At first the medical profession and most provincial governments denounced it as “fiscal blackmail” and a “sham.” Those responses were largely predictable after federal Health Minister Monique Bégin tabled her long-awaited Canada health act last week. But health care lobby groups and the New Democratic Party applauded the fact that the legislation will impose dollar-for-dollar penalties on provinces that allow hospital user fees or extra billing by doctors. Then, to the surprise of many observers, the federal Progressive Conservatives also declared their support for the bill. And by week’s end, even the 38,000-member Canadian Medical Association had softened its stand. Said former CMA president Dr. Marc Baltzan, standing in for Dr. Everett Coffin who was ill: “We wish to take a nonconfrontational approach to the Canada health act.”
The provinces, doctors and the federal Tories have consistently maintained that inadequate federal funding is eroding Canada’s health system. But Bégin maintains that user fees and extra billing are the real causes of the problem. She said last week that the inability or refusal of some provinces to prevent extra health charges had con-
vinced her that it was “absolutely essential” to legislate stiff penalties for user fees and extra billing. Bégin added that the national total of those charges had increased to at least $106 million in the year ending last September—$70 million in extra billing and $36 million in user fees—from $53 million in 1978.
Under the new legislation, Ottawa will deduct from its cash payments to the provinces the exact amount that the provinces allow in user fees and extra
billing. The federal government would also withhold “discretionary” amounts from provinces that break other medical rules, such as the requirement that 100 per cent of residents be entitled to medical insurance. Current legislation requires only a 95per-cent entitlement. Bégin hopes that the new bill will become law by next April. Over the following three years federal funds that are withheld because of extra billing and user fees will be placed in a special trust fund, and the provinces can recover the
money if they ban extra charges.
At the beginning of the week, Coffin, of the CMA, described the act as “dictatorial” and the “dogmatic thrashings of [a] government desperately seeking a way to get re-elected.” He called an emergency meeting of representatives of provincial medical associations in Toronto last week and said that the CMA would support any doctors’ strikes to protest the bill. But at the gathering the doctors made an about-face and decided to become more conciliatory, calling for a meeting with Bégin and the Prime Minister. Said Baltzan: “You do not go to war first. You try diplomacy.” And if the provinces banned extra billing, he said, then each provincial medical association would take whatever action it wanted. The CMA’s new stance, however, may have little bearing on them. Said Edward Moran, general secretary of the Ontario Medical Association, earlier in the week: “If in fact we are captured in a master-servant relationship with government, we will become union-like.” Militancy on the part of doctors likely will be directed at their provincial governments after the act becomes law, but the two groups are now strong allies in opposing the legislation. Like the medical profession, the provinces say that the act sidesteps the real threat to medicare: inadequate federal funding. Nova Scotia Health Minister Gerald Sheehy said that federal money accounts for 43 per cent of his province’s health costs. He added that Nova Scotia, which has no user fees but does permit physicians to extra bill, could not afford to lose the estimated $3.4 million that the province’s doctors extra bill. The large provinces with Conservative governments stand to lose much more and they may find themselves in a confrontation with their federal counterparts. Ontario doctors who have opted out of the provincial health plan extra bill for about $50 million annually, while Alberta physicians extra bill roughly $14 million.
There will likely be a concentrated debate over the terms of the act in the months ahead. Conservative health critic Jake Epp said that he wants to make a number of amendments to the bill, including an extension of its scope to include such areas as home and community-based care. And the CMA wants to meet with the health minister. But Bégin said that she will not change the essentials of the act. Despite the opposition, the medicare bill will likely survive intact.
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