[Recorded by Electronic Apparatus]
Thursday, November 23, 1995
.1534 
[English]
The Chair: Order, please.
The finance committee of the House of Commons is continuing its pre-budget consultations. We are pleased to have with us today a very distinguished group of panellists who deal mainly with health care.
We have with us: Sharon Sholzberg-Gray, from the Canadian Association for Community Care; Carol Clemenhagen and Gaston Levac, from the Canadian Health Care Association; Carol Guzman and William Tholl, from the Canadian Medical Association; Judith Oulton, from the Canadian Nurses Association; Noëlle-Dominique Willems, from the Canadian Pharmaceutical Association; John Service, from the Canadian Psychological Association; Barry McLennan, from the Coalition for Biomedical and Health Research; Pierre Ritchie, from Health Action Lobby; Robert Burr, from the Canadian Public Health Association; and Marnie McCall, from the Canadian Consumers' Association.
Have I missed anybody?
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We will start our opening remarks with Mr. Ritchie, please.
Mr. Pierre Ritchie (Spokesperson, Health Action Lobby): Merci, monsieur le président, and good afternoon, members of the committee.
I am acting today as the chair of the Health Action Lobby. I'd like to thank you for accommodating our rather large group, which occupies most of this side of the table with the exception of the biomedical group, which is not formally part of our coalition.
I also have Alistair Thompson with me today, who assisted with the preparation of our submission.
[Translation]
With your permission, I would like to give you an overview of the joint recommendation of the Health Action Lobby. Each group will then be free to make its own comments. Some of our members would like to raise at this time other issues associated with the budget. We hope that this panel discussion will give you a broader perspective on the interests and concerns of the health care community with respect to the federal budget.
[English]
Mr. Chairman, I would like to begin substantively by addressing you and the other members of the committee on your work last year. After several years of drawing attention to the precarious state of our health care system caused by the reduction of health transfers, it was indeed a pleasure for us to be heard. Your recognition of the need for a federal transfer of cash to provide a mechanism to sustain the Canada Health Act was a very positive sign.
Today we will put flesh on your recommendation by proposing a specific mechanism through which the government can ensure the future of our medicare system.
[Translation]
I know that there is no need for me to repeat all of the arguments in support of our national health care system. You can read them for yourselves in the newspapers and hear them directly from your constituents. Canadians are deeply attached to their health care system and want to maintain and protect it. They are rightly concerned about the system's survival. Its shortcomings are becoming increasingly apparent and restrictions and cuts are being felt everywhere.
[English]
Yet this government, particularly through the Prime Minister, the Minister of Finance and the Minister of Health, has consistently assured Canadians that it will protect medicare. We believe that it is now time for the government to send Canadians a signal that this commitment is real and substantive.
HEAL, as a coalition of diverse interests and concerns, has worked together over the past five years to examine a variety of funding options for health care.
As you are aware, last spring we expressed our concerns about the Canada health and social transfer as a mechanism to sustain the Canada Health Act. As we all know, without a cash floor for help, we are merely postponing the demise of our health care system. Our brief provides a concise history of health care transfer payments, and highlights the flaws of the proposed CHST. Our concerns have been shared by others and most recently the CHST has been the subject of studies by groups such as the Caledon Institute of Social Policy and the C.D. Howe Institute.
As a health care coalition, our brief addresses only the health portion of the CHST. However, we interpret health very broadly and acknowledge the importance of continued support for social services and post-secondary education across the country.
Following our own scrutiny of the CHST and possible funding options, the Health Action Lobby proposes the following prescription for medicare. This is the real essence of our proposal.
We recommend that on April 1, 1996, a health-related cash transfer of $250 per capita for each of the next five years be established and guaranteed within the new Canada health and social transfer. Beyond the five-year period, we recommend that the federal government preserve the real value of the cash transfer by means of an appropriate escalator.
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[Translation]
This is a simple, fair and straightforward solution in line with the government's current fiscal framework and with the Canada Health and Social Transfer. Health-related cash transfers independent of tax transfers would stop the erosion of the system.
Moreover, this type of cash transfer would send a positive, tangible message to Canadians that this government is indeed committed to protecting medicare and will not allow cash transfers to be reduced to zero.
[English]
Another cornerstone of HEAL's position has been the need for a stable planning horizon. It is extremely difficult without it for provincial governments and health care planners to continue the reforms of our health care system in a way that does not harm quality of care. What that really means is the health and the capacity to sustain health and recover from illness of individual Canadians. A five-year period would provide for the necessary stability.
[Translation]
We support the government in its efforts to restore Canada's fiscal health. We are also confident that once current problems have been resolved, the government will be in a position to make a renewed commitment to health care by restoring adequate transfer payment growth.
[English]
Ours is a very simple, fair and easy proposal. A per capita figure reflects the fact that all Canadians require health care. The $250 figure is not arbitrary. It is based on the health-related cash portion of EPF in the lowest per capita province of Ontario. The size of the transfer will grow at the same rate as the population, and the total cash of about $7.5 billion will ensure that the Minister of Health has the means to sustain the Canada Health Act.
[Translation]
These are just a few of the reasons why we encourage you to support this proposal. Our brief lists a total of 25 such reasons. For the sake of Canadians' health, we urge you to accept this prescription. We will now be pleased to answer your questions.
[English]
The Chairman: Is it $7.5 billion a year that you are asking for?
Mr. Ritchie: Correct.
The Chairman: Thank you.
Ms Sholzberg-Gray, please.
Ms Sharon Sholzberg-Gray (Co-Executive Director, The Canadian Association for Community Care): Mr. Chairman and members of the committee, the Canadian Association for Community Care is a newly formed association resulting from a merger between the Canadian Long Term Care Association and Home Support Canada.
We are committed to the goals of the health action lobby and to the principles upon which it was founded. We strongly support the HEAL brief to this committee, which makes a compelling case for a health-related cash transfer within the context of the new Canada health and social transfer program.
We would like to note that the $250 per capita cash transfer for health for a five-year period as proposed in the HEAL brief is entirely within the government's fiscal framework and does not materially alter the proportion of federal resources going to health as compared to other social services.
It provides a specific commitment to health that is clearer to Canadians than the concept of tax points, which will also continue. It has the benefit of being morally and practically sufficient to support the principles in the Canada Health Act.
We would like to make several additional points. We consider home care community support programs and facility-based long-term care to be integral parts of the health continuum of care, although some of these services are currently provided under the Canada assistance plan and extended health care or other funding mechanisms.
One of the HEAL principles adopted some years ago at the inception of HEAL reads as follows:
- Changing health needs of individuals and society require a broad range of community-based
and institutionally-based services. An integrated continuum of care, providing co-ordinated
access to a range of types and levels of services, should be the model for the Canadian health
system. Administrative and financial arrangements should be designed accordingly.
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We believe the services covered by the principles in the Canada Health Act must be redefined and clarified in order to fit the changing health care system, but that is really a subject for another venue, perhaps the national forum on health and the various provincial definition exercises.
We want to make one point absolutely clear. It is entirely inappropriate to shrink the universally accessible hospital system while denying universally accessible health services outside hospital walls. Most Canadians don't even know about the plethora of user fees and co-payments for home care and long-term care services until they need them.
We'd like to add a few words on another subject - the GST. The House of Commons finance committee, in the report it issued after public hearings on the GST, acknowledged the merit of points brought to its attention by the then Canadian Long Term Care Association. These points were related to the inequities of the GST rebate system as it applies to long-term care facilities with rebates of 0%, 50%, 57.14% or 85%, depending on the nomenclature of the facility, without regard for the type of care it is providing.
We also talked about the inequitable way in which consumers of home care are treated. We don't wish to repeat the details here, but we would like to urge the government, when it recrafts or replaces the current consumption tax, to make sure it does not continue to harm the health sector by adding extra cost to long-term care providers and home care consumers.
In conclusion, we sincerely hope that the finance committee and the government will see fit to make a commitment now to a cash-specific transfer for health and not wait until some future date when it's too late.
The Chair: Just for clarification, you want us to completely decouple from post-secondary education welfare the health portion of the federal cash transfer.
Ms Sholzberg-Gray: We want to make it specific, yes.
The Chair: You want us to go back to the old system and give you a fixed amount, guaranteed in perpetuity.
Ms Sholzberg-Gray: Well, $250 in perpetuity in fact wouldn't be very much.
The Chair: It would be guaranteed in perpetuity, $250 for 5 years and indexed thereafter. I understand.
Thank you.
Next, from the Canadian Nurses Association we have Judith Oulton.
Ms Judith Oulton (Executive Director, Canadian Nurses Association): Thank you, Mr. Chairman.
The Canadian Nurses Association also welcomes this opportunity to present its views to the finance committee as part of its pre-budgetary process.
As you know, the CNA is a federation of 11 provincial and territorial nursing associations representing over 110,000 registered nurses. Our mission is to advance the quality of nursing in the interests of the public. We are one of the founding members of the Health Action Lobby. We are committed to its purpose and support its proposals.
We wish to emphasize today what we believe to be a critical role for the federal government, and that is playing a part in ensuring accessible and quality health care for all Canadians through national standards. Given that health care delivery is largely under provincial jurisdiction, the financing function is perhaps the federal government's greatest opportunity to influence health. This means the actions occurring throughout the government's budgetary process, including the role of this committee, are very important.
I must say we were encouraged to see that during last year's process the finance committee made a serious effort to hear the views of Canadians. We were pleased that in its report the committee acknowledged we must not replace national fiscal debt with national social debt, and the government should not resort to the use of slash and burn policies. Finally, we were pleased to see that the committee recommended transfers to the provinces for health not be reduced.
The Canadian Nurses Association has long been a proponent of health care reform and we recognize the need for change. However, the continuous cuts in federal health transfers, including those announced in last year's budget, seriously threaten the quality of care Canadians receive. Many of these cuts have been made in an unpredictable manner, forcing the provinces to scramble to make up for fiscal shortfalls.
I have no doubt that you've heard from your constituents and seen media reports about the public's increasing number of unfortunate experiences within the health care system because of reduced funding. Concern about the cuts in the acute care sector have been well described in the media. I would like to, however, draw your attention to concerns about another important sector that was just previously mentioned, and that's long-term care.
.1550
We have concerns that the care for Canada's elderly is required to meet increasingly complex needs. We're concerned about the funding cutbacks, the reductions in gaps and services. We're particularly concerned because of the growth in the elderly population.
In addition, the reduced federal transfers are leading some provincial governments, such as Alberta, to consider privatization as a solution for their health care funding woes. We are getting closer and closer to the point where the provinces are more likely to simply forgo reduced federal transfers in order to follow their own standards.
The absence of national standards, as you know, will result in either twelve very different health care systems or similar systems deteriorating to the lowest common denominator. We fear that despite the federal government's verbal commitment, we are moving more and more towards a two-tiered system where access to health care is dependent on one's ability to pay.
The creation of the CHST, with all its intricacies, has sent a signal to Canadians that the federal government is not willing to make a commitment to maintain a presence in health care beyond the next few years. While the government has stated that it is committed to the five principles of the Canada Health Act, the reality is that these will cease once health transfers end. We believe there is an important role for the federal government to ensure an equitable health care system for all Canadians. We believe that is through funding and through maintaining the standards of the Canada Health Act.
We have been very involved in the development of this proposal that's before you today. We believe the government must commit to health-related cash transfers as of April 1, 1996. The proposal that is before you of $250 per capita to the provinces and territories is an important one. Beyond the five-year period, we also urge the government to ensure that cash transfers grow by means of an appropriate escalator. We believe the proposal feasible, and we believe your role important.
Last, we also wish to emphasize your role in research. That's an important leadership role for the government. We need to promote and fund more research in areas that will contribute to improving the future of health care and the quality of life for Canadians.
Let me just conclude by reinforcing that we believe this leadership role is fundamental and it is through funding. Thank you.
The Chair: Next is Noëlle-Dominique Willems from the Canadian Pharmaceutical Association.
[Translation]
Ms Noëlle-Dominique Willems (Director of Government and Public Affairs, Canadian Pharmaceutical Association): Ladies and gentlemen, members of the committee, I welcome this opportunity to lend my support and that of the Canadian Pharmaceutical Association to the brief of the Health Action Lobby.
I would also like to share with you some of the minor concerns that we have regarding the taxation of extended health care insurance, an issue that you examined last year. I know that you examined these plans and identified certain elements of inequity.
We represent 10,000 pharmacists across Canada and we feel that if extended health care plans were taxed, this would only shift the cost burden onto the traditional health care system, that is on hospitals.
As hospital pharmacists, we are seeing more and more people without extended health care coverage who cannot afford to take medication outside a hospital setting. These people remain as long as possible in hospital. Our concern is that the taxing of extended health care benefits will drive up costs in other areas of the system.
Thank you for your attention. I will now turn the floor over to my colleagues so that you have more time to ask us questions concerning the Health Action Lobby brief.
The Chair: Thank you very much. The next witness is
[English]
from the Canadian Medical Association, Carole Guzman.
Ms Carole Guzman (Associate Secretary General, Canadian Medical Association): Thank you, Mr. Chair. The Canadian Medical Association thanks you for having us meet with you today.
You have our brief in front of you, and I will only briefly walk you through the main points.
The Canadian Medical Association remains committed to the delivery of high-quality health care and to the future national integrity of health and health care programs in Canada. Maintaining the universal health care system is vital for at least three reasons.
[Translation]
Medicare is a unifying force for Canadians. It contributes to a healthy economy and plays a vital role in ensuring the welfare of Canadians.
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[English]
CMA recognizes that the federal government must attend to its own fiscal house. However, the government must also be upfront with Canadians when it comes to long-term cash commitments to help in social programs.
Canadians are now deeply concerned that reducing the federal fiscal deficit and cost shifting to other levels of government are translating into higher social costs.
In a recent poll reported in Maclean's magazine, 58% of Canadians reported that they expect the health care system will be worse in the next 10 years. Many Canadians believe that the fiscal agenda will overwhelm the social agenda to the extent that the social values and ideals that sustain them will be forgotten.
CMA recognizes that the current fiscal situation must be carefully managed. However, the federal government must not ignore the implications that its fiscal policies will have for the health care system, for the economy and for society.
Medicare is a unifying value. Among Canadians, 84% see medicare as a defining characteristic of being Canadian. Again, 84% of Canadians feel that the system provides high-quality care. However, 65% of Canadians are now concerned about continued accessibility to a full range of publicly financed benefits.
Medicare contributes to a healthy economy. Canada's medicare system is internationally recognized as one of its greatest assets. Expenditures on both public and private health care are lower than those of our American neighbours and yet we are able to maintain the same or better health styles.
Universality and portability, which remove one of the major impediments to labour mobility, are just two of the important advantages of our system. Canadian business is unequivocal in terms of the high value it places on our health care system. Its support rests on the faith that the system has the capacity to deliver high-quality care while keeping costs under control.
Business is also aware that Canada's health insurance system seems to provide employers with a competitive advantage over companies in the United States.
Medicare contributes to the well-being of Canadians. Canadians believe that medicare will be there when they need it, that they won't be made bankrupt by illness. However, with increasing frequency Canadians are experiencing difficulty in access due to hospital closures and long waiting lists.
There are emerging quality concerns and problems. The health care system has already suffered very large cutbacks in the last few years, some $12 billion out of the public system since 1991, without effective evaluation of its impact on quality and access to care.
Physicians and their patients are experiencing difficulty in accessing appropriate testing technologies and treatments. Nursing services in hospitals are being stretched unreasonably. Home care services are suffering. Canadians are all becoming concerned that the universal medicare system that they have supported through their tax dollars may not be available when they need it most.
The CMA has four recommendations:
- first, that the federal government negotiate in a transparent process a stable, predictable five-year funding arrangement with the provinces and territories, as you heard in the HEAL brief;
- second, that the current federal government policy with respect to non-taxable health benefits be maintained;
- third, that the federal government provide funding for a national research and evaluation strategy for health and medical services research; and
- fourth, that the federal government use a measured approach to restoring the tobacco tax and implementing adequate tobacco education and enforcement strategies.
Thank you.
The Chair: How much for the research component of this?
Ms Guzman: We are suggesting that there must be a national research strategy, because there is a very definite lack of research, particularly in the area of evaluation of the reforms that are going on now and of the research we need in order to have an effective system five, ten or twenty years down the road.
The Chair: So you're not putting -
Ms Guzman: We're not putting a dollar figure on it.
The Chair: So it won't necessarily cost us anything. It's just a matter of coordinating better what we already do?
Ms Guzman: Where you don't have a figure for it, what we're saying is there has to be a comprehensive strategy in approaching it to ensure that research is there.
The Chairman: Thank you, Ms Guzman.
Robert Burr, please.
.1600
Mr. Robert Burr (Director of Public Affairs and Communications, Canadian Public Health Association): Thank you, Mr. Chair. On behalf of the Canadian Public Health Association, I'd like to express our appreciation for this opportunity to address you and members of the committee.
The Canadian Public Health Association is a national voluntary association representing public health in Canada. More than 25 health disciplines are represented in our association.
The position of the Canadian Public Health Association on the transfers to the provinces for health, social services, post-secondary education, and specifically the structure of the Canada health and social transfer, is best understood within the context of public health recommendations for the future direction of Canada's health system.
The public health community has long held that as a society we have focused too much on health care, institutional care, physicians services and pharmaceuticals at the expense of health promotion and disease prevention programs.
Of course, public health is not against having in place a world-class, state-of-the-art illness treatment system and a public insurance structure that ensures universal access to required services. This we have in Canada.
We must look beyond this system if we are to achieve improved health gains. There is in Canada - and I point out that we are world leaders in this area - a growing body of knowledge providing hard scientific evidence that the major determinants of health lie outside our illness treatment system. In other words, resources are required to address the determinants of health - for example, adequacy of income and employment for marginalized groups, education, housing, childhood care and support, environmental health and social services - if we hope to improve the health status of different populations.
How does this relate to the new transfer arrangements presented in the Canada health and social transfer? First of all, while we do not wish to see the integrity of the national health system diminished, changes can happen and are happening in terms of a shift to community care, health promotion and disease prevention.
If the federal government is to remain involved and able to provide leadership for change, change for a new direction as well as maintaining what we have, our national standards, you must continue to provide support through cash transfers, as I'm sure you've heard many times.
As you are well aware, with the CHST as it is presently constituted, cash transfers could fall to zero in a very short period of time. It's for this reason that we provide support and we recommend a cash per capita floor for health.
We're also calling for targeted federal cash transfers, formally supported under the Canada assistance plan and EPF, in order to provide for reasonably comparable levels of health, social service and post-secondary education delivery across the country.
We recommend support for what have traditionally been considered the non-health-related sectors, reflecting the new knowledge becoming available showing the importance of these sectors in affecting health status. Our recommendation for a cash health-related floor is made not only to protect the integrity of the existing system but also so that the federal government can remain a player, provide leadership and establish a new direction.
I would draw your attention to the fact that it was 50¢ federal dollars that strongly encouraged the shape of the current illness treatment system we have today. We'll be looking to the federal government for leadership in providing new direction for the rest of this century and into the 21st century.
With respect to the structure of the CHST and the absence of any guaranteed commitment to a cash floor, we are opposed to the CHST being used as a vehicle for further reductions in federal transfers.
On the other hand, the CHST does have, in our opinion, a positive side. The Canadian Public Health Association supports the policy direction established by the CHST in removing the artificial barrier between health and social service transfers. This could and can and is providing improved flexibility to the provinces in the development and implementation of programs addressing a broader range of health determinants.
To sum up, we do not support further reductions in cash transfers. We call for the strengthening and protection of national standards in health and social policy. We are asking for a guaranteed health-related cash transfer. This is not to be, however, at the expense of the sectors covered under CAP and EPF.
In this regard, we recommend, as I mentioned earlier, that enough targeted cash be transferred to the provinces to provide reasonably comparable levels of health, social service and post-secondary education delivery.
We support the CHST in removing the artificial barrier between health and social service transfers. Finally, we call for federal leadership in reorienting Canada's health care system more towards health promotion and disease prevention.
Thank you.
The Chair: Could I just ask you, Mr. Burr - I think I missed this - did you give us a figure for the non-health component of the CHST?
Mr. Burr: The cash figure?
The Chair: Yes.
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Mr. Burr: Do you mean after we took off the guaranteed health component we're asking for?
The Chair: As I understand it, you like the suggestion put forth by HEAL that we go to $7.5 billion guaranteed for the next five years, thereafter indexed for health alone, splitting it apart. Then you want a certain amount for post-secondary education and the welfare component as well?
Mr. Burr: Yes.
The Chair: How much?
Mr. Burr: We're not putting a dollar figure on that for the future; we're saying we should start with what that cash component is in the present year.
The Chair: But unlike HEAL, you do like the idea that the three components are lumped into one rather than split apart.
Mr. Burr: We have seen positive benefits of that, yes.
The Chair: Thank you.
Carol Clemenhagen of the Canadian Health Care Association is next, please.
Ms Carol Clemenhagen (President, Canadian Health Care Association): Mr. Chairman, the chairman of the board of the Canadian Health Care Association, Mr. Levac, will be making our presentation.
[Translation]
Mr. Gaston Levac (Chairman of the Board of Directors, Canadian Health Care Association): Thank you, Mr. Chairman. I'm the Chairman of the Board of Directors of the Canadian Health Care Association, formally known as the Canadian Hospital Association. I'm also the CEO of Thunder Bay General Hospital in Ontario.
[English]
The CHA federation represents over 1,000 regional health authorities, hospitals, health care facilities, and agencies, which themselves are governed by Canadian citizens from every walk of life, across all provinces and the Northwest Territories.
We also thank you for the opportunity to put on record what our federation believes is essential for this federal budget. We believe the federal budget in 1996 is this government's opportunity to act firmly and responsibly to secure the future of medicare. CHA's position on the Canada health and social transfer is straightforward as well.
We believe it is essential for this federal budget to do the following things.
First, it should establish a guaranteed cash floor specifically for health transfers at the current $7 billion plus in cash transfers for health. Indeed, CHA also urges the federal government to flat-line equal per capita cash transfers for health for a five-year period.
What will this deliver? The federal government will meet the public's expectations about its role in protecting medicare as a national priority. Taxpayers across Canada will see accountability demonstrated in the match between the federal moral authority and its practical spending authority to promote compliance with agreed-upon national principles for medicare. This match is now sadly missing, in our view. The health system's fiscal framework will be stabilized, enabling those involved in the delivery of health care to manage the transition to a renewed health system that delivers services better and less expensively in the future.
CHA agrees that Canada must put its fiscal house in order, and we pledge our support in this effort. The CHA board of directors is firm in its commitment to promote innovation and shared responsibility for health service improvement. We do not see our role as being that of a sectoral interest group simply asking that our sector not be cut back further. To the contrary, we are a partner that brings experience and thoughtful reflection to consensus building around health renewal. The health sector is not asking for budget increases. Our sector is working very hard so that increasing health care costs can be absorbed within a sustainable fiscal framework.
Where, then, should federal priorities lie? Health care affects every single Canadian at some point in their lives. We need to be intellectually honest with the public. In a current social and political environment that tends towards decentralization, health care and equalization are probably the only two areas where there is a solidly entrenched consensus at all levels that the federal role is not only beneficial but is in fact essential.
The specific questions that were pre-circulated by this committee are difficult, far-reaching and uncomfortable. Health associations exist to represent and promote their members' interests, not to provide a potential hit list for cutback targets. Nevertheless, I feel a duty on behalf of our association to attempt to answer some of this committee's direct questions.
Where should federal priorities lie? In our view, they clearly lie in establishing a guaranteed cash floor specifically for health and the CHST at the current $7 billion plus in health transfers; in guaranteeing that a stable and adequate flat-line base is in place for a five-year period; and in considering an appropriate escalator for health transfers to take effect once Canada's fiscal house is in order.
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Should health care spending be given a higher priority than other programs should? Medicare is recognized within Canada and internationally as our most successful social program. Recognized and agreed national standards embodied in legislation already exist for medicare but do not exist for other social programs.
The federal role in providing incentives for and ensuring compliance with medicare's national standards is highly recognized and supported by Canadian taxpayers. As indicated by former speakers, survey after survey has confirmed that medicare is Canada's most valued social program.
As far as research on medical care of differing importance, research is an essential component of the health system. It is both an underpinning for and an advancer of the scientific basis for health care delivery. Both research and health care require strong federal support. Consumers of care must be the first concern of the health service delivery system.
The next question was what the low-priority federal program areas are. I offer two examples where I believe limited public funds could be spent better.
The first example is areas where regulatory burdens are diverting direct patient care dollars to meet regulatory requirements. There are numerous examples listed here. For example, though WHIMS has benefit, we question the value-added benefit in light of the priorities of the small and shrinking health care pie.
Health Canada sustaining grants for associations is another area where you might have opportunity for review. Health associations should be self-supporting. In last year's federal budget, business clearly said business subsidies should end. Our board thinks it behoves health associations to do the same this year.
The next question was about what areas the federal government must be involved in. We see three areas, and it's repeated for emphasis, Mr. Chairman. They are: stable and adequate cash transfers specifically for health, equalization, and maintaining agreed national health principles.
What room exists for private sector involvement? As you know, the private sector is already very involved in Canadian health care. That sector contributed 28% of health expenditures in 1993. We emphasize and we believe that there is enough money being spent overall for health care, both private and public. It was $72 billion for 1993.
But we cannot offload onto the private sector and assume that we have saved health care costs. We definitely need to reach consensus on what we as Canadians want the ratio of public and private funding to be. We do not have a specific recommendation. We don't know if the 28% private sector contribution is enough, too much or just right.
We believe that we need to examine this in a national dialogue with Canadians given medicare's importance to us all. The Prime Minister's national health forum is interested in this area and will hopefully shed more light on it.
How should government best target its programs? We feel the first thing it should do is have guaranteed timeframes. Think about five-year periods. It should have stable and adequate cash transfers that provide incentives for provincial compliance with agreed national principles embodied in the legislation. It should have equal per capita transfers. It should consider escalators when the fiscal house is in order. It should monitor and assist in developing monitoring and reporting mechanisms at the national level. It should provide a legislative framework that enables federal enforcement of agreed national standards.
These are repeated, but they're part of the different questions that you've asked.
Is government spending the appropriate amount? Right now provinces pay the largest percentage of health care expenditures. It was 46.5% in 1993. Federal contributions have been declining for more than a decade. It was 23.5% of all expenditures in 1993, down from 30.3% in 1980.
All the levers of control in health care spending are being pulled with significant effect, Mr. Chairman. Even though health care represents about one-third of provincial budgets, more and more balanced provincial budgets are being presented with the one-third maintained.
Waiting lists for services are growing. The level of tension in the health system is intense. The public is becoming more uncertain about our ability to guarantee access to high-quality care. It is therefore now essential that the federal contributions be stabilized.
The 1996 federal budget is the time for the federal government to articulate its clear intention to maintain a stable and adequate cash floor specifically for health at the $7 billion plus in existing transfers for the next five years. This will provide the health policy and fiscal framework we need to complete the tremendous health reform and renewal effort now unfolding at the grassroots of health care delivery across our country.
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Thank you, Mr. Chairman.
The Chair: Thank you, Mr. Levac.
Mr. John Service, please.
Mr. John Service (Executive Director, Canadian Psychological Association): Thank you, Mr. Chairman. Thank you for this opportunity to speak to this issue today.
Many of the points I'm prepared to speak on have been made by other members, so I'm going to contract my comments.
We are a member of the working group of HEAL and strongly support the HEAL brief. It's a practical solution to a difficult problem and speaks directly to what we consider to be a couple of the serious issues: a continued and stable funding mechanism, and an appropriate cash component to preserve national standards.
CPA, the Canadian Psychological Association, recognizes that we are going through a period of tremendous change. Many factors are causing this. Many of them are fiscal and our fiscal realities are very important.
CPA believes it's the role of the federal government to provide a significant measure of stability during this period. This can be accomplished without a large infusion of dollars, dollars that aren't there.
Stability would be enhanced if we knew what the five-year plan was. You would agree that it's very difficult for any organization, government or company to effectively plan when fiscal parameters are changing rapidly and yearly. We would like to see a long-term plan. We would also like to ensure the cash component in order to preserve the federal government's role in the health care system.
In addition, Mr. Chairman, the Canadian Psychological Association is a member of the steering committee of the National Consortium of Scientific and Educational Societies and has a deep concern about basic and applied research. This research is performed in universities, university-affiliated hospitals and in business and industry.
We strongly support the recommendations you'll be receiving in another forum from the National Consortium of Scientific and Educational Societies to support the work of the National Research Council and to support the funding that is available in the CHST and was available in the established program financing supporting post-secondary education.
This HEAL proposal is not a proposal that intends to take away from social welfare programming or funding or post-secondary education, but it is a whole package.
The Canadian Psychological Association represents scientists, academics and practitioners in the discipline of psychology. It's a very heterogeneous group. We thank you for this opportunity to speak to you today on this very important issue and we look forward to the discussion to follow.
The Chair: Thank you, Mr. Service.
Mr. McLennan, please.
Mr. Barry McLennan (Member, Board of Directors, Coalition for Biomedical and Health Research): Thank you, Mr. Chairman. Good afternoon, ladies and gentlemen and members of the committee.
I want to mention the CBHR report that has been handed to you. The Coalition for Biomedical and Health Research brings together various biomedical and health researchers from all across Canada, who represent the medical schools, the Canadian Federation of Biological Societies, the Canadian Society for Clinical Investigation, and about 28,000 medical practitioners. It represents a large group of people from right across the country.
I particularly want to thank you, Mr. Chairman, for the opportunity to address the committee again this year. This consultation process is a sound strategy. We really appreciate this partnership. We hope you will continue this dialogue. We think it's very important.
Canada is at a crossroads. In order to regain our competitive position in the world, we must focus on investment spending rather than on consumption spending with respect to the delivery of health care, education and social programs. It's imperative that the finance committee avoid recommending across-the-board cuts in these areas. I refer you to the box at the top of page 2 in our report.
CBHR suggests that health care spending be given a higher priority. However, if cuts are to be made they must be based on evaluative research so they're cost-effective and so they do not compromise the quality of the health care program, an item that has been referred to by earlier speakers.
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CBHR urges the support for the National Advisory Board on Science and Technology recommendations, specifically to allocate 1% of the federal spending on health care for health services and health determinant research. You'll be aware that granting councils such as the MRC, for example, have broadened their mandates, so I'm talking about a wide definition here of health research.
As the NABST report explains, over a period of five years this would generate $7 billion in yearly savings to the health care system, and I refer you to the box on the top of page 4 in our report.
In order to reduce the overall demand for remedial social programs, CBHR urges the committee to support the NABST recommendation to allocate 0.5% of the current spending on social programs for research in the efficiency and effectiveness of these programs, and I refer you to the box in the middle of page 4.
Federal support for the direct cost of research is provided, as you know, through the three granting councils - the Medical Research Council, the Natural Sciences and Engineering Research Council, and the Social Sciences and Humanities Research Council. This does not provide indirect support. The federal support for the indirect cost of research is provided through the EPF transfer programs.
CBHR urges the committee to reiterate most forcefully to governments its recommendation to spare the granting councils from spending cuts in 1996-97 - we had a cut, of course, this year and will have cuts in future years and I refer you to the box at the top of page 5 - and also put in place a mechanism to provide support for research infrastructure costs by the time the new CHST program is implemented, and I refer you to the box on page 6.
What we're talking about here is a partnership. Provincial and regional areas of emphasis within the context of the national plan are both necessary and reasonable to develop new approaches to health care. This partnership approach is critical to the improvement of the health of the population and to meet the economic challenges of the 21st century. This exercise should be completed in the next 12 to 24 months, and I refer you to the final box on page 8.
Mr. Chairman, and members of the committee, it's time to act, it's time for leadership.
Thank you very much.
The Chair: Thank you, Mr. McLennan.
Our last speaker is Marnie McCall from the Consumers' Association of Canada. Welcome back, Miss McCall.
Ms Marnie McCall: (Director of Policy Research, Consumers' Association of Canada): As some of you may be aware, and particularly those members who were here last night, the Consumers' Association of Canada is a national not-for-profit, non-government volunteer organization whose purpose is to represent and inform consumers and advocate on their behalf to improve quality of life, very broadly defined.
CAC has 12,000 members in Canada and we reach another 200,000 Canadians through our publication, which is circulated with American consumer reports. We get feedback from both our Canadian members and the Canadian readers of our bulletin through that magazine, so we often have information from a very broad sector of the Canadian public.
We recognize the fiscal constraints that are facing the Government of Canada and we are pleased to have the opportunity of being here, in this forum, with our health care partners today.
As a member association of HEAL, CAC fully supports the prescription for medicare that has been presented here. However, as an association that deals with a complex variety of issues facing Canadians in a rapidly changing social policy environment, we at CAC have learned about the danger of looking at issues in isolation. Everything is connected to everything else, and it's very difficult to maintain any kind of social cohesion and integrity when you look at things apart and try to make changes without considering their implications for the rest of the things in our lives, as Canadians, that are special to us.
We are not qualified nor is it our mandate to recommend the type of approach the government should be taking for allocating federal financial support to social assistance, social services and post-secondary education. But we very firmly believe that a truly healthy and financially secure Canada is dependent upon maintaining consistent support for all of the elements included in the CHST, in a way that ensures reasonably comparable levels of service can be provided throughout the country.
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We recognize that the Government of Canada's primary objectives for the next few years are sustainable economic growth and job creation, but without healthy citizens neither of those goals will be attainable. To safeguard the integrity of Canada's health care system, the federal government must continue, as recommended in the HEAL brief, to provide direct substantial cash support to the system.
Such support assists the provinces in meeting their requirements to comply with the criteria of medicare currently embodied in the Canada Health Act so there are reasonably comparable levels of services across the country. As was pointed out by one of the earlier speakers, having those reasonably comparable services permits labour mobility, and that's one of the necessities for job creation and sustainable economic growth.
Without the cash component, no moral authority to ensure compliance with the act exists, nor does the Government of Canada have the leverage it needs to work successfully and cooperatively in joint decision-making.
It is time for the Government of Canada to send Canadians a strong signal that its commitment to the overall health of Canadian consumers is real. That commitment must extend beyond the institutional framework of health into community-based health. It must recognize there is a continuum and that social services are necessary to enable people in many circumstances to regain health, or assist them while they're recovering from illness.
We wish to point out that the need for the federal government to make the commitment very clear is absolutely essential if we're going to maintain a functioning system that meets the needs of Canadians in the future. It must provide access to all and be fair, responsive, accountable, publicly funded and recognize that the integration of social services, educational opportunities and social assistance is necessary to attain a healthy society. Thank you.
The Chair: Thank you, Ms McCall.
Before we start questions, please accept my apology. I have referred to many of you as Mr. or Ms, and I know most of you should be referred to as Dr. I apologize to you for that.
We will start the questions with Mrs. Stewart.
Mrs. Stewart (Brant): Thank you all for being here. I am constantly amazed at the plethora of different associations working in the area of health. Quite frankly, I'm glad to see there is an ability to coalesce under one coalition.
I want to question two particular areas, and certainly the notion of the $250 per capita transfer for health. I would be interested to know where the $250 came from. Did you start at the $7.5 billion and go backwards until you came to $250 per capita, or did you look at it and decide that it seemed to be an appropriate figure per capita? I'm interested in the strategy you used to figure that out.
Second, I'm particularly fascinated by the notion that not only do you want stable funding but you want earmarked dollars as well. It seems to me that if stable funding can be identified, Mr. Burr's strategy of reducing the artificial barriers between these social transfers makes a lot of sense.
As we talk about the need to focus our priorities and get the roles and functions of different levels of government correct, it would be far easier for you to talk to the provinces about cash transfers at the same time as you talk to them about their tax-transferred dollars. You could do that as opposed to coming to the federal government every year and saying you want your cash transfers and going to the provincial government and saying you want to make sure you still have the money from the tax point transfers.
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I just don't understand the logic. If in fact we can agree to some kind of stable funding, which seems to be a reasonable proposal, why would you, in addition, want to have those earmarked dollars?
I prefer the strategy of Mr. Burr, that we've really got to understand that these social programs are interrelated, that making an artificial boundary between them doesn't make sense.
Finally, in the same area, as the chair points out, your doctors or your administrators of hospitals, people who tend to be in higher income brackets, and certainly in maybe another forum, would come to us and say, ``In terms of funding this thing, we sure don't want you to do it on the revenue side. Don't tax us any more''. So I'd have to ask you sincerely, as we focus on this and agree that this is a very high priority of the government, that social programs and health care are important, where do we cut in order to sustain that?
Mr. Ritchie: You've asked a series of questions, and I'm going to try to take them one by one. If I leave a piece out, it's not deliberate. It's probably just a function of my current short-term memory.
The first is how we derived the $250. I think the starting point was that it had to, in a fundamental sense, fit the targets that had been set by the Minister of Finance, because we made a commitment to you last year, and indeed earlier, that we weren't going to come in here at any point and ask for new dollars. We felt that we had a responsibility, just like every other Canadian or every other group of Canadians, to address the matter of the state of Canada's public debt and its public finances. That is one starting point.
We've also looked at a variety of per capita notions. If you want to know some of the complexities of the analysis, that's why I have Alistair here with me. The $247 current-year per capita for Ontario happens to be the lowest for a province. So rather than come in here and put it at the highball level, we thought, again as a gesture of good faith and in order to get something locked in that would, quite frankly, be fiscally responsible, we would propose that. That's the strategic thinking behind it, rather than the technical thinking. Alistair could certainly share the technical aspects with you or your research staff.
Mrs. Stewart: That's appropriate for later. That's fine. And the second issue?
Mr. Ritchie: The second issue is the integration or non-integration of social, post-secondary education, and health dollars as a single federal transfer.
The reason fundamentally why we're calling for earmarked dollars for health is that health is distinguished from the others because there is a piece of federal legislation, the Canada Health Act, that sets out the core principles around which the national medicare system is to be administered. Provinces are totally unfettered within those five principles to administer, as is proper under our Constitution, under Canada's health care system. But those five principles are ensconced in federal legislation, and the federal government has reflected, in a way different for health than in other areas, a broad commitment on the part of Canadians, expressed through many governments and different political parties, to the maintenance of a national health care system that is anchored in federal legislation and that is anchored in a set of principles. We think that within that context it's appropriate in the transfer arrangements that there should be earmarked dollars.
What you've heard from all of us - and I would like to note that I don't believe you've heard anything from Robert fundamentally different from what you've heard from the rest of us - is that we are all supporting the notion that social programs also merit federal support. They're less easily anchored in terms of core principles than the health situation.
Mrs. Stewart: In the arrangements we have now with the Canada Health Act, if we find provinces that are not in compliance with the five principles, we withhold funds. If it's lumped together - we're talking in 1996-97 of $22.1 billion - then can we withhold part and parcel of all of that as opposed to just the $7.5 billion that you would be asking for?
Mr. Ritchie: Under Bill C-20 there is that authority. Again, one has to be careful about that.
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Mrs. Stewart: This is separate from the tax transfer. This is the cash component solely.
Mr. Ritchie: That's right. Under the current provisions, that cash is continued under Mr. Martin's last budget. The cash component is $16 billion in the current year, and it's scheduled to go to $12 billion in the next budget year based on his two-year rolling projections.
Mrs. Stewart: Are those real numbers?
Mr. Ritchie: Yes, and they eventually go to zero.
Mrs. Stewart: So essentially what you're saying is that you don't feel the clout we have at those levels, even with the numbers you've quoted, is sufficient to maintain that capability.
Mr. Ritchie: If you look at the quotes we provided on pages 6 and 7, what we now see, in a rhetorical sense, is a commitment to the maintenance of cash for health. There are statements from the Prime Minister, from the Minister of Finance, and from the Minister of Health. The Minister of Health then goes on most recently to say that the structure of that will be addressed by Mr. Martin.
It's in the spirit of those remarks and given the invitation to address the structure of it that we're presenting what we believe is a reasonable way to go about structuring the CHST as it's projected to come on-line beginning next year. We think earmarking the health portion is a reasonable way to go. Quite frankly, our fundamental concern is more at the level of providing continued incentive rather than the big stick approach.
Mrs. Stewart: There is a third piece of this question. As we agree that social programs are critically important to us and as we all agree that we still have a way to go in terms of managing our fiscal situations, where should we cut? Should it be on the revenue side? How do we maintain that? Have you thought broadly? Can you give us some advice so that we can make good on the request you're making here for stable funding in identified amounts?
Mr. Ritchie: I'm not sure I'm going to answer your question adequately because I'm not truly sure whether you're asking for recommendations for new taxes or recommendations for other kinds of cuts.
Mrs. Stewart: Do you think you could sell recommendations for new taxes to your membership in terms of support?
Mr. Ritchie: What we've done is tried to take the minister, Mr. Martin, at his word in terms of what he's trying to achieve with his notion of rolling multi-year targets. We think the general concept is a good one.
Within that we're trying to say that given those targets, here's how we think it would best be managed. In that sense, I realize we're not making recommendations for cuts in other areas. I think we would be very reluctant to do that, because one thing we're not, whatever names or titles we carry, is economists; we're not fiscalists. But we do know an awful lot about the economics of the health care system and what would be necessary to sustain a healthy health care system.
Mrs. Stewart: That having been said, I would recognize Mr. Levac and the recommendations he made for cuts internal to the system. I appreciate those.
I have a second line of questioning if I might, Mr. Chair. It speaks directly to the report of the CMA, particularly item 3 on a national health research program.
We are talking so much about building partnerships with the public and private sectors. At an earlier round table, we had groups of representatives from different labour capital funds identifiable where the government, through various tax expenditures both at the federal and provincial levels and RRSP deductions, in fact supported specific capital investment funds.
One group in particular that was here visiting us was the Medical Discoveries Fund, which focused on medical research and the movement of good research into the practical domain so it can be usable. They collect private moneys, and individuals who contribute to these funds get significant tax concessions. This particular fund I speak of is directed at health research.
In your report you ask that the government fund a concerted national and integrated research and evaluation strategy. What would you think about including that area, which we already fund through the tax structure, in the design of this national health research program?
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Ms Guzman: Our association doesn't have a policy on the kind of question you are asking. I'm familiar with the fund you are talking about, and it's a venture capital fund, clearly.
The linkage of the private sector with public funding for research is well recognized and is important, certainly. What we're saying in our brief, however, is that the federal government has a role in ensuring that the various components of research funding are coordinated. There are all kinds of things going on at the federal level and provincial level and at the private, public and mixed levels. Our sense is that there is a need for more coordination and facilitation of these roles.
It's not directly that we're asking for more money for research. I think what we're saying, in an unspoken manner, is that we wouldn't like to see the research funds cut further.
Mr. Tholl may wish to complement what I've just said. He's from our association as well.
Mr. William Tholl (Director Health, Policy and Economics, Canadian Medical Association): You might be aware of the health innovation fund that has been talked about for a number of years. It's building on that kind of concept, but it's not speaking to the issue of a separate $500 million spread over five years.
At least as a first step, hook together all the provincial health innovation funds and show some leadership in the federal government with unprecedented health reforms in this country. This is a unique opportunity to figure out whether that's helping or harming the health and health care of Canadians, whether it's helping or harming Canadian business. We believe it's harming.
It's penny wise and pound foolish simply to continue to cut in health care. If cuts in health care are going to continue to come - and Dr. Guzman mentioned $12 billion since 1991 according to provincial health accounts - then use the existing amounts to at least evaluate what the effects are on the health care system and on Canadian business.
Mrs. Stewart: So this request from you is strictly a request for federal coordination. As an association you would see a specific role for the federal government, and an important role in terms of coordinating those provincial strategies.
Mr. Tholl: That may in fact require some leveraging of money on the part of the federal government through existing programs, perhaps like the NHRDP program. We wouldn't want to presume the allocation by program, but there's obviously going to have to be some leveraging of money from the federal government onto the provincial governments. Otherwise, they're not going to play ball.
Mrs. Stewart: Thanks very much.
Thank you, Mr. Chair.
The Chair: Thank you very much, Mrs. Stewart.
Mr. St. Denis.
Mr. St. Denis (Algoma): Thanks, Mr. Chairman.
Thank you all for being here. It's been an extremely useful discussion already.
I'd like to focus on research as well, if I could. Mrs. Stewart touched on that subject in her questioning.
I wonder if I could maybe start with Dr. McLennan. Or is it Mr. McLennan? It's kind of hard to know.
Clearly, as the best country in the world, we didn't get there by fluke. As many weaknesses as there are within our education system and so on, part of it must be that we have done a reasonably good job with that, although it is acknowledged we can always do more.
One of the pressures on the government, of course, is to do more with less. Even though we always need to have pure research just for the new knowledge it provides for the long term, there is of course the pressure to have more research that is more immediately applicable to the average consumer - or patient in the case of health care. As a first question, I'm wondering what the proportion is within the biomedical and health field of research in terms of what you might call pure research and that which is applied or consumer-related research.
Mr. McLennan: There isn't really a strict proportion. Basic research becomes applied research. There isn't a procedure or treatment in use today in this country that didn't start as basic research.
I accept your point that we must continue to do basic research. Interestingly enough, there's an article in Tuesday's Globe and Mail pointing out that in Japan and in the United States they are falling behind in their relative competitive positions because they are failing to nourish the university-supported basic research programs.
As you have just commented - and I would emphasize this - we do have an excellent cadre of trained people in Canada. Canadian students and researchers are well respected around the world. They have no one to apologize to. Where we are suffering - and this comes back to your question - is that the university system and the research institutions and hospitals and so on have handled severe cutbacks. Particularly, they are now at the bare bones with respect to infrastructure.
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So we have a situation where you have clinicians who don't want to pursue research, they don't take up these programs; they're discouraged. You see, research reports requires long-term planning, and this is one of the points that was made earlier by the previous questioner.
You can't solve research and address research questions, basic research or applied research, in a few months; you need a long-term policy. Part of our difficulty in Canada is that there has been such uncertainty in funding that institutions have not been able to lay down long-term plans and do perhaps the most effective research.
Let me give you an example on the social policy side. Right now there's a program in Canada called the youth employment pilot project or program. It was started a couple of years ago in Manitoba. This is a program to enhance job training for students who already have a BSc degree or a technical certificate but they can't get a job. They're on unemployment insurance. This program is an excellent one short term to match up a training program...they're put in research labs to enhance their training at the same time as they collect their UI. The initiative here is for them to get back into the job market.
So that's a program that works really well. We have, as I say, an excellent cadre of researchers in Canada but we're at a very critical point in terms of the infrastructure support, and the worry as we cut EPF transfers is how that infrastructure component will be introduced.
Mr. St. Denis: Is there a way to measure - and if anyone wants to jump in here, please feel free - what happens to a dollar invested in either basic or applied research when it comes out the other end as a new health procedure or health-related product? Are there measures?
Mr. McLennan: Yes, there is. The answer on the health research side, on the basic research side, is fairly straightforward. The peer review of the system that's in place in Canada is your quality control measure. If the procedure, the test, the result doesn't survive the peer review test, it goes.
Where we are deficient is on the social science side. In the broader definition of health research, it's very clear that rather than just blindly continue to do what we're doing, we must evaluate the procedures, the determinants of health, health outcomes, research and so on. So there's no simple measuring stick for that domain, but that's where we need to put some effort into it.
Mr. St. Denis: Is that what you mean when you refer to ``evaluative research'' on page 3?
Mr. McLennan: Yes, exactly. There are two kinds of research: discovery research, which somebody might call basic research, and evaluative research.
We have, again, a vast asset in this country. We've done lots of research but we haven't spent much time evaluating health outcomes research, population health research, health informatics and so on. We have the data. We need to look at it to determine which procedure or treatment has been most cost-effective.
I'll give you a simple example. Right now in Saskatchewan, the province I come from, the Saskatchewan Government Insurance corporation is funding research into soft tissue injury. They spend billions of dollars, and the insurance companies generally spend billions of dollars in North America and around the world, on insurance claims. Generally, they don't have a cold clue whether those treatments are any good or not because no one's ever done the research on it. That's just one example.
Mr. St. Denis: It leads me to wonder whether it might be in the interest of insurance companies to be providing a lot more money to the health sector, because if they could increase the average age of death by one year, that would affect the bottom line. That must be worth a couple of billion dollars and would increase the age of Canadians by one year.
Mr. McLellan: They're certainly interested in reducing claim costs.
Mr. St. Denis: Right. Hopefully you put as much pressure on them as you do on governments.
Mr. McLellan: Absolutely.
Mr. St. Denis: I have a concluding question, Mr. Chair, related to the whole question of relating a dollar invested in R and D to some kind of benefit to the citizen or the health consumer at the end. On the same page, you tie together investment in research to health systems savings, which is another way of relating a dollar in to a dollar out. Is this just a notional linkage that you make or is there some real complex connection there that allows you to make that claim, which I hope is the case?
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Mr. McLennan: There are some good examples. A recent one would be the analysis of expenditures on carotid artery surgery. The Robarts institute in Ontario recently did an analysis of this and pointed out that the procedure they were using was not producing any useful result; and the current saving probably in Canada alone was $20 million a year just on the abandonment of that item alone.
So, yes, there are cost savings to be recognized and recovered in our current system. We need to look at what we're doing and analyse treatments, regimens and so on. The savings from that is collectively calculated at $7 billion a year in Canada, if we looked at that. So I couldn't agree with you more.
Mr. St. Denis: Have we gotten to the point where we export much of our new health technology; are we a net importer or a net exporter of some health knowledge?
Mr. McLennan: I think it depends on the area of health. We certainly have knowledge and technology that we could export. Part of the difficulty, indeed, in the whole process of patenting and commercializing research results is having money in place to take it from the bench to the marketplace.
Certainly other countries are interested in what we do in Canada. Other countries are looking at our health care system to adopt and put in place in their own country. Yes, I believe we have procedures and systems that we could export in health reform, in medical care practice, and basic research and so on.
Mr. St. Denis: Thank you.
I might come later, Mr. Chair, if there's more time. But if we could [Inaudible - Editor] a higher average age of death, I think we'd be saving a lot of money for everybody.
The Chairman: We'll keep working on that one. Thank you, Mr. St. Denis.
Mr. Discepola.
Mr. Discepola (Vaudreuil): On the contrary, I think if you increase the age you're going to increase the health care costs.
One of the reservations I have, Mr. Chair, is that when we go with a lump sum amount...I think in Canada we've been conditioned over the past 20 or 30 years to usually budget - and municipalities, federal and provincial governments, as well as private industry were all the same - by taking last year's budget, looking at the inflation, and thinking you could get away with it despite your boss, you'd be trying to increase that. So I have a hard time figuring out how you arrive at $250 per capita when you take a look at what Brent just said, that we might live longer or we might be healthier and therefore we might not require as much health care costs - if we have a better diet, better preventive health medicine, that we might not require as much health care.
However, we're just as guilty, because we compare to the other industrialized nations, and as a government we've fixed an objective of trying to get our medical care costs down approximately from the current 8% of GDP down to about 7% of GDP.
I wonder if there is anyone around the table who could tell us what percentage of health care costs is administrative and overhead, what percentage of health care costs is medication, for example, and how does that compare with other provinces?
In my home province of Quebec, for example, they built a hospital expansion in my municipality when I was mayor, so I couldn't criticize it; but now that I'm an MP, I see that five minutes from that expansion of $52 million we have a federal institution that has empty floors sitting there. Now, with the current government you have 10 or 15 hospitals on the island of Montreal being closed under the astonishing fact - and I have to support them on this - that if you compare the number of beds in Quebec compared to Alberta, for example, per capita, it's an astonishing figure. I don't remember an exact figure. It was something like 1,300 or 1,400 beds versus 600 or 700. That seemed to me an astonishing figure.
The two questions I had were, how do we compare administration cost-wise, and how do we compare medication cost-wise?
[Translation]
Ms Willems, perhaps you would care to tackle that question? As a government, are there some basic services that we absolutely should be providing? Should the government be providing services other than basic ones?
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[English]
Ms Willems: That's a loaded question.
[Translation]
It's nearly impossible to put an exact dollar figure on the components that you just spoke of. For example, you say that you are uncomfortable with the figure of $250. This amount doesn't even cover the cost of medication for one month for a person suffering from AIDS. We cannot lose sight of the context in which we are operating.
This figure also excludes all hospitalization and home care costs and other treatment that a person may need. I think the $250 is really a minimum amount and that the provinces will have to kick in considerably more if they want to have a decent, universally accessible health care system. That answers your question in part.
I think that $250 is not a large sum, if we consider that this is what will be used to try and maintain Canada's health care system and impose federal standards in a field which increasingly is falling under provincial jurisdiction.
We must take into account all of these facts, and that's why we support the brief. A minimum basic level of service must be guaranteed and, along with the option of regulating or ensuring access to the system for all Canadians. To accomplish this, you will need the financial resources to maintain the regulatory component of your mandate.
I haven't answered all of your questions.
The Chair: Dr. Levac.
Mr. Levac: Thank you. It's Mr. Levac.
The Chair: I apologize.
Mr. Levac: That's quite all right.
The Chair: It was a serious mistake. I feel very guilty.
Mr. Levac: You're forgiven, Mr. Chairman.
[English]
I'd like to express some comments on the first question, about administration and overhead costs, infrastructure costs that might not be as efficient as they could be in the total delivery system.
I think no one around this table has actually said that there aren't significant efficiencies to be achieved by a restructuring of our health care system.
I want to give a very personal example of a community with which I'm involved. I can say this because I'm new there. I can't take the credit; I'm just part of the implementation.
There are more and more communities across Canada, of which Thunder Bay is one, where they've merged governance of a number of hospitals in the city and merged management teams. I'm working for a corporation now that has three former hospitals under its governance. I'm the president of three organizations, whereas there used to be three CEOs, three presidents. We're going to one management team, whereas there used to be three. In fact, we're going to one site.
Significant shifts of dollars will be possible from the infrastructure management non-clinical side to the improvement of clinical programs that for a long time governments have not been able to support in communities such as Thunder Bay.
If you look across the land, the issue of merging governance models is a phenomenon in all jurisdictions. Some are more voluntary than others. Others are more legislated. There are opportunities for shifts of dollars and for savings in the system.
The point we're making today, though, is not that there aren't opportunities for savings. We're all committed to working with governments to achieve that agenda. The point we're making today is whether or not the federal government is serious about having a say in how Canadians will access care, how Canadians will deal with the issue of portability and having it always available to them from one province to another.
In order for the federal government to continue to have a say in whether Canadians can continue to enjoy the five principles, it must have a strong fiscal presence. You can determine whether $7 billion is adequate to do that. That's your call. We're recommending strongly to you that you've reached a point at which any further reduction might well leave provinces telling the federal government, ``We have so little left that we might as well just forgo it and adopt our own principles''. That's the risk you are taking by continuing to erode the transfer payments to those provinces for health. We're here to talk about health.
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Mr. Discepola: But do you have any figures on how much administration or medication costs the health care system, for example?
Ms Clemenhagen: Yes. Mr. Chairman, drugs account for something like 15% of total health expenditures, and that is indeed the area that is the fastest growing sector of expenditures.
Interestingly, however, with regard to the previous questions on research, it's the pharmaceutical industry that funds the majority of medical research in this country. The average hospital budget spends about 4% of the operating budget on drugs; however, we're getting extremely good at drug utilization review. That's one of the areas where the health sector has used evaluative research very effectively to save dollars.
Hospitals account for something like 40% of all health expenditures; however, that figure has been decreasing over time. So the levers of control on the big spending areas like hospital services are fully pulled and have been so for a number of years.
With regard to the $250 per capita we're asking for, keep in mind that the federal contribution to health care is only about 23%. I believe the per capita amount that we spend on health care in this country is something like $2,500, so the $250 is minimal. However, it would appear that it may be just enough to maintain the moral authority and the practical authority of the federal government to protect and preserve for Canadians a system that has been very good in terms of health impact and one that is highly valued.
We're a federation, as are many of the organizations around the table. We hear from our provincial member associations that we're very close to a certain limit, a seuil. Once we pass over that doorstep, the federal government will not have the credibility that Canadians now invest in the federal government as the protector of national standards.
Even in Quebec, public opinion polls suggest that there's a valuing of the national principles of medicare and a concern about going to a system whereby provincial principles, however well-founded and however sincere.... There's a concern that provinces would not be able to maintain national standards and there's a confidence that the federal government can. So we're very serious in cautioning that we may be on the brink of losing that very important ability.
Mr. Discepola: My concerns were twofold. Has everything possible been done in terms of reducing the administrative overhead, and how does that compare with similar hospitals in other industrialized countries, for example? The second part of the question was should we be providing services for vasectomies for men, for example, or other cosmetic surgery for other people? Is that something fundamental to the core of what medicare was all about back in the 1970s, when it was implemented?
Ms Clemenhagen: That's an excellent question. On the subject of efficiencies, across our membership in the hospital community we're now seeing provinces going to bed-to-population ratios of something like 2.5 beds per 1,000. That's down significantly from historical trends, which saw some provinces with 5 beds per 1,000 population. There are other figures that certainly are not viable in this climate with our ability to do more in terms of day surgery or our ability to do more in terms of community-based care.
So the hospital sector has reacted very quickly to the pressures that have been put on it. Certainly there's more to do. That's what we're here for. We're managers and trustees of the health system. There are always ways to increase efficiency, and that must continue.
The Canadian Health Care Association supports the approach to defining core benefits for Canadians, which would look at what is the basic basket of core insured services. Logically, in that recommendation we're assuming there may be some room for looking at things that are currently in that basket of publicly insured benefits but that may indeed be taken out of it. That's a very complicated endeavour, and we need to get on with that very quickly. But it's going to take a very concerted effort of the medical community, the research community, and consumers in order to tackle that.
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Mr. Tholl: Perhaps to address some of the statistical questions.... I happen to be a mister, too - and that means I'm in the economist variety, not the physician variety.
I'd like to make four points. One, apropos of the comment that if we just had everybody live another year longer that would ease the demands on the health care system, that just defers demand; it doesn't eliminate it.
Two, in terms of administrative costs, I think the record will show that Canada has one of the most administratively economical systems in the industrialized world, OECD countries, at 2.5% of total health care spending. To put that into context, the U.S. spends about 12.5% of its total health care spending on administration. That's from the Government Accounting Office and Congressional Budget Office in the United States.
The record will show that we have one of the most administratively efficient systems in the world. Why? It is because historically we've relied on a single-payer system for hospital and medical. The record will also show that among OECD countries Canada now ranks 16th out of 24 in proportionate total health care spending coming from the public sector. That's in the low end, not in the top end. I think that would surprise most Canadians and might surprise some committee members. In other words, by the instalment plan we are losing the very capacity to keep those administrative costs down.
My last point is that one of the things that has allowed us to keep administrative costs down is the national integrity of the programs. It avoids duplication, overlap, and all the other things that one assumes about our system.
One thing is quite clear: as the federal government's contribution goes from what it is now, $15 billion, to what it will be next year, $12 billion, to what it will be at the end of what Mr. Martin has indicated politically, not legally, will be $10.3 billion, as that process unfolds, going down to zero will certainly endanger the administrative efficiency you're talking about.
Mr. Discepola: I wasn't purporting that we should go down to zero. I was -
Mr. Tholl: The fourth statistical point is that I've heard the figure of $7 billion bandied about again this time. When we were here the last time, the Maxwell studies proposal was thrown up twice as saying that best practices would suggest that $7 billion could be safely taken out of the system. That was in 1989-90 dollar terms. We are now in 1995. Many, if not all, of those savings have already been squeezed out of the system. Again, the numbers will show that when Health Canada gets around to releasing them in two or three weeks' time.
Ms Sholzberg-Gray: I will make one point about the basket of services to look at in terms of core services. I made the point in my earlier remarks that one might actually have to add to the basket as we subtract other things, because we now have a lot of things that are not in that basket, such as long-term care, certain kinds of community care, and home care. So we might have to increase the universally accessible system on one side and decrease it on the other, but it's for Canadians together to decide what should be universally accessible.
Mr. Discepola: Very true.
[Translation]
Mr. Laurin (Joliette): Mr. Chairman, I'm not quite sure to whom I should direct my question. Since I missed the presentations of several witnesses at the start of the meeting, I will put my question in a general way.
The Chair: Mr. Laurin, you can either direct your question to the physicians or to the non-physicians.
Mr. Laurin: I will put it to all of the witnesses. Those who wish to do so may respond.
Mr. Chairman, when we talk about a health care system such as the one we have in Canada, we're clearly talking about a matter of choice. What level of health care do we wish to provide? I listened to a doctor speaking at a conference recently. He pointed out that in Quebec, health care costs were higher during the final six months of a person's life than at any other time.
Clearly, as a society, we have some choices to make. Other choices will also need to be made in such areas as basic health care, as mentioned earlier. When the times comes to make choices, it seems to me that the infrastructure and Canadian standards in place are not sufficiently flexible to meet individual needs and that a great deal of inefficiency results from administrative charges to two structures, one provincial and the other federal.
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For example, one province may invest more than another in research. In my view, research is a fundamental component of health care.
Other provinces could follow the lead of the large insurance companies which offer a variety of plans and options. People select the type of coverage they want based on the quality of life they seek and the price that they are willing to pay. In our Canadian system, this is impossible because all provinces are required to meet national standards.
Wouldn't you say that this structure is too rigid to allow for increased efficiency while operating with the same budgets? Wouldn't it be preferable for the federal government to assist those provinces that may not be able to afford basic health care for a few years, rather than impose strict, inflexible standards on everyone?
I'm not asking you to voice a political opinion. I'm asking you if the current system is perhaps responsible in some way for making health care less flexible or for making fewer options available to the public.
Mr. Ritchie: The simple answer, which is neither partisan nor provocative, is no.
The current system is not rigid because it is based on five fundamental principles. What is very clear from coast to coast is that Canadians, whether they hail from Alberta, Quebec or Prince Edward Island, share the fundamental values associated with these principles.
What is equally clear is that in Canada, under the current health care system, only provincial governments have the power to administer health care. With the exception of members of the Armed Forces, certain native groups and several services, the federal government is not involved in the administration of health care.
Therefore, the basic question that springs to mind is this: Do Quebeckers, Albertans and Ontarians share the same values insofar as health care is concerned and do they support the principles involved?
Poll after poll, election after election, people have demonstrated that regardless of the region of the country they come from, they share these principles and these values.
Mr. Laurin: As a human being, I cannot conceive of an Albertan, for example, being less sensitive than I, as a Quebecker, am to the health of people, no more than a Quebecker could be any more sensitive than a resident of Saskatchewan or British Columbia. As civilized human beings who have adopted a Charter of Rights and Freedoms, we all seem to agree that the welfare of people must be safeguarded. As a federal member of Parliament, I'm not any more of a health care advocate than I would be if I were only a member of the Quebec National Assembly. Being a federal, rather than provincial, member of Parliament does not make me a stronger advocate of public health care.
I believe that if we trust people's intelligence, sensitivity and humanitarianism, we will come to realize that everyone wants a decent minimum level of health care to be provided to the public. Why must it be the federal government that makes the decisions and imposes standards?
If a province experiences financial problems at a particular point in time and wishes to impose user fees, why shouldn't it be allowed to do so? Current federal standards preclude user fees.
To date, one province has been penalized and another is on the verge of suffering a similar fate for failing to comply with the wishes of the almighty federal government in Ottawa. I'm not convinced that we're not wasting money by failing to place enough trust in the provinces.
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The principle involved here to provide insurance, to have as many people as possible share the misfortune of a few. While this may apply to health care in North America, I'm not so sure that we all share the same priorities.
You answered no to my question, arguing that the same values hold throughout Canada. I agree that it is possible to uphold the same values without resorting to money or threats. Right now, the government's position is this: If Alberta does not do as Quebec does, or if Quebec does not do as New Brunswick does, then the province is acting behaving badly and won't get any more money.
I agree that some of the duplication is not desirable and that this money could be better used for research or for providing better health care services.
The Chair: Perhaps Dr. McLennan would care to answer your question.
[English]
Mr. McLennan: Thank you. I'd like to answer several of your questions this way. I think all of us in this room would probably agree that for the last 25 or 30 years we've looked at phase one of medical care - the universality and the accessibility - and implicit in there were the minimal national standards. I think we still need the minimal national standards. There's no debate there. Phase two, health reform, is what we're all in, accelerated of course by a severe fiscal problem. But health reform in phase two would have to happen anyway.
My comment on several of your questions is that the $7 billion savings - and this goes back to a question asked earlier - do not come from better mechanisms. The savings come from the research results from evaluative research. In phase two of health reform, we need to evaluate what we're doing, and the savings will come from evidence-based decisions. This is phase two: health reform in various stages across the country. Thank you.
The Chairman: Dr. Burr.
Mr. Burr: Mr. Burr, thank you. I think there's a -
The Chairman: You responded as if I'd insulted you. I'm sorry.
Some hon. members: Oh, oh!
Mr. Burr: I'll move to the point. I think the point with respect to national standards is crucial, particularly when we look at the five principles of the Canada Health Act. The principle of comprehensiveness as it is currently defined is, as we all know, narrowly focused on medically required services. If we look at the Canada Health Act and what's in the body, and if we look at the preamble of the Canada Health Act, what is accepted in Canada today, the way, as my colleague mentioned here, health reform is going, and what we want as a country in terms of standards for ourselves, maybe the new direction is the focus of standards on health status. Maybe there's a need to open our perspective here, still keeping a national focus on what we as a society are going to protect and insure right across the board. But we cannot be narrowly focused on medically required and institutional services and open the door and the freedom on the basis of evidence.
Let's look at what works and what doesn't work, let's look at the treatments that don't work, and let's look at the health prevention and promotion measures that do work and might save some money, and include the ones that do work right across the board and open the door for examining national standards on that basis.
[Translation]
The Chair: Is that all, Mr. Laurin.
Mr. Laurin: Yes.
Mr. Ritchie: Very briefly, your basic question is a constitutional one. As far as the health care system is concerned, I have to tell you that in all honesty, there is no proof whatsoever of any duplication that costs us more in the long run.
It's one thing to talk about other options or about organizing a system. However, as far as costs go, there is no indication that the present system is more costly.
The Chair: Thank you, Mr. Laurin.
Mr. Walker, please.
Mr. Laurin: I would have liked to hear from Ms Clemenhagen.
The Chair: Ms Clemenhagen, please.
Ms Clemenhagen: The temptation was too great when you asked us to refrain from being political!
How, as Canadians, have we come to be so proud of our health care system? How have we built this system together?
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I would answer that the system sprung from negotiations between the provinces and the federal government. These negotiations must continue in order to clarify national standards and greatly improve upon the principles that underlie the system and serve us very well. To do this, the provinces and the federal government must engage in non-partisan talks, the focus of which must be the needs of the public and the welfare of Canadians.
There is a political consideration underlying this issue. The impediment to this kind of positive dialogue between the provinces and the federal government is the fact that Ottawa has slashed transfer payments dramatically. Over the last decade, transfers have been reduced by $29 billion, creating an atmosphere hardly conducive to non-partisan, positive dialogue between the provinces and the federal government.
I think it's time for the federal government to resolve this dilemma by making a commitment to Canadians to maintain a stable, adequate level of transfer payments. Then, we will be able to hold discussions on clarifying the Health Act.
The Chair: Thank you. Mr. Walker.
[English]
Mr. Walker (Winnipeg North Centre): Thank you very much, Mr. Chairman.
I think the government has indicated, and this committee has indicated since the last budget, that we are very concerned about the cash component. I think neither the budget nor any statement from any minister indicated we're about to abandon the cash component. I think that part of the debate should be put to rest. I think it's simply not reading the documents in good faith when the people continue to insinuate that we're going to be out of this on a cash basis.
When we come to the health allocation, if I can just take off on the HEAL presentation, of so much per person per capita, one of the great frustrations from various federal governments in the last 18 years has been the function of EPF. I always ask people in less generous moments whether they could pull one letter of thank you from any file anywhere in Ottawa from a provincial government, and the answer is that nobody's been able to find one so far. So that's been a frustration, because it's a lot of money at stake. And people tend to forget the amount of tax given over to allow them the capacity to deliver these programs.
The strategy of the federal government has been in this halfway house for the last twenty years of saying, do whatever you want in these fields, fulfil some minimal conditions, and you have your money. Then the question becomes - we have a really important point here - how do we begin to transfer ourselves into this new structure? I guess I have a couple of difficult questions. If you want us to have a per capita allocation for health, is your suggestion now that we be able to track that $250? If you can't track it, how do we know that $250 has been spent?
Okay, start with that.
The Chairman: Mr. Tholl.
Mr. Tholl: I guess I've been around the business long enough to remember Madame Bégin's 1979 charge to your late-departed Justice Hall, in which there was also the allegation of diversion of federal funds and an attempt to try to track these dollars through the system. Justice Hall, after 18 months, basically came to the conclusion that you can't do that. Moreover, even if you were able to do it, the only thing that would matter is whether the provinces spent enough money to at least absorb the federal transfer in order for them to be in compliance with federal law.
No, I don't think we're making the point at all that the $250 ought to be earmarked and have ``health'' written on it and flow to the provinces. The point we've been trying to make is that the $250 is making a political statement in terms of priorities of this federal government. It's a statement about political accountability and transparency. That's what that's all about.
And your points are well taken about the cash. The Minister of Finance has been clear about flat-lining cash contributions, but he has not been clear about at what level, nor has he been clear about at what point in time. We are here before you today saying that you do not have the two years for Mr. Axworthy to finish his allocation exercise. You have until next spring, when the provincial ministries of health start to axe programs, because - to borrow Mr. Martin's words from last spring - once they're gone, you can't buy yourself back into confederation. Yes, he said he'll flat-line it, but he's not said at what level and, more importantly, he's not said when.
Mr. Walker: Never, because we've been moving onto your target. That's what we've said from day one on all aspects of the budget. We haven't gone beyond two years for anybody.
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Mr. Ritchie: But what we have been invited to do, I think, both in meetings with the ministers.... I think in fairness to everyone - yourselves last year - we were pushed on some specifics to concretize what we meant, and it's really in that spirit, not at all a provocative one -
Mr. Walker: No, I'm sorry, I don't mean to be provocative.
Mr. Ritchie: - of saying we think you're not being true to your word. But when people say, as the Minister of Health did, that Mr. Martin's going to deal with the structural aspect of CHST, I think in good faith you would want us to come forward with a proposal. That's how we ended up putting this proposal on the table, after a fair bit - more than a fair bit, actually, a lot - of in-house research.
The Chair: Is there someone else who wishes to respond to Mr. Walker? Carol Clemenhagen.
Ms Clemenhagen: Mr. Chairman, I think one of the things the health community has really appreciated is the work of this committee last year, and we're certainly looking forward to your deliberations this year, because we feel you have understood where we're coming from and what we're trying to put forward.
However, we've got this thing called the Canada health and social transfer, which is now this merged pot of funds that has managed to set health care, social services, and education against each other. It has not achieved the goals - sincere goals - that I think perhaps were intended for it. It's done just the opposite. It's created a great sense of uneasiness and conflict at the provincial level and possibly at the grassroots level.
Furthermore, we worry about the Department of Finance. The Department of Finance has not looked particularly favourably upon medicare or social programs over the year, and the Department of Finance maintains a very closed budget process. So we worry about the excellent work of this committee. How does it fit into the overall budget process? Maybe it does and maybe it doesn't. How can we help to make sure it does? Here at least we feel we've had a good series of discussions.
Mr. Walker: I don't ask you to give a final answer on this, but if we do a per capita on the health side, do we do a per capita on the post-secondary education side and on the CAP side? There are three components to it. The reason I raise that with you is that we chose this year to give out the form we call a historical pattern, and when we come into the new world, we've got to figure out whether we're doing this per capita. Are we doing this on a historical level or is there some notion of, however defined, need? Or we could just assume that the equalization act can be financed at a higher level with the capacity to answer the need question as compared to the per capita question.
I'm not by any means trying to be antagonistic. I'm just trying to find out what you're thinking, because it makes a phenomenal difference as to where some of the major provinces in this country end up. I think the work by the Caledon Institute, for example, has been very influential as to just how significantly different the distribution can be according to the premise you make on the per capita.
So I just raise that with you as a question. Any thoughts you have on that would help us out a lot.
Mr. Tholl: There are three points. One is that I've read some of the recent documents, including one called Looking for Mr. Good-Transfer, which you may have seen, in which the argument is made, I think with some merit, that at least for the income security portion of welfare programs, something that's not per capita based in terms of an ongoing escalator or index is probably warranted.
With respect to health, there are two points. One is to underline the point that was made earlier. The last time we appeared before this committee, the committee was interested, I thought, in the issue of Ontario fair share. So the $250 per capita, which is the current amount going to Ontario, is intended to redress, at least in part, the inequities and the post-CAP cap environment.
With respect to per capita as an indicator or a proxy for relative health status, this committee would maybe want to check back with the Department of Health, because there's been significant work done on whether there are other kinds of indicators that might work better than population as a proxy.
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Let me just sort of jump to the bottom line. That work that was done - it took at least a year to a year and a half - added everything in there, from the number of aboriginals in Saskatchewan, which would tend to increase Saskatchewan's draw on the entitlement, to Prince Edward Island in its age structure, and B.C., and so on. When you added all of those together in trying to adjust per capita amounts, statistically it was a wash.
So population is certainly an easy-to-measure, but not a bad, proxy for relative health status across the provinces.
Mr. Burr: To respond to your question on whether or not we're recommending a per capita transfer on the income security, social service, and post-secondary education side, I'm afraid that I'm not going to be very helpful beyond to say that we are not specifically recommending a per capita transfer in that area.
As Bill mentioned, we're aware of the difficulties in how that transfer is eventually set up in terms of equality or of fairness of distribution. Our call is simply that if we move on the health side then we're going for an equal, not necessarily per capita, move, but a cash move on the other side as well.
The Chair: Would any of the panellists, or witnesses, like to make a thirty-second summary?
Mr. Ritchie: To represent the motley crew, I want to stress what you've heard before.
We came here today with a real sense of optimism and a sense of hope - based on your track record, not on ours. We appreciate the audience you've given us. Particularly, the back and forth during the last hour has been really helpful to get to advancing the issue.
I want to stress that we, and most particularly our very excellent resource people, Alistair, Bill, and others, will be available to you and to your staff as you work on this. We know it's a thorny problem. We hope this makes a constructive contribution.
The Chair: Thank you, Dr. Ritchie, and this very unmotley crew.
Ms McCall, you probably want to have a word too.
Ms McCall: Today it is Mr. Ritchie. Thank you very much.
The Chair: I forgot to introduce Stephen Vail from the Canadian Nurses Association and Alistair Thompson from HEAL. I apologize to both of you.
I appreciate, as I think all members do, the fact that you came together and formed a group. We didn't get a whole bunch of diversified opinions. You've given us one issue to deal with. You have made the compromises and reconciled any differences that there might have been before you came to us. It facilitates our task greatly.
We also appreciate that you have stated that you respect our budget difficulties. We have to get our deficit and debt under control. You've said at the same time, in order to help us there, that you're not asking for anything new, and you will not.
You have also said - and I believe this is fundamental to all of you - that you need stability in funding so you can plan for the future. I've heard this from so many other people you represent today, who've said, ``Please give us some idea. We have to have five-year plans because we have to deal with human lives. They don't think from budget to budget. They plan their lives''.
You have talked about the need for a national strategy for and a national coordination of medical research. Canada has made incredible strides in medical research. We've seen the benefit from it, not just in terms of health care but also as one of the industries of the future.
I believe we have an obligation to work with you. I welcome the fact that you're prepared to work with us to see that developed, to see it coordinated on a national basis. That was a very good recommendation.
I understand and appreciate that you want a cash component to the CHST and that you want it split apart from the rest and guaranteed for health care alone, cut asunder from the portion devoted to post-secondary education and welfare. In my own mind, I'm not sure yet whether two threads woven together are stronger or whether threads used singly and in tandem are weaker.
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We now have about $22 billion in the pot, and perhaps more, which we can use as the lever directed to protect health care and the Canada Health Act as well as the others. That will be diminishing in years ahead. We know that. It will probably be a smaller pot. I'm just not sure that is the best way to achieve your goals.
I want to assure you that there is some feeling expressed here today, particularly by Ms Oulton, that our government's adoption of the CHST was perceived as a lack of commitment to the Canada Health Act. Surely anybody who might have thought that a while ago would have realized that our confrontation with the provinces this fall, when we made clear that we would not countenance any breach of the Canada Health Act and that we would pull back funds, indicates that we as a government are committed to this concept.
Let me also say that those of you who are here today represent and really are the heart of Canada's health delivery system, a system that I believe is probably the finest in the world. We thank you not only for your efforts here today but for being the heart and soul of this fantastic system. I can assure you that we will fight side by side with you to not only preserve it but hopefully to enhance it.
Thank you very much. The meeting is adjourned.