CBC In Depth
Studied to death?
CBC News Online | June 10, 2005

A lot of dollars and a lot of ink have been devoted to finding a cure for what ails Canada's health-care system. Health care may not have hit the 21st century, but studying it sure has.

By the end of 2002, three major studies on fixing the system had been released.
The Mazankowski Report | Jan. 8, 2002

Don Mazankowski testifies at the health care commission
In August 2000, Alberta Premier Ralph Klein asked Don Mazankowski – a cabinet minister and deputy prime minister under Prime Minister Brian Mulroney – to chair the 12-member Premier's Advisory Council on Health. Klein wanted recommendations on how to control the spiralling cost of health care, which ate up a third of the province's annual budget.

The report called for strong medicine for the province's health-care system, including an expanded role for private funding in the system.

"Unless we are prepared to change how we fund and how we deliver health care services, the health-care system in Alberta is not sustainable," Mazankowski said.

Among his 44 recommendations:

Limit coverage
Set up an expert panel to decide what should be dropped from medicare and what should continue to be covered. The panel would also decide whether a new treatment, service or drug would be covered.

Service guarantee
Reduce waiting lists and ensure that all Albertans have guaranteed access to certain services within 90 days of a diagnosis and recommendation by their physician.

Establish an electronic health record
Use a system of health-care "debit" cards that people use to pay for services. The cards would allow the government to track how individuals use the system.

Provincewide standards
Create a commission that would measure how the health-care system is doing against provincewide standards. The commission would also be responsible for keeping Albertans updated on the status of health care.

Blend private, public and not-for-profit health-care providers
Insured services would no longer be provided only by the public system. People could get both insured and non-insured health services in a private facility.

New sources of revenue
The report suggests a list of possible options for additional revenue to help finance the health-care system. The options include increasing health-care premiums, introducing user fees, taxing people for the services they use and expanding private insurance.

Require physicians to work a percentage of their time in the public system to ensure both the private and public systems have access to the best doctors. The report also recommends re-evaluating the way doctors get paid to maximize the level of care they are able to provide their patients.

What's happened?
Alberta has acted on some of the report's recommendations. In October 2003, the province became the first in Canada to transfer its health records into a computer database, making them immediately accessible to any doctor or pharmacist in the province. A system of electronic health records was a key recommendation of the Mazankowski report.

The province also set up a panel to look at which services should continue to be covered by the province and which should be de-listed. Alberta – like the other provinces and territories – was also waiting to see what improvements the federal government was going to make before making other significant changes.

The Senate Report

Senator Michael Kirby
For two years, the standing Senate committee on social affairs, science and technology studied the state of the Canadian health-care system and the federal role in that system. It heard from more than 400 witnesses in more than 200 hours of testimony.

It looked at the history of health care in Canada – and other countries – as well as how health-care systems were structured and what trends would affect the future of health care delivery.

The committee's work was divided into six phases – although most attention was focused on the report of the final phase: Recommendations for Reform.

The key recommendation in the Kirby report – released on Oct. 25, 2002 – was a tax that would raise $5 billion a year. The money would go to expand hospitals, buy new equipment, recruit doctors and nurses, and do whatever is needed to improve the system.

The committee's chairman, Nova Scotia Liberal Senator Michael Kirby, suggested a dedicated tax on Canadians to raise the cash. A dedicated tax means a health tax that would cost lower-income Canadians less than higher-income Canadians. Kirby recommended Canadians earning less than $31,000 a year would pay 50 cents a day (about $180 a year) while Canadians earning more than $100,000 year would pay $4 a day (about $1,500 a year).

"Some will call this another tax," Kirby said when he brought down his report. "We look on it as a much-needed investment."

Kirby's report suggested the tax to save Canada's medicare system be called the Variable National Health Care Insurance Premium.

Other Kirby report recommendations:
  • If a patient cannot receive timely care, the government should pay for out-of-province or out-of-country treatment.
  • Cap individuals' out-of-pocket expenses for prescription drugs at three per cent of family income.
  • Provincial and federal governments should contribute 50-50 to fund a post-acute home care program.
  • An independent health care commissioner should evaluate and monitor the reforms.
  • Change the way hospitals and doctors are funded.
When Kirby delivered his report, he warned that if his recommendations were not implemented, a compelling case could be made to prove that private health-care insurance is needed.

What's happened?
Kirby's key recommendations have not been adopted at the federal level, although Ontario brought in a health tax in 2004. The Liberal government used its first budget after unseating the Conservatives in the 2003 election to introduce a health tax. The new tax tops out at about $900 a year for high-income earners.

The Kirby report had the misfortune of being released a month before the far-more-anticipated report of the Royal Commission on the Future of Health Care in Canada, chaired by former Saskatchewan premier Roy Romanow.

The Romanow Report

Roy Romanow
April 2001 – Prime Minister Jean Chr�tien is less than six months into his third majority government. After promising to repair the nation's health-care system, he appoints former Saskatchewan premier Roy Romanow to head the Commission on the Future of Health Care in Canada.

The commission's mandate was "to engage Canadians in a national dialogue on the future of heath care and to make recommendations to preserve the long-term sustainability of Canada's universally accessible, publicly funded health-care system."

In February 2002, Romanow released an interim report that gave a hint of what would be in his final report: "I am convinced that the medicare house needs remodelling, not demolishing," he wrote.

Eighteen months and $15 million after he was first asked to look at the state of medicare, Romanow released a 356-page report that contained 47 recommendations. He also acknowledged that health care reform would be impossible without the co-operation of the provinces and territories. They run the system. He urged them to reaffirm the importance of maintaining national policies to prevent medicare from eroding into 13 vastly unequal plans.

Among Romanow's main recommendations:

Cash infusion
The federal government should raise its annual contribution to medicare by $6.5 billion in 2005-06. In July 2002, the provinces demanded an immediate increase of $7 billion per year. Senator Kirby's report suggested a hike of $5 billion a year. He proposed the money be raised through a special, permanent tax that would be based on income.

Romanow suggested the extra money come from general revenue, noting that Ottawa has been accumulating surpluses for the past few years. He calls a direct tax "regressive."

Stable funding
Romanow called on the federal government to provide a guaranteed minimum amount of money every year, allowing the provinces to improve the way they budget health care dollars. He says Ottawa should never pay less than 25 per cent of the cost of insured medical services under the Canada Health Act (CHA). The phased-in federal increases being proposed, along with the extra annual $6.5-billion infusion in 2005-06, would move it to this mark, according to forecasts cited by the commission. Romanow also wants an "escalator" provision, renegotiable every five years, to make sure that funding covers creeping costs – such as inflation and technological advances.

Governments must do a better job showing Canadians how money set aside for medicare is actually spent, according to Romanow. Provinces have used federal transfer payments for everything from buying lawn mowers to trimming taxes. He's proposing a mechanism to track what happens to the cash. Romanow wants a newly-created Health Council of Canada to issue public reports on spending. This plan would make "accountability" a sixth pillar of the CHA. The act currently states that medically necessary services provided by doctors and hospitals must be:
  • Universally available.
  • Comprehensive.
  • Portable between provinces.
  • Accessible to all patients without direct charge.
  • Administered by a publicly run plan.
Canada's Auditor General Sheila Fraser has also complained that Ottawa's transfer payments for health care are not monitored closely enough. But several premiers are opposed to the idea. They say Ottawa has no business dictating how the money is spent, since health is a provincial responsibility.

Limited pharmacare
Medicare's founders always intended to expand basic coverage beyond hospital stays and doctors' visits. With the price of prescription medication skyrocketing, Romanow says it's time to begin work on a national drug plan that helps offset the fastest-growing expense in health care today. Creating a separate federal rebate system "would only further complicate the patchwork of programs that already exist." Instead, he suggests provinces be given more money on the condition that they expand drug coverage. They would be reimbursed 50 per cent of the cost of prescription medication above an annual threshold of $1,500 per patient.

Critics of pharmacare say even a limited plan is too expensive, and argue that people who want coverage can buy their own private insurance. But Romanow says a National Drug Agency would be able to keep drug costs down by wielding the power of a single buyer in the pharmaceutical market. "Catastrophic" needs, such as high-priced drug treatment to keep people alive, will be the short-term priority. He eventually hopes more drugs will be covered, deductibles will be lowered, and eligibility requirements relaxed.

Home care
A revamped public health-care system must also help pay more home-care bills, Romanow says, because these are beginning to balloon beyond people's means to pay. Hospital stays are now shorter and less draining on the system than before, but patients are being forced to cough up more for services outside such facilities.

He wants the Canada Health Act broadened to include three services:
  • Care for mentally ill people at home.
  • Aid to people who need follow-up treatment and rehabilitation after day surgery – known as "post-acute home care."
  • Coverage for palliative care to help people who are dying, so they can spend their last six months of life at home.
Private sector's role
Romanow says governments must preserve "the integrity and viability" of public health insurance by limiting the role of the private sector. In particular, he wants diagnostic services such as MRI scans included in a revised Canada Health Act. This would prevent private clinics from charging people extra fees. "One of the most difficult issues with which I have had to struggle is how much private participation within our universal, single-payer, publicly administered system is warranted or defensible," Romanow says. Some private services are already a key part of the overall system, and "the notion of rolling back its participation is fraught with difficulty." But he says letting people who can afford to pay for diagnostic services get their results faster and then "jump the queue back into the public system for treatment" is at odds with a principle at the heart of medicare – "equality of access."

What's happened?
Ottawa has freed up a lot more money � a 10-year, $41-billion deal was reached during a first ministers conference on health care in September 2004, two months after an election campaign in which the Liberals focused on health care. Romanow said some of the provisions of the agreement went beyond what he recommended. Several billion dollars were set aside aimed at reducing the length of time patients had to wait for certain procedures.


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Canada's Health Care System

Canada Health Act

Canadian Institute for Health Information - Health Care in Canada 2005

Canadian Health Coalition � Found: Federal funding. Lost: A plan to stem privatization [pdf]

Canadian Institute for Health Information

Report: National Health Expenditure Trends [pdf]

Organization for Economic Co-operation and Development Public Expenditure on health, % of GDP [Excel file]

The Romanow report [pdf]

The Senate Report on health care

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