Notes for Remarks by
Roy Romanow, Commissioner
Commission on the Future of Health Care in Canada
The Canadian Club of
November 20, 2002
Check against delivery
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
These consultations have given me some real insight into the values that
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.
ATTACHED TO MEDICARE
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
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
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
VALUES & NOTIONS
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
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
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
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.
TIMELY ACCESS FOR
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
- 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
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
EVOLUTION: HOMECARE & PRESCRIPTION DRUGS
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
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.
TOWARD A REAL
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
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
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
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.
THE WORLD’S HEALTHIEST PEOPLE
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
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
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.