Martin has had to doctor his catchy prescriptions for curing the health care system, writes JOHN GEDDES
WRITING A NEW Rx
Martin has had to doctor his catchy prescriptions for curing the health care system, writes JOHN GEDDES
IF WATCHING the Olympics got Canadians used to having their hopes dashed, the ability to shrug off a letdown could come in handy when the Prime Minister and provincial premiers hold their Sept. 13-15 health care summit. Back in the spring election campaign, Paul Martin promised voters he would convene the meeting and settle for nothing less than “reforms that will fix medicare for a generation.” He vowed the First Ministers wouldn’t leave the table until they had hammered out “a long-term plan for a health care system that is properly
funded, clearly sustainable and significantly reformed.” But that sort of I-guarantee-a-goldmedal bluster has given way to we’ll-give-it-our-best-shot realism. “If it’s going to take two meetings, three meetings, four meetings, that’s what it will take,” Martin hedged last week. As they said in Athens, there’s always Beijing.
Federal Health Minister Ujjal Dosanjh is also playing down
any need for a breakthrough of the sort Liberals talked up during the election. “To suggest if we don’t have a deal in mid-September that’s satisfactory to all of us, or a deal at all, that somehow the federation will fall apart, I’m not of that view,” Dosanjh told Maclean’s. Doctors and health policy experts are not surprised that the hot air is being taken out of the inflated expectations for the Ottawa summit. What ails the health
system doesn’t lend itself to campaign-trail prescriptions. Cut waiting times, boost home care, control drug costs, reform the way family physicians and hospital emergency rooms provide basic services—it’s too much to expect it all to be accomplished by a single act of political will. “I don’t think you’re ever going to get that watershed moment,” says University of Toronto health policy professor Raisa Deber.
Yet delivering such a moment is precisely what Martin ran for re-election on. So far, the provinces aren’t making it easy for
him to even partly deliver. They’re asking Ottawa to take over their plans that cover some prescription drug costs, a $12-billion-a-year burden that Martin and Dosanjh are refusing to accept. Even worse, Alberta’s Ralph Klein, who favours a shift to more private care, has declared he will attend only one day of the three-day summit, clearly slighting the Prime Minister. Martin’s best
hope for salvaging something from the meeting may be to lock down at least verbal support from the premiers on his signature issue, shrinking waiting times. Under the campaign slogan “five in five,” the Liberals said they would spend $4 billion to achieve major reductions in waiting times over five years in five areas: cancer, heart disease, diagnostic imaging, joint replacements, and sight restoration.
Setting clear goals, with deadlines attached, is a strategy Martin made work for him when he was a finance minister bent on beating the federal deficit. But seeing what’s wrong with a balance sheet is easier than sorting out which health problems most urgently need attention. Many who actually deliver services have doubts about the Prime Minister’s tidy to-do list. “It creates two tiers of services. Everything’s insured, but these five things are special,” says Dr. Albert Schumacher, a Windsor, Ont., family physician and the Canadian Medical Association’s new president. “Mr. Martin could have picked them out of his back pocket.” Maybe not quite that randomly. Long waits for Martin’s big five have gotten a lot of bad publicity. But other services will get left behind if new funding is earmarked for only a few high-profile concerns. Consider psychiatric care for children: studies show it’s in alarmingly short supply in both Cana-
da and the U.S. The Canadian Psychiatric Association recommends one child psychiatrist for every 3,800 children and youths, and while there are no exact national figures, the association points to Ontario’s ratio of one child psychiatrist for every 36,356 kids and adolescents as “grossly inadequate.” Young people’s anguish, however, doesn’t get much play in the political arena. “Mental health isn’t like heart surgery—it isn’t sexy,” says Schumacher. “It hasn’t had big overarching strategies or national vision.”
In fact, national vision on waiting times is hard to come by even in the areas that do attract scrutiny. Controlling access to highdemand health services is notoriously difficult, and there are few notable success stories. But the Cardiac Care Network of Ontario is often cited as one. Long waits for heart surgery in Ontario in the late 1980s, and the deaths of patients waiting for operations, led to the establishment of the net-
work in 1990. It links 17 cardiac care centres in the
province, tracking 75,000 procedures a year. Patients can check out the wait times at different hospitals on a website, and are given the option of travelling for quicker care. Still, after 14 years of coordination on a scale unmatched in North America, the network hasn’t eliminated waits: about 70 per cent of patients get treatment within the recommended times. But Dr. Kevin Glasgow, the network’s CEO, suggests the fairness it provides is as important as its speed. “Patients appreciate that there’s a system to ensure equity,” Glasgow says. “It’s not a matter of who you know or how rich you are.”
There are no such assurances for most Canadians waiting for care. On the other hand, many seem satisfied: a recent Statistics Canada survey found that 87 per cent reported no difficulty accessing elective
surgery and 79 per cent had no trouble arranging to see a specialist. And beyond limited studies and anecdotes, there’s no way to assess how bad things are for that minority who run into problems. “We don’t have anything approaching good data on waiting times, and until we do, we can’t fix it,” says Sam Shortt, director of Queen’s University’s Centre for Health Services and Policy Research. Yet the federal government vows not only to create that missing national data on waiting times, but to push ahead reforms to shrink them, and make sure they don’t vary widely from province to province. “We want there to be certain benchmarks across the country on wait times, and ensure that all Canadians get the care they need without having to wait unreasonable times anywhere,” Dosanjh declares.
Some experts are skeptical major progress can be accomplished in five years. Just training the needed doctors and some of the specialized nurses and technicians can take longer than that. And since health is primarily a provincial jurisdiction, setting and enforcing national standards will be hard. What if a province decides to tackle, say, hip and knee replacement first, and put less emphasis on cataract surgery? Or disagrees with Martin’s plan entirely and prefers to spend more on home care for the elderly? It’s hard to imagine the federal government insisting on its priorities.
The only way to maintain uniformity would be to refuse federal funding to provinces going their own way. And according to Dosanjh, Ottawa won’t be that inflexible. The five federal priorities, he says, “aren’t etched in stone. If some province finds that there are another five areas, or three they want to concentrate on, and they can demonstrate that need, then so be it.” But in that case, “five in five” appears to be less a firm commitment than catchphrase— and the notion of coast-to-coast standards on waiting times for key services looks unlikely to be achieved. That would not surprise those who know the system best, and are used to thinking in provincial rather than national terms. “National standards and coordination will be difficult,” says Glasgow. “We have 10 provincial systems.”
The real pressure on provinces to cut waiting times may come less from Martin than from sick citizens who have grown angry waiting for treatment. Last spring, fed-up patients in Saskatchewan, with the help of the
opposition Saskatchewan Party, went public to put pressure on the province’s NDP government. Among them was John Barnsley, 52, a farmer from near Assiniboia, who protested having to wait several months for surgery to remove a tumour that had grown where his cancerous left kidney was removed seven years earlier. A surgeon in Saskatoon finally cut out the malignant tumour last April 28. “That only occurred because we went to the legislature and raised a ruckus,” says Barnsley. Adds his wife, Joan: “In my mind, we wasted a whole bunch of valuable
SEEING what’s wrong with a balance sheet is easier than sorting out which health problems most need attention
time for no good reason. You can imagine the terror we were living under.”
Stories of that sort put another kind of terror in the hearts of politicians. In the wake of the uproar, the Saskatchewan government boosted health spending 6.3 per cent, to about 44 per cent of provincial spending, in its March 31 budget. But provincial Finance Minister Harry Van Mulligen also warned that such hikes can’t continue year
How much does health cost Canada?
billion in 2003.
EXAMINING HEALTH CARE, BY THE NUMBERS
How fast is that cost growing?
Conference Board of Canada forecast to 2020: L6% a year after inflation.
How does Canada compare internationally?
Average OECD health spending in 2001:8.4% of GDP; Canada: 9.7%; U.S.: 13.9%. Why does the system seem underfunded?
We’re still playing catch-up from the federal deficit fight: health funding from 1992 to 1996 would have had to grow % to keep up with inflation and population. Instead, per capita, health funding fell slightly.
How much more should Ottawa give the provinces?
To close the funding gap identified in the Roy Romanow report, about $3 billion more a year (the 2004-2005 cash transfers to provinces and territories were $35.5 billion).
What else might cost big money?
The Canadian Medical Association has called for a $1 -billion federal fund to train more doctors. Liberals promised $4 billion to cut waiting times and $2 billion for home care, along with a catastrophic drug plan, and primary care reform.
after year: “This is simply not sustainable. We need to find new ways to achieve our goals.” Provinces across the country make the same complaint. A Conference Board of Canada study projected that by 2020 health will eat up 44 per cent of all the taxes and other revenues collected by the provinces, up from 37 per cent in 2003. Even more ominously, the report noted, the demographic bulge of baby boomers aging into seniors will come after 2020—so pressure to spend more can only get worse.
At least some more money is on the way from Ottawa. Martin has promised to boost health transfers to the provinces, though by how much and how quickly will be a matter for hard bargaining. Meanwhile, Dosanjh urges toning down the apocalyptic talk of a system on the verge of collapse. He stresses that by the broadest measure of health spending—how much of the overall economy it consumes—Canada is in the middle of the pack among developed nations. “To continue to say health care is unsustainable adds to the erosion in public confidence in our system,” he says. “We’re not spending inordinate amounts on it.” Welcome words, no doubt, for anyone who fears for the future of universal health care. And if medicare isn’t in critical condition, maybe it doesn’t need the miracle cure promised last year on the campaign trail after all.
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