A wealth of advice - Comments

Community Action, Dec 9, 2002

Canada is rich in health care advice. In the past two months we received two major reports on the health care system: one from the Senate Committee headed by Michael Kirby, and the other from former Saskatchewan Premier Roy Romanow.

Both reports are thoughtful, and agree on most items. They agree that: Canada's single payer, one-tier health care system should be maintained and strengthened; that it should include coverage for drugs and home care; and that the system needs more money and adequate, predictable funding.

The strength and the weakness of the Kirby report is that it has the approach of a pragmatic insurance company manager. Being more prescriptive, it offers many specific and useful recommendations. For instance, he proposes treating teaching hospitals as "national assets" and not as regional institutions, as they are now. This is an idea among others, that is worth considering.

The Romanow report gives vigorous expression to the health care system as a reflection of Canada's social values, and as a way that Canadians define themselves. Romanow's report, as controversial as it is, is likely to engender fewer arguments among politicians and can serve as a basis for federal provincial negotiations.

Two basic differences appear in these reports. These are: how to pay for the health care system, and what should be the role of the private, for-profit service providers within Canada's single payer health care system.

Romanow would use the federal budget surplus that he foresees over the next five years to pay for an improved and expanded system. He believes that Canadians would not countenance any kind of tax increase at this time.

Kirby rejects this approach. He is not certain that the budget surplus will be there. Depending on general revenues makes the funding of health care subject to the rate of tax collection and the vagaries of changing political moods. It would place health care in competition with other demands for public services. Kirby believes that Canadians are willing to foot the bill to insure a stable health care system.

Therefore, his solution is to impose a health insurance premium, really a tax levied on the basis of income. The rate would be set by the amounts needed to operate the health care system. The money collected would be kept in a segregated fund to be used only for health care. This method of financing is used in many countries that have publically financed health care programs. Kirby believes that Canadians are as willing as Europeans to pay this special tax.

On the issue of providing health care services, both recognize the current health care system includes both for profit and non-profit organizations as service deliverers. Non-profits are the major providers.

Kirby advocates a government role of funder and contractor of services, awarding contracts based on competing bids. Whether the funder is a for-profit or non-profit service does not concern him. Contracts would be awarded to those who offer efficient services at the best price. He believes that this will lead to many needed reforms, to greater innovation, and flexibility in health programs. This approach is similar to that of the Mazankowski report in Alberta, and is favored by many politicians, particularly in British Columbia and Ontario.

Romanow takes a different stand. He believes that the role of non-profit organizations should be strengthened and expanded. He argues that community-based health care organizations are the best instruments for reforming primary health care services. They will improve the way health care professionals are used, they will offer preventive health services, and they will control costs. He firmly believes that the non-profit approach relates to values of social cohesion that underlie Canada's health care system better than do private health care providers.

The two reports are beneficial to Canadians. They have dispelled the fatalistic gloom about the future of our health care system that has prevailed in recent years. Both indicate that with political conviction we can deal with our current problems and move on to an improved and expanded health care system. The issues raised in both reports will be subject to vigorous arguments over money and jurisdiction, as is usually the case in Canada. But it will be argued in a more positive frame of mind than we had before the two reports. For this alone we should be grateful to Kirby and Romanow.--L.K.