The premiers' annual theatrical performance:

Consensus masks confusion

Winnipeg Free Press Thu Aug 5 2004

Dr. Michael Rachlis


LAST week, Ontario Premier Dalton McGuinty hosted his 12 provincial and territorial colleagues in historic Niagara-on-the-Lake, Ont.

On Oct. 13, 1813, British Maj.-Gen. Roger Sheaffe marched his troops from the town's garrison to reinforce Gen. Sir Isaac Brock's men who were losing ground against the invading Americans at nearby Queenston Heights. The British/Canadian forces won and as a result we have medicare and annual premiers' meetings.

Now Niagara-on-the-Lake is known more as the picture-postcard home of the Shaw Festival. In keeping with the setting, the conference featured a plot twist, unlikely stars and a surprise ending. Perhaps fittingly, the premiers' theatrical performance may well trump any history that might have resulted from their discussions.

On Wednesday afternoon, the premiers arrived to the sound of thunder and loud protests against privatization. Despite McGuinty's attempts at pre-meeting interprovincial diplomacy, the premiers were still deadlocked on the big-ticket issues of for-profit care and accountability to the feds for new money. But by Friday afternoon, the clouds had parted, the premiers were best friends and many of the advocacy groups had joined in the love-fest.

British Columbia Premier Gordon Campbell fired up the love train with the idea that the feds should take over the costs of provincial drug plans. When Campbell became premier, B.C. had the country's most generous drug plan. But three years of cutbacks have slashed coverage. No doubt he plans further cuts if he is re-elected next year. Why not just unload the political and economic costs onto Ottawa? Coincidentally, the Ottawa-based Canadian Federation of Nursing Unions brought three recommendations to Niagara-on-the-Lake, and one of them was for a federal takeover of provincial drug programs. Toronto economist Dr. Armine Yalnizyan, who authored the CFNU report, sensibly noted that Ottawa already sets most of the rules for drug therapy in this country, including writing the rules for licensure and patent protection. Ottawa could buy the country's drugs in volume and lower prices through tough negotiations with the manufacturers. Australia, another parliamentary federation, bulk-buys its drugs and has the lowest drug costs of any wealthy country.

Dynamic CFNU president Linda Silas hails from New Brunswick and used her connections with Premier Bernard Lord and Newfoundland and Labrador Premier Danny Williams to lobby them. By Thursday afternoon, a national pharmacare plan was the talk of the town. Provincial delegates were visibly relieved as they worked through the night and early morning on the details of the final communiqué.

By Friday afternoon when the premiers met the media, the love-in was in full flight. McGuinty declared that the premiers had made history. Claiming to speak for baby boomers and Gen-Xers from coast to coast, he noted that, as his parents had given their children medicare, now he and his colleagues could pass pharmacare on to their children. Other premiers layered on the good feeling. Alberta's Ralph Klein said it was a "stroke of brilliance." Newfoundland's Williams enthused about a national vision. At one point, it almost seemed they would burst into a spontaneous rendition of Age of Aquarius, followed by O Canada.

Even Quebec Premier Jean Charest's ritualistic assertion that Quebec would continue to run its own plan -- while Ottawa would be expected to pay for it -- passed with barely a murmur of discontent. CFNU president Silas was in a justifiably celebratory mood. Her organization's short paper had provided the foundation for the most surprising turn in federal-provincial-territorial relations in a decade.

But like any grand plan, the devil is in the details. And this one has potential demons in every nook. First, and most importantly, even a conservative version of the premiers' plan would cost billions more than Ottawa has been prepared to spend. The premiers want Ottawa to pick up the entire cost of provincial drug plans, which totalled $7.6 billion last year and are growing at more than 10 per cent a year. On the other hand, new federal Health Minister Ujjal Dosanjh was careful to use the phrase "catastrophic drug coverage" when he talked to reporters. Although he never quantified the difference, the Romanow Commission estimated that a catastrophic plan would cost roughly $1 billion, assuming the feds would pick up the tab for individual drug costs above $1,500 per year.

Starting off negotiations $7 billion apart is bad enough, but it may not be the biggest political hurdle for the plan. Provincial drug plans now vary considerably. Most provinces already have better catastrophic coverage than Romanow recommended, while some have none. Even if the feds did assume existing provincial plans, they would still have to come up with new money to cover Canadians currently without catastrophic plans -- or cut coverage in the other provinces. However, it's difficult to imagine the reaction of already-volatile voters if this so-called policy success resulted in massively increased user fees for most Canadians with public drug coverage. Of course, the feds could "level up" coverage to the best anywhere in the country, and the final tab would be more than $10 billion. Unfortunately, that's not the end of the cash controversy. The premiers also want Ottawa to cover 25 per cent of overall provincial health-care expenditures with their Canadian Health Transfer (CHT). If drug spending would no longer count as provincial spending, then Ottawa would have to pony up at least another $2 billion. Finally, the premiers are also unhappy at the equalization program and want another $3 billion-plus for this item. Mais oui, they want all this money without any strings whatsoever.

While the premiers projected unity, discord was never far from the surface. The premiers are bitterly divided on the role of the private sector in health care. Mr. Klein continues to muse about why Canadians can buy other commodities but not new hips. He would like to see more for-profit care within medicare and non-medicare options as well. On the other hand, Manitoba's Gary Doer and Saskatchewan's Lorne Calvert are opposed to for-profit contracting, even if the public pays the bills. Of course, Klein had admitted to the Alberta press corps in June that his own caucus had overturned plans to establish for-profit orthopedic clinics in Calgary and Edmonton. But the national media usually don't keep up with provincial news and Klein played them like a violin, teasing them with his controversial language.

The final communiqué reasserts that all provinces support the Canada Health Act. Unfortunately, given the auditor general's documentation of the lack of federal oversight and action and the premiers' disagreements, it's pretty clear that this oath of fealty means less and less all the time.

Accountability for federal cash doesn't bother Ontario or the six smaller provinces. They are either ideologically onside or so desperate for funding that they would sing Dixie if the feds promised more money for its performance. Jean Charest has budget problems as well, but can't appear to be any friendlier with Ottawa if he hopes to win re-election. And, with oil touching $44 a barrel and Alberta's debt almost history, Mr. Klein scorns even the loosest threads of accountability to Ottawa. Forget the tight strings.

Unfortunately, the premiers paid scant attention to the elephant at the health-policy table. Poor-quality care costs thousands of Canadian their lives every year while wasting billions of dollars in the process. In May, the Canadian Patient Safety Study revealed that 10,000 to 25,000 Canadians die every year from adverse consequences from their hospital stays. In February, an Ottawa group showed that one-sixth of area seniors were readmitted to hospital within 30 days of discharge. Most of these incidents could have been prevented with better and cheaper community care. Adverse effects of prescription drugs kill thousands and hospitalize tens of thousands every year. Too many Canadians wait too long for care, even though most delays can be fixed with better management rather than more money.

To be fair, premiers continue to talk about tactics such as primary health care and home care. But, their reform language is parsed with "more, more." On the other hand, the international literature increasingly recommends that health systems should focus on continually reducing waste and improving quality, rather than simply cutting or adding money. The true strategy for sustainability should be based upon providers delivering quality, patient-centred care from high-quality workplaces.

The premiers may have stage-managed the Niagara-on-the-Lake love-in, but now they have only a month to prepare for their next performance at the Sept. 13-15 first ministers' meeting in Ottawa. So far, their national pharmacare proposal has dazzled the audience. But, it's unlikely that their masks of consensus will continue to disguise the confusion and controversy seething just below the surface.

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 February