Transcript of an interview with Armine Yalnizyan on Sunday Edition

November 24, 2002

ROY ROMANOW (Commissioner, The Future of Health Care): As you know it was just a year and a half ago that the Prime Minister established the Commission on the Future of Health Care in Canada and gave me the honour of serving as its sole commissioner.

I must stop there to say that people often ask me afterwards; what’s it been like travelling the country and going here, there and everywhere and trying to sort out the complex issues of this very complex and important program.

And I’m reminded very much of the story that is attributed to the former President of the United States, Lincoln, who used to tell a story of the guy who was tarred and feathered and run out of town on a rail. And so the boys after he was tarred and feathered and run out of town on a rail went out to meet him outside of town and picked him up and cleaned him up and said; So, what was it like? And the guy that was tarred and feathered said; Frankly, he said, if it wasn’t for the honour of it all, I just as soon of walked.


ROMANOW: And sometimes, I feel that way dealing with this tremendous challenge.

MICHAEL ENRIGHT (Anchor): Well, he wasn’t tarred and feathered, yet. But Roy Romanow did break his elbow during his one-man investigation in Canada’s health system.

Given the immensity of the job Canadians have asked him to do the broken bones seem mild by comparison.

ROMANOW: My mandate is to recommend in the words of the Prime Minister, the following amongst other things, How to "ensure the long term sustainability of a universally accessible, publicly funded health system".

ENRIGHT: And that’s what’s been keeping Roy Romanow and his commission on the Future of Health Care in Canada busy for these last 18 months. During the time he’s been travelling across the country talking about medicare, commissioning studies, making speeches. Trying to sort facts and fiction and hysteria from well-founded concern. This Thursday he will drop his 300-plus-page report on the Prime Minister’s desk.

The former Saskatchewan premier has been giving lots of speeches over the last few months and he has hinted at what kind of issues he’ll be addressing when he makes his recommendations public.

We thought this morning we’d try and decode some of these hints, to see if we can take a peak behind the words. And to do that we’ve h asked the help of an expert on health care issues. Armine Yalnizyan is an economist. She was Program Director with the Social Planning Council of Metropolitan Toronto for more than a decade. In 1998 she wrote a groundbreaking report on income inequality in Canada. And she is the first recipient of the Atkinson Foundation Award for Economic Justice. She is using the funding from the award to work with the Canadian Centre for Policy Alternatives on the future of Canada’s public health care system. And Ms. Yalnizyan joins me in our Toronto studio this morning.

Good morning!

ARMINE YALNIZYAN (Economist): Good morning Michael.

ENRIGHT: Let me go back to the mandate that the Commissioner Romanow talked about. It seems pretty wide and deep and broad. I’m wondering if we’ve asked him to take-on too much? Is it possible for one man and one commission to fix the health care system?

YALNIZYAN: I don’t think he’s been asked to fix it. I think he’s been asked to signal what it would take to ensure that the principles on which medicare was founded in 1966 are supportable for the next generation of Canadians. And I think it can’t be fixed unless the politicians take a look at his recommendations and are willing to act on them.

ENRIGHT: We know that Canadians have testified, they’ve told Commissioner Romanow that medicare is in a sense, the health care system in a sense has defined who we are as a people and what are vales are and what we believe in. That’s all very well and good, but what is he going to tell us we have to do to reinstate this system as something that does what it is supposed to do?

YALNIZYAN: I think he’s going to have to say something about why it is that people are now needing to approach basic health care needs based on how much money they’ve got in their pocket, whether that’s for drugs or for home care for immediate post-acute care in hospitals or for long-term care.

I think he’s going to have to come-up with something that explains how all Canadians are not going to be asked to keep paying increasing taxes for services that are being provided increasingly, even now as we speak, from service providers who are delivering medical services for profits. So there’s a couple of pieces that need to be addressed.

ENRIGHT: Yeah, I want to talk about that business of private medical attention a bit later on, but I want to get to this point of..., he uses the words sustainable and sustainability and he’s gone back to that a number of times over the course of the last 18 months, this is what he had to say at Harvard, he made a speech at Harvard and this is what he said about sustainability.

ROMANOW: Sustainable, at least to me, means the following; Ensuring sufficient resources are available over the long-term to provide timely access to quality services that address our evolving health needs.

ENRIGHT: All right Armine, let me ask you this. In terms of sustainability, how profound is his fixing going to have to be?

YALNIZYAN: He goes on in that speech, actually, to talk about..., he’s very specifically..., he’s talking about all resources that are needed, not just cash. But that one of the main reasons we’re even looking at the sustainability issue, is that over the course of the 1990s both the provincial governments as well as the federal government actually cut funding for the first time in medicare’s history. It started-off, ironically, with Saskatchewan in 1991-92, precipitated then into Alberta, then virtually every province with the exception of Newfoundland, by 1998, had cut spending on health care. And the federal government joined in the bashing in 1995..., In 1996-97 the introduction of a brand new way of financing health care that Paul Martin brought in, called the Canada Health and Social Transfer, cut off funding right off the top, but gave the provinces more latitude to do what they wanted with the money that they were getting.

So, we’re talking about sustainability in terms of all resources, but we’re talking about it after something like a decade of figuring out ways of cutting the costs.

ENRIGHT: Let’s move on to this question of affordability. Here’s what he has to say about that.

ROMANOW: Well, we all know that health care costs have been soaring in recent years, but here’s an interesting and little reported fact. If we were to compare cost increases in the publicly funded, privately funded and mixed-blended funding that I described earlier, ladies and gentlemen, it is the publicly funded group, hospital and physician services that wins with respect to costs and cost containment that wins hands down!

ENRIGHT: All right, help me with some math on this in small words.


ENRIGHT: How..., costs have been soaring, cutbacks have been happening and yet the completely publicly funded system is cheaper than the private, hands down.

YALNIZYAN: Oh god, Michael I’m with you 100 per cent. Say it in small words. Do we have a crisis are don’t we? This is the..., when I first started looking at the numbers I began to realize that it depends on who you are and what kind of case you want to make, because the numbers will support virtually any case you want to make.

Do you want to look at the period just before this fiscal year’s results? Do you want to look at the last three or four years? Health care costs are soaring. If you want to look at the last decade, we have basically had no problems. If you want to look at since 1975 – health care costs are on the rise. So it depends on what period you look at.

ENRIGHT: We know that..., those who are called boomers, have now come into an age bracket where ultimately they’re going to need care and it’s the largest demographic bulge in the history of the country and..., so isn’t it possible for demographers to sit there with health economists and say, if you’ve got so many people coming into an age where they’re going to need health care, then that means you have to have so much health care resource? Is that asking too much? Is that alchemy?

YALNIZYAN: No it’s not alchemy and indeed if we did proper needs assessment that is regionally based, we should be able to do a lot better planning on how many doctors you need, how many nurses you need, how many beds and how much equipment do you need, but we don’t do planning that way. It’s done centrally and people and in communities are not particularly well..., there’s not a very good input system to decision-making..., but may I also point out that not only is the demographic bulge we’re looking at in 20 to 30 years the biggest in our own history of this country, it’s the biggest..., it’s going to be the biggest one on the planet.


YALNIZYAN: The baby boom in Canada was bigger than any other baby boom, post-war baby boom in any industrialized country, and where as we don’t have the oldest population at the moment (I think it’s Japan that has the oldest age profile) we are going to have the most rapidly aging profile, unless we do something very, very different in terms of immigration.

ENRIGHT: Armine Yalnizyan is an economist. She is studying..., is about to embark on a long-term study on Canada’s Health Care System. This morning she’s in our studio in Toronto we’re talking about Roy Romanow and his Commission. He is going to report out on that Commission of Thursday. And we’re trying to go over in parts some of the things he’s said in the last 18 months and see if we can get some clue as to what he might recommend.

In addition to money, he talks about other things that have to work properly. They have to..., it’s how it gets done part. Listen to him here.

ROMANOW: In addition to cash, money, a properly functioning health delivery system also depends on the right type of health care providers, buildings, equipment and information systems and how they’re organized.

Figuring out how to apply those resources to our ever-changing health needs is the real big challenge.

ENRIGHT: All right, he talks about a properly functioning health delivery system. It would seem, on the face anyway, that it’s operationally dysfunctional. You have the Ontario Hospital Association coming out and saying that, to quote, "The hospital system in Ontario, by all measures, is insolvent". That the number of GPs has plummeted. You’ve got people with the so-called orphan patient. They don’t have a family doctor, 30 per cent. There are so many areas that aren’t working, how do you make these areas work?

YALNIZYAN: The short answer is you need public and political commitment to make it work and without it we will continue to see these problems of not enough doctors, not enough resources and increasing clamouring to get private-sector investors to make these things happen where communities are saying, we need a hospital here or we need a doctor here or we need a diagnostic clinic here.

So the short answer is, finding the cash. And we have had now, oh gees, almost 15 years of governments that are committed to shrinking what they provide citizens, not to expanding them. So this will take a sea-change in political optics that politicians are willing to say, yes for us to have enough doctors in all the parts of the country, not just the urban areas, but the remote areas. We’re going to have to take a very different look at how we deliver services. And here we’ve got the traditional fight with the doctors that has been in place..., the historic fight that has been in place since the run-up to medicare, which is the doctor as the gatekeeper and the ultimate authority on health care services.

And we know that primary care services can be delivered with a much less professional modality. Where you’ve got a lot more care being delivered through nurses rather than doctors. So the doctor being..., it’s almost like a higher hierarchy of health care needs so the immediate first point of contact doesn’t always need to be a doctor and that we could be using our doctors much more effectively.

But that, in and of itself, requires a public investment to ensure that those types of primary care facilities even exist. And they don’t.

ENRIGHT: All right. Aren’t you..., you said a few moments ago and Romanow has said that it’s money and resources. Is it..., aren’t you both saying that it is money? The whole thing is money?

YALNIZYAN: Well, I’m an economist….

ENRIGHT: So this is a problem..., one of the problems that can be solved by throwing vast amounts of money in?

YALNIZYAN: Okay, well..., It is and it isn’t a question about money. It’s always a question about resources and where the resources are coming from. But it’s also a question of how you allocate those resources. You need money to be able to allocate resources.

So, two issues come up for me as an economist, right?. If you’re not going to do it through the public system, you know, you and I as citizens and as taxpayers, know that we’re going to end-up paying anyway because if you or I get sick and we don’t have a doctor we’re going to find somebody that can provide the services to us. That will cost us money.


YALNIZYAN: If we keep shrinking the comprehensiveness of publicly delivered services, I know that I’m going to be paying more and I’m going to be paying more, more rapidly if I’m doing it through the private sector.

ENRIGHT: Say that again. If we’re shrinking..., go ahead.

YALNIZYAN: So, if we have fewer and fewer doctors available in the public system, for me to find a doctor I have to skirt around the system and find a doctor that doesn’t go through the public system at all, that does strictly private billing, which is legal under our scenario, you just can’t double dip.


YALNIZYAN: And I’ll pay out-of-pocket to find that doctor who’s setting-up his own private practice and not billing the government for anything, that’s going to cost me more, ultimately, right?

ENRIGHT: All right. Now this question of money of money has come-up time-and-time-again in the Romanow Commission and on Wednesday of this past week, he..., he told Ottawa, they’ve got to come-up with some more dough.

ROMANOW: The fact is the system does need more money. It was starved in the 1990s, as governments everywhere, regardless of ideology followed the public debt. The system does need more money if it is to meet today’s needs and if it is to successfully transform, note the word I used, itself for the future, fundamental transformative change. While recent federal budgets have seen the beginning of improved funding, Ottawa still contributes less than it did and less than it should.

I therefore believe that there is considerable merit in having a minimum threshold of federal funding established. A floor below, which is, should not fall.

ENRIGHT: All right. The floor, Senator Kirby in his committee report, suggested a dedicated tax, almost a surcharge that the money would funded, that would go directly into the funding of medicare. John Manley turned around, I think within 25 seconds and said there will no such thing on my watch. And now Mr. Romanow, seems that he’s going to suggest on Thursday that there be a floor. What does he mean and how likely or unlikely is he to get it?

YALNIZYAN: There’s a distinction between talking about a floor and talking about a where is the money for that floor come from. And so far, Romanow has been very careful not to talk about a tax increase or..., what he has hinted at is maybe surplus financing is the way to go to find the money. So he says...,

ENRIGHT: If we’re going to have tons of surplus in the next four or five years.

YALNIZYAN: Apparently.

ENRIGHT: We’re told...., we’re told.

YALNIZYAN: Yeah, we’re told, who knows? It depends on whether we have a war. It depends on whether the American economy goes down the tubes. It depends on all sorts of things. But standing today, I’m looking forward, it looks like we’re going to have, depending on who you talk to, Manley says one billion dollars this year, which isn’t much of a surplus.

But Romanow is not talking one billion. If you take a look at the federal share of provincial expenditures, we started-off in 1977, when slightly less than 50 per cent of provincial costs were being cost-shared by...,

ENRIGHT: By Ottawa.



ENRIGHT: Slightly less than 50 in ’77.

YALNIZYAN: Yeah. Yeah.

ENRIGHT: What is it now?

YALNIZYAN: It’s 16 cents on the dollar that the provinces spend on health care. Why? Because so much of what is health care that the provinces provide falls outside the ambit of the Canada Health Act, falls outside doctors and hospitals.

ENRIGHT: But that means..., does that mean anything when it’s the same money. I mean it’s coming from you and me.

YALNIZYAN: Well it means that the provinces can justifiably say: "You can’t call the shots on what the national standard should be for health care for citizens across the country because you don’t pull your weight."

So, if the feds are going to have any role on what it means to have universal access to health care they have to pony up more dough. That’s what it comes down to.

Ponying up more doe is not a billion dollars, here. We’re talking about many billions of dollars, in terms...,

ENRIGHT: How many is many? Ten?

YALNIZYAN: Well..., Kirby tallies it up. All the different changes..., Kirby tallies it up to, it’s almost $9 billion in additional costs. So, eight, ten, nine..., I don’t know. Many billions of dollars. It depends on, as Romanow is saying, what are you buying for the extra money.

Because it really would not do if the feds simply handed to the provinces that extra $9 billion. You know what would happen. It happened when they did their early child development fund. When they did the child tax benefit, where they give money to the provinces...,


ENRIGHT: You mean they built roads or...,

YALNIZYAN: Some of the provinces..., No, some of the provinces just clawed back. They actually defrayed their own costs. So, we’re not seeing any net improvement in the system.

So, how can the feds buy change? They put significant amounts of money into, for example, establishing a floor for drug care. Whether it’s catastrophic or whether it’s for kids under 12, as was the original vision.

They do something that says we really want to move care from the hospital into the community. We want to support preventive programs and health promotional programs. They are buying change for these investments that Romanow was talking about: targeted investments that immediately lever, changed health behaviour that are supplementary to what the provinces are doing, but gives the feds an ability to say, these are our national targets for preventive care. These are our national standards for drug coverage. These are our national goals for health outcome and we’re going to buy movement in that direction.

But frankly, Michael, you have to ask yourself, if we are talking in the order of many billions of dollars, where does the money come from? Three places: surplus financing; or reallocation from other programs that are already in the system (in other words taking from other things that the feds spend on and then shifting it over to health care); or raising taxes. And if you’re looking at the raising taxes phenomenon, than you’ve got the Kirby proposal which is a type of dedicated tax or you’ve got a general tax increase which is verböten. Manley has already said, "not touching the hundred billion". Kirby’s whole dedicated tax idea was actually to give Martin the space to hang onto his $100 billion tax program.

So, I’m not clear on how Romanow is going to be able to finesse a proposal to raise money. Presuming that surpluses are ephemeral, you can’t provide stable financing.

ENRIGHT: Here today and gone tomorrow.

YALNIZYAN: They may be. If we go into war they may be gone. Any number of things and they can be gone. Right? If the economy starts tanking, they’re gone. You cannot base a program that requires stable commitments to funding on something that’s as ephemeral as a surplus. You can do it in maybe year one, year two, you can buy extra goodies, but you can’t build-in a new level of contribution.

And the other side of it is that Romanow is a politician too. He knows that the hundred billion tax cut program was not just Martin’s idea, though it was his brain child, it was a Chretien government promise. Right? So, is Chretien going to back away from that? This is going to be the million-dollar question. Actually the multi-billion dollar question!


ENRIGHT: Let’s stay with the affordability question for the moment. The Globe and Mail’s asked in a series of editorials that one of the things the health care system needs is a little more capitalism.

To bring-in some elements of..., into the publicly funded system, which he..., which Romanow says he’s got it sustained, but to bring some elements to it that God knows there’s money in the private sector and there are resources out there and there are things out there, you have the Shouldice Clinic, which is a clinic in Toronto treating hernias and,... but, it’s an amazing place. It’s publicly..., it gets its money through the public system, it’s a private hospital. You have those clinics in Alberta and so on.

Let’s listen to the Commissioner. This is Roy Romanow in which he touched on this issue of private versus public funding.

ROMANOW: Let’s face the facts. Across the system we have significant gaps in supply and demand, resulting in unacceptably long waiting lists for many medical procedures. These problems threaten to undermine public confidence and when that goes, then the siren call of privatization begins to sound as a panacea for all of our problems.

Now we already have 30 per cent overall total costs of health care in the private health care sector. People who say this is an "either/or" debate misread this. We are 70/30, increases and decreases, but the reality is that the siren call of more privitization is at the heart of the concern of people when they see long waiting lists. They then reach-out for solutions, which solutions may not be supported by the facts. But in my view, the suggestion that greater private for profit sector participation in our health care is the answer to the problems of timely access and wait lists, with the greatest of respect, defies logic.

ENRIGHT: All right, the hell with respect, why does it defy logic?

YALNIZYAN: Because when the Globe and Mail talks about capitalism and when Romanow talks about commercialization we’re talking about one thing: the ability to earn a profit. To get a rate of return on the money that you put down for an investment. That’s the heart of capitalism.

ENRIGHT: If I’m the private person..., the private system, I want money back, I want a profit.

YALNIZYAN: Yeah, we’re turning to the private sector to provide stuff that we are "unable" or "unwilling" to pay for publicly. Somebody will come forward and say sure, I’ll provide the dough, but I’ve got to get more out of it than I put into it. That’s the nature of capitalism and that’s the nature of commercialization.

ENRIGHT: And what’s wrong with that?

YALNIZYAN: Well, because you end-up paying more, number one. You’ll end-up spending more for the same service that you would have if it was delivered publicly with the exception of the argument that it is faster or cheaper.

The only way it can be cheaper… I think I pointed out to you before that 85 per cent of all our costs going into health care delivery is in labour… so the only way to get significantly cheaper is by doing something with either the staffing levels or the staffing mix. You know, moving from more professional to less professional.

Now when you think about the nature of companies, for-profits companies, they like to attract the best and the brightest in terms of their chief executive officers and some of the top names. So if you’re paying more at the top, you have to pay lower at the bottom.

ENRIGHT: All right, let me give you an example. The MRIs, the machines, they’re very expensive. They’re a very high ticket, I don’t know, $6-7 million dollars a copy. We don’t have enough of them in Toronto. We don’t have enough of them in Ontario. We don’t have enough of them in Canada. What is wrong with the international MRI manufacturing association, coming in and saying we’ll give you ten of these machines if you let us run them and charge for them and make a profit?

YALNIZYAN: Well because...,

ENRIGHT: If..., we’ll cap it..., we’ll cap your profits at seven per cent or something.

YALNIZYAN: Well let’s say that that was the end of the story Michael, but it isn’t. The machine isn’t going to do the test for you, it’s the radiologists that do the tests and the radiological association says it takes six technicians per machine. So where are these technicians coming from? We’ve got a labour shortage.

Let’s say that because the hours are shorter in one of these free-standing-for-profit clinics; because the pay is higher and the stress is lower than working at a public hospital… they start attracting the current pool of technologists. What happens in the public system?

ENRIGHT: It gets raided.

YALNIZYAN: Yeah, it gets..., you basically have a hydraulic effect. These for-profit companies are not providing one more new technician. They’re giving you technology but not the people to operate the technology. We have got a massive labour shortage as it is. So it isn’t just lack of capital that is an issue here, it’s the lack of all the resources, as Romanow rightly pointed out.

ENRIGHT: That’s why you mentioned, I skipped right over it, it didn’t occur to me at the time you mentioned immigration, that’s what you were talking about.

YALNIZYAN: Darn right.

ENRIGHT: You said get more people in.

YALNIZYAN: Yeah, which of course has a hugely ethical overtone. That means we’re now poaching on the training of the Philippines and the Caribbean to get the right number of nurses in town.

ENRIGHT: Yeah. Is it true that we have the only universal..., we are the only country in the world with universal coverage or close to it, where people are not allowed to buy private medical services?

YALNIZYAN: For doctor and hospital services, yeah.

ENRIGHT: That they can do it in Sweden and ever-lovin’ Finland….

YALNIZYAN: Ah do you know, I’m not..., I’m actually not an authority on that. This is what..., this is my random memory kicking in that tells me that yes, in fact that we are unique in that we have prohibited through law user fees and extra billing for these services. I think we are unique in that respect.

ENRIGHT: All right, accessibility then that’s what we’re talking about. It is still viable in an age of restraint and diminishing resources?

YALNIZYAN: The restraint and the diminishing resources are a political choice. Where accessibility becomes a big question mark in my mind is the explosion of technological possibility, whether it’s in terms of diagnostic techniques or curative techniques, including drugs.

And there frankly, there will never be enough resources to keep up with the incredible technological breakthroughs that are occurring. That are being driven by the way..., it’s the U.S. that defines those accelerated achievements. Why? Because there is a market there, at the fringe there is always somebody that will buy the next best and brightest. And so there is a market there for very rapid promulgation of advances. Whether it’s Viagra or hair growth products or much more serious issues like how to control and manage diabetes or cancer.

ENRIGHT: It’s funny, because in all the anecdotal evidence we hear about how badly off the system is in this country. I’ve had occasion in the last year to use emergency room services twice. First time I waited, I think eleven minutes, the second time I think I waited four minutes before I saw a doctor.

YALNIZYAN: Well, God bless you.…. and God bless the hospital!

ENRIGHT: I just want..., you know you wonder if all these horror stories you hear about..., I know there are horror stories, but...,

YALNIZYAN: You know, the part of..., that we shouldn’t divorce this from the context in which health care reforms are taking place and the way the economy is growing.

You know worldwide we are talking about a phenomenon of an aging society. There is a captive market there. So we’ve got this tension built right into our economy where we want to contain the cost of health care, as we know that the needs for health care will grow on the one hand. On the other hand, it’s a frickin’ economic driver. One in ten people in the labour market work in the health care industry. It supports an awful lot of people. It means an awful lot of income,

Over the next three years the collective agreements – I know the doctors’ associations won’t balk at this – but the collective agreements that have been signed for physicians will cost us $3 billion more, $2.5 billion more minimum, forget all the bells and whistles, just in terms of increased fee-for-services, for 58,000 people. Like it is..., it represents real money. And big pharmaceutical companies as well as large corporations like the ones that run hospitals and long-term care services in the United States see this as a cash cow!

The public system is guaranteed payment for guaranteed service, right? So, why wouldn’t you want to get a piece of the action? So it isn’t just simply that we have under-funded chronically..., under-funding has been a very serious issue in the Canadian system over the 1990s, we’ve done it like no other nation has done it.

On the other hand, there are people waiting in the wings to get a piece of the increased public pie.

ENRIGHT: The single payer system has been the best thing that happened to doctors since, you mentioned the stethoscope, they will now admit that, although the CMA fought at this as it was being born.

YALNIZYAN: Well, but as we say that Michael, you have to remember that in the province where they have tried the hardest to make doctors function as public servants, which is in Quebec, where they have said we need you to operate these fundamental emergency services, those are the doctors that are leaving the province in droves.

ENRIGHT: Yeah. All right. Where do we stand now? The report comes out on Thursday. There’ll be a number of recommendations. Briefly, the politics of all of this, what has to..., what has to energize the politicians to move on this subject in your view?

YALNIZYAN: Well, I don’t want to overstate this too much, but in a sense from what I heard in his last speech, before he gives his report [Romanow], I h