CMAJ invited the 8 contenders for the leadership of the Liberal Party—Michael Ignatieff, Bob Rae, Stéphane Dion, Gerard Kennedy, Ken Dryden, Scott Brison, Joe Volpe and Martha Hall Findlay — to sketch their views on several of the more pressing policy issues facing the health care system.
Curiously, while it's often cited as the foremost issue on the minds of Canadians and while the system must now resolve a raft of challenges ranging from a shortage of physicians to soaring drug costs, health care has received little, if any, attention in the run-up to the December 2nd vote in Montréal, during which roughly 5500 delegates will stamp the party's imprimatur on a successor to the indecisive Paul Martin.
Hall Findlay bluntly accuses her rivals of having deliberately shied away from health care issues out of fear.
“Our heads are in the sand on this,” she argues. “Everybody is afraid of the issue. They're terrified of talking about the problems the health care system faces…. I believe in a single-tier system, but we're losing it real fast. Yet, there isn't enough political will to even talk about it.”
That proposition is partially borne out by the fact that two contenders — Kennedy and Volpe — opted not to participate in the CMAJ survey, despite having had more than a month to formulate their responses. Neither the former Ontario education minister nor the ex-federal Immigration minister mustered any form of explanation for their decisions.
Of the candidates who responded, Rae has clearly done the most thinking on health care and, as the only one who has issued a health policy paper as of the CMAJ's press deadline, appears to have more detailed and nuanced positions than his rivals. Candidate responses can be viewed at www.cmaj.ca.
For the most part, the contenders don't appear adverse to some measure of privatization, or other forms of systemic change, although they're still quick to sing from the same hymnal the Liberal choir has used for decades to cast the party as the great defender of a universal, single-payer medicare system.
All respondents vowed to, in some manner, invigorate the federal role in health care, although some appeared more vigorous in their enthusiasm than others. Asked what specific role the private sector has in the aftermath of the 2005 Supreme Court of Canada landmark ruling that Quebec's ban on private health insurance for medically necessary services violated provincial human rights law (CMAJ 2006;175:17-8), none expressed outright opposition to privatization except for Dryden, who stood staunchly against “private health insurance coverage or private service delivery by physicians.” Rae essentially ducked the issue, but others were more sympathetic to private sector involvement. Brison argued for “customized” solutions by provinces, while Dion called it “an advantage for Canadians to have many provincial health systems, as each one innovates and learns from the success of others.” Ignatieff and Hall Findlay argued more private delivery could yield needed cost-efficiencies.
As a consequence of the above-mentioned Chaoulli decision, all jurisdictions have, de facto, been forced to move toward the establishment of wait time guarantees. They are now contemplating forms of publicly funded recourse mechanisms for Canadians lingering on wait lists, particularly as the first nationwide effort to compare wait times suggests it's all but impossible to ascertain whether the situation is improving, even in the so-called priority areas of cancer, heart, diagnostic imaging, joint replacements and sight restoration (CMAJ 2006;174:1246-7).
Asked how the determination should be made as to when such a recourse mechanism kicks in, most candidates either ducked the issue or deferred it to the relentless rubicon of Canadian politics: intergovernmental consultations. Dryden noted that physicians should have a role to play in determining whether a provincial system can't provide timely care, but only Rae offered a specific mechanism, calling for the establishment of a “swift response ombudsperson for patients,” as well as the adoption of federal Wait Times Advisor Dr. Brian Postl's recommendation that regional centres of excellence be established to handle “backlogs and bottlenecks.” Hall Findlay rejected the entire notion of guarantees as a “politically motivated, expensive band aid” that wastes resources. The real solution lies in “more trained personnel, more equipment, and the efficient allocation of both.” Ignatieff hedged, noting that while he believes in guarantees, “shuttling patients around the country is not a viable long-term solution.”
With delegates to the CMA general council in Charlottetown earlier this year having urged governments to remove existing prohibitions against simultaneous practice in both the public and private sectors (forcing physicians who bill patients for necessary medical services to opt out of the public system), the candidates were asked whether they believe such bans should be lifted. All but Brison were staunchly opposed, primarily on the grounds that the current shortage of physicians precludes allowing such parallel practice without seriously compromising the public system.
Asked how the shortage should be resolved, the respondents universally agreed that more entry spaces should be created in medical schools, while there should be accelerated recognition of the credentials of international medical graduates (IMGs). Rae and Hall Findlay urged measures to ease physician workloads by off-loading selective duties onto the shoulders of “specialty trained health care professionals.” Dryden and Brison urged the creation of some form of health human resources planning body or framework. Ignatieff took the ambiguous position that “any reforms of the health care system cannot create financial disincentives for physicians to practice.”
The respondents had conflicting views in regard to proposed revisions to the existing process for assessing and licensing both Canadian-trained graduates and IMGs, although a blue-ribbon panel struck to resolve means of alleviating the shortage of physicians in Canada urged that a national agency be established to oversee a comprehensive “pan-Canadian” strategy for educating, recruiting and licensing doctors (CMAJ 2006;174:1827-8). Among measures urged by Task Force Two were harmonized licensure of new graduates, standardized revalidation of existing and international physicians, and a national repository. Brison definitely favours a national approach, and even a multilateral international regime, but Rae fears it would step on provincial toes. Hall Findlay and Ignatieff believed it unnecessary bureaucracy.
The respondents were less than enamoured with the notion of establishing an arm's-length national patient safety agency that would investigate mishaps and recommend regulatory or process interventions to improve safety, as recommended in a Health Canada commissioned report earlier this year (CMAJ 2006;174:1699-700). Only Rae thought the notion had any merit whatsoever.
They were equally tepid about the creation of a national pharmacare plan, although Liberals have toyed with the idea since Mr. Justice Emmett Hall's 1964 Royal Commission on Health Services recommended that medicare be gradually expanded to include prescription drugs. Such a plan was also the centerpiece of the 1997 final report of the National Forum on Health, a blue-ribbon panel appointed by three-term Prime Minister Jean Chrétien, but the Liberals deep-sixed it for a more modest approach that provides assistance only for so-called “catastrophic” drug costs for families. The current crop of leadership contenders favours continued incrementalism, with only Rae and Ignatieff expressing unequivocal support for a full-scale national plan, eventually. Ignatieff posited that a national plan would reduce costs by “allowing bulk drug purchases.” He also urged creation of a national drug formulary.
Although other health issues have rarely registered on the campaign radar screen, they've made an occasional blip.
Among specific commitments were ones by Rae, Dion and Ignatieff to bolster health and biomedical research funding at the Canadian Institutes of Health Research. Canada must be “a leader, not a laggard in such research,” Rae said.
Rae, Dion and Ignatieff have made some form of commitment to resurrect ParticipACTION, the now-defunct federal fitness program, so as to promote healthier lifestyles and ultimately reduce the financial strains on the system.
Rae and Dion have vowed to bolster spending on measures to improve Aboriginal health, with Rae being the most specific in calling for adoption of the Population Health Strategy recommended by the Health Council of Canada, which included calls for major investments in programs to prevent and manage chronic diseases.
Dion has also advocated “a better drug approval process, and better international cooperation on dealing with pandemics that we must prevent in Canada. We need to strengthen our public health agency.