canada should have been working on that, as far as I am concerned, for years. I have no idea what has been done on that. I have never seen or heard anything. That is urgent.
I do not know who in Canada, other than the Mazankowski Commission in Alberta, has expressed a way of deciding what medicare should cover in terms of public funding. They offer one view. They offer a process of defining and redefining constantly what should be insured. They suggest a committee of medical experts; no need to say there should be more than medical experts on the committee, but at least they offer a view. The way they speak suggests a narrow definition of coverage.
Mine is not a narrow definition of coverage. I am only too familiar with European systems where for less GDP total health expenditures, people have access to a much broader coverage, the spectrum including alternative medicine in many countries.
I would like to see a broad coverage under comprehensiveness. I would like a method — committee or otherwise — that constantly reviews evidence-based new elements to be insured and old ways of doing things to be de-insured at one point. That should be done, of course, not just by the feds. That is crystal clear.
By the way, your fifth volume is almost entirely addressed to the operations of the system, which is provincial. You are right; it is very provincial. However, the feds have their homework to do as well because the Canada Health Act is federal legislation.
I have already made comments about drugs and direct substitutes. That should be done yesterday. That is easy to do.
You want priorities. I identified governance, home care and pharmacare as domains that somebody should study to come to a solution. The feds have a direct role in that, because they will have to be payer.
I forgot to mention that you speak eloquently in your reports of high-tech medicine and the need to entirely modernize the stock of medical equipment. That would probably cost another $5 billion. The feds could play a national role of facilitator/enabler.
What is unbelievable to this student of the health care system for at least 25 years is the Canadian disease of ``pilot projects.'' It is truly unbelievable.
I just checked the Web this morning under Health Canada's info-way. They think it is a year old. They had $500 million in seed funding to get started. That was in 1997. We are now in 2002.
The CHEO hospital of Ottawa cannot speak electronically with the Ottawa Hospital. We do not have electronic records. I am talking about just Ottawa. The Riverside Campus and the Civic Campus still do not have the same information systems.
Senator Robertson: Thank you for coming, Ms Bégin. I have so many questions, but I will restrict myself to two, if I may, Mr. Chairman.
You alluded earlier in your remarks to the Canada Health Act and the five principles. We have heard from a number of witnesses who feel that there is an element of restriction in those five component parts.
Yesterday a witness from British Columbia talked about the restrictive elements of the Canada Health Act relating to the method of funding things. He said that provincial governments are duly elected and able to be responsible to their own electorate. Yet, there is an element in the Canada Health Act that does not allow them to be responsible. It treats them as if they were children, in his view.
Where do we go? Are you satisfied with those five principles, or would you rather modify them considering the years passed since they were introduced? Can we modify them so that they will better serve the system and make it easier for the participants to participate?
Ms Bégin: I, too, hear constantly that it is a very restrictive legislation in the way of change. I must say that to this day I have not seen one concrete example of that claim.
I am sorry; I do not understand what the problem could be. Please clarify.
Senator Robertson: I will try to clarify the question. Take the perspective of the patient; the patient does not really care how it is funded as long as they do not have to wait two years. Do they wait two years for an invasive process or is there some other methodology that can be approved by the five principles that will allow earlier access? Much of the problem comes from the lack of access because in some parts of the country accessibility is terribly important.
Ms Bégin: Accessibility is important everywhere in the country. Is your question whether private clinics should exist? Is that what you are saying?
Senator Robertson: Part of it, yes.
Ms Bégin: I am decoding you because I do not understand.
The question of private hospitals or private clinics is a new challenge to the system, and we must address it. We must figure out clear rules of the game about which everyone knows. Right now, there are no rules of the game under the concept of public administration. That term is not what it means in the Canada Health Act.
For example, Shouldice is a historical hospital that was permitted by the legislation prior to the Canada Health Act. It is a specialized hospital that specializes in hernia operations. It operates entirely within the official fees paid under medicare by the Province of Ontario.
I have no idea how they manage for capital investment. However, I understand the place works and functions beautifully. I have no idea what their profit is.
I have no problem with that approach to life at all. They do not surcharge the patient. There are no extra charges of any kind.
However, while there is room for specialized hospitals, there are problems with them. The main problem is that they tend to skim the easy cases off the top. However, that is fine, if proper and very good linkages have been negotiated with the general hospital that must cover the crises. You think it is an easy patient, and then he has a heart attack in the middle of an operation.
There are problems, and they do skim off the top. That question must be addressed.
There remains room for specialized hospitals or clinics. The funding should be entirely within the public funding without surcharge to patients. As a person who never succeeded in becoming rich, I do not understand how they would make a profit. I do not understand that unless they have extremely low-paid staff. I would like to see it addressed.
Another concern is the private labs under consideration. The Province of Ontario sends requests for proposals and a number of lab companies apply. The province chooses one or two private labs. They enter into the contract with the province and accept such money for the contract they perform.
When I go to these private labs, I simply present my OHIP card. Thus, there is a mechanism whereby the province finds them more efficient. We do not wait at these labs. They do function. I hope that they have quality standards and do not mix up my file with someone else's. That instance of privatization works.
However, in general, if that was to apply to specialized hospitals — I will speak of general hospitals later — it raises, in theory, the issue of fair profit. Any economist knows there is no answer to that question. It has been studied and super studied, and I do not think there is an answer to it.
As to general hospitals, I just do not know how a general hospital from the private sector operates on a not-for- profit basis. They would reinvest automatically in their own budgets. Could they not go into a better business than that? I just do not understand. Someone has to pay the profit. I want to know who and how much.
The Chairman: I do not know the answer to the question with regard to general hospitals because I think that is a problem. Specialized hospitals are able to, as you put it, make a profit for two different reasons. One is that there are huge efficiencies in doing simple procedures repeatedly. They also provide better care. We have talked to an orthopaedic surgeon who only does shoulders. He can get a complete practice only doing shoulders, and the result is that he is very good.
Second, even publicly owned hospitals at the moment make on the order of 15 per cent of their income from the surcharge they put on private and semi-private rooms and televisions, et cetera. Specialized hospitals have a tendency to only have private and semi-private rooms, so in effect they are getting a patient contribution, just as a public hospital does now. The Ottawa Hospital gave the figure of roughly 15 per cent that comes from the surcharge for people who want private or semi-private care and other things such as the cafeteria they run, renting televisions, et cetera. It is a bit of that.
The big thing is if you do a limited number of simple things in large volume, you avoid a whole lot of overhead, as you said. However, you better have a general hospital ready to pick up the case that goes bad. As I understand it, the Shouldice Clinic has an arrangement with one of the general hospitals close by to cover the case where something goes wrong. That is how they are able to make a profit. Your point is doing that in a general hospital where you have the overhead and a multitude of procedures is a much more difficult thing to do.
Ms Bégin: There are fewer semi-private and private rooms. I do not know if you are aware of that.
The Chairman: Yes.
Ms Bégin: The question becomes complicated. There are specialized, high-tech labs, such as MRI only, or the fanciest scans possible, et cetera. You pay your $1,000 and have your scan. It is queue-jumping.
I want to see articulated and expressed the rules of the game where it is not acceptable or is acceptable. I go and I pay my $1,000. I wish I could do it for a colonoscopy for example. Then the day after or the same afternoon, I have my medical dossier. I have the pictures. However, I come back to Ottawa, and I queue-jump. That is unacceptable. For me, that is the one principle that has been clearly articulated.
The other thing is that our physicians are trained with some public money. Students pay a fee in our universities, and it is huge in medicine, but in our country, the taxpayer enormously subsidizes medical studies.
The other point where we need to articulate something is when doctors play both the private and the public system. Doctor X will be accredited to Private Hospital Z but will also keep accreditation to a public hospital — we do not use those terms in Canada, but just to be understood — because he or she needs it at times. Which will get the preference? Human nature being what it is, the doctor will give the preference to his or her practice in the private clinic. Something has to be clarified there as well.
Senator LeBreton: Is the patient going to a private clinic and having a MRI, even though they are paying for it, and then bringing that x-ray or picture image back really queue-jumping because they have not had to wait on a six-month list? Is it necessarily queue-jumping? If they simply bring the pictures back to their own GP or doctor for immediate assessment, rather than wait six months for the test, is that really queue-jumping for that patient? Is it not just facilitating the doctor to make a quicker diagnosis?
Ms Bégin: That patient has already won six months by getting ahead of others just by paying. I find that unacceptable. I find it a major problem.
Senator Morin: If the same patient, instead of going to Vancouver, went to Buffalo or Mayo Clinic, would that still be queue-jumping? How do you prevent that?
Ms Bégin: Why does not he or she stay there and have the whole operation there? That does not bother me one bit.
Senator Morin: In any case, he is queue-jumping by going to the Mayo Clinic.
Ms Bégin: Just a minute. If the patient goes to the United States for a private exam and if the patient stays for the corresponding treatment, I have absolutely no problem with that. However, if the patient comes back to Canada for the free treatment, I have a major problem. It is the same problem I have with the patient going to Vancouver, Montreal or Toronto.
Senator Morin: But he is still queue-jumping?
Ms Bégin: Yes, for the treatment.
Senator Morin: But if the whole treatment were done in Vancouver, would you have objection to that?
Ms Bégin: Of course. It is queue-jumping.
Senator Morin: It is queue-jumping in relation to Ontario, but if he goes to Vancouver and has his treatment —
Ms Bégin: I was Minister of National Revenue before becoming Minister of National Health and Welfare. For me, a buck is a buck is a buck, whether it is in Vancouver or Toronto.
The Chairman: The Carter commission is still alive.
Ms Bégin: Absolutely. Senator Morin, if the test as well as the treatment is entirely in the private sector in Canada, I have no problem. The system has always permitted that. If it is entirely private and no public funding is involved, there is no problem.
However, it never really happened in the past because we did not have the volume of population to sustain such private initiatives. Now, we see it happening through sophisticated expensive tests and through sophisticated single- issue procedures such as the eyes or the orthopaedics or hernias. We have to study that and articulate where it is okay and within what boundaries.
Senator Robertson: The primary care is of great importance to you, Ms Bégin, as it is to many senators. We have had a great deal of information on primary care. A number of witnesses have talked about the importance of primary care. I wish to speak about senior citizens in particular since we have an aging population.
At present, seniors are either in special care homes or at home with a relative. It is usually a female who is helping to look after this senior. There seems to be much warehousing going on, especially with special care homes. That is the information some of us are receiving. However, some of us would like to see a simplification of process. For example, we could consider the situation of an average Canadian citizen living at medium income or around the poverty line, perhaps both partners are working to keep the roof over their heads, but their mother or father may need a bit of supervision. The preference is to keep them at home. They do not have the money to hire help while they are at work and one partner cannot really afford to give up their job even though it may be a job paying minimum wage.
Considering the diversity and ethnicity in small communities or large communities, instead of spending more money and building buildings to stick people in where they sit and wait to die, would it not be an appropriate role for the federal government to consider financial support to such families? In this situation, where they have support from their children, seniors are kept out of institutions. Of course, in order to be successful in their application, there would need to be careful screening.
Is there a possibility of some other methodology rather than the institutional model and making an attempt to keep people in their homes where they are happier, they live longer and stay healthier?
Ms Bégin: The obvious avenue that comes to mind is revenue through a tax deduction or tax credit, but there are expenditures just the same. I am not privy to any intelligence as to a possible cost in the country. However, I already know that there will be quite an ideological debate on the legitimacy of claims.
Perhaps I spoke too fast when I said I was Minister of National Revenue. I do not know today what the situation is for such tax recognition of handicapped children or dependants. There is something. We see that on the tax form but I am not familiar enough with the way it works now. I do not know how a person proves that they are a handicapped dependent person. At least I know it is provable.
The ideological debate will be two-pronged; First, there will be concern about the legitimacy of claims and how to ensure the system is not abused. The second point is that the whole debate of a tax credit for a mother at home would come back into the open. You are saying that both caregivers need to work full time. If they are required to prove that they cannot simply accommodate that additional caregiving role, there will be an ideological debate to which I do not know the outcome.
It is feasible through the tax system. It could probably be on the honour system, unless a medical assessment is made. I do not know. That would be something to explore.
Senator Robertson: As far as the tax circumstance is concerned, when you consider the cost that has been paid to nursing homes and special care homes by governments, there might be a balancing act there.
Ms Bégin: Are you are saying that it would be both federal and provincial?
Senator Robertson: I have no answer to that.
Senator Callbeck: Ms Bégin, thank you for coming again and sharing your expertise.
You have commented on a number of the principles that we laid out in our report. However, you have not commented on principle 20, where we set waiting times for each major procedure or treatment.
The Chairman: The care guarantee principle.
Senator Callbeck: If that maximum time is reached then the patient can go out of the province or to another country and the government will be required to pay for the treatment.
The Chairman: Principle 20 is the maximum waiting time that says essentially for all major procedures there would be a maximum waiting time and when a patient has reached the maximum waiting time the insurer — the government — would then have to pay to get that procedure done immediately.
Ms Bégin: Senator Callbeck, in September 2000 a group of which I am a member published a collective text. We did not spell out what the punishment would be for the unacceptable waiting list. I love what is here, the general idea I like very much, and I said I agreed with these principles.
With respect to the exact practical penalty that you spell out — which is that they should pay for treatment elsewhere — I would like to hear views as to possible distortion. At first reading, I find that a great idea.
In our text, published under the Institute for Research on Public Policy and modestly entitled ``Recommendations to First Ministers'' — the chapter in which we recommend a patient charter was inspired by the U.K. situation and their patient charter. By the way, it takes an ombudsperson at the other end to ensure it is respected.
The idea is that for certain diseases with high incidence such as cardiac care or breast cancer, we can isolate a certain number of disease conditions in which the processes are well known. By ``processes,'' I mean what is the acceptable time of waiting and what is not acceptable, et cetera. It is not just about being on the waiting list for the first, but also for all the subsequent steps that follow. If that is not respected something should be done.
The committee went one step further than we did and said what should be done. On the face of it I approve, but I am not equipped to judge the indirect consequences that I do not know.
It is a great image that you gave the public. That is very important.
Senator Callbeck: Another question I have is on your brief. You mentioned that in the health care system there is actually a potential saving there of 15 per cent if there were some very simple steps taken. I had not seen that 15 per cent before. Is that from a study?
Ms Bégin: That comes from the famous Queen's study, for which I have given the reference there.
Senator Callbeck: Yes, I see that in the next paragraph. You agree that if the health care system is expanded to take in home care and pharmacare, there needs to be new funding?
Ms Bégin: Yes.
Senator Callbeck: I would like to hear your comments as to how you think the system should get that new funding. For example, the C.D. Howe Institute came out recently with a report saying that Canadians should pay a new tax based on what they have cost the medicare system that year, and that any family making $10,000 or less would not have to pay; there would be a cap on it of 3 per cent. I would like to get your comments on that proposal, as well as any others you might want to mention.
Ms Bégin: I got the text from the Web. I printed it and started reading it, but did not have the time to study it. My comments are based on a superficial understanding based on the way the media reported it.
The idea is well-known. I find it totally unacceptable. It is really a tax on disease. I do not find it interesting to consider at all.
How would I see new funding? First, between the two, home care and pharmacare, I am tempted to think that home care is more urgent, but I am not certain. I do not have recent figures. However, shortly after the National Forum on Health released their report in February 1996, I believe, the Pharmaceutical Manufacturers Association of Canada had a report prepared by a group of economists. I think the figure of non-insured Canadians — Canadians who have absolutely no access to drug insurance at all — is a relatively low percentage, a little less than 20 per cent.
I do not know today's figures. Maybe that is what tainted my idea that home care may be more urgent. When I say that, people, especially seniors, tell me, ``No, it is drugs.'' I am sorry; I am unable to make a choice. I still think maybe home care is a little more urgent, because some insurance does exist for pharmacare.
Can I backtrack a minute? I am not shocked at all. I expressed it in my short brief by the fact that in most European countries, people do have to pay a little something out-of-pocket every year. It is historical. However, they have much broader coverage. In Canada, we did it in another way. For what we call medicare, I would not accept any surcharges of any kind. For home care and pharmacare, which are new programs to Canadians, I would see room for some out- of-pocket contribution. I do not know how much and in what form. However, I think it should remain manageable. The idea is to help people in an equitable fashion. Past that point, I do not think I can tell you more.
I strongly disagree with the Chair of this committee, whom I came to know when I was a minister and he was a senior official in finance, who thinks there is no additional money out of public funding. I happen not to believe that. I believe it is a question of priorities. In September, we suddenly found many billions.
It is crystal clear. Every senior civil servant around cabinet committee tables, and even ministers who copy them, used to refer to the Department of National Health and Welfare as the non-productive department. That is their view. The rest follows.
However, it is just not true. There is money. It is question of choice and priorities.
Senator Roche: I want you to note that Monique Bégin and I entered Parliament for the first time together 30 years ago this year. I have been an admirer of her from that day to this. I have two questions, or maybe only one and a half, as you have started on home care.
Like you, Ms Bégin, I favour a comprehensive home care program and giving it priority over pharmacare, although I would like to have both.
Mr. Chairman, the witness introduced a very interesting idea when she referred to European instances of what she called ``out-of-pocket expenses.'' She applied that to new programs. She would not accept it for ongoing programs, but for a new program — in this case home care — she would allow out-of-pocket expenses, otherwise known as user fees.
Ms Bégin: That is not necessarily so. There can be co-payments or be other, very different approaches. That is why I used the generic word, ``out-of-pocket.''
Senator Roche: I will accept that. If the restructuring of health care will cost money and we are going to ask Canadians to pay more money in some form, will we not have to explain in understandable terms why more money is needed in the system? If we introduce home care, then people will understand something new is being added. However, if they are paying through taxes for the additional home care, can we then expect them to pay out-of-pocket expenses?
I would like you to address that in the context of what you think would be a ballpark figure for how much the home care program would cost in Canada. I will stop there.
Ms Bégin: I cannot answer that. I have absolutely no idea. However, I want to clarify, before we go any further, the use of the word ``restructuring.'' When I speak of the restructuring of what we call medicare under the Canada Health Act, it is crystal clear to me — and I hope I expressed it clearly in writing — that the existing funding should cover more than doctors and hospitals. It should include all primary care, all rehab care, some chronic care — I say ``some'' because there are the boundaries between chronic and home care at one point — and mental health, which technically now is not covered by the Canada Health Act. That does not require new funding. The potential savings of some 15 per cent should cover that easily. This is being done right now.
Senator Roche: Can home care be inserted into a restructuring program that includes primary care and rehabilitation? Can the system afford this addition?
Ms Bégin: That is for you to decide. You are equipped to study that. I am not. I have never seen the cost of home care. I do not think that a satisfactory study exists of the inventory of private care, does it?
Senator LeBreton: No, it does not.
Ms Bégin: I believe the University of Toronto is doing some work on that. I am not sure. It does not even exist. Ideally for me, there would be a new Canada Health Act covering the spectrum of medicare, home care and pharmacare under the same rules of the game.
Senator Roche: Okay.
Ms Bégin: I do not think that will ever happen because in home care and in Pharmacare where we did not move 10 or 15 years ago when we probably might have done it, the private sector is in it in an important way. We have to respect that. Some of them have done great jobs. Separate parallel legislation probably will have to be designed — perhaps with the same five principles; I am not sure. You have to study that.
I assume that additional funding will be needed. Say that we go universal pharmacare and universal health care, the majority of Canadians will say that what they pay out of this pocket to a private something they will now pay from that pocket to a public something. They are no fools. It is their money, and it is the same money probably. Only for some Canadians who do not have access because of lack of resources, would it will be a real additional funding.
Senator Roche: On the question of additional funding that the system needs, do you think it has been exaggerated or overstated that the system presently is unsustainable?
Ms Bégin: I totally disagree with that. Rather, I think I disagree with that statement of your committee, and I wrote on that. I am not sure because you are not completely clear on page 62.
You start with a very strong assumption that it is not sustainable across the board. I believe you are talking about the existing hospital system. Then, at the top of page 62 you say that obviously ``some expansion of coverage — to close gaps in the health care safety net — is required...'' That means more money. I do not know what you mean by ``expanded coverage.'' I have spelled out what I think. I do not know what you think, I am sorry. I cannot answer.
Senator Roche: On the question of costs, could I draw the attention of the research staff to this report that was referred to in The Globe and Mail today published by the Canadian Centre for Policy Alternatives of Ontario. I do not know anything about them. They have published a study that says, with respect to Ontario, that the charge that the system overextended is inflated. In other words, it is presently sustainable. I would like the research people to look at that.
The Chairman: Sure.
Senator Roche: One final question. I want to draw on Madam Bégin's political instincts in respect of federal- provincial relations. If the restructuring of the system requires more money, could that additional cost be split between the federal and the provincial governments, or is the federal government going to have to pay everything and raise the money accordingly?
We have been told that the provinces think they are maxed out in their present expenditures on health care and would not welcome any additional expenditure on a restructuring system. What is your reading of federal-provincial relations as to whether a cost sharing formula for additional costs for restructuring is viable?
Ms Bégin: Again, I do not know exactly what you have in mind in terms of restructuring. I wrote this at the end of February:
As was emphatically stated last week at the McGill Conference on Health Care in Canada, when health care budgets represent 40 per cent going on 50 per cent of provincial resources, we must ask ourselves questions about balance.
I went on to say that when Canada fixed the public finances — and I think Paul Martin did an essential and great job — a result of that was a sum of $30 billion taken out of health care in the country. We were not the only ones having to put our financial house in order. Most countries did the same, except that Canada did it particularly well. However, our cuts to health care were the most brutal of all the OECD countries. We should put that into perspective.
Everyone knows what I think of the Established Programs Financing, EPF and the CCST. The EPF politically may not have been avoided in the mid-1970s, but it is a huge political mistake. It is more than political; it has been a nightmare. I did not know that I would be stuck with the consequences of it as a minister. It is still a problem.
The Ontario TV publicity campaign regarding the percentage the province and the feds put in for health care was vicious and against the common good. Canadians do not want to see things like that going on.
We should revert back to a 50-50 share, ideally. The feds are seen and are still collecting taxes and should help the provinces. It is the notion of transfer payments between regions of the country. It is also sharing. It is about choices, values, priorities and good use of the spending powers, as far as I am concerned. The feds should increase their contribution proportionately. It is so important in terms of accountability that the public should see ideally a 50-50 sharing, but I think we could start with 25 per cent and go up, slowly increasing the federal share.
Senator Roche: Thank you.
Senator Fairbairn: It is good to see you again. I should say the value you bring to these meetings is great. Every time I go into an airport, I see Madam Bégin rushing to yet another meeting somewhere in the country. She probably has a more intimate input from various organizations than we do.
My concern is on the issue that we were just discussing. I agree completely with you completely, particularly when you look at the demographics. It has never been a secret. The demographics suggest that the issue of home care becomes almost a mandatory addition to the umbrella of our health care system because of the large number of senior citizens we will be having across our country. Our country will not be able to sustain the care of that part of our population unless there is a significant change that enables people to live in more healthy ways in their homes.
As to the notion of opening up the Health Act, I suppose the challenge — I would like your thoughts on this — will be that if this were to take place, we do not want to lose the five principles that are there. One would have to be very clear, persuasive, and careful to bring home care in as another principle. It would have to be enshrined in there so it carries virtually the same weight. People will say this will be impossible.
On the other hand, as I was listening to the conversation back and forth, people were saying the social union that was negotiated, the agreement between the federal government and the provinces a few years ago, was impossible. It turned out not to be. It is the reality of having to share some stuff that, in the past, you would have said, ``No, that is our jurisdiction; it is not yours.'' That may be a positive element in the notion of what you refer to as restructuring.
As far as the home care is concerned, I agree with you that it is most important, because it is happening now, and not well. It may be better in some provinces. People always tell me it is better in Alberta. I am not sure of that. If it is, then people in Prince Edward Island and Newfoundland ought to be able to access that same level.
I am wondering what your thoughts are on that tricky part where you get people around a table and try to pull in this element that would involve money. If you are seriously talking about national home care, I do not see how that can happen in our system unless both the provinces and the federal government see that it is in their best interests to team up on it.
Ms Bégin: Yes. The question is entirely in the realm of politics, not just public policies.
In my opinion, the time is ripe for reopening the Canada Health Act without losing what we already have. That is my political sense, for what it is worth.
If you think of the sequence of events, the Romanow Commission will be reporting and so will your committee. Until now, and despite the best efforts of both institutions, I do not think there has yet been enough public debate. That is an urgent matter for all sorts of reasons. I deplore that it has not yet reached the level it should have reached.
You will be reporting. The government will have to do some homework on the reports. A proposition will be made to the public. It may hit an election period on top of it all — which is certainly not ideal for a complex issue because elections are a Manichean exercise of good and bad, black and white, the usual oversimplification of issues.
Someone will have to manage it, and that is political leadership. Technical knowledge will be needed to translate it into concrete proposals and costs and to make a choice of recommendations that become public policies. Political leadership will be a key ingredient to pilot and manage the dossier in the public opinion. Past that point, I am speaking in theory.
Senator Fairbairn: I would agree with that, particularly on the issue of home care. This is almost an ideal issue that might well more easily become a part of public discussion because of the fact that it is happening in most households in one way or another.
In your notes, you talk about the continuing care through the hospital system and into the home. That is one of the difficult issues that is definitely attached to the larger home care issue. It may just be the kind of area that, if managed openly, honestly and with great skill, the public in this country can understand and perhaps influence.
Ms Bégin: You are making a very good point in strategic and tactical terms. If home care were to be isolated as one important new program that came to the public's attention through federal-provincial discussions, and did not carry what medicare carries, it would be a new program. That would be very interesting. The feds do not need any legislation for that and could announce important investments not for pilot projects but for info-structure, and at the same time, or not, the upgrading of medical equipment across the country.
I see some strategies being devised like that. The fixing of medicare would be done separately, and perhaps more low-key. I see the positive side to home care as a new dossier.
Senator Fairbairn: With all of the complexities and how difficult it is to understand so many of them, I would think that if we cannot come together on the home care issue with something viable, we will have a lot of trouble getting consensus on some of the other issues.
Senator Cook: Ms Bégin, I wish to thank you for the benefit of your wisdom and expertise again today.
I have two questions. I want to pick up on what Senator Fairbairn said about home care. The face of home care is complex. I will share a story with you. A 77-year-old lady in St. John's, Newfoundland, had a bypass on Monday and the doctor said that barring any complications she could go home on Thursday or Friday. If there was ever a need for comprehensive home care in an envelope, surely it follows that person. She is going home to a partner of the same age, relatively speaking. She has a lifeline. There are systems in place. If there was ever a reason to examine what is home care in the context of how we are doing business today in the health care field, I think that is the case.
I want to talk about the regional health boards as they apply to my home province of Newfoundland Labrador. With all due respect, there should be an additional principle added here, namely the principle of reality. There are five boards in my province. However, one of those boards is a wholly tertiary care hospital so the impact begins there. There is a regional board run by volunteers; I was one of them for a number of years.
Ms Bégin: Which one is headed by Sister Elizabeth Davies?
Senator Cook: That is St. John's Public Care. We amalgamated the five hospitals. However, that hospital also services the entire Province of Newfoundland with certain disciplines. There is only one tertiary care hospital, which is run by a group of well-meaning, uninformed volunteers who make decisions on behalf of the people of the province and the government.
To try to put best practices into place, there is the government on one side whose advice is to run the deficit, when we repeatedly say that there is not enough money in the system to make the system work but do not cut beds. Then there is the Department of Health, the Treasury Board, the Auditor General, all the arms of government as pressure points trying to make this board more efficient in the delivery of services when there is not enough money.
How do we get around that? How do we reform in order to do a decent job and not have the pressure points coming until they are moved on to a higher plateau, which is the federal government? What is the answer to that muddle?
Ms Bégin: I do not know the specifics, but what you describe is that of a part of Canada with one concentration of population and resources, even if limited, in outlying communities, which makes it difficult to accommodate health needs. Beyond that observation, I cannot suggest if it is properly done in Newfoundland or not. I apologize.
Senator Cook: I am attempting to get at sufficient money to do a job properly and have accountability.
Ms Bégin: I do not know the specific situation in Newfoundland. I cannot answer your question; I apologize. That is one of the key problems. The provinces' accountability for health dollars is such that no one really knows who spends what for health. Some provinces call it ``social services.'' That is a well-known problem of not being able to understand each other when it comes to speaking about health expenditures.
No one trusts anyone else's figures. That is wrong. First, we have to reach a level of trust on what is the reality of each province. We have to start from there in terms of different contributions from the federal government.
Senator Cook: Do you think there is a role here for accountability from a national federal perspective?
Ms Bégin: Absolutely.
The Chairman: Ms Bégin, thank you very much for coming and spending two hours at our committee meeting. As usual, your comments and insights are extremely helpful.
Ms Bégin: Might I conclude by saying, Mr. Chairman, that as a committee you would do a fabulous service to Canada, and Canadians, if you could work on what I call an ``implementation strategy,'' as well as on a calendar? Usually committees and commissions forget that when they do not exist it is lost. This committee could do a fabulous job.
The Chairman: We hope to do that. We will be giving a specific funding proposal. As you know, committees do not normally do that because they do not want to stick out their necks. I guess we crossed the bravery and stupidity line a long time ago by getting into this in the first place, so we might as well continue.
The committee adjourned.