Winnipeg Free Press Sunday, June 13th, 2004

A Reality Check on Health Promises

By Michael Rachlis

Health is the number-one public issue for Canadians, between elections. But usually, once the Governor General drops the writ, the party positions seem to flow together. This time, Canadians have stark choices which should permit them to identify the party which best reflects their values.

The Liberal platform proposes to increase federal health transfers to the provinces over the next five years by at least $9 billion over and above the planned increases of the 2003 federal-provincial Health Accord. Of this, $3 billion would be untargeted while $4 billion would be allocated to wait-list reductions and $2 billion to home care.

The Liberals further promise to negotiate with the provinces on a built-in escalator for the federal transfers, as well as a pharmacare program. Of course, these negotiations are not a slam-dunk. Canadian governments have repeatedly missed the deadlines they set in the Accord to define terms of the agreement.

Meanwhile, Auditor General Sheila Fraser has repeatedly criticized the Liberal government for not enforcing the Canada Health Act -- she claims that Ottawa isn't even collecting the data it needs to enforce it. The Liberal platform says that it will refer governmental disputes about the act to a three-person panel for adjudication, which would then report to the federal health minister for action. But given that the federal and provincial governments are already winking at each other's transgressions, without provisions for third-party or citizen intervention this proposal promises to make enforcement of the Canada Health Act even more difficult.

The Conservatives promise to spend $13 billion over five years above the amounts in the 2003 Accord. This includes $10.2 billion for provincial transfers and $2.8 billion for a catastrophic pharmacare program, which would cover annual drug expenditures beyond $5,000.

The Tory platform does not mention any specific funding escalator, but does say that a Conservative government would be prepared to negotiate a "long-term federal commitment" in return for the provinces pledging to meet the Accord's "broad health reform goals". The platform does not mention the Canada Health Act or its enforcement.

The New Democrats are committed to spending an additional $28 billion on medicare over the next five years. They promise to implement pharmacare and home-care programs within a stronger Canada Health Act, but also pledge to avoid "one-size fits all solutions" and embrace "flexible federalism".

Only the NDP would fulfill the Romanow Commission's recommendation to specifically designate diagnostic imaging, such as MRI scans, as medically necessary in the Canada Health Act. This would eliminate those clinics which sell scans privately to patients willing to pay cash to jump the queue. If you can get a faster diagnosis, you can get faster treatment.

None of the three major parties is explicitly suggesting so-called two-tier health care, under which those with money can buy their way to faster or better care. The Liberal and Conservative platforms do not mention private-sector involvement in health care at all. But Stephen Harper has stated his belief that, as long as the public purse is paying, it doesn't matter whether the service is delivered by for-profit or non-profit organizations.

The NDP promises to prevent public money going to for-profit hospitals, although it doesn't say specifically how it will accomplish this task. The Liberals remain muddled on the issue. Just before the election, Health Minister Pierre Pettigrew flip-flopped on the issue. One day he agreed with Harper's suggestions for greater for-profit involvement, but the next day he apologized and claimed the Liberals favour public delivery. The Liberal platform does not clarify their position.

The March, 2004 federal budget promised to fix Canada's public-health system, which has displayed its vulnerability through SARS and other calamities in recent years. The Martin government committed to $1 billion in new funding over three years, moved $400 million in spending from Health Canada to the new Canadian Public Health Agency, and promised there would be more money coming.

The Liberal platform also includes plans for a national child-care program, which has been repeatedly identified by advocates such as Dr. Fraser Mustard as promoting better health. The Liberals also commit at least $1 billion over five years for subsidized housing.

The Conservatives' public-health platform focuses solely on emergencies, especially infectious-disease outbreaks. The party supports the establishment of the new Canadian Public Health Agency and installation of the first Canadian Public Health Officer, but the Conservatives only identify $100 million per year for the agency. They also have promised $200 million for fitness programs.

The NDP does not explicitly identify its public-health funding, although it would increase overall health spending by more than double the rates of the other parties. The party commits to developing a broad public-health service, which would consider the impact of poverty and environmental pollution. The NDP claims its broad social agenda (billions for childcare, housing, meeting Kyoto targets, etc.) would reduce the demand for health services.

So, with all that, how about a Reality Check: Can the parties fulfill their promises?

Perhaps the only issue bigger than health care in this election is trust. With the Ontario Liberal government's failed promises haunting the hustings, Canadians question whether any of the parties can be trusted to fulfill their promises.

Mr. Harper's Conservatives claim federal spending is out of control. The Liberals, clad in their traditional election pink, claim there is enough money to pay for their new promises that Finance Minister Ralph Goodale vehemently claimed were imprudent in March. The NDP says that Canada can afford even more spending than the Liberals.

In fact, despite claims that the federal government takes too much of our economic pie, Ottawa's slice is one-third smaller than in 1993. Current federal spending of 15 per cent of GDP is dwarfed by the 23-per-cent rate spent by Brian Mulroney in his last year in office. Our federal government is spending less of our economy that it has for more than 50 years. Even though the federal government has offloaded some of its responsibilities to the provinces, provincial spending is also at a 20-year low in terms of GDP share.

Ottawa's recent priority has been tax cuts to the tune of $50 billion a year -- enough to pay for universal child care, pharmacare, home care, and a tripling of the military budget. Despite these massive cuts, economic growth has created large budget surpluses -- Liberal finance ministers typically have sketched out tight budgets in the spring, only to have large surpluses miraculously appear 18 months later. Then the money is used to pay down the debt.

Call it a sneaky enforced-savings plan or poor financial planning, but from 1999 to 2002 the Liberals estimated surpluses of just $11 billion in their budgets and actually ended up with $47 billion.

The Liberals say they are finally being truthful about the country's finances and that, barring any further tax cuts, Ottawa will have enough money to pay for $27 billion worth of Liberal promises. But will anyone believe them given their track-record?

On the other hand, the Conservatives promise to increase health-care spending by at least $13 billion, buy the military more equipment and still cut taxes by $38 billion. In other words, they would need to find more than 100 scandals of the magnitude of the sponsorship fiasco to afford their health-care promises. A Harper government would have to moderate the party's promised tax cuts or take a broadaxe to spending.

The NDP's numbers appear to add up, but some of their revenue sources might not be realized. The party promises to pay for $63 billion in spending by repealing some of the Liberal tax cuts and implementing a U.S.-style estate tax. Their plan looks fairly sound, but $8.5 billion is dependent upon recovering currently unpaid taxes, which might be difficult to accomplish.

The bottom-line here is that Canadians have clear choices on health policy in this election. The Conservatives would provide slightly more funding but encourage the provinces to explore for-profit delivery. They would be unlikely to enforce the Canada Health Act. The NDP would provide a lot more money to the provinces, promote non-profit care, and strenuously enforce the CHA. The Liberals promise to continue their muddling of the past decade -- more money, more nice words about medicare, but a lackadaisical approach to CHA enforcement.

Identify which platform reflects your values and make your choice. You may have to live with your decision for next five years.

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.