Prime Minister Trudeau it is time for federal leadership and real action on health care

Council of Canadians protest the loss of the Health Accord at the Council of the Federations, 2015

This week the provincial health ministers will meet with their federal counterpart - from January 20th-21st in Vancouver - to discuss the future of public health care in Canada.  The Council of Canadians will be present in Vancouver and is calling on the Liberal government to show real leadership and fulfill its election promise to reach a new Health Accord with the provinces.

While such a meeting should be regular practice, after nearly a decade of disregard by the Harper government there will no doubt be many important matters to discuss.  In our letter to Minister Philpott welcoming her to the post of health minister, we outlined some of the important topics that need to be addressed.

In his mandate letter, Prime Minister Justin Trudeau tasked Ms. Philpott with, “engaging provinces and territories in the development of a new multiyear Health Accord” with “a long-term funding agreement.”  While the liberal election platform had been worryingly vague in regards to health care policy (the Liberals didn’t attached any numbers beyond pledging $3 billion over four years to improve access to home care), health advocates across the country were pleased to see the importance of the Health Accord acknowledged in the mandate letter (including the call for a long-term funding agreement [the last accord was ten years], not a four year agreement that would jeopardize health policy to the whims of elections cycles).

Prior to the holidays, the tone of the discussion seemed to have changed again.  Minister Philpott stated to the media that “Money isn’t necessarily where the problem is... I don’t think Canadians necessarily want us to spend more on health care.” This week that Minister Philpott was blitzing multiple major national media outlets further stressing that money isn’t the answer with statements like, “I think that most of my colleagues will agree with me that injecting more money into the system isn’t always the way to go, and isn’t always the best way to be able to drive change.” She further stated that, “My hope is that we won’t allow ourselves to be inappropriately distracted by conversations about details of the transfer at this stage of the conversation.”

The problem with statements like the ones above is they include sweeping generalizations and strawman fallacies (among others), which distract from the real discussion that needs to occur. No one is advocating we simply throw money willy-nilly at health care and call it that; nor has that been the case in the past.  Additionally, there is nothing inappropriate about discussing fiscal details in relation to the Health Accord.  This is like telling someone on a bike not to worry about peddling to make it move.  What we need now is a robust and realistic discussion on the future of medicare.

Below are a few highlights of what we should expect from our provincial and federal governments in order to protect, strengthen and expand public health care through a Health Accord.

Funding:

The Health Accord is many things, but first and foremost it is a fiscal tool to create a funding arrange between the provinces/territories and the federal government. We’ve highlighted in the past that the loss of the Health Accord, which is due to expire in 2017, would mean a $43.5B cut (for all intents and purposes) to medicare.  Currently, the federal government’s contribution to health care is only one fifth of provincial health spending, and there is a strong case to be made for, “a return to the original 50/50 funding arrangement, which is one of the key reasons the provinces signed on to medicare in the first place and has steadily been eroded in the decades since.”  At the last Council of the Federations meeting the Premiers jointly called on the federal government to cover a minimum of 25% of health care funding by 2025.  This is not only fair, but also a very achievable target for the federal government to meet.  In order to accomplish this, the federal government needs to provide a minimum 6 per cent annual increases. This is again both a realistic and reasonable ask if this government is truly interested in real change (if the conservative had planned a 3% increase tied to the GDP, the liberals can surely do better than 3%). What the medicare system needs is an injection of predictable, long-term, and stable funding to ensure good public health policy and quality patient outcomes.

In addition to the Health Accord and overall federal funding, another area likely to draw much discussion is regarding the Canadian Health Transfer. The previous federal government eliminated the equalization portion of the Canada Health Transfer and replaced it with a per capita transfer (meaning Alberta was the only provinces to see an increase in funding while other provinces saw billions less). This is an additional $16.5 billion less funding to health care nationally. There has already been discussion in the media from provincial health ministers in BC, Alberta and the Atlantic provinces regarding this problem, and it is one that should be addressed.  Clearly, the solution is not to pit provinces and the age of their populations against each other, as the Ontario health minister recently pointed out regarding aging populations, “The evidence points to the contrary, that it does not necessarily, and is not creating a tsunami of increased health care costs.” What we do need is a return to an equalization formula which puts equity and need in the forefront.

At the same time, the provinces need to come to the table and do their part.  Across Canada we have seen egregious violations to the Canadian Health Act (CHA) which put our medicare system, based on need and not the ability to pay, in peril. For too long provinces have been complicit in the privatization of our medicare into a two-tiered, US style system.  From Bill 20 in Quebec, private for profit MRI services (and likely for-profit blood/plasma in the near future) in Saskatchewan, co-pays and user fees in Ontario, to the double billing in private orthopedic clinics in BC (the Dr. Day case) - just to name a few of the long list of ongoing violations - the provinces our undermining our universal public medicare.  A new Health Accord must include the provision that funding is conditional with provinces strongly upholding the CHA and prosecuting those who violate it.  Further, provincial data needs to be shared with their federal counterparts (it currently isn’t) in regards to CHA violations.

Where we do agree with Minister Philpott is that funding needs to be used in a more purposefully attempt to bring about positive change in our medicare.  While the delivery and administration is most often the constitutional responsibility of the provinces and territories, a new Health Accord must have an accountability framework in place. Money needs to be directed to improve the quality of our public health care system and, importantly, patient outcomes in a multitude of areas.  The Health Accord should not be a blank cheque for provincial finance ministers to give plump raises to the already exorbitant salaries health region and hospital CEO’s, buy quick labour peace with doctor by increasing their earnings, investing in more shoddy P3 projects, and so forth. Along with the enforcement of the CHA, conditions need to be attached to improve the quality and accessibility of care. 

Unfortunately, what seems to be missing from the mandate letter and the liberal platform are any clearly articulated goals or visionary plans in this regard. We need less flowery language around ‘innovation’ (which can mean many good things but is often a code word for privatization), or ‘efficiency’ (because no one has ever worked to improve services for patients or reduce expenditures through better management?), ‘scaling up both horizontally and vertically’ (whatever that really means), and ‘health transformation’ (meaning patients and services are being offloaded from public hospitals and usually the coverage of the CHA). What is needed is clear goals and conditional funding to improve the public funding, delivery, administration of health care.  If we are to scale things up, why not emulate the many successful and evidence based pilot projects which have been undertaken through public health services based on best practices, and spread them across the country to truly advance our health system.

 

The Council of Canadians calls for:

-A new Health Accord for an adequate period of time (a ten year period or comparable length to the 2004-2014 Accord).

-Increased funding at a minimum of a 6 per cent increase per year (as with the previous Accord)

-Reaching a minimum 25% federal share of health funding by 2025

-Conditional funding to uphold the CHA and an accountability framework to ensure funding reaches needed areas of the public health system

-Funding to support and strengthen the universal access to publicly funded and delivered medicare

 

Council of Canadians supporters educating the public on privatization of health care at the Prince Albert Health Care Festival

 

Seniors Care:

As the Canadian population ages, seniors care will remain an increasingly important topic for our public health system. If anything, longer lives are a clear outcome of the success of our universal public health system and we need to support Canadian seniors in their healthy and meaningful lives. While Canada’s aging population does not represent a “crisis” of sustainability as Medicare critics suggest, it does mean that the demand for continuing care for seniors will rise. This topic will no doubt be included in the upcoming meeting and discussions surround a new Health Accord. To begin with, the Liberal government needs to join the wide range of groups and political parties who are calling for a national senior’s strategy to address the needs of aging Canadians.

Outside of a national senior’s strategy, the Prime Minister’s mandate letter included a comment on the need to, “support the delivery of more and better home-care services.”  This could indeed be a positive development if done properly.  We need improved standard to ensure a minimum number of direct care hours per resident per day in home care. Services should follow patients to home-care or community care settings where appropriate. Further, we need to invest in public and non-profit delivery to improve both the quality and access of services while reducing costs (widely acknowledged evidence has demonstrated that for-profit long-term care facilities are associated with lower quality of care and poorer resident health outcomes).  Lastly, there are no federal standards for continuing care (home/community and residential) and it is a poorly regulated patchwork of programs. Access  to continuing care currently falls outside the scope of medicare, is often two-tiered, with long waits lists, and the quality is uneven. It is evident to anyone who has a loved one in this situation that we need a national senior’s strategy that creates a national continuing care program tied to Canada Health Act standards.

It is important to point out that the above paragraph does not mean we should reduce funding from acute care; as is too often the case, health funding becomes a zero-sum game which hurts patients in the long run.  What we need is an adequately funding continuum of care where medically necessary services are free of charge, safe, and high quality at the point of use - whether the setting is a hospital, LTC facility, home or community agency.

 

The Council of Canadians Calls for:

-A national senior’s strategy.

-Focus and adequate funding on a continuum of care from the hospital to the home.

-Established through stand-alone legislation, with Canada Health Act standards, minimum staffing standards and a program to phase out for-profit delivery.

 

 

Pharmacare:

A discussion surrounding what is known as pharmacare, or a national prescription drug plan, will be on the agenda at the upcoming meeting.  Already, it has been reported that, “the Premier of British Columbia and Ontario’s Health Minister say a national pharmacare plan – one that goes beyond an agreement by provinces and the federal government to buy drugs in bulk – should be a key consideration as provincial health ministers meet this week with their federal counterpart.” This echoes the public’s sentiment, as a Canada wide poll released prior to the election found that more than 90 per cent of Canadians back the concept of pharmacare. 

The idea of universal public pharmacare in Canada been around since the genesis of Canadian medicare, but the script remains unfilled. Prescription drug coverage was recommended as a commonsense next step by the 1964 Royal Commission on Health Services and evidence based studies to the present day continue to support the call for this needed program. The World Health Organization which has declared that all nations are obligated to ensure equitable access to necessary medicines through pharmaceutical policies. Consequently, every developed country which has a universal health insurance system provides universal coverage of prescription drugs – except for Canada. Of the 33 countries in the OECD, Canada provides a lower percentage of its citizens with a public drug plan than every other country other than the U.S. (two-thirds of the countries cover 100 per cent).

For too long the result of our fragmented and patchwork system between provinces is that many Canadians have no drug coverage at all. One in ten Canadians are not being able to afford their prescriptions (this does not include people who ration or skip taking their medication due to costs) and a new research study has estimated this could be actually be as high as 1 in 5. These medications are needed to keep people healthy and save lives; yet, every year over 3 million Canadians are unable to afford necessary medications that include everything from asthma inhalers to insulin because they cannot afford it.

 This is not only unsafe, but it is fundamentally unethical that Canadians are covered for their prescription drugs based on varying factors like their socio-economic status, age, where they live, or work, rather than their medical needs.   Not only are Canadian’s health needs not being met, but drug prices in Canada are among the highest in the world due to our poorly structured system. Yet, study after study shows that a universal pharmacare could save between $9 and $11 billion dollars a year depending on how the program is organized.

It is time for a universal, comprehensive pharmacare program with 1st dollar coverage that will meaningfully improve the health outcomes of Canadians. Recently, the Council of Canadians recently joined over 280 professors and health policy experts in calling for universal pharmacare in Canada.  Pharmacare, would allow Canadians to access drugs more effectively, more economically and more fairly.  There is no reason, other than political will, that Canadians cannot have a publicly funded and administered program to cover universal access to medically necessary drugs. Such a program would also help ensure safe and appropriate use of drugs along with improving the health outcomes of Canadians.

The time for half measure and inaction is over.  Successive Liberal and Conservative governments have ignored the evidence before them while similar nations around the world have implemented pharmacare. What is needed is real federal leadership on the pharmacare file. Not only are many Canadians suffering because of our current patchwork system, without a national pharmacare plan spending on drugs will continue to increase by a remarkable 8 per cent a year above inflation (largely due to the fact that our provincial and federal  leadership do not leverage their buying power together to get a better cost). This rate is not sustainable in the long term and will only increase as expensive biologics becomes more common as a treatment option. At the same time, our federal government is signing trade deals which will significantly delay the entry generic drugs into our market by granting even more intellectual property rights to big pharma (for more information on how the TPP and CETA is undermining our chances for universal pharmacare see here and here).

There is a very real worry that the new federal government is still not willing to fully dive in and put the health of Canadians first. Part way attempts to implement partial pharmacare won’t address the major issues we have at hand.  These different approaches know as ‘bulk buying strategies’, ‘some drugs’, or only adding ‘catastrophic coverage’ to the table ignores the real health implications faced across the country. Firstly, these half measures are aimed more at containing costs (or keeping embarrassing stories out of the news) than improving the quality of life of patients; where as a full universal pharmacare program addresses both issues.  These programs also pit patients against each other when they should all be getting the medically necessary support they need (it shouldn’t matter what need or disease you have).  Further, covering life saving drugs and having people live more years shouldn’t simply be our end goal, as the real solution needs to include drug coverage the improves quality of life. In some schemes the federal or provincial government provides some coverage to patients if a percentage of their income is spent on drugs. This ‘top up’ doesn’t lead to the price of the drug being lowered, ignores the fiscal barriers in different population demographics (for example, 20% of your income spent on medication is very different for the rich and the poor), and disregards the fact that co-pays have been proven to discourage people from filling prescriptions (leading to negative and costly health outcomes later on).  This list of issues could go on and on, but the point is we need Minister Philpott and the Trudeau Liberals to show real leadership by working to implement a full universal pharmacare system that will truly begin to address the issues at hand.

 

The Council of Canadians calls for:

-A comprehensive national pharmacare program that is universal and provides first dollar coverage.

-Access must be based on a patient’s need and not their ability. The program must cover the full cost of covered drugs without deductibles or co-pays.

-Public administration for the program ensuring appropriate use of drugs, public education and monitoring

-An evidence-based national formulary drawing on the best clinical and economic facts. All drugs on a national formulary must be covered under the program.

- ‘Carving out’ health care from harmful international trade deals and a creating mechanism addressing the impacts of negotiated deals.

 

Other Important Areas:

While the Health Accord is primarily a fiscal tool, and the political moment is indicating that improved seniors care and pharmacare are possible, there are other important areas which the health ministers need to address. The Health Accord may not be the best apparatus to fully address these areas, but they are worth a quick mention and future action.  Though not an exhaustive list, some topics include:

-Creating a framework, in consultation with a wide range of stakeholders, to address the health needs of Aboriginal populations in Canada. 

-Strengthening access to mental health services at every age and life stage.

-Identify and improve the health outcomes for people with physical or mental disabilities.

-Invest in population health research and expand the mandate for the CIHI to publically report data on a wider range of outcomes.

-Create a health human resources strategy to meet sectoral changes and varying needs across Canada.

-Provide a plan to engage in serious deliberation regarding the social determinants of health and a health in all policies approach.

 

 

 

In closing, the Romanow report in 2002 stated that, “medicare is as sustainable as Canadians want it to be, we now need to take the next bold step of transforming it into a truly national, more comprehensive, responsive and accountable health care system.” We have a historic opportunity to get health care back on track when the health ministers meet this week. This takes the provinces working together and, importantly, federal leadership.  The Liberal government was elected on a progressive platform; it is time to deliver.