CANADA

SACRED TRUST ?

SO FAR ONLY QUEBEC WANTS MEDICARE USER FEES, BUT OTHERS MAY FOLLOW

BARRY CAME,LUKE FISHER,TOM FENNELL August 30 1993
CANADA

SACRED TRUST ?

SO FAR ONLY QUEBEC WANTS MEDICARE USER FEES, BUT OTHERS MAY FOLLOW

BARRY CAME,LUKE FISHER,TOM FENNELL August 30 1993

SACRED TRUST ?

CANADA

SO FAR ONLY QUEBEC WANTS MEDICARE USER FEES, BUT OTHERS MAY FOLLOW

They are unlikely combatants, a pair of greying Montreal grandparents. But for the past three years Jack Gottheil, a 76-year-old retired Montreal salesman, and Reva Gesser, his comrade-in-arms, have been waging war with the Quebec government. As members of a coalition representing 500,000 senior citizens, Gottheil and Gesser opposed a provincial plan to slap user fees on drug prescriptions for the elderly. They lost the battle a year ago when Quebec forced seniors to pay $2 for each prescription they submit to a pharmacy. Neither Gottheil nor Gesser has given up the fight, however. “If other user fees are introduced,” says Gesser, “it may eventually break the back of universal medicare in this country."

Although millions of Canadians no doubt feel the same way, the debate about medicare user fees is far from settled. During the Conservative leadership race, several candidates—including the eventual winner, Kim Campbell—mused publicly about charging Canadians a cash fee whenever they sought medical treatment. The Quebec government supports user fees in some circumstances in order to contain health-care costs—which reached an estimated 9.9 per cent of Gross Domestic Product in 1991 from 7.2 per cent in 1975. “I personally hope medicare becomes a major election issue,” Quebec Treasury Board President Daniel Johnson told Maclean’s. “User fees may not be the answer, or at least not a complete answer. But we’ve got to start discussions soon.”

According to Johnson, those discussions could begin at the annual meeting of provincial premiers, scheduled for Aug. 25 in Cape Breton. Addressing a recent meeting of his party’s youth wing, the minister said that Quebec plans to press for changes to the 1984 Canada Health Act, which penalizes provinces that impose user fees by cutting back federal transfer payments. Most of the other provinces oppose user fees, although Alberta Premier Ralph Klein has left the door open, saying that he wants to hear what Albertans think at a roundtable on health care later this month.

Up to now, Ottawas stand on user fees has been harder to nail down. A Maclean’s/CYM poll of delegates to the Tory convention in June found that 80 per cent of the respondents favored user fees or would accept them in order to control health-care costs. Campbell herself said that she opposed user fees, but was open to discussing the idea with the provinces. “Maybe it’s possible to have an experiment with one province or two provinces to demonstrate the efficiency, or not, of such a program,” she told reporters in May.

When the race ended, Campbell began to retreat from her earlier comments. In July, the new Prime Minister said that she would not permit user fees for “medically necessary services”—the definition of which would be worked out by Ottawa and the provinces. But she again left open the possibility that fees might be imposed on some services that are now covered by medicare.

Based on Campbell’s comments, both the Liberals and the New Democrats intend to campaign in defence of medicare. Spokesmen for both parties maintain that a re-elected Tory government would move to relax restrictions against user fees. “We are foursquare against the concept,” says Winnipeg North MP and Liberal health critic Rey Pagtakhan. “All studies in the past have shown that, from the point of view of costs, user fees don’t work.”

With the federal election fast approaching, the Tories seem determined to ensure that the future of medicare does not erupt into a major election issue. Maclean’s has learned that Health Minister Mary Collins plans to speak out forcefully against user fees when she addresses the annual meeting of the Canadian Medical Association this week in Calgary. “I would not be prepared to recommend user fees,” she said in an interview. “It is a fundamental part of the Canada Health Act that there are no fees, and it is very much the basis of our system.” Collins said that she and the Prime Minister are in complete agreement on the issue, although she acknowledged that Campbell’s earlier remarks “may have been a little bit off target.”

Collins also said that she wants to confer with Quebec health authorities over the widespread changes that are now being introduced in the provincial health-care system. Foremost among them is what Quebec calls a $5 “disincentive fee” to steer patients away from hospital emergency rooms towards similar services provided by one of Quebec’s 158 regional community health clinics. “I want to know what their thoughts and plans are,” she said. “If this is a fee to use basic health or hospital services, it would be a user fee under the terms of the Canada Health Act. Calling it something

other than a user fee isn’t going to get it through necessarily.”

Despite the controversy, even Quebec officials say that they are not totally wedded to the idea of mandatory user fees. “Personally, I’m not sure that user fees are the way to go,” said Montreal-area MNA Russell Williams, parliamentary secretary to Health Minister Marc-Yvan Cote. But Williams noted that health costs account for $13 billion of the province’s $40-billion budget this year, adding that “something has to be done pretty quickly to bring those costs into line.” If nothing else, he said, the proposed $5 disincentive fee has at least generated debate. “It is at least as important for the future of the country,” he said, “as the debate over the Constitution.”

The $5 fee is only one small part of a massive five-year reorganization of health care in Quebec that was launched two years ago. Among the proposed reforms: new “smart” medicare cards, possibly containing a microchip with an individual’s medical history; tighter regulation of doctors’ salaries;

tighter restrictions on the number of medical students; steps to encourage younger doctors to practise outside major urban areas; and user fees on, among other items, adult eye examinations and drug prescriptions for senior citizens.

It is the latter measure that is galvanizing Jack Gottheil and Reva Gesser. Both argue that the $2 fee on prescriptions has not resulted in any significant savings, but has discouraged many low-income seniors from purchasing prescribed drugs. Even more ominous, they say, is the trend that the fee may herald. “Is it the beginning of the end of medicare?” asks Gottheil. At the very least, Quebec’s drive to contain health-care spending signals the beginning of some fundamental changes.

EASING THE MEDICARE CRUNCH

Which of these options would you support to reduce or control health-care costs?

(percentage in favor)

Impose a $5 user fee for visits

to hospital emergency wards 73

Allow nurses and paramedics

to perform more medical functions 71

Use more midwives 68

Put a ceiling on doctors’ incomes 60

Privatize some hospitals 42

Impose a $25 fee for each night

spent in hospital 33

Charge everyone a $30-a-month medicare premium 31

SOURCE: ANGUS REID/SOUTHAM NEWS POLL CONDUCTED MAY 18-20 1993

BARRY CAME

LUKE FISHER

TOM FENNELL