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News Release

The Canada Heath Act

A Brief by the Medical Reform Group of Ontario

Presented to:
The House of Commons Committee on Health and Welfare
Ottawa, Ontario
February 7, 1984

Medical Reform Group of Ontario
P.O. Box 366 Station J Toronto, Ontario M4J 4Y8

Preamble

A group of physicians and medical students founded the Medical Reform Group of Ontario in 1979 because they were concerned about the erosion of Medicare. In particular, they saw the increasing numbers of physicians who opted out of OHIP in 1979 as a threat to access to the health care system for poor and moderate income Ontarioans. The MRG presented a brief to Justice Emmett Hall's Review of Health Services in April, 1980. It criticized the practices of extra billing, user fees, and the premium system of medicare entitlement. Since that time the group has presented briefs to a variety of task forces and commissions and participated in a series of conferences organized by the Ontario Ministry of Health to chart new directions for the health system. Representatives of the MRG, in 1983, met with both Honourable Monique Begin and Honourable Larry Grossman (who was then Ontario health minister) as well as a variety of opposition spokespersons. Although the original focus of the group was public health insurance issues, the MRG has also been active in the fields of occupational health, community care of chronic mental patients, workers' compensation, and women's reproductive choice.

In keeping with our stands on medicare, the Medical Reform Group applauds The Canada Health Act because it reasserts the original principles of medicare. In particular it identifies extra billing and user charges as potential threats to reasonable accessibility. Also it asks for provinces to insure 100% of their residents (as opposed to 95% in current legislation).

I. Accessibility

A. Physician Extra Bills

However, we do have some concerns about the proposed legislation: The Act proposes withdrawing one dollar in federal transfers for every dollar of extra billing in a given province. We are concerned that some provinces, especially Ontario, may decide to accept this penalty as a "license fee" to continue their present practice. Section 15 states that;

"the Governor in council may, by order, a) direct that any cash contribution or amount payable to that province for a fiscal year be reduced, in respect of each default, by an amount that the Governor in Council considers to be appropriate, having regard to the gravity of the default;"

We are concerned that the cabinet is given discretionary power not to penalize offending provinces. The regulations (p.9) require the provinces to submit estimates or statistics on the amount of extra billing. Unfortunately the information systems in Ontario do not allow this data to be collected. Therefore unless new systems are put in place the federal government will not be able to accurately calculate any penalty.

Although this committee will hear many organizations criticize practice of physician extra billing, the MRG as a physicians' group to the struggle. Firstly, physicians do not extra billed is of an upper income bracket. Secondly, although some physicians' organizations claim extra billing is a method of "injecting private money" into the health plan, the money goes to doctors not the health plan as a whole. Thirdly, there is no evidence that extra fees improve quality of care or indeed that the best doctors are the ones that extra bill.

The United Kingdom has a system of "Merit Pay" that the MRG would like Canadian Provinces to consider. Doctors within a given area and specialty decide which of their colleagues deserve extra pay. The amounts are, according to the Toronto Star, 8,000 to 44,000 Canadian dollars. This is a significant amount of money for a British doctor. The MRG agrees with other physicians' organizations that a flat fee schedule is unfair to better doctors, particularly those that spend more time with their patients. However, it decries opting out and extra billing ie. taxing the sick, as a method for rewarding excellence: We believe that many of Canada's best doctors operate within their provincial health plans. The MRG recommends that provinces which presently allow extra billing outlaw the practice in line with the Canada Health Act section 18. We suggest they investigate a "merit pay" system to reward excellence in the medical profession.

B. User Fees
The MRG is concerned that provinces may pay the penalties rather than eliminate charges for acute care hospitalization. We are also concerned that the regulations only require estimates of the amount of money raised in user fees.

II Universality
The MRG is concerned that the regulations (p. 10) do not require the provinces to provide the numbers of residents who do not have eligible health insurance to the Minster of National Health and Welfare. A select committee of the Ontario Legislature discovered in 1978 there were over 12 million OHIP numbers for 8.5 million Ontarioans. Without a single identifying Ohip number it is virtually impossible to determine how many Ontario residents have not paid their premiums. We know from our experience that there are significant numbers of people in Ontario without valid OHIP. We have seen their suffering. We are told this is also a problem in Alberta and British Columbia, the only other provinces which have premium systems.

The MRG is concerned there is no stipulated penalty for lack of Universality. We fear Ontario, Alberta, and British Columbia will continue their premium systems. Premiums were recognized by the Parliamentary Task Force on Federal Provincial Fiscal Arrangements as:

"... a regressive form of taxation and that their use for financing a service as basic as health care is regrettable."

The task force also stated:

"Either through lack of knowledge, unwillingness to apply, or the difficulty in obtaining assistance, however, lower income groups often are not adequately covered".

The MRG recognizes the Provinces have the constitutional authority to levy health insurance premiums. However, we urge you to amend the Act in such a way that it can be more effectively determined how many persons are deprived (or believe themselves deprived) of health insurance benefits. This could be done by periodic surveys. We also urge you to amend the Act with specific significant penalties for provinces who do not measure up to the new definition of universality.

III Private Insurance
The MRG recognizes the provinces have the constitutional authority to regulate insurance. Therefore, the Federal Government may not prohibit private insurance for physician extra bills and hospital user charges. However, the MRG notes that this practice has led to significant erosion of public health insurance programs and public fiscal control in other countries, particularly New Zealand. We also note that it has been well documented by Justice Hall and others that privately administered insurance is significantly less cost efficient than publicly administered plans.

The Future
The Canada Health Act attempts to protect the principles of Medicare. However, it unfortunately does not address the other problems of our health care delivery system. While recognizing this committee is reviewing the proposed Act the MRG would like to note its suggestions for improving our health system.

Science increasingly tells us that the roots of the common causes of illness lie in correctable social, ecdnomic, occupational, and environmental conditions. Unfortunately we spend almost all of our resources on diagnosis and cure. The MRG recommends that more money should be devoted to epidemiological investigation and eradication of the causes of disease.

The MRG believes the institutions and organization of the health care system must be changed. The valuable contributions of non physician healthworkers should be recognized and they should be used more appropriately. Both the public and all health workers should have more input into health policy and services.

The MRG believes that governments should explore different methods of funding health services. The predominance of fee-for-service as a method of paying Canadian physicians can no longer be construed as in the best interests of patients and physicians. Many physicians would welcome the opportunity to practise under a salary or capitation system. The MRG is also in favour of policy initiatives for the development of community health centres where physicians and other health care providers would deliver programs and services with input and advice from patients and lay community groups.