“Fuzzy” elements of CMA transformation blueprint may yet undermine medicare, critics say

The Canadian Medical Association’s ballyhooed proposals for transformative change of the health care system may yet prove to be code for diminution of the principles of equity that underlie medicare, warn two of Canada’s foremost defenders of a publicly funded health care system.

Proposals like ones to create tax-deductible long-term care insurance or to allow more activity-based funding of hospitals could erode fairness within the system, while the rhetoric underlying the CMA blueprint’s talk of financial sustainability may be code for privatization, says Dr. Robert Woollard, vice-chair of Canadian Doctors for Medicare.

As the proposals are refined, it is essential that they be scrutinized against the five principles of the Canada Health Act (universality, accessibility, portability, comprehensiveness and public administration), Woollard, a Vancouver, British Columbia, family physician and professor of family medicine at the University of British Columbia, said during a press conference Monday at the CMA’s 143rd annual general meeting in Niagara Falls, Ontario.

Although the CMA appears to have shifted toward reform that is consistent with the spirit and principles of the Canada Health Act, it is essential that more detailed manifestations of the proposals be examined with “the lens of equity and fairness,” Woollard said. “That’s the lens that in fact Canadians draw upon. And Canadians are not thoughtless in this regard. They can smell unfairness when it’s presented to them.”

Dr. Danielle Martin, chair of Canadian Doctors for Medicare, added that several of the proposals outlined in the blueprint have had “mixed histories in other jurisdictions and when we are pursuing these ideas, it makes sense to have clear criteria to tell us whether or not we are headed down the right road.”

“Tax deductible long-term care insurance is one example,” she said. “If millions of people were to purchase such insurance, it would cause a huge transfer of wealth from individuals and governments to insurance companies. And, in fact, we predict that tax-deductible long-term care insurance would be likely to worsen access to long-term care for the most financially vulnerable members of our population.”

There are similar concerns about “activity-based funding and pay-for-performance, as these can have different impacts depending upon how they’re operationalized,” she said. “At times, they’ve been used as a stalking horse for privatization and certainly, some of the original advocacy of the CMA for activity-based funding, in particular, we feel originated in a desire to move the system more towards for-profit delivery of health care services.”

Martin added that implementing change without ensuring that Canadians have access to care based on need, rather than ability to pay, “risks undermining the very system we are working to improve.”

The currently murky elements of the blueprint “must be operationalized in a way that respects equity,” Martin argued. “If it turns out that, as we get into the details, discussing this transformation agenda, that in fact, some of that language is intentionally vague, so as to leave room for privatization advocacy, that’s obviously a huge cause for concern.”

Another concern rests in how Canadians resolve financing of health care that does not currently fall under the rubric of medicare’s medically necessary services umbrella, i.e., “how do we come to terms with the need to pay for things that were not originally included in the medicare basket but are becoming more important drivers of costs, like pharma, like long-term care, home care, etc.,” Martin added.

A far less analytic eye was trained on the transformation blueprint by Minister of Human Resources and Skills Development Diane Finley, who delivered the federal government’s annual address to the CMA gathering and mustered only a few words about the blueprint.

“I know the CMA recently issued a report with its prescription, if you like, for the transformation of health care,” Finley said in the prepared text of her keynote address. “It provides thoughtful input and will be an important part of future dialogue on health care.”

Filling in for Health Minister Leona Aglukkaq, who was travelling in Nunavut with Prime Minister Stephen Harper, Finley offered little in the way of additional insight into federal plans and often drew gasps of incredulity from delegates.

There were times when “jaws were slackened” by the simplicity of her comments, like those about Canada Health Infoway, Liberal Party health critic Dr. Carolyn Bennett later told reporters. (Finley’s comments were of the nature that information technologies “can be put to good use” in the health care system and could allow for such benefits as alerting physicians “to a patient’s use of different drugs that may have been prescribed by others.”)

Bennett also chided Finley for breaking tradition by refusing to field questions from delegates and instead, bailing through the back door. The government “has wrapped itself in a constitutional cocoon and thinks that everything to do with health and health care is provincial jurisdiction,” Bennett said.