Our unhealthy, uncaring health-care system

This May Hurt a Bit: Reinventing Canada’s Health Care System, a new book from Ontario political consultant Stephen Skyvington, will be released on Saturday. The following excerpt looks at how politicians have used and misused the Canada Health Act in ways that makes the system less caring — and Canadians less healthy.

With all the noise and chatter about the Canada Health Act over the years, it’s easy to forget the act only deals with how Canada’s health-care system is funded, not how each individual province sets up its system and delivers care. It’s also instructive to remember that as a result of the way our country’s constitutional powers are divided, adherence to the conditions set out in the Canada Health Act is completely voluntary. In other words, no province or territory is obligated to embrace the act or follow it to the letter. However, the federal government made sure the legislation contained enough disincentives that every province would eventually find it to their benefit to fall in line and adhere to the criteria and conditions of the Canada Health Act.

Should any province decide not to comply, something that has happened from time to time over the past three-decades-plus since the act became the law of the land, the federal government had the right to withhold all or part of a transfer payment, depending upon how egregious the offence. For instance, Section 20 states quite clearly that should a province violate the prohibition on extra-billing or user fees, an amount equal to that collected would be deducted, dollar for dollar, from that province’s transfer payment.

In 1993, the federal government reduced British Columbia’s transfer payments by more than $2 million after it was discovered the province had allowed roughly 40 doctors to extrabill patients over a four-year period. Three years later, it was Alberta’s turn. The province had its transfer payments reduced by more than $3 million because it turned a blind eye when private clinics started charging patients user fees. Newfoundland and Manitoba also suffered government clawbacks during the late 1990s, for much the same reason as Alberta. Nova Scotia was similarly dinged for allowing user fees in private clinics. It’s important to note, though, that to date all issues regarding non-compliance have been, for the most part, settled through negotiation or discussions between ministers.

Those are some of the conditions and administrative details. Let’s take a closer look at the five principles of the Canada Health Act:

PUBLIC ADMINISTRATION

Section 8 of the act says that in order to be eligible for health-transfer payments from the federal government, all provincial health plans must be administered and operated on a non-profit basis by a public authority appointed or designated by the government of the province; the public authority must be responsible to the provincial government for that administration and operation; and the public authority must be subject to audit of its accounts and financial transactions by such authority as is charged by law with the audit of the accounts of the province. Again, it’s important to note that we’re talking here about the funding of health care, not the delivery of services.

Nowhere does it say that health-care services can’t be privately delivered, or even, I would argue, privately funded.

COMPREHENSIVENESS

Section 9 says that provincial plans must cover all insured health services provided by hospitals, medical practitioners or dentists, and where the law of the province also permits, similar or additional services rendered by other health-care practitioners. While the act makes clear in Section 2 what is meant by insured services, there’s been a significant amount of debate over what should or should not be covered today in the 21st century. As has been pointed out, the Canada Health Act almost exclusively defines insured services as those delivered either in hospitals or by physicians. But with the shifting of care from hospitals to the community over the past 20 years, along with a growing dependence on home care, there undoubtedly is a need to re-examine these definitions and modernize them so that they better reflect the world as it exists today, not as it was back in the mid-1980s.

UNIVERSALITY

Section 10 states that all insured persons must be covered for insured health services provided for by the plan on uniform terms and conditions. Strangely, the act’s definition of insured persons doesn’t include those who may be covered by other provincial or federal legislation, such as active members of the Canadian Armed Forces or RCMP, inmates of federal penitentiaries, those covered by provincial workers’ compensation plans, and some Indigenous Peoples. It also doesn’t include permanent residents or Canadians returning to Canada after having resided in other countries, the latter of whom are subject to a waiting period not to exceed three months before being classified as insured persons.

PORTABILITY

According to Section 11 of the Canada Health Act, provinces must not impose any minimum period or residence, or waiting period, in excess of three months, before residents of the province are eligible for, or entitled to, insured health services. After the waiting period, the new province or territory of residence assumes healthcare coverage. It’s worth noting that portability provisions are subject to interprovincial agreements, as there can be variations from province to province vis-àvis what is considered an emergency and whether or not the care received is to be paid at “home” province or “host” province rates, which can also vary from one part of the country to another.

ACCESSIBILITY

Of the many criteria and conditions of the Canada Health Act, perhaps none have caused as much controversy over the years as this one. Section 12 states that each province’s insurance plan must provide for insured services on uniform terms and conditions and on a basis that does not impede or preclude, either directly or indirectly whether by charges made to insured persons or otherwise, reasonable

access to those services by insured persons. Further, principle five allows for reasonable compensation for all insured services rendered by medical practitioners or dentists, as well as payments to hospitals to cover the cost of providing care to patients. And yet nowhere in the Canada Health Act is either “reasonable access” or “reasonable compensation” defined.

To understand the inherent weaknesses of the Canada Health Act, and why our country’s health-care system is failing to live up to any of the principles set out in the act, it might be instructive to stop for a moment and examine some of the crucial differences affecting healthcare spending between today and 1961, when the Hall Commission was first struck (setting the stage for medicare).

Since the early 1960s, Canada’s population has more than doubled, rising from 18.2 million in 1961 to 36.6 million in 2017. Meanwhile, per capita spending on health care during that same period has increased more than sixty times — it was less than $100 per person in the early 1960s while it is a whopping $6,604 per person in 2017. In 1961, 57 per cent of health care in Canada was privately funded, while the rest was covered by government. Today, roughly 70 per cent of health care is funded by the government, leaving approximately 30 per cent to be covered by the private sector. At the same time that government coverage of health costs has been increasing, Canadian life expectancy has also increased, from 68 (males) and 79 (females) in 1961 to 80 (males) and 84 (females) today. With the rise in life expectancy, there has been an out-of-control growth in chronic disease in the last few years; today, it eats up more than 70 per cent of health-care costs in Canada.

Obviously, given the spiralling costs of Canada’s health-care system, the status quo simply can’t continue to be an option. Whether we amend the Canada Health Act, add some sunset clauses, or just plain scrap it, the time is fast approaching where doing nothing will be the worst course of action possible.

Even with all the money being poured into our health-care system, there’s still not enough to fund patient demand. As a result, wait times are getting longer and longer, putting lives at risk and leading to an unconscionable amount of suffering by forcing people to wait mind-boggling amounts of time in order to access care. Our elected officials and civil servants have made a mockery of the principles of the health-care system that they proclaim they will fight to the end to preserve.

As one of the judges in the 2004 Chaoulli case said “Access to a wait list is not the same as access to care.”

And yet, there are still those who think there’s nothing wrong with using the Canada Health Act as a sort of protective shield against the sick and infirm. In British Columbia, for example, Dr. Brian Day, medical director of Cambie Surgery Centre, and some patients have been trying to convince a judge their Charter rights have been violated by the B.C. government. Dr. Day’s Charter challenge asks the following fundamental question: Why should Canada, in contrast to every other country on earth, refuse to allow its citizens to purchase private insurance to cover physician and hospital services?

During the first six months of the trial, Dr. Day and his group burned through the $2 million they’d raised by asking those who care about health care and our country to donate to the cause, all because the government had deep pockets and endless resources designed to distract the judge from the real issue and tie up proceedings for months on end. Shamefully, the British Columbia government assigned 20 lawyers to the case and spent $20 million in the first six months in hopes that Dr. Day and his patients would run out of money and have to abandon their Charter challenge.

What are they fighting about? “Privatization.” Privatization involves governments shifting responsibilities to the private sector. It’s important to remember that privatization of financing is not the same as privatization of delivery. Privatization of financing occurs when the government does things like delist services, or cut programs, or reduce fees in such a way as to make it unprofitable for medical practitioners or institutions to continue to offer a particular service.

Privatizing the delivery of health-care services is different. There are plenty of examples of this. In many cases, provincial and territorial governments have entered into agreements with the private sector to provide services in non-traditional, noninstitutional settings that are paid for by the government out of public money — typically with an eye toward reducing wait-lists for a politically sensitive constituency, such as seniors (hence the special attention paid to things like cataract surgery and hip and joint replacement).

But the privatization of delivery outside the medicare system … well now, for some reason, that’s different. At least it is in the minds of our elected officials and pro-medicare types. “We must not allow two-tier medicine to gain a foothold here in Canada,” they say. “It’s against everything we believe in as Canadians.” What our leaders and those defenders of the status quo — particularly unions — are really concerned about is that the private sector just might deliver a better product at a cheaper price, all because of a little competition.