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Speech: Creating a National Health Care System for Canadians
November 2002



Notes for Remarks by

Roy Romanow, Commissioner
Commission on the Future of Health Care in Canada


The Canadian Club of Winnipeg
Winnipeg, Manitoba

November 20, 2002

Check against delivery



Thank you.

And thank you to the Canadian Club for your generous invitation to join you today.  As we get closer and closer to the release of our Report, I expect these kind of opportunities for fine dining will be coming my way somewhat less frequently, so I am delighted to be here today!

It was just over a year and a half ago that the Prime Minister established the Commission on the Future of Health Care in Canada and gave me the honour of serving as its sole Commissioner.

My mandate was as broad as it was clear: to review medicare, listen to Canadians and make recommendations to enhance the system’s quality and sustainability.   When I agreed to serve, I promised that my recommendations would be based on hard evidence and rooted in Canadian values.  I have kept that promise.

Over the past 18 months, we have completed a rigorous research program and exhaustive consultations, involving tens of thousands of Canadians - health experts and ordinary citizens, Health Ministers and Premiers, researchers and health care workers.

Canadians, from sea-to-sea-to-sea, have contributed to our deliberations.  Indeed, in just 12 months, our web site has logged over 24 million hits from people interested in our work! 
These consultations have given me some real insight into the values that Canadians cherish.

My goal, through both the research and consultations initiatives, was to cut through the rhetoric and find the reality, to determine the true state of affairs and decide on the best course of action.



Throughout those many months, I heard Canadians, again and again, express their strong attachment to - as well as their very real concerns over  - our health care system.  And I was reminded again of just how deeply committed Canadians remain to the core values that lie at the heart of a system which has served them so well in the past.

What I can say today, having examined the research and heard from Canadians, is that this system can continue to serve Canadians well in the future.   But - and it is a significant but - only if we make some important changes.

The fact is that medicare is as sustainable as Canadians want it to be; that the system itself needs fixing, not replacing, and that medicare remains a strong foundation on which to build.

I have spoken a great deal over the past 18 months about the importance of values in any evaluation of our health care system.  I have done so and I now strongly believe that any reform that does not resonate with the values Canadians hold will never attract the support such reforms must have.  

These values are equity, fairness and solidarity.



These values are not abstract concepts - they are tied to our understanding of citizenship, to our common resolve to share the burden when illness strikes and to our determination to make our national policies reflect our national character.

These values also have direct implications for the policies we pursue and the kind of health care system we create.   If equity and fairness are to have meaning, then access to medically necessary treatment cannot be a product of wealth or status, but a right of citizenship.  And if solidarity is a basic principle, then medicare itself must be national in scope, even if it is delivered locally.  That, in turn, means governments must act together, working for medicare, not fighting over medicare.

I can also say, without any hesitation, that the health care system our values have inspired is one of the world’s best and perhaps, in this imperfect world, the world’s best.  That will no doubt surprise those who have been caught up in the over-heated rhetoric about costs, effectiveness and viability. 



Indeed, when we look at the evidence, we see that medicare has consistently delivered affordable, timely, accessible and high quality care to the overwhelming majority of Canadians.  It has contributed to our competitiveness on the world stage and to the high standard of living we enjoy.

Nonetheless, Canadians still have been exposed to an increasingly divisive debate about medicare’s sustainability. 

We’ve been told that with escalating costs, an aging population, increasing expectations and ever more expensive technologies that we’re headed for a brick wall; that we just can’t keep going the way we’ve been going.

So what’s the reality?  Is medicare sustainable?   I’ve concluded that it is if we want it to be and we have the foresight and dedication to make it so.

Let me explain.

Governments tend to talk about sustainability in terms of costs - and in particular, who pays those costs.  They don’t look at the overall level of spending.   As a result, we overlook some pretty basic facts, for example: health spending in Canada is not out of line with wealthier countries of the world and substantially below that in the United States.  

In fact, we are actually spending less on health care as a percentage of our GDP than we did a decade ago.  So let’s be clear: health care spending in Canada is not out of control in comparative terms.

Perhaps what’s more distressing about the debate on sustainability is the notion that our health care system is somehow on auto-pilot, beyond our ability to change its direction or reduce its costs.

But I believe that the imagination and the ingenuity which that has helped to define us as a nation can also be applied to our health care system; that we can choose how and where to invest; that better management, a stronger focus on prevention, better institutions, and more effective use of technologies can both improve the health we enjoy and reduce the amount we pay.  

Does that mean that no more money is needed?

I wish I could say that were so.  But the fact is the system does need more money if it is to meet today’s needs and if it is to successfully transform itself for the future.  While recent federal budgets have seen the beginning of improved funding, the federal government still contributes less than it did  - and less than it should.

I therefore believe there is considerable merit in having a minimum threshold of federal funding established - a floor - below which it should not fall.  Fiscal reality may dictate that this floor may not be reached overnight, but we should move toward it and make some targeted investments immediately.

While it is a beyond my specific mandate, I have also been convinced by the presentations of many provinces that consideration of equalization bears directly on the sustainability of health care programming.

In this regard, we should build on the commitments set out at the First Ministers Meeting in 2000.



Before leaving the sustainability issue, let me point out that individual Canadians view it from a very different perspective.  The issue for them is not “what does it cost?” but it also is: “will it be there for me and for my family when we need it?”.  The two issues are intertwined.

These questions are already very real for Aboriginal peoples and those living in rural or remote areas, where care is not always available, certainly not in a timely way.  

Let’s face the facts: across the system we have significant gaps in supply and demand, resulting in unacceptably long waiting lines for many medical procedures.  These problems threaten to undermine public confidence, and when that goes, the siren call of privatization begins to sound as a panacea for all of our problems. 

But in my view, the suggestion that greater private sector participation in our health care system is the solution to the problems of timely access and waitlists defies logic. 

And, why?  Because the solutions sometimes advocated amount to a cannibalization of the public system.   What do you think will happen to waitlists if we reduce the supply of health professionals practicing in the public system to allow more of them to practice privately?  Great Britain has tried this, and the result has been even longer wait times in the public system.

Some argue that allowing more private delivery of care- the creation of a parallel system- will relieve pressure on the public system.  How?

  • Will they process patients more quickly?  It’s hard to see how this can be achieved unless they cut corners or fail to follow standard medical procedures.
  • Will they focus more on prevention?  If the discipline of market forces is indeed the rationale for allowing more private delivery, what incentive would private practitioners have to reduce demand?
  • Will they work longer hours?  Possibly.  But this can also be arranged in the public system.


And what happens when a patient who has received care from a private provider falls ill as a result of failed procedure?  They end up in a hospital emergency room and are treated by the public sector!  Where does the private provider’s liability end under these circumstances?  All this suggests that we’ll still need to have the public sector around- but a diminished one- to provide a back up to the private sector (and to pick up whatever high cost or high risk procedures it is uneconomic for the private sector to deliver…).

Friends, the proposition that more private care will magically solve the access problems confronting our health system just doesn’t add up.  The evidence just isn’t there, and neither is the logic.

In my final report, I will be proposing solutions to tackle the issue of timely access to quality care for all Canadians, including those residing in rural and remote communities and for Aboriginal peoples.  These solutions will be consistent with the spirit and intent of the Canada Health Act.  I will also be making recommendations to encourage a national approach to health human resources planning.



One of the most basic challenges we face in reforming health care is to bring it in line with today’s realities.  When medicare was established, health care meant doctors and hospitals.  That’s no longer true.  New drugs have replaced surgery.  New surgical techniques have shortened hospital stays.  And more and more of the burden of care has fallen on families - especially women.

As a result, homecare has become a critical part of the equation, but we haven’t made it part of the health care system.  Similarly, new drugs are undeniably welcome, but they can also be unbelievably expensive, especially for those who don’t have a drug plan.

Many families, struggling to juggle jobs with the provision of homecare and drug therapies to loved ones are facing real financial pressures.  And some are going bankrupt trying.  That’s not Canadians’ idea of fairness.  That’s not Canadians’ idea of equity.

I believe that priority must be given to establishing a national platform for homecare services delivered by the provinces as well as short-term measures to improve catastrophic drug insurance coverage for Canadian families.  The details of both cannot be revealed until later next week.

I know that proposals in these areas will be controversial, especially from those who want to see “less government” and less public money.  But they miss the point.  They’re only looking at the cost to governments, not to Canadians. 

Sure, we could narrow medicare and spend less, but that would only pass the buck to individuals and ask them to bear the cost of critical services.  That’s not the Canadian way.  That’s not consistent with the values and vision of medicare.  And that’s not the way to build a caring, compassionate society.  And while passing the buck may seem advantageous for governments in the short-term, it would likely be more expensive for our society as a whole in the medium and long-term.



I mentioned a moment ago that Canadians view health care as a national program, even though it is delivered locally.  I wish to stress this does not mean that the federal government should intrude into areas outside of its jurisdiction. 

Nor does it mean that we can adopt a one-size-fits-all approach, or that experimentation and innovation must be discouraged.  In a country as diverse as ours, and with the relentless pace of scientific and technological advance, such rigidity is neither feasible nor desirable.

But the opposite danger is equally real: that medicare will fragment into 13 or more separate health care systems, each with differing methods of payment and each with its own list of covered services.  The most important point of all is this: quality care for all Canadians may be compromised.  

Today, we are seeing this very trend develop.  Provinces and territories - sometimes by design, sometimes by financial necessity - are increasingly willing to go it alone.  This trend is divisive.  It offends the notion of equity.  And it is no way to renew a program of such immense national importance or to strengthen the foundations that unify us as a nation.

I will be recommending a series of measures aimed at modernizing the legislative and institutional foundations of medicare so that governments have the tools they need to move forward together and provide Canadians with the quality health care they want.



Throughout the course of our consultations, one of the recurring themes was the need to do a better job of integrating all of the various elements of health care into a true “system” of care. 

Because as much as we talk about a health care “system”, what we really have is a series of isolated islands of service, often with no bridges between them.  Patients are forced to navigate a complex labyrinth of services and specialists; required to find the nearest facility, the best treatment; to repeat lab tests and retell their medical history over and over, all because the various parts of the so-called “system” aren’t connected to one another.

Take the elderly person who is discharged from hospital and can’t find the home or community services they need, or, if they can find them, can’t afford them.  Or women - one in five - who are providing care to someone in the home, an average of 28 hours per week, half of whom are working, many of whom have children, almost all of whom are experiencing levels of stress that cannot be countenanced and must not continue.

Or health care professionals, working longer hours, and being asked to perform tasks ill-suited to their training.

This is more than a formula for frustration, it is a recipe for destroying the confidence of Canadians in a system that does not meet their needs.

I will be recommending a series of measures to create a more comprehensive system, whose component parts work together, to serve Canadians better.



Another concern that struck me as I began my work, was the lack of information about how our health dollars are spent.  Publicly and privately, we spend more than $100 billion on health care in this country and yet no level of government has done a very good job accounting for how effectively that money is allocated.

The data we do collect is haphazard. We gather information on some health issues and not others.  And much of the information can’t be properly analysed or shared.  How can we hold health care managers accountable if what they’re managing is not being measured?  And how can we make evidence-based decisions if we don’t have the evidence?

What’s more, Canadians demand - and certainly deserve - a much fuller accounting of how the health care system is operating.  They have a right to know if things are getting better or getting worse; what’s happening with waiting lists; what’s going on with respect to the number of hospital beds, doctors and nurses; whether gaps are being closed, or community care is being strengthened and whether the number of diagnostic machines is adequate.

Quite simply, the time has come to give Canadians the facts!

So, we need to improve transparency across the health care system, to make decision-making structures more inclusive and to accelerate the integration of health information, including the development of a secure electronic health record for Canadians that fully respects and protects their right to privacy.  I will deal with all of these areas in my report.



During the course of our public hearings, many presentations focussed on the need to improve our understanding of the determinants of health.  What factors contribute to the health we enjoy?  How much is genetic and how much environmental?  What roles do education and income play?

What’s the connection between spiritual, emotional and physical health?

These issues are vital to the long term sustainability of medicare.  They also speak to concerns for social cohesion and a sense of inclusion.  They will lead to the kind of services and infrastructure - such as public housing, a clean environment and education - that will enable Canadians to make healthier lifestyle choices.

I will make recommendations that address these issues.  In particular, I think we need to place greater emphasis on prevention and wellness, and new resources for research into the determinants of health.  Ultimately, the goal is to make Canadians the healthiest people in the world.



Friends, early in my mandate, I challenged those advocating radical “private” solutions for reforming health care-- user-fees, medical savings accounts, de-listing services, greater privatisation, a parallel private system -- to come forward with evidence that these approaches would improve and strengthen our health care system.

The evidence has not been forthcoming.

I have also carefully explored the experiences of other jurisdictions with co-payment models and with public-private partnerships, and have found these lacking.

There is no evidence these solutions will deliver better or cheaper care, or improve access (except, perhaps, for those who can afford to pay for care out of their own pockets).  More to the point, the principles on which these solutions rest cannot be reconciled with the values at the heart of medicare or with the tenets of the Canada Health Act that Canadians overwhelmingly support.

It would be irresponsible of me to jeopardize what has been, and can remain, a world-class health care system and a proud national symbol, by accepting anecdote as fact, or on the dubious basis of “making a leap of faith”.

Tossing overboard the principles and values that govern our health care system would be betraying a public trust.  Canadians will not accept this, and without their consent, these so-called “new” solutions are doomed to fail.  Canadians want their health care system renovated; they don’t want it demolished. 

Some have described it as a perversion of Canadian values that they cannot use their money to purchase faster treatment from a private provider for their loved ones.  I believe it is a far greater perversion of Canadian values to accept a system where money rather than need, determines who gets access to care. 

My final report will address this issue in very direct terms, and in a way that is consistent with what Canadians want and expect from their health care system.



Canada’s journey to nationhood has been a gradual, evolutionary process, a triumph of compassion, collaboration and accommodation, the result of many steps, both simple and bold.  This year we celebrate the 40th anniversary of medicare in Saskatchewan, a courageous initiative by visionary men and women that changed us as a nation and cemented our role as one of the world's compassionate societies.  The next big step for Canada may be more focused, but it will be no less bold.  That next step is to build on this proud legacy and transform medicare into a truly national health system that is more responsive, comprehensive and accountable to all Canadians.

Getting there requires leadership.  It requires us to change our attitudes on how we govern ourselves as a nation.  It requires an adequate, stable and predictable commitment to funding and cooperation from governments.  It requires health practitioners to challenge the traditional way they have worked in the system.  It requires all of us to realize that our health and wellness is not simply a responsibility of the state but something we must work towards as individuals, families and communities and as a nation.  The collaborative system I speak about is clearly within our grasp.

Medicare is a worthy national achievement, a defining aspect of our citizenship and an expression of social cohesion.  Let’s unite to keep it so.

Thank you.