FINA Committee Report
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CHAPTER SIX — THE PRIORITY OF HEALTH CARE [I]t is only the federal government that is accountable to all Canadians for achieving access to comparable services no matter where they live in this country. Federal leadership is critical. (Canadian Healthcare Association, 22 October 2002) Canada’s publicly funded healthcare system plays an important part in our social safety net and in our national psyche. The country is currently involved in a debate over the future direction of our healthcare system. The Standing Senate Committee on Social Affairs, Science and Technology released the last in a series of reports on the healthcare system in October 2002, and the Final Report of the Commission on the Future of Health Care in Canada, chaired by Roy Romanow, is expected at the end of November 2002. In the September 2002 Speech from the Throne, the federal government announced that the Prime Minister will convene a First Ministers Meeting early in 2003 to put in place a comprehensive plan for reform. It also indicated that the upcoming budget will include “the necessary federal long-term investments,” and included a number of other healthcare commitments:
We fully support the government’s apparent openness … to explore new concepts and new ideas to improve the delivery of health care services to Canadians. Fixing the healthcare problems will require more than just money. We believe there is considerable scope for ‘back office’ management efficiencies that would enable a higher proportion of healthcare resources to be devoted to front-line patient care and to the procurement and operation of the latest diagnostic and treatment technologies where under-investment has contributed to the well-documented current deficiencies. (CanWest Global Communications Corporation, 9 September 2002) According to the Canadian Institute for Health Information (CIHI), Canadians — individually and through government — spent more than $100 billion on health care in 2001, up 4.3% from the previous year, adjusted for inflation and population growth. While healthcare costs have generally risen over the past several decades, during the 1990s healthcare spending — after adjusting for inflation and population growth — fell. As a share of GDP, healthcare spending has fallen from 10.2% in 1992 to 9.4% in 2001.56 The federal, provincial and territorial governments are already working together to improve the healthcare system for the benefit of Canadians. In September 2000, the federal government announced — together with an agreement on early childhood development — that it would spend an additional $23.4 billion over five years to support the healthcare system. This investment consisted of two major components: $21.1 billion over five years to the Canada Health and Social Transfer (CHST) and $2.3 billion for the purchase of up-to-date medical equipment, improved information systems supporting health services and accelerated changes in the way primary health care is provided to Canadians. As Figure 19 indicates, total federal CHST funding, including tax points, was $34.2 billion in 2001-02. Figure 19
The [Canadian Medical Association] believes that to achieve real reform, more than ‘tweaking’ of our current system is required. We see change as requiring a fundamental rethinking of the system including its governance and accountability structures in order to move forward and turn the corner towards a sustainable healthcare system. (Canadian Medical Association, 22 October 2002) During the Committee’s pre-budget discussions and consultations, many witnesses such as the Ontario Hospitals Association shared their views on healthcare reform, addressing such issues as the treatment of mental health problems and the need for more comprehensive reform of the healthcare system. Although witnesses may have disagreed on how extensive reform should be, all were supportive of a revitalized and sustainable healthcare system. Since the Committee does not, at this time, have the benefit of the Romanow Commission’s report, we feel the best means of contributing to the healthcare debate is by highlighting a number of key themes that emerged during our hearings. Canadians Overwhelmingly Support a Public Healthcare System Public health care is not merely an expression of Canadian values: it is also a sound business investment. As the Canadian Healthcare Coalition remarked to the Committee, “[b]usiness leaders continue to recognize the economic benefits of our publicly funded health system in terms of [a] healthy workforce, increased productivity, economic development (through health research and innovation), quality of life related to business decisions to locate in Canada, and increased global competitiveness.” Its universal nature enables the delivery of health care at a lower cost than is possible in the largely privatized U.S. system. The Ontario Chamber of Commerce told the Committee that privatization moves costs around without necessarily reducing them, “since ‘patients’ are often ‘workers’ and their employers have to bear the costs.” Increased and Stable Funding of Health Care is Needed from the Federal Government While most witnesses agreed with the need for increased funding to the healthcare system, there was disagreement about the best way to fund such an increase. The Ontario Chamber of Commerce told the Committee that “[a]llocating ever larger amounts of financing to this area will not remedy the current pressures on the system.” It expressed a preference for “significant structural changes in the healthcare system.” Other groups recommended that the federal government use its expected surpluses to effect a funding increase. One option, a dedicated health tax of the type advocated by the Standing Senate Committee on Social Affairs, Science and Technology, was rejected by most witnesses. Several groups recommended returning funding to its 1992 level (in real terms) and including an escalator to reflect future inflation and population growth. The Canadian Medical Association and the Canadian Nurses Association told the Committee that there is a shortage of physicians and nurses in Canada, particularly in rural and remote areas, and that high tuition fees are creating barriers that discourage people from applying to medical school. We were also informed by the Nova Scotia Association of Health Organizations (NSAHO) that the federal government’s per capita health funding formula is inadequate because it does not recognize that provinces with older populations are relatively more intensive users of health care. The NSAHO argued that healthcare funding allocations to provinces should reflect the underlying demographics of provinces. A number of the Committee’s witnesses recognized that money alone is not the solution to current and future healthcare challenges. In their view, restructuring is also needed, as is a focus on transparency and accountability with respect to the expenditure of public funds. Restructuring could, for example, result in the reallocation of funds to the use of new information technologies to improve the accountability, efficiency and effectiveness of the healthcare system. Investments in health technologies and health-related information technologies are a key part of helping to ensure the delivery of quality health services. A number of presentations to the Committee mentioned pharmacare and homecare programs in the context of expected healthcare reforms. The Canadian Union of Public Employees, for example, recommended that these programs be funded on a 50/50 cost-shared basis with the provinces and territories. Currently, spending on drugs — which is only partially covered by federal, provincial, territorial and private insurance — represents the fastest-growing component of the healthcare system. According to the Canadian Institute for Health Information, Canadians spent about $15.5 billion on drugs in 2001, up 8.6% from the previous year, making it the second-largest category of health expenditure.57 Homecare offers the possibility of lower-cost, non-institutional care. At present, however, these programs are unevenly funded across the country. As the Health Charities Council of Canada remarked to the Committee, [t]he access to health care is currently limited to access to physicians and hospitals. Access to less costly and more appropriate health care providers outside the hospital system is not covered by public medicare. This characteristic of the [Canada Health Act] has in some ways provided a perverse incentive to Canadians. That is, many Canadians have been conditioned to using the most expensive health resources for even minor and non-medically related needs. Accessibility, therefore, needs to include funding for all services and should begin with the implementation of primary healthcare models. The ALS Society of Canada, which advocates for persons with a progressive neuromuscular disorder sometimes called Lou Gehrig’s disease, also noted that increased funding to homecare would benefit their members, since ALS sufferers require minimal hospitalization and depend mostly on homecare. The Committee also heard other suggestions for further expansion of the healthcare system. For example, the Canadian Dental Hygienists Association suggested that dental work be covered for seniors and low-income Canadians. Accountability and Transparency Should be Ensured in the Future Healthcare System Transparency and accountability should exist whenever public funds are spent, since Canadians have a right to see where and how their tax dollars are being spent. Accountability is necessary in order to evaluate whether a particular program is effective, efficient and meeting intended goals. There are a number of means by which enhanced transparency and accountability might be realized, including, for example, a Canadian health commission to report annually on the performance of the healthcare system and the health status of the population. There is a consensus that the delivery of monies to the provinces and territories for several program areas through a single program — the CHST — interferes with transparency and accountability, and can result in federal funds intended for one purpose being used in other areas. The Canadian Institutes of Health Research Enjoy Widespread Support Witnesses strongly supported the federal government’s investments in the Canadian Institutes of Health Research (CIHR), with most — including the Council for Health Research in Canada and the Heart and Stroke Foundation of Canada — recommending budget increases in order to support advanced Canadian health research. Witnesses also suggested that the CIHR increase support to such areas as ALS and vision research. Preventive Health Care Should be Emphasized To the extent that prevention can reduce use of the healthcare system, and thus reduce healthcare costs, groups such as the Canadian Cancer Society recommended increased investments in primary prevention and community care. The Insurance Bureau of Canada suggested investing in a national injury prevention program to promote healthier lifestyles and reduce the risk of occupational/recreational injury and death, while other groups — such as the Coalition for Active Living and Sport Matters — stressed physical activity as a way to reduce future healthcare costs through healthier living. The Coalition, for example, recommended a $500 million investment over five years in the development of an aggressive strategy to cure what it believes is a physical inactivity epidemic in Canada. Various groups and individuals told the Committee that in addition to homecare and pharmacare, Canada’s healthcare system does not provide adequate assistance to certain groups. The Canadian Alliance for Children’s Healthcare recommended that the federal government implement programs to aid “extraordinary care children” (those with serious illnesses and disabilities) and their caregivers. A number of the Committee’s witnesses spoke about palliative care. The Canadian Nurses Association informed us of recent study results indicating that “while more than 80 per cent of Canadians die in hospitals, 80 to 90 per cent would prefer to die at home, close to their families and living as normally as possible.” Consistent with the request for support for extraordinary care children and their caregivers, similar programs are needed to support palliative care patients and their caregivers. The Committee also heard, from the Canadian Mental Health Association among others, that mental health has been relatively neglected. Moreover, the Mood Disorders Society of Canada suggested that the federal government spend $50 million on a national action plan on mental illness and mental health, which would provide “a concerted, long-term approach towards mental illnesses as well as to the encouragement of positive mental health.” According to the Society, “[i]n 1998, mental illnesses and disorders were the seventh highest among all diseases in terms of the overall cost of illness. It is estimated that mental illness is the second-leading cause of hospital use among those aged 20 to 44, a period in life normally associated with high productivity.” The Manitoba Schizophrenia Society Inc. and the Lifelinks Health Program mentioned research and disability tax credits in the context of diseases of the brain. The Committee wishes to note the Canadian Medical Association’s recommendation of several relatively small, one-time investments that could support the healthcare system. They respond to specific needs, such as the shortage of medical personnel (including nurses) and the modernization of the healthcare system through the use of information technology:
Finally, the Canadian Executive Council on Addictions recommended a comprehensive federal/provincial drug strategy, coordinated with the CIHR, that would reduce the resource imbalance in combating drug addiction away from supply reduction and enforcement and toward the social sector. [I]t is imperative that the federal government view health as its foremost funding priority. To do otherwise would be to ignore the values and priorities of its citizens and the advice of the commissions and committees mandated to advise the federal government on this matter. You may well ask whether this should be a blank cheque? Absolutely not — governments and providers need to be publicly accountable for their health funding decisions and the results achieved from these decisions. (Nova Scotia Association of Health Organizations, 30 October 2002) The Committee supports the main themes articulated by witnesses: the need for a public healthcare system with stable funding at an appropriate level; an approach to health care that recognizes prevention, pharmacare and homecare, and that provides services to Canadians experiencing a full range of illnesses; accountability and transparency, which could be enhanced through the unbundling of CHST allocations; and support for the Canadian Institutes of Health Research. For this reason, the Committee recommends that: RECOMMENDATION 25 The federal government work with provincial and territorial governments, and other stakeholders, to ensure that the Canadian healthcare system of the future respects the following principles:
Moreover, as resources permit, the government should consider the one-time funding of initiatives that would yield significant benefits for relatively little cost.
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