Could Hollywood write a happy ending to the Medicare Sequel?

Winnipeg Free Press Sunday, September 12th, 2004

Dr. Michael Rachlis

AS summer winds down, seasonal blockbusters move to smaller screens and the film world gathers in Toronto. And tomorrow, Ottawa will host the latest release in the longest string of sequels ever produced -- another federal-provincial conference on medicare. But how did this sequel get developed, and what could happen if Hollywood wrote the script? The provinces complained bitterly that Jean Chrétien didn't play fair with them during negotiation of the 2000 and 2003 health accords. Paul Martin promised that he would run a more open and transparent government. He was going to improve the federal-provincial relationship, especially on health-care issues. He committed to meeting the premiers "for as long as it took to get a deal."

Of course, the prime minister's promises were predicated on a majority Liberal election result, allowing him to decide later how to play his cards. With a minority, Mr. Martin will need to play his cards very well indeed -- and much sooner than the 24 months or so that his government might survive.

Mr. Martin says his priority is wait-list reduction. The Liberal platform promised to increase health transfers to the provinces over the next five years by at least $9 billion over and above the planned increases of the 2003 health accord. Of this, $3 billion was to be untargeted, while $4 billion would be allocated to wait-list reductions and $2 billion to home care. The Liberals further promised to negotiate a built-in escalator for transfers, as well as work on a pharmaceutical strategy.

This week, Finance Minister Ralph Goodale aired Ottawa's worst-kept secret. As predicted last year by everyone but Goodale's own department, the federal surplus for fiscal 2003/4 will be much higher than projected. So now the feds are offering billions more in funding, and various leaks suggest they are prepared to jack up equalization payments and tailor health deals with individual provinces to ensure that everyone signs on.

Of course, with the bad blood between Alberta and the feds, and an imminent provincial election, Premier Ralph Klein is unlikely to agree to anything. But the feds can tolerate Ralph not being part of the photo op.

The premiers threw a mean curve-ball at Ottawa when they had their July love-fest at Niagara-on-the-Lake. The magic moment happened when they realized that they could all agree that the feds should take over their drug-benefit programs. They extrapolated a federal commitment for catastrophic drug coverage to full funding for all their programs. Catastrophic coverage would cost up to $1.5 billion a year. The provinces' suggestion would cost at least $8 billion. The provinces claim that long waiting lists are due to lack of funding and that, if the feds paid for pharmaceuticals, this would allow them to divert drug money to reduce waiting lists.

There are some good reasons for more federal involvement in pharmaceuticals. But this pharmacare proposal was unexpected and further destabilized the Liberals, who were already in disarray after the unanticipated loss of their majority. Both the PMO and Health Minister Ujjal Dosanjh's office lacked personnel in key policy positions for weeks after the election. Provincial proposals disappeared into this policy-making vacuum. As late as Thursday, there was no agenda set for the meeting.

Even a Hollywood scriptwriter would have difficulty crafting a credibly happy ending to this sorry beginning. But what could the first ministers accomplish if the meeting were a movie rather than real life?

First, it would help if the participants reread the words of one of their late colleagues, Tommy Douglas. He always asserted that medicare would be implemented in two stages. The first would be public coverage for the old private system which was based on treating illness. But the second stage would feature a new delivery system with care focused on prevention. Decades ago, Douglas bemoaned that our health-delivery system was "lamentably out of date." He warned that without service redesign, costs would rise faster than the ability to pay for them and medicare would lose political support.

Canadians have already forgotten the devastation SARS wrought in a system desperately unprepared for such an emergency. The federal government committed to public health reform but, so far, the money doesn't match that recommended by a commission headed by University of Toronto's dean of medicine, Dr. David Naylor.

When someone develops a chronic disease like diabetes, we could prevent many complications with better follow-up in primary health care. Nationally, 10 to 20 per cent of seniors with serious conditions are readmitted to hospital within 30 days. Tens of thousands of hospital admissions could be averted through better preventive follow-up care.

The ministers would hit several targets at once if they committed to develop a network of public health-oriented primary health-care centres. This would be a great benefit to Winnipeg, which has the best network of primary health-care centres outside of Quebec. These centres could deliver local public-health services, provide personnel to manage public-health emergencies and help reform primary health care.

The first ministers should also craft a strategy for dealing with waits and delays. Fresh thinking is required in this area. Some delays, such as with joint replacements, are due to present capacity being less than demand. However, most undue waits are due to poor organization rather than lack of money. For example, in many parts of Canada, women undergoing a work-up for breast cancer face a series of separate investigations, each with their own waiting lines. However, the Winnipeg Breast Health Centre, like some others across the country, aims to do several tests on one visit. A similar approach in Sault Ste Marie reduced the wait to diagnosis by 83 per cent.

Most waits for doctors' appointments could also be remedied through redesign of services. The Sault Ste Marie Group Health Centre gets by with about half the national average of doctors. Toronto's under-resourced Rexdale Community Health Centre services one of Canada's most disadvantaged urban communities, but manages to see its patients the same day they call for an appointment.

In Britain, the National Health Service has run with these new ideas -- almost half of the family doctors' offices offer same-day appointments, and half of the country's emergency departments now discharge all patients in less than four hours. Canada should establish a similar organization to the UK's Modernisation Agency, which would catalyze action around service redesign.

Finally, the first ministers should agree on a pan-Canadian approach to solving our health-care problems. During the election campaign, Mr. Martin claimed to be the protector of our national health system. He said he would insist on national standards and prevent evildoers -- he specifically fingered Ralph Klein -- from privatizing the system. However, more recently, Ottawa government has been rather silent on privatization. Even NDP premiers Gary Doer and Lorne Calvert seem to have given up pushing their colleagues to observe the Canada Health Act and reduce for-profit involvement. As the auditor general has repeatedly observed, Ottawa isn't even collecting the data it needs to monitor provincial compliance with the statute.

It's difficult enough to get the provinces to agree to spend federal money on national priorities. The provinces have successfully fought off significant targeting in the last two health accords. But, even Quebecers tend to identify as much with Canada as their home province. Citizens in other provinces overwhelmingly identify with Canada. Every Canadian should have first-dollar coverage for needed home care and pharmacare wherever they live.

In a Hollywood blockbuster, a supporting character, perhaps a child, would jar the warring first ministers to recognize their national responsibilities. As the strains of O Canada played in the background, our political leaders would join hands and pledge to honour Tommy Douglas's memory and focus on preventive, quality, patient-centred care delivered by happy providers working in a redesigned, pan-Canadian public system.

In the real world, whatever the first ministers deliver will have to be "as good as it gets." Let's all hold our breath and hope they display the "right stuff."

Dr. Michael Rachlis is a Toronto-based (but Winnipeg-born) health policy analyst. HarperCollins Canada published his third book, Prescription for Excellence: How Innovation is Saving Canada's Health Care System in March.