This article was originally published in Maclean's Magazine on December 9, 2002
Managing Health Care a Challenge
FROM THE OUTSET it has embodied all the elements of a fine spectator sport: adaptable principles, skilled deception, bullying and emotional blackmail. Little wonder Canadians love their medicare.
True, the health-care system we have evolved over the past almost 60 years - the envy of at least some of the world - has provided no small share of little miracles. A near cure for diabetes. Heart transplants, even for (otherwise healthy) seniors. Long-distance care via television for remote communities. The mere fact, for most Canadians, of being able to see an emergency room doctor in the middle of the night with an ailing two-year-old - with cost not a factor - should never be taken for granted.
Still, let's be frank here, medicare has broken our hearts. We wanted so desperately for it to be Tommy Douglas simple - timely, common-sense care for everyone, regardless of income. Instead, we ended up with chronically unhappy doctors, soul-destroying fed-prov confrontation, too-long waiting lists for cancer treatment, government-induced nursing and physician shortages (we have become that rare civilized country that believes you can have too many doctors), and elderly parents spending their last hours on a stretcher in a hospital corridor. Sixty years of medicare. It's been a roller-coaster of collective emotion that - got to say it - reflects our national character.
We Canadians love to play one government off against another. Elect the Liberals to Ottawa, we'll tend to put another party in power provincially, just to watch them spar. Just to make sure no one in a plush leather chair somewhere in authority is going to take any of us for a ride. And of all the political toys at our disposal, medicare has proven the most accommodating, a game board for ideological as well as regional competition.
We used governments to beat doctors into submission. Then we let them turn on each other - the feds against the provs for the most part - to provide the cheques and balances for a system that deals in life and death. Initially, provinces wanted Ottawa's involvement to defray the costs of a public health care. We forget now, but in the post-war years and into the early '60s, when first hospitals then doctors were brought under the public umbrella, Liberal Ottawa had to be coaxed into the game. Later, of course, the provinces wanted Ottawa out, especially when it wrapped itself in medicare's cloak and started bossing them around, curbing their experiments with extra-billing and private clinics. Now they want the feds to pony up another large chunk of cash, to be partners again (maybe, but on whose terms?), and shake hands on a brave new start.
What's on the table? A "modest" drug-care program to rescue those with bankrupting chronic disease. Subsidized home care for the terminally ill, the mentally ill and those just released from hospital. Public money for the latest in diagnostic equipment. And a new medicare "covenant" to settle on priorities and minimize the fighting. If there is one thing Ottawa, the provinces and the medical elites agree upon, though, it's that there is no going back once you've let the genie of rising expectations out of the bottle. Medicare's proponents have had great success decrying the slippery slope of private, profit-driven care, as if every new sports medicine clinic will be the last straw that drives us back to the era of the charity ward. It's a valid argument but it belittles our cranky Canadian pragmatism: we've had private X-ray and blood analysis clinics for decades, but according to the purists we're not to have those that offer state-of-the-art CAT scans or MRIs? Even if they can shorten surgical waiting time by months?
And, of course, the same slippery arguments cut both ways. In recent years, the onslaught of time-saving surgical techniques and innovative drug therapies has shifted the health burden from publicly covered hospital care to individuals and private drug plans. Prescription drugs and the broad category of home care are today's fastest growing components; and most provinces offer funding incentives to hospitals to shorten patients' stays and get them out the door as quickly as possible. If Canadian well-being is the ultimate criterion, why shouldn't these areas be publicly covered?
So what would Tommy do?
The late T. C. DOUGLAS: a jaunty bantam rooster, long-serving Saskatchewan premier, the first leader of the federal NDP and the father of medicare, a title he would share with jurist and Royal Commissioner Emmett HALL, a fellow Saskatchewanian. For Douglas, a lengthy childhood stint in a hospital ward, where he might have lost a leg if it hadn't been for the charity of a visiting surgeon, steeled his resolve. And so by a little province they were all led.
Saskatchewan was the first to implement publicly funded hospital care, in the mid-1940s, though others were also getting into the game in distinctive ways, provincial experimentation being a much misunderstood hallmark, even today. But Saskatchewan was the first to take on the doctors - the real battle. British Columbia had wanted to but flinched at the last minute. And the 1962 strike - 23 days long, the great majority of Saskatchewan doctors shutting their doors, many even leaving the province - was North American in its impact. Newly elected president John F. Kennedy was trying to introduce a more modest medicare package south of the border in the teeth of fierce physician opposition. Canadian high school students were being asked to debate the merits of "socialized medicine."
Douglas couldn't win a seat in Saskatchewan later that year when he switched to federal politics. But his legacy lived on - feisty, pioneering, pragmatic. He had spent much of his time in office rooting out hospital waste and cautioning Saskatchewan residents not to expect the moon: public health insurance was designed for "reasonable access," whatever that meant, and to keep those with serious illness out of the poorhouse. But of course that message didn't always sink in.
It would be wrong to blame Douglas for the megaphone politics that came to dominate the medicare debate all these years. But that, too, is part of his legacy, and part of what Roy ROMANOW, medicare's newest Royal Commissioner, himself a former Saskatchewan premier, has experienced first hand. Both as an NDP cabinet minister in the 1970s and early '80s, and as premier during the '90s, at the time of the biggest of the federal cutbacks, Romanow was at the sharp end of federal-provincial dust-ups. He was the one who closed 52 rural hospitals in Saskatchewan and delisted a few insured services, all the while using the legacy of Tommy Douglas as his shield. It didn't help: in the 1999 election his party barely clung to power and he stepped aside a year later.
In the early days of medicare, Ottawa and the provinces circled each other like awkward suitors at a high school dance. But that soon changed. By the mid-1970s, Ottawa was tired of paying automatically for the provinces' happily expanding systems; they in turn were fed up with the annual nitpicking negotiations. So the two sides settled on a scheme of fixed transfers, one that has befuddled economists ever since.
That, too, didn't last. In 1984, a resurgent Pierre Trudeau - a patriated Constitution and new National Energy Program under his belt - enacted the Canada Health Act. That gave Ottawa the power to withhold funds, which it did ($245 million worth over three years), if the provinces didn't outlaw extra-billing - charges beyond those covered by their health insurance plans. Now the feds had elevated themselves from partner to judge and jury. Then they started slashing back on transfer payments. Paul Martin's cuts in 1995, when he was Liberal finance minister, were the sharpest of the bunch. They did everything to put federal finances in order for the future. But they spread through the country's health-care system like germs in a schoolyard.
Want an example of medicare mayhem? Look to May 1996, when Alberta's Ralph Klein, the most determined of the contemporary experimenters, capitulated on private clinics. Or did he?
For six months, Ottawa had been withholding $420,000 a month from Alberta because the province allowed speciality clinics where doctors billed medicare for part of their work, and charged patients directly for the rest. The political battle ripped through national headlines - for many it provided a twisted separatist subplot to the fateful Quebec referendum cliff-hanger that had just ended. And when truce was called in May, a referendum-weakened federal government claimed victory. But it also signed a document extolling the 12 principles of Alberta health care, including: to ensure a strong private-sector role both within and outside the public system, and to allow doctors to practice in both systems at the same time. So what exactly changed? Two years ago, Klein passed Bill 11, a law to encourage entrepreneurial and, as he sees it, cost-saving clinics, setting the stage for yet another medicare battle and the post-Romanow meeting of first ministers, now set for late January.
The timing is either exquisite or painfully brutal. The feds have money in the till right now, their house is in order. But this is Romanow's swan song, Jean Chrétien's too. Maybe even Ralph Klein's. Will heir apparent Paul Martin take up the new health-spending mantle as a campaign commitment (as his health minister father did all those years ago)? Is that what we need right now, another medicare election?
The battle lines are already forming, the posturing at least. New money is welcome, Alberta, Quebec and others are saying, testily. But we have our own health priorities now. We don't want funding that comes with strings attached. Or with Ottawa as medicare's judge and jury. And do Canadians really want an end to the fighting - despite what they tell pollsters - that in so many ways befits our cranky, regionally suspicious way of doing the nation's business?
The test of commissioner Romanow's mettle will not be whether his ideas can winkle more money from Ottawa's supposed multi-billionaire surplus. But whether they can staunch the bluster that has prevented so many practical reforms from going forward, and find a way to keep the conflicts creative and pragmatic - by focusing on the goals and not the slippery slopes. He suggests a national health council, a group of government and citizen appointees to monitor and referee, or at least whisper ideas in the right ears. But do we really need a new bureaucratic mechanism just so Ottawa and the provinces won't squabble in public anymore? Remember, if it wasn't for one feisty little dust-bowled province with a chip on its shoulder, we'd never have this thing we are all so perversely fond of in the first place.
See also HEALTH POLICY.
Maclean's December 9, 2002