By Philippe Couillard, Antonia Maioni, André Picard, Bernard Lord
Bernard Lord leads Antonia Maioni, Philippe Couillard and André Picard in a discussion on how Canadians and their politicians might act to improve health care. —Report from a presentation at the 2011 conference of the MUHC-ISAI
Bernard Lord: Should the Canada Health Act be changed?
André Picard: There is no question we have to expand our statement of principles, because the Canada Health Act (CHA) reflects 1960s values, not 21st-century values. This could be done by opening up the Act or by supplementing the Act. However we do it, the important issue is that we expand our guiding principles to include things like accountability and cost-effectiveness.
Antonia Maioni: I think Canadian values are very clear and we do not necessarily need legislation at all. The CHA is given way too much importance in the grand scheme of things. It acts as a velvet handcuff and we have allowed ourselves to be limited by it when it should not, in fact, be limiting.
Before we start changing things, I think we have to ask why we want to change them. The CHA is a simple statute of the Government of Canada and could be changed tomorrow, if the majority government in Ottawa wanted to. But they would have to have a compelling reason for doing so in order to gain public support.
Philippe Couillard: The CHA never prevented me, as Minister of Health in Québec from bringing in changes. Steps we took to enable private delivery of care under public funding were entirely compatible with the CHA. I do not think it needs to be changed and it would be a tremendous political struggle to even announce an intention to reopen it.
Bernard Lord: If the CHA does not stand in the way, what are the obstacles to change?
Philippe Couillard: There is an innate resistance to change, which is stronger in certain provinces, including Québec, and in certain stakeholder groups. There is also a fear that as soon as we start changing the system, we will inexorably move toward an American system. The fear is not rational. Why would we want to have that system here? It is not a wise choice and there are many other models in the world we can look at that have similar levels of expense, similar levels of equity and social justice but higher levels of performance.
André Picard: Fear is a central obstacle. Canadians fear what the alternative would be if we were to change. And we have this U.S. bogeyman hanging over us. That is the biggest impediment. In this particular area, Canadian cautiousness is rooted in cultural fear that is not serving us well.
There are also structural impediments as our system reflects a 1950s sickness care system rather than the healthcare system we need today. Europeans have found it easier to make the shift, because they are not bound by this cultural fear.
Lobby groups and interest groups are another key obstacle. We keep hearing that drugs are the main cost driver but it is really physician services that have seen by far the biggest increase over recent years. Doctors do very well in our system and they have an inordinately strong voice. We have to shift some of that balance of power to the public and back to politicians and policy makers.
Bernard Lord: We have had the conversation, consultation and recommendations, but there seems to be a lack of political will in making the proposed changes. Is this a response to the perception of what people want?
Antonia Maioni: If there were a real feeling among the population that changes were needed, politicians would be the first ones at the barricades trying to do just that. The political will to get everyone to the table would be a lot stronger if there were more momentum in the population.
Philippe Couillard: Health care has become a danger zone for politicians. They see how much political capital they would need to invest and wonder what there is to win by venturing into it.
Bernard Lord: Certainly, health care has not been a dominant issue in any of the recent provincial elections.
Philippe Couillard: I was part of a team that campaigned in Québec in 2003 with health care as its first priority, and despite significant efforts and investments we saw very little reward. Other politicians across the country observed that and learned from it.
Bernard Lord: What will motivate the public and the elected officials?
André Picard: Knowledge will make a difference. And the population has to create a safe space for politicians and back them up when they dare to propose something different.
Philippe Couillard: The role of institutions like the MUHC-ISAI, commentators and the public is to create a zone of safety for the politicians to make them want to venture into health care once again. An important feature of our current political landscape is a federal government that has the political capital and the political space to move on health care but has not yet decided whether it wants this to be part of its legacy.
Bernard Lord: It is a big unknown. The Conservatives’ election platform only stated they would continue the 6% annual funding increase for health care. They have limited the debate since taking office.
Bernard Lord: What do you take home from presentations on the British and Dutch reform efforts?
Philippe Couillard: The Europeans decided from the start to cover a much wider scope of services, even if coverage was not quite as deep and there were certain user fees. The scope we chose when founding our system was doctors and hospitals. That was fine in the 1960s and 70s when we had a young society with acute-care problems. Now, this is not the case. So we face a kind of disease lottery: If you get hit by an acute illness, you will be taken care of extremely well and most of your expenses will be assumed by the state, except for prescription drugs when you walk out of the hospital. But if you have to struggle with Alzheimer’s disease, then you will be responsible for much more of the costs yourself.
An OECD report in 2009 on Canada’s healthcare system described the non-Medicare part of our health care as basically a U.S.-style system, based on out-of-pocket payments and private insurance if you can get it through your workplace. That is essentially what we have now and is one of the major differences between our system and many European ones.
Antonia Maioni: What we see in European models, particularly countries with mixed models, is regulation, regulation and regulation. Without proper regulation, a mixed model just does not work. As well, in most mixed systems in Europe and elsewhere, part of the profit motive is taken out of health care, at least at the primary care level, and often at the private insurance level. You can have a mixed system but not a for-profit private system.
André Picard: We pretend we have no private care here, but we have $7 billion in private care. The difference, and it is not a good difference, is that here we have a bifurcated system where we pay 100% for physicians and hospitals and virtually nothing for dentistry; very little for home care and about 50% for drugs. Other countries have a mixture across the board. We could benefit from greater variety of insurance and ?a greater mix of public and private across the board, rather than these rigid silos.
Antonia Maioni: The centrality of the family doctor in European systems appears to give them significant advantages. We do not yet have that “medical home” and I think that is the biggest change we can hope for in the near future. We also lag behind in how much we know about cost, quality and outcomes in our system.
Bernard Lord: Is the fear of private for-profit sector involvement warranted? We do not seem confident that we can put the safeguards in place that would make us less fearful of privately driven innovation.
André Picard: The OECD report that Dr. Couillard referenced made the point that the private care Canada does have is really very much “Wild West.” There is no regulation at all. Even U.S. private care is much more regulated than in Canada. It seems Canadians prefer to pretend we have no private care, while in fact we have a lot of it and it is not regulated in any way. I would much rather have more private care and more regulation than the system we have now.
Philippe Couillard: No country on earth, and particularly in Europe, uses private health care without regulating it very strictly. It seems obvious that we should do this. And I was part of the only government in Canada (along with those who introduced the Ontario IHF model many years ago) who has taken steps to regulate private health care.
Antonia Maioni: Because that would be to admit it existed.
Philippe Couillard: Exactly. We say it does not exist so we do not need to regulate it. When I tabled legislation to introduce regulation, soon after the Chaouilli ruling, I was accused by some of giving legitimacy to the private sector. And let me tell you it is total “Wild West” out there. When we were designing legislation to regulate private surgical clinics, the Ministry went around to check on what was going on. There were literally people doing plastic surgery in their garage. This is the result of ignoring that private health care exists. I believe private care can be used for the common good and social benefit if it is strictly regulated.
André Picard: There was a big scandal in Ottawa in early October with a private colonoscopy clinic that was treating many patients with unclean instruments. There are thousands of these clinics now and they do whatever they want. That does not serve the public well. The media has a role to play, but the regulation angle was lacking in coverage of the colonoscopy clinic, which dwelled on the individual doctor herself.
Antonia Maioni: Does Canada have the mechanisms in place to be able to regulate health care the way that mixed European systems do?
Philippe Couillard: Yes, and it has been done.
Antonia Maioni: Do we need a healthcare czar who is above the fray, above the stakeholders and the politicians, and can give the straight goods about what is good and bad and needs to be changed?
Philippe Couillard: The idea of a supreme judge is risky. Much as I said earlier that we should keep partisan politics out of the management of healthcare delivery, decisions about what we do and do not pay for collectively are fundamentally political in a democratic society, and we have to let the democratic game play a role here. The role of physicians and other experts is to explain to the public why it should be done and gain support.
Bernard Lord: The MUHC-ISAI was designed to provide a forum where people can come together and discuss the issues around improving our healthcare system. When we started out four years ago, I was coming out of public life and certainly understood the need for changes in health care. It is our hope that the conference and other discussions we organize as part of the MUHC-ISAI programme will inform people about alternatives in place in other countries and help create that safe space for political actors and healthcare administrators to propose and try out new ideas.