Why Medicare in Ontario?

MR. KENT: It has been announced that the Government of Ontario is studying plans for medical care for all its citizens and both the Liberal and New Democratic parties in Ontario are advocating the immediate adoption of a medicare scheme. Thus this subject has become an issue of great importance to all of us. We have not been told so far as 1 know all the advantages and disadvantages of such a scheme or how much it will cost. To learn more of this subject, we have invited our guest to address us today. He is Dr. Patrick Bruce-Lockhart of Sudbury, Ontario, the President of the Ontario Medical Association and he is eminently qualified to discuss this subject.

He graduated in Medicine from Edinburgh University in 1941, and after 4 years as a medical officer in the British Army, serving chiefly in India, he took further specialist training and became a member of the Royal College of Obstetricians and Gynaecologists. He practised under the National Health Service in Britain and then came to Canada in 1953 to accept an appointment in a clinic operated by the International Nickel Company. Since 1956, he has carried on his own private practise and is a consultant in Obstetrics and Gynaecology. He is the chief of this division in the Sudbury General Hospital.

He holds his present office because the members of the profession in Ontario recognize him as a leader and spokesman with the ability to present their views.

His surname in Scottish, his Christian name Irish and he was born in England. He has come from Great Britain to raise his family of two sons and a daughter in Canada. His subject is: "Why Medicare in Ontario?".

DR. BRUCE-LOCKHART: Medicare is the word now used to describe Government run health services insurance. To place this problem in perspective one should keep in mind certain things. Firstly the word is new, but the concept isn't. It began in Germany under Bismark in 1888, which is 74 years ago. There is thus a lot of experience and of history to draw on, and we would be foolish to ignore it.

Secondly voluntary prepaid medical insurance which was pioneered by doctors some 25 years ago in this province, has only developed extensively in the last 10 years, is now covering over 60% of the population, and is uniquely North American in both its breadth of coverage and extent of development.

Thirdly, we should understand that, at the present time, there are 3 groups of people who either cannot prepay, or pay for their medical care. These groups are: the frankly indigent; then a group of people who can lust pay their way, but haven't a sufficient margin of income beyond the bare necessities to pay for or prepay their medical care; finally people who because of age or illness are bad insurance risks, and thus cannot buy insurance even though they can afford it.

It is fair to say that these people all get medical care at present, partly through Government financing, partly through teaching hospitals and their out patients clinics, and partly through the profession treating them without charge. At this point I wish to make it clear that the Medical Profession is not asking for money for treating these people. It is the politicians and sociologists who raise the question. "Is it right that these people should be the objects of charity, or should the State pay for their medical care?"

Following on from this one should appreciate that these groups have not been forgotten and that progress is being made in dealing with them. Since 1935 the O.M.A. has run a Medical Welfare Plan under contract with Government, and this provides payment for medical services in Home and Office. It began with recipients of relief, but has gradually extended to include others, for example people on disability, on old age assistance, on Mothers allowance. It now covers over 220,000 people. Early this year the Association approached the Government regarding the possibility of extending this plan to the 2nd group I spoke of, with marginal incomes. The Government was not unsympathetic, and at present is looking into the problem of defining this group. Lastly the Canadian Health Insurance Association has developed a plan which they presented to the Royal Commission on Health Services, outlining a mechanism of pooling the high risk group between all the companies which could enable this group to buy insurance at a reasonable premium. The doctor sponsored service plans have tackled the same problem another way, by making first some towns, and now a whole county, into a group and allowing everyone to buy insurance.

Fourthly one should realise that there are other problems beyond that of paying medical bills, which require Government resources. Most people do not realise it but there is an equal amount of mental illness as there is physical illness. The modern concept is to treat the mentally ill in their community hospital near their families. Tremendous reorganization and new facilities are required if we are not to lag far behind the times in this area. There is a shortage of hospital beds-particularly in Toronto; of medical schools -we are dependent on the immigration of doctors to keep up with our population growth; of training schools for all types of para-medical personnel such as physiotherapists, laboratory and x-ray technicians and so on. Community centres for rehabilitation are required. All these things need attention and money, and in the profession's view should have considerable priority.

If we now look at the problem of Medicare, keeping these things in mind there arises one fundamental question. "Is it better for everyone that Government should control and administer any plan, or merely assist and inspect?" You will notice that I phased the question "Is it better for everyone?" Surely this is what we should be talking about and not just "What the Public wants" nor "What is easiest administratively", and certainly not "What will bring the most votes." If you look at history and at the experience of those countries in which Government has taken over the control and administration of medical care, you will find 3 problems arise. The first and major one is that costs immediately rise beyond expectations and just have to be controlled. Secondly there is a tendency, often not apparent for many years, for medical research to slow down. Thirdly, in time the status of the profession falls, and later the quality of person becoming a doctor deteriorates.

The first point is incontrovertible. The reason for the rise in costs is a simple one. Human nature being what it is, as soon as personal responsibility is replaced by State responsibility, the individual changes his attitude. Waste and abuse no longer concern him as much as getting his rights and entitlement, and his money's worth.

Thus in medical matters the utilization of services jumps, and the citizen considers only his own wants in this regard and no longer merely his needs. You would think that there would be a natural limit to this but the evidence is to the contrary, and some figures are staggering. For instance, in Germany in 1928, 40 years after the start, one out of every two insured took 24 days sick leave a year.

Now obviously this sort of thing is intolerable, no Government has unlimited funds and so controls are instituted. A bureaucracy develops, which is an additional expense, and tries by regulations to control wants and yet supply needs. This means an assessment by someone at the centre, and his only possible yardstick is averages. Averaging produces a mediocrity of care geared to the mass and not to the individual.

Another way to control costs, as has been done in Britain, is to limit facilities and doctors. Less hospital beds means long waiting lists but reduces costs. Overcrowded doctors offices is also a deterrent to ones use. Some countries have said "Cut costs by controlling doctors earnings." But history shows that this is only a stop gap measure. So long as patient utilization of services rises uncontrolledly the cost very quickly soars past saving. Further the doctors resent it and lose their traditional interest. It should perhaps be pointed out that in Austria, Italy, and Germany there have been token doctors strikes within the past year.

In its struggle to keep down costs Governments naturally find less money available for research, and this has to be controlled. Now research thrives on freedom and initiative. It is noteworthy that today the best research work in medicine is coming out of North America; that Germany at the time of the start of Government health insurance was the leading medical centre in the world, and that from the point of view of research Germany had become a nonentity before Hitler and the last world war.

The problem of a deterioration in the quality of the individual who becomes a doctor is hard to assess objectively, and because it can only be an assessment any resultant opinion can be challenged. However I personally think it is likely very real, and would draw your attention to two facts, which are food for thought.

The first is that a British committee studied medical manpower problems some six years ago, and recommended a slight decrease in the intake of students to medical schools, as in their opinion there would be a surplus of doctors. Today there is a definite and fairly serious shortage, and the mistake the committee made was in underestimating badly the number of doctors who would leave the country.

The second one is that something over 80 doctors have left Saskatchewan over the recent crisis there. If we would put this in perspective we should realise that this is equivalent to 900 doctors leaving Ontario.

So far I have talked about the problems raised by Government control and administration. It should be appreciated however that some countries have tackled the problem differently, and realistically. In Switzerland and in Australia the Governments assist individuals who buy insurance from multiple approved carriers, by paying the insurance carrier a benefit for each service the patient gets from a doctor. This is about equivalent to 40 % of the fee schedule, and enables the patient to insure himself for only the remaining 50%. Both Governments audit the books, and pay larger benefits for those who can show their need. In both the patient has to pay something out of his pocket for each service received. Thus the Government's liability is limited, the patient's responsibility is maintained and costs have stayed within reason. Further the Australian Bureaucracy for the whole plan is some 40 people, in contrast to Britain where administration outnumbers the doctors. Both the Swiss and Australian doctors are of top quality, have high status, and considering their numbers provide good research work. Sweden has gone halfway. That country where the welfare state has developed to an extent which is as yet quite undreamed of in our philosophy, requires the patient to pay 25 % of doctors bills out of pocket, up to a certain maximum and excluding the very low income group, and also to pay something for each day in hospital. I think it would be worth quoting a comment on the importance of patient responsibility by Sir Ronald Grieve, Chairman of the Medical Benefits Fund of Australia in 1961. "With some knowledge of Government I would state advisedly that any Government that would disregard this axiom will be drowned, in a budgetary sense, by a flood of its own creation."

I have made a few comments from history on some aspects of the fundamental question "Is it better for everyone that Government should control and administer any plan, or merely assist and inspect." I would suggest that it is worth your while to think on these things.

The Ontario Medical Association's view is simple. We believe that the essential thing in medical care is to treat the individual as an individual because he is different from every other human being. Different in his reaction to his environment, to management, to being ill, to a particular disease and to drugs.

We believe that the public wants personal attention from a freely chosen individual physician. We believe that Government administration and central planning which must deal with averages and with the mass and not the individual, will harm individual medical care and lower its standard. We are afraid of medical needs competing at the Treasury and political level with roads, education and so on, and political expediency not medical needs deciding the issue.

Lastly if Government becomes the sole purchaser of the profession's services, history has taught us that this is ultimately complete control. We look on this as conscription, and like any other group of citizens would bitterly resent it. We have no objection to anyone working for Government by choice, but do not think it right for anyone to be compelled to work for one employer or else leave the country.

Now I am sure some of you will be saying "but this is state medicine he is talking about. Medicare is different it is merely Government insurance. The doctors believe in Health Insurance-What is wrong with Government run insurance? It will be just like P.S.I. or any other good insurance plan, only better because it will also cover those groups not covered at present. What difference will it make to the doctors?" The point here is simply that because it is called insurance the public thinks of Medicare in these terms. The doctors however consider it just the same as State run medicine. It is true that we strongly support medical insurance, and as I have said pioneered it through our doctor sponsored plans. But if in "Medicare" we are talking about insurance, then why have the State run it. Why not have the experienced, efficient insurance companies and non-profit agencies run it, have them kept efficient by competition, with the Government supplying financial benefits through these agencies, and very properly auditing their books to see that all is above board. Incidentally, in Australia doctors, patients and all political parties are happy with the scheme. But no one mentions it here. What is suggested and what has developed in Saskatchewan, is an insurance plan run by a Commission.

You of course all know that a commission is a Government agency set up under an Act of Parliament, with the power to make regulations under the Act, subject only to the approval of the Lieutenant Governor in Council, which means the Cabinet. These regulations have the power of law, do not go to the Legislature, and the commission's decisions cannot be appealed to the Courts.

The Ontario Hospital Services Commission is an example of this. It runs a hospital insurance plan-but it is not just insurance as Blue Cross was. You should understand that the hospitals are quite free to work outside the Act. They do not have to accept the Commission's rulings, but no one else is allowed to insure patients for hospitalization, and the commission will only pay the hospitals if they follow the regulations. Thus, in fact, the commission controls the hospital budgets, the salaries it may pay its employees, the detail even of the amount of money they may spend per day per patient on food and the number of beds it may put up. The commission has to approve the By-laws for the medical staffs, and takes the money the hospital earns from its outpatients services (which are not insured services under the Act) by paying them that amount less for their in-patient expenses. Now, is this what you understand by an insurance plan like P.S.I. or Blue Cross? We in the profession do not think so and this is why the doctors consider that medical insurance run by a commission is just State medicine, under a more tactful name. Thus the problems of cost and controls and administration are the same.

The planners would not agree with this view. I use this word for a mixed group of economists, sociologists, experts of various types, and general minders of everyone else's business who, somehow, always seem to get into the act. Those planners survey the whole field, or the one facet of it that comes into their view, see clearly one or more deficiencies and say essentially, "If I controlled this I would cure these problems easily-the thing only needs planning", further, "Organization produces efficiency, eliminates duplication and waste and ensures that everyone gets everything he needs." Now these statements may be true when dealing with things, but when dealing with people they assume that the expert or planner knows what individuals need, better than they do themselves.

I believe that very few people outside the profession realize the complexity of the issues, or realize the fact that medical care and practice often changes profoundly, rapidly and always unpredictably. The change is unpredictable because the direction of advance of medical knowledge and new discoveries cannot be foretold. Thus there is tremendous danger in the well intentioned planners solving some problems by organization, only to create quite unwittingly a dozen new ones. I hear it increasingly said "Well if it is all so difficult why don't the doctors, who should be the ones' to know, why don't they come up with a plan?"

Gentlemen, this is a very fair question, everyone likes the positive approach, but you know the trouble is that at this point you come so easily to discussing the merits of various plans, which in a sense is what I have been doing today. Then everyone assumes that there should be a plan. What if you genuinely believe that medical care, and by that I mean personal medical services rendered by a physicianis better when it is not planned or organized, or controlled except (a) by the natural forces of the market place, which here is the demands of the individual patient, his personal contract with his chosen physician, and his free choice of a variety of insurance plans, (b) by the supervision of the medical authorities under Act of Parliament, and of the Government, each in their proper sphere?

I would suggest to you most strongly that we have here at present a very high standard of medical care second to none; that this is the result of an evolutionary process whose corner stone is simply "Does it meet the test of dealing in the best possible way with the individual patient's needs"; that this process produces steady sure progress; and finally that before one meddles with it one should be very sure that one is not harming it.

Government, and every citizen can assist the process, and has so done, and should continue to do so, but gentlemen, I would suggest to you that history shows that trying to control, or run, or centrally plan medical care can and usually does harm it.

THANKS OF THE MEETING were expressed by Dr. Harold V. Cranfield.