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News Release

MRG Brief to the Senate Standing Committee on Social Affairs, Science, & Technology

September 1984

Summary

The Medical Reform Group of Ontario (MRG) believes that access to high quality health care is a universal right, that the determinants of health are 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 should 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 that continue despite the Canada Health Act, the lack of development of alternate models to fee-for-service in primary health care delivery, the inadequacy of physician-government bargaining procedures, the negligible control by consumers and non-physician health care workers over the health care system, and the continued disparity in health status between people of different incomes. The MRG views with particular alarm organized medicine's promotion of privatization of the health care system as a mechanism for funding health care, and provincial governments' response to the Canada Health Act.

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.

With the above in mind the MRG recommends that:

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

o unless provincial governments change their approach and comply with both the spirit and letter of the Canada Health Act, further action be taken by the federal government to ensure access to insured services regardless of payment of premiums, and to end opting-out, extra-billing, and user fees.

o the drug benefit programs be extended to the entire population, with no dispensing fee for the patient.

o free-standing (non-hospital) abortion clinics be established for women seeking first trimester abortions.

o Canadian governments recognize that the attainment of the highest possible level of health for all Canadians requires the action of many other social and economic sectors in addition to the health sector. Government should look beyond the health care system for solutions to health problems.


Introduction

The Medical Reform Group of Ontario (MRG), constituted in October, 1979, is committed to the following principles: that patients' 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 continued high levels Of unemployment, shortages of affordable 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 combatting 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.


Current System - Gains and Failures

The failures in the Canadian health care system have regrettably compromised the gains. The premium system of coverage in three provinces, the continued opting-out of physicians, the lack of growth of alternatives to fee-for-service for health care provision and the institutionalized hostility in government-medical association fee negotiations all attest to the problems of the current system.

That the governments of Ontario, British Columbia, and Alberta use premiums to finance a portion 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.

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 210 - 25 per cent of patients using community health centres were not covered by OHIP. As more citizens have joined the ranks of the unemployed they have lost the OHIP benefits granted them as employees. Clearly, the best solution to the problem is abolition of health insurance premiums and payment of health costs out of general taxation. Short of abolishing premiums, provincial governments must comply with the Canada Health Act to provide access to insured services for all citizens regardless of premium payment. If they do not, the present disparity in access to health services will continue.

Extra-billing and other forms of user fees (such as charges for use of hospital services) are 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. It should also be noted that the burden of user fees and extra-billing falls more heavily on the poor not only because of their lower income, but because there are higher levels of illness and need for services among the poor.

Some of these problems have been addressed by the Canada Health Act, which includes provisions for penalizing provinces which continue to allow user fees, and for making access to insured health care services no longer contingent on payment of premiums. However, the Canada Health Act will be effective in ameliorating the problems of inequality in access to high quality health services only if the provincial governments respond appropriately. At the time of writing, Ontario has failed to act to decrease opting-out or other user fees, and no move has been made to provide access to insured services for those who have not paid their premiums. With the exception of Nova Scotia, in which extra billing has been banned, and Quebec, in which regulations have eliminated extra billing for a number of years, the situation is similar in most other provinces. If provinces react to the Canada Health Act by simply paying the financial penalties for user fees, the disadvantaged will continue to suffer. In effect, the taxpayers will be subsidizing opting out, because the provinces will be foregoing tax revenue in order to protect opted out physicians.

The role of organized medicine has been just. as disturbing as the provincial governments, reaction to the Canada Health Act. The Canadian Medical Association (CMA) and the Ontario Medical Association (OMA) have fought the Act at every turn. Further, the OMA aligned itself with the National Citizens Coalition which made highly publicized misleading, frightening, and false statements about the effect of the Canada Health Act.

Organized medicine has consistently refused to accept the principles of one-hundred per cent first dollar coverage and unimpeded access to insured services. In a time of relative economic hardship 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, organized medicine has taken a self-interested approach, apparently disregarding the needs of Canadian citizens, especially the disadvantaged.

The position of the CMA is typified by then CMA President Dr. Marc Baltzan's remarks in a November S, 1982 address to the Saskatchewan Medical Association. Dr. Baltzan 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, protection from "catastrophic health care costs" (whatever that means). Baltzan and the CMA 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 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 position disturbing and offensive - all citizens must have the right. to the physician of their choice.

Representatives of organized medicine have made a number of arguments defending their rejection of the principle of access to high quality care as a right. They contend that the poor will not suffer as a result of extra-billing. Well conducted studies in Canada and the United States have documented the decreased utilization of health care that follows the introduction of user fees. The CMA contend that the relationship between doctor and patient benefits in some mysterious way from direct payment, but fail to provide evidence to support their claim. The CMA has rejected calls that doctors who do bill directly inform their patients prior to providing service, suggesting that direct payment is not an attractive subject for discussion between doctor and patient. They contend the health care system is underfunded, and that private capital (in the form of user fees) is needed to correct the problem. It has not been established that the system is underfunded, or rather whether resource allocation is the major problem. Even more important, the source of funding (taxes, extra-billing, user fees) is an independent issue from the question of whether the system is overfunded or underfunded. If rigorously conducted research demonstrated underfunding, the solution to the problem would not be to shift the burden of payment. on to the shoulders of the ill. The inefficiencies, inequities, and inability of government to control costs in the American health system attest to how inadequate a strategy of privatization is as a solution to our health care problems.

The disturbing attitudes and actions of organized medicine extend, in Ontario, to the supposedly independent College of Physicians and Surgeons of Ontario. During Ontario's physicians' fee dispute of April, 1981, 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. The College is mandated to monitor the effect on patient care of such actions. Subsequently, without consulting the general membership the Ontario College made a statement supporting user fees. This is despite the evidence that user fees decrease health care utilization among the groups that need it most, the poor and elderly, and despite the College's mandate to safeguard provision of health services to Ontario citizens.

In contrast to this bleak picture of organized medicine in Canada, there have been, aside from the Canada Health Act, other advances in the evolution of the health care system which warrant comment.

The MRG views the increased consumer consciousness of the past five 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 and Canadian Health Coalitions and note that their membership includes groups representing immigrants, senior citizens, native Canadian Indians and nurses - those sectors who hold little power and those who are most economically disadvantaged.

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.

However, in addition to the problems of opting out and health insurance premiums, the health care system has other major difficulties. 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 negotiation process between the Medical associations and the Health ministries 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 believe 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 medical associations must be bound to any agreement made
with the government, meanings that there must be no separate medical association 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 medical associations have all recognized the limitations and inappropriate application of the fee-.for-service system Of physician remuneration.

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 to provide educational and home services.

Another area in which economic barriers to high quality care are still a major problem is drug therapy. If patients are not covered by a drug benefit scheme (provincial or otherwise), they are required to pay the full cost of the medication and the dispensing fee. For many patients, especially those with chronic diseases requiring long term therapy, this expense constitutes an onerous burden. The situation is made worse by the policy of the drug houses, which aggressively advertise brand name products which generally sell at substantially greater cost than the pharmacologically equivalent generic products. Prescribing medication is the one area of. health care in which the Canadian physician must still take the patient's financial situation into account when deciding on diagnostic or therapeutic measures. We know that non-compliance with prescribed medication is a major problem in effectively treating many illnesses. Although formal research into the contribution of drug costs to non-compliance has not, to our knowledge, been undertaken, cost of medication may be a major contributor to non-compliance among the poor. At any rate, the principle of access to high quality care without financial burdens is violated by individual patients having to pay the cost of their medications.

Our discussion up to now has centred largely called the traditional system of health delivery. However, this system is only one contributor to the health of Canadians, and probably a relatively minor one. There is a great deal of evidence suggesting that organized medicine has played a minor role in the vast improvements in morbidity among Canadians in the last century. Improvement in sanitation, diet, overcrowding, and living conditions in general are largely responsible for the gains in health. Similarly, occupational, environmental, social and economic factors remain major causes of ill health.

Within the last few years, several studies. have demonstrated that a. large gradient in life expectancy and overall health status has persisted between the rich and poor in Canada, despite our medicare system. Very little research has been done to identify the factors that have created these differences, and to determine which of these factors can be modified. Challenging though such an undertaking may be, it is essential if we are to provide Canadians with equal opportunities to lead healthy lives, rather than simply equal access to care when they are sick. So far, the Canadian health care system has not been committed to the goal of providing equality Of access to health for all. A firm policy decision in this direction is essential.

Providing the opportunity to lead a healthy life requires a genuinely multi-sectoral approach to the delivery of health care "services". The welfare system, worker compensation, unemployment. insurance, day care, pension benefits, housing and transportation policy, and many other sectors of the economy have a direct impact on human health, and have a role to play in preventing disease and minimizing disability. Yet these sectors do not share common goals and philosophies which relate to the achievement of optimum health status for all. With the economy in crisis there is a tendency to try and "hold the line" on social spending, without adequate consideration given to the possibility that many programs (such as subsidized day care and pension benefits) may be investments in a healthier future.

There are many other, less radical options open to federal and provincial governments, initiatives which would improve Canadians health to a greater extent, and with far more certainty, than would maneuvers within the health system itself. The experience of other countries tells us that many lives could be saved if cigarette advertising was banned, or if speed limits on our highways were lowered, and the lower limits enforced. Occupational disease remains a major cause of morbidity in Canada, and is probably responsible for a substantial proportion of the nation's cancer deaths. The problem of disposal of toxic industrial waste teaches us a lesson about how the problems of chemical exposures in the workplace can be spread to threaten the community as a whole. A comprehensive plan to control exposures to toxic substances at the workplace and in the general environment must be developed and enforced.


Desired Direction for Health and Health Care: Specific Proposals

The MRG has specific proposals for action but recognizes that any action, no matter how progressive it appears within the health care system, will only succeed in the context of a general reduction of social inequalities.

o The MRG recommends that, unless provincial governments change their approach and comply with both the spirit and letter of the Canada Health Act, that further action be taken by the federal government to ensure access to insured services regardless of payment of premiums, and to end opting-out, extra-billing, and user fees.

o The MRG recommends that governments develop and encourage alternate systems of payment to fee-for-service for physician services.

o The MRG recommends that community health centres be a major method of primary health care delivery.

o The MRG recommends that more money be allocated to areas of preventive medicine and community-based services with demonstrated utility, and that research be undertaken to establish other services that would improve health. Money for these projects must not come from cutting other essential services such as education and social services.

o The MRG recommends a suitable bargaining procedure between the health ministries and the medical profession be established, and that this procedure conform to accepted labour practices.

o The MRG recommends that all health care workers including physicians have the right to withdraw their services except for essential services; "essential services" roust be defined.

o 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.

o The MRG recommends that the drug benefit programs be considered for additional patient groups, including children, students, low income groups, and those with chronic disease.

o The MRG recommends that the Canadian government commit itself to the principle of equality of access to health for all, and formulate future health policy based on this principle.

These recommendations cannot be effected in isolation from ore another. 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 a two-tiered system of health care.

The attitudes of the provincial governments and of organized medicine suggest that the dismantling of our national health care system is still a threat. Should this happen, it will preclude any advances in health care and
make discussion of prevention and other issues irrelevant.

In summary, the MRG's goals for health care recognition and commitment to the principle that sufficient quality and quantity of care/service be rich and poor - and that differing levels of care health care delivery policy. Control over the shared amongst all health care workers and the social and economic roots of ill health addressed. demand the government's provision of equal and available to all citizens - not be considered as part of health care system must be consumers in Canada. The must be acknowledged, and the problems addressed.

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