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Consolidating the Gains of the 1970s:
Do or Die for Ontario's Health Care System

A Brief by the Medical Reform Group of Ontario

Presented at:

Minister of Health's Policy Conference
"Ontario's Health Care System in the 80's and Beyond"
Toronto, Ontario

April 24-27, 1983


Executive Summary

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 system.

* alternate systems to fee-for-service be developed with community health centres and preventive medicine being major areas of resource allocation.

* 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.

INTRODUCTION

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 of society.

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 being destroyed.

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 ACTION

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 abolished.

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 irrelevant.

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' incomes.

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

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