Medicare reform: Renewing medicare

I am among those who had mixed feelings when the interim report of the Romanow Commission on the Future of Health Care in Canada was released in early February.1 As one who strongly believes that society's financial and other commitments to a publicly funded universal health care system cannot neglect the values that are its foundation, I was quite pleased that someone with the credibility of the Commissioner would put the question of values squarely in front of Canadians. But then my frustration rose with each successive chapter of his report. Here I might have been unfair, but I certainly felt impatient at the nicely assembled picture of our system and the challenges it faces. Too general, too vague, almost abstract, I felt. “We all know that,” I thought. “Why an Interim Report if it's only philosophizing?” But, of course, Mr. Romanow did not have much choice: the order-in-council that created his Commission mandated an interim report — an unusual request for an undertaking of this kind and, as far as I am concerned, possibly a waste of time and resources. In my opinion, the Romanow Commission presents a unique window of opportunity to question in depth how we deliver health care in this country; to figure out what we want to achieve for the coming, say, 20 years and why; to reconsider the Canada Health Act; and to redesign our health care system(s) accordingly. (By the way, the Kirby Senate Committee — which, because of an unusual set of circumstances, now coexists with the Romanow Commission —should not be viewed in terms of competition but rather as another set of viewpoints and perspectives nurturing the much-needed public debate on our health care system.) Although we do not have a perfect blueprint for redesigning our health care system, a number of attempts to create a common vision for health policies have, disjointedly, been developed, the latest being the priorities for action agreed by the First Ministers in September 2000.2 This very public undertaking crowns years of federal/provincial/territorial meetings of health ministers, deputy ministers and technocrats, as well as academic and professional efforts to define where an outcome-oriented and evidence-based health care system should be going. Our First Ministers “new prescription for Canadian health care,” which was in fact nothing new, pointed toward an integrated, seamless and rather inclusive model of health care delivery. But to the First Ministers' commitment to health promotion, wellness, disease prevention and primary care, I would add much-needed support in the fields of mental health, rehabilitation and chronic care as well as in home care and drug therapy when these are the direct substitutes of hospital care. (Ideally, complete universal home care and pharmacare programs should be included, but for lack of access to relevant data I cannot make a considered judgement at this point and leave the issue for future debate.) The cornerstone of this extended and integrated coverage should be an uncompromised notion of quality and excellence fed by evidence-based knowledge at all levels. Goals and objectives for the population as a whole and, even more significantly, for subgroups and regions, should be agreed on. Accountability and reporting mechanisms would then inform experts, health care professionals and citizens alike of the outcomes of our integrated approaches: maximizing longevity with quality of life, reducing the burden of disease and illness, and so on. How do we get there? At the system level that I am discussing, money and governance are both the problem and the solution. We have not been able to address the reforms that we know should be undertaken by the provincial systems to ensure their sustainability, and I worry seriously about that. This doesn't have much to do with the need for more money, as can be seen in the classic research on sustainability led by Doug Angus at Queen's University and the University of Ottawa,3 and the most recent research on health management led by Cam Donaldson at the C. D. Howe Institute.4 This is a first observation. But then, with increased coverage of services, additional public funding will also be necessary. Our system is certainly sustainable and, generally speaking, Canada's expenditures have not been out of control. The federal government, however, is seen as not sharing fairly in the risks of a constantly evolving and growing health care system: the burden falls squarely on provincial governments. With health care budgets approaching 50% of provincial resources, we must ask ourselves about balance.5 The whole contentious issue of the value — and the very fact — of federal tax-points transferred in 1977* to the provinces for health care should be put to rest once and for all. These tax points are a taxation capacity “lost” forever and carry no enforcement power whatsoever. So let us stop talking about them. We should revert to the spirit of a 50–50 cost-share arrangement, block funded by cash transfers established in multiyear blocks. The federal share could immediately reach, say, 25%, with increases based on capacity, keeping in mind that provincial health budgets need stability and predictability. I would expect that Mr. Romanow, a former premier, will rightly be sensitive to this issue, which is key to both accountability and good governance. If the health care system itself is not — yet — in deep trouble, its governance certainly is. That familiar mechanism of government partnership and collaboration in health care, the federal–provincial conference, has become utterly dysfunctional over the years, and nothing points toward any form of improvement. How can we somehow depoliticize our intergovernmental relations? How can we move from a “federal/provincial/territorial” approach to a “national” one? Again, my hope is that the Romanow Commission will address this issue in an innovative way and, ideally, bring citizens and taxpayers into the equation. If governance is not addressed, conflict resolution cannot be solved and nothing will change. My wish list of badly needed solutions also includes a new definition of 2 crucial criteria or principles of the Canada Health Act: comprehensiveness and public administration. How do we decide as a society what health services should be insured? What are the boundaries of the public–private interface in health care, and at what point and in what form(s) is private partnership an erosion of medicare leading to a two-tier system? Articles to date in this series Lewis S. The bog, the fog, the future: 5 strategies for renewing federalism in health care. CMAJ 2002;166 (11): 1421-2. Maxwell J. Bringing values into health care reform. CMAJ 2002;166(12):1543-4. Suzuki D. Broadening the health care debate. CMAJ 2002;166(13):1678-9.

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