Understanding Health Care Reform: Bridging the Gap Between Myth and Reality

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Feldman is a renowned cardiovascular researcher who has led many clinical trials, and his work on the molecular biology of heart failure has been published in more than peer-reviewed articles. He is the current and founding editor-in-chief of Clinical and Translational Science. His lab was the first to recognize the role of G proteins, pro-inflammatory cytokines and vasopressin receptors in the development of the heart failure phenotype.

Feldman has translated his basic science work to the clinical arena, chairing the steering committees of numerous multi-center clinical trials. He was a co-founder and member of the Board of Directors of Cardiokine, Inc.

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Skip to main content. Home News. We wish to extend our appreciation for their efficiency and hard work. During this period, the Committee has heard the views of over witnesses. As one would expect, given the complex, ideological and political nature of health care issues, the advice we received was often conflicting. Nevertheless, the Committee considered seriously the views of all the witnesses in arriving at our recommendations.

The recommendations in this report reflect the unanimous view of the eleven Senators on the Committee seven Liberals, three Progressive Conservatives, and one Independent. The experience of the eleven Committee members in public policy and health-related issues is as deep as it is varied. The Committee includes:. The Committee believes that its recommendations meet the four objectives the Committee set for itself at the outset of its work:. For its report to be truly useful, the Committee felt it could not be vague on the question of precisely how its recommendations would be funded;.

The Committee believes it has worked out a detailed, concrete and realistic plan which, if implemented integrally, would lead to the strengthening of the publicly funded health care system in Canada and help guarantee its sustainability for the foreseeable future. It looks forward to pursuing its work in this direction, along with all those who share this objective. For the past two years the Standing Senate Committee on Social Affairs, Science and Technology has been studying the state of the Canadian health care system and the federal role in that system.

The Committee has sat for over hours and held 76 meetings. Most of these meetings were public sessions during which the Committee heard from over witnesses, many of whom represented organizations that have thousands of members such as the Canadian Medical Association and the Canadian Nurses Association. To date the Committee has published five reports.

These recommendations flow from the principles enunciate in Volume Five. The major topics covered in the five previous reports, as well as the subjects to be treated in future reports, are summarized in the following table:. As the table indicates, following the release of this report, the Committee intends to examine a number of additional health-related issues. The Committee will be releasing a report on this issue, and readers of this volume are strongly encouraged to read that report as well. To formulate realistic recommendations to improve the provision of health care services to Canadians, it is necessary first to have a clear view of the health care system now and an assessment of its strengths and weaknesses.

The Committee believes that an ongoing evaluation of the health care system is essential, conducted in as objective a fashion as possible. In this chapter the Committee presents its recommendations for the creation of a new National Health Care Council chaired by a Health Care Commissioner charged with carrying out this task by producing an annual report on the state of the health care system and the health status of Canadians.

These summarize the basic approach that the Committee has adopted in the course of its multi-volume study, as well as the objectives it has sought to achieve in developing its recommendations. The Committee identified the various roles of the federal government in health and health care; Volume Four set out these roles, together with a set of policy objectives for each. As the Committee makes clear in the present volume, making changes in the way the health care system is structured and operates will require spending more money - money that must be raised primarily by the federal government;.

The principle of accountability to the taxpayers requires the federal government to have a say in how that money is spent. Finally, it is very clear to the Committee that Canadians want the provinces, the territories and the federal government to work collaboratively in partnership to facilitate health care renewal. Canadians are impatient with blame-laying; they want intergovernmental coop eration and positive results.

The Committee has pointed out that federal policy in health care flows from two overarching objectives — objectives that the Committee strongly supports as the primary goals to be pursued by the federal government in the field of health care. These two objectives are:. Implicit in these two objectives, particularly the first, is the requirement that the medically necessary services provided under Medicare be of high quality. With respect to the pre-eminent piece of federal legislation in health care, the Canada Health Act , the Committee has repeatedly expressed its unqualified support for the four patient-oriented principles in the Canada Health Act.

The Committee has also endorsed the intent of the fifth principle of the CHA , although it is of a different character:. The public administration principle refers to the funding of hospital and doctor services, not to the delivery of those services. The misunderstanding of the principle of public administration has arisen out of the confusion between publicly funded and administered health insurance and the actual delivery of health care services themselves. Under the Canada Health Act , services do not have to be delivered by public agencies.

Indeed, in Canada today the great majority of health care services are delivered by a variety of private providers and institutions. The Committee reaffirms its commitment to the principle that every Canadian should be guaranteed access to medically necessary services by a publicly funded and administered insurance program, everywhere in Canada.

This has been the essence of Canadian health care policy for over 30 years, and is clearly reflected in the Canada Health Act. Canadians pay taxes to their governments, which then use the money in part to fund a universal insurance plan that provides to all Canadians first-dollar coverage for medically necessary services delivered by hospitals and doctors.

These services must be accessible, comprehensive, and portable among provinces and territories. Two constraints must be taken into account in assessing fiscal sustainability. The first is the willingness of taxpayers to pay consent of the governed. The second is the need, for economic development purposes, for governments to keep tax rates competitive with those in other OECD countries, and particularly with the United States. If this ratio becomes too large it may indicate that spending on health care is crowding out other necessary government spending. The Committee recognizes that sustainability can also be considered in terms of the total share of the Gross Domestic Product GDP that is devoted to health care, whether paid through the public purse or privately.

However, what that share should be is impossible to say without thorough analysis of the benefits Canadians derive from health care. Regardless of how it is expressed as a share of GDP, share of government spending, etc. The Committee believes strongly that Canada should continue to adhere to this most efficient and effective model of universal health care insurance, and it is clear to the Committee that Canadians believe this too.

Therefore, in formulating its recommendations, the Committee has not concentrated on measures of funding related to GDP. Instead, it has sought to assess how much public spending is necessary to sustain Medicare and, in particular, how much is needed to accomplish the changes that are essential if this highly popular and largely publicly funded program is to meet the needs of Canadians into the twenty-first century.

The lack of sustainability is already manifest in the fact that the system does not currently have sufficient resources to respond to all the demands that are placed upon it. In particular, timely access to quality health services is increasingly not the norm. Nonetheless, the widespread perception of deterioration in the quality of service available to Canadians highlights the fact that Canadians must decide what future course of action they want their governments to take.

The Committee stressed that there are three basic options from which the Canadian public must choose:. As will be evident in the remainder of this report, the Committee fervently hopes that Canadians will agree with the Committee that the second option is the most desirable choice. Having unanimously reached this conclusion, the Committee has departed from usual practice in parliamentary committee reports by specifying in some detail how much additional public money is required to ensure the long-term fiscal sustainability of the health care system, recommending where this new money should be spent, and recommending how the increased government revenue could be raised.

Understanding Health Care Reform: Bridging the Gap Between Myth and Reality - CRC Press Book

The Committee also stresses, however, that unless changes are made to the structure and functioning of the system, no amount of new money will make the current system sustainable over the long term. In general, the principle that the Committee has followed in working out its vision for reform of the system has been that incentives for all participants must be introduced in the publicly funded hospital and doctor system — providers, institutions, governments and patients — to deliver, manage and use health care more efficiently and effectively.

This recommendation, described in detail in Chapter Six, is designed to address the problem of growing waiting times for access to health services by requiring governments to meet reasonable standards, by ensuring patients have access to services in their own jurisdiction, elsewhere in Canada or, if necessary, in another country.

Meeting reasonable patient service standards is an essential part of the health care contract between Canadians and their governments. In presenting its proposals, the Committee also believes that it was important to acknowledge that its preferred option for raising new money, and its plan on how to spend it, including implementing the health care guarantee, are not the only options available.

If, after public discussion, governments decide that they are not willing to pay more to fund hospital and doctor services, or if the insurer government decides not to implement the health care guarantee, then the result would be the continued and probably increased rationing of services and lengthening of waiting times. Moreover, as the Committee points out in Chapter Five below, allowing waiting times to grow longer - that is, failing to implement the health care guarantee - could have significant additional consequences.

Such failure is highly likely to lead to the Supreme Court issuing a judgment that since timely access to needed medical service is not being provided in the publicly funded system, then government can no longer deny Canadians the right to purchase private insurance to cover the cost of paying for the provision of service elsewhere, i. Thus, failing to implement the health care guarantee is likely to move the Canadian health care system in the direction of introducing a second private tier of services available only to those who can afford to pay for them out-of-pocket or through supplementary private health care insurance.

When this possibility was raised in previous reports, some commentators felt that the Committee was in fact advocating greater privatization of the health care system. As this volume should make abundantly clear, that is not the case. The Committee has worked out a detailed, concrete and realistic plan that, if implemented integrally, will lead to strengthening the publicly funded health care system in Canada and guarantee its sustainability for the foreseeable future.

However, this option costs money, and the great majority of Canadians would be required to contribute additionally in taxes in order to implement the proposed plan. In the event that governments are unwilling to raise increased revenue to invest in the publicly funded health care system, it is essential that Canadians fully understand the implications of such a decision. One such implication is likely to be not only the continued deterioration of the system, but also judgments by the courts that hasten the development of a parallel private system of health care in Canada. The question of governance which is to say leadership brings together a number of issues that the Committee has raised in previous volumes and that witnesses have addressed from a number of perspectives.

One thing is very clear. Canadians are tired of the endless finger-pointing and blame-shifting that have been recurring features of intergovernmental relations in the health care field. Fundamentally the underlying issue is one of accountability. In order to establish who is to be held accountable for the deficiencies and also the strengths of the health care system, the Committee has repeatedly pointed out that detailed and reliable information on the performance of the system and on health outcomes is essential. This is why the Committee has placed such importance on the development of a capacity for health information management, on putting in place a national system of electronic patient records [8] and on sustaining and expanding the health research infrastructure.

Information must be analyzed and interpreted objectively if it is to serve as a reliable guide to evidence-based decision-making. In Volume Five, the Committee identified four fundamental elements that are necessary to create the capacity to evaluate fully and fairly the performance of the health care system and the health status of the Canadian population, as well as to hold the appropriate parties accountable:. No body that reports exclusively to, or was created exclusively by, one level or the other would have the necessary credibility. The Committee makes specific recommendations with regard to these organizations in Chapter Ten.

The Committee believes, however, that, on their own, existing organizations are not enough.

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The Committee also believes that this body should be responsible for advising the federal government, on an annual basis, on how new money raised for renewing and reforming the health care system should be allocated. Such a body must have sufficient resources at its disposal, and work with CIHI and CCHSA and possibly others , to collect and assess the data and information it requires. The CMA has proposed a two-pronged approach. This Charter would set the parameters for better national planning and coordination, particularly with respect to reviewing core health care services; developing national benchmarks for the timeliness and quality of health care; determining resource needs, including health human resources and information technology; and establishing national goals and targets to improve the health of Canadians.

The commission proposed by the CMA would be chaired by a Canadian Health Commissioner, who would be an officer of Parliament similar to the Auditor General appointed for a five-year term by consensus among the federal, provincial and territorial governments. Its deliberations would be made public, and its composition would not be constituency-based but would reflect a broad range of perspectives and expertise. In a paper prepared for the Romanow Commission, [13] Professors Colleen Flood and Sujit Choudry of the University of Toronto argue that there is a real need for a non-partisan national body, protected from day-to-day politics, with a longer-term view than is possible for an elected government.

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They propose the creation of a Medicare Commission that would be an expert, independent body, appointed jointly by provincial and federal governments, but funded by the federal government. Funding for the commission would be separate from federal transfers for health care.

It would consist of new federal money, a consolidation of all one-off payment initiatives in the health care area currently undertaken by the federal government for example, in primary care and other areas. One possible method Flood and Choudry describe for composing the commission is for each province to appoint 1 commissioner and the federal government to appoint 5, for a total of 15 full-time commissioners, who would then select a chief commissioner from among themselves.

All decisions would require a two-thirds majority, meaning that federal commissioners would require support from a majority of provincial commissioners for any decision. Tom Kent was a senior federal public servant at the time Medicare was created, and is often referred to as a father of Medicare. Her has suggested that Ottawa and the provinces appoint, by consensus, an advisory council with a wide range of expertise.

Bridging Gap

Rather, the council is conceived as a collaborative mechanism that would be a bridge between the two levels of government, thereby bringing political reality into harmony with the way most Canadians already see Medicare, namely, as a joint responsibility within our federal system. It would employ an executive director and staff, who would be neither federal nor provincial officials.

It would report to a joint committee of health ministers, for which it would conduct investigations and make recommendations over the whole range of medicare principles and practices. The proposed council would provide a focus for collaboration that would facilitate innovation and efficiencies, as well as provide a forum for broader consultation on health policy. Administratively, it could be used to supervise the implementation of agreements on such matters as electronic health records, health care information, a national drug formulary, bulk purchasing, facility sharing, etc. Importantly, Kent argues that the agency could foster public accountability by preparing regular reports for the ministerial committee to issue.

Its functions might include:.

This Council would be part of a network of bodies that would contribute to improving the governance of the health care system. This Council was a permanent body where deputies and ministers liaised with a number of health commissions at both the federal and provincial levels. It had a permanent secretariat staffed by highly skilled people who related to full-time public servants in provincial health departments. This arrangement enabled greater continuity in policy making and more coordination of federal-provincial relationships than is possible today.

To legitimate such reports with all levels of government, and yet to ensure their independent production and thereby their credibility with the Canadian public, the Committee recommends that the following structures and procedures be put in place. It would also select the members of a National Health Care Council that the Commissioner would chair from among those nominated by the Commissioner. In making nominations to the Council, the Commissioner would have the responsibility of ensuring that the membership of the Council is balanced, and that the public at large is represented.

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Councillors should be appointed on the basis of their ability to take a global view of the health care system, and not as representatives of specific health care constituencies. The Commissioner should be appointed for a five-year term, with the possibility of a single renewal. Council members should be appointed for three-year terms, with the possibility of a single renewal. Half the council would be up for renewal every three years. Eight is a reasonable number of councillors, a total of nine including the Commissioner. They should be adequately compensated for their work with the Council, but would not be full-time employees.