The values of reform; Do we care? Renewing Canada's commitment to health; Edited by Margaret A. Somerville; McGill-Queen's University Press, Montreal & Kingston; 1999; 166 pp. $44.95 (cloth) ISBN 0-7735-1877-0; $19.95 (paper) ISBN 0-7735-1878-9 FIGURE
Do We Care?, the collected papers from a conference on Canadian health policy held in Toronto in October 1998, offers many interesting analyses of the problems affecting Canada's health care system, but ultimately not enough precision in recommendations for reform. Former Ontario Premier Bob Rae claims that "there is a great deal of consensus across the country on what needs to be done," which raises the question of why it has been so hard to implement the reforms on which there is such evident agreement. The answer appears to be that the Canadian élite no longer support medicare and that this attitude has started to spill over into the general public. Rae observes that we cannot support European-style services with American-style taxes. Canadians used to describe their aspirations as "peace, order and good government," but increasingly we are more likely to be seduced by "life, liberty and the pursuit of happiness." As Alberta law professor Timothy Caulfield notes, medicare's strength is the strong collective values of the population it serves. Its weakness is the individual values of consumers. Several of the authors note that the future of medicare will be defined by how we strike a balance between these two perspectives.
Pharmacare is an excellent example of the challenges facing medicare. Like home care, pharmacare was recommended by Justice Emmett Hall's 1964 Royal Commission on Health Services, but it was not included in the 1966 federal medicare legislation. The provinces did implement drug plans, but these were incomplete and were scaled back further in the 1990s. At the same time, shortened hospital stays mean that patients have to pay more of their drug costs: medications prescribed out of hospital are not covered by the Canada Health Act. The National Forum on Health in 1998 strongly recommended the introduction of a national pharmacare program, claiming that, like medicare, it would lead to more equitable drug coverage, administrative savings and lower overall costs. However, despite lower overall costs to society, the costs to government would rise. University of Toronto Professor Raisa Deber notes that the "first law" of cost control is to shift costs onto others; indeed, in an era when fewer Canadians are interested in collective solutions to their problems, Canadian governments have shifted, and shafted. FIGURE
Nathalie St-Pierre, executive director of the Federation of Quebec Consumers Associations, describes how the implementation of Quebec's new drug policy shifted costs away from government, left overall costs unchanged and saddled poor and elderly people with greatly increased costs. Other analyses have estimated that the new plan led to hundreds of deaths and thousands of hospital admissions as sick patients were forced to choose between buying food and having a prescription filled.
Given such a toxic policy environment, how can we get medicare back on the rails? First, it's important to reaffirm the values of public finance. After all, medicare is a modern-day miracle. Public finance allows access to high-quality health care for the poor as well as the rich, but it also controls costs. Moreover, medicare is the country's most effective economic development strategy. Despite repeated attacks from the business community, medicare greatly reduces business costs.
One would never know about the virtues of medicare from reading our national newspapers. In his introductory essay John Ralston Saul comments that Canadians would not allow medicare to be eliminated explicitly, but they are now being convinced that it doesn't work - so that a private system can be implemented in its place.
We need to be more precise in our prescriptions for reform. Current recommendations tend to focus on developing intersectoral strategies to improve health as well as improving the efficiency of health care services. However, John Wade, former Manitoba deputy minister of health, notes that intersectoral policy-making failed in his province. He blames the way governments are organized, and no doubt he is at least partly correct. However, perhaps equally to blame has been the tendency to treat health as a bureaucratic or technical construct when, to paraphrase Rudolf Virchow, "health is politics." Governments don't coordinate different policy areas unless there is a pressing need such as a war. Advocates for healthier public policies need to relocate health in the political playing field and then develop new tactics to support local communities in pushing health issues such as early childhood development up the political ladder.
We also need to be more specific about the changes needed in health care delivery. To use the economists' language, most of the recent focus has been on technical efficiency (doing things right) instead of allocative efficiency (doing the right things). We have pared down the costs of cholecystectomies with laparoscopy, time-motion studies and with cost-shifting that requires consumers to recover at home. But should we be removing as many gallbladders as we do? We can now identify the day a stroke patient becomes "subacute," but we have done little to reduce the risk of stroke for the 70% or more of Canadians with hypertension whose blood pressure is poorly controlled.
We have downsized the hospital at the bottom of the cliff, but we have not yet put a fence around the top. Why should we be surprised that the bodies continue to fall? There is a great potential pay-off from the better monitoring of chronic illness in the community, but we need to identify this clearly as a management challenge. We should then deal with the systemic barriers to a truly comprehensive primary health care system. Ironically, the only author who touches on this issue in Do We Care? is Terrence Montague, who found such little support for his ideas within government and academia that he now works for the drug company that sponsored this conference.
Although this volume fails to offer many solutions, readers will still find it a useful addition to the section of their library that diagnoses problems. Many of the authors identify the crucial issue as one of values. John Ralston Saul declares, "If we decide that we care, and choose the direction we want to go in, then we will find a way to make it happen." I believe Canadians do care. But do their politicians have the skill to mobilize the support medicare needs to survive?