A Personal Romanow Commission Submission
This submission is prepared as a personal presentation, but reflects my
involvement in a number of community organizations and my exposure to many
health related issues. Through my activities I have heard numerous
comments on the status of our health care system and on the experiences of
members of my community. However, problems do not necessarily tell us to
what to attribute the cause and what the solutions are. Life experience
and reading widely does lead me to draw conclusions that have a certain
Community associations listed below do reflect my biases, but other sources
of input to the Commission are no less biased. And as you, yourself, have
noted, we all bring biases to the situation, but our biases do not
necessarily prevent us from having useful things to say and to move beyond
our biases. I am on the executive of the Kingston and Islands NDP Riding
Association; Secretary of the Kingston Health Coalition; past president of
Progressive Independent Community Press, Inc.; member of the executive of
the Injured Workers Support Network Kingston and Region, past chair of the
Kingston/Cuba Medical Support Network.
There have been many reports in the media of the Commission's interest in
the application of user fees in Sweden. This is reinforced by the strong
lobby from the private sector and ideologically committed proponents of
application of market mechanisms to health care. Not having access to the
research protocols the Commission is following to investigate this option,
this issue instigates some comments on the context. Projecting from the
comments, the Commission may determine areas for further investigation.
North America does not have a good record on distributive justice. That
is, in North America the rich are getting richer and leaving the less
affluent farther and farther behind. In the United States there are
millions of people not covered by any medical insurance program. The same
corporate forces that have been lobbying for privatization of the medical
health system in Canada and pressuring governments to cut back on taxes on
corporations and on the well to do have some responsibility for the
inequity of the American health care system.
This is very different from the situation in Sweden. Swedish society has
ensured a more even distribution of income and affluence. Furthermore,
Swedish society has maintained a strong social welfare system. In such a
context the imposition of users fees is relatively insignificant compared
to what they would be in a culture such as ours. Our media and our elected
governments have reinforced an antagonism toward the support of the poor
and the disadvantaged. For many of our less well off citizens users fees
will be a significant deterrent. It can be expected that this would be
true to a much greater degree than can be observed in Swedish society.
No evaluation of the function of users fees in Sweden can apply to Canada
without due analysis of the North American context. As an ex-American I
can personally bear witness to this dynamic. Prior to my immigration to
Canada in 1965 while growing up in New York I had several experiences that
sensitized me to this issue. In my own case, I suffered from regular and
disturbing headaches that were due in part to a severely deviated septum.
My cousin, who was a doctor of great renown, urged me to have the problem
corrected. He offered to arrange services from a doctor gratis. All I
would have had to pay was the hospital bills. But, being a student of
limited means, I couldn't even afford that alternative. It was only after
I arrived in Canada and had access to the Manitoba physicians services
and Canadian hospital insurance that I was able to access treatment of my
condition. As trivial as this problem might seem, my health was
significantly improved by the treatment and my headaches disappeared.
At 17, I owed a large bill to my dentist. Despite my dentist being a
progressive man with a strong sense of social justice and a man who would
have treated me regardless of my owing money to the practice, my
embarrassment lead me to eschew seeking treatment. At times the pain was
excruciating, to the point that I undertook to manage the pain by
stimulating it while trying to convince myself that it was enjoyable. I
ceased this practice when I began to fear that it was having a negative
effect on my mental health. When I finally was able to accumulate
sufficient funds to pay my outstanding bills, the tooth required root canal
work and had to be extracted prematurely thereafter.
This kind of experience was not restricted to me, I assure you. On a few
occasions I had the opportunity of attending emergency rooms and clinics in
public hospitals in New York. They were crammed full of people waiting to
be served, mainly Black people. Many of the people were holding their
children in their laps. It was obvious that the conditions for which they
were seeking help involved routine illnesses and injuries that the more
affluent people would have had treated in doctors' offices or community
health clinics at earlier stages. (Unconscious individuals and trauma
victims were on stretchers in the hallways, these more serious cases were
seen first. The more routine cases were seated in the waiting room being
seen more slowly.) The fact that, in that era, emergency room services at
public hospitals were free hardly made up for the hours and hours of
waiting to be seen in the emergency rooms sitting on hard benches and in
hot crowded waiting rooms. The situation was its own deterrence.
My experiences in New York included observing friends and associates who
were nigh pauperized by long-term illnesses because of co-payments required
in order to receive treatment. Some had insurance, but the illnesses
exceeded the coverage.
The consequences of multi-tiered user pay systems of medicine can be
surprising. Hollingshead documented such unanticipated phenomena in his
1963 book entitled Hospital. In this study of a major medical centre in
Connecticut, he discovered that the wealthy often received inappropriate
medical care because of the demand economy. Unfortunately at the other
extreme, public care patients were misused by receiving experimental care
without informed consent and by facing delays and shaming experiences.
We should not assume that it can't happen here. The introduction of users
fees, the growing exclusion of services from public insured health care and
the changes to health care delivery without including the expanded delivery
modalities (e.g. home care) in public insurance coverage are steps toward
multi-tiered service. The growing costs of pharmaceuticals and increased
importance of pharmaceuticals in the health care regime means that access
to such care is selectively available. There is a direct correlation
between health care access and affluence.
DELIVERY of SERVICES
People in my community have been having experiences that were unheard of a
few years ago. The injustices and deprivations are mounting. Many of us
have concluded that there is a willful policy to undermine the public
health care system. By leaving people vulnerable, those with the ability to
pay will demand access to private care and fee based care.
One problem is the lack of doctors and other health-care professionals.
For example, my neighbour's doctor took ill and was forced to terminate his
practice. This year, my neighbour was awaiting a procedure to treat an
aneurism. But she could not find a doctor accepting new patients. A
doctor who took over her former doctor's practice accepted only a small
number of patients. This left her unable to receive a prescription for a
blood test that was a prerequisite to the treatment. She fretted and
called for days to every possible doctor in town. To no avail. Even the
so-called after-hours clinics couldn't help her. Within weeks of this
situation she had a major coronary attack. While one condition is not
directly related to the other, it also is likely that the stress and worry
contributed to the severity of her condition.
Nurses are reporting that their work loads have increased significantly.
Nurses in long-term care facilities tell us that they have less and less
time to provide care to sicker and sicker patients. Patients may still
receive essential physical services, but staff are slowly burning out. This
has serious implications for a system with an aging cohort of nurses. And
nursing care has been reduced to meeting physical needs while social and
psychological needs are going unattended. Nurses feel powerless to help
patients and families facing diseases or patients socially isolated due to immobility. And during a recent stay in hospital I noted that basic care, such as feeding patients is being left to families. But what if no family members are available?
ADDRESSING SERVICE DELIVERY ISSUES
The response to these needs by previous governments has been to increase
funding. During difficult economic times, such costs put the government
in a deficit position. The current Ontario government is committed to three
solutions to the problem. Decrease taxes, especially corporate taxes.
Pass the problem to higher and lower levels of government by demanding
additional federal funding and by downloading services to boards and to
regional and municipal governments. The final solution to which it is
ideologically committed is privatizing services and moving to direct pay
The federal government has been similarly preoccupied with reducing its
exposure to health care costs.
It shouldn't be assumed that commitment to these principles in the public
domain is matched by allowing the market place to work without intrusion.
The Ontario Health Coalition has noted that large laboratory companies
have been assigned quotas because smaller companies were cutting into their
business. Smaller companies were required to compensate companies such as
MDS for lost business during the period of open competition between 1995
and the introduction of these regulations. To make matters worse, the
employees of the large corporations are mainly not represented by unions.
Public laboratories are assigned the more difficult laboratory functions
that cannot be readily automated. And the public facilities are
constrained not to compete with the private sector by investing in labour
saving technologies. Even if competing was possible, boards and managers
tend to be committed to private corporate agendas. There may not be
collusion, nor favouritism, but good will is not forgotten at the higher
levels of decision making. (It is interesting that the person appointed
to "straighten out" the hospitals in the City of Ottawa is reported to have
been affiliated with a major private health care service.)
All these policies have been detrimental to health care services. They are
going the wrong way. The pay level for people employed in the delivery of
health care services have been more stratified than ever and many front
line workers are unhappy with their working conditions and their pay. If
the provinces wanted market forces to help keep costs manageable they
would have increased the number of health care professionals being trained. The
cut back in hospital beds and hospital employment opportunities would have
been preceded by expansion of alternative service delivery modalities and
concomitant employment opportunities. The rights of working people being
eroded by new labour legislation in Ontario reflects the disrespect for
their work that health care deliverers sense. This erosion of rights are
highly concentrated in the scheduling of work. Work schedules for our
health care deliverers has always been one of the most sensitive problems
since they often are required twenty four hours a day, seven days per
The problem worsens.
Will privatization solve these problems? Apparently not, looking at the
US. Costs have soared in the US. Patients feel they have lost rights. US
companies are endlessly trying to lure our professionals away from Canada.
And 40 million people lack medical coverage. The only benefit in the US
system is the profit margin of the Private Companies delivering services.
If the road we are travelling has not worked, what options are there.
The government is on the right track when it seeks to reduce hospital
stays. It is also on the right track when it seeks to increase community
options, including home care and assisted living centres. But trying to
make these changes on the cheap is destructive. A recent BC study
discovered that meeting the ancillary home care needs such as housekeeping
pays off in lower hospital stay costs and in longer survival in
independent living. Adequately paid staff working predictable work schedules and providing care to consistent case loads encourages consistency in care and
a motivated work force.
To allow these options to work themselves out fully, governments have to
maintain tax levels and stop pandering to the ambitions of the wealthy.
Adequate funding of the programs need to be maintained. Boards, such as
Community Care Access Centre's, need to be fairer in their treatment of
non-profit and public service bodies. Biassing decisions in favour of
private companies who promise the world to the boards needs to be ended.
History has shown that the private companies fail to deliver the quality,
nor the quantity of service they are committed to deliver. First they
assure the board that they have the staff available to provide the
service, then leach the work force of non-profit and public agencies , then push
the work force until they are ready to leave the field. Meanwhile the money
that is the difference between what the workers receive and what the
private companies are paid by government leaves the community and pays for
private jets and corporate executive salaries.
But there are other steps that can be considered. The health care system
of Cuba offers us many lessons. In saying this, it needs to be recognized
that, just as in the case of Sweden, there are contextual factors that
should dissuade us from importing Cuban practices holus bolus. (Not the
least of these is how our societies manage diversity of opinions).
Nevertheless, the following should be noted.
Cuba has trained doctors and nurses in such large numbers that there are
perhaps twice the ratio of doctors to population as in Canada. In
addition, the medical care system is highly integrated into the community
and family doctors and nurses set preventive medicine goals for their
caseloads. Cuba has maintained a truly universal public health care system
and has invested heavily in public bio-research and pharmaceutical
programs. In certain areas, the results have been so impressive that Cuba
has exported vaccines for encephalitis and treatments for Cholera to other
countries. Cuba has hundreds of doctors working in Haiti and other
The Cuban system has many qualities in common with some of the best
examples of Canadian practices. In Kingston, there is one community health
clinic operating. The doctors work under salary. The patients are provided
with a range of services under one roof. Another program in Kingston that
provides integrated care is the Family Medicine Centre at Hotel Dieu
Hospital. This unit provides family medicine training for Queen's
University's medical school. Again, this program also emphasizes
continuity of care. Preventive health efforts are encouraged as part of
the training of the residents.
In the Family Medicine Program there is a less obvious attribute that may
provide a suggestion as to how costs can be managed within a public
system. In the case of the Family Medicine Centre these are Resident Physicians.
But they could be Nurse Practitioners. Where diagnostic indicators
suggest more expertise for differential diagnosis is required the doctor can step
in. With our highly sophisticated technical resources we should be able
to add back-up redundancy to help make the system work. For example,
diagnostic algorithms combined with new sensory devices can contribute to
the quality control of such a system.
This multi-level health care option has some similarities to the best
aspects of the Cuban system. In Cuba, the local doctor provides first
line care. Where assessment options require or treatment options require, the
patient goes to a Poly-Clinic. There, specialists and laboratory services
are provided. Short term interventions can be provided. This intermediate
step is backed up by medical facilities in large hospitals that have the
trained and skilled specialists and specialized equipment and the means of
providing longer term care where needed. In this system, much emphasis is
placed on encouraging people to stay healthy.
This system lends itself to the expansion of publicly delivered health
care. But do not assume that this has to be via highly centralized
institutions. Locally run consumer co-operatives might sponsor such
clinics. Community Boards might be selected to run the health care
centre. It also lends itself to decentralized, but integrated delivery of home
care services. By being integrated into the community, the home care can be
matched to the support network of the patient.
There are other possible interpretations of this model. It could just as
readily be applied to HMO type operations (and probably is). The
community clinic could be financed and delivered by private organizations (including doctor operated clinics). The problem is that HMO's have engaged in
profit driven decision making that denies patients important services and fair
access to treatment. In the United States, HMO's can vary in the services
they approve depending on the amount being paid for insurance. Employer
selected programs can be chosen for low cost rather than quality of care.
Too many of our citizens are unable to follow through on medical advice
because they cannot afford the prescriptions. Too many of our citizens
have to pay an inordinate portion of their incomes to keep themselves
healthy. People should not be forced into poverty because they have
become ill. Profit is the driving force. The implications of this issue were
most apparent in the case of the AIDS drug battle in South Africa. The problem
is that in North America our vulnerable and needy are fewer in number and
more scattered. The morality or lack of it in profiteering on the back of
the sick is not as apparent.
The Kingston Health Coalition hears too often of people taking half doses
of medication to make them last because the patients cannot afford the
full dose. We are all aware of growing costs of pharmaceuticals. We cannot be
sanguine about this. The argument of the drug companies that these charges
are due compensation for costs of development leave our society in a bind.
Drug companies are spending large amounts of money on advertising their
drugs and encouraging doctors and patients to use them.
A somewhat different perspective provides a critical view of the way the
pharmaceutical companies are profiting from production of medications.
There is a tendency for corporate interests to claim intellectual property
as their justification for drug profits. They discount the extent to
which their efforts are based on public support for university research. They
discount the extent to which they are standing on the intellectual effort
of others in history. They also don't allow for government subsidies, tax
relief, and government co-operation.
Governments can do something about this problem. First of all, they can
reduce the duration of patents on medicine back to fifteen years or less.
Second, governments can invest in publicly operated pharmaceutical
enterprises as Cuba does. Of course, in the Canadian context, that does
not mean we will displace commercial pharmaceutical companies. Government
enterprises will produce alternatives that allow us to meet essential
needs and will facilitate comparisons of cost and fair pricing
arrangements for consideration by the Board that reviews Drug Pricing.
Furthermore, the government should ensure that public contribution to the
research community are matched by equity and some say in the marketing of
derivations from that research. This is especially important now that
Universities are actively forming co-operative arrangements with
corporations and spinning off profit making companies from the work
carried out under the Universities' aegis.