By Pierre-Gerlier Forest
How important is the CHA in shaping our healthcare system, and what are the risks and benefits of updating the Act to respond to changing priorities? Pierre-Gerlier Forest expresses his views on the question. —Report from a presentation at the 2011 conference of the MUHC-ISAI
Asking if the Canada Health Act (CHA) is adapted to the needs of the health system can mean three different things revolving around three distinct questions. First, do we need a national framework that expresses the common dimensions of the health system? Second, is this national framework in accordance with the national consensus about what Canadians want this system to be and to do? And, third, is the national consensus aligned with new knowledge about how best to deliver health care?
We need to remember that the CHA is essentially a money bill. It instructs the federal government on the type of provincial and territorial health programs it should support financially and specifies that recipients of federal funding must comply with principles contained in the Act. However, it does not describe what provincial health programs should look like. And, contrary to popular conception, the federal government has no real enforcement powers under the Act. It is true that the few sanctions implemented during the legislation’s first years were not inconsequential, but they ended up being cancelled.
Do we need a national framework that defines the health system?
The CHA has come to embody the common dimensions of our health system and this was clearly the intent of those who crafted the Act. But the CHA was not an attempt at social engineering and was very true to the state of Medicare at the time the Act was passed. The 1980 Hall Commission Report concluded that the system put in place at the end of the 1960s was going backwards in terms of access and comprehensiveness. The CHA introduced four years later was an effort to redress that situation, not a plot to impose a new direction.
Three of the five variables that define the global architecture of any health system have a pan-Canadian dimension: who pays, what is covered, who decides. But the two other factors, namely where care is delivered and by whom, are decided by the provinces. The CHA was respectful of this division of authority.
However, if the Act were to be abrogated tomorrow, I doubt that much would change because the CHA is only the expression of a deeper “compact” resulting from decisions and compromises made decades ago. Historians would trace these back to the 1930s, when the Canadian Medical Association (CMA) and a few provinces like Alberta — the first province in Canada to actually introduce a bill on public health care — started to play with the notion of a public healthcare system.
Strong provincialists may be irritated by this symbol of federal interventionism, but it is not the Act that created the national dimensions of the system. The CHA merely reflects the system that existed at the time the legislation came into force; it adopted the standard operating procedures of the day.
The Act does not define what is “medically necessary” nor does it stipulate exactly what needs to be covered. Decisions related to coverage are the product of complex arrangements among doctors, provincial governments and, increasingly, the public. It is a political process, which is why there is such resistance to all attempts to impose “rationality” or “evidence” to limit the size or the content of the basket of insured healthcare services.
Neither is the CHA the force behind centralization. A national framework would exist even without the legislation. Not only do we have a plethora of powerful groups and lobbies that take interest and pride in doing things at a national level, but underlying forces in the economy and labour markets also contribute to creating a dense web of norms and constraints.
Nothing illustrates this better than the existence of a quasi-common curriculum for doctors and the tradition of a national examination for professional certification. Doctors, who initiate close to 70% of all health expenses, are trained to expect the same conditions of practice under a very similar set of rules and in a very similar social environment right across the country.
Tracing the evolution of the Canadian health system since 1957, when the national system for hospital care was established, we have proven that changes can be made without destroying the compact. We did it in 1968, when we added comprehensiveness to the package, and in 1984, when we distinguished more clearly between universality and accessibility. Why are we confined by five principles today when new variables may require a different response? The system needs to continually evolve when changing circumstances dictate doing things differently.
Commissioner Roy Romanow recommended making a distinction in the law between public administration and accountability. This would have opened the way to a much more flexible regime of healthcare delivery, with public oversight on the one hand, and on the other a general obligation for all providers, public or private, to report on performance and quality.
Does the CHA still reflect the national consensus about health care?
The question is natural given how much the country has changed in the past 30 years, notably because of a profound demographic transformation. The CHA has such an iconic status in Canada that it probably should be reconfirmed periodically. (I personally would not oppose a constitutional disposition that imposed a fundamental review of the laws of the land every 25 or 50 years, as is the case in a large number of American states.) My guess however, given what we are told repeatedly in polls and at the polls, is that public support for the Act and what it represents would be overwhelming. Support for Medicare is virtually intact as it has been for the last three decades, in the 80% range.
During the Romanow Commission consultations, we repeatedly heard that the health system does not belong to doctors, nurses or governments, but to the Canadian public. This does not mean we are stuck for infinity with this legislation as if it were the Ten Commandments. But it does mean that no change can be made that ignores the will and the wishes of the people.
The 2003-2004 Health Accord was inspired by a recognition of Canadians’ deep attachment to Medicare and a desire to meet the public’s wishes. At the time, there was a collective sense that health services were underfunded, and that the federal government was largely responsible. All participants were eager to demonstrate their loyalty to the cause — ergo, the decision to invest close to $41 billion over 10 years and the symbolic reaffirmation of the CHA principles in the Accord.
However, the focus of special funding was exclusively on issues related to access, such as wait times, diagnostic services and primary care. The areas that were identified as priorities at the time fare better now than they did. But we could have achieved more, much more, with the resources we invested collectively in the last eight years. When access is regarded without concern for quality, affordability or appropriateness, the result is a system that is no longer among the best in the world, that is costly by international standards, and that provides very few indications of value for money spent in both the public and the private sectors.
The national consensus goes far beyond access and the public is adequately informed and mature enough to engage in an “adult conversation.” Canadians are surprisingly sophisticated regarding health care. They are not as easily manipulated by the media as some might have us believe, and they are quite able to appreciate the trade-offs between equity and economic development.
They know the system could be better organized. They recognize when a doctor does a lousy job. They understand that they are sometimes pushed into consuming more care than they really need. They notice when something is taken away that they traditionally had and may have fought for.
The public is ready and willing to discuss these issues. During the Romanow Commission consultations, a senior citizen in Montreal patiently explained to the Commission why a system that is not accountable could not be fully equitable. No equity without accountability would be a very good starting point for a conversation about Health Accord renewal in 2014.
Is the national consensus aligned with new knowledge about how best to deliver health care?
When the Canadian health system was established, our understanding of the reasons why some people are sick and others are healthy was based on a very different appreciation of the respective roles played by conditions and circumstances. We knew that social conditions played a role in determining a person’s health, but thought that circumstances over which one had little or no control played an even greater role.
Believing that anyone could be struck by the misfortune of bad health, it was a rational choice to protect all Canadians equally. There was a small element of redistribution in our regime but it was conceived, first and foremost, as an insurance system with a very wide distribution of risks and benefits. We wanted to be ready for the worst case scenario and ensure that everyone would be protected.
The social insurance systems we built in the 1950s and 1960s were based on the premise that the equal distribution of risk would naturally lead to the equitable allocation of collective resources.
We know now that risks are not evenly distributed and that social conditions play a much greater role than previously imagined in determining health. Neither is individual responsibility a straightforward concept with clear applications, as lessons learned about smoking and obesity underline. However, it is not clear we know how to incorporate this newly acquired knowledge into our national health system.
Our new understanding of the social distribution of health questions our very notion of equity. If as a society we are responsible for the socio-economic conditions that are often the root cause of disease, we cannot redeem ourselves just by offering free health care to people once they are sick. If we want to prevent disease and promote health, we first need to address these inequalities, and this means that resources may not be distributed in the future the way they were in the past.
The CHA would ideally include something along the lines of the newly updated National Service Act in England, which imposes on the Secretary of State “a duty to reduce inequalities between people… with respect to the benefits that can be obtained from the health service.”
But addressing the health challenges confronting the most vulnerable must not come at the expense of the needs of others. We will not be able to sustain the system for long if people do not believe they get out of it what they put into it. This is underscored in the current debate on services for the elderly and intergenerational equity in pensions. One of the earliest pillars of the welfare state is under attack for this very reason.
New approaches are required. One option would be to reintroduce some elements of insurance into the healthcare compact. For instance, while everyone requires the assurance of catastrophic health coverage, Canadians might welcome more tailored personalized services when it comes to primary care.
The idea is not treasonous to our social and democratic ideals, but a way to let people express their autonomy and responsibility while improving their sense of ownership of the public system. However, it might entail the introduction of a flexibility principle within the overall national framework.
Governments the world over are contending with rising costs for health care and, without exception, these costs are not associated with a corresponding improvement in productivity or quality. Failures in health reform are rampant. The greatest difference between Canada and the rest of the world might be the incredible importance we give to a single piece of legislation as if the health system in its entirety was contained in its few pages.
This is terribly misleading. The Canadian health system is much more than the five principles of the CHA. In the end, what matters to people are visible and significant improvements to the way the system operates to better meet their needs.
Do we need a national framework that expresses the common dimensions of the health system? The answer is an emphatic yes. It already exists, with or without the CHA, and it is better to have it expressed in a legislative framework.
Is this national framework in accordance with what Canadians want the system to be and to do? For the most part, yes. But the public that owns and pays for the system clearly wants a better deal.
Finally, is the national consensus aligned with new knowledge about how best to deliver health care? Nowhere near. We need to incorporate new knowledge and evidence to enhance the system to help ensure that it remains responsive to the needs and expectations of all Canadians.
Producing better health outcomes for Canadians must start by changing the system itself. Mechanisms to increase accountability and address affordability and quality concerns must be developed. And the system must be infused with sufficient flexibility to encourage innovation: there are plenty of constructive things we can do to make the system more efficient and effective.
It is not the CHA that impedes this progress. Ultimately, we will only change the legislation by reaching a consensus on just what kind of system it is that we want.