Health Care: We Can’t Go On Like This. Is There a Way out of our Health-Care Dilemma?

Head Table Guests

Ann Curran, Partner, Lewis Companies Inc. and a Director, The Empire Club of Canada; Reverend Christopher King, Rector, Little Trinity Anglican Church; Gavin Hefferman, OAC Student, Forest Hill Collegiate Institute; Dr. John Bonn, Registrar, College of Physicians and Surgeons; Dr. Lesia Wynnychuk, Board Member, Canadian Medical Association and Board Member, Ontario Medical Association; David Pattenden, CEO, Ontario Medical Association; John Dunton, Regional Manager, South Western Ontario, MD Management; Julie Hannaford, Partner, Borden & Elliot, Chair, Bloorview Children's Hospital Foundation and a Past President, The Empire Club of Canada; David MacKinnon, President, Ontario Hospital Association; Carol Jacobson, Chair, Ontario Health Providers Alliance; and Catherine Steele, Vice-President (Toronto) and Partner, Gervais Gagnon Covington & Associates and a Director, The Empire Club of Canada.

Introduction by George L. Cooke

It is my pleasure to introduce as our guest speaker today, Dr. William Orovan, President of the Ontario Medical Association.

The Ontario Medical Association represents the political, clinical and economic interests of the province's medical profession--about 24,000 doctors--which is almost half of the number of doctors in Canada. The Association was founded in 1880 and has played a vital role in the development and promotion of health-care services across Ontario.

As well as his position as President of the OMA, Dr. Orovan has served in many key roles which include Clinical Professor of Surgery at McMaster University; at St. Joseph's Hospital in Hamilton, Senior Consultant of Medical Affairs, Chief of Staff, and Chief, Department of Surgery; at the Hamilton Regional Cancer Centre, Senior Consultant and Chief, Urological Oncology.

Dr. Orovan completed his M.D. at McMaster University in 1975 and continued there with his residency training. He has received several awards including Recognition Award for Outstanding Contribution to the Community from Hamilton and District Chamber of Commerce, Excellence in Quality Management of Medical Care Award from The College of Physicians and Surgeons of Ontario, and Distinguished Services Award from the Hamilton Academy of Medicine.

Health-care issues are current, relevant and important. Canada is likely fast approaching critical decisions as to how quality health care will be maintained. Our speaker today will almost certainly be a significant participant.

Dr. Orovan, welcome to The Empire Club of Canada.

Bill Orovan

I want to thank the Empire Club for this opportunity to talk about what is clearly the most troublesome issue on the minds of Canadians today--their health-care system. While issues such as the dollar, economic confidence, job creation, education and a host of other important concerns register on Canadian public opinion with varying intensity, very few have as much resonance as health care; virtually none as much relevance to people's lives.

I'm sure you will agree, that not since health care was put on the national agenda by Tommy Douglas some 35 years ago have we, as Canadians and care givers, seen such extensive and rapid change to our health-care system as we have in the past few years. And, I'd suggest that because of this there has never been as much anxiety about the future of our health-care system as there is today. What we see, read and hear today is a cacophony of voices, more often about chaos than confidence, more often about crisis rather than competence. What we are more likely to witness is pointing fingers rather than helping hands, and rhetoric as opposed to solid debate. As a result, many Canadians feel the health-care system has become unanchored, that it has lost its compass. And most important, we feel it has lost its vision as to where we go, about what we should do next, and we worry about the leadership that is necessary to get us there.

I do not intend to be one who adds but another discordant voice to the many. And I can tell you that as president of the largest provincial medical group in Canada, our doctors do not intend to do so either. I am here to tell you it is time to change the channel instead of merely turning up the volume. I say this because we're now at a critical juncture where each and every stakeholder must join this debate or risk the loss of something that we as Canadians perceive as fundamental to not only our well-being, but also our own being. What ails the health-care system today is a lack of leadership. What ails the debate is a lack of partnership. And what ails the confidence that Canadians have in their health-care system is a lack of certainty.

• A lack of certainty in what the health-care transformation will mean to them for the future.

• A lack of certainty regarding such fundamental principles as accessibility to quality care.

• And a lack of certainty as to the kind of health-care system that will be there for them when they need it.

I am here to tell you today, on behalf of my constituency what we intend to do to get this issue moving forward. The Ontario Medical Association and our national partner, the Canadian Medical Association, as well as the Ontario Hospital Association have spoken out in the past about these issues. We have acknowledged the need to shape the evolving debate on finding innovative solutions to our health-care dilemma. But this clearly hasn't been enough. We are now at a critical juncture and as the title of my remarks indicate: "We simply cannot carry on like this."

I personally experience the difficulties of our system every day as a practicing surgeon who has to make crucial decisions about patient care. I, my colleagues and our patients know firsthand why the latest Angus Reid poll confirms the number-one issue in the country today is health care.

There is no one cause for this crisis in health care. We have all been part of the problem. Governments tend to deal with the health crisis of the day. As stakeholders, we have tended to look at the immediate needs of our own worlds. My profession itself isn't blameless in this regard. The challenge now is for all of us to be part of the solution. But in order to do so, we must challenge some fundamental assumptions that we share, and find a common platform for focused discussion.

To begin with, discussion among Canadians about health care is based on the widely held belief that we have the best health-care system in the world. But what if that is not true anymore? As a matter of fact, I believe it is not true anymore.

Ask the people who were being driven around Toronto recently in ambulances looking for an emergency room with an empty bed. Ask them whether we have the best system in the world.

Ask patients who have waited six months, 12 months, 18 months for a new hip. Ask them if we have the best health-care system in the world.

For those who must wait anxiously for brain surgery, psychiatric care, dialysis treatment, or heart treatment, for those who are put on a three-month waiting list for an MRI scan when they could drive to Buffalo with VISA card in hand and have it in a day. Ask them if we have the best health-care system in the world.

Is it acceptable that elderly patients may wait one or even two years for cataract surgery? Is it acceptable that women with breast cancer can wait 13 weeks or more for access to definitive treatment? Ask them if we have the best health-care system in the world.

Yet, despite these harsh realities we remain the envy of many world communities, some of whom have taken the best parts of our system and adapted many of our practices to their own circumstances, making it better and easier for people in their countries to get the treatment they need. To many of those governments, health-care delivery is an evolutionary process of continually adapting to new circumstances and integrating new medical and structural innovations.

In fact today as I speak there are debates taking place on health-care reform, how to do it better, and how to find new and innovative solutions to existing circumstances in many other countries including Germany, France, Britain, Holland and Sweden. And so we would not be alone in having a nation embroiled in a discussion about health care. It is critical that now we, as a nation, have the courage to put aside our vested interests and prepare for some very tough choices that will be inevitable in the near future.

I say that the time has come when we are compelled to confront this issue and get on with the job of solving rather than dwelling on our problems. We must begin somewhere. And that somewhere is, in my view, with one of the greatest hindrances to finding solutions or in even having a rational debate about our health-care system. That somewhere is the Canada Health Act.

If there is to be a common, national platform where we can begin anew, it must begin here. We've had this Canada Health Act since 1984. It enshrines the principles of today's medicare system. Since that time, not once, not once has it been openly re-examined to see whether the legislation still applies to today's changed realities in health care.

These are the realities: We are in an underfunding crisis. We suffer from a crisis of confidence among the very people who need the system. A system governed by an outmoded Canada Health Act.

Compared to 15 years ago we are working with very different medical approaches, very different health-care delivery systems, and very different demands.

Fifteen years ago CAT scans were in their infancy; magnetic resonance imaging machines and advanced ultrasound didn't exist.

Fifteen years ago we didn't have the sophisticated and very expensive drugs we now have for cardiac care and other uses.

Fifteen years ago we didn't have extensive screening and prevention programmes such as routine mammography, cholesterol testing, screening for prostate cancer, and, of course, the ever-expanding world of genetic research.

It is a fact that changes to our health-care system have moved beyond the increasingly narrow framework of the Canada Health Act.

Patient needs have also grown and changed dramatically since the introduction of the Canada Health Act. An aging population means a greater impact of certain diseases like heart disease and stroke, hypertension and chronic conditions such as diabetes, Alzheimer's and others where new and very different treatments are required.

While some governments can say they are spending more on health care, now, more than ever, it is apparent that they are not keeping pace with these new and escalating demands placed on the medical system. And these demands are about to increase dramatically.

We have an aging population that is bearing down on us, the baby boomers, who will make our current problems pale in comparison. The reality is that there are more people over the age of 60 than under the age of fifteen in this country right now.

The latest projections show that the 65-and-over age group will triple again over the next 30 years. By the year 2030, persons aged 65 and older will represent 23 per cent of the entire Canadian population.

In the province of Ontario, we add 2,000 additional seniors to the health-care system every month. We know that patients in their seventies need four times as many dollars for health care annually than do those in their thirties.

Clearly, the demographics of today are dramatically different from the demographics of 1984 when the Canada Health Act was proclaimed. So we know, without any fancy modelling forecasts, that the per-capita spending that we have right now will simply not do once the baby boomers reach their sixties and seventies. This reality raises a question: Is the Canada Health Act constructed in such a way that it can help respond to and resolve these current and impending issues? Does it allow us to keep pace with changes in health-care delivery? The concise answer is no.

Few recall now that the original impetus behind the Canada Health Act was less about health and more about money. Its principal objectives were to ban extra-billing, user charges and set uniform standards across the country. At the same time, it irrevocably linked provincial delivery of health care to federal government transfer payments. But then Ottawa's money started to run out, provincial needs began to change and patients got caught in the middle with longer waiting times and decreased access to care.

The inherent difficulty is that the Canada Health Act places obligations and requirements on provincial providers but does not require the federal government to provide adequate funding to meet these obligations. As an example, we've had $7.5 billion extracted by the federal government from national health-care funding over the past three years. And about three billion of that, at least, should have been destined for Ontario. That's why today, the federal cash payment for health-care delivery in Ontario is 9 per cent, or nine cents on the dollar, compared to 50 cents on the dollar in the mid 1960s when medicare was first introduced.

By severely restricting the nature of health-care delivery by the provinces and using the hammer of reduced federal transfer payments, the Canada Health Act directly and indirectly has been a barrier to the quality of health care that we, as doctors, can deliver to our patients. The Canada Health Act has stifled innovation, experimentation, and flexibility in creating both better alternate delivery methods and funding options.

In the process of its development, the Canada Health Act formalised a whole new vocabulary about health care in Canada: the five principles of the Act. You know them very well: universality; accessibility; portability; comprehensiveness; and public administration.

But what about quality? Quality is not one of the principles of the Canada Health Act. Yet quality is at the very core of what we, as physicians or any other health-care provider, practice each and every day on behalf of our patients. The issue of quality and quality standards should be paramount in any national health-care discussion.

And what about accountability? Physicians are accountable not only to their patients but also to their peers and, financially, to their government payors. Patients, on the other hand, face no accountability. In fact, patient accountability is forbidden by the Act. This, we believe, stymies innovative approaches to health-care delivery such as reform of our primary care system. We will only have true reform when the Canada Health Act allows an appropriate balance of accountability for doctors AND patients.

In truth, the five principles of the Act are not now being fulfilled and instead of facilitating health-care delivery, they are hindering it.

Let's look at accessibility. As I mentioned earlier, accessibility is clearly a critical problem yet the term is never adequately defined under the Act. This crisis in accessibility is symptomatic of a system not keeping pace with growing demands.

The Act also speaks about providing medically necessary services, but never defines what these might be. We know that standards of insured services differ significantly across the country. We need to look to a common and agreed-upon definition of what it means when we say medically necessary.

But perhaps the most fundamental barrier posed by the Canada Health Act relates to funding.

We need to answer these basic questions:

• Where are the new dollars needed to fund health care in Canada to come from?

• What do we want as Canadians?

• Do we want to pay ever more taxes to fund our health-care system?

• Or, do we want to look at a system with mixed public and non-public funding?

• And if we want a mix, what should that ratio be?

If you look at OECD countries, we are right in the middle of the 29 member states in the percentage of private expenditures versus public expenditures on health care.

Here in Canada, we have about 31-per-cent private funding. We have no difficulty in Canada spending private money on health care--things like prescription drugs, rehabilitation services, private and semi-private care, ambulance services, and extra duty nurses, for example.

Where we are totally outside the OECD range is in the area of acute care, hospital services and doctors' services. Ninety per cent of the funding for acute care in Canada is public. This level puts us in the extreme compared to the other countries.

I believe Canadians would feel very comfortable living with the values of many of these other OECD countries. I'm thinking for instance of Australia and New Zealand and those I mentioned earlier. They fund health care, particularly acute health care, very differently. They look very much to other sources of funding; private sources for some acute care services. Such actions are currently prohibited by the universality provisions of the Canada Health Act.

It seems to me that any time someone contemplates a new way of funding acute care, we immediately look at the United States and say: "We're not going down that road." I think that accusation is scare-mongering. It ignores the historically proven fact that we can have a made-in-Canada health-care system.

The problem is that our Canadian system is now dominated by a myth. The myth is that we have a totally public-funded system. This myth should be laid to rest. There has been a slow but steady increase in the private sector's share of total health expenditures. It was already almost 25 per cent when the Canada Health Act was passed in 1984 and now, as I mentioned, is more than 31 per cent. This is private funding spent on health care in Canada. On top of that, Canadians spend at least $1 billion a year to receive care in the United States.

I have no doubt that, as Canadians, we can design something that improves what we have without compromising our most basic principles.

To do that, we must have a starting point. Nationally, as I've said, we must begin with the foundation that must frame the debate--the Canada Health Act. And upon that platform we must bring stakeholders together and, in a very deliberate way, ask serious questions in a serious forum.

We need to ask these questions:

• What exactly do we mean by quality health care and how do we measure it?

• What is a realistic national standard on accessibility?

• What is medically necessary?

• How much money is needed for our health-care system and, most importantly, where will it come from?

• What rights and expectations do patients have?

• And, perhaps as importantly, what responsibilities do they have for their own health in a publicly funded system?

We also need to ask:

• What do we mean by public accountability and how should we measure and report it?

If we do not have the courage to challenge the Canada Health Act and address these important questions now, then we betray our position of leadership and our responsibility to both our patients and our society.

That's why, within the next several months the Ontario Medical Association will convene a summit of health-care stakeholders to discuss the appropriateness of the Canada Health Act. We will discuss how it hinders our ability to build a system that allows us to keep pace with the growth in demand for health-care services. We will announce details of the summit within the near future.

The time has come to lead, to put patients first, and to begin to forge a proper and far-reaching national debate. This will I hope begin here in Ontario and be taken up by the Canadian Medical Association on a national scale.

And so, ladies and gentlemen, let me conclude with some final thoughts. The debate ahead is surely not an easy one for any of us to contemplate because it challenges what defines us as Canadians. If a fundamental cornerstone of our society such as health-care changes, it changes who we are. And, if "who we are" is no longer financially sustainable, then it is obviously time for a serious debate.

Surely, as Canadians, we can restore that confidence not only in our health-care system, which distinguishes us as world citizens, but also in our own ability to forge consensus about a fundamental cornerstone of our collective consciousness. As Sir Winston Churchill said: "I never worry about action, but only about inaction." The time has come for action on the Canada Health Act.

I urge all of you here today, as business leaders and as community leaders, but also as parents, as sons or daughters, as brothers or sisters, as friends, and ultimately as patients, to join us in taking this issue forward into the next century.

Thank you very much.

The appreciation of the meeting was expressed by Ann Curran, Partner, Lewis Companies Inc. and a Director, The Empire Club of Canada.