In pharmacare debate, look to T.C. Douglas, Emmett Hall

In pharmacare debate, look to T.C. Douglas and Emmett Hall, not Bill Morneau
Finance Minister Bill Morneau undercuts pharmacare debate. Art Babych photo.

The Liberals promised in the recent federal budget to look into pharmacare and they lured Ontario’s health minister Dr. Eric Hoskins away from provincial politics to lead consultations on how to proceed. This may be mostly a ploy to thwart the NDP which, along with the labour movement, has been trying to build support for a universal, publicly–financed pharmacare program.

The Liberals under Jean Chretien promised in 1997 to expand medicare to cover prescription drugs. Chretien blithely ignored that promise after being elected. Now Eric Hoskins will consult and then report in the spring of 2019, just in time for the Liberals to make another promise going into the October election.

“Plan” or “strategy?”

But let’s leave politics and talk rather about design. When I heard Finance Minister Bill Morneau’s speech, I assumed that he was talking about a national, universal and tax-financed program. But less than 24 hours later he undercut that idea. Speaking to the Economic Club of Canada, he said that he was looking for a national pharmacare “strategy” but not a national pharmacare “plan.” He said that his preferred arrangement would “fill the gaps” left by the existing patchwork of private and public plans.

What Morneau likely has in mind, even before Hoskins consults Canadians, is to have the government subsidize private insurers to arrange drug coverage for those without it, rather than devising a universal plan akin to medicare.

The medicare analogy

The medicare analogy is one relevant to pharmacare. The architects of medicare in Canada include Tommy Douglas, whose CCF created a universal, tax-financed plan for health insurance in Saskatchewan in 1962, and Judge Emmett Hall whose royal commission report on health care in 1964 recommended Saskatchewan-style medicare for all of Canada. Douglas said a public plan for doctor and hospital visits was a good start but that public health insurance should eventually include much more. Hall, in his royal commission report, actually proposed universal pharmacare, vision and dental care.

It is instructive to follow Hall’s reasoning.  By the 1960s, medical insurance plans, many of them owned by physicians’ groups, were providing private health insurance to millions of people, but only to those who could afford it. Hall found, however, that 40 per cent of Canadians either had no health insurance or had plans whose coverage he deemed inadequate.

When he sifted through the evidence, Hall decided it would be far better to have the federal government subsidize provincial health plans for single-payer, universal insurance than it would be to pay for a patchwork of private plans to include people without coverage. Both Hall and Douglas were also opposed to subjecting people to a belittling means test to decide who can and cannot afford to buy insurance.

Savings with pharmacare

In 2017, the Parliamentary Budget Officer (PBO) found that there were about 26 million Canadians covered by various drug plans, largely through their employers.  About 700,000 people had no drug coverage at all, and another 3.6 million had inadequate coverage. A central question is how best to provide for these 4.3 million people. There are numerous private insurers who will want the government to pay them to do it, and they will therefore oppose a universal, single-payer plan.

Prescription drugs represent the most rapidly rising cost in the health care system. The PBO reports that Canadians spent $28.5 billion on pharmaceuticals in 2015. The PBO also says that on average Canadians pay 22 per cent more for patented drugs than do people in other countries belonging to the OECD. A universal, publicly-financed drug plan would allow for bulk purchasing by federal and provincial health plans, and the PBO estimates that could save  between $4 and $11 billion a year. But it would also mean shifting much of the expenditure from individuals and employer plans to the public sector in Ottawa and the provinces.

Mobilize for it

There are billions of dollars at stake in profits for the pharmaceutical companies, and we can expect that they are lobbying aggressively against any a single-payer and universal plan. One of the threats they often make is to move their production elsewhere if they don’t get their way.

We will get universal publicly-financed pharmacare only if Canadians mobilize for it as they did for medicare and more recently for improvements to the Canada Pension Plan.

Dr. Brian Day’s medicare challenge: he’s no freedom fighter

Dr. Brian Day, a Vancouver-based orthopaedic surgeon, is using the courts to attack medicare
Dr. Brian Day, undercutting medicare. (Day website photo)

Vancouver orthopaedic surgeon Dr. Brian Day is challenging a law that prohibits doctors from working in both the public and private health care systems simultaneously and extra billing their patients while they do so.

Day did some boxing in his youth and now, bizarrely, he compares himself to the late Muhammad Ali as a kind of freedom fighter against injustice. He says he’s going to court not out of self-interest but rather on behalf of patients on waiting lists.

Opposes equal access

The basic tenets of medicare, which covers hospital stays and physicians’ services, are that it be tax-financed, publicly administered and equally available to everyone. Day is not impressed with equal access as a core value. He told the National Post: “We in Canada will give the same level of services to a wealthy person as to person who isn’t wealthy, and that doesn’t make sense.” Muhammad Ali he is not.

Extra bills patients

In fact, it seems that Day has been extra-billing patients for years. According to a B.C. Medical Services Commission audit initiated in 2008 and completed in 2012, Day’s clinic illegally charged patients hundreds of thousands of dollars more for services covered by medicare than is permitted by law. Day filed his legal challenge in 2009, after the audit had begun, claiming that the law preventing a doctor from extra billing patients is unconstitutional.

Wants it both ways

In Canada, the fee for physicians’ services is negotiated between the medical profession and agencies of a provincial government. There is nothing to stop a doctor from practicing entirely outside of the public system and billing his or her patients rather than the government. What Day wants, however, is the right to provide services in both the private and public systems, and also to charge more than the negotiated fees. Then-Health Minister Monique Begin made that illegal in 1983 because she believed it created a financial barrier for the poor and people of modest means.

Reform, but don’t privatize

Day’s critics say that his solution would mean reduced services for patients who don’t have the extra money to jump the queue. Former Saskatchewan Premier Roy Romanow, who led the Royal Commission on the Future of Health Care in Canada, concluded in 2002 that Canadians cherish their health-care system and see it as a right of citizenship. Most often it works well, but it’s also in need of improvement and innovation, which Romanow said demands thoughtful reform but not privatization.

Political door is closed . . .

Most Canadians and their doctors support medicare, too. But attacks upon it have been constant and led most notably by the Fraser Institute, a Vancouver-based lobby group that also dislikes unions and public schools, and challenges the science of climate change. Some politicians, including former premiers Ralph Klein and Mike Harris, also wanted to undermine medicare but citizens and voters wouldn’t stand for it. Interestingly, both Harris and Klein after retiring from politics became associated with the Fraser Institute, which receives at least part of its financing from groups in the U.S. linked to the Koch brothers and far-right organizations.

. . . so use the courts

In Canada, the political door has been closed to Day and his backers so they are now are trying to use the courts in their bid to to undercut public health care.

This article was published on the United Church Observer website on September 15, 2016. 

 

Bill C-14, churches one voice among many in debate on assisted dying

Faith groups in Canada are one voice among many in assisted dying debate
Faith groups one voice among many in assisted dying debate

The current debate surrounding Bill C-14 — the legislation regarding medical assistance in dying — is a reminder of how Canada has become a more secular society in which organized religion plays a diminished role in public life.

My own parents, both in their 50s, died within 16 months of one another in the 1970s. During their ordeals in our rural Saskatchewan community, there was never any mention of assistance in dying and no possibility of their choosing such a path even if they had wished it so. We didn’t even have the language to describe it. There had, of course, been suicides in our predominantly Catholic community, and they were considered a grievous sin equivalent to murder. We were told that, ultimately, our lives didn’t belong to us but rather to God, and that it was God who chose when and how those lives would end.

Sue Rodriguez sought assisted suicide

Fifteen years later, such concepts were challenged by Sue Rodriguez, who believed that her life did, indeed, belong to her. She was diagnosed with Lou Gehrig’s disease and fought to have the legal right to assisted suicide. Her case then went to the Supreme Court, where she argued that a ban on assisted suicide was an infringement of her Charter rights to life, liberty and security of the person. Meanwhile, religious leaders — including the Canadian Conference of Catholic Bishops and the Evangelical Fellowship of Canada (EFC) — appeared as intervenors before the court in opposing Rodriguez. This marked the beginning of an informal alliance between bishops and evangelicals which has continued on other public issues, including legal opposition to same sex marriage.

Rodriguez eventually lost in a 5-4 judgment and, in 1994, she took her own life with the help of an anonymous physician. But fast forward to 2011, when the B.C. Civil Liberties Association went to the Supreme Court on behalf of two other gravely ill women, once again challenging the law against assistance in dying. That time, the court ruled that the Criminal Code prohibition was unconstitutional because it breached the same provision of the charter that Rodriguez had challenged more than 20 years earlier. In 2015, the court then instructed parliament to draft new legislation allowing medical assistance in dying in certain limited circumstances — something that’s now being debated.

Civil society on C-14 

The Canadian Medical Association (CMA), which represents 83,000 physicians, has come out in support of Bill C-14. The Canadian Psychiatric Association and the Canadian Association for Community Living were more cautious, although not opposed to the bill. The B.C. Civil Liberties Association, which launched the challenge at the Supreme Court, is keenly disappointed that the provisions for medically assisted death are, in its estimation, too restrictive.

Response from faith based organizations

And once more, the most vociferous opposition has come from the Catholic-Evangelical leadership and a number of allied groups. A news conference on Parliament Hill organized by the EFC and Catholic bishops also included representatives from the Canadian Council of Imams, the Salvation Army and a local rabbi.  Curiously, neither the United Church nor the Anglicans, Canada’s largest Protestant denominations, have released an official position on Bill C-14. The Anglicans have set up a task force and the United Church says it is developing a statement.

Religious leaders no longer talk, at least publicly, about our lives belonging to God. They do, however, talk about medical assistance in dying as “intentional killing,” and as being morally and ethically wrong. Catholic leaders warn that their many hospitals will not participate in any such procedures and will not make referrals to other physicians on behalf of terminally ill patients who request it. One wonders how they can do so when most of their funding comes from governments.

A diminished role

Indeed, times have changed. Religious leaders used to meet with the entire federal cabinet. Today, churches and religiously based organizations are merely a few among many mature and competent voices, such as the CMA, debating public policy. The contributions from faith-based organizations are valuable but no longer prescriptive.

This piece appeared in somewhat shorter form on my blog with the United Church Observer on April 28, 2016.

CMA’s Demand A Plan a winner in 2015 Canadian election

Canadian Medical Association (CMA) President Dr. Cindy Forbes. Photo courtesy CMA.
Canadian Medical Association (CMA) President Dr. Cindy Forbes. Photo courtesy CMA.

I belong to Ottawa’s Parliamentary Press Gallery and had access to a rich variety of information circulated during the 2015 federal election campaign. The most impressive advocacy that I saw was the Demand A Plan campaign, which was launched by the Canadian Medical Association (CMA) and several supporting groups. Now, that campaign has been shortlisted for an international prize in the annual Reed Awards, which will take place in Charleston, S.C. on Feb. 18.

Multi-media campaign

The Demand A Plan alliance last year waged a multi-media advocacy campaign, calling for a national seniors’ strategy. According to the CMA, more than 30,000 Canadians used the campaign’s website and sent roughly 25,000 letters to candidates across the country, asking where they stand on seniors’ issues. The campaign website also provided a “promise tracker” tool, which allowed visitors to compare the policy statements of different political parties.

Medicare must adapt

Although it was created more than 50 years ago, when the average age was much younger, medicare has not adapted well to serve the growing number of elderly Canadians. By 2036, people aged 65 and over will make up a quarter of the population and account for 62 percent of health costs.

The alliance says that it supports universal public health care but fears the system won’t survive unless seniors’ care is redesigned. For example, the group says that it takes nine months to get a hip replacement in Canada because hospital beds are crowded with seniors — many of them suffering from dementia and other chronic diseases without long-term care and home-care support. Interestingly, the group says that caring for someone in a hospital costs $1,000 a day, compared to $130 a day in long-term care and $55 a day at home.

Dr. Cindy Forbes: “momentum”

“We cannot lose momentum as we continue to push for federal leadership in the development of a national seniors’ strategy,” CMA President Dr. Cindy Forbes says, adding that the alliance has documented the Liberal Party’s election promises as they relate to seniors’ care (Those, too, are published on the website). They include negotiating a new Health Accord with the provinces and territories; investing $3 billion over the next four years to deliver more and better home-care services for all Canadians, including access to high-quality, in-home caregivers, financial support for family care, and, when necessary, palliative care; and investing in affordable housing and seniors’ facilities.

This spring, the CMA and its alliance partners want the Trudeau government to convene a meeting of provincial and territorial premiers to discuss seniors’ care. They also want to see a national seniors’ strategy in place by 2019.

No mention of pharmacare

Unfortunately, there is no mention in either in Demand A Plan or in the Liberal government’s promises, of a national pharmacare plan. Pharmaceuticals are the fastest growing component in health care costs and the need for such a plan is urgent.

They’ve come a long way

Still, there is no doubt that Canada’s doctors have come a long way since the CMA strenuously opposed the introduction of Medicare in Saskatchewan in 1962, and just as adamantly opposed recommendations for a similar national program by the Hall Commission in 1964.

A version of this piece ran in the United Church Observer on February 18, 2016.

Justin Trudeau’s ‘sunny ways’ and the challenges ahead

Justin Trudeau’s “sunny ways”. Photo by Wikimedia Commons, Alex Guibord
Justin Trudeau’s “sunny ways”. Photo by Wikimedia Commons, Alex Guibord

As Prime Minister-designate Justin Trudeau stood before an election night crowd in Montreal on October 19, he quoted former Prime Minister Sir Wilfrid Laurier, saying: “Sunny ways my friends, sunny ways.”  Referring to his Liberal party’s convincing upset victory in capturing 184 seats, well beyond the 99 for the Conservatives and 44 for the NDP, Trudeau said, “This is what positive politics can do.” Continue reading Justin Trudeau’s ‘sunny ways’ and the challenges ahead

Whither the Canada health accord?

Paul Martin negotiated health accord, Creative Commons photo
Paul Martin negotiated health accord, Creative Commons photo

The existing health care accord between Ottawa and the provinces and territories is set to expire on March 31, 2014 and the long term consequences are alarming. The issues are complex and the amount of money involved is in the many billions, but the key to understanding what is happening is this: Canada has a public, single payer health system for visits to the doctor and stays in hospital thanks to earlier political leaders, including Tommy Douglas, Woodrow Lloyd and Lester Pearson. Publicly-funded expenditures account for about 70% of all health care spending in Canada. The remaining 30% is private spending on items such as dental and vision care and pharmaceutical drugs. When publicly funded health care was first introduced in the 1960s, its costs were shared on a 50-50 basis by Ottawa and each of the provinces, which actually deliver most of that care. That cost-sharing arrangement has evolved greatly and will change even more dramatically in future, given a unilateral announcement made in 2011 by Jim Flaherty, who was Canada’s finance minister at the time.

Federal contribution dropping

According to a 2013 study by the Canadian Institute of Actuaries and Society of Actuaries, health care transfers from Ottawa to the provinces, which once accounted for 50% of all public expenditures, had fallen to 21% in 2012. The actuaries estimate that the federal contribution would drop to a mere 14.3% by 2037 under the revised formula announced by Flaherty. Continue reading Whither the Canada health accord?

Pulpit and Politics, best stories 2012

I worked for years in newsrooms and each December we would produce what we called Year Enders, which summarized the most significant stories that we had covered in the past 12 months. In that tradition, I have reviewed Pulpit and Politics for the year past and this is a brief summary of what I have found. Continue reading Pulpit and Politics, best stories 2012

U.S. Catholic bishops fight Obama’s Affordable Care Act

The U.S. Supreme Court has ruled that President Obama’s Affordable Care Act for health reform is constitutional but the country’s Catholic bishops remain staunchly opposed. When the president signed the ACA into law in 2010, the bishops claimed that it would force insurers to pay clients who received abortions and birth control services and advice. The president moved to assure the bishops that public money would not be used to provide for abortions, but that still left contraception. The president also made an exception there which, he says would exempt the employees of churches. The bishops say that doesn’t go far enough, and they want the exemption to apply to employees in all Catholic institutions, including hospitals and schools. In short, the bishops are prepared to scuttle health care reform for 300 million Americans because of its limited provision for contraception as an insured service. Continue reading U.S. Catholic bishops fight Obama’s Affordable Care Act