The Commission on health care has reported to Parliament. Led by a prominent public figure from Saskatchewan, the Commission spent two years travelling across the country and marshalling research on health services and financing in Canada. The report’s recommendations include two major points: the necessity of the federal government to provide stable and secure funding for provinces for universal and comprehensive health programs; and a new “Health Charter for Canadians” to embody fundamental principles about the role of individuals and governments in health care. Politicians and pundits on the right are aghast at the scope of new public funding this would entail, as are fiscal conservatives inside the federal cabinet. Several provincial governments resist these initiatives, particularly Quebec, which raises the issue of federal interference in provincial jurisdiction, as well as Alberta and British Columbia, where very different types of health reform initiatives are being considered.
Sound familiar? And yet, the Report of the Royal Commission on Health Services in Canada, led by Saskatchewan Chief Justice Emmett Hall, was released in June 1964, nearly forty years before the Commission on the Future of Health Care in Canada, led by former Saskatchewan premier Roy Romanow, reported in November 2002. The passage of time between the two reports illustrates well that plus ça change, plus c’est pareil in health care as in other matters. Although the landscape of medicine and health, and of politics in Canada, has changed irrevocably over time, the essential issues at the heart of the health reform debate remain the same: What should be the respective roles of the public sector and private markets in health care? Who should make the rules and take responsibility? Provincial or federal governments?
In 1964, Canada was at a crossroads: the federal government, having already engaged in a cost-sharing exercise with the provinces in hospital insurance, was on the cusp of repeating the exercise with medical insurance. The provinces were experimenting with different types of insurance models, from the public model in Saskatchewan to the voluntary model in Ontario. Quebec was launching its own initiatives in harnessing the state to modernize education and health care. And key stakeholders, particularly medical lobbies, were doing their utmost to retain professional autonomy in the changing climate of health-care reform.
Between the formation of the commission in 1961 and the release of its first report in 1964, the federal government had changed hands; the new Liberals, recast by Lester Pearson as a party of social reform, were in a minority situation in the House of Commons; and the Saskatchewan NDP had implemented publicly-funded medical insurance after a bitter doctors’ strike. The Hall report provided a roadmap for change that built on provincial innovation and existing fiscal partnerships, but at the same time evoked a blue-skies vision of what governments could accomplish in ensuring health care for all Canadians.
At the beginning of 2003, Canada is at a different bend in the road. The scope for change is more limited; choices about health reform are constrained by past legacies, and by current realities. Health care has become an enormous fiscal commitment at a time when governments are attempting to reduce public spending. Cost sharing has been replaced by block grant funding that allows for both more flexibility and more disengagement from responsibilities. The brief window of postwar federal-provincial co-operation, already on the wane by the late 1960s, has given way to conflict over political space and taxpayer money. And the blue skies are now clouded with a constellation of stakeholders and interests that go well beyond patients and doctors.
Roy Romanow entered into this fray with confidence and conviction. His Commission report is not a revolutionary document, but it does send a firm message that the basic premise of publicly funded health care in Canada is as relevant today as it was 40 years ago. In the current political and economic context, this is a courageous message. Like the Kirby report that preceded it, the Romanow report takes a big-picture view of health-care reform in Canada. And, like Kirby, it is not so much a call to arms as a wakeup call: the status quo is not an option; and if we don’t reform the health-care system, we are going to lose the public model.
The Romanow report is, first and foremost, about reaffirming confidence in public health care. The report insists that, crisis-talk to the contrary, the sky is not falling in health care and that the fundamental principles of a health-care system built primarily on a public financing model need not be open for negotiation.
These are important arguments, forcefully made, and eminently defensible with the kind of rich evidence presented in the report. However, framing health reform as an exercise in “building on values” leaves the Commission open to criticism about ideological bias, even though such attacks would be unfair given the report’s scope and content. Values can be seen as a warm and friendly concept, or as an exercise in moral suasion, but at the end of the day, most Canadians”” and their political leaders””are not going to be to be swayed about the sustainability of the public model simply because it’s the right thing to do.
Much more important is to demonstrate that it is the best thing to do, in terms of controlling costs, guaranteeing the quality of health care, and ensuring the best possible health outcomes. There has never really existed an ideological convergence around the principles of publicly financed health care in Canada, either in terms of the public, or stakeholders or political leaders. The frosty reception that the Hall report received from the Canadian Medical Association in 1964 speaks volumes about the deep opposition to government involvement in health-care matters that prevailed in influential circles. Instead, a general consensus has built up over time, a consensus that endured””and was contingent upon””real life incentives and the relative success of the public model in delivering health-care services and keeping Canadians in good health.
The main message of Romanow’s report is twofold. First, the report reminds us that one need not be dogmatic to argue that organizing a health-care system around the principle of need rather than ability to pay makes good sense, both in health terms and in fiscal terms. Second, costs are better controlled and money better spent when revenues are raised and spent through the public purse. This simple but powerful message, that can stand on its own merits, resonates among Canadians precisely because it does not have to be packaged in terms of national values or political ideology.
Romanow is reminding Canadians of what they already sense is true: that health care is an essential good, not a market commodity, and that the best way to ensure that all of us can afford these services and have access to them is to harness our spending power and pool our resources. In other words, markets do not necessarily have the upper hand in efficiencies in financing and delivering services, and health care has to be regulated in order to function properly.
What kinds of change does the report propose? Three related reforms are necessary, and they have to do with money: more money, money better spent, and accountability for the money. Essentially, Romanow agrees that the health-care system needs more money in order to function properly. To admit that underfunding is a problem is simple yet extremely important, and to insist on sustained, multiyear transfers is a clear message to the federal government that it has to pull its fiscal weight in health care. To the question of, “Where do we get the money?” the answer is crystal clear: a dollar is a dollar, whether you are taxed for it or whether you pay it directly out of your pocket. The report marshals the evidence to support this argument to have as much money as possible flow through single-payers (provincial governments) for essential services already covered, and for the types of services that will be increasingly in demand in the future.
The Romanow report also insists that money has to be better spent in the health-care system and that it is to be targeted where it is needed most: to improved access to care for remote and rural area populations, including aboriginal Canadians; to reduced waiting times for diagnostic services; to promotion of primary-care reorganization; and to covering home care and catastrophic drug costs. These are not new ideas in health circles, although they bear repeating. What is new is the mechanism for targeting money to specific health-care funds, and the provision for accountability by governments.
Here is where the ideal policy options meet the real world of politics, and the results are messy indeed. Targeting health-care money where it is needed most and ensuring that governments are accountable are laudable goals, but in the Romanow report they start from the premise that “medicare” can be strengthened from the centre, despite the fact that the very term is a misnomer, as health care in Canada is a mosaic of different provincial and territorial health plans.
The proposals for national bodies to monitor health-care delivery and financing are problematic in a federal-provincial climate already fraught with toxic politics. The use of health care as a political football in the intergovernmental game is deplorable, but it is real. At the same time that provinces have been weighed down by the fiscal burdens of health-care financing, they have become increasingly territorial about their jurisdictional space. But the dismissive attitude of many federal politicians toward their provincial counterparts, and the enduring myth in Ottawa that health-care conflict, like other intergovernmental issues, is only about the money, serves to make matters worse.
As Romanow himself has pointed out, none of this does much good for individual Canadians. Presumably, we can’t wait for federalprovincial relations to improve before tackling the hard choices in health-care reform. By the same token, however, unless both levels of government come to understand what it means to share responsibility for something as essential to Canadians’ lives as health care, there is little chance that the types of solutions envisioned in the Romanow report will be workable.
When John Diefenbaker appointed the Hall Commission in 1961, critics warned that it would be another exercise in avoiding decisive action. Emmett Hall called the bluff, however, argued that the Saskatchewan experiment in medical insurance was worth replicating, and recommended the federal government enjoin the provinces through a cost-sharing program. The main political obstacle was to get consensus on these recommendations through the Cabinet, and in the House of Commons, where a minority Liberal government was buffeted by a socialdemocratic opposition party in full tilt on the health insurance issue.
Today, the challenges facing the implementation of the Romanow recommendations run deeper. The lukewarm response of federal leaders, including key ministers of health and finance, does not bode well for consensus-building in a fractured government. In the House of Commons, the report faces open hostility from the majority of opposition members. And in the federal-provincial arena, the federal government faces an increasingly restless group of provinces that, as strange bedfellows, have different views on the public-private mix in health care but agree that federal money should be free of onerous conditions. Intergovernmental politics in the health-care arena have become riddled with mistrust and””some would say””misinformation. Both levels of government have become empowered through health care, making compromise and concession more difficult.
This not to say that change is not possible in health care, but the direction and scope of change are far from certain. There are three potential scenarios in health reform that can play out in the wake of Romanow, Kirby and the stream of provincial commissions of inquiry over the past few years. The first is change with policy direction that reinforces the public model. In an ideal world, this would take some measure of federal leadership through sustainable funding, some sort of federal-provincial resolution on the boundaries of The Canada Health Act, and a good measure of political will from governments to engage in reform. The second scenario involves change though policy direction that stretches the boundaries of the public health-care model and involves provincial innovation in mechanisms for alternative payment and delivery, sort of the Saskatchewan experiment in reverse.
The most likely scenario, however, is change without any precise policy direction.
The scramble to respond to today’s concerns has overshadowed the need to adapt to tomorrow’s challenges and makes the kind of sweeping scenario in the Romanow report difficult to be implemented as a coherent package. Governments have been discussing health-care “reform” for at least 10 years, but the actual changes in health care across Canada have been less the result of concerted long-term policy options than they have been short-term adjustments to tighter fiscal realities, new developments in medical practice and technologies, and the evolving needs of patients.
The risk of this kind of incremental change in a rapidly changing health-care sector is that, in the long run, difficult decisions are postponed and real needs are not addressed. Health care in Canada will necessarily be transformed in the years to come, perhaps in much more profound ways than we can envision today. Regrettably, this will most likely occur without a clear roadmap and regardless of whether Canadians are happy with the new landscape or not.
