The Canada Heath Act
A Brief by the Medical Reform
Group of Ontario
The House of Commons Committee on Health and Welfare
February 7, 1984
Medical Reform Group of Ontario
P.O. Box 366 Station J Toronto, Ontario M4J 4Y8
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).
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
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.
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
"... 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 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.
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