The Good, the Bad, and the Ugly

Sun Sep 19 2004

By MICHAEL RACHLIS

Last week in this space, I noted that even Hollywood couldn't likely write a happy ending to the first ministers' health summit, given the rather unhappy premise. Our leaders didn't disappoint their audience. The dull Monday and Tuesday ritual recitations for the cameras were replaced with last-minute, highwire, backroom tension before an agreement was announced in the wee hours of Thursday morning. As they high-fived and mugged for reporters, they encouraged all Canadians to share their delight. But should average Canadians partake in this party? The agreement does move us one step forward in preserving and enhancing medicare, but it also takes one step backwards and at least one sideways. If Hollywood were writing the script, this movie could be titled, with apologies to Sergio Leone, The Good, the Bad, and the Ugly.

The good part includes a lot more cash than the feds said they could afford -- $18 billion over six years and an estimated $42 billion over 10 years. Some economic pundits claim that these expenditures might throw Ottawa into deficit, but the federal government appears to have had at least a $7-billion surplus last fiscal year -- the final report on the 2003/4 accounts will be announced next month. And, with revenues rising at four to eight billion a year, the Liberal minority government can afford this deal and still keep its other election commitments, as long as it doesn't cut taxes.

The first ministers committed to first-dollar coverage for a limited array of home-care services and pledged to reduce wait-times for priority services such as cancer and heart care. They also agreed to develop a national formulary for drugs over the next two years. That's all good.

But there are a number of bad things as well. Tommy Douglas, the father of medicare, always said that it would be implemented in two stages. The first would be public payment for the old system, which was based on the treatment of illness. The second stage would feature a reorganized delivery system focused on prevention. Douglas was adamant that we needed to change our delivery system, which more than 20 years ago he decried as "lamentably out of date".

Despite general agreement with Douglas's analysis, and the claims of royal commissioner Roy Romanow and Senator Michael Kirby that new federal money should be used to buy change, in this deal Ottawa hands over almost all of its money with no strings attached. There was a lot of fine talk about wait-times, primary health-care reform, health human-resource planning, home care and pharmacare. But there are few, if any, requirements that the provinces actually make needed reforms.

During the election campaign, Prime Minister Martin accused Stephen Harper of planning to turn medicare over to the provinces. But this agreement follows the Tory platform and allows the provinces to set their own standards for wait-list management. And, while the premiers look like big men when they beat up on the prime minister, they often look more like "girlie-men" when they get home. After the 2000 and 2003 agreements, the premiers were mugged by their own doctors, nurses and other health workers. They were forced to hand over large salary increases for the providers to deliver services pretty much as they always had. Untargeted money takes away provincial leverage for reform.

Finally, there is an ugly footnote at the very end of the first ministers' communiqué. They cryptically agreed to "formalize the agreement reached on dispute avoidance and resolution with regard to the Canada Health Act in an exchange of letters in April 2002."

The provinces have been upset for years that Ottawa unilaterally interprets the health act, even though it is federal legislation. Attempting to make peace with Ralph Klein (and safeguard her Edmonton area seat), then-federal health minister Anne McLellan agreed to two extra steps before the feds would levy penalties under the act. First, either the federal government or the offending province could propose fact-finding and negotiation. If there were still no agreement then either party could refer the dispute to a third-party panel. Each side would nominate one representative and then the two parties would agree on a chairperson. The panel's report would be made public.

While this process may seem just and transparent, it camouflages the current situation with the Canada Health Act. It's being virtually ignored. Almost every week, the media reports on obvious breaches of the act. Private MRI clinics offer cash-on-the-barrel scans, which can then be used to jump the queue for faster consultations and treatment. In Quebec, doctors are leaving the public system to offer $100 office visits and $125 housecalls.

In 2002, the federal Auditor General noted many apparent infractions and claimed that the federal government wasn't even collecting the data it needs to enforce the act. In fact, Ottawa usually relies on the provinces to provide them with the very information which might incriminate them. Within this context, adding two extra steps will simply make it even more difficult for Ottawa to do the right thing.

As the premiers bask in the afterglow of their love-in with the prime minister, it's clear that the good feeling will be short-lived. Some premiers have already indicated that they will be back for more money sooner than 10 years. And, with a federal election expected within two or three years, and a new government a definite possibility, it looks like Paul Martin's hoped "fix for a generation" might have referred to gerbils rather than human beings. Of course, it was unrealistic for any of us to expect anything as complicated as medicare to be fixed within a short period of time. In Canada, policy usually evolves incrementally. Health services are gradually being modernized. Within the system, there is an emerging understanding that new techniques of management can dramatically reduce wait-times, and that focusing on prevention can improve quality and foster sustainability. In real life, it takes many years for policies to change and programs to develop. A lot of positive change is occurring on the ground, kilometers below the radar of our first ministers.

At the end of the movie The Good, the Bad, and the Ugly, anti-hero Clint Eastwood finds himself in a three-cornered gunfight. In the end, he survives to fight another day. Paul Martin might reconsider his eagerness for another 14-cornered confrontation. Either that or he should ensure that, next time, some of the others are fighting on his side.

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.