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Wherefore art Thou Canada? (con
permiso de The Globe and Mail, Globe Interactive. Prohibida su copia.
Copyright, The Globe and Mail. Traducciones, Copyright Canadá en Español
Network, Cactus Rock New Media Ltd.)
By
ROY J. ROMANOW, Q.C.
From Friday's Globe and Mail
In April 2001, the Prime Minister established the Commission on the
Future of Health Care in Canada and gave me the privilege of serving as
its sole Commissioner. My mandate was to review medicare, engage Canadians
in a national dialogue on its future, and make recommendations to enhance
the system's quality and sustainability. At the time, I promised Canadians
that any recommendations I might eventually propose to strengthen this
cherished program would be evidence-based and values-driven. I have kept
my word.
My team and I have worked hard to assemble the best available evidence.
We began by analyzing existing reports on medicare and by inviting
submissions from interested Canadians and organizations. To clarify our
understanding of key issues, we organized expert roundtable sessions and
conducted site visits, both in Canada and abroad. Where we identified
knowledge gaps or needed a fresh perspective, we commissioned independent
experts to conduct original research. Finally, I met directly with
Canada's foremost health policy experts to hear their views, challenge
them and have them challenge me.
We also worked hard to engage Canadians in our consultations, because
medicare ultimately belongs to them. We partnered with broadcasters,
universities, business and advocacy groups, and the health policy
community to raise awareness of the challenges confronting medicare. The
contribution of the health research community to this effort has been
invaluable. We also established formal liaison contacts with provincial
governments to share information, and I spoke with the Premiers and heard
from many health ministers. I also had the privilege of leading one of the
most comprehensive, inclusive and successful consultative exercises our
country has ever witnessed. Tens of thousands of Canadians participated,
speaking passionately, eloquently and thoughtfully about how to preserve
and enhance the system. We also sought advice from health experts and from
Canadians in interpreting the results of our processes. I am proud that
respect, transparency, objectivity and breadth of perspective have been
hallmarks of this process.
These past 18 months have been among the most challenging and rewarding of
my more than three decades in public life. Having examined the research,
and having met with Canadians from sea-to-sea-to-sea, I am more confident
than ever in the system's potential to meet the needs of Canadians, now
and in the future. Canadians remain deeply attached to the core values at
the heart of medicare and to a system that has served them extremely well.
My assessment is that, while medicare is as sustainable as Canadians want
it to be, we now need to take the next bold step of transforming it into a
truly national, more comprehensive, responsive and accountable health care
system. Making Canadians the healthiest people in the world must become
the system's overriding objective. Strong leadership and the involvement
of Canadians is key to preserving a system that is true to our values and
sustainable.
Canadians Remain Attached to the Values at the Heart of the System
In their discussions with me, Canadians have been clear that they still
strongly support the core values on which our health care system is
premised - equity, fairness and solidarity. These values are tied to their
understanding of citizenship. Canadians consider equal and timely access
to medically necessary health care services on the basis of need as a
right of citizenship, not a privilege of status or wealth. Building from
these values, Canadians have come to view their health care system as a
national program, delivered locally but structured on intergovernmental
collaboration and a mutual understanding of values. They want and expect
their governments to work together to ensure that the policies and
programs that define medicare remain true to these values.
Medicare Has Served Canadians Extremely Well
I am pleased to report to Canadians that the often overheated rhetoric
about medicare's costs, effectiveness and viability does not stand up to
scrutiny. Our health outcomes, with a few exceptions, are among the best
in the world, and a strong majority of Canadians who use the system are
highly satisfied with the quality and standard of care they receive.
Medicare has consistently delivered affordable, timely, accessible and
high quality care to the overwhelming majority of Canadians on the basis
of need, not income. It has contributed to our international
competitiveness, to the extraordinary standard of living we enjoy, and to
the quality and productivity of our work force.
The System Is as Sustainable as We Want It to Be
For years now, Canadians have been exposed to an increasingly fractious
debate about medicare's "sustainability." They have been told
that costs are escalating and that quality of services is declining. They
have heard that insatiable public expectations, an aging population and
the costs of new medical technologies and prescription drugs will
inevitably overwhelm the system. They have been warned that health
spending is crowding out other areas of public investment. Thus one of the
fundamental questions my report addresses is whether medicare is
sustainable? My answer is that it is if we are prepared to act decisively.
Governments talk about sustainability in terms of "costs" and
financial impacts. This discussion often has more to do with "who
pays" than "how much" we pay. In listening to these
debates, it is sometimes hard to realize that health spending in Canada is
on par with most countries in the Western world, that it is substantially
lower than in the United States, and that we devote a smaller portion of
our Gross Domestic Product (GDP) to health care today than we did a decade
ago.
More troubling is the notion that somehow our health care system is on
"auto-pilot" and immune to change. I believe this is
fundamentally inconsistent with the ingenuity and innovation that has for
so long defined the Canadian way. It is baseless and false. Governments
can make informed choices about how and where to invest; they are not
powerless to change current spending trajectories. Better management
practices, more agile and collaborative institutions and a stronger focus
on prevention can generate significant savings. Technological advances can
also help to improve health outcomes and enable a more effective
deployment of scarce financial and human resources. Indeed, our health
care system is replete with examples of excellence in innovation, many of
them world-class. The bigger issue is whether we have the right
information and the courage we need to make the choices that support
sustainability.
To be sure, the system needs more money. In the early 1990s, the
federal share of funding for the system declined sharply. While recent
years have seen a substantial federal reinvestment into health care, the
federal government contributes less than it previously did, and less than
it should. I have, therefore, recommended the establishment of a minimum
threshold for federal funding, as well as a new funding arrangement that
provides for greater stability and predictability - contingent on this
replenishment supporting the transformative changes outlined in this
report. Money must buy change, not more of the same.
But individual Canadians view sustainability from a very different vantage
point. The key "sustainability" question for the average
Canadian is, "Will medicare be there for me when I need it?"
While it is very clear that a majority of Canadians support medicare in
its current form, it is not perfect. Some people, particularly Aboriginal
peoples and those in rural and remote parts of the country, cannot always
access medical services where and when they need them. There are also
inefficiencies and mismatches between supply and demand that have resulted
in unacceptable times for some medical procedures. These problems must be
tackled on a priority basis or they will eventually erode public
confidence in medicare and with it, the consensus that it is worth keeping.
I have, therefore, recommended new initiatives to improve timely access to
care, to enhance the quality of care the system provides, a more co-ordinated
approach to health human resources planning, and a special focus on the
health needs of Aboriginal peoples.
We also need to renovate our concept of medicare and adapt it to today's
realities. In the early days, medicare could be summarized in two words:
hospitals and doctors. That was fine for the time, but it is not
sufficient for the 21st century. Despite the tremendous changes over the
past 40 years, medicare still is largely organized around hospitals and
doctors. Today, however, home care is an increasingly critical element of
our health system, as day surgery has replaced the procedures that once
took weeks of convalescence in hospital. Drugs, once a small portion of
total health costs, are now escalating and among the highest costs in the
system. The expense associated with some drug therapies or of providing
extended home care for a seriously ill family member can be financially
devastating. It can bankrupt a family. This is incompatible with the
philosophy and values upon which medicare was built. It must be changed. I
have, therefore, recommended that home care be recognized as a publicly
insured service under medicare and that, as a priority, new funds be
invested to establish a national platform for home care services. I have
also recommended the creation of a national drug strategy, including a
catastrophic drug insurance program to protect Canadian families.
I know these views will provoke a hot debate in Canada, particularly
among those who advocate "less government" and less government
money in health care. The problem with these arguments is that they are
focused on the cost to governments, not Canadians. A more narrowly
structured system of medicare might free up governments to spend tax
dollars on other priorities, or simply on tax relief. But either way,
individual Canadians would still be left to personally bear the costs of
services that are not covered. To me, that is contrary to the spirit and
intent of medicare. It is not the Canadian way.
Canadians Want and Need a Truly National Health Care System
As I noted earlier, Canadians' attachment to medicare is based on their
understanding of it as a right of citizenship. They connect with the
values that define medicare, not the particular features of the system in
place in their province or territory. Canadians expect the system to
guarantee them relatively similar access to a common basket of medicare
services of equal quality, regardless of where they live. They expect
governments, providers and caregivers to work collaboratively to maintain
a system with these attributes.
The fact that Canadians perceive health care as a national endeavour
should not be construed as an invitation for federal intrusion into an
area of primary provincial jurisdiction. Nor should it be interpreted to
mean a "one-size-fits-all" approach to health care delivery. In
a country as geographically, economically, regionally and culturally
diverse as ours, this is neither realistic nor desirable. Medicare must be
constantly renewed and continually refined, if it is to remain relevant
and viable. A new common approach is needed to encourage, not constrain,
innovation. If we allow medicare to become static, it will become brittle
and eventually break.
Canadians realize that illness and injury know few boundaries; they
afflict all of us. They understand that organizing health care solely
along constitutional lines or provincial boundaries makes little practical
sense. They recognize that sometimes by design, sometimes by financial
necessity, and more often by default, provinces are increasingly willing
to go it alone insofar as their respective health care "systems"
are concerned. Today, we sit on the cusp. Left unchecked, this situation
will inevitably produce 13 clearly separate health care systems, each with
differing methods of payment, delivery and outcomes, coupled by an ever
increasing volatile and debilitating debate surrounding our nation, its
values and principles.
This is no way to renew a program of such immense personal and national
importance and, for sure, it is no way to strengthen those foundations
that unify us as a nation. It is time for governments, caregivers and
Canadian citizens to embark together on the road to renewal. The reality
is that Canadians embrace medicare as a public good, a national symbol and
a defining aspect of their citizenship. I have, therefore, recommended a
series of measures to modernize the legislative and institutional
foundations of medicare that will better equip governments to move forward
together to provide Canadians with the health care system they want.
Canadians Want and Need a More Comprehensive Health Care System
We must transform our health care "system" from one in which
a multitude of participants, working in silos, focus primarily on managing
illness, to one in which they work collaboratively to deliver a seamless,
integrated array of services to Canadians, from prevention and promotion
to primary care, to hospital, community, mental health, home and end-of-life
care.
Indeed, despite our common use of the term "our health care system,"
the relevance of this term is increasingly doubtful. A system where
citizens in one part of the country pay out-of-pocket for "medically
necessary" health services available "free" in others, or
where the rules of the game as to who can provide care and under what
circumstances vary by jurisdiction, can scarcely be called a "system."
There are many examples of the "disconnect." Elderly people who
are discharged from hospital and cannot find or afford the home or
community services they need. 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, and almost all of whom are
experiencing tremendous strain. Health professionals, who are increasingly
stressed, while performing tasks ill suited to their abilities and
training. Patients, who are forced to navigate a system that is a complex
and unfriendly mystery, in order to find the right specialist, the nearest
facility, and the best treatment. People who are forced to repeat lab
tests, and to recount their medical histories time and time again. We need
clear and decisive action to modernize the system and make it more durable
and responsive. In my Final Report, I have recommended a series of
measures to create a more comprehensive system whose component parts fit
together more seamlessly.
Canadians Want and Need a More Accountable Health Care System
Accountability must also be improved. Health care in this country is
now a $100 billion enterprise, one of our society's largest expenditures.
Yet no level of government has done a very good job accounting for how
effectively that money is spent. Canadians still do not know who to
believe in the debate over which level of government is paying what share
for health services.
Canadians are the shareholders of the public health care system. They own
it and are the sole reason the health care system exists. Yet despite this,
Canadians are often left out in the cold, expected to blindly accept
assertion as fact and told to simply trust governments and providers to do
the job. They deserve access to the facts. Canadians no longer accept
being told things are or will get better; they want to see the proof. They
have a right to know what is happening with wait lists; what is happening
with health care budgets, hospital beds, doctors, and nurses, and whether
the gaps in home and community care services are being closed; whether the
number of diagnostic machines and tests is adequate; and whether treatment
outcomes are improving.
Information is a key ingredient. We live in an age of laser surgery and
are unlocking the mystery of the human gene, yet our approach to health
information is mired in the past. We gather information on some health
issues, but not on others. And much of the information we gather cannot be
properly analyzed or shared. Indeed, we know far more about resources and
the dollars being spent than we do about the return on those investments.
Better information will facilitate evidence-based decision making. How can
we hold health care managers accountable if what they are managing cannot
be measured? If we are to build a better health system, we need a better
information sharing system so that all governments and all providers can
be held accountable to Canadians. As a result, I have recommended a series
of measures to improve transparency across the system, to make decision-making
structures more inclusive, to accelerate the integration of health
informatics, to provide for a secure electronic health record for
Canadians that respects their right to privacy, and to give Canadians a
greater say in shaping the system's future.
Making Canadians the Healthiest People in the World
During our public hearings, many presentations focused on the need to
improve our understanding of the determinants of health. I heard that the
quality of the air we breathe, of the water we drink, and of the food we
eat directly affects our health and our health care system. I learned that
educated, employed and physically active Canadians are far more likely to
be healthy than those who are not, and that spiritual, emotional and
physical well-being are often inextricably linked. I also heard that
lifestyle changes can markedly reduce the incidence and severity of many
major and debilitating diseases. Keeping people well, rather than treating
them when they are sick, is common sense. And so it is equally common
sense for our health care system to place a greater emphasis on preventing
disease and on promoting healthy lifestyles. This is the best way to
sustain our health care system over the longer term.
The health care system must be on the front lines of this effort.
However, we must also invest in related areas of public life to create
community mobilization, a sense of social inclusion and provide the
infrastructure that enables healthier lifestyle choices. Investing in
public housing, a clean environment and education are all part of the
solution leading to a healthier Canada.
But we need more than rhetoric; we need action. And so, I have recommended
a greater emphasis on prevention and wellness as part of an overall
strategy to improve the delivery of primary care in Canada, the allocation
of new moneys for research into the determinants of health, and that
governments take the next steps for making Canadians the world's
healthiest people.
A System Based on Canadian Values
Early in my mandate, I challenged those advocating radical solutions
for reforming health care - user fees, medical savings accounts, de-listing
services, greater privatization, 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."
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.
It has been suggested to me by some that if there is a growing tension
between the principles of our health care system and what is happening on
the ground, the answer is obvious. Dilute or ditch the principles. Scrap
any notion of national standards and values. Forget about equal access.
Let people buy their way openly to the front of the line. Make health care
a business. Stop treating it as a public service, available equally to all.
But the consensus view of Canadians on this is clear. No! Not now, not
ever. Canadians view medicare as a moral enterprise, not a business
venture.
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 "new" solutions are doomed to
fail. Canadians want their health care system renovated; they do not want
it demolished.
But we must also recognize that since the earliest days of medicare,
public and private sector care providers (including fee-for-service
doctors) have been part of our health care system. Our system was never
organized according to a strict protocol; it evolved in accordance with
the existing capacity of public and private providers, changing notions of
what constitute "core services," and the wishes of Canadians.
One of the most difficult issues with which I have had to struggle is
how much private participation within our universal, single-payer,
publicly administered system is warranted or defensible. On the one hand,
I am confronted by the fact that the private sector is already an
important part of our "public" system. The notion of rolling
back its participation is fraught with difficulty. On the other hand, I am
acutely aware of the potential risks to the integrity and viability of our
health care system that might result from an expanded role for private
providers.
At a minimum, I believe governments must draw a clear line between direct
health services (such as hospital and medical care) and ancillary ones (such
as food preparation or maintenance services). The former should be
delivered primarily through our public, not-for-profit system, while the
latter could be the domain of private providers. The rapid growth of
private MRI (magnetic resonance imaging) clinics, which permit people to
purchase faster service and then use test results to "jump the queue"
back into the public system for treatment, is a troubling case-in-point.
So too is the current practice of some worker's compensation agencies of
contracting with private providers to deliver fast-track diagnostic
services to potential claimants. I agree with those who view these
situations as incompatible with the "equality of access"
principle at the heart of medicare. Governments must invest sufficiently
in the public system to make timely access to diagnostic services for all
a reality and reduce the temptation to "game" the system. In
order to clarify the situation in regard to diagnostic services, I have
recommended that diagnostic services be explicitly included under the
definition of "insured health services" under a new Canada
Health Act.
Conclusion
Canada's journey to nationhood has been a gradual, evolutionary process, a
triumph of compassion, collaboration and accommodation, and 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 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 co-operation 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 toward as individuals, families and communities,
and as a nation. The national 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.
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"Canada must be a just society...and Our dreams for this beautiful
country will never die" Rt. Hon. Pierre Elliott Trudeau
1919-2000