Health

‘DOLLARS BUYING CHANGE’

Romanow calls for more federal funding, but only if provinces spend it wisely

JULIAN BELTRAME December 9 2002
Health

‘DOLLARS BUYING CHANGE’

Romanow calls for more federal funding, but only if provinces spend it wisely

JULIAN BELTRAME December 9 2002

‘DOLLARS BUYING CHANGE’

Romanow calls for more federal funding, but only if provinces spend it wisely

Health

JULIAN BELTRAME

ROYAL COMMISSIONS have played a dubious role in Canadian public affairs. Often created under duress, they are trumpeted by the enacting government as an impartial search for solutions to a national dilemma, released to great media fanfare, debated vigorously by politicians and interest groups—then put on the shelf to gather dust. It is against this bleak backdrop that Roy Romanow presented his 356-page prescription for what ails Canada’s publicly funded health-care system last week, hoping and pleading that this time things would be different. Two years ago, the federal government put $23.4 billion into the system, Romanow noted, and “two years later, Canadians are saying, ‘Why are the waiting lists not shorter, why are the outcomes not better?’ This time, we’ve got to have dollars buying change.”

Romanow’s report might have more impact than most. For years, Canadians have told pollsters and politicians they’re fed up with hallway medicine, shortages of hospital beds, doctors, nurses and state-of-the-art equipment, and, most of all, long waiting periods for diagnostic tests and treatment. They are losing patience and want governments to fix the problems. So his timing is right. And Romanow, while touting innovative approaches, has accurately read the federal government’s mind on how it wants health care reformed—make the existing single-payer system better, broader and more efficient, but in no circumstances even hint that private, for-profit delivery systems have anything but a peripheral role to play

in Canada. After all, that’s why, when Prime Minister Jean Chrétien looked for the ideal person to lead the commission, he fixed on a left-leaning former politician from the socalled birthplace of medicare and not, say, Preston Manning.

For better or worse, Romanow has fulfilled the government’s expectations. The former Saskatchewan NDP premier offers a centrist, bureaucrat’s vision of Canada’s health-care future. He would have politicians write a “health covenant,” a kind of toothless patients’ bill of rights, setting out the services Canadians should expect and the system’s responsibility to meet them. He would create a Health Council of Canada, a watchdog group composed of representatives from Ottawa, the provinces and the territories, with a dose of non-aligned public participation, to monitor how the

system is functioning and report to Canadians on its shortcomings. He would establish a National Drug Agency to ensure that patients from British Columbia to Newfoundland have access nationally to a list of pharmaceuticals recognized by all provincial plans.

He would also make the system bigger, with more services than currently encompassed in the Canada Health Act. Romanow wants Ottawa to set the wheels in motion for a national home-care program, including paying Canadians to take time off work to care for loved ones. He stops short of recommending that all medical drugs be covered—a national pharmacare program—but wants some compensation for individuals facing impoverishing bills of more than $1,500 a year. And he says the provinces, which administer health care, should use funds to lure doctors and nurses to rural and remote areas to ensure more equitable services across the country.

All this costs money, of course, and Romanow wants Ottawa to pay more. He accepts the provincial mantra that the feds have been shortchanging the system for at least a decade, causing provinces to cut back on the number of physicians and nurses entering the stream and scrimp on new equip-

ment purchases. Now it’s time for Ottawa to pay its fair share, he says. He wants the federal government to pony up an additional $6.5 billion annually starting in 2005, bringing the federal contribution, by his calculations, to 25 per cent of the total— what he calls “the historic level” before cutbacks. An escalator clause would be negotiated to cover subsequent increases in health-care payments. This, he says, constitutes the stable funding required to sustain health care into the future. In the meantime, Ottawa should provide bridge financing to the provinces—an extra $3.5 billion next year and $5 billion in 2004/05.

But there’s a catch—or several, actually. The provinces only get that money if they agree to funnel it into five key areas where Romanow feels funds are most needed (see box). For even greater accountability, he adds, future transfers of funds to the provinces

for health purposes should be lifted from the general fund Ottawa provides for health, education and welfare and put into a special cash stream specifically earmarked for medicare. “We need stable, predictable and long-term funding,” he explained, “that is allocated in a way that makes it clear who is spending what, and with what results, so we can understand where accountability rests.” And that, says Romanow, would eliminate the main cause of the squabbling that characterizes federal-provincial discussions on health.

If the recommendations are carried out, Romanow believes Canadians will start seeing improvements in a few years. More doctors, more nurses and more diagnostic equipment. Shorter waiting lists and less need for desperate patients to dig into their own pockets for an MRI or a CAT scan at a private clinic. Nor will as many Canadians feel the need to travel to the U.S. for care they could not speedily get in their own country.

Will it work? Unions, nurses, the NDP, the Liberal government applauded Romanow’s ideas. Most have-not provinces welcomed increased federal funding regardless of the strings attached. The one proviso, said most supporters, is that new money must produce real changes to the system—something

Romanow repeatedly endorsed. Easy to say, but hard to do. A key, says Robert Calnan, president of the Canadian Nurses Association, is improvements in primary care, a major recommendation of the report. The idea is to make a team of health professionals—not just family physicians, but also nurses, nutritionists and pharmacists, who tend to be less expensive—more accessible, to keep patients out of the line-up at emergency wards or the competition for scarce hospital beds. As well, primary-care providers are best placed to practise preventive medicine, realizing further savings, says Calnan. Without such a sea change, “$6.5 billion will never be enough to make a real difference,” says Calnan.

But there were plenty of doubters, too. Within hours of the report’s release, the fault lines that have hampered progress on health issues in the past had resurfaced. Alberta Premier Ralph Klein led the attacks, calling the report “not a starter.” He was joined by Ontario, British Columbia, Quebec and, to some extent, Newfoundland. The problem, they said, was that while Romanow correcdy identified inadequate federal funding as the problem, he missed the mark in attempting to direct how the money is to be spent. One sticking point: specifying diagnostic imaging as a medicare service— effectively banning any extra-billing—would not sit well with private operators of those services. Canadian Alliance leader Stephen Harper accused Romanow of producing an inflexible ideological document that fails to appreciate the value of private-sector delivery systems.

Ottawa owes the provinces the recommended money because of its cutbacks, said Bloc Québécois leader Gilles Duceppe, but “don’t come with your national standards and structures and bureaucrats.” In addition, many premiers said they wanted no part of a watchdog group to monitor outcomes. “I don’t want to add more bureaucracy,” said New Brunswick’s Bernard Lord, “I want to improve health care at the bedside.”

Critics also questioned whether the additional funds—while substantial—would be enough to do all that Romanow says needs doing. Some provinces had difficulty matching federal funds for new technology two years ago, said Alberta Health Minister Gary Mar, because they couldn’t afford to support the equipment they already owned. To add expensive new programs such as pharmacare,

home care and palliative care is unrealistic, he said. “I think you’re going to see a great deal of push-back,” said Mar, “if the federal government moves forward on conditional funding in areas where we don’t currently spend.”

Moreover, adds Walter Robinson, federal director of the Canadian Taxpayers Federation, more money in the system will fuel salary demands from doctors and nurses. What’s more, he says, the system may well not get all the money he’s asked for. Commenting favourably on the report, Chrétien said Ottawa will pay more, but not as much as Romanow recommends. “Our health care system remains on life support,” says Robinson. “In five years we’ll see some improvement, but before long we’ll be right where we started.”

Still, the momentum is with Romanow. Chrétien would dearly love to have a revamped health-care system at the top of his legacy list when he retires in early 2004. “I

can make one promise here tonight,” he told a fundraiser in Saint John, N.B. “The Romanow report will not gather dust on the shelf. We will move quickly.” Provinces, in turn, will be hard-pressed to turn down billions of dollars and a guarantee of stable funding just because it offends their sense of jurisdictional purity.

The negotiations are due to kick off this Friday, when federal and provincial and territorial health ministers meet to consider the recommendations. Then Chrétien and the premiers will get together to consider the report in late January. Any province seen to be standing in the way of real reform will pay a political price, says federal Health Minister Anne McLellan. Canadians are not interested in jurisdictional fights, she says, they only want to know health care will be there for them when they are sick. “They’re saying to us, ‘What do you two governments not get about the fact that this is Canada’s most cherished social program?’ ”

Which is mostly good news for Romanow, who sees the immediate reaction as a staking out of bargaining positions. As a former provincial minister who helped cobble together the compromise that allowed the Charter of Rights and Freedoms to be included in a patriated Constitution, he knows he will have to put water in his wine. But for now at least, he can take solace in knowing that, unlike so many before, his Royal Commission report didn’t arrive in Ottawa on life support. [?il