The province that invented medicare is trying to save it
Saskatchewan's NEW IDEA
The province that invented medicare is trying to save it
It was one of the fiercest provincewide political battles in Canadian history because emotions ran so high and no one was neutral. It raged around a single issue: the Saskatchewan government’s introduction of North America’s first state-run medical care insurance—prepaid and universal. The medical profession told Premier Tommy Douglas that it would not co-operate, but the CCF-NDPdominated legislature passed the health bill anyway in November, 1961. When it came into force on the following July 1, Liberals, editorial writers and doctors declared war on the government and its supporters. Foes said the plan would wreck the doctor-patient relationship. Supporters said it would make quality care accessible to all. Both sides railed at each other in newspaper ads, and circulated petitions. In cities and towns from Swift Current in the southwest to Prince Albert in the north, there were hot-tempered rallies and fistfights. Most doctors closed their offices. Some left the province and never came back. The province recruited replacements in Britain. But after 22 days on strike, the doctors capitulated to an implacable government. “For me as a younger person,” recalls NDP Premier Roy Romanow, now 56, “medicare was a passion.”
It also proved to be contagious—by 1972, all the provinces and territories were covered, with Ottawa sharing the costs, and a nation shielded from crippling medical bills praised the aging Douglas as the father of medicare. Douglas died in 1986 and now, 33 years after medicare’s implemenation, his once healthy offspring faces a gloomy prognosis. Governments, free-spenders in the 1960s and 1970s, are heavily in debt and, scalpel in hand, are looking frantically for places to cut. Medicare is a fat target. Some provinces have closed hospitals. Others ponder user fees. Still others want to exclude certain procedures from coverage. There is talk of private hospitals.
But hold on—Saskatchewan has a new idea. It began to germinate shortly after the NDP regained power under Romanow in November, 1991, when the government, faced with an annual deficit running at a bruising $842 million, sent its medicare architects back to the drawing board. The result could well serve as a model for other provinces struggling to preserve public health care. “We’re at the leading edge of saving it and redirecting it,” boasts Romanow. “Saving not only money, but saving medicare.”
The jarring reorganization began 372 years ago when the government closed 52 of the province’s 132 hospitals and turned them into community health centres. It slashed spending on its 20-year-old, once universal drug plan almost in half by raising the scale of
patient-paid deductibles so high that now only the poor and the aged can really hope to qualify. And it divided Saskatchewan into 30 largely autonomous health districts, each responsible for its own hospitals, nursing homes, ambulances, home care and public health services such as restaurant inspection. The districts, run by governmentappointed boards whose members will be elected starting this fall, get annual grants from the government based on the size and age breakdown of their populations. Doctors still send their bills to the headquarters of the Saskatchewan health plan in Regina as they have all along.
The changes upset many people. Rural communities grumbled about losing their hospitals and the jobs that went with them. Scores of nurses there and elsewhere were laid off. And a sizable portion of the province’s 1,600 doctors complained bitterly because the district health boards now either own or control the hospitals and, as a consequence, their admitting privileges. “Regionalization is an assault
on the doctor’s working conditions,” says Dr. Marc Balizan, president of the newly formed Saskatoon and District Medical Association. “In Saskatoon, we had three hospitals and, if you got into difficulty at one hospital or they weren’t giving you what you wanted, you went to another hospital and struck a deal. All of a sudden your bargaining power over working conditions is dead.” Nor, he claims, would the overhaul “make the health-care system one dollar more efficient. It was undertaken so governments could cut and let somebody else be the fall guy.”
But reform was clearly overdue. The province’s population of about one million, thinly scattered over an area 2V2 times the size of the United Kingdom, had more hospital beds per capita than any other province, a legacy from the days when communities were isolated by poor roads from urban medical care. Yet hospitals are politically popular, and successive governments kept building them even after the roads got better. “Hospitals were built alongside good highways, in some cases four-lane, heading towards either Saskatoon or Regina,” says Cliff Wright, the 67-year-old chairman of the Saskatoon District Health Board. “There were fully equipped maternity wards in this province that had never delivered a baby and understandably so—why would somebody stop halfway here? There were rural hospitals that lacked the two main ingredients I have always thought a hospital needed—patients and doctors. They had kitchen staffs that I guess basically ate their own food. There were eight-bed hospitals that had an average daily occupancy of two, and they were always the same two. We had that all over Saskatchewan as a means of justifying beds being there.” Even after the 52 closures, Saskatchewan still has nearly three times as many hospitals per capita as the Canadian average.
Of all the districts, the Saskatoon health board was the first and
has become Romanow’s showcase for reform. When it began operating in February, 1992, Saskatoon’s three hospitals— City, Royal University and St. Paul’s—each had a broad range of medical and surgical services such as obstetrics, ophthalmology, pediatrics and psychiatry. TTe board eliminated most of the duplication so that patients now must go to the hospital that specializes in the type of care they need.
At the same time, it laid off between 600 and 700 nurses, housekeepers, maintenance workers, dietitians and kitchen staff—about 10 per cent of the workforce. It centralized management, purchasing and maintenance. It cut beds from a combined 1,250 to about 900, set up one office to book all operating rooms and closed City Hospital’s emergency department between midnight and 9 a.m. It co-ordinated hospital, nursing home and home care. “When we started, there were almost 50 people in hospital waiting for a place in a nursing home,” says district g president John Malcom. o ‘Today, there are two or three.” Moving patients down the chain saves money: a hospital room costs $700 a day, a nursing home $100 and home care—which now looks after 4,000 people, compared with 3,200 last year—only about $35. Says Malcom: “Some think we’re quite heartless, but with limited resources it is important that we be frank.”
Being frank—and frugal—apparently works. Board chairman Wright, a general contractor and mayor of Saskatoon from 1976 to 1988, says that the district has managed to cut $11 million out of its budget for acute care, which is $200 million for 1995. (The total district budget, including home care, long-term care, public health and the ambulance service is $302 million this year.) The quest for further savings is relentless. The board told its orthopedic surgeons that if they could agree on the kind of hip and knee prostheses they wanted, bulk purchases would be more economical. The surgeons did. The savings this year: $100,000. “Next,” says Malcom, “we’re going to shop for pacemakers.”
While the government’s drive to reshape medicare in the province of its birth has irritated doctors, nurses and opposition politicians, other experts believe the NDP has taken the right road. Montreal-born Allen Backman, a health policy specialist and professor of management and marketing at the University of Saskatchewan, says flatly: “This is the model that all the provinces should move towards if they want the greatest efficiencies in the way they spend their health dollars.” Impending federal cutbacks “are going to devastate provincial health-care systems,” Backman says. “Saskatchewan is more advanced than any other province in preparing to deal with that crisis.”
For Romanow, the whole exercise is a crusade, a mission shaped and driven by history. Wearing a dark green golf shirt, beige slacks and brown loafers, he sits in his Saskatoon office against a backdrop of royal blue velvet drapes and gives a history lesson arising from Douglas’s contention that medicare’s first objective should be to
remove money as an obstacle to medical and hospital services. “The second phase,” Romanow says, “was to reorganize the whole system, the delivery system, based on the approach that good health meant more than bricks and mortar, pills and medical technology; that you needed to shift away from the belief that modern medicine could do anything and get back to the understanding that the home was the first clinic.” This is the “wellness” philosophy that his government says is behind its health-care reform, based on the idea that preventing disease is better than treating sick people. Would he penalize smokers, drunk drivers, drug abusers? “No,” says Romanow, “because at the end of the day there has to be compassion.”
Then he adds: “Some day, economics might force us to do something, but I wouldn’t consider it at this stage in the game.” Education and counselling, he says, would be better.
There is a whiff of Douglas’s oratory when Romanow says: “I couldn’t live with myself if, at the end of the day, the reforms we have undertaken should prove, heaven forbid, to have been wrongly focused.” Chop of the hand. “That would be, in effect, a betrayal of the legacy and of the very thing that got me into political life.” His pursuit of that legacy, however, has proved to be risky. In g the June 21 provincial g election, the NDP lost 10 z seats in rural Saskatch§ ewan, probably, analysts say, because of the hospital closures and a feeling in those areas that health reform favors the cities.
As for the rest of the country, says Romanow, “what we need to do is to design an affordable health-care scheme for Canada which might be a little less, but it’s uniform, it’s comprehensive, it’s universal, it’s accessible, it’s portable, it’s publicly administered and publicly financed. But I don’t see that happening. It doesn’t have to be the Saskatchewan approach, but there should be some voices at the national level saying: ‘Please, please don’t destroy this.’ ” Across the country, the voices, equally impassioned, are already there by the thousands.
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