December 2004: Medicare Still on Life-Support

Health accord flawed by poor accountability and enforcement
December 1, 2004

The health care accord reached last September by the federal, provincial, and territorial first ministers is a better deal than those signed in 2000 and 2003, but suffers from the same flaws: poor accountability, reporting, and enforcement. Despite this agreement, Medicare is still on life-support—not because of a lack of money, but because of weak or nonexistent controls on where and how the extra money will be spent. The agreement falls well short of Prime Minister Martin’s election promise of “a health-care fix for a generation,” and fails to live up to his pledge to stem the tide of health-care privatization.

Martin gave Canadians a firm assurance that his government would steer away from private, for-profit delivery of health care after the election. His new minister of health, Ujjal Dosanjh, also promised to do whatever was necessary to prevent privatization and expand public delivery “so we have a stronger health care system for all Canadians.”

But the September accord does not address—nor even mention—this most serious threat to the integrity and sustainability of Medicare. It contains no plan or proposal to stem the tide of privatization—a crucial gap that is amplified by another glaring omission—the failure to affirm the health-care vision and values reflected in the Romanow Report. Canadians see Medicare as a moral program, not a business venture. Tossing away the values that imbue our health-care system in the name of federal-provincial relations is nothing short of a betrayal of a public trust.

In light of the prime minister’s election promises, Canadians are owed an explanation as to how and when the federal government intends to curb health-care privatization. Any such action must start, first, with a commitment to spend public dollars solely for the public, non-profit provision of health care, and secondly, with a vigorous enforcement of the principles and conditions of the Canada Health Act.

Such federal accountability and guardianship are essential to ensure that public funds are used to protect and strengthen Medicare. An independent public accountability mechanism is needed to make sure that essential health-care reforms are made and to defend against the rapacious powerful business interests that want to privatize the potentially profitable parts of Medicare. This is a role that Canadians have a right to expect the federal government and the new Health Council of Canada to play.  

Canadians have to “follow the money” and insist on a full public accounting of every tax dollar devoted to health care. The future of Medicare rests on the ability of the people of Canada to hold their governments to account—to demand that they protect the values and principles of the Canada Health Act from the forces of encroaching commercialization.

We now examine the main terms of the September 2004 accord and grade their effectiveness on a scale of A for Acceptable to F for Failure.

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Stable Funding: A

The funding agreement exceeds the amount originally promised by Prime Minister Martin, and also the amount recommended by the Romanow Commission. The new $19 billion base transfer will increase by 6% per year, ensuring predictable, stable funding, and enabling the provinces and territories to undertake reliable multi-year planning and serious reforms. In the last four years of the 10-year agreement, an additional $23.2 billion will be transferred, for a total of $41.2 billion in new funds.


Accountability: D

The agreement is based more on “trust” and an assumption that the public will hold governments to account. Since such weak accountability fails to prevent privatization by stealth—and may even facilitate it—Canadians will have to be extra-diligent to ensure that public health care is adequately protected and enhanced. Before federal cash is transferred, rules and penalties need to be put in place to deter violations of the commitments made in the accord.

The current accountability requirements contained in the Canada Health Act are already being ignored by Ottawa, which has failed to monitor and enforce compliance with its criteria. The spread of privatization that this lack of enforcement has encouraged is the most serious threat to the integrity and viability of Medicare. The new Health Council of Canada has the potential to correct this failure of accountability, but will have to be closely watched to ensure it performs this up-to-now badly neglected function. (It is no coincidence that the governments that most strongly resisted strengthening the accord’s accountability section—Alberta, Quebec and British Columbia—are also the ones most determined to privatize more health-care services.)

Curbing Privatization: D

The First Ministers’ 2004 Health Care Agreement is ominously silent on the issue of for-profit delivery of health care. The proliferation of investor-owned, for-profit clinics acts like a viral infection in the body of Canada’s public health-care system, feeding off and weakening it. But the first ministers studiously avoided talking about it, despite the proliferation of privatizing initiatives across the country. Both the letter and the spirit of the Canada Health Act are being undermined, threatening universal access to a publicly-funded health-care system on uniform terms and conditions anywhere in Canada.

This omission in the September accord ignores the warning of concerned physicians in the United States, who have seen the damaging effects of privatization in that country. In his testimony to the Kirby Senate Committee two years ago, the eminent U.S. Dr. Arnold Relman asserted that “no one has ever shown that for-profit makes for greater efficiency or better quality, or that it serves the public interest better. Never.”

If Canadians are duped into believing in the miraculous power of “the market” to solve their health-care problems—as many of the first ministers evidently have been—we will pay dearly for that blunder.

Reducing Wait Times: C-

The provinces agreed to reduce wait times by March 31, 2007, in the areas of cancer, heart surgery, diagnostic imaging, joint replacements, and sight restorations. The question is: how will this be done? Attempts to reduce wait times by allowing more for-profit delivery have failed whenever they have been tried. Only an expansion of the public system will effectively reduce wait times and improve access.

But the provinces already disposed to expanding private, for-profit delivery will almost certainly use the extra federal money to contract out to profit-driven providers, especially in joint replacement and cataract surgeries and diagnostic imaging, where the waiting lists are longest. The inevitable consequence will not be shorter wait times, but a growing two-tier system in which private providers will benefit from longer, not shorter waiting lists, as will the doctors who invest in the for-profit clinics.

The contracting-out approach fosters a tendency to place more patients on wait lists if the capacity is created to treat them—whether they really need the treatment or not.

Home Care: B-

First-dollar coverage will be provided for acute home care services by 2006. This is a welcome and important step forward, but the improvements are limited and narrowly focused on medical coverage, so there is still a long way to go before we have a comprehensive national home care program.

Citizens need to insist that public funds for home care not be used to pay for investor-owned for-profit providers. This pressure is required to ensure the quality of care, and to protect the vulnerable from profit-seeking agencies.

Elder Care: F

Despite an aging population and the increased demand for nursing home care, this vitally important service was ignored in the September agreement. The need for high-quality, accessible care for Canada’s elderly is more urgent than ever as more people live into their 70s, 80s, and 90s. So are national standards for such care, and for the care to be provided by non-profit institutions.

The failure of the first ministers to allocate any additional funds for elder care is ominous. It probably signals their intention to promote the opening of more for-profit nursing homes and to keep downloading the costs of this care onto individuals and their families. One predictable outcome will be an increase in preventable hospitalizations of older people.

It is long past time that long-term elder care became an integral part of Medicare, with strong and enforced standards of care instead of leaving so many of our senior citizens at the mercy of investor-owned private homes that provide worse care and less nursing than public homes.

Pharmaceuticals: D

The agreement recognizes the need for equal access to essential medicines, cost controls, creation of a “catastrophic-drug” plan, and other key elements of a national pharmaceutical strategy to be implemented by a Ministerial Task Force. But there is no indication that governments are prepared to move quickly on these reforms, since they are not scheduled to “report on [their] progress” until June 30, 2006. This means that Canadians won’t have expanded coverage for essential drugs any time soon.

The strategy does at least contain the three objectives cited by the Canadian Health Coalition: equity of access, safety and efficacy, and cost control. Still missing, however, is any effort to address the abuse of monopoly drug patents, to speed up (and open up) the drug approval process, or to maintain the ban on direct-to-consumer drug advertising. The multinational pharmaceutical lobby has already announced it is looking forward to “partnering” with the Ministerial Task Force on Pharmaceutical Strategy. The task force should be on the alert. Goldfish don’t usually partner with sharks.

Primary Care: D

The first ministers may think they are making progress on primary care reform, but that rosy view is not shared by the millions of Canadians who are in need of family physicians or waiting anxiously for diagnostic or surgical services. What Canadians want is timely access to primary care on a 7/24 basis, with interdisciplinary teams of care-givers. The community health centre model has proved successful in delivering primary care in this way, but governments have taken no concerted steps to promote this model. On the contrary, the Quebec government has decided to dismantle that province’s highly effective and popular CLSCs that were providing care of the quality that the first ministers now say they want to achieve.

For real reform of primary care to happen, the provinces have to take on the powerful medical associations that have a vested interest in maintaining the status quo. Unless they are challenged, the provision of high-quality, cost-effective care by interdisciplinary teams of care-givers—including nurses, nurse-practitioners and social workers, as well as MDs—will not happen. The current system of solo practice and fee-for-service reimbursement is a barrier to progress in primary care that must be overcome. Otherwise, the new money to be pumped into Medicare will feed the continued excessive use of expensive technology and dubious drug prescriptions.

Health Protection: D

Protection, prevention and promotion are parts of what Medicare pioneer Tommy Douglas used to call the “second phase” of Medicare. But several barriers stand in the way of implementing these extensions of the health-care system. Health Canada, charged with the responsibility of protecting Canadians’ health, instead plans to scrap the present Food & Drugs Act and replace it with new legislation that would shift the focus from preventing harm from happening in the first place to “managing the damage” after the harm is done. The damage that Health Canada wants to “manage” is preventable illness and death.

The economic and profit incentives in Canada today are not aimed at keeping people healthy, but in selling unhealthy junk food that makes people sick and obese, then selling them drugs and treatments to cure their ills. The profits are in “disease management,” not in disease prevention. The timid approach by governments to health promotion, such as it is, focuses mainly on encouraging individuals to stop smoking and overeating, while paying no attention to the social and economic determinants of health such as poverty, hunger, and inadequate housing.

Recognizing and breaking down the barriers to health protection and illness prevention—such as the corporate-driven food and drug regulation policies of Health Canada—is essential if the current deficiencies of Medicare are to be corrected. The September health care accord failed completely to address this serious shortcoming in our public health-care system.

Northern, Aboriginal Health Care: B

The federal government has agreed to help meet the unique challenges facing the development and delivery of health-care services in the North on a priority basis. A Territorial Access Fund ($150 million over five years) will provide direct funding for medical transportation costs as well as long-term health reforms. This amounts to $10 million a year for each Territory.

Aboriginal leaders and the federal government agreed to a $700 million plan over five years to implement “specific measures to close the gap between the health status of Aboriginal peoples and the Canadian public.” An important step, indeed, but only a fraction of the funding that should be allocated. Additional funds and federal cooperation are necessary to make major needed additional improvements in the health status of Aboriginal peoples.

Trade Laws: F

The health care accord contains no plan to protect public health care delivery from the GATS and other international trade deals. On the contrary, Ottawa actually plans to expose public health services and health insurance programs to the rules of such trade agreements. This is clear from its rejection of the Romanow Report’s recommendation that “clear and immediate steps” be taken to protect Canada’s health-care system from possible trade challenges.

Some politicians say that Canada should “experiment” with private, for-profit delivery of publicly-funded health services. They fail to mention that there is no such thing as “experimentation” under international trade agreements. Once precedents are set, they are irreversible. Health-care privatization in Canada is therefore a one-way street. If it fails, Canadians could be stuck with it.

For an up-to-date analysis of what federal trade negotiators are up to, read Bad Medicine, the CCPA study by Scott Sinclair and Jim Grieshaber-Otto, which can be found on the CCPA website.

Enforcement: F

Enforcement of the Canada Health Act is relegated to the last and shortest section of the agreement, even though it is far from being the least significant. It consists mainly of an exchange of letters between former federal Health Minister Anne McLellan and Alberta Health Minister Gary Mar in April, 2002. Talk about the fox in the hen-house! In effect, McLellan agreed not to invoke Section 14 of the Act dealing with non-compliance with its terms until after a “third party” dispute resolution panel had completed its work. The three-member panel consists of a representative of each government and a third member they mutually agree upon. The panel is authorized by the federal Health Minister to interpret the principles of the Canada Health Act!

This section of the agreement exposes the serious weakening of the Canada Health Act’s enforcement that has taken place over the past 10 years. Canadians have a right to expect that their federal government will take seriously its responsibility to be the national guardian of Medicare instead of delegating that role to “third party” panels.

The proper role of the federal government is to enforce the Canada Health Act, not bend over backward to avoid such enforcement.

(Mike McBane is national coordinator of the Canadian Health Coalition. This article is based on the Coalition’s longer analysis of the First Ministers’ Health Care Agreement, which can be found on its website at