Consolidating the Gains of the
Do or Die for Ontario's Health Care System
A Brief by the Medical Reform
Group of Ontario
Minister of Health's Policy Conference
"Ontario's Health Care System in the 80's and Beyond"
April 24-27, 1983
The Medical Reform Group of Ontario (MRG) believes that health care
is a universal right, that health is political and social in nature
and that the structure of the health care system must be changed
and democratized. The MRG believes that the major direction for
the health care system must be the elimination of the current inequalities
in the system. These inequalities are manifest in the premium system
of health insurance coverage, opting-out and extra-billing, the
lack of development of alternate models to fee-for-service in primary
health care delivery, the inadequacy of physician-government bargaining
procedures and the negligible control by consumers and non-physician
health care workers over the health care system. The MRG views with
particular alarm organized medicine's promotion of privatization
of the health care system as a mechanism for funding health care.
The MRG recognizes the inability of traditional medicine to combat
the social and economic forces which produce disease. We realize
that any improvement in the health care system will be limited by
the inequalities in society at large and that changes in the health
care system will never be successful unless these inequalities are
reduced or eliminated.
The MRG views government as ultimately reflecting the political
forces which encourage poverty and disease and holds the government
accountable for a health care system which does not presently meet
the needs of many of Ontario's residents. The MRG views organized
medicine as one of the major impediments to progressive changes
in the health care system. We believe that until power over the
system is shared amongst all health care workers and consumers that
govern-ment in concert with organized medicine will prevent urgently
needed changes in the structure of the health care system.
With the above in mind the MRG recommends that:
* OHIP premiums and opting-out be abolished with a government commitment
to prohibit user fees and
any other measures which lead to privatization of the health care
* alternate systems to fee-for-service be developed with community
health centres and preventive medicine being major areas of resource
* suitable bargaining procedures be established between physicians
and government including granting physicians and all health care
workers the right to withdraw all but essential services.
* free-standing (non-hospital) abortion clinics be established
for women seeking first trimester abortions.
The Medical Reform Group of Ontario(MRG), constituted in October,
1979, is committed to the principles that patient access to high
quality health care without deterrents is a universal right; that
health being political and social in nature demands the direct involvement
of health care workers including physicians in the eradication of
social, economic, occupational and environmental causes of disease;
that the health care system should be structured in a manner in
which the equally valuable contribution of all health care workers
is recognized; and that the public and health care workers should
have a direct say in resource allocation and the setting in which
health care services are provided.
The MRG believes that the medical profession and government have
too often ignored the economic and social conditions which cause
disease and have promoted the faulty notion that diagnosis and cure
alone can contend with disease processes. The health care system
-its means of providing services, its methods of physician remuneration,
its over reliance on high-priced technology and high-priced physicians
does not operate as a system unto itself. It is inextricably bound
up with the economic and political system.
The current economic crisis with rising unemployment, less available
housing, cutbacks on social assistance - in short increasing poverty
-directly affects the health care system and its consumers.
The association of poverty with disease has been documented for
centuries. Yet the medical profession, in a folie a deux with government,
persists in deluding itself that medicine holds the answers to disease.
The MRG believes that the health status of all citizens is determined
by the political and economic forces in society (as shown by the
1980 Black Report on the National Health Services in the United
Kingdom) and that medicine alone has little to offer in combating
those forces that produce disease.
The hierarchy of the health care system mirrors those forces which
produce inequities and promote disease. Resource allocation favours
high-priced physicians and high-priced technology which preclude
the growth of other worthy but less powerful health care sectors
such as nurse practitioners.
It is from the position of its principles and from its analysis
of the health care system that the MRG answers the questions raised
in the December, 1982 invitation to this conference.
CURRENT SYSTEM - GAINS AND FAILURES
The failures in the Ontario health care system have regrettably
compromised the gains. The premium system of CHIP coverage, the
continued opting-out of physicians, the lack of growth of alternatives
to fee-for-service for health care provision and the institutionalize
hostility in government - medical association fee negotiations all
attest to the dismal state of the current system.
There have been advances in the evolution of the health care system
which warrant comment.
The MRG views the increased consumer consciousness of the past
four years as a definite gain and a positive direction for health
care in the 1980's. In accordance with its principle of democratization
of the health care system the MRG welcomes the increasing number
of consumer groups demanding improvements in the system.
We laud the efforts of the Ontario Health Coalition founded in 1979
and note that its membership includes groups representing immigrants,
senior citizens, native Canadian Indians and nurses - those sectors
who hold little power and those who are most economically disadvantage
We note with hope the emergence of ex-psychiatric patient groups,
patient rights groups and the Ontario Coalition for Abortion Clinics.
For it is through consumer demands that the health care system will
ultimately meet the particular and pressing needs of different sectors
The MRG supports any tendency towards unqualified universality
(meaning all residents being covered for insured services) and thus
views the improvement in numbers of Ontario residents covered after
the institution of OHIP as a gain.
But the gain has been limited. The Ontario Select Committee on
Health Care Financing and Care and Costs (1978) found that about
one-third of those eligible for full premium assistance and almost
none of those eligible for partial assistance were receiving premium
assistance benefits. A 1981 survey of two Ontario communities found
that 20-25 per cent of patients using community health centres were
not covered by OHIP. As more citizens join the ranks of the unemployed
they are losing the OHIP benefits granted them as employees. The
Ontario government has produced no evidence that its premium assistance
program has caught the newly unemployed or those previously uncovered
despite recent attempts to publicize the program. The MRG believes
that the premium system of health insurance coverage precludes 100
per cent coverage or any number close to 100 per cent.
Just as the MRG supports any tendency towards universality it.
views the post-OHIP accessibility to insured services as a gain.
But this too has been a limited gain.
Opting-out and extra-billing prohibits those, who cannot pay from
access to the services of non-participating physicians. Extra-billing
also results in an unfair distribution of consumer costs which become
determined by local rates of opting-out. Some physicians (particularly
general/family practitioners) charge for non-insured services such
as telephone advice and sick notes.
The MRG questions whether accessibility to insured services means
accessibility to an adequate quality of services. The College of
Physicians and Surgeons of Ontario 1981 program of peer assessment
revealed that "The level of care was judged satisfactory in
75 per cent of the 117 general and family practices assessed"
(all randomly selected office practices). Should we be content with
one-quarter of primary care physicians being judged unsatisfactory
by their own College?
The gains of the current system have been overshadowed by the failures.
The most disappointing failure has been the refusal of organized
medicine to accept the principles of one-hundred per cent first
dollar coverage and unimpeded access to insured services. In a time
of economic crisis the medical profession of the 1980's has the
opportunity to behave in the tradition of compassion and responsibility
associated with the practice of medicine. Instead consumers are
'greeted with increasing intransigence by a profession whose business
practices, unhindered by government, are destroying the soul of
Medicare. Tragically the soul of the medical profession is also
The Ontario government's use of premiums to finance over one-quarter
of the health care budget constitutes a major failure of the current
system. Premiums are a regressive form of taxation -whereby lower
income residents pay a higher proportion of their incomes than their
more fortunate and wealthier fellow citizens. Premiums continue
to act as a deterrent for those citizens who do not qualify for
premium assistance yet cannot afford premiums. In 1981 a family
of four with an income of $27,000 or less paid more in OHIP premiums
than it would have paid in increased taxes had OHIP premiums been
abolished and replaced by a general income tax increase.
Extra-billing is another major failure of the current system. Extra-billing
decreases access for lower income patients, increases total health
care expenditures, distributes health care costs unequally according
to local rates of opting-out and, of course, solidifies the traditional
disparity between the health care received by the poor and that
received by the rich ... the two-tiered system of health care.
The spectre of user fees along with the promotion of the privatization
under-funding argument by organized medicine is a major failure
of the current system. Although an extension of organized medicine's
refusal' to accept the principles of universality and accessibility,
the dangers of the privatization argument merit special attention.
The MRG believes that the source of funding (taxes, premiums, extra-billing,
user fees) is an independent issue from the question of whether
the system is over-funded or under-funded. Furthermore the MRG questions
whether resource allocation (rather than under-funding) is part
of the problem.
Secondly, the MRG rejects the notion that money must change hands
between patient and doctor in order for doctors to deal directly
with patients in a proper, competent and ethical manner. The argument
presented by Dr. Marc Baltzan, president of the Canadian Medical
Association (CMA), that the "doctor - patient contract and
the intang-ible but very real and important doctor - patient relationship"
will be eroded unless money is exchanged is absurd.
And finally user fees, the next major thrust towards total privatization
will result in the sick (and there is more illness among the poor)
paying more than the well and utilization being determined by ability
to pay rather than need for services.
The negotiation process between the Ontario Medical Association
(OMA) and the Ministry of Health is a failure of the current system.
It has increasingly become a process laden with acrimony and a process
that has intimidated the bewildered consumer. The MRG believes that
a suitable bargaining procedure that conforms to generally accepted
labour practices (including the possibility of binding arbitration)
must be established in a manner acceptable to both doctors and the
public. The MRG holds that should an impasse be reached that all
health care workers including physicians have the right to withdraw
all but essential services - "essential services" must
be defined through the negotiating process and the definition adhered
to in future bargaining. Furthermore the MRG believes that the OMA
must be bound to any agreement made with the government, meaning
that there must be no separate OMA fee schedule or opting-out once
an agreement has been reached.
The current system has failed in its lack of development of alternate
methods to the fee-for-service funding of health care delivery.
The MRG is not alone in its pursuit of alternatives to fee-for-service.
Consumer groups, governments and the OMA have all recognized the
limitations and inappropriate application of the fee-for-service
system of physician remuneration. Indeed, anaesthetists are partially
paid by fee for time spent (units), not service.
The MRG considers consumer/worker controlled community health centres
to be a major method by which primary health care should be delivered.
The MRG believes that such centres should be financed in accordance
with the demographic characteristics of the particular community
and funded with incentives to eliminate high volume practice and
incentives to provide educational and home services.
The Government of Ontario must accept major responsibility for the
failures of the current system. The government's lack of political
will in reducing the inequalities in health care is consistent with
its lack of recognition of inequalities in Ontario society. The
government's attitude is best illustrated by a statement in December,
1982 from Margaret Birch, cabinet minister responsible for all the
government social development ministries. ' Mrs. Birch declared
that elderly women living alone (and we note that elderly women
living alone are the poorest people in Canada) "are receiving
their fair share". Medicine truly does have little to offer
in combating those forces that produce disease. And the health care
system does not operate as a system unto itself.
DESIRED DIRECTIONS FOR HEALTH AND HEALTH CARE: SUGGESTIONS FOR
The MRG cannot separate its struggle for positive "directions
for health and health care" from "suggestions for action".
Thus we have merged these two headings, a more logical expression
of our views
The MRG's desired direction for health and health care is to re
the inequalities in health care. Our goals evolve from our state
of principles enunciated in the introduction to this brief. We believe
that health care is a right; we believe that health is political
and social in nature; and we believe that the institute of the health
care system must be changed and democratized.
The MRG has specific proposals for action but recognizes that a
action, no matter how progressive it appears within the health car
system, will only succeed in the context of a general reduction
of social inequalities.
· The MRG recommends that OHIP premiums be abolished and
that funding for health care come from progressive forms of taxation.
· The MRG recommends that opting-out and extra-billing be
· The MRG recommends that any consideration of user fees
or other measures which privatize health care be abandoned and further
recommends that the government publicly declare that user fees and
other privatiz-ation measures will never be permitted in Ontario.
· The MRG recommends that the government develop and encourage
alternate systems of payment to fee-for-service for physician services.
· The MRG recommends that community health centres be a major
method of primary health care delivery.
· The MRG recommends that more money be allocated to areas
of preventive medicine and community-based services, and that this
money not come from cutting other essential services such as education
and social services.
· The MRG recommends that a suitable bargaining pro-cedure
between the OMA and government be established which conforms to
generally accepted labour practices.
· The MRG recommends that all health care workers including
physicians have the right to withdraw their services except for
essential services; "essential services" must be defined.
· The MRG recommends that free-standing (i.e. non-hospital)
abortion clinics be established in which women can obtain first
trimester abortions quickly, safely and in a sympathetic environment.
The inadequacy of current abortion services is an example of an
unmet and particular need.
These recommendations cannot be effected in isolation from each
other. For example, if increased government support for community
health centres is accompanied by a premium system of insurance coverage,
continued extra-billing and user fees then community health centres
will become community poor people's clinics. Support for community
health centres without elimination of all deterrents (premiums,
extra-billing and user fees) will serve only to expand and dramatize
the classic two-tiered system of health care.
DISCUSSION; OPPORTUNITIES FOR CHANGE
The MRG has addressed some major problems of Ontario's current
health care system and has proposed solutions that would remedy
those problems. We have not addressed other issues such as the role
of non-physician health care workers, mechanisms for preventing
particular diseases such as occupationally related illness or the
specific details of resource allocation. We have not addressed these
issues because the immediate tasks of the MRG are to consolidate
the few gains made in the post-OHIP era and to defend Medicare from
the onslaught of organized medicine and the inaction of government.
We believe that the dismantling of Medicare will preclude any advances
in health care and make discussion of prevention and other issues
The MRG's goals for health care demand the government's recognition
and commitment to the principle that provision of equal and sufficient
quality and quantity of care/service be available to all citizens
-rich and poor - and that differing levels of care not be considered
as part of health care delivery policy. If government feels compelled
to consider differing levels of health care for different classes
of people then it must first ensure that "sufficient quality
and quantity of services" is defined and available to everyone.
The MRG has yet to see a just proposal that would permit consideration
of differing levels of health care provision according to ability
to pay. So far all such proposals would ultimately allow the transformation
of health care into a saleable commodity. We believe that the hazards
of placing health care in the free market far outweigh -any ideological
comfort that the government (or the "medical profession) would
gain by free market initiatives.
The MRG views with despair and professional shame the current position
of the CMA/OMA - powerful and controlling forces in health care.
Dr. Marc Baltzan in a November 5, 1982 address to the Sask-atchewan
Medical Association admitted that user fees, extra-billing and premiums
"do deter these people (those on limited income) from getting
the medical care they require" His solution? Coded identity
cards, poor people's cards, charity medical care, humiliation and
protection from "catastrophic health care costs" (whatever
that means). Baltzan and the CMA/OMA want Medicare to become a throwback
to the pre-insurance days when physicians, conducting office means
tests, determined who could pay and who could not. The CMA/OMA wants
"middle and upper income Canadians" to pay for the "physician
of their choice ... without loss of insurance benefits". It
seems that those on "limited incomes" would not have the
choice of physicians, the right to that "very real and important
doctor - patient relationship". The MRG finds the CMA/OMA position
offensive and reckless - all citizens must have the right to the
physician of their choice.
In the same address Baltzan castigates the federal government for
its budget deficit - evidence that governments cannot manage health
care systems. But the CMA seems to have difficulty managing its
own house. The February I/ 1983 CMA Journal reported a 1983 deficit
for the CMA approaching $200,000 above its 2.8 million dollar budget,
despite a 19 per cent increase in dues'. And what does the CMA offer
as reasons for its deficit? One was an unavoidable 1983 annual meeting
to be held in Monaco.
It is clear that governments and consumers cannot rely on the CMA
or its provincial affiliates to contribute anything but proposals
that will tear the heart out of Medicare and increase physicians'
Indeed, in Ontario the public cannot even depend on the supposedly
independent College of Physicians and Surgeons of Ontario to protect
patients from the actions of the OMA. During last April's fee dispute,
Dr. Michael Dixon, the College's Registrar (and former Director
of Medical Services for the OMA), acknowledged that several of the
College's Council members took part in the OMA's wildcat walkouts.
And the College is mandated to monitor the effect on patient care
of such actions....
The MRG believes that control over the health care system must
be shared amongst all health care workers and the consumers of Ontario.
Organized medicine has lost its credibility and sense of goodwill;
the government has done little to preserve the spirit of Medicare.
If Medicare is allowed to die the gravestone commemorating its
short life will read:
"Where the patient is user
the transaction is usury
And the doctor is charging
a usurer's fee."
Medical Reform Group of Ontario delegates:
Dr. Philip B. Berger, Toronto
Dr. Debby Copes, Toronto
Dr. Bob James, Dundas
Subject Headings: Abortion
Rights – Community
Health – Community
Health Centres – Drug
Substitution – Epidemiology
Medicine – Health
Administration – Health
Care Budgets – Health
Care Cost Containment – Health
Care Costs – Health
Care Delivery – Health
Care Finance & Fund-Raising – Health
Care in Canada – Health
Care in Ontario – Health
Care in the U.K. – Health
Care in the U.S. – Health
Care Myths – Health
Care Reform – Health
Care Resources – Health
Care Services – Health
Care Workers – Health
Clinics – Health
Determinants – Health
Economics – Health
Expenditures – Health
Issues – Health
Policy – Health
Service Organizations – Health/Social
Justice Issues – Health
Statistics – Health/Strategic
Planning – History
Medicine – Medical
Associations – Medical
Costs/Foreign – Medical
Education – Medical
Ethics – Medical
Human Resources – Medical
Personnel – Medical
Research Funding – Medicare
Use – Medication
Use/Seniors – NAFTA/Health
Health & Safety – Patients'
Rights – Pharmaceuticals
Compensation – Physician
Human Resources – Pro-Choice
Issues – Public
Health – Publications/Health
Policy – Women's
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