Friday, November 23, 2007

Is it time to remove the Canada Health Act from its pedestal?

This story, "Medicare's Mr. Fix-It", is by Gloria Galloway (Globe and Mail, Dec.18, 2004):

"Twenty years ago, Bill Tholl helped to draft a law so irritating to Canada's doctors that some of them hit the bricks. Today, he's their top troubleshooter. Did he change his tune -- or did they?

A glass-encased handwritten letter occupies a prominent spot on the wall in Bill Tholl's expansive office at the Canadian Medical Association.
It's from Monique Bégin, the former Liberal health minister, thanking Mr. Tholl for his role in the creation of the Canada Health Act -- the thread that binds the country's cherished public health system.
"A most sincere 'thank you' for all your work in our Medicare legislation," Ms. Bégin writes. "As one of the three musketeers -- with Don and Dave -- you won all your fights against time, stupidity, resistance, passivity, etc., etc. Good for you! And good for all of us, for it is such a great program,"
Twenty-one years ago, Mr. Tholl and his Health Department colleagues Donald MacNaught and David Beavis were handpicked by Ms. Bégin to draft the law that today ensures all Canadians have equal access to publicly funded medical treatment.
It was also the law that ended doctors' ability to charge patients more than medicare would pay, and the law that eventually prompted Ontario doctors to close their office doors for 23 bitter days in the spring of 1986.
So what is a self-declared, public-health advocate like Bill Tholl now doing as secretary-general of the CMA -- that is, the doctors' chief advocate?
Even today, the question of support for socialized medicine periodically comes up for discussion, and "it always," Mr. Tholl says, with characteristic understatement, "engenders a very animated debate. But when it comes time to push the button, yes or no for medicare, the answer is always yes.
"And the biggest push came on April 17, 2001, when they went out and hired a guy they know is committed to medicare. Why would they hire me, if they didn't think that's really where they wanted to go?"
Outgoing and outspoken, the 51-year-old health economist hails, appropriately, from Saskatchewan, the home of Tommy Douglas and Roy Romanow. In the fall of 1983, when he got the call from Ms. Bégin, he was assistant director of her department's health-policy branch. "She brought me in as the new kid on the block," he said, as someone "who had a different policy sense."
The Canada Health Act that she envisioned was controversial from its inception.
The initial 50-50 cost-sharing agreement between the federal and provincial governments had been replaced in the mid-1970s with block funding for health care. This approach gave the provinces much greater flexibility in spending and took away Ottawa's ability to claw back funds when it disagreed with what a province was doing. But it also opened the door to accusations that health-care money was being diverted, that it was building roads instead of hospitals.
Still, Ms. Bégin -- someone possessed of "tremendous political instincts," Mr. Tholl says -- had to persuade the cabinet of Pierre Trudeau that a new law was needed. And there were some powerful opponents, including every province and the Canadian Medical Association.
"The provincial governments are saying, 'You don't need this, just give us our flexibility,' " Mr. Tholl recalls. "Meanwhile, extra-billing and user fees are starting to go up and there are more and more concerns, particularly from the Canadian Labour Congress and . . . the Canadian Health Coalition."
Ms. Bégin asked him to put together a "stoplight" chart for the cabinet that would show where all the parties stood on the various elements of the proposed act, each denoted with a red, yellow or green sticker. The top half, representing the provinces and the doctors, was awash in red. The bottom half, representing labour, nurses and health-care advocates, was green.
Mr. Trudeau took a look at the chart and said: "Now, let me understand this. The doctors are against it, all the provinces are against it, but the people of Canada want it. We're going do it," Mr. Tholl says, recounting Ms. Bégin's version of the meeting.
So the Canada Health Act was on the agenda -- and the battle lines with the nation's doctors were drawn.
One of Mr. Tholl's first tasks was to establish an appropriate penalty for provinces that allowed doctors to overbill. "We actually did a bunch of studies, and said, 'How much is it going to take to bribe provincial governments to not allow this stuff?' "
They settled on a dollar-for-dollar clawback. Some provinces, including Quebec, Alberta and Ontario, protested loudly but eventually relented and ended the extra-billing. And the medical profession was livid.
In June, 1986, Ontario doctors took to the streets. Emergency wards were closed, the public was frantic and, at one point, Liberal premier David Peterson found himself surrounded by 150 placard-waving doctors calling him a "gutless tyrant." The strike ended just over three weeks later with all sides bearing scars.
Mr. Tholl won't talk about the current dispute between the Ontario Medical Association and Queen's Park. However, he believes that the province's doctors stropped short of walking off the job this fall after rejecting the government's offer because the wounds from 1986 -- and the belief that the public has never forgiven those 23 lost days -- still linger.
Even after the doctors returned to their jobs, the CMA and the OMA pressed ahead with a court challenge against the act that they had launched a year earlier.
"I was the lead guy in developing the agreed statement of fact for the government of Canada," Mr. Tholl says. Because the act had no provisions for resolving disputes, the doctors were calling it "organized begging, not organized medicine."
Then, in July, 1988, Mr. Tholl was part of a delegation to Poland that included Dr. Léo Paul Landry, a former CMA secretary-general. "For 10 days, we rode on this bus through Poland and I kept . . . using the line, 'If you win, you lose. If you win in the court of law, you lose in the court of public opinion forever. This is stupid.'
"We got off the plane in Montreal and he said, 'You are going to come to work for me some day,' and I said, 'Never, not as long as you guys are taking the Canada Health Act to court. It's an albatross around your neck.' And so we struck up a friendship."
A short time later, Mr. Landry called to ask if he would meet the CMA executive to explain the organization's many shortcomings. Mr. Tholl revelled in the opportunity. And it wasn't long before he was formally asked to work for the doctors' association as director of health policy and economics -- and to extricate the CMA from the court challenge. He took the job.
"We signed a letter saying, 'We're sorry and we promise we'll never do it again,' and we paid an amount that was substantially less than $1.3-million," which was what the government was demanding.
In 1996, Mr. Tholl left the CMA to become executive director of the Heart and Stroke Foundation of Canada, but he was recruited back in 2001, this time to the association's top position. The former enemy was now in charge -- a fact that Mr. Tholl said signalled something beyond mere acquiescence to the publicly funded system. The doctors, not all of them, but a clear majority, had embraced medicare.
"I think there has been a sea change in medicine's approach to things. My past was absolutely not a secret. Everybody and their dog knew who I was. Would they have hired me as secretary-general if they hadn't crossed that Rubicon?"
He and the CMA played a key role in the federal-provincial health accord reached with much fanfare in September, and will help to oversee its implementation. However, he warns, the accord falls well short of the much sought-after "fix for a generation," and the Canada Health Act still has detractors within the medical profession.
They are "those libertarians . . . who fought hard to make sure that governments never got in between them and their patients," and "really don't want to get sucked into an employer-employee relationship with government," he said.
But there is also a whole new generation of doctors raised in the post-medicare world. Younger doctors "wouldn't know what to do with a Visa machine if it were put in their office tomorrow to charge people," Mr. Tholl says. "They are not entrepreneurs; they are great clinicians."
And many have gown more fearful of the big health-management organizations (HMOs) that run medicine south of the border than they are of government control. "Doctors in Canada get a heck of a lot more clinical autonomy and flexibility than they do in the United States," Mr. Tholl said
He laments the huge southward migration of doctors during the 1990s as the federal government chopped transfer payments to the provinces. He also laments that the migration is still taking place -- a net loss of about 200 doctors a year.
But "there is a certain kind and class of physician that's been left in Canada and it's almost a kind of Darwinism," he said. Also, as the defected doctors age, many are returning to Canada to be with their families -- and to take advantage of this country's health system.
After all, as Mr. Tholl noted, it was the Canadian Medical Association that first proposed a national health-insurance program back in 1933.
That was "way, way, way before governments were even thinking about it," he said. "So, I like to think, in many respects, it's almost a return to the basic sense of the most caring of the caring professions." "

With this background to the CHA, is it surprising that six months after this story was written, Quebec's Chaoulli decision came in June of 2005? Some Canadians were wondering what took so long. The damaging consequence of state-run, single-payer monopoly medicine was successfully challenged. The promises that the CHA makes are broken in practice all the time. For years, provincial governments, through sheer inertia, were able to simply bulldoze, dismiss, bluster, and gloss over the accruing problems festering under utopian-CHA cover. We wanted to believe the snake-oil that Douglas, Tholl and Begin, Romanow, the CLC and Trudeau were selling, and for years the charade of sustainability and the perception of a government-orchestrated, yet market-receptive healthcare system were seemingly working before our very eyes. A true wonder - doctors who don't know about Visa machines, while central-planner bureaucrats bribe provinces to interfere with the healthcare market!
Nothing wrong with that "libertarian" picture at all!
Which leads us to 2007, and the healthcare mess Ontario is in now, after two decades of Thollist-style market manipulation: Ontario is now also facing its own constitutional healthcare court challenge. Individuals are only now able to fight back against the no-patient-choice medicare menace which ostensibly was supposed to help them, but is now working against patients, and almost killing them.
The collective must answer to the individual. Or, do we believe that the individual must submit to the collective?
I believe the Canada Health Act must be reformed to preclude it from being utilized as a cover, an enabler, an apologist, for authoritarian collectivized health-care.
It's utter stupidity to passively maintain this Liberal charade.

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