Consideration of Bill 26, An Act to achieve Fiscal Savings and to promote Economic Prosperity through Public Sector Restructuring, Streamlining and Efficiency and to implement other aspects of the Government's Economic Agenda / Projet de loi 26, Loi visant à réaliser des économies budgétaires et à favoriser la prospérité économique par la restructuration, la rationalisation et l'efficience du secteur public et visant à mettre en oeuvre d'autres aspects du programme économique du gouvernement.
The Chair (Mr Jack Carroll): Good morning, ladies and gentlemen. Welcome to the standing committee on general government hearings on Bill 26. We're happy to be in Niagara Falls this morning on a beautiful, almost springlike morning. It's nice to see Niagara Falls in the wintertime.
Mrs Elinor Caplan (Oriole): Before the motion is placed I do have what I think is a point of order; certainly it's something that is disturbing me. Yesterday, Mr Clement, when we had the government error in having amendments released first to the media, said that those amendments were housekeeping amendments. Mr Chairman, they are not housekeeping amendments.
The first amendment, when you take a close look at it, deals with the powers to the commission. What we have heard from delegation after delegation is that the minister shouldn't be delegating powers to the commission, and in fact that amendment allows him to delegate further powers and greater powers to the commission. I'm very concerned that this committee and the people who were here yesterday have been misled. I would ask Mr Clement to correct the record today at the start of this hearing that those in fact were not housekeeping amendments. While they may not have been significant in the context of the bill, they certainly were not housekeeping.
Actually, I think I've been given the wrong copy here. Tonia? Sorry; that was why I was looking back and forth. I'm going to move to another motion, because the wrong copy's been provided, so I'll come back to that one.
I move that this committee recommend to the government House leader that the 84 individuals and groups that requested to appear before the standing committee on general government in Niagara Falls be given the opportunity today to see the government's amendments to schedules A, B, C, D, E, G, H, I, J and K and the remaining amendments to schedule F of Bill 26.
The Chair: Thank you, Ms Lankin. Out of respect for the people who are here to make presentations, can I have all-party approval for just one-minute comments, one from each party, on this motion? Agreed. Ms Lankin.
Ms Lankin: Mr Chair, as you know, I have been requesting virtually every day that the government table its amendments to this bill. It is, to my way of thinking, absolutely unacceptable that the government has indicated areas where it intends to make amendments, it has told presenters that as early as the first day of the public hearings -- December 18, in Toronto, the minister indicated areas that he was going to amend -- and through that whole period of time we have not seen those amendments. So presenters come forward and they continue to make points on parts of the bill that the government intends to amend, and the presenters and the opposition have not had the opportunity to understand what the government's intent of amendments is with respect to any parts of the bill and/or to make comment on whether those amendments go far enough to address the concerns that have been raised.
As you know, we begin clause-by-clause analysis of the bill on Monday. This is down to the wire in terms of presenting the amendments and people being able to understand them and being able to respond to them in an informed fashion. I fear we have a complete replica of what we had when this bill was tabled: an intent to ram the changes through without proper public scrutiny, certainly without any public scrutiny in terms of the amendments, and without proper time for analysis.
Let me just wrap up by saying that we received seven amendments yesterday from the government, a couple more in the afternoon. They're very minor amendments. They don't go far in terms of addressing the concerns that have been raised. I suspect we'll see some more today and tomorrow. This is a totally, totally unacceptable way to proceed. I implore the government members to table all of their intended amendments today.
Mr Tony Clement (Brampton South): I must speak against the motion. Forgive me, Mr Chairman, if the tone in my voice does evidence some frustration. We have been hearing from the committee members that they wanted to see amendments. We have given them our undertaking that we would table them as soon as we felt comfortable that they reflected the government's position, based on what we heard from the presenters. We wanted to allow the committee the time to hear from as many presenters as possible, to show them the respect they deserve and require that their views are important to us. We felt we had come a long way in doing so with our amendments to the hospital restructuring which we tabled yesterday.
Quite frankly, we are not going to table amendments until we feel comfortable that we reflect what we have heard from this committee and have shown the presenters the respect that is due to them, but also that they reflect the need for this government to do its bit to get our spending under control and also to reinvest some of the savings into the health care sector, which is direly needed. I'm not going to be precipitous and table amendments until we are quite convinced that they are the amendments that are needed for Ontario.
Mrs Caplan: The entire way that the government has handled this bill from day one, both in the way they presented it in the Legislature when we were in a lockup, to the way they are changing procedure about tabling amendments -- we've said to you it is tradition in this House that you table amendments quickly --
Mrs Caplan: -- so that people who come here can know what your intention is around changes. You'll always have the right, as the government, to table additional amendments as you listen to people and they influence you for further changes. But to say to them, "We're not going to let you see what we're thinking about," even in the form of a draft amendment tabled, is the height of arrogance and it is typical of the process that we have seen here where you're closing people out, you're not letting them be heard. You wanted this entire bill, without amendment, passed before Christmas.
I'll tell you something: The people of this province are not going to let you get away with this and they're not going to forget it. If you don't table those amendments today, it is inadequate time for people to look at them. That's not the way to run a government.
Ms Lankin: Earlier in the week, at one point in time, Mr Clement said he had sympathy with some of the points I was putting forward. Let me say to you today, with due respect, I have no sympathy for the fact that you feel frustrated. If you think you feel frustrated, how do you think the people who won't have a chance to be heard today in Niagara Falls feel, all of the people who have applied in cities across this province who are not being heard by this committee because this government insists on ramming through this process and getting this bill passed by January 29? How do you think people feel who don't know what it is you're going to pass the end because you refuse to table the amendments and show us what the amendments are?
I got a commitment from the Minister of Health that those amendments would be tabled in a timely fashion. I asked for them before we went out on the road so the public knew in fact what you were intending, and the opposition knew. Yesterday, we had the spectre of seven amendments being tabled and then, surprise, surprise, we find out that the media have got additional copies and we have to raise points of privilege. The government files the additional copies with us, makes apologies and says, "But they're only housekeeping," and as we look at them in the afternoon we find out that there is a major, substantive amendment which runs absolutely counter to the presentations we've been hearing.
Ms Lankin: We would not have had that before us yesterday if it hadn't been that a member of the media had those. Take a look at the paper this morning. You can see that the Toronto Star yet again, day two, has amendments and knows what's coming before members of the committee have been presented them and before the public has a chance to see it. This is an unacceptable process. It continues the arrogance of this government in ramming things through without public scrutiny and without democratic debate. You should be ashamed of yourselves. And if you're frustrated, let me tell you, the rest of us are just fed up.
The Chair: We would very much like to hear from the presenters who are scheduled, so I would ask that we not waste a lot of time. A minute is a minute, folks, so try to keep it to a minute, please. Ms Lankin.
Whereas there has been overwhelming public interest in Bill 26 and that 39 groups and individuals have requested to appear here today before the standing committee on general government in Niagara Falls, which far exceeds the 15 spaces available today for hearings;
I move that this committee recommends to the government House leader that when the House returns on January 29, 1996, that the order with respect to Bill 26 be amended and that the bill be returned to the standing committee on general government so that further public hearings can be arranged for the community of Niagara Falls;
I think the reason for this motion is painfully obvious. This week and last week two committees are travelling this province, to cities. We have had over 1,000 applicants, groups and individuals, who requested to appear before the standing committee. There are fewer than 300 spots available for people to be heard.
Virtually every day we learn something new about this bill. We've been through it and through it and through it, and yet we still find out when people from the public come forward that there are unexpected implications of aspects of the bill that we didn't know about as legislators or that we couldn't have foreseen without hearing from the public. That's what the process of public hearings is about.
You have taken the most unprecedented scope and depth and breadth of legislation, strung it all together in what you call one bill -- it's really about 15 or 16 different pieces of major legislation -- and you're trying to ram it through in a time period that doesn't allow public scrutiny, doesn't allow full understanding, and as we can see, you won't even give us the amendments to tell us what it is you're intending to do.
I'll just wrap up by saying this motion simply recommends from the committee that the government House leader take a look at this issue. It doesn't bind the government House leader; it doesn't force him to do anything. I would implore the committee members, if they're truly listening to what people are saying, who have said over and over again, "Slow this process down," to please support this motion today.
Mr Clement: I will speak against the motion for the, I believe, tenth straight day. As I said on previous days, this is a bill that will have had by the end of tomorrow 750 separate presentations from the public, with differing points of view, with a multiplicity of points of view on this issue. We have heard the gamut of points of view on this. This bill has had more committee time than any other bill in the previous two parliaments in the last 10 years to discuss with our communities throughout the province of Ontario and in Toronto: more time than any other bill in the previous two parliaments.
The Chair: Excuse me. You've got a choice. Do you want these people to spend the day arguing or do you want to be heard? I think we're here to hear you, not to hear these people argue with one another and take political postures.
Mr James J. Bradley (St Catharines): Thank you very much, Mr Chairman. Speaking in support of the motion, this is a motion which the two opposition parties have endeavoured to have passed in some form or other across the province, and it's become increasingly clear to those of us who have observed the results of these hearings that there are a lot of people and a lot of organizations out there that wish to make further representations. The bill, though not worthy of support because of its general concept, already will have been improved marginally as the result of those representations.
I appreciate the history lesson from the newly elected member for Brampton South. In my 18 1/2 years in the Ontario Legislature, I have never seen a bill so complicated and a bill so extensive and a bill that requires these kinds of hearings for more than the allocated period of time. As the House leader for the official opposition, for the Liberal Party, I can assure you that I, as one of the three House leaders, will willingly agree to an extension of these hearings and will endeavour to persuade the government House leader of the wisdom of extending these hearings so that this legislation can be appropriately amended, or perhaps withdrawn, as a result of those representations which are made.
I think this is a very sensible motion, as the others have been. I think it's worthy of the support of all members of this committee, and I hope the Conservative members will join the two opposition parties in trying to improve the legislative process at Queen's Park.
Ms Lankin: Mr Chair, if Mr Clement is any indication of the other government members of the committee and their feelings about what they've heard in these public hearings in saying that people have been coming forward and saying the government needs these tools, the government has to proceed, the government needs this legislation, then I have no faith that we will see amendments come forward that reflect the public interest and what the public concerns have been.
Virtually every group that has come forward has been in opposition to many parts of this bill. The very few groups that have come forward that have said they support the intent of the bill have then gone on to list a whole bunch of things that they think need to be amended and changed. No one has given the kind of unequivocal support that Mr Clement would have this committee room believe. It's a shame that he would present it that way, and it makes me believe that this government committee has not been listening at all to the people of Ontario.
I urge the members to take another look at this, to support this motion, to realize that people want a government that is democratic and that is prepared to listen to the people. That is all we are asking for: for you to listen, finally; to listen not to us but to listen to the people.
Mr Kormos: On a point of order, Chair: When is a public hearing not a public hearing? Firstly, when those people who want to participate in that process are denied access to it. Secondly, when they're not even admitted into the room because the chambers that are selected are not sufficient to contain interested members of the public.
Further to my point of order, this committee is meeting tomorrow in Hamilton. It's going to be bused to Hamilton, which I can tell you is a 45-minute bus ride. They're going to be contained in accommodations there overnight. In view of the fact that they're all well-paid people, in view of their salaries, especially their just-shy-of-$100 per diems, perhaps this committee could extend its sittings today through the evening to at least 9 o'clock to accommodate a few more of those people and groups that have wanted to make presentations. They're ready, willing and available. Some of them are sitting right here.
It is repugnant that public hearings cannot accommodate the public in terms of physical space, and equally repugnant that well-paid members of this committee can't do a little bit of overtime, which is what a whole lot of hard-working people in this region do on a regular basis to try to support their families, to accommodate people.
I can't think of any reason why this committee cannot sit through until 9 o'clock this evening to hear these people. As I say, it's a 45-minute bus ride, and if people are worried about becoming overly tired, I'll make sure they have comforters on their beds at the Royal Connaught, or wherever the hell it is they're staying in Hamilton tonight.
I'm urging a member of this committee to move, first of all, that more chairs be brought into this chamber. There's space for seating. There are some people here who are seniors, among others. Secondly, I'm urging a member of this committee to move that this committee extend its sittings today through to 9 o'clock, and that the clerk immediately start contacting those groups on the remnant list of people who were denied access, so that they have a modest opportunity to provide some input to a very, very important process.
Ms Lankin: The motion is, first of all, that chairs be brought into the room to accommodate the people who are now standing and want to attend through the day to listen to these public hearings and, secondly, that the sitting of the committee be extended to 9 o'clock tonight and that the clerk be asked to contact those groups who requested but were denied standing, and schedule groups through into the evening for the committee to hear.
Out of respect for the people who have come to make presentations to our committee this morning -- we've already taken up almost a half-hour of the time -- could I ask for all-party approval to discuss that motion at lunchtime?
Ms Lankin: If you would like to, Mr Clement, then we should discuss it now. I don't need to make any more comments. My colleague has put forward the reasons. I don't need to add anything else directly.
The Chair: Our first presenter this morning is Robert Wright from the Community Action Programmes. Welcome to our committee, sir. Questions, should you leave time for them, would begin with the government. The floor is yours.
Rev Robert Wright: Thank you, Brother Chairperson and sisters and brothers on the committee, the local MPPs. It's good to see Mr Hudak and Mr Bradley and Mr Kormos from this area again. Last week we were here and had, I thought, some very fruitful discussions take place. My name is Robert Wright. I'm a community outreach minister and a community development worker with the Community Action Programmes and REV Ministries.
I might say also that I'm an Aries. I read my horoscope this morning and it says: "In the end, you will do what your conscience tells you, but for a while you're tempted to do otherwise. You also could be asked to give some advice. Consider your words carefully." I've been rapidly revising my presentation during the interim.
I wish to thank the organizers of this event for giving me the honour of welcoming the members of the standing committee to this Niagara region. I've prefaced the report with some quotes from two of the political leaders, and I apologize to the leader of the Liberal Party. If the members of the Liberal Party would pass that apology on to her, I would appreciate that. I didn't pick up any recent quotes in the paper from her and you might inform her that it's not necessarily a liability not to be quoted in Juxtaposition.
I also want to apologize to the New Democrats for misspelling the name of the leader of your party, although perhaps we are to see some rays of sunshine. Perhaps Mr Kormos would even be willing to turn over his title as Sunshine boy in exchange for Mr Rae turning over his mantle to you.
In many ways this region presents a microcosm of Canadian life, yet it also has many unique qualities which we believe can be of benefit to and provide many insights for the rest of this province, for our country and indeed for the world.
My presentation is going to be somewhat general in nature. Other presentations today will, I'm sure, be dealing more specifically with the issues involved. In the time I have, I intend in this presentation to offer some reflections on the context within which we find ourselves at this time in our history, a bit about how I perceive we got here and some suggestions for future directions. These reflections will also be something of a transition, here at the beginning of the morning, between last week's more general discussion and this week's focusing particularly on health care aspects of Bill 26.
Right at the beginning, I want to affirm that it is my very carefully considered opinion that the passage of this omnibus bill on January 29 would be a major error, that it should be split up into manageable sections and that there should be widely varied opportunities for intense consideration of these issues by as many citizens as possible within their communities. I recognize that such action might be perceived by some as a failure of nerve on the part of the government. However, as a pastor and as a person with many years of involvement with people and communities and their development and growth, I personally feel that it is a sign of strength to be able to revise plans we have made and to back off a bit from precipitous action. I think whether we think the amendments which have been proposed are significant or insignificant, it is significant in itself that these are to be brought forward. It shows a willingness to be flexible, and I would urge you to be more flexible.
I also feel it is of utmost importance that the process followed should be to the greatest extent possible without the limitations imposed upon us by narrow partisan political posturing. The issues are far too crucial for us to take inflexible stands which do not have the wellbeing of the populace at large as the motivating factor.
Perhaps I can illustrate this point more clearly by referring to an experience we had in this Niagara area with the establishment of a group we called the Working Future Coalition, which brought together representatives of business, community groups, government and labour to look at common concerns, especially around the local economy. I think that regardless of what our political position is, we have to say that previous governments have followed that attitude, not only the New Democrat government which just went out, the Liberal government before it and the Progressive Conservative government which was in power in this province prior to that.
The successes of the Working Future Coalition were very modest -- some would say almost undetectable -- yet we did find that when a real effort was made to listen attentively to one another for the wellbeing and the common good, we did make real progress in bringing the community together in this way.
In the spirit of that, the method I used in preparing this brief was myself to get out and speak to people in doughnut shops, in seniors' residences, seniors' meetings, meetings of young people and various groups. While all of their comments are not contained within my presentation, they have had impact on what has been put in here and I urge the committee to follow that kind of method in pursuing the work which has been set before you.
The concept of wide-scale community involvement in decision-making was a major aspect of the election manifesto which swept the Conservative Party into power last June. That manifesto also stressed the need for sacrifices to be shared equitably by all sectors of the population.
My personal observation of the reality which confronts us is much different. It seems to me that it is those who are at the bottom of the economic scale who are suffering most. I do not see any evidence that those at the top are sharing in the necessary sacrifices. I read the business section of the newspaper religiously every day, and I see profits of banks and other large institutions continuing to skyrocket. I see CEOs' incomes continuing to rise. I ask, what sacrifices are they making, from a base which is much more secure and prosperous than those at the bottom? And I don't ask that just rhetorically. I ask it because I want to know. If you do know of sacrifices which are being made by those people, please tell us.
Instead of sharing in the extreme suffering which is being experienced by so many lower-income working people, we see the people at the top being subsidized by our tax money in many ways. For example, there's been a lot of publicity around Team Canada's trip to Asia -- Mr Harris, Mr Chrétien and the other premiers -- in order to get trade deals for big corporations. I personally do not see how that expenditure will help those of us in the lower-income levels. Instead, why are those who are going to benefit from these trade deals not paying for that trip? Think of all the other places where our money could be spent in reducing the deficit and improving the quality of life of the average Canadian.
Similarly, can anyone tell me how much is spent on food and health care for the average prisoner in our correctional institutions? How do these amounts compare with the recommended budget for welfare recipients or for actual expenditures received for our health care?
It is very difficult for those at the bottom to see common sense in cutting off the people's purchasing power, cutting out jobs and reducing significant services such as health care. Who is hurt, beyond those whose income is cut back and whose jobs simply disappear? It is becoming increasingly obvious that it is small business people, the workers, employed or unemployed, organized or non-organized, and so on now increasingly up into the middle class. Already business people in corner stores, barbershops, hardware stores and doughnut shops are feeling the pinch. I have spoken this week to two doughnut shop proprietors who have told me their business dropped dramatically, as soon as the government cuts were announced. How is it common sense to take money from people who will spend it immediately within the community and instead turn it over to those who will in most likelihood not be spending it here in Canada?
According to a recent report, in Europe it is being said: "Communism failed. Capitalism isn't working. We have to try a third way." Fortunately, in Canada we have had a third way, and it has worked. It has been a glowing example to the world, in countries like our own, in the Scandinavian countries and many parts of the developing world and elsewhere. We have proven that there is a third way and we are the beneficiaries of that third way, which many of us and our forebears have struggled to build. The guiding principle is that we do not have to be inexorably controlled by the marketplace, driven as it is by the need of the giant transnational corporations to amass greater and greater monetary wealth. By putting checks on powerful financial institutions, we have been able to avoid the depth of the previous Great Depression, which many of us remember so well but which many of us feel is rapidly coming upon us again. Our heritage is in great danger of being destroyed.
Recently, I discussed some of these issues with a group of young people. They were very charming; they were very affable. They quickly recognized that the rhetoric we hear is true, that a household must balance its budget and cannot go on forever running on deficit financing. They know that from their own families, their own homes. They hear it from their parents all the time, and they realize it's true.
But they also realized, as one person put it, that a family or a household which would cut out spending on food for the children or risk losing the breadwinners' jobs while continuing to buy beer would be seen as a very dysfunctional household or family. Isn't our society becoming very dysfunctional, very unhealthy, as we continue to take from those who are already overburdened and transfer their modest means to those who are already far more than adequately endowed with resources of wealth and power?
After the Second World War, the welfare state developed very quickly, and I can remember those days very well. I was a teenager at the end of the Second World War and I was caught up in the excitement of reconstruction. The decision of the society we were building was not to go back to being ruled by mean and brutal free market forces. The idea was to have a balanced economy, with private, cooperative and public sectors all working together in harmony. Units would be kept small and as close as possible to direct control by the people working together in communities.
A public health plan was a major requirement of this movement. It was recognized that a healthy society requires that individuals have maximum opportunity to enjoy good health, and people from all parties -- the CCF, as it was then, the Liberals and the Progressive Conservatives -- all joined in that effort. How would we pay for it? We would pay for it partly as any other insurance is paid for: in advance. We would also pay for it by better health, resulting in reduction in costs.
Just the other day I read an article which reminded me of a fact I have known since the days of the Second World War and postwar reconstruction. The seniors who have joined me here at the table will also remember this. We came out of the Second World War with a big debt, for those days. We had operated on deficit financing and needed to pay off our debts from the Second World War.
We were able to do so relatively quickly because we had a full employment economy; everybody was working. That has to be driven home all the time: because we had full employment, not like now, because the less employment there is, the less there is paid in in taxes, the more we have to go into deficit financing, and it's a vicious circle.
Debt we owed was largely to ourselves. I bought war savings stamps, which I turned into war savings certificates, and when I cashed those in, I bought my first bicycle. Everyone was involved. We were in debt but we owed it to ourselves, not the gigantic financial institutions outside our country. And everybody was willing to sacrifice. I don't want to overromanticize this. There were some who took advantage of this. Some of the powerful people in our society, we discovered later, were milking the system. You talk about welfare bums, these corporate welfare bums should have been brought up in the war crimes trials.
The other thing was this: that because we knew the public sector, the private sector, the cooperative sector, could all cooperate together, we weren't afraid of public ownership. We weren't afraid of community or cooperative ownership. We recognized that all of those ways have a valid part to play.
A vital aspect of a truly effective health care plan, to address that topic in particular, is that it be administered as much as possible by the people themselves, that it be subject to their control and that it not be the preserve of vested interests which seek to get rich off the ill health of others. All of us who are of my age in this room can tell stories from before the time when we had a health care plan where we were robbed because of the fact that we didn't get proper health care and society as a whole suffered for that. It's also vital that health promotion and prevention of disease be items high on any agenda.
Now we are told, however, that our achievements have to be sacrificed on the altar of deficit reduction, yet it was not we who ran up the debt or the deficit. We have been productive citizens all of our working lives. We have paid taxes in order to enhance the quality of life for all of us. As with all other insurance which we carry, we hope never to have to draw on our health or unemployment or other social insurance. We did it for those less fortunate than ourselves, an investment for the wellbeing of our children and our grandchildren and of society at large.
Now we find that those very programs in which we invested -- and it's our money, remember -- are being wiped out, and with them is being wiped out the safety of the most vulnerable in society, without any consultation by those of us who are directly affected. In fact, Bill 26 removes control farther from those of us who have paid for these services. Again, I find it very difficult to understand where the common sense is in that.
Bill 26 goes in exactly the opposite direction to what is needed in our society. We see power being centralized in the hands of the minister instead of being disseminated among us. At the same time, legislation is being put in place to override the will of the people, to wipe out citizen boards, which are a major part of the process of making democracy as directly accessible as possible.
Last Thursday, Lord Acton was quoted, "Power corrupts, and absolute power corrupts absolutely." I would add to that one of my teachers, the theologian Reinhold Niebuhr, who said, "Because of the sinful nature of mankind, democracy will never be perfect, but because of the sinful nature of mankind, democracy is absolutely imperative."
Perhaps I can make an analogy with the process which took place in the Ministry of Housing, with which I was working prior to being laid off because of the cuts, where a program was put in place called Planning Together. The motivation for this program was the idea that tenants have a right and a responsibility to participate in decision-making which affects them. With greater participation, my friends, comes greater responsibility, and with greater responsibility comes greater efficiency and effectiveness. People see why it is logical, why it is common sense not to be wasteful, because what is wasted here and now will not be available when it is needed elsewhere later on.
We have built the welfare state well. Let us recognize that. In Canada the welfare state is a shining example to the rest of the world. It enshrines one half of the equation: our rights -- to each according to need. Every human being has certain inalienable rights, simply because we are human. But we must now go beyond the welfare state to a new type of fully cooperative living. The fundamental emphasis on rights must be coupled with an equally important emphasis on responsibilities.
The wealthy have a responsibility to provide for the poor. When we are recipients of society's largess, in whatever form -- financial, spiritual, emotional or intellectual -- we have a responsibility to return in whatever way is appropriate the skills, talents, training, wealth which we possess, and that was happening within the Ministry of Housing in this Planning Together program. Industries which are built on the resources, human and natural, in our society are responsible to return a generous portion of that which they have been given out of the wealth of the nation to enhance the wellbeing of all. From each according to ability is the other half of the equation, and I'm quoting Karl Marx but I'm also quoting the book of Acts in the New Testament.
Prior to the establishment of a national health insurance program, the Hall commission held hearings across the country. Various faith communities, including my own denomination, the United Church of Canada, presented briefs to that commission. I was privileged to be involved as one of my denomination's representatives in preparing that presentation. Appended to the brief which the United Church made were many pages of statistics, but those were placed along anecdotal evidence compiled by a group of clergy serving in a wide variety of outreach ministries -- in financially depressed urban and rural areas, on Indian reservations and in traditional middle-class communities where there was hidden poverty behind the pleasant lawns and shrubbery.
It was concluded that it was to the economic advantage of all Canadians to establish a Canada-wide health care scheme. We now have that. It is far from perfect, and the imperfections lie in the tendency to have the pyramid with power at the top. That power has to be disseminated and brought to the people. It is far from perfect but it will be improved only by decentralizing power and decision-making, not by concentrating power and decision-making, as Bill 26 proposes, nor by shortsighted cutbacks in funding. I might make the point that this is not a partisan position. This is a conservative position, a progressive conservative position.
It is particularly in regard to long-term programs of health awareness and promotion, which include early detection of disease, that effective programs of prevention can take place, in the long term saving us all significant funds. Certainly this requires initial investment, although it is minimal compared to treatment after disease has developed. That's much more expensive. These programs, especially for children -- and I emphasize the importance of stopping the cutbacks to children's programs, because that is going to have an impact very soon and for generations, for decades -- pay huge dividends, both directly in financial savings and long-term in building healthy communities.
In regard to confidentiality of medical records, it's imperative that these be regarded as a sacred trust. If we are interested in prevention, we must take with utmost seriousness the importance of confidentiality. As one who has been privy to the privacy of the confessional -- although we Protestants don't term it that, in point of fact that's what it is, the absolute privacy of the confessional. We have learned in the case, for instance, of prevention of the spread of venereal disease, its reduction and, we would hope, eventual elimination, that people must feel free to approach physicians without the fear of rules of morality being imposed on them. They have to feel free to come in confidence. The same applies with regard to various emotional or mental illnesses where a deeply perceived threat inhibits effective recovery or cure. Medical records must be totally confidential, and I am pleased to read in the papers that it appears that that is going to be respected and recognized.
I had an additional comment from a nurse. I didn't have a chance to integrate it into the presentation today, but she pointed out that one of the problems we have is overmedication. Physicians tend to prescribe more than is necessary. As we talked, she said, "Maybe, because there is a need to bring that under control, user fees would be the way." But then, as we talked, she said: "No, that wouldn't work. User fees prevent the people who are most needy from acquiring that medication."
What we did talk about is a program that the CAW, I know, has instituted where they are working through their retirees membership in order to find out what medication retirees are using now, where they are overmedicated, and to show them alternatives, and that's a much better way of doing it, I believe.
All right. As for the proposal to move doctors around to more needy or remote areas, it would seem that the concept has some merit, but the way in which Bill 26 proposes it be implemented seems to me lacking in common sense. I suggest an alternative from my own denomination's point of view. The more such programs can be achieved in conciliar rather than adversarial fashion, bearing in mind special needs and responsibilities such as family commitments, the more effective and rewarding they will be for all involved. The more coercive and forced, the more it will be a bitter experience for all.
To take up Mr Rae's challenge, which I quote on the front, congratulations and thanks to all the workers. That includes all of us, the members of the committee, the visitors who are here today -- and the attendance here shows what a great concern this is to everyone -- workers with hands or brains, in management or on farms, in factories or offices, employed or unemployed, male or female, on whose contribution to our common wellbeing the good life we enjoy depends. Let us all give ourselves and one another a pat on the back. Let us celebrate the great things we have accomplished and let us, above all, be careful lest we throw out the baby with the bathwater.
I thank you, the members of this standing committee, you who are our employees, the MPPs from this region who are in attendance here today, also our employees, the media who give us access for our views to the wider public, and especially the members of the staff who today have facilitated the behind-the-scenes work of bringing us together for this important occasion.
I do encourage you to report back to Mr Harris and the cabinet that, in all honesty, you feel that passage of this Bill 26 on January 29 would be precipitous and ill-advised, that because of the great importance of the issues involved it is imperative that there be much greater opportunity for widespread consultation.
I apologize for the length of my presentation. I want you to know that I spent some time, a year and a half, in Jamaica with the United Church there and I discovered that there is a different attitude in the church in Jamaica than there is in Canada. If you didn't have a two-hour church service, the people didn't feel they got their money's worth, so I've erred on the side of being overloquacious. But thank you for listening.
Dr Heime Geffen: I'm Dr Heime Geffen. I'm chief of medical staff at the St Catharines General Hospital. My role here is merely to introduce the speakers who represent the physicians who practise obstetrics at our hospital. We also have with us a patient who's going to give us her viewpoint. Carolyn Ioannoni is the patient, who will be speaking first.
Mrs Carolyn Ioannoni: Good morning. As I sit here, I'm looking behind me and I see a majority of a room full of women who at one point in time had to have obstetric care. Every day we read in our newspapers our lack of obstetrical doctors, who are leaving town. There's not one of us who cannot at this point in time appreciate the fact that these men are greatly needed. We need an even larger number of women to be practising obstetric care, but what we're reading daily is that our doctors are leaving.
There is no incentive to bring doctors to our area. Every day we read in our newspapers in Niagara Falls this severe lack. There are patients who are going to clinics because they don't have their own family physicians. What do they do when they're pregnant? Where do they go to get the proper care they need?
I'm a mother of three, ranging from 11 to 5, and I've had fantastic obstetric care. The first two children were born through an obstetrician, the third through my family doctor, Valerie Bayley, who is wonderful. I had as excellent care with my family physician as I did with my obstetrician.
In St Catharines at present there are only five obstetricians to handle a caseload of approximately 2,300 pregnant women. As we all know, pregnancy is a time of joy. It is also a time of stress, worry whether we will get the proper care and, as everybody here knows, there's no dignity in giving birth. There is absolutely none.
You can only hope that the person who you have gone to for nine months will be the person you end up in the delivery room with, because the fear and the trepidation of having a strange doctor deliver your child is overwhelming. This is not the person you have bonded with for nine months, who has listened to your problems. With five doctors handling this size of a caseload, you are not guaranteed your doctor.
We have another doctor leaving February 1, Dr Chan. That even lowers the number of obstetricians we have. This is an essential service. This is not something that can be thrown away and not looked into. We need these doctors. We need to bring incentives to our area to bring them here.
Reading your bill, I do not understand why anybody these days would become a doctor, let alone stay a physician. You are hindering them greatly. I've read that doctors stay in it for the money. That can't be. I've watched them, I've sat in offices. They have to do it out of sheer dedication, out of sheer will to want to help. As women we have to have the obstetric service, and the men, who don't, are pushing away the essential service that we all need.
I would like to be sitting here in front of you in maternity clothes, and if this session had been done last week, I would be. I would have been in my second trimester. Unfortunately, I miscarried last week and I was able to have top-notch obstetrical care. Dr Valerie Bayley helped me and I was lucky enough in the short span of time to get Dr Cheema, who assisted me and performed my surgery. Not only did I get great surgical care, I got great support care. Anybody who has gone through it or is going to go through it knows this is the care we need. This is not optional; we need it.
I beg of you to look into your agenda. This is not going to help anybody. One of our doctors wrote a letter saying our unborn children are at risk, and I heard somebody mention that that's a little melodramatic. Let me tell you, from my experience last week, that is not a little melodramatic, that is factuality. I beg of you to please look into this.
The family practice model emphasizes comprehensive continuing care, and nowhere is this more true than in obstetrical care. Thus I counsel my patient prior to conception, I look after her the whole way through her pregnancy, I deliver her baby, often spending hours in repeated visits at all times of the day, and I provide ongoing continuing care for both mother and baby. Aspects of Bill 26 severely threaten this essential service.
In 1988 the government agreed to provide a rebate for any increase in malpractice after that date. Bill 26 proposes to cancel this agreement. The obstetrical portion of the CMPA or the malpractice insurance fee approximates $2,500. The OHIP fee schedule for a delivery is about $250, and this has not changed since 1988, and it does not include the current 18% OHIP reduction. It does not include office expenses, which we have to pay, expenses for continuing medical education to keep us up to date, or other professional fees.
Even with the rebate we are currently receiving, it is apparent that obstetrics is not a financially rewarding service. With this rebate physicians will basically not be paid for the first 10 deliveries in a year, and in fact may even lose money. Many family physicians only do about 10 to 20 deliveries per year. It obviously does not make sense for us to continue.
A few years ago in St Catharines, there were 28 family doctors doing obstetrics. There are now only 12 of us. And with the passage of Bill 26, we will not be able to afford to continue. Who is going to deliver the 500 babies that are usually delivered by family practitioners in St Catharines?
Bill 26 also proposes to limit physician billing numbers. Therefore, new graduates will likely go north or go south. There's already a shortage of family doctors in the area. St Catharines is unlikely to get any new physicians. As has been mentioned, there are now only five obstetricians practising in an area that requires 10. Family doctors rely on these colleagues for assistance with complications. If they are overburdened, we might be forced to practise outside our professional guidelines. Thus, Bill 26 threatens not only accessibility but safety of obstetrical care.
There seems to be an impression that physicians have all the control over the health care system. But we certainly have no control over whether patients get pregnant or not and somehow we are being penalized for this.
Yes, there need to be reductions, but obstetrics is an essential service, not a luxury. True, no one else in society is expected to work for free, but as I mentioned, I do obstetrics because it is personally rewarding. Ultimately, it is the patient who is going to suffer. We cannot afford to compromise obstetrical care in this community.
I can give you some statistics, more specifically to my own hospital, and I would like to set the scene for you. This is not a whining session. We are five obstetricians currently practising in St Catharines. You have heard the caseload is roughly in the order of 2,300 deliveries a year. If we add the other six smaller hospitals in the Niagara to that, we will approach 5,000 deliveries per year.
Currently, there are only 12 of us who provide this service in this area. In St Catharines, it's five of us doing approximately 1,500 to 1,600 deliveries per year. The guidelines of our own society state that we should be delivering, on average, 20 to 25 patients per month to be practising at a safe and reasonable level. All of us are exceeding that by far, delivering 35 and more patients per month. Our offices look like disaster areas most of the time. We are practising under enormous stress.
Bill 26 was not the injury; it was the final insult. The injury had come long before. The climate to practise medicine, and particularly obstetrics, has been steadily declining. I've had the privilege of working in this wonderful country for the past six years. I'm a foreign medical graduate. I'm now a very proud Canadian citizen and I am desperately worried when I see the decline in our system in just the mere six years I've been in this country. And I'm seeing it decline further.
As Dr Warren does, I enjoy obstetrics. I chose to do obstetrics when I was 18 years old. I'd already decided that was what I was going to do. At the moment, I am being forced to practise it in a way which I think is unacceptable for myself and unacceptable for my patients. I'm sure I echo the feelings of every one of my colleagues in the room here today with me and every one of those who could not be here and are working today.
Some mention has been made of the CMPA fees. I absolutely feel disgusted that I have to lower myself to speak about money, but this is what it boils down to. Instead of my worrying about my patients and their unborn children, I'm worrying about where the money is going to come from to pay for my office overhead and to give them the infrastructure they deserve. CMPA fees in Canada, since I came here in 1990, have risen from approximately $11,000 per year at that point to $23,400 per year now. That is a doubling in five years. Obstetrics is a privilege to practise, but it's also the most dangerous subspecialty in medicine. One out of five practising obstetrics persons in Canada will be sued every year, and that number may rise due to one of the clauses in Bill 26, with contingency fees being allowed to lawyers in cases of medical malpractice. Those fees may just keep rising. It is making it impossible for us to continue practising.
Dr Warren alluded to the fact that the average family physician has to do 10 to 20 deliveries per year to survive. The average gynaecologist will have to do between 100 and 110 deliveries to just cover CMPA premiums. This is not paying the salary of my nurse or my secretary or any other costs that I have. It's terrible to have to talk about money, but those are the realities I have to face every day.
Why don't we have enough obstetricians? This predates Bill 26, unfortunately. Some of you will remember that since July 1, 1993, it has become impossible for even a fellow Canadian who graduated in a province other than Ontario to enter into practice in this province. So we cannot recruit people. It is not as though we are trying to guard this little cake for ourselves. We would desperately love some help. But we can't recruit people from anywhere but in Ontario. Young graduates are going further south than the peninsula because there is no incentive for them to join us in the peninsula. We cannot recruit people from outside of the country's borders. It's quite enlightening to realize that of the 12 obstetricians practising in the area here, there is only one Ontario graduate. The rest come from outside of the borders of the province, and most from outside of the borders of the country. We have a serious problem.
Previous speakers have also mentioned the fact of confidentiality. As an obstetrician-gynaecologist, I have always regarded my work as being very special and extremely private in its nature. Most of the time it's very difficult for my patients just to come to me, to build up the courage to come to me and discuss some of these issues, let alone ask for or consent to some very sensitive testing. Now they're going to think not only twice, they're going to think 10 times before they ask to be seen, to be listened to and to be tested. I think this is a serious problem.
Furthermore, this bill may allow a bureaucrat with no training -- this is not a peer; I don't mind if a peer would do this -- can sit down after the fact if I've, as an example, done a hysterectomy on a patient who has been suffering horribly, take her chart, look at the chart and decide, "This hysterectomy was unnecessary. We will take back the money, Doctor, that you were paid for doing this procedure," ignoring my patient's rights, ignoring and underestimating her ability to act as an advocate for herself.
Let me remind you, do not underestimate any of these people in this room. They know how to act as advocates for themselves. This is 1995. Our patients are pretty well informed and there are very few of them who will allow me to do a procedure or recommend a treatment without questioning me very well upon that. That's just been taken away. A bureaucrat can now tell me, "That's unnecessary; I'm not going to pay you for it." I've taken the medical and legal risks. My patient is improved. But I really don't think that's the way a system should be functioning.
First of all, I feel we should all realize that this system is a very precious one. It has users; it has providers. At the moment, as a provider I'm feeling I'm being singled out as the root cause, as the only cause, for the great disaster we are facing, and that's not true. There are users as well. There may be unscrupulous physicians, as there unscrupulous teachers, unscrupulous engineers, and we can carry on down the line.
Dr Viljoen: Ms Lankin. That is true. But I think our patients should also just be asked, "Won't you also contribute to this mess?" I was not thinking about user fees; I'm just thinking about education. Just educate people as to how does one use a system correctly. That is all we ask.
The next thing is I would really urge the government, please rethink your position on the CMPA rebates. It is making it very difficult for us to continue providing the care we currently are so proud to do. Just to give you an indication of exactly how proud we are of our care in St Catharines, our C-section rate, which is a very contentious figure always in obstetrics, is well below the national average. Our C-section rate, we are proud to say, is between 10% and 11% per year, which I think is pretty remarkable for guys who have been worked to the bone. Our perinatal mortality rate is 2% below the national average. I think that's pretty good. Now we think we are gods, all of us, every day that we practise obstetrics, and I can tell you that's true, to realize our own fallibility. We know how close to danger we always live and we will almost certainly not ride on this wave.
We would love to continue giving that level of care to our community. They deserve that kind of care. In the current atmosphere and in the atmosphere that seems to be coming, that is going to be virtually impossible. We need the support from the community. We need them to become vocal. We need them, just like the patients here, to just give us that little bit of credit to what we are trying our darnedest to do and to stand up and also to speak up for us. We desperately need that. Thank you.
Mrs Janet Ecker (Durham West): Thank you very much for taking the time to come here today and put forward your concerns. Also, Ms Ioannoni, thank you very much for coming and sharing what must be a very painful and difficult memory. I very much appreciate you taking the time to do that.
I think one of the things we've certainly heard at these hearings is that people believe very strongly in their positions. Every patient I know would certainly justify that doctors are one of the highest-paid professions in Canada for a reason and that they're worth every penny. So I certainly can sympathize with people's concern about wanting to make sure they have physicians here.
Mr Wilson, the Health minister, has announced that he is working out a system to make sure that obstetricians are not forced to choose between not delivering babies and paying CMPA fees. I guess one of the things that I find really difficult to understand when you look at CMPA -- which, in its last annual report, said there was no crisis, said there was not a significant increase in the number of cases, yet tried to hit us all up for a 20% increase. They were talking about a 30% increase next year. I've got to start wondering why they're trying to rip off front-line docs and the taxpayers here on this thing, without the justification for it.
What I'd like to know from the physicians is, are you aware of anything that your bargaining unit or your representative organization, the OMA, have done to try to address the increases? And secondly, how would you recommend that the government and the OMA deal with the CMPA to try to stop this kind of increase that does not appear, at least from the evidence they presented, to justify the need? Mr Wilson has met or has written to other Health ministers across Canada to say, "Look, can we solve this?" Do you have any suggestions for the minister on how we might get at that?
Dr Geffen: Can we just step back a little and look at the reason and the purpose of this CMPA rebate? I think it was the Peterson government that negotiated with the OMA at the time that the CMPA rebate, this 50% contribution towards physicians' portion of malpractice insurance, would be granted to physicians in lieu of an increase in fees.
Dr Geffen: So since 1988 physicians have had no increase in fees. By summarily withdrawing this 50% rebate of fees, they have summarily reduced physicians' incomes or reduced the increase in lieu of fees that was given to them in 1988.
Dr Geffen: One of the reasons given to us by the CMPA is that there is a need to build up a fund for future malpractice claims. What happens at the moment is that a claim against a physician can take place 10, 15 or 20 years after the event. Provision has to be made for funds in the insurance scheme to contend with those claims. With the threat of contingency, I have no doubt that the size and the number of claims is going to increase in the near future. So the CMPA feels that a large surplus is needed to cope with those increased claims.
Mr Bradley: We deal in this bill, and we deal on a daily basis, with the question of the values that Canadians and Ontarians have in our society. One of the highest values that we've had consistently has been that of a very good health care system. We've been prepared to pay for it in years gone by.
Part of the government's program is to borrow $20 billion, with $5 billion in interest being charged on that, for the purpose of delivering a 30% tax cut in provincial income taxes for people in this province that would benefit those at the very top end the most. Is it your belief that the government would be better to not cut as deeply into health care services, to provide the funding that you are asking for, that you believe is very legitimate, rather than borrowing $20 billion more to deliver a tax cut to the people of this province?
Dr Geffen: I can't give you a yes or no. My own personal feeling as a physician is that we are not at this stage asking for more funding for physicians. We understand that cuts have to take place. As responsible taxpayers and responsible citizens, we realize there is a crisis and there is a problem. None of us are whining and asking for more money. What we're asking for is a government that understands our position and is prepared to work with us to try to solve the problem, that listens to our concerns and listens to our input. What you've presented me with is a fact I did not know about and haven't had a chance to think about.
Mr Bradley: The issue comes down to whether you think there should be a tax cut delivered to the people of this province in the present economic circumstances, in a situation where the doctors that you represent and others in our society will not be able to maintain even what you have today in terms of service if the government delivers this tax cut.
Dr Geffen: I'm speaking in my own capacity. My own personal feeling is that I would be quite content not to have a tax cut. I'm prepared to make a sacrifice. I understand that sacrifices are needed from everybody and I'm prepared to make a sacrifice. What I'm looking for is a government that, I must say, many of the physicians put into power -- many of us voted for this party -- that would listen to us and would be prepared to negotiate with us and not impose upon us a bill that vests so much power in the Health minister.
Ms Lankin: I'll be sharing my time with Mr Kormos, but I just want to say, following up on Mr Bradley's point, that as a result of this 30% tax cut that this government is ideologically committed to giving to people and that's going to benefit the wealthiest people in this province the most, we are seeing greater cuts being made to needed health and social services and community services, and, by and large, the burden of paying for that tax cut is falling on the backs of many people who are very vulnerable in our society. I applaud your personal position with respect to that. I believe that many people in this province are prepared to give up that tax break in order to preserve the needed services and the needed infrastructure and support for people in our community.
With respect to the issue you've raised around the malpractice insurance rebates that the government has contributed to, in the practice of obstetrics in particular, I want you to know that we have heard across this province that many doctors who are currently obstetricians will stop that practice and/or leave the country to practise someplace else as a result of this. We have heard from new graduates that they will not practise in Ontario as a result of this, and we have heard from students making their way through medical school that they will not pick up the specialty of obstetrics.
The minister has made some vague promise that he will work to fix this in your area. We haven't seen the amendment; we don't know what it's going to be. We hope that in fact the minister does that, but I need to tell you that orthopaedic surgeons are facing exactly the same issue. So are neurosurgeons. To me, it underscores the fact that this government moved ahead with a set of amendments, an agenda that -- I don't know where it came from, because it wasn't in the Common Sense Revolution. They didn't consult with anybody. And now in a couple of short weeks we're trying to fix all of these problems.
Mr Kormos: People, please, you've got to understand that this government didn't even want to include the public to the extent that it has. It took Alvin Curling, a member of the opposition party, to risk uric poisoning by sitting in the Legislature overnight to force the government to have these two weeks of modest travelling hearings. We've got 17 schedules in this bill; that's effectively 17 different pieces of legislation, all of them with a profound impact.
It was developed in secrecy. Government backbenchers weren't even aware of the legislation until after it had been tabled as a bill in the Legislature on first reading. They were coming to members of the opposition, asking us for copies of the bill. Not only hadn't there been any consultation with the public prior to this legislation being written; there hadn't been any consultation with the government's own caucus. In fact, now that they discover error after error, they're scrambling in retreat to try to clean up messes they created with their haste.
Of course, you've been described as Ontario's highest-paid profession. See, that's part of the imagery that this government relies upon. They want to paint doctors, small-town Ontario doctors like you and a whole lot of folks in Welland-Thorold and across the region, as being the Mercedes-Benz, Caribbean crowd, while the fact is that the pay envelope for Frank Stronach of Magna last year was $47 million. The government's telling you to take a hit, but they're not telling Frank Stronach to take a hit, based on a $47-million pay envelope.
Mr Brian McLeod: Mr Chairman and members of the committee, I'd like to thank you for the opportunity to appear before you today. My name is Brian McLeod. I am vice-president of marketing for Merck Frosst. Joining me this morning are Bob Stinson, manager of government affairs for the province of Ontario, and Mr Greg Szabo, manager of drug plan affairs for the province of Ontario.
I would begin today with a brief backgrounder on Merck Frosst, followed by some very specific comments and recommendations on the proposed legislation and changes to the Ontario Drug Benefit Act and the Prescription Drug Cost Regulation Act contained in Bill 26.
Merck Frosst is Canada's largest integrated pharmaceutical company. The prevention and treatment of disease is the mission, heritage and business of our company. We spend more on research and development, including basic research and clinical development, than any other Canadian pharmaceutical company. Indeed, our investments in research and development place us among the top 10 R&D corporations in Canada in all industries.
In 1995, we invested close to $52 million in research and development, approximately 14% of our total national sales. We have 1,100 employees across Canada involved in the discovery, manufacture and marketing of medicines and vaccines for human and animal health. Our manufacturing division produces over 150 prescription and over-the-counter medicines for Canada and international markets. Here in Ontario, we operate a regional business and distribution office in Mississauga. We have 123 employees based in the province, and last year spent $56 million on goods and services in the province.
The money we spend on R&D had a direct impact beyond our company. Currently, 35 hospitals in Ontario and nine universities receive research and development support from Merck Frosst. This creates direct jobs within those research facilities as well as additional indirect jobs for suppliers and support companies. Our research effort is part of a worldwide mandate of Merck and company aimed at treating patients with a wide range of conditions, including cardiovascular disease, osteoporosis, AIDS, asthma and prostatic disease.
Further, we are taking the lead in developing integrated patient health care programs, what we call patient health management, to improve the delivery of patient health outcomes and bring cost savings to the health care system. To this end, we are currently funding a three-year program at the University of Western Ontario and Victoria Hospital in London. This program is custom designed for the patients, physicians, pharmacists and other health care professionals who are involved in a coordinated manner to strive for implementation of best medical practices in the area of cardiovascular medicine. The end goal of this project is to improve patient outcomes and reduce overall costs.
Before offering our specific comments on Bill 26, I want to take a moment to express our views on how drug benefit programs should operate, together with their contribution to the health of Ontarians and the growth and development of the province's pharmaceutical industry.
At all times, the overriding focus must be the patient's health. Each of us, as health care providers, bear a particular responsibility to make this end goal a reality. In doing so, we believe there are several goals the drug benefit program must achieve.
The first goal of the drug benefit program should be to provide equitable access to prescription medications at a fair and reasonable cost to both beneficiaries and to the taxpayers who fund the program.
The second goal should be to ensure that Ontarians receive access to the newest and most cost-effective drug technologies in as timely a fashion as possible to ensure optimal care, defined as being the best care at the lowest cost.
The third goal should be to ensure that the drug benefit program is managed efficiently to achieve all possible savings for consumers and taxpayers. This in good measure can be accomplished by ensuring that drug reimbursement prices, drug listings and usage guidelines are open and transparent to all affected parties.
I'd now like to turn to the proposed legislation and offer our comments in four areas: first, reimbursement determination and listing decisions; secondly, drug interchangeability; thirdly, treatment guidelines and reimbursement; and lastly, consultation and the regulatory process. I would comment that we have also provided, in addition to this, a detailed analysis of our specific recommendations and it's provided to you under separate cover.
Turning first to drug reimbursement and listing decisions, Merck Frosst supports the government's proposed amendments to the newly named Drug Interchangeability and Dispensing Fee Act to eliminate best available price, BAP, and move to a more deregulated environment. This will serve two purposes: first, to eliminate a level of duplication with pricing authority of the Patented Medicine Prices Review Board, commonly referred to as the PMPRB; and second, to encourage price reduction in the non-regulated ODB pharmaceutical sector through greater competition.
The PMPRB is already an effective regulator, not just of introductory prices for new medicines, but of price increases for established medicines which limit annual increases to the level of the consumer price index. Under the PMPRB, Canada cannot have the highest price for a new or existing drug within the seven international drug markets compared by the board. Since the PMPRB came into creation in 1987, patented drug prices have increased by an average of only 2.1% per annum, compared to a CPI over the same period of 3.3%, as noted in a speech by Minister Wilson. In short, effective controls on patented drug prices already exist.
We believe that the elimination of the BAP, or best available price, will not result in excessive or discriminatory prices for patented medicines in the non-ODB sector because there is no mechanism in place for us to differentiate the price of our product charged to an ODB customer versus a non-ODB customer at the pharmacy level. We establish our ex-factory prices taking into consideration cost-effectiveness, the competitive environment and the PMPRB guidelines. As part of our pricing practices, we adhere to a one-price policy for all of our products to all customer types.
Additionally, we are of the opinion that sufficient competitive mechanisms exist in the Ontario marketplace today to mitigate against price increases and quite possibly lead to decreases in prices in both the non-ODB and the ODB segments.
On the related topic of reimbursement prices, Merck Frosst is of the opinion that the reimbursement price for listed drugs with a valid patent should be equal to the current best market price which also reflects available discounts and rebates offered to the non-ODB segment of the market. Therefore, the negotiations between the government and the manufacturer referred to in the proposed legislation should be limited to identifying and agreeing to discounts and rebates which exist in the marketplace.
We would recommend that government not arbitrarily set the reimbursement level lower than the current best price as described above. To do so would mean the difference would be borne by the patient. We would submit that this is a punitive form of copayment in that it is not based on the ability to pay.
With respect to drug listing decisions, the criteria in the legislation are not yet established in regulations. We look forward to receiving additional details on the implementation of this process. It is our view that the government now has an opportunity to take a more comprehensive and integrated approach to drug listing.
Price is one factor. Value is another. Many medicines save the health care system money in other areas through reduced hospital stays and fewer medical interventions. It is our obligation as manufacturers to prove the value of our products by demonstrating improved health outcomes through the conduct of drug cost-effectiveness studies. We believe in turn that the government should factor this value into its listing decisions. Cost-effectiveness studies permit the scientific evaluation of the effect a new drug will have on broad health care costs, such as hospital costs and other medical interventions. As such, they are a management tool available to government and industry to work together and find solutions to rising health care costs. Simply put, if cost-effectiveness studies indicate a drug offers value to the overall health care system, it should qualify for approval.
As I mentioned in my introduction, Merck Frosst is pioneering patient health management programs in Canada which employ proven, best medical practices, patient education, drug and non-drug treatment compliance programs and other measures to deliver better patient health outcomes, lower total cost and improved patient satisfaction.
We would recommend that the government lend its support and endorsement for patient health management programs as a means of improving the health of the citizens of Ontario and of effectively managing health care expenditures.
A final factor in product listing that should be considered by the government is patent status. Generic drugs have an important role in cost reduction once the patent for the drug they are copying has expired. Questions about patent status and intellectual property rights should be resolved in advance of a generic coming to market. Listing a product on a formulary with unresolved legal issues violates these principles. We believe the government should establish criteria that respect intellectual property rights and prevent patent infringement by allowing a generic to be marketed with outstanding patent claims against it.
Turning now to treatment guidelines and reimbursement, Bill 26 proposes to restrict drug reimbursement under the ODB act to specified prescribing criteria or clinical guidelines that will govern whether a prescribed drug receives reimbursement from the ODB program. We support well-founded treatment guidelines that promote medical practices consistent with current scientific evidence of efficacy and cost-effectiveness in obtaining optimal patient outcomes.
Merck Frosst is of the opinion that implementation of treatment guidelines as an educational measure is the most appropriate route to follow. Therefore, we are opposed to the linkage of reimbursement to treatment guidelines. Physicians are in the best position to judge the most appropriate treatment for the patient, and we believe that reimbursement systems must allow for physician judgement in the appropriate treatment of each patient as a unique individual.
In sum, well-founded, evidence-based treatment guidelines can be helpful in improving patient outcomes. They have a useful role in promoting best medical practices and Merck Frosst supports their development and use in this manner. We recommend that the government support patient health management programs in which guidelines are used to educate and encourage the best practice of medicine.
Turning for the moment to the issue of drug interchangeability, for many years now the ODB program, as well as other provincial drug benefit programs, have imposed drug interchangeability between generic and brand names as a means of keeping costs down. Mandatory substitution rules in Ontario legislation are the mechanism used to achieve this goal.
It is important that interchangeability allow for only interchangeability between different manufacturers' copy of identical molecules. Drugs composed of different molecules, even within the same therapeutic class, are not the same drug. Their interchangeability for either therapeutic or pricing purposes is not possible.
We raise the issue because proposed amendments contained in schedule G would allow the government to determine the drug benefit price based on a comparison of the price of "other drug product" in section 22 or a "class of drug product," which leads us to express the following concern.
Interchangeability of different molecules increases the probability of degradation of patient health outcomes. Not every drug in one therapeutic class acts in exactly the same fashion, providing the same health outcome. This could potentially be more pronounced in a patient taking drug therapy for a chronic condition, such as heart disease.
Turning to the last section, on consultation and the regulatory process, we have certain questions based upon eventual regulations and criteria not yet published that will give effect to the proposed changes contained in Bill 26. We welcome this opportunity to present our concerns to the committee and offer suggestions for improvement and clarification.
The legislation changes proposed will create a new business environment for our industry. We believe that it would be reasonable, because of our expertise, that we be given a full opportunity to work with government through a formal consultation process and review supporting regulations and criteria. This is particularly important in the areas of reimbursement determination and listing criteria, drug submission requirements and clinical practice guidelines.
The need for the government to take immediate steps to get the province's finances under control has led us to this stage. We understand this. The next step is to create a more open and transparent regulatory process, both to ensure legitimate input is received and prevent future problems from arising. We hope this committee will recommend such process in its final report.
The regulatory process is equally important in determining new product listings on the formulary. We support the minister's recent commitment to streamline the drug approval process. This should take the form of reduced red tape by lessening redundant information requirements for each submission, more transparency behind each listing decision, regular status reports to companies on where their drugs stand in the approval process, and greater certainty in eventual results. The results should be a greater number of cost-effective new products listed in a more timely fashion to the benefit of all Ontarians.
Let me close by thanking each of you for the opportunity to appear before you today. The changes proposed by the government to Ontario's drug legislation are significant and require your careful consideration. We believe that our recommendations will provide Ontarians with improved health and pharmaceutical care, improve the management of the drug program and assure continuing investment by the research-based pharmaceutical industry into this province's future.
Mr McLeod: I think it's important to understand, as a pharmaceutical industry, we're a highly regulated industry. Government is an exceptionally important partner in the delivery of pharmaceutical care. So there it would not surprise you to know that we've worked with the present government, past governments --
Mr McLeod: Going back to what I was saying earlier, it would be our opinion, as I've stated before, that for patented medicines there's already a system in place and it's highly unlikely and would not be for our products that there would be price increases.
Ms Lankin: Mr McLeod, with only two minutes, I'm going to make some observations and not ask a question because I appreciate your presentation. It's very clear in terms of your company's position on certain aspects of the changes to the drug legislation.
I note there are other aspects that you haven't commented on, even with respect to the drug legislation, like the structure, the copayments and whether or not that deals with utilization versus some of the other very good suggestions you've made about prescribing guidelines and how they should work in terms of peer education.
My big problem with this, besides the fact that it's buried in a whole huge bill and we're trying to deal with so many aspects of change to public life in Ontario, is that I don't believe the government really knows yet what the impact of some of these changes will be.
I appreciate that you believe that deregulation of drug prices in the open market, outside of the Ontario drug benefit program, will lead to competition and will lead to lower prices. I put to you that the generic drug industry came before us and said they didn't know that that was the case, and had some differences of opinion with the brand-name companies, which is not unusual but at least the committee received differing advice.
London Life suggested that at least in the next three to five years, the prices would go up until people gained new tools to be able to manage this kind of open competitive market. Rx Plus, which is drug benefit program management company, said that they thought it would go down. We don't know and we went back and took a look 10, 15 years ago when the drug legislation came in and what was going on there, and you had people from the Niagara region and Hamilton driving all the way to Honest Ed's in downtown Toronto to be able to get the best price on drugs, and the minister has suggested that the consumers will drive a competitive market because they'll shop around. I'm concerned about that.
One member of the government committee said: "Well, this has got to be good because deregulation is good. Look at the airlines." To me, necessary medication for people who are ill is not like deregulation of airlines.
I understood from the question Mrs Pupatello asked you that the price of patent drugs would stay the same. What has setting the price or the ceiling for generic products done to the price of generics, in your opinion? I know this will be in your opinion; I just want to hear what would happen in different classes of drugs.
I think what has happened is that it has led to a situation where generic prices, although lower than the name-brand prices, are relatively close to our prices, and they have not moved down all that low all that quickly. I guess that's what I would say. By opening up a competitive marketplace, there might be potential -- it's difficult to know -- but it might create more competition and there might be opportunities within that particular segment. Does that answer your question?
Mr Kormos: On a point of order, Mr Chair: There's a whole lot of nurses in this room. Perhaps they could stand up -- the members of the nursing profession -- and let us know that they're here. They called making inquiries to participate in this hearing, and were told that they didn't have a snowball's chance in hell of getting on to the list of presenters. Why doesn't this government want to hear from nurses in Niagara region who are the front-line service providers?
The Chair: Thank you very much, gentlemen. Welcome to our committee. You have roughly a half-hour to use of our time. Questions, should you allow the opportunity for them, would begin with the New Democrats. The floor is yours.
Mr Bill Wilkerson: My name is Bill Wilkerson. I'm the president of Liberty Health. On my left is Gerry Byrne, the senior vice-president of the company. Gerry will participate both in the presentation as we go, as occasions allow, and in the question area; as will Tom Boa on my right, who manages Liberty Health's businesses in the south and western part of the province, including this particular community.
We appreciate the opportunity, obviously, of being given a chance to express ourselves today. Liberty Health is the former Ontario Blue Cross. It is the province's largest supplementary health benefits management company, and our coverage includes more than two million individuals, both in terms of reaching them through their group plans as employees as well as direct to them as individuals themselves.
On a daily basis, Liberty Health deals with 200 hospitals, 2,400 pharmacies, 2,500 dentists, and various other providers in all regions of the province, often through electronic claims processing, giving us knowledge of benefit issues across the province we think in a unique enough way. It also gives us a perspective on the utilization issue which, bearing in mind the implications of this bill, is now a very real issue in Ontario drug management areas.
I'd like to make two kind of personal qualifiers before we begin the substance of our presentation. One is that Liberty Health is here today as a voice, if you will, not of the industry represented by insurers; we are not an insurance voice at these proceedings. At the same time, we want to underline, I guess, that what we are offering you is a combination of our analysis of the implications of Bill 26, particularly as it relates to the drug plan, and also that we are reflecting the voice of our customers, those being employers, public sector employers who constitute more than half of our customer base, employers who represent larger and smaller groups of people. In this community alone, Liberty Health represents the regional municipality and has a very real and immediate concern for the implications of this legislation on the public sector employer and public sector employees.
Supplementary health, I might just add another point parenthetically, by way of a position in the health care spectrum today represents about $1 in every $3 expended on health care in Canada and represents to us not a growing area in terms of replacing primary care or core service in health care delivery, but in fact a support sector which is growing by way of the need of the individual.
Our customers represent, and thus the voice we hope you will hear today, people living in both urban and rural communities, job entrants, pensioners, large manufacturers, entrepreneurial firms, municipalities, universities, school boards, hospitals and the agencies and institutions which represent the backbone of the Ontario public sector. In fact, one person in five, just about, in Ontario receives Liberty Health coverage in some form.
We're here, therefore, not as petitioners for a particular point of view corporately but as a vehicle through which to express some of the concerns and feelings reflected to us from this range of Ontario life.
In doing that, I think we need to underline, as should anyone who is going to present a view on this bill, it seems to me, that there is an inevitability that government must reduce expenditure, government must deal with deficit. The challenge posed, however, by deficit reduction -- deficit reduction born of a decade or more of building a culture of debt in this province and across this country -- is that deficit reduction must be connected in the broader context of human need and the impact in very particular human individual terms. This legislation, as it relates to the drug plan, must be considered in that light. We urge you, whether it's substantively related to the provisions of this bill or dealing with the aftermath of it, to give expression to the need for people to understand how this affects them and not just organizations and not just large corporations such as ours have the opportunity to prepare to be here with you.
There will be human implications and there will be a human impact as a consequence of the changes proposed in Bill 26 as it pertains to the drug plan amendment. We would like to characterize that impact to you as a community cost. In this sense, the changes set out in Bill 26 become not a matter of cost reduction only -- yes, in government terms, it comes off the books of the government of Ontario -- but represent in very particular ways a cost transfer from government into the wider community. The people in this room are the people who are going to pay for it not only as taxpayers but in other forms -- as employees, as representatives, as family leaders. That may not necessarily be the wrong thing ultimately, but we urge you to consider that it is a cost transfer, not a cost reduction, when you see it in the broader community light. If 225 million bucks that come off the government books go on the people's backs, I think the fact of that may well be that this bill needs time.
The shift in costs is accompanied by a shift in accountability and responsibility for drug usage and benefit management. The shift to seniors, to unions, to business, of course, as employers, the public sector as employers, municipal governments as employers, universities as employers is a community cost that we submit to you had not yet been assessed with respect to the point of whether or not the full implications of this legislation are known. We submit to you that this cost impact has not been suitably assessed as yet.
The cost transfer does something else. It shifts a new level of direct cost on to the employer base, both public and privately owned organizations, we submit to you, without suitable notice. This at a time when that cost base in competitive terms or in service terms, when you relate to the public sector employee, is already overloaded, given the environment we're living in and the society we're living in today. That the cost transfer happens may not be the wrong thing, but that it is happening in an unforecast, unheralded manner could make it unmanageable when it lands with full impact in the community.
In one example, one large employer we serve faces an estimated $2-million annual liability that was not planned yesterday. On a compounded basis, that can have a major effect for the employee and for the consumer that organization serves.
For public sector employees the implementation of these changes is critically timed, obviously. For employers in this sector, currently covering pensioners over age 65, for example, increased liabilities will coincide with a significant decrease in transfer payments.
For the people of Ontario generally over 65 not covered by third-party drug plans, and whose incomes exceed the proposed levels of $16,000 and $24,000 a year, not a very high level in terms of the base, access to drugs could be limited by the installation of the copayments.
Limiting access in this way could also result in cost increases in other areas of the health care sector. One must accept the inevitability of spending cuts. No one argues with that, I don't think -- perhaps in principle, but not in commonsensical terms.
Certain customers of our business, both the public and private sector employer, have suggested that a period of transition and adjustment is needed to accommodate the changes contemplated by this legislation, and we believe the recommendation which we are conveying to you on their behalf here today is a reasonable one.
We also recommend that the government delay the implementation of $100 deductible and dispensing fee copayment, or alternatively increase the proposed income level ceilings of $16,000 and $24,000 a year. Those are not very high levels of earning in today's world.
Our customers also question whether changes to the ODB plan may ultimately put the concept of early retirement at risk in this province. We ask you to reflect on that. That could be a profound question, not only in terms of that issue as a means by which organizations have more compassionately downsized in the face of rushing necessity, but individuals changing, preferring a change in their life, may find that change at an earlier age rather than later no longer within their grasp.
One little analysis we have done so far suggests that particularly for the larger employers this bill opens the door to cost increases for early retirement purposes being multiplied anywhere from one to five times the current. The note I have here from one of our senior executives says, "Add to that the impact of accounting requirement changes unrelated to this bill, and the capitalization of this very progressive concept of drug benefit as a guarantee is jeopardized."
I think the issue of what drug benefits are as part of an overall benefit program is worth reflecting on. We used to hear the term "fringe benefits" in the labour negotiations or in other terms. Fringes are no longer what we view benefits to be. We see them as guarantees and they are centre stage in employees' minds and we, philosophically as well as operationally, think that is a correct perception. Suddenly now employers, though, have an unclear picture of long-term liabilities in drug and other benefit areas and will be forced to re-examine long-term obligations in providing benefits which facilitate early retirement and other forms of pensioner security.
Benefits, by extrapolating this concern, not in an exaggerated sense, I would think -- and Mr Byrne, who's been analysing these matters for a long time, has had many years with Ontario Blue Cross and now Liberty Health, will tell you when we discuss the point, I think, that we are perhaps nearing an era when benefits could emerge as a take-away, or not a guarantee, because of the compounding effect of the cost transfer taking place here.
We believe the proposed deregulation of pharmacy pricing may well lead to increased costs being passed on to the consumers and the employers. Particularly vulnerable are those employers and employees in the municipalities, universities and public sector generally who face the pressure we mentioned earlier. To meet these budget targets, in fact, employers will begin capping their contribution levels to benefit plans, and this is going to increase the accountability of the employee.
We hear about cost increases presumably driving price increases. I would have urged this committee to acknowledge that consumers, not companies, drive prices down. Companies don't bring down prices as an act of charitable goodwill; companies bring down prices in order to remain competitive and to service and deliver business, as will we, going forward. We are a business and we will bring prices down in order to meet consumer needs.
That being the case, we think coming out of this bill, aside from the substance of it, there must be in this province a real era of consumer information and consumer education to help the consumer walk up and down the street, so to speak, making informed choice. Liberty Health will offer itself, with a tradition of public service as well as a real, live business objective, as a catalyst for that. Under Mr Byrne's leadership, in fact, we'll be launching a very aggressive heavier, rather than less, investment in capital for information technology to help facilitate an incremental growth in consumer information and consumer knowledge about what is available to them in the form of prescription drugs. Consumer information will bring price down, not corporate thinking.
I also ask you one other issue. It's kind of ironic, in Ontario's historic desire to distribute more fairly physicians in this province, that this legislation on the drug side has the portending risk of making it less attractive for pharmacists to live in non-urban areas. In this respect, we ask you to listen to the voices from northern Ontario with great intent. We at Liberty Health have a fundamental interest in the wellbeing of Sudbury alone, through their major employer and that municipality. We ask you to listen to their voice as to the implications of this legislation.
That being the case, we recommend to you, and to the government, that regulation of drug prices continue through 1997. The government should continue to enforce the protections now offered through the Prescription Drug Cost Regulation Act through next year.
We've got to understand one other point, as it goes to questions of price and cost and consumer effect and employee effect and human impact: that on average the drug component portion of a prescription represents 72% of the cost. This government perhaps, in policy terms and in directional terms, is on the right track with deregulation. But you are pulling the plug on protection of the consumer for 72% of the drug price, which relates to the manufacturing aspect of that cost -- 72%. We ask and wonder whether that is known.
In the face of change of this magnitude, consumer information, as we mentioned, becomes crucial. We will work with health agencies, pharmaceutical manufacturers, employers and other groups to increase consumer information and awareness in order to enhance consumer choice. We feel very strongly that employees, as members of group plans, should be seen and treated and respected as consumers and not as people who have no voice in this. In fact, they must have a voice as consumers, through their representatives and as employees directly.
Final point: We are going to encourage our customers, two million in Ontario -- and Liberty Health is committed to expanding beyond this province -- to access drug dispensing by mail order or through hospital-owned pharmacies as a means to consumer choice and cost containment.
A hard-case example of that is, when a husband-and-wife team is insured, for group purposes or dental benefit purposes, by two different employers, then that risk has got to be divided between those two employers. The duplication -- the phrase being "duplicate coverage" -- is an undiagnosed ill in the system in this province.
Through network use we will urge that the dispensing of medications be reviewed annually to ensure quality. The 1980s taught us that business can overextend. The 1980s taught us something else: that when you've got to restructure and bring price down, quality's got to go up. Those things are not anathema, and it seems to us that they must be a fundamental pivot upon which this legislation is introduced.
Ms Lankin: Let me just continue on the comments that I was making to the last presenters. I think you've underscored it. If I understand your presentation, in two or three different areas you're saying: "Let's not proceed immediately. Delay the implementation of aspects of the copayments and the dispensing fee and the deductible, because we don't know exactly what the impact's going to be, first of all on individuals and the cost factor, and secondly, with respect to shifting that cost out into the private sector."
I think that's an argument that could be made throughout this bill. There are going to be higher costs to benefit packages outside of medicare. That either means fewer people are going to get those benefit packages or they're going to be scaled back, or there are going to be greater costs in the system. We know right now that health care costs to employers in our province are one of the big competitive edges they have. In the auto industry, for example, in the States it costs $4,000 per year, per employee to fund their health care insurance programs; in Canada it's $700 per year, per employee -- a big issue.
Ms Lankin: My bottom line, I think, is that this is not a well-considered schedule in this whole bill. There are a lot of questions that could be answered by the kind of process that you've suggested putting together at the end of your presentation.
Would you support a recommendation to the government that said: "Look, we know there are issues you want to deal with here. You're going a little too fast. Could we take this schedule out of Bill 26 and spend another couple of months looking at the implications of it and working out some of these problems, and bring it back in the spring session and deal with it then?" Would that be a rational way to proceed?
Mr Wilkerson: We would endorse that. We would also endorse the view that Liberty Health -- and I'd like Mr Byrne to comment further on this very point -- would offer itself and our good offices as both a public-interest company as well as a commercial-interest company to help facilitate that process. We're going to do it anyway on our own. If this bill is law we have an obligation, we feel, to help sort out the implications.
I want to underline one thing particularly. This is not a criticism of the government's intent or attempt to bring order where order is needed or to bring costs down in terms of the tax base of the province. It is a question of timing and a question of understanding implications of things; it's a question of placing these changes into the context of the human effect they are going to cause. That isn't philosophical or partisan. That is a basic, fundamental business and community issue.
Mr Clement: With respect to the human effect, I agree with you. When government acts or refuses to act, there is a human cost to that. We felt, on balance, that refusing to act would create greater misery than that which you have spoken about.
I wanted to flesh that out, because with the money saved from copayments and accountability in the system, we have been able to announce at the same time an extension of the Trillium drug program to 140,000 of the working poor who had no drug plan protection in the past. The money is being reinvested, in a sense, in that program. Are those the kinds of actions that you're looking for from a government?
Mr Gerry Byrne: Absolutely. We do not at all disagree with extending it to the working poor and to a greater degree under Trillium. What we have in fact understated here is that this is a cost transfer to an employer base and a consumer base that has an inability to absorb or an inability to pay. Many are tied up in negotiated agreements through some time and are picking up, as Bill mentioned earlier, a cost that was not anticipated. The reality is that in human terms, in many cases the only offset will be perhaps additional layoffs, which is totally against what we are trying to do. It's basically a timing issue.
Mrs Pupatello: I first want to say that you've put together succinctly, better than many -- your presentation was excellent. You represent big business and small business; you represent business. It's very surprising to hear how strongly you feel about the process of the bill, about the fact that parts have to be separated and that we have to delve further because in theory things look wonderful, but practically they can be an absolute disaster. It begs the question about who the government consulted and to what degree when this was put together. Mr Byrne, could you continue your remarks to help us convince government members today that the bill must be split apart and that additional comment and time for hearings in this process are critical.
Mr Byrne: I'll even extend your definition of "corporate" and "business." As Mr Wilkerson mentioned earlier, we are representing our customers, and we did seek their input. We've had meetings with them. That includes individuals; I personally met with 60 pensioners in Belleville. We have gone out on our own and got the voice of our customer. The issue here is time, transition. Philosophically, I would say the consumers themselves do not argue with the issue, the fact that we must change. But it is a timing issue and a way to adapt, both transitionally within the companies and also within the behaviour of the consumer.
Mrs Caplan: We received this morning answers to questions that had been asked in Ottawa from the Royal Ottawa Health Care Group regarding protections of the Mental Health Act, confidentiality. It's not clear to me in the answer to the question, and I'd like further clarification from the ministry.
Do the provisions of the Mental Health Act override the concerns that have been raised, effectively override Bill 26? Also, as the Mental Health Act applies to inpatients, why is special protection for mental health patients or anyone seeking psychiatric services given only to those on an inpatient basis? What's the rationale for having different confidentiality protection for people who are in hospital when we're seeing a shift to community, to outpatient, and drug therapies are allowing people to be deinstitutionalized? Is the government aware of that disparity as the legislation stands?
Second, in view of the number of nurses here -- we have not heard from nurses; we have heard from many associations of doctors, many associations of hospital administrators and hospitals and so forth -- I'm asking if this committee would allow the nurses at this time to take the available slot, and I do so move.
Mr Bradley: A quick point of order, Mr Chair: If the government members agree, if all members agree, perhaps the solution might be to have Dr Shimizu make his presentation now and the nurses immediately after.
Ms Lankin: Mr Chair, I want to add a question to be tabled. I received answers to my questions with respect to the cardiac surgery network -- totally unsatisfactory answers. They did not answer the questions I tabled.
Second, the series of questions I tabled with respect to independent health facilities, the ability of American for-profit companies to come in and start to take over delivery of health care services through that sector, also have not been fully answered. I specifically asked for a list of the American companies, or the Canadian subsidiaries of American companies, that the Minister of Health had met and consulted with, and there is not one reference in the answer to that question in the material I received. I place that question again and I ask for that, otherwise I will proceed with a freedom of information request.
Mr Kormos: Mr Chair, I have three questions, please. First, why do the Tories persistently refer to the new costs as copayments when they are in fact the user fees that Mike Harris promised wouldn't be imposed upon consumers in Ontario? Second, why did Mike Harris lie to the voters of Ontario about imposing user fees? Third, understanding that the Administrators Coordinating Committee for Niagara Region Hospitals is not here today -- it's not any secret that they're purposely not here -- what did the government cave in on with respect to the Ontario Hospital Association such that the local Administrators Coordinating Committee for Niagara Region Hospitals feel no need to appear today? Obviously, they got greased, they got pieced off. What about doctors and nurses and consumers and sick people? How come they're not being accommodated in the same way?
Dr Art Shimizu: My name is Art Shimizu. On behalf of the Lincoln County Academy of Medicine, we would like to thank you for inviting us to make this presentation today. I am the current president of the Lincoln County Academy of Medicine and a nephrologist, a kidney specialist. With me is Peter McMain, a paediatrician. We will be making the presentation jointly.
At the outset, we wish to express our wholehearted support for the position on Bill 26, the Savings and Restructuring Act, taken by the Ontario Medical Association presented to your committee recently in Toronto by Doctors Warrack, Gray and Orovan.
My comments are going to be very brief because I'm going to let Peter McMain do most of the talking. I wish to make some observation, however, on Bill 26, focusing my attention on the possible impact it may have on patient-doctor relationships and possible detrimental effects it may have on the quality of medical care delivered to patients.
Since the days of Hippocrates in the fifth century BC, physicians have had a moral commitment to give the best possible care to their patients and to act as their advocates in this respect. The Minister of Health, in his drive to contain costs, appears to have come to the conclusion that every single clinical encounter the doctor has with his or her patient must be monitored vigorously, since they may create opportunities for fraudulent behaviour.
(1) Legislation to expand sets of circumstances under which the general manager of OHIP could refer a matter to the medical review committee of the College of Physicians and Surgeons of Ontario and actually permit the general manager to bypass the MRC referral.
This latter aspect of the law may have been modified, since the Minister of Health last night stated that OHIP inspectors were not necessary, but he still leaves intact the intent of the legislation. In this climate of Big Brother looking over the shoulders of physicians, doctors may begin to indulge in defensive medicine to avoid practices that may be interpreted as fraudulent by the minister.
This has a potential to deter physicians from providing all the necessary services and from always acting as an advocate for their patients. Doctors may become reluctant to challenge the rules governing which services are appropriate. Soon, many physicians may find themselves conforming to the restrictions and deceiving themselves that they are acting in the best interests of the patient. Such a scenario would certainly be detrimental to the delivery of quality care to patients.
(2) Bill 26 allows the general manager of OHIP a general power to request the medical review committee to review physicians' provision-of-service patterns, even in the absence of reasonable grounds of any impropriety. This would involve a review of doctors' overuse of laboratory tests, diagnostic imaging, such as X-rays, CAT scans, MRIs and consultations with other physicians. The problem I see with this is that some physicians do see sicker and more complicated patients with very difficult diagnostic problems than some other physicians, requiring extensive use of diagnostic tests and second opinions to diagnose and treat patients appropriately. Restricting use of such investigative tools and opinions of other consultants would prevent the delivery of optimal care to patients.
I presume guidelines will be used to determine the appropriateness of investigative tests. Guidelines are developed from evidence derived from large randomized clinical trials. These clinical trials are carried out in well-defined, specified groups of patients, which in clinical practice may not apply to one's patients because they are outside these definitions and one cannot apply them. There are many grey areas, as pointed out by Dr Naylor recently in Lancet, and evidence-based medicine cannot always be used. In fact, it's in a minority of cases in your general practice. Just because one uses clinical guidelines that your peers and the university physicians have developed doesn't mean it can be employed in practice.
For instance, I deal with a lot of hypertensive patients. Huge, randomized clinical trials have been performed in the last 10 years that state that beta blockers and diuretics are the treatment of choice, but many patients cannot take these. It may be that a patient has asthma or there may be other lifestyle reasons. For instance, you can't jog very well if you're on beta blockers. The guidelines say to use them, but I use something else, much more expensive stuff, ACE inhibitors, and calcium channel blockers. Am I going to be penalized because of that?
Young mothers of Ontario will have difficulty in finding a physician to deliver their babies because of the discontinuation of the physicians' malpractice premium supplements. Again the patients will suffer because of these measures. Some strategy must be worked out to solve this urgent problem.
Finally, although some closures of hospitals and emergency rooms are probably necessary, it cannot be denied that if extensive, it will be harmful to the interests of patient care. I do not think that limiting these powers to four years mitigates the harm it does, as stated by the government last night. The surviving hospitals will be told by the officials of the ministry to increase or decrease volumes of various services or to cease to provide specified services. This certainly threatens the quality of patient care.
In summary, constraints, for whatever reasons, envisioned by the omnibus bill will lead to deterioration of the quality and accessibility of care. I firmly believe that reform and restructuring of our health care system is necessary. However, in that endeavour, we must keep the interests of the patient foremost. I do not believe Bill 26 fulfils this goal. Thank you.
Dr Peter McMain: Chairman Carroll and members of the committee, I'm grateful for the opportunity to participate in these hearings. My name is Dr Peter B. McMain, and I'm a representative of the Lincoln County Academy of Medicine, an organization of which I am a past president, and I am engaged in the practice of paediatrics. To my left is Dr Elliott Halparin, who is the local OMA representative for district 5.
That our health care system is experiencing serious difficulties is an obvious reality, especially to those who are unfortunate enough at present to be ill. If the members of the committee take a random walk through any of the hospitals in this region, I guarantee that they will see peeling paint, crowded waiting rooms, long waiting lists for surgery; disgruntled patients being discharged home prematurely to be cared for by inadequate home care services; overstressed doctors, overworked nurses and disillusioned students.
The final ignominy is to see printed in the Globe and Mail, which I have here today, an ad by the University of Virginia Medical Centre advertising its ability to provide knee and hip replacements for Canadian citizens. Can anyone believe they would be advertising here unless they know of our long waiting lists for treatment? The last line of this ad is very pertinent to our situation. It says: "Pain doesn't wait. Neither should you."
We in the medical profession are fully cognizant that our province faces a fiscal problem of major proportions. With a provincial debt greater than $100 billion and with 30% or more of the provincial budget being spent on health, we are in accord with the government that there is an urgent need to contain the costs, but we believe that Bill 26 fails to properly address the roots of our difficulties and will in fact compound them.
To put Bill 26 in proper historical perspective I wish to draw your attention to the evolution of our present problems. You will recall that in 1984 the Canada Health Act was firmly entrenched into the legislative fabric of our nation. It consolidated previous federal legislation and strengthened the federal commitment to the principles of universality, accessibility, portability, comprehensiveness and public administration. As such, it was the envy of the world.
The delivery of the act was attended with a euphoria of high hopes and expectations which one usually associates with births. Unfortunately, a small caveat by Justice Emmett Hall was overlooked. With unusual prescience, he warned that the cost of the health care system was sustainable only if any further increase in service was proportionate to the rate of increase in the gross domestic product. In other words, "Don't get into deficit spending." Successive governments have ignored this advice. Whether it was through ignorance or whether it was to woo the electorate, I will leave you to speculate. But the net result is that the costs have spiralled upwards ever since.
During the 1980s, flush with profligate spending, the health service appeared deceptively robust. However, it was in reality seriously sick, with uncoordinated, fragmented services, unnecessary duplication of services, top-heavy administration and lacking proper vertical integration. As a result of this pathology, the health service corpus is now in a state of collapse, is seriously anaemic and in dire need of fiscal transfusion and intensive care -- some might say the last rites.
We in the medical profession are tired of being blamed for what is essentially a political and administrative and consumer problem. With simplistic sophistry, we are blamed for the high cost of care because we are the gatekeepers of the system. The trouble is that the government took the gate off the hinges a long time ago. In reality, ours is a consumer-driven system with an insatiable appetite for service. Add to this the increasing cost of technology and it is easy to see why costs are getting out of control.
To date, most of the government's efforts to sustain costs have been directed at the providers of health care and not at the consumers. These problems, however, are not unique to Canada, and other countries have found workable solutions. In Sweden, probably the most socialized of European countries, a user fee is employed. Britain allows its citizens access to private insurance and private practice. Oregon in the United States, after consultation with health professionals and the public, has decided on a list of illnesses and medical procedures which the state insurance will cover, leaving self-limiting illness to be paid for by the patient.
To those who claim that adoption of similar measures here would lead to two-tier medical care, I reply that it already exists. In our hospitals we have private, semi-private and ward coverage. We pay out of our pockets for ambulance service. We also pay directly for artificial insemination, plastic surgery and certain eye procedures. Consider the newspaper reports of prominent politicians or their relatives who go to the USA for their cancer treatments or bypass surgery.
The French philosopher René Descartes said that the two greatest impediments to clear thought are (1) haste and (2) prejudice. Unfortunately, Bill 26 fails on both these counts. Another old English adage says, "Act in haste and repent at leisure." The inordinate haste to pass such sweeping legislation represents, I fear, a panic reaction to a problem which has been years in the making. The problems are systemic and there is no quick fix. Prejudice is also manifest in the statements of the Minister of Health, who points to failed negotiations between previous governments and the OMA as a reason for refusing to negotiate a mutually acceptable fee structure and compulsory arbitration in the event of unresolved disputes.
At best, the portions of Bill 26 relevant to health care represent a clumsy wielding of legislative authority which goes beyond the mandate accorded by the electorate. The uncompromising, coercive and indeed punitive tone of the bill sounds more in keeping with totalitarian regimes than those of a Western democracy. They also sound strangely dissonant with a government which espouses, as part of its political ideology, individual liberty and a free market economy. Indeed, there has been speculation that the health provisions of the bill represent the work of a cabal of civil service bureaucrats, served up to be regurgitated half-digested by a fledgling minister.
Schedule I of the proposed bill, with its provision through the Physicians Services Delivery Management Act, 1995, represents a blatant attempt to extinguish contractual rights and obligations. I find this ironic, when only last week Prime Minister Chrétien was asked if a change in Indian government would result in cancellation of contracts and he replied that governments respect signed contracts.
The provisions of the bill which effectively prevent physicians who work in hospitals to a right of hearing and appeal is an offence against natural justice and could lead to a court challenge. No matter the outcome of this challenge in the courts, I am sure that the Canadian public would be left with lingering doubts concerning the moral integrity of the government.
We object to the provisions contained in Bill 26 which empower the Minister of Health to unilaterally define insured services and set fees for these services. We object to the lack of provisions for settlement of fee disputes and an arbitration process. We object to being disenfranchised. We object to the loss of doctor-patient confidentiality which this bill will entail.
The portions of the bill dealing with physician eligibility and geographic billing numbers represent a crude attempt to conscript and exploit the young members of the medical profession for services in the rural areas of the province. The problem of providing medical services in these areas is a matter of prime concern for the members of the OMA. The factors inhibiting the recruitment of young physicians to these areas is due to facets of rural life, some actual and some perceptual. These are professional and geographic isolation, lack of technologically trained support staff, limited social and cultural activities, limited employment opportunities for spouses and fewer educational choices.
The answer to this problem is not to dragoon physicians into some kind of medical gulag, but to provide proper training for rural service and adequate financial incentives, subsidies and a mechanism for the provision of locums. I am also very certain that citizens living in these areas do not care to be treated by a resentful conscriptee.
Consider the plight of a new medical graduate, married with a young baby and living in a metropolitan area where her husband works. The government proposes to dislocate her to a northern community before she can practise her chosen profession: Go there and proclaim the values of family unity to her patients. I find it rather ironic that the European Parliament in 1993 passed legislation allowing for the free movement of doctors within the European economic community while we set up restrictive barriers.
It is common knowledge that the cost of malpractice insurance is escalating and that for some branches of our profession the burden is particularly onerous. The removal of government contributions to the insurance will have the effect of decreasing the already small number of family doctors who practise obstetrics and will encourage the flight of obstetricians south of the 49th parallel. Senior experienced physicians who currently plug the holes in the system will no longer be able to afford the practice. The net result of this will be manifest, I regret to say, in rising perinatal mortality and maternal mortality rates. I am appalled that I now have to tell students that in addition to the long lists they have to know of the causes of perinatal mortality, they must now add to that list government parsimony.
Unfortunately, medical Utopia is still on a far distant shore, and like Ulysses of old, it seems that we will only get there by proceeding from one shipwreck to the next. If the good ship Ontario Health is to make it, then Health Minister Wilson, as master, would do well to consult as his chief navigator the Ontario Medical Association and to employ a willing crew of health professionals who have not been press-ganged into service. If we are to negotiate the shoals which immediately beset us, then the ship should be made more buoyant by consigning large parts of Bill 26 to the deep six.
Mrs Margaret Clark: I would like to take this opportunity to thank Peter Kormos for the opportunity allowing the nurses to speak. Many of us are here on our days off. We were not one of the chosen few to be given time. My name is Margaret Clark. I'm a registered nurse at the Welland County General Hospital.
I would like to ask the panel: Who of you on this panel is prepared to give 24-hour care at home because a loved one has been sent home from hospital because there are no beds or because of early discharge? Where do you get the skills to know when the patient's condition is changing? Do you know the signs of septic shock due to overwhelming sudden infection? What do you tell your employer if you have to stay home with someone? How does it affect your economic situation? Do you realize how little care is available in the community? The stress of the situation of having a critically ill patient to look after is better dealt with by the professional registered nurse.
Mr Kormos: I should note as well, let's face it, that not being a member of committee and not getting that $100-a-day tax-free per diem, I wasn't entitled to move a motion. It was Ms Caplan's motion, which we're grateful to. So this was a collaborative effort. There's a whole lot of people who are opposed to this Tory Bill 26, trust me.
Mrs Gagné: Thank you, then. As Marg said, my name's Susan Gagné and I'm a registered nurse at the St Catharines General. I work in the intensive care unit. I guess right now my only point of dismay is that I wasn't in Alberta when that man needed his heart. If you know the story, he couldn't get his heart because there weren't enough qualified nurses available to care for him.
My concern when I read the bill and the synopsis of the bill was with words: the words "without regard," "take over the powers," "no liability to government," "unlimited power," "remove requirements for citizen referendums," which to me implies full control by Bill 26 and the government to take over health care in Ontario.
Another statement that I hope everybody listens to, re-reads, is that of services prescribed "only if they are provided to insured persons in prescribed age groups." I hate to tell everybody in this room, but we can't stop the clock and we're all going to be in a prescribed age group whereby we might not be able to get the service or the care that we need. Frankly, when I'm 80 and I'm young and hopefully still interested in maintaining my health, I won't have somebody say: "I'm sorry. You're too old, Susan. Therefore you go without."
I'd like now just to briefly talk about the Health Services Restructuring Commission that is going to be set up to deal with this whole restructuring, re-engineering, rationalization issue. In my brief, it was stated that it will sunset in about four years. I think within these four years, then, we're going to have the health care corporations that are the determinants of health in the US, the Americanization of health care, come in and take over. It's interesting to note that the net worth of one chairman of one of these health care corporations is in excess of $800 million. He's getting very rich for a service which isn't even available to all the people in the US.
I'd like to end my presentation now with once again the sunset in about four years. Probably if we carry on with Bill 26, we will see the sunset of our medicare system within four years. I would like to know how this government can believe that we should not fight against the Americanization of health care in this province. I would like to know who is going to be the watchdog of this proposed Orwellian state that Michael Harris wants to create. Thank you very much.
Mrs JoAnne Shannon: My name is JoAnne Shannon and I'm a registered nurse at Greater Niagara General Hospital. As a registered nurse, I am speaking as a patient advocate. I am speaking on your behalf. Some day, everyone in this room and on this panel will be a patient requiring health care. The restructuring that is being proposed by Bill 26 will affect the quality of care that you receive. We've been reminded of the relationship between cost and value. Restructuring based simply on cost does not necessarily give value.
The re-engineering process that is currently being undertaken in this region with no input whatsoever from front-line workers is going to result in a less skilled caregiver who will be replacing the registered nurse at the bedside. The thrust of this government is to provide the best quality of care for the least cost. Does the least cost truly provide the best quality of care? Think about it.
Ms Margaret Dempsey: My name is Marg Dempsey. I'm speaking actually as a private citizen, but also as a nurse who works in the community. First of all, I didn't think I was going to have this opportunity, so the first thing I want to say is to express my feelings as a private citizen as to how offended I was by the government's intent to pass this bill without debate and without consultation. I did not vote for this government. There are members in this room, the opposition, who represent my views, speak for me, and they were not going to have a voice. Therefore, I was not going to have a voice. That's what I find offensive.
I definitely believe in the democratic process and I know that the majority rules. I have no problem with that and I have no problem with decisions being made that I do not agree with as long as there is debate and as long as opinions are heard that represent my feelings. So I'm delighted to have this opportunity.
Speaking as a nurse in the community, we do see things from a different perspective than in hospital care. I really think you have to consider the impact in the community at large on some of the provisions of this bill, particularly in regard to reducing or deregulating drugs and imposing user fees. I work particularly with the senior population. Seniors in their own homes often have great difficulty making ends meet on fixed budgets and so on, but they are also a different population in terms of how they perceive what they're going to spend their money on. Imposing user fees on seniors, and particularly confused seniors who don't necessarily understand the implications of some of these proposals, will inhibit them going out and getting the necessary drugs.
The interesting thing is, when we think about the health care system and we think about the fact that OHIP funds the entire system, be it the acute care, the community care process or the institutional care, everybody has their own little budget. The previous group that was speaking -- I think they were a health insurance provider -- made the excellent point of saying that we're not necessarily reducing costs; we're transferring costs. I believe that to be the case in many ways with some of these proposals, because what's going to happen is you're going to get seniors not getting their drugs. They're going to end up in hospital. It's going to cost the government more. You just think you're saving money because you're reducing the cost by imposing user fees or by making it more difficult for these people to get their drugs, and in the end it's going to cost the system more because they'll end up in the hospital system, in the acute care system, and then finally into the institutional care level.
Mrs Ecker: Thank you very much for coming at very short notice to this. I'm glad we had unanimous three-party agreement to allow you to come and I'm very pleased that you were able to do it. I appreciate the fact that --
Mrs Ecker: It's unfortunate that when all three parties were drawing up their list of priority presenters -- all three parties -- we haven't been able to get more nurses' groups here before us. We had two excellent presentations --
Mrs Ecker: You make two very good points, which I frankly would share. I would join you on a barricade to fight against the Americanization of our health care system because I think that one of the things that Ontario has going for it is an excellent health care system. I had the experience of actually having to be there Saturday night in emergency with a loved one, so I know how valuable that system is. All of us have elderly parents and children and family members, and we know how important it is that that system is there to make sure it's there when we all need it. So I would certainly share that concern. I don't think that's what's happening, but I can appreciate your concern about that.
The second point and I just wanted to ask, you made the point about generic workers, and one of the things I think has been an excellent step in the health care system is the Regulated Health Professions Act, which very clearly sets out scopes of practice for regulated health professionals, which include nurses, which are starting to include nurse practitioners, and I think that the quality objective of that legislation is supported by most observers of that system.
I have concerns about generic workers in terms of what that might be doing to undercut what the RHPA has built up. I just wonder if you would like to elaborate a little bit more on what you see is happening with some of those generic workers, because I share your concern on that.
Mrs Shannon: We don't have them currently, but the move is towards them and that's our concern. The multiskilling of other workers is beginning. They're beginning to break down what we do into tasks. Our concern is that these tasks will now be given away to less skilled people, who we will still be responsible for supervising and making sure that the care given is quality care. I don't think the generic worker is out of place not giving direct patient care. Direct patient care should be left to professionals, but there is a place for them in non-direct patient care.
Mrs Gagné: I was just going to say my concern with the generics is you're basically chopping up the patient into bits and pieces. In order to really care for somebody, meaning from the time of admission, the goal is to get that person back to their return to activities and to earning a living. Okay, that's the goal. If you chop that person up into different little pieces, I'm concerned that the return to activities of daily living might be compromised, and that person's not going to realize full or the best potential recovery.
As simple as it sounds, the bed baths -- so we'll give the generics the bed baths. There is so much information gleaned from that time with a patient. The other thing is that that's where the health teaching care is on, during that time. You can't trivialize these things. It has to be in the whole package. If you have someone who has the knowledge base, the critical thinking skills, to do those seemingly menial tasks, the outcome is going to be more successful.
Mr Bradley: I'm glad that my colleague Elinor Caplan was able to move the motion to have you appear before the committee today. I know it has received support from the members of the opposition and today the members of the government.
My first question is, and I'll let any one of the three of you answer as citizens of our society, the members of the opposition had to take extraordinary legislative action to ensure that we would have meaningful hearings in the month of January when everyone would be attuned to them and, second, across the province where people from various communities could have input. Do you believe that the opposition did the right thing in taking extraordinary legislative action to ensure that we have these hearings?
Ms Dempsey: Absolutely. I was delighted. As I said earlier, I really believe that we need to have a voice. That's the parliamentary system from my understanding, that we have an opposition that expresses the voice of the people as well as those who are in government, in power. This to me is essential debate, because it is very precipitous to implement something this profound in such a short time frame and with no debate.
Mr Bradley: Subsequent to that, do you believe that further hearings across the province past the January 29 date that the government has set would be useful to enable the government and enable the opposition in the Legislature to ensure that whatever legislation is passed is a better piece of legislation, better reflecting the views of those who are aware of the consequences?
Ms Dempsey: I would say, again, absolutely. I think we don't appreciate the implications of something like this. To hear those who are actively involved in the direct care of individuals, particularly within the health care system, the implications are many and, as I said, I don't believe that what you're doing is necessarily cost-effective. It may look cost-effective at this moment in time with the information you have, but if you consider the bigger picture, you may find that in fact it's going to cost a lot more money than you expected it to.
Mr Bradley: One of the differences between Canada and the United States I think that people objectively observe is the health care system and the attitude of our citizens towards that system. The United States has lower taxes; we have, I think, a better health care system. Given the choice, do you believe that the people of this province would rather have a 30% cut in their provincial income tax or that they would rather have that money remain within the health care system to provide for people in this province the kind of quality health care that we would like to have for many years to come?
Mrs Gagné: My answer is yes. But my answer is yes, as long as we do realize a maintenance of what we currently have and we don't have the user fees and we don't have the $150 per member per month -- and that's a union phrase, sorry, but all the extra fees added on top. I don't know. Right now, I'm a bit cynical. I think I have to see from this government true sensitivity.
When I see the Premier on TV and his response to the labour movement in London -- and I have to say that my dad, he's 74 years old and he marched in London -- and his response was, "Yes, well, I know they're going to be upset." I think if the public can see some true sensitivity from this government to maintain health services, we might start believing them.
Mr Kormos: Ms Clark may want to join us by sitting in this chair here. I want to ask you a question, Ms Clark. Hospitals in this province are basically private institutions with boards of directors picked out of a very small, incestuous group of people who are inclined to join the hospital association. In the Welland County General Hospital, I'm told that the members of that association number no more than 200, and out of that mere 200 comes a board.
Because it's public moneys that by and large are spent in our hospitals, would you agree that one of the ways to really start addressing the issue of accountability in where the money goes is to have publicly elected boards, in view of the fact that hospitals are spending taxpayers' money in such huge amounts?
Mrs Clark: Definitely. This has been one of my top priorities in Welland, constantly, constantly going to the board members and saying, "I want the board to be elected and I want it to be open." They refuse, absolutely refuse, to allow any employee of the hospital to sit on the board, and unless that is legislated by this government, it will never happen.
The only reason that we nurses and other union members are sitting on fiscal advisory committees today is because it was legislated. For years we've been fighting to sit on these boards and they have refused to allow it. This board is the board that reviews the whole operational budget that the hospitals get, and we've only been on them now for about four years. Now our next fight is to get on the hospital boards themselves, because this is where the decisions are made.
Mr Kormos: Nurses as the front-line service delivery people, you're the folks, women and men, who are with our parents and our family members and ourselves when we're ill. You're with us 24 hours a day. Nurses have been prepared -- quite frankly, isn't it nurses who have the best input into concepts of restructuring and finding efficiencies and finding economies that haven't been discovered before? How come you haven't been more actively involved in that process? Why are people slamming the door in your face?
Mrs Shannon: We have not been allowed to be part of the process. As RNs we recognize that the health care system needs to be restructured, but we would like input on how it's restructured. We feel, as patient care advocates being at the bedside 24 hours a day, we know what is waste and duplication in the system.
Mr Kormos: You may or may not have read about these two little brochures, unendorsed, unsigned, paid for by all of you taxpayers of Ontario, printed by the government, which contain -- it's called spin-doctoring, it's called damage control. The Tories spend thousands of bucks, hundreds of thousands of bucks on spin doctors and damage control people. They've got their little staff people here, four or five of them, who review what's heard here today and then advise this panel of Tories on how they should be responding so they can control damage.
One of the things that these most deceitful and dishonest little bits of hack propaganda indicate is that Bill 26 was held with extensive consultation -- expensive too, expensive to the sick and the elderly and the poor in this province -- with the stakeholders. Were nurses consulted in the course of the preparation of Bill 26?
Mr Kormos: Well, I think it's disgraceful. It seems that the Ontario Hospital Association is becoming increasingly satisfied and complacent. I have no doubt that Dennis Timbrell and his gang, being related almost by blood as he is with this gang of Mulroneyites and Reformers in Queen's Park, were consulted.
I want to tell nurses in this region and in this province that you are the women and men who attend to our sick on a daily basis, 24 hours a day. You're the ones who suffer the injuries, who suffer the bad backs and other workplace injuries associated with the very physically strenuous as well as mentally strenuous and demanding task of nursing.
This government clearly devalues and dismisses the public sector, be it public sector in broader public sector nursing in our hospitals, be it public sector nursing in our communities and the prophylactic role that they play in terms of preventing disease and preventing illness and creating economies that way. I think it's disgraceful that nurses should come under attack by a government.
Mike Harris promised no reduction in health care. Well, by God, the impression that a whole lot of people have is that Mike Harris lied. It was a bold-faced lie, it was an unabashed lie and it's a lie that's being demonstrated now by virtue of these hearings on Bill 26. It's an indefensible lie and a shameful lie, and I encourage you people to keep fighting back.
Mr Kormos: Mr Chair, please, I appreciate that the Chair is trying to be timely, but the fact is that obviously committee members are still en route back from their lunch; perhaps they're making phone calls, any number of things. Could we defer the commencement of this for five minutes so that committee members have a chance to -- I mean, why should people bother making a submission if people aren't here --
Mr John Dawson: My name is John Dawson. I'm a regional councillor for the municipality of Niagara. To my right is Mr Wayne Hardwick, who's vice-president of the Niagara Falls and District Labour Council and former president of the Ford glass union.
I have here a document that I was going to pass to the Conservative caucus, but I find that most of them are not present once again. Perhaps I'll wait till after I give my submission. It is on the supposed long-term care reform model which necessitates the establishment of a new agency to operate the placement coordination and home care services.
Copies went to the Conservative caucus and I might just mention here that it says: "In these times of scarce tax dollars, I do not understand how the dismantling of programs which are now functioning very efficiently justifies the spending of limited government funds to establish a new governance organization." I know that copies of this letter from the regional chair went to the local MPPs and I might just pass it around to get their comment on this matter. Also, it says, "During these difficult times, the community needs to pull and plan together, rather than become more divisive with the creation of a new agency. Our regional council representatives are reflective of our entire community."
Thank you for allowing me to appear before this committee to express my views on what I consider to be a decline in health services as a result of Bill 26 and other government legislation. The thoughts I express are my own and not those of regional Niagara.
Health care costs amount to approximately 6% of GDP and are no doubt well worth the expenditure. High interest rates, interest on the debt and diminishing federal and provincial revenues are all additional factors that contribute to that problem. Health care costs are not, I would argue, a serious area of concern in relationship to the deficit.
One of the Conservative panel members, who has not arrived back yet, I might say, referred to the $1-million cost per hour required to reduce the deficit. I would like to just comment on that by relating a little experience I had at my favourite financial institution recently. I was there to renew a matured investment and naturally the young lady was eagerly trying to convince me to reinvest at that particular bank. My response was, "Ms, my country is in trouble, my province is in trouble; the banks are not in trouble." I proceeded to purchase an Ontario savings bond, much to her disappointment. If my memory serves me right, the Ontario treasury was, from all the purchases of the bonds, richer by over $2 billion. The money stayed in the province and did not go abroad to foreign bond holders.
I began to think about the loudest and most vocal critics of our health system, as well as the debt and deficit: the corporate community. Are they concerned about our province, our country, our health care system, when they pay only 7% to 10% of their profits in taxes? One writer in a Toronto newspaper recently -- and this is not the Toronto Sun -- said that Alcan owes the federal government $1 billion, probably in unpaid or deferred taxes. Finance Minister Paul Martin's company, CSL Group Inc, made a pre-tax profit of $19.7 million in 1990 and paid no income tax. They received tax credits equalling $400,000 as well. This lack of revenue federally worsens the provincial scene when they also reduce the transfer payments. Are the corporate community and the profit-hungry banks concerned about our province, our nation, our health system? Does their conscience not bother them that their inadequate contribution to the tax burden is helping to destroy a good health system in Ontario?
You, as elected members of the provincial Legislature, should concentrate your efforts in persuading the federal government to bring in a fair tax system so that Ontario's health care system will not deteriorate any further. Prominent Conservatives like Mr Dalton Camp are highly critical of the Klein and Harris agendas -- much to your embarrassment, I'm sure.
Bill 26 gives the Health minister sweeping powers and authority to close hospitals, taking power away from local communities over their own health care. The local district health council did not receive any approval from peninsula residents to make major changes to local hospitals or health service delivery systems. At any meeting I attended, those in attendance were opposed to drastic changes. Improve it, yes, as the previous government had been doing.
The Harris government promised not to cut health care, yet we discover $1.3 billion is to be taken from hospitals over the next three years. The Premier promised not to introduce user fees in health. Now, come next June, seniors and welfare recipients will have to pay user fees for prescription drugs. Seniors will have to pay the first $100 per year for their medically necessary prescription drugs, plus more than $8 for each prescription. This will cost seniors, many with limited finances, hundreds of dollars more per year. Drug prices are likely to soar, because under Bill 26, Ontario will be the only province that does not set a price ceiling.
One of the most ominous parts of the omnibus bill is that it opens the door to disclosure, as many people have mentioned today, by government officials to a citizen's private medical records including information that should remain completely confidential. This legislation, if passed in late January, will encourage private US companies to open more private health clinics, opening the door to a two-tier health system. Projected population increases, especially at the senior level, are not being taken into consideration with your unplanned dismantling of our health services. Hospitals, seniors' homes and other health care infrastructure may indeed be required for future population increases. The people of Ontario value their efficient health care. You weaken and try to destroy it at your peril. We are prepared to fight back.
Mr Wayne Hardwick: My name is Wayne Hardwick. I'm the vice-president of the Niagara Falls and District Labour Council, representing some 4,500 union members in the Niagara area, and I am pleased, along with my colleague Mr John Dawson, to be able to participate in these hearings and to express our concern and opposition to the far-reaching, undemocratic implications contained in this health care section of Bill 26.
The following pages examine just a few of those provisions of the act. The extensive nature of such a bill is such that all of the important amendments proposed demand more time and analysis than is available, given the government's attempt to railroad through this omnibus legislation. A detailed analysis and full democratic discussion must be available to all citizens of Ontario in order to fully understand its ramifications.
The changes to the Ministry of Health Act create a new Health Services Restructuring Commission which one suspects is designed to provide cover for the government on unpopular decisions like closing hospitals.
In the Independent Health Facilities Act it becomes more evident that the government is trying to facilitate the privatization of health care. The bill gives the minister broad new powers to designate new services and facilities to be covered by the act.
The omnibus bill repeals the existing subsection 6(3) preference for non-profit facilities for Canadian ownership. This is an obscure section worth emphasizing. If the government's intention is not to encourage American for-profit companies to take over more of Ontario's health care, then what is the intention of this clause?
Schedule G amends the Ontario Drug Benefit Act, the Prescription Drug Cost Regulation Act and the Regulated Health Professions Act, 1991. As advertised, this introduces copayments and deductibles for seniors and social assistance recipients. It also deregulates drug prices. The new name of this act is the Drug Interchangeability and Dispensing Fee Act, since it no longer regulates costs.
Ontario will become the only province that does not regulate drug prices. The government will say deregulated drug prices will go down, but there's no reason anyone should believe this. Or perhaps Ontarians with health problems will be expected to haggle over prices with pharmacists, as they do with grocers over tuna.
The Ontario drug benefit user fee or copayment will come into effect on June 1, 1996. The prices for drug products will be set by agreement with the manufacturer and they will replace the best available price, BPA, mechanism now utilized.
The markup percentage on drugs will no longer be restricted to between 10% and 20%, as it is now. The markup will be set by regulation. The minister's office says this will "allow for greater flexibility."
The government will no longer pay the difference between generic and brand-name cost for no-substitution claims. If a generic drug is not suitable, the individual must pay the difference between the generic and the brand name.
The government will set the maximum Ontario drug benefit dispensing fee by regulations. Under current legislation, negotiations are made between the government and the pharmacists. Now the government will set the dispensing fee by regulation. When asked why this change is necessary, the minister's office staff replied that it was never a useful process to negotiate with pharmacists.
Together they provide the government with enormous powers over doctors, from whom I'm sure you're going to hear today. The Minister of Health can restrict the number of eligible physicians, determine that a particular area is oversupplied and impose a moratorium in new eligible physicians in that area.
The amount paid for services may be varied, depending on the geographic area and other factors. One amendment to the Health Care Accessibility Act, subsection 2(3), may open the door for hospitals to expand their user charges for such items as toothpaste.
The Physician Services Delivery Management Act treats doctors like the Leamington mushroom workers who were decertified with the repeal of the Agricultural Labour Relations Act. It voids the OMA's agreement, strips the OMA of any negotiating rights and says a judge's ruling, decision, award or order to the contrary "shall be of no force or effect." In that case, they're above the law.
The essence of these amendments is to make it harder to gain access to documents and, conversely, easier to deny access. Institutions will be able to deny access on the grounds that a request is "frivolous or vexatious." It will be easier to dismiss appeals when access is denied.
Bill 26 gives the Minister of Health new powers to obtain confidential health information and disclose it to whomever he chooses. While the minister says he only wants to combat fraud, the bill says the minister "may disclose information obtained under the act if...(he) is of the opinion that the disclosure is necessary for the more effective management of the health care system or for the delivery of health care services." This is a dangerously broad mandate.
These changes facilitate privatization and downsizing because they eliminate the danger that the superintendent of pensions or anybody else might order that the public service pension plan or the OPSEU plan be wound up, in whole or in part, in the interest of this group of employees being cut loose through privatization or downsizing or whatever.
These two acts are now exempted from previous provisions of the law that require that they be wound up at least in part when a "significant" portion of the employees are terminated. There have been cases where this has been ordered when less than 20% were terminated.
Winding up the plan is better for the employees being terminated, mostly because many people who are short of full pension are allowed to "grow into" an unreduced pension at, for example, a factor of 80. That's a combination of years and work service. But winding it up is also more expensive for the employer.
If the government lays off 20,000 government employees, as it is expected it will, should this bill be passed, it will have the authority to deny full pension benefits to those people. Thomas Walkom of the Toronto Star, on December 7, 1995, puts it this way: "In effect, it will be able to cheat public service pensioners of between $400 million and $500 million worth of money owed to them." These amendments are retroactive to the day the OPSEU plan was established, January 1, 1993.
Schedule Q: This schedule amends the Fire Departments Act, the Hospital Labour Disputes Arbitration Act, the Police Services Act, the Public Service Act and the School Boards and Teachers Collective Negotiations Act.
Working people covered by legislation that denies them free collective bargaining and instead forces them through their unions to submit to compulsory legislation now face even further restrictions. Teachers, firefighters, police and, in this instance, hospital workers are now subject to the restrictions of Bill 26 which inserts statutory criteria which an interest arbitration board is required to consider when it is making a decision or award.
These provisions constitute a significant interference with the independence and integrity of the arbitration process and must be opposed. Traditionally, boards of arbitration have been extremely resistant to looking at the criterion of ability to pay since it could require public sector workers to subsidize the provision for public services and also since it usually equates more readily to the willingness of an employer to pay.
In conclusion, on Tuesday of this week, approximately 1,000 employees at Toronto area hospitals were laid off as part of their downsizing and/or restructuring, which will lead to closed beds and reduced services. As Bill 26 is not legislation at this time, this is obviously an omen of things to come.
Our local hospital, the Greater Niagara General Hospital, of which I am a board member, has been in a restructuring mode for some time and has been touted as one of the most efficient in the area. But increased funding cuts will negatively impact this facility with job losses, closed beds and services, putting patients and emergency services at risk.
Where have your government's commitment and campaign promise not to cut funding and quality of health care gone? The hospital workers, patients and residents of Ontario expect first-rate, quality health care. Nothing less is acceptable. Thank you very much.
Mr Bradley: First of all, I appreciate your representations. I thought they were very much to the point. I want to zero in specifically on the health aspects of the bill and one of the implications I heard this morning that you would no doubt be interested in.
Is it your concern that employers, faced with additional costs in the field of health care, as Liberty Health said this morning would happen, will now begin to initiate activity involving the stripping of contracts of those fringe benefits which relate to health care? What are the implications of that?
Mr Hardwick: There is no doubt in my mind that is exactly what is going to happen. This government said they would give employers the tools to cope with their workers' collective agreements, and this is a way of underhandedly undermining the collective bargaining process which every worker has a right to have, the process of bargaining. They're taking that away from us.
Mr Dawson: I share the concern of my co-presenter in that question as well. Could I ask, Mr Chairman, if the Conservative caucus had a chance to read the letter from the regional chair and would like to comment on it.
Gentlemen, I want you to know this: This committee has spent one week in Toronto, and now is just wrapping up its second week in communities across Ontario, purportedly listening to people in the communities. Obviously Niagara is no different from every other jurisdiction that this committee visited. It refused to accommodate all those people who wanted to make submissions.
You've got to understand that this committee has three full-time standing Tory members plus the Chair, one New Democrat, one Liberal. I want to apologize to you, because these are all MPPs who make around 65 grand a year plus -- if you're in the government especially, when you get the perks for being a Chair or a Vice-Chair or a parliamentary assistant -- each member of this committee also receives a $99-a-day tax-free per diem, an honorarium just for doing what they're normally paid for.
I want to apologize for the Tory caucus, because I know Mrs Ecker, who arrived but then disappeared again, who is a voting member of this committee, was not here during the course of your presentation. I submit to you that apologies are in order. It may seem peculiar that I should apologize for a member of the government with whom I have little in common, but I think apologies are appropriate.
Here's a member who's making her per diem, who's earning her full MPP salary, who purports to be committed to this committee, yet obviously has no interest. Now, what that illustrates is that this government, its spin doctors and pollsters and little media relations people, try to create the impression that they're listening to people while the facts speak for themselves. Clearly the members of this committee have no interest in what you or others have to say. Their absence from this committee, when they're paid members of this committee, illustrates that in a most graphic way.
Mr Tim Hudak (Niagara South): Gentlemen, thank you for your presentation today. I've a question, if I have time, one for each of you. First, Mr Hardwick, if I may. I'm a representative of the Niagara Peninsula. I think roughly one fifth of the population falls in my riding. It covers the Falls, and then more rural communities like Fort Erie, Port Colborne and Wainfleet. This area is underserviced in terms of GPs. I think we're close to 5% underserviced. The OMA and the previous government had five years to try to solve this problem, to get more doctors into the peninsula. A solution hasn't come forth in that area. One of the recommendations we have heard is for the minister to limit billing numbers to ensure that doctors will practice in underserviced areas. What's your opinion of that and what kind of answers do you have to get more doctors into the peninsula?
Mr Hardwick: First of all, I'm really not going to comment on whether there should be more doctors. That's not my field. I'm not a doctor. All I know is right here in Niagara Falls I have my doctor, I have my health care, I'm satisfied with that part of the health care system. As for the rural areas, you'll have to have somebody from that rural area come down and answer that question. I'm sorry. I can't do that for you.
Mr Hudak: I'll move on to Councillor Dawson. Good to see you again. I enjoyed your presentation, like last week's. I just want to hit on one issue that you touched on, and that's the district health council report. In your opinion, how has the visiting process gone so far? How do you feel the public input has been in the DHC report so far as the minister is going to listen to?
Mr Dawson: I attended several meetings over the past year that were sponsored by the district health council. For example, at one meeting they had Dr Fraser Mustard, and his comment was, "Beware of the zombies," I think, and he referred to you people on the far right that wanted to dismantle our health care system -- you and the Reform Party because you're so much alike.
I got the impression, sir, that the district health council was not listening to people. They were making recommendations. People who went up to the microphone were strongly in favour of retaining our health system, yet they were making recommendations to the government that were not based on public input.
Ms Lankin: On a point of privilege, Mr Chair: I believe that my rights as a member of the Legislature have been violated, and I'm referring specifically to an amendment we were given a copy of this morning. These amendments, a few of them, were tabled in the other committee dealing with the non-health sections of Bill 26. The very first amendment is an amendment of the Municipal Act which sets out that no bylaw under which a municipality can impose a fee can be done in the form of an income tax, a poll tax, a gas consumption tax etc.
I want to refer you, Mr Chair, to the fact that in direct questioning in the Legislature of Ontario, when we put the question to the Minister of Municipal Affairs of whether or not Bill 26 allowed for municipalities to impose poll taxes, head taxes, gas taxes, he said unequivocally that it did not. In fact, I will read to you from Hansard. He said, in an exchange with Bob Rae, the leader of my party: "I wish the honourable member across would read the entire bill. It says this legislation allows fees and charges to be applied on services provided by the municipality. That's what it says. Read it. It does not say, and it does not apply to, sales tax, gas tax, property tax or any of them. You're wrong."
In further conversation with Mr Rae in the Legislature he says, "I'm going to repeat it one more time: Read the legislation. You are wrong. I'd ask you to resign if you were wrong, but you're on your way out anyway. The legislation is very, very specific. It speaks. The legislation allows fees and charges to be applied to services by the municipality. Read it."
He goes on to say, "Yes, because the act doesn't allow it. The act doesn't allow any kind of charge. Read it. It doesn't allow sales taxes, gas taxes or any of that type of tax just by definition. I think you'd better go back to your lawyers and get them to look it over again. It's very clear to us. It does not give the municipalities the tools to impose a gas tax."
Later that day, in response to a question from the media, the Minister of Municipal Affairs, the Honourable Al Leach, indicated that in fact he knew his legislation, that he was right and that if he was wrong, he would resign.
I want to place on the record today on behalf of the New Democratic caucus, the call that was issued by our House leader, Dave Cooke, in Toronto today, that given they have now tabled a motion to amend Bill 26 to clarify the very points that Bob Rae and the New Democratic caucus and that Lyn McLeod and the Liberal caucus and that many municipalities made over and over and over again, that Bill 26 did in fact in its original form allow for those taxes to be imposed, now that the government itself has had to put an amendment in to stop that action and Mr Leach is absolutely wrong, I repeat the call and I place it on the record today. It is time for him to live up to his promise to the people of Ontario and tender his resignation from his position as cabinet minister.
Mr Dominic Agostino (Hamilton East): Mr Chair, before you go to that, could I quickly table with the committee -- it's not a point of privilege. I was in North Bay last night at a hearing in the Premier's riding, where obviously the Premier refused to hold public hearings, and a number of groups came forward. Over 100 people attended a hearing and on their behalf I want to table to this committee, so the Premier can take a look at what people in his own riding are saying, the briefs that were sent to us last night on behalf of the people of North Bay to this committee. The Premier of Ontario can find out what people in his own riding have to say.
Mr Ray Wilson: Thank you, ladies and gentlemen, for the opportunity of being heard here this afternoon and allowing the democratic process to be expressed. One of my children came home this past week and said, "Dad, did you hear the latest Bob Hope joke?" I said, of course, no. He said: "You know all the women that I've tried to date must be very religious. Every one of them told me that I didn't have a prayer." I hope that isn't the case in the presentation of my brief today.
I have been very successful in the past. I've been a political activist for some 40 years, and along with Premier Davis, at one time we were able to establish the park at Effingham Hills. So that is one of the attributes of your previous Premier.
However, Chairperson, as a concerned citizen who has paid his way through his life, I take offence at the changing of the health act if it means additional cost to us. The idea of making an alternative drug available if it is cheaper and does the job is a reasonable conclusion, providing it meets the standards of the health board. But we are concerned that, with this Bill 26, it will not give us the results that are desirable.
I am one of the oldest taxpayers in our community, who has worked very hard for what we have in Ontario, and I am dedicated to protect it however I must. We have never taken anything from the government, raised six children and taught them the honesty of the work ethic, and as parents we are proud of all of them. We now have a total of 35 in our family and we are very concerned with their wellbeing.
Our governments have made Ontario, if not all of Canada, a place where we are at risk in many areas. Pollution of our environment has made us all prone to many of the afflictions that are making many of us ill today. Some years ago I was a pioneer in the environmental field. Studies proved then what was happening to our air, water and soil, but unfortunately, to some degree it fell on deaf ears. Today we are reaping what we have sowed. In many instances, our companies raped our lands, and we paid them to do it. Must we pay again for this atrocity?
I quote the St Catharines Standard dated December 26, 1995: "Governments are attempting to cure sickly financial situations by tossing elderly patients out of hospitals and into homes with inadequate care. There used to be tribes that sent old people out in the cold to die. Is this what we are coming to? Will those who occupy chronic care beds be told to find other places to live? There is a waiting list now in certain areas. It takes years to get into a government-subsidized nursing home."
This is the same scenario that existed 25 years ago, when I had documented cases where these folks had no place to go, their children didn't want them, so the police would come and pick them up and place them in a cell for the night. Because of this inhumane treatment, we circulated petitions in our city to have Dorchester Manor built. It was a big battle at that time, and the churches and labour supported us well.
Canadians are a people who will put up with a lot, that's our nature, but perhaps it is time for expressing again. We have built a province that was the envy of all provinces, but we were naïve to think the politicians would carry on this great heritage.
Our young people see the situation for what it is today. Many who have become educated want to obtain jobs and pay their way but find it hopeless. Is this the kind of country we are building today? If it is, then we should hang our heads in shame. We told them they must get an education, and they did, only to realize our factories are shut down and moved somewhere else. These youngsters see what is happening quicker than we did.
Because of our attitudes, our politicians again want to burden the segment of society that is the most vulnerable. Family life is fast becoming a thing of the past. Look for a moment at the statistics of broken homes, single-parent families. At last count, there were 180,000 children in Ontario going to school hungry every day.
We introduced lotteries a number of years ago. We never in our wildest dreams expected the revenue that it generates today. And the profits, where do they go? They were supposed to go to hospitals. Well, maybe a pittance does, but I believe most of that money goes into the general fund, along with the other taxes that have been imposed upon us.
Our income has been reduced this past year some 2.5% because of inflation. We lost our municipal tax subsidy, and the list goes on. In many of the communities across Ontario, most of the volunteers who perform the little jobs that make a community click are performed by seniors. With this change, do you think we will be able to do them? Many of our seniors have had to sell their homes and move into an apartment. If this is compassion, then we had better go back to school and learn what it means. Our governments have declared they will cut social programs to the bone and allow further tax cuts for the wealthy in our society. We cannot in the autumn of our years allow the unscrupulous pilferage of the Canadian way of life.
As the Spicer commission pointed out so ably, Canadians are at the mercy of a group of political and media élites who are trying to dictate the future of this country. These high priests of the media-political Canada are themselves a minority group among the 4,000 or 5,000 who hold power over the real Canada. As Mayer Anselm Rothschild has said, "Permit me to control the money of a country and I care not who makes the laws."
The Minister of Health declared a few weeks ago that he was slashing $132 million from this year's budget; $9.7 million less for hospitals. Four birth centres will be closed and several medical research programs will be axed. When these facilities are closed, is the loss of money incurred when this office equipment is sold or the expertise of the employees who administer these programs ever considered? There must be a lot of office equipment out there for sale at fire sale prices.
We realize the fraud with the present health card system and were assured at election time this would be corrected with the use of photographs. Now this is set aside, in spite of the fact that it would save health care dollars as it would reduce fraud. If this is what the Common Sense Revolution is all about, it is time it's repealed.
There was a commitment to create 725,000 jobs. Where are these? We are shutting our province down. We are no longer doing business. According to statistics, in the first four months after the election, employment fell by 20,000. Is this the proper way to operate our province? Even I, as a farmer, know that you must spend money to make money. We acknowledge the fact that the federal government has cut $9.5 billion over the next five years. We have been cut more than any other province. Some 44% of our national debt is due not to us in the marketplace but is due to the tax breaks to large corporations. Taxes owed by large corporations in 1993 were $1.45 billion. If it was me, you would lock me up and throw the key away.
In 1990 the government realized the need for home care services and allocated some $70 million. They recognized a need and took care of it. Funds were allocated for the development of 25 new elderly centres and, in addition, $2 million to support the operation and funding of elderly persons centres in Ontario. Seniors with special needs were given an additional $5 million to improve transportation services. We cannot understand why these services may be cut. We certainly paid enough taxes down through the years so that in the twilight years of our lives we would be taken care of to some degree.
It is time for us folk to unite and join with other seniors' organizations in the fight for fair treatment of seniors and our families, to preserve our rights and the way of life we spent our youth and lives building in this province. Ladies and gentlemen, this is the submission of a Canadian family that goes back many generations, who have done what was necessary for our country. I have served on almost every board and commission in our city and have received recognition for my input in society. I do ask that you give this brief your attention.
Mrs Lesley Penwarden: Hi. I am Lesley Penwarden. I am here on behalf of the Ontario Network of Injured Workers Groups and the Canadian injured workers' alliance. I would like to thank Mr Ray Wilson for sharing his time with me and giving me this opportunity to speak. You'll have to bear with me. Due to the extreme shortage of time and notice, this is a first draft only; it has not been proofread.
I would like to preface my comments by saying that never in my own experience nor that of any other individual or organization of my acquaintance have we encountered such an effrontery of blatant contempt for the public's democratic right to fully informed access and participation.
Perusing schedules F, G, H, I and K within Bill 26, which have direct or indirect relevance to the health care system, I was alarmed not only by the content but even more so by the deliberate omission of complete and unsevered references. For example, in schedule F, covering amendments to the Ministry of Health Act, the Public Hospitals Act, the Private Hospitals Act and the Independent Health Facilities Act, I counted 119 severed and/or incomplete references, many of which are actually a sequence of references, making the number of insufficiencies even higher.
It is the standard practice of governments which are proud of their legislation to supply the full wording of clauses changed or referred to in other acts so that the aggregate, integral intention and objective be clear. Why have you not done this? You invite the obvious assumption of a deliberate attempt to obfuscate and prevaricate your true objective.
In part I, Amendments to the Ministry of Health Act, section 8, the Ministry of Health creates an additional and extremely expensive layer of bureaucracy entitled the Health Services Restructuring Commission. Statutes outlining the specific purpose or jurisdiction of the proposed commission are conspicuously missing. The broad scope of subsections 8(6) through 8(8) and "Immunity from liability," subsection 8(9) indicate a large bureaucracy with undefined, unbridled dictatorial powers against which we, the citizens, are to have no recourse. This sort of manoeuvre was found to contravene and not be legally absolute under the Canadian Charter of Rights and Freedoms in 1989.
Section 5: "The minister may as a condition of providing...require the recipient of the funds to secure their repayment...." surreptitiously opening the door for profit-oriented hospitals. Under this proposal, in order to secure their operating capital from government funding, hospitals can be forced to hold monetary assets such as cash, accounts receivable and investments, reducing the Ontario Hospital Association to a mere business which must secure loans and therefore be profitable.
The government obviously requires reminding that government money is the citizens' tax money, and we have the right in a democratic society to inform the government how it may spend our money. The present government further requires reminding that it agreed that preservation of the Canadian health care system is inviolable when it was soliciting votes.
In terms of competing in the global economy, the excellent overall health of the Canadian workforce, combined with relatively low insurance benefit costs to companies, is one of our major assets. Do not destroy this advantage.
Subsection 8(1) creates another layer of expensive bureaucracy, called investigators. There is no mention of qualification or competence standards. There is no mention of the conditions of provocation of a hospital investigation other than "where the Lieutenant Governor in Council considers it in the public interest," which remains undefined. Although untried in the case of a public hospital administration, this may be found to contravene the Canadian Charter of Rights and Freedoms, which protects legal rights. Everyone has the right to be secure against unreasonable search or seizure, not to be arbitrarily detained, not to be subjected to cruel and unusual treatment or punishment etc.
Once more, this government was elected to reduce bureaucracy, bureaucratic power and expense, and accomplish greater freedom from government intervention, not increase it. Borrowing from humour of the macabre, it's déjà vu all over again, folks.
Section 9's replacement produces yet another layer of bureaucracy, to be known as hospital supervisors, to do the work already being done by existing hospital administrations. Top administrators receive some of the highest remuneration in Canada. There's no protection from frivolity and no offered recourse such as public hearings or judicial review.
Numerous sections are devoted to protecting the crown and its employees from liability and preventing legal proceedings for anything done under the auspices of the act. Schedule F alone contains no less than 11 clauses intended to protect this government and its employees from being held responsible for their actions.
Under subclause 32(1)(t)(iv) the government gives itself in effect ownership and total control over our medical records. Amendment 44 gives unlimited, unrestrained dictatorial decision-making powers over hospitals and physicians, without holding hearings.
Amendments to the Private Hospitals Act: In section 15, the licence may be revoked arbitrarily and without prior notice. They may cease operation of a hospital upon receipt of a notice and reduce or terminate amounts payable arbitrarily. There is no entitlement to a hearing or appeal. The ministry may seize total temporary control for a maximum of six months. The ministry may make alterations or repairs when in control and force the closed private hospital to cover the cost.
Amendments to the Independent Health Facilities Act: The definition of "facility fee" in subsection 1(1) has been changed to allow charging fees for medical services which are no longer covered by OHIP, creating an Americanized, two-tier system.
Under subsection 7(10) and clauses 8(8)(a) and (b), the director may demand a facility to cease operating if the director has "reasonable and probable ground to believe." There is no description of "reasonable and probable grounds" and the order is final.
Sections 18 and 20.1 claim to override the Statutory Powers Procedure Act by denying any form of stay. The only available notice occurs under the new subsection 19(3), with at least six months' notice for arbitrary cancellation of services that are already licensed, but there is no recourse of appeal.
Suspicion alone is now just reason for the minister to refuse payment and/or deduct amounts deemed recoverable and ministerial powers may be delegated unrestrictedly. Suspicion alone is just reason for the director to give notice to the registrar regarding an independent health facility.
A licensee of an independent health facility shall submit information and disclose information to a director, and the information may include personal information. This is assumed to take precedence over acts to the contrary.
The minister has ownership rights of use over any personal information collected under the auspices of the act and may employ the information unfettered. It further states "prescribing conditions under which persons are required to submit or disclose information."
Conclusion: This is an unprecedented assault on the rights, freedoms, the very dignity of Canadian citizens residing in Ontario. There are no words to describe a piece of legislation so extremely Fascist in nature. Fascist Germany of the 1930s and 1940s would be proud to call it their own.
The Chair: Our next presenters are the Canadian Mental Health Association, represented by Sheila Bristo, the executive director from St Catharines; Linda Hambling, executive director from Niagara South; Corwin Cambray, the president from St Catharines; and Mike McCallion, who's on the board of CMHA Niagara South.
Mr Corwin Cambray: Good afternoon and welcome to the beautiful Niagara region, with its falls, canals, forts, orchards and wineries. We hope you have a chance to look around; some of you are more familiar than others.
My name is Corwin Cambray. I'm the president of the St Catharines and district branch of the Canadian Mental Health Association. With me is Mike McCallion, a member of the board of directors of the Niagara South branch, who will contribute a personal testimony to the importance for people of what you are considering. Certainly I believe that each of you deeply believes in putting people first.
Our two branches cover the Niagara region and its 400,000 people distributed among two dozen communities. We are community-based, non-profit charitable organizations with an active volunteer base of over 120 individuals. We have provided services to individuals with serious mental health problems for over 30 years. Today, we serve 450 consumers who are struggling to develop and maintain meaningful lives in our communities. It is not easy, and it should be not made more difficult. We also provide support to people at risk of having serious mental problems, as well as mental health promotion to the general population.
The number in need is growing as activity in our programs continues to rise. The Niagara District Health Council estimates that there are just over 3,000 residents in Niagara over the age of 15 who view themselves as limited in their daily functioning because of psychiatric disorders. Approximately 1,500 or more of these residents will seek psychiatric services due to mental health problems. High unemployment and higher proportions of elderly -- 15% of Niagara's population compared to 11.5% of the population -- further point to the need for community mental health services.
Mr Mike McCallion: Good afternoon, members of the committee. First, let me briefly describe my position in the community as a means of introduction to this committee. My wife and I have a small business which employs eight people. We face international competition daily and therefore recognize and support both the scope and the urgency of the changes being contemplated by the government of Ontario.
The credential for my appearance before this committee is that I'm a member of the board of directors for the Niagara South branch of the Canadian Mental Health Association. My reason for being a member of the voluntary board of directors is a lifelong involvement, as a family member, with schizophrenia. Possibly this experience will be of some benefit in describing specific areas of our concern to this committee.
My father spent the last eight years of his life in the Hamilton Psychiatric Hospital after being admitted with a diagnosis of schizophrenia. This was during the 1950s, when the only readily available treatment for the medical profession was electroshock therapy. The benefit, if any, from his treatment was limited. My father left the hospital only once during the time he was there.
In the early 1970s, my younger brother developed schizophrenia at the age of 28. He struggled with his disease and, even with the recent availability at that time of new medicines, was only able to function independently for a very brief time. Unfortunately, in the early stages of drug therapy, the medical profession did not fully recognize the incidence of depression among patients undergoing drug therapy. In addition, there was not the same awareness among the patients of the consequence of not taking their medication and they were not comfortable with the side-effects. My brother, during a period of depression, committed suicide.
The reason for describing this situation is to point out both the turmoil and difficulty a person with schizophrenia faces in an uncertain period of treatment. It also points out to society the consequences of not being in a position to provide the required care.
My wife and I have three wonderful children whom we, like the members of this committee who have children, are very proud of. Our youngest is at McMaster University, working through his final year, and intends to continue with his studies in medical research. The middle child is a professional engineer. He works with severely disabled people -- quadriplegics. Our oldest child is an outgoing lady with a diagnosis of schizophrenia. I will only refer to my daughter in the third person and not by name, hopefully to prevent any embarrassment to her. My wife and I are fortunate in that our daughter, after only one crisis subsequent to her initial psychotic episode, learned the necessity for her to take her medicine always. Please bear with me.
The event that led up to her having the second crisis was not the result of any action on her part but was the result of her psychiatrist attempting to change her medicine to allay some of the side-effects of the medicine she was originally prescribed. If you were to meet my daughter, you would notice that she normally stands with her elbows bent in front of her, like this. She is not conscious of this and, if she's reminded, she will put her arms down into a more natural position. However, once her concentration is on other matters, her arms will return to being held in front of her, which is a side-effect of the medicines she takes. Our daughter and family are lucky to have only this minor side-effect as part of our existence. Other patients on drug treatments are faced with terribly discomfiting facial tics, for example, and other involuntary movements associated with tardive dyskinesia. There are other negative side-effects too numerous to describe here. We are fortunate so far, but this could change, and one of the devastating characteristics of tardive dyskinesia is that even when the patient is taken off the drug, the side-effects may continue permanently.
Our family would like to change the drug treatment to one of the newer drugs available which does not appear to have the same propensity for side-effects. Unfortunately, we are inhibited by the one time we did try a change and it failed. However, the crisis might not have developed if our daughter's overworked psychiatrist had not taken a well-deserved vacation during the change. He was one of only two psychiatrists attached to the local hospital. There is now only one psychiatrist at that hospital, and there are only nine psychiatrists in all of the Niagara region -- too few.
Another problem with our daughter changing her medicine is obtaining current medical advice. Our daughter is being attended to by a capable general practitioner, who monitors her blood tests. These tests are made to try and anticipate the effect of the current medicines on her liver and its possible deterioration. Our daughter's general practitioner has neither the background nor the time to keep up to date on the changes in these types of medicines.
As I mentioned, we are fortunate that our daughter approaches her medical regimen with diligence. She is fortunate also in that she has a loving, supportive family to turn to when there is confusion and uncertainty. Many people with psychiatric disabilities are on their own. When they are bothered by side-effects of the medicine they should take or tired of the stigmatism of having to take these kinds of drugs or, even further, when the drugs are working well and they really feel good about themselves, they stop taking the drugs and spiral down into an ever-deepening crisis. Every effort must be made to help these people maintain their medical regimen. Systems should not be set up which will place roadblocks in their way, such as a dispensing fee.
Imagine yourself in this situation. You are living on a disability pension and your total discretionary spending after accommodations and food is $30 or $40 per month. Your medical practitioner is reluctant to prescribe more than a week's requirement of drugs, to help prevent a drug overdose or to prevent the drugs being wasted or misused. So now you are faced with picking up your drugs weekly and facing a $2 dispensing fee when you do so. This means that 20% to 25% of your discretionary income now has to be used for you to take something you don't want to take. What if you smoked cigarettes and the decision was whether you buy a pack of cigarettes or pay the dispensing fee? If you talk with community support workers, you will find their experience is that people who smoke will buy cigarettes over food. The net effect: more people in crisis, more hospitalizations, continuing high-cost, poor-result treatment.
One of the difficulties our family faced when our daughter survived her initial psychotic crisis was a diminished cognitive ability. We struggled to find an environment where she could function independently in a safe manner. We were hoping to find a program similar to the program available in Hamilton. What we found was an underfunded, frequently overworked staff trying to function without the benefit of support from the medical profession.
We tried avenues which were available, and achieved varying degrees of success. These included halfway housing, secure housing and community programs not specifically designed for people like my daughter. Our daughter has not always found safety through these efforts, but she has been fortunate in having support from the Canadian Mental Health Association staff and from her family. As she tries to fit back into society, her concentration is not sufficient to maintain her education or employment, even though she has tried frequently. However, our daughter is now doing volunteer work with a local food bank twice a week, with the support of CMHA staff. She is making her contribution to society in that manner, and we are very proud of our daughter. She has her family behind her.
There are many people with psychiatric problems who are on their own. Don't put roadblocks in their way. They have enough problems. Don't set up a system which will only focus on crisis management and not provide the community and family support which will reduce high-cost crisis management.
I started this presentation by stating my support for the changes being made, and I recognize the urgency to overcome the lethargy and the self-interest of what is now in place. However, when haste is made, the opportunity for error increases, and the result of error in the area of concern by the Canadian Mental Health Association is tragedy, lost hope and misdirected funding. You have a difficult task. I wish you and yours well.
(1) Dispensing fees: A $2 dispensing fee will not help people. A $2 fee may seem small to some, no doubt, but not to those of limited means, and it accumulates from week to week. Larger prescriptions are not the answer either because of overuse or misuse. Such types of user fees have been shown -- this goes for user fees much broader -- to neither control health care costs nor improve the appropriateness of care.
(2) Drug substitution: Drug substitution is dangerous, as Mike has pointed out, to the health of the consumers we serve. Mike has outlined one example. There are many others. If a physician prescribes a no-substitution drug or the consumer requests a specific drug, it is because that drug has been proven most effective in treatment and the drug should be fully covered under the Ontario drug benefit plan.
(3) Access to specialists: Niagara is underserved by psychiatrists while in certain areas of Ontario there is an oversupply. This imbalance needs to be corrected for, in the end, it is a public health care system. The specialists need to have strong ties with our communities rather than to the Hamilton Psychiatric Hospital, for example. Emphasis should be on treating people with severe mental illness. No family should be told that there are no services for their schizophrenic child while Ontario spends over $300 million a year for the traditional Freudian psychoanalysis, the most generous coverage in North America to see analysts nearly every day.
(4) Confidentiality: Section 13 of the Ontario Drug Benefit Act may be changed to use or disclose personal information. Our branches as well as the Ontario division of CMHA believe that all medical information should be confidential and private. Psychiatric consumers should not suffer any social stigma as a result of their illness through loss of confidentiality.
(5) General hospitals: Our branches enjoy a good working relationship with the general hospitals in our communities. However, we are concerned that the hospitals will concentrate more and more on core services that could impact negatively on traditional marginalized mental health units by exposing them to severe bed cuts or closures. These facilities in community hospitals are needed to provide emergency backup when cyclical crises occur. On the other hand, the $385 per day cost to care for individuals in provincial psychiatric hospitals could be much better redeployed to help individuals stay in the community or, when needed, a local hospital.
(6) Funding sources: Many comments have been made about using the existing funding more effectively rather than the need for more funding. Also, there is this shifting of view from a hospital-centred health system -- a built bed is a filled bed -- to a home- and community-centred system. This will be challenging as we work towards a seamless health care system from the patient's home to community centres and institutions with the focus on primary care in the community. Why then enable hospitals to establish crown foundations to solicit major charitable donations? This situation will reinforce the past and undermine fund-raising activities of community organizations like our branches and even, we believe, the United Ways on whom we depend for needed program funding.
(7) District health council: The health council, or a similar local planning body, should be given the ability to redesign a community-based, integrated health care system in Niagara. Individual institutions cannot do it, nor can a more central body located in Toronto. Dr Fraser Mustard in 1974 recommended the devolution of funding envelopes to regions. His report established district health councils. It is time to take the next step.
In conclusion, Canada and Ontario enjoy a very good health care system. A 1993 Gallup poll found that 96% of Canadians preferred Canada's system to the one in the United States. That being said, it is acknowledged that our health care system can be made more efficient and effective without reducing and charging for needed services. We know that you will put people first.
Mr Kormos: Thank you, people. I'm from Welland. Stella May Williams was one of my constituents. She had a lengthy history of mental illness and had been treated for a period of time, including numerous hospital stays. She was 48 years old, a loving mother and grandmother, she worked some 10 to 15 hours a week, which was as much as her condition would permit her to, making change in a laundromat for minimum wage.
Three weeks before Christmas she received a letter from the Community and Social Services office in Welland advising her that she was no longer eligible for Family Benefits Act assistance. She was no longer disabled, according to Mike Harris's definition of disability. Three days later she killed herself. Most insulting was, even after her death, a letter was posted to her advising of her right to appeal. She left behind a daughter and two grandchildren, a suicide note that was poignant, indicating that she just couldn't face the future without the prospect of being able to pay her rent and engage in the most modest of gift-giving for her children and grandchildren.
Let me tell you people, Stella May Williams's death is the direct result of Mike Harris and Dave Tsubouchi and their attack on the poor, the sick and the disabled and, by God, I hope she's on your conscience, because her children and two grandchildren have lost a mother and grandmother, our community has lost a just, kind, loving person who was a victim of mental illness and then a victim of government policy that simply doesn't give a damn about the sick and the disabled.
I grieve for Stella May Williams and others who will follow. I hope you have the decency, the respect for the sick and the poor and the disabled, to reflect on the fact that the blood of her death is on your hands because of your support for that outrageous, cruel regime dedicated only to the rich in this province and not to the working people, the sick or the poor. Shame on you. You should be disgusted.
Mr Tom Froese (St Catharines-Brock): Thanks for coming. I appreciate your presentation. I don't think anybody in this room would say that the mental health associations and what is in the province and what it has been, people are affected and we would not minimize the whole aspect of the tragedy that's in our province. I for one am familiar -- I'm just like you, Mike, as far as having some of these tragedies in my own extended family. My uncle committed suicide as well, some time ago. So I'm very much aware and very concerned about this issue.
You talked about core services or you talked about the Niagara District Health Council and general hospitals and funding sources and so on. I have two questions. Has the association from the local community, the Niagara district area, made a submission to the Niagara District Health Council to ensure that, when the district health council looks at the whole aspect of the health care in the region, it is core service? The other question is, you've given us some recommendations and I thank you for that. Can you elaborate more on what we as a community can do to assist your association?
Mr Cambray: On the first point, yes, we have. We're in constant contact with the district health council and have made them aware of our concerns, and also the hospitals. The second point, what you can do to help, I think first of all you could support the recommendations that we have in here. I think that's fundamental because we view the foremost importance to be providing the delivery of services to consumers, to the people we serve. The second area -- and you did help us there, I must admit; you came to one of our meetings and made a presentation. I think just the awareness and constant contact on mental health issues, which is a very difficult issue to deal with, is very important.
Mrs Lyn McLeod (Fort William): I'd like to bring us back to Bill 26, Mr Chairman, a bill which this government intends to make law in nine days. I want to thank you for your presentation of the concerns that you have about Bill 26, particularly the effects that this bill will have on psychiatric patients and those suffering from psychiatric illnesses. Those effects will be real unless this government changes this act. It doesn't matter what statements of concern the government members make, they have to change the act to prevent those negative effects that you've outlined from taking place. That's what this is all about.
I'd like to ask you specifically about confidentiality, because you've just touched on it in your brief, and your concern that this bill would give government bureaucrats and in fact politicians access to medical records and an ability to disclose the most confidential information about patients, including psychiatric patients.
When others have presented this concern, one of the members opposite indicated that people shouldn't be concerned because the Mental Health Act would supersede Bill 26. We challenged that and today we received an answer that indeed the Mental Health Act would only protect the confidentiality of patients who are in psychiatric institutions.
I'm wondering how you feel about there being two classes of psychiatric patients: those who have their confidentiality protected in some way and those who can have their records examined, copied and disclosed with no penalty for misuse of the information.
Mr Cambray: We are concerned. As I said to the previous one, first of all, we have recommended making these changes. We realize the legislation has been changed. The second point, we are concerned that confidentiality is a big issue. Our Ontario division, which has more resources to look into that, is concerned.
Two levels: We don't see that at all. We deal with consumers in the community. They're not in the hospital, they're out in the community, and the intent is to try to get more and more people out in the community, so it must be confidential. People we serve face enough stigmatism without having their records appear all over the place.
Mrs Caplan: This morning I asked a question in relation to the provisions of the Mental Health Act and confidentiality and asked for certain clarifications. There is a policy issue that was just raised by our leader, Mrs McLeod, and I'd ask this to be answered by the minister. That is, how can he justify two classes of mental health patients in this province, one that has the special protections afforded under the Mental Health Act and those who will be impacted only by the provisions of Bill 26? How can he justify, by policy, the fact that under the Mental Health Act only some patients with psychiatric requirements, psychiatric needs, will have access to those confidentiality provisions while other patients in the community and in community hospitals may not have those same protections? What is the policy that would justify patients with similar or totally different mental health problems being treated so differently? Could the minister answer that question in writing.
The Chair: Thank you, Mrs Caplan. Is the Niagara South Social Safety Network, Mary Beth Anger, here? The St Catharines Labour Council? The St Catharines Labour Council is ready to go but they need about three minutes. So we'll just take a quick three-minute recess.
The Chair: Okay, our presenters are ready, if we can take our seats again, please. From the St Catharines Labour Council, Allison Williamson and Gabe MacNally. Welcome to our committee. Questions during your half-hour would begin with the government, if you allow time for them. The floor is yours.
Mrs Allison Williamson: My name is Allison Williamson. I'm president of Local 1097 of the Canadian Union of Public Employees and a member of the St Catharines Labour Council. I would like to thank you for the opportunity to present this brief to you today on behalf of the St Catharines Labour Council and of the Canadian Union of Public Employees.
Before I start, I would like to say to you that I represent what the government refers to as a special-interest group. I am a consumer, a taxpayer, a mother, a provider of health care as an RPN for 35 years, and of course a trade unionist. I make no apology for who or what I am.
This bill attacks me and people like me on every front. It is unparalleled in its contempt for the average citizen. As far as I am concerned, the real "special interests" being promoted by this bill are not for people like me, the average citizen.
As the hearings draw to a close, you will have become acutely aware of the strong objections to every clause of every amendment of the 47 acts dealt with in Bill 26. I am also sure that those who have come forth to support the bill are the rich or those who will reap personal gain or power through the proposed changes.
Most of the electorate who voted for you, with or without reservation, based on your Common Sense Revolution platform, placed their X based on the promise made by Mr Harris that if health care was cut, he would resign. This gave us a false sense of security, thinking that health care was sacred and would escape cuts. We all know that Mr Harris should have resigned before he introduced Bill 26 if he was a man of his word. He broke his promise when he cut funding in November 1995. I feel confident that should an election be called tomorrow, the results would paint a very different picture.
Virtually every clause that pertains to health care in Bill 26 is aimed at dismantling our system. Clearly, government is trying to fashion a "made in the USA" health care system for the people of this province, a system that delivers one level of care for the rich and a different level for the rest of us.
Bill 26 will give the Minister of Health virtually unlimited powers with respect to funding and operation of public hospitals. It will allow the minister to ignore the needs and desires of the local communities. The minister can decide that the availability of financial resources is the only relevant criterion when making funding decisions. The minister has the unlimited authority to close hospitals, force mergers, and order hospitals to change or eliminate types of services that will be delivered. Since the government is saying that 33 hospitals should be closed in Ontario, the bill will provide it with the necessary mechanism to achieve this goal quickly and aggressively. No public consultation will be necessary on even the most superficial basis.
Bill 26 also provides tremendous levels of liability protection to the government during the restructuring procedures. They cannot be sued or held accountable for virtually any action they take under the authority of the new legislation. The Ministry of Health will become a dictatorship, and the citizens of Ontario will have no recourse to protection from the damage that will be inflicted on them by the Harris government.
We in the Niagara area are a have-not community; we have not adequate funding in every aspect of health care. In order for hospitals to balance budgets, they've had to close beds and curtail services, limiting the number of inpatient beds. Surgical procedures are now being delayed, as beds and operating time are unavailable. Medically ill and accident victims are held in emergency rooms on stretchers awaiting discharge of inpatients occupying those beds. This increased pressure for bed spaces forces the doctors to discharge patients earlier than they believe medically advisable. Consequently, patients are forced to return when they experience a relapse. Unfortunately, it is difficult to keep statistics on readmissions, as these patients do not always return to the same facility.
If Bill 26 passes, those requiring hospital beds will wait longer, become more acutely ill, and take longer to recover, which will increase costs instead of decreasing costs. As a result of these occurrences, people will die unnecessarily.
The hospitals at present in the Niagara area have limited paediatric services. The St Catharines General has no paediatric intensive care unit. Therefore, if children require that level of care, a makeshift intensive care unit is set up in the child/adolescent unit. In Niagara Falls and Welland, they place these children requiring intensive care into the adult intensive care unit. Only Niagara Falls and St Catharines General have neo-natal intensive care units. Those children who require care and treatment beyond the technology and specialities of our paediatricians are taken by ambulance to a helicopter pad and flown to either Toronto, Hamilton or London. The bill calls for amalgamation and reduction. I would ask you, move what to where?
The statistical comparison by the OHA -- this is not in my brief, by the way -- that shows the dollars per capita spent on hospital funding indicates to us that we here in the Niagara area are funded at approximately 38% below the provincial average. I ask you, do you want to take more from us? We're not getting our fair share now.
Despite the dense seniors population within the Niagara region, one of the highest in the province, we have no clinics that specialize in geriatrics. You cannot even find a gerontologist listed in the current telephone directory. Our facilities have already closed chronic care beds, and long-term-care patients are now occupying the active medical-surgical beds. The senior citizens' homes have already had funding cuts. Those requiring placement in these facilities are closer to being classified as chronic rather than those who require the care at the placement level provided in a nursing home and homes for the aged. With fewer staff available, the level of care is decreasing. Who suffers?
It is clear that every cut has a direct impact on the quality of care for the residents. Our seniors are the citizens who fought for and won quality health care for all of us. That includes Mr Harris. Bill 26 will deprive them of their deserved rights, their dignity and self-worth in their twilight years.
I would like to have been able to provide to you at this time a brief that is being prepared by the municipal government here on chronic care and long-term-care facilities. Unfortunately, it's not ready right now, but this will contain the current number of beds in the system and those on the waiting list. This report will be available tomorrow and I would ask that I could forward it to you to be accepted as part of my brief.
The figures that I do have at hand right now are that in the Niagara area, the totally funded beds for the chronically ill and long-term are 2,921; the waiting list as of December 31 was 1,029. So we actually have at least one and a half people for every bed that we have. Those are the current figures. Accurate ones will be out on Friday.
Bill 26 provides explicit authority to allow the cabinet to make regulations that could increase user fees. This will open the door for hospitals to charge for even the most basic elements provided now, like linen, food and rooms. The worst example of user fees that could happen has already been announced. Hospitals will have the right to charge a daily user fee to those patients in acute care beds who are awaiting placement in chronic care facilities or nursing homes. In the Niagara area -- and I've told you already what the waiting list is. Where does the government expect these people to get the money to pay for this? From their spouse who is already on a fixed income or their family who are probably already overburdened financially? Or from a different purse of the government? If you can't pay, what then?
Bill 26 proposes to change the Health Insurance Act. These changes would give the cabinet the right to decide which services are insured and under what limitations and conditions, most likely limiting access to services now provided. By removing the phrase, "medically necessary," the criteria for coverage will probably be cost. We all know what this would mean: the ability to pay. So if you are rich, the medical treatment will be there and if you are poor, medical treatment will not be available.
Bill 26, F and H, opens the doors for the Minister of Health to collect, use or disclose personal medical information in the name of effective management. Confidential medical information will become a thing of the past. Those who are most vulnerable in society, namely, the senior citizens, the mentally and physically challenged, the chronically ill and the poor, will find themselves deprived of the necessary level of care because the government deems them to be abusers of the system. The bottom line is economics, not the necessity for medically necessary medical care and treatment.
It is difficult economic times that historically reflect the physical and mental wellbeing of the people affected by unfair economic and political agendas that blatantly target the poor. Consequently, unnecessary pain, suffering and death will occur. This is an onslaught on the principles of the Canada Health Act that we cherish, which has provided all Canadians with quality health care since its inception.
Bill 26 also provides changes to the Ontario drug benefit plan. If schedule G is passed, the bill will put a two-tier health system in place. User fees for prescription drugs could be introduced along with the proposed $100 deductible. For the poor this would mean prescriptions will not get filled because they cannot afford them. Once again, the hardest hit would be the senior citizens, the disabled and the poor.
It has been suggested that we shop around. Locally the cost of filling a prescription is $10.50 at the top and $3.99 at the bottom. The unfortunate reality of this suggestion is that seniors, the disabled and the poor would have little access to the low $3.99 because the particular drugstore does not deliver. The public transportation in Niagara is inadequate and, generally speaking, these citizens have no transportation of their own. Marketplace competition and profit-making have no place in the provision of health care.
In conclusion, this bill is a disaster for the health care system and catastrophic for the people of the Niagara area. Major restructuring of health services was done in St Catharines in the 1970s. We are already cut. We have the second-highest unemployment rate, 9.3%, of any metropolitan centre in this province, only a hair behind Sudbury at 9.4%. In addition, there is a very high population of people over 60, almost 21%.
All of these factors mean that more and better health care and long-term care services are urgently needed. But much less and worse is what we are going to end up with if this bill goes through. I am here to tell you today that the people of the Niagara area will not settle for less or worse health care. We will not accept being lied to by the government that has done a complete about-face on its health care pledges. We have fought back major attacks on our health care system before and won. If you are determined to push this bill through, we are as equally determined to stop you.
Mr Gabe MacNally: If I may supplement Allison's presentation, I have with me a petition which was drafted by a group of members of our union, young workers whose plant just closed and is moving to Magog in Quebec. Being more concerned about the attacks on seniors in this province than the loss of their own jobs, they took the time to circulate this petition and came up with approximately 300 signatures. I was asked to pass it on to Peter Kormos so he could present it in the Legislature to the Premier.
Mr Hudak: Thank you for the presentation today. When you talk about lack of paediatric care, when you talk about long waiting lists for nursing homes -- and the group before you pointed out the lack of psychiatrists in the area -- you very clearly point out that the status quo is not working.
This government was elected to change the status quo, to do better with less, so we can reinvest that money in essential services like paediatric care or more psychiatrists for the area. I know, representing the southernmost portion of the Niagara Peninsula, that we need more GPs in the area.
At the same time as you recognized that the status quo doesn't work, obviously you have a lot of reservations about Bill 26. My question to you then is, what suggestions do you have for this government to do better with less so we can make the savings in the health care system and invest them into the areas where we really need the money in health care again?
Mr MacNally: I guess that's a philosophical question, whether you believe we have to do better with less. I don't know of anybody who has been able to do better with less, and I guess there are a lot of welfare recipients out there who will attest to that. The question is, is the present tax system that we have in this place in this province and this country working? I would suggest it isn't and I would suggest we can maintain our current level of social programs if you address the root of the problem prior to making any changes to any of the current social programs we do have. You asked for an answer; I gave you an answer.
Mr Hudak: I was speaking to the nurses today, just outside in the hallway, and they told me how there is a lot of duplication in this system. I agree completely that they should have a lot more say in where savings could be made. They would disagree. They would say there are savings to be made that could be put back into the system. Mental health made an excellent presentation. But I appreciate your point on taxes. I disagree. I think a lot of people in Ontario, the taxpayers, would disagree with that as well.
I wanted to get to the point also about GPs. For five years there's been an agreement between the OMA and the government to try to get more into this area. As a representative for the southernmost portion of the riding, the southern portion of the Falls and Fort Erie and Port Colborne and Wainfleet, I'm very concerned about the lack of GPs in that area. It has been suggested that the minister limit billing numbers to areas that are underserviced, in other words, to get doctors out of Toronto and into areas like Niagara South.
Mrs Williamson: I wouldn't want to speak on behalf of the doctors, but I will say, if the facilities for them to take care of their patients were in place in the Niagara area, they would be here. They come here, they have their patients -- because I refuse to use the word "clients" -- to take care of and no place to take care of them. They have to send them out of our community to Toronto, Hamilton, London or somewhere else, because we don't have the facilities here for them to take care of them.
I believe that's probably why we don't have enough physicians here, because even if they're here, they have to send outside, they are being used as a referral centre to get help somewhere else. We need the services here in the Niagara area. The doctors will come if it's here for them to be able to carry on their business. That's my personal belief.
Mr Bradley: An excellent brief presented to the committee. I want to deal with a couple of spinoffs from the brief and from other briefs today and get the reaction of the St Catharines Labour Council. This morning representatives of Liberty Health, who in effect are the successors to Blue Cross, indicated that, as a result of Bill 26, one of the implications could be that drug pricing would go up to such an extent that it would discourage companies from becoming involved in early retirement packages.
In the Niagara region we have had several companies either downsize significantly or close. General Motors, with the foundry closing, is one example of where early retirements have been used to good effect. What would be the impact on the workforce in this area if General Motors and other companies did not utilize the option of early retirement to address its problems of layoffs?
Mr MacNally: If we hadn't been able to negotiate that agreement, we probably now would have had people on layoff not just collecting UI and SUB benefits but also knocking on the door of the social assistance people for social assistance. We have had some members on layoff since 1992. We have been fortunate enough to keep those numbers low by negotiating an early retirement package.
In response to what increased drug prices would do for the future, it's certainly going to put a heavier burden on employers in regard to either paying those premiums or their employees, and thus we're going to be faced with a choice. Do we tell a corporation for which we represent workers to pay those extra premiums and maintain the current level of health benefits and take a lesser increase or a decrease in wages to do that and thus have a trickle-down negative impact on the economy because of that?
Mr MacNally: Not only that, Mr Bradley. I come from the auto sector and it's no secret that we have a cost advantage over our US counterparts of approximately $3 to $4 an hour because of the Canada Health Act and the current health benefits within our country versus the private enterprise in the US. That gives us a competitive edge, so to speak. Without that competitive edge, certainly we would see many of our jobs disappear to the US southern states, Mexico or other countries, and the unemployment level would increase.
Mr Kormos: Sister Williamson, Brother MacNally, welcome. There, I've said it. I can hear the Tory wheels turning. "Look, Kormos is in bed with labour." Let me put it this way: I feel entirely comfortable in bed with labour. It beats the hell out of being in the back pocket of corporate Bay Street.
I've got a copy of a letter here from a Fonthill doctor to his patients. It's called a "Billing Notice, 1996," annual fee $50 per patient. This doctor is requiring each and every one of his patients to pay an upfront $50 fee to be that doctor's patient. That's cash on the barrel head in exchange -- it's sort of like joining a record club, I suppose, because in exchange for paying that upfront $50 fee he makes a commitment to giving discounts on the fees for unlisted services.
I think we should review some of the fees that are being charged currently, clearly: "telephone renewal of prescriptions, $15; telephone advice, $15; in-office injections" -- I presume if you have to get injected with something or other -- "$5 to $10 per injection; pre-employment physical, $75." How does an unemployed person who has no income, who wants to get a job, cough up $75 cash on the dash for a doctor if that physical is necessary to get that job?
"Canada Pension Plan disability medical report" -- again we're talking about a person with no job, they can't work; they're applying for the Canada pension plan disability -- "$60. Electrocoagulation of benign lesions, $15 a lesion."
Unfortunately, Bill 26 is going to enhance this level of user fee. Bill 26 is going to create, very clearly, two types of medical care for people here in the province of Ontario: one for the rich, one for the poor. This government is more and more interested in privatization of health care services, has no commitment to the Canada health plan, has no interest in providing universal accessibility to health care and indeed envisions an American-style health care system here in Ontario. This government will make Ontario the Mississippi of the north when it comes to health care.
How are poor people, how are unemployed people, how are seniors on very fixed, limited incomes supposed to be able to pay these fees and other user fees? And how does Mike Harris get away with calling them copayments when they're in fact user fees, and when he lied to the people of Ontario when he promised no user fees but in fact introduces user fees under the guise of copayments? Can you differentiate between copayments and user fees?
Mr MacNally: No, I really can't. I think they're one and the same, but you ask specific questions. I think they should be referred to the members of the government so they can answer those, because within Bill 26 there are very few answers to many of the concerns that we have as residents of this province.
Mr Kormos: Unfortunately, Bill 26 was developed in such secrecy that even the government caucus wasn't aware of its contents, even the cabinet didn't have an opportunity to see all 17 schedules to it presented in one form. It was leaked out a bit at a time to cabinet. Caucus members were shocked and surprised that the bill indeed had been tabled, read for first reading. In fact, the ministers of this government have been miserably incapable of explaining the contents of Bill 26. Al Leach clearly didn't understand what Bill 26 meant to the areas regarding municipalities and taxation powers of municipalities. The Minister of Health -- we've seen this incredible back-pedalling on the part of the Tories, this effort to clean up, to spin-doctor. They've spent a whole lot of taxpayers' money introducing their no-name little bit of propaganda, which is a shameful bit of hack crap.
Mrs Pupatello: My question's for the Minister of Health, and I think it's appropriate that we get the answer as quickly as we can. Daily as we've gone to town after town, the Conservative members sitting around this committee have continued to imply and ask questions of those who are presenting, intimating to them that somehow their town or region is now going to be assessed as an underserviced area and that after the passing of the bill, suddenly we're going to have this even distribution of doctors. When has Niagara ever been classified as underserviced? It never has.
Mrs Pupatello: Absolutely there's a question. It is absolutely false to suggest that after this bill, Niagara region will be considered underserviced. That is misrepresentation on their part. If the Minister of Health knows which areas will be classified as underserviced, we in Windsor and any area in Ontario which is non-teaching are desperate to know that they too would be classified as an underserviced area. It is misrepresentation on his part --
Mrs Pupatello: -- and we all resent it highly. We need to know immediately which areas of Ontario will be classified as underserviced and we need to know right away, because otherwise every member on this committee has been blatantly misrepresenting themselves, every one of us.
The Chair: Welcome to our committee. We appreciate your being here. You've got a half-hour to use. Questions, should you allow the opportunity for them, would begin with the Liberals. The floor is yours.
Ms Angela Browne: Hello, folks. The Niagara Mental Health Survivors Network, hereinafter referred to as the Network, is an incorporated self-help and economic development organization for individuals who receive treatment for mental health problems, whom we're referring to in this paper as mental health survivors.
I didn't really have a terrible lot of time to go through Bill 26. I just took some of the fine points and I also distributed to you A Common Sense Approach to Mental Health Reform, which is one of our consultation papers we had with our membership a few months ago before I made a presentation to the Clarke Institute of Psychiatry and the Canadian Federation of Mental Health Nurses.
With approximately 100 general and associate members throughout the Niagara region, the Network has established its priority interests as (1) employment-economic development; (2) skills-knowledge development, research; and (3) advocacy. Throughout the past year and a half, we published several reports, including On Our Way to Work: Removing the Barriers to Economic Dignity, our report to the standing committee on human resources development on social security reform, A Common Sense Approach to Mental Health Reform, which you've all got in your hands, and we'll soon have available an information and advocacy booklet for survivors.
We've also produced numerous position papers on issues ranging from mental health reform, systemic advocacy, definition of disability, guaranteed support program for the disabled to community economic development. We try to take a realistic approach to things, particularly as we understand that we are dealing with fiscal limitations, but we still at the same time need to have a balance with human services.
In general, as an organization, we do support the concept of greater fiscal program accountability, cost-effectiveness and open democratic processes. For this reason, we appreciate being given an opportunity to speak on Bill 26.
The concepts of accountability, cost-effectiveness and open, democratic principles are issues that most of us can embrace, regardless of where we come from on the political spectrum, particularly as programs with good to excellent outcomes should be rewarded and less effective programs get penalized. The emphasis is on performance, effectiveness and value for dollar, which is crucial for the delivery of services, particularly if you hope it would lead to better programs. We really need to look at that before we consider taking something wholesale and just cutting it.
Henceforth, we recognize that more spending in any area does not necessarily lead to a healthier population, nor does it necessarily provide long-term stimulation for the economy. However, we do believe there is a role for government in reducing and ameliorating the pain, suffering and economic loss associated with long-term social disadvantages, including mental health problems and other disabilities.
We do believe there is an association between increased use of mental health services and lack of access to meaningful jobs and a decent income for the majority of mental health survivors. We do believe that reinvestment into proven community-based and preventive approaches would not only save us money, but keep us healthier in the long run. Healthy populations do not use hospitals as much and mental health survivors who have decent access to employment and community-based supports do not require as many costly services. These are the things that do save money.
With any changes to health care or related social services, it is organizations like ours that are a barometer to the effects felt by people at the street level. It is organizations like ours that receive the telephone calls, referrals and crisis visits by individuals who are genuinely afraid of how they are going to live next month, whether or not they are going to eat, let alone maintain a roof over their heads. In the past two months, we have encountered three separate incidents in which survivors have taken their own lives. In one particular case, the person stopped by our office to discuss what appeared to be a no-win situation related to general welfare assistance. We tried to do what we could for her, but a week later she said that she told her family goodbye and she told her boss that she would not be back -- she was working part-time -- and told me that I had done all I could. A week later she took her own life.
While we recognize these deaths do have other factors in their causation, our experience suggests that a procrustean-bed approach to belt tightening does leave many people quite vulnerable. This person is a different case from the case that was mentioned about Miss Stella Williams; this is a different person. The cases are remarkably similar, and I am just trying to study some of the backgrounds in them before I can really get into specific comments or research on it.
The Ontario Council of Health, under section 8 of the act, is replaced by a Health Services Restructuring Commission, which is a corporation without share capital and is given authority to carry out any duties assigned to it under the Ministry of Health Act or any other acts. The range of authority or limitations given to this new commission is neither clear, nor does there appear to be a consultative process included in any of the decisions that can or will ultimately be made by the commission.
The government seems to be willing to amend the bill to include the role of district health councils, perhaps as the regional bodies to make recommendations to such a commission, and while we do cautiously support such a move, we anticipate the government would also be reviewing the structures, appointments processes and operating guidelines of district health councils to ensure there is appropriate community and sectoral representation on all DHCs. As this role would give the DHCs increased influence over regional health matters, it is crucial to ensure that those appointed to such bodies, or any of the other subcommittees of the DHCs, have at least minimum qualification and no conflicts of interest with respect to their own affiliations with any ministry-funded programs.
Our companion document entitled A Common Sense Approach to Mental Health Reform details some of the issues that must be dealt with prior to releasing any new mental health dollars -- and there should be new mental health dollars. I don't think we should be cutting in this vital area, because there is a need for the services -- maybe redirected or reshifted or rethought, but not cut at all.
Please note another one of our recommendations stems from the composition of the health structuring commission. This commission must include regional, sectoral and other interests -- for example, consumers. However, we would recommend that no member of the commission be part of any local district health council or ministry-funded programs. This will give health proposals another set of eyes with the potential to be objective and free of conflicts of interest.
Proposed sections 5 and 6 give the minister broad powers to close or amalgamate hospitals, reduce volume or stop providing certain services, or provide or increase certain services if the minister considers this direction to be in the public interest.
While we have no problem with the fact that hospital services do need to be operated more efficiently, with more dollars flowing to community-based services and programs, it is not clear which circumstances constitute a "public interest," other than a vague reference to the quality of management and administration of a hospital, the quality of care and treatment of patients in a hospital, the proper management of the health care system in general and the availability of financial resources for the management of the health care system and for the delivery of health care services.
First, it is not clear how this is determined or how it is adjudicated. We would like to see the formation of a board or a special panel to which the investigators report, with some composition that includes members of the public, consumers and others, including those with an expertise in management and also an expertise in the health care sector in the community. Then this board or panel can make a recommendation to the minister.
Secondly, it is unclear who the investigators are. Is there a possibility that you might want to rejig this, to rethink this and make it into something where we can have quality control panels go out, with representatives of the public examining the way hospitals are and to make sure that, if a hospital is well functioning, if it does serve the community properly, it is not going to be put on the cutting block, to protect some of the needed services? But if it is not functioning properly, either get it functioning properly or use some of the provisions of the bill.
These investigators must be able to carry out inspections without prior notice, particularly in the event of a complaint. This will allow members of the public to have more input in decisions about the future of hospitals in their area while avoiding vested interests.
As major psychiatric facilities are not covered under the Public Hospitals Act, we would suggest these conditions also apply to these facilities. It is important to note that patient care in many psychiatric hospitals remains poor, due to lack of informed consent, frequent or inappropriate use of restraints, overmedication and poor discharge planning. Putting psychiatric hospitals at risk for closure as a result of poor patient care might encourage these facilities to develop proper guidelines for patient care and enforce them if they wish to continue operating.
But as I'm going to say later on, I don't think we should start considering closing psychiatric beds before you have the dollars there in the community. If you start closing psychiatric beds down and there are no community services, we're going to end up with people overloading and overflowing on all the other social services. It increases the demand, and I don't see where the cost savings would actually be realized, given the possibility of other health problems and also the possibility of perhaps petty crimes or other kinds of incidents that actually would increase your costs.
Amendments to the Ontario Drug Benefit Act, the Prescription Drug Cost Regulation Act and the Regulated Health Professions Act: Eligible persons under the act will bear part of the cost for prescription drugs. The amount will be prescribed by regulations. It was proposed that a $2 charge be levied on all prescriptions issued under the act to eligible persons, including those receiving general welfare. The very reason many people are on welfare to begin with is poor health. For many, they must take medication.
We are concerned these costs are borne disproportionately by the poor: $2 for a wealthy senior is coffee money, while $2 for a person on welfare is dinner. When faced with the choice of paying for groceries or medication, what do you think they will take? They will take the groceries first. Many survivors will opt to stop taking their medications, which will result in increased hospitalization, which will wipe out any cost savings from the decreased support on the Ontario drug benefit.
The recent proposal to allow pharmacists to waive the aforementioned fees may do well where there may be competition among many pharmacies in urban centres. However, mental health survivors living in small towns or rural areas may not be able to find a pharmacist willing to waive the fee. This will be difficult, particularly close to the end of a month.
Privacy and disclosure of medical records: We consider the medical file to be the property of the individual and their doctor and nothing else. This is a personal record of yours, it's personal information, and it should not be disclosed to anybody without that person's consent. The right for an individual to review, copy and/or object to contents in their own medical file must be preserved, while the confidentiality of such a file must be protected from third-party interests.
We do not feel comfortable with the minister and/or his official staff having access to our personal medical records. People with psychiatric or other similar types of disabilities feel there need to be some guarantees of confidentiality, particularly if it is in their interests to proceed with their therapy. Otherwise, people will drop out. Many people will be reluctant to seek medical care for conditions like AIDS for fear of disclosure to an employer or to an insurance company or other ministries. They may be reluctant to seek care when treatment is possible, or much cheaper to carry out.
We see no reason for ministry officials to have access to our private medical files. If this measure is implemented for the purposes of fraud, is it really necessary to include patient names and identifying factors? Why not remove all the identifying factors on these medical files and assign a number and maybe even a code for each of the services that were performed, without going into a lot of details about the person? There are lots of ways that these things can be done and put together so you can still investigate fraud or if something has been mishandled or something.
A better idea also would be to set up a pay scale that reduces incentives for physician fraud, for example, putting them on salaries. I admire that Mr Wilson is looking at some of these options, but I think they should continue to look at these options. This is necessary, to start looking at different billing practices of physicians, and also possibly put some limitations on the annual billings for tests and other matters, of course keeping it flexible in certain circumstances, or if you have a lot of patients with particular conditions or something. The amount of this restriction could be negotiated with the physicians' association. Then they would allow the physician to decide about tests within the new prescribed limitations. That way, you're not going to get into a person's personal medical files, you'd be clearly investigating for any misappropriation in billings or whatever you're looking for, without having to get into people's personal history.
Amendments to the Health Insurance Act and the Health Care Accessibility Act: The bill authorizes the minister or cabinet to make decisions about what medical services to insure and for whom and how to insure them. The proposed subsections 11(4) and 11(5) of the Health Insurance Act authorize age to be used a criterion for the definition of "insured services." It is discriminatory to deny essential health services to seniors, and it may be subject to a charter challenge.
You may be familiar with the Roberts case, where a senior citizen was granted visual technical aids as a result of a visual impairment and he was denied it because it was only available to certain people within a certain age group and he wasn't using it for work. So he took it and he won the case at the Ontario Court of Appeal to say that was something that he was entitled to regardless of his age.
This is a problem when you start classifying age groups, disability types, severity of disability. They would all be subject to charter challenge or a judicial review, and it can be a problem where the government may be facing legal bills that it may not be eager to pay for. There has already been that ruling, as I said, and there are other rulings too that were done before that.
This wide discretion may also be problematic in that under the proposed subsection 18(2) the ministry may refuse to insure services that are not deemed to be medically or therapeutically necessary. Who is going to determine this? Are they a group of doctors, and do they know this patient? I have a real problem when someone else is going to decide what services are not necessary and they're not medical personnel and they're not somebody who has the background or skills to even know what types of tests and so forth would be necessary in any given circumstance.
Also, how is this determined? Does this mean people with multiple handicaps that cannot be cured but maybe treatment might just make them feel better, or perhaps people who are terminally ill can be denied treatment on the basis of if it was given to them, it would not be viewed as helpful? If somebody's dying of AIDS or dying of cancer, would palliative care services be denied because this individual is not going to get better? What tests will be deemed necessary and what tests will be deemed unnecessary?
These are all questions that are going to be reviewed, and how are you going to apply them in each individual case? I don't think the government of the day has the time to do that, personally. I think you have to leave it up to your family physician. What you need and your services are between yourself and your family physician.
Under another proposed section of the Health Care Accessibility Act, subsection 2(3), hospitals may be permitted by regulation to charge patients for insured services, such as medications prescribed during a hospital stay, meals, therapy and other services. This has the potential to create a big barrier to access to care, as health problems will not go away because they get defunded. They may end up costing more in the long run as the patient is sent to emergency services or admitted to hospital for a longer period of time.
The next part is cost-effective use of health care resources. Several studies have shown that user fees of any kind in the health care system deter people of lesser means from accessing the care they need when a condition is still in its early stages. We do not support the introduction of user fees of any kind in our health care system, because people simply cannot afford it. Most people who are mental health survivors are out of work. They don't have the money to pay extra for prescriptions or for extra services they might need. It's bad enough sometimes to have to travel to outside areas to get the care they need, and sometimes this even presents a hardship. And I think we really need to know who we're talking about and who we're trying to work with.
However, as our concerns primarily lie in the area of mental health, we did not see many references to mental health care specifically in the bill. We would assume the Health Services Restructuring Commission would work with the local district health councils in making recommendations to the minister. But there was really no indication of where this fits in or what structure you're recommending this to be. We would also presume this commission will also deal with mental health programs.
Our concern about hospitals closing is that many psychiatric beds will be lost with the $1.3-billion cutback. We are concerned that care must be taken to ensure that dollars flow from the institutions into comprehensive, community-based mental health programs prior to approving any bed cuts in any hospitals. This is very crucial, because when you're leaving people without care in the community, they're going to be putting a lot of pressure on other services, and it's not going to save money, because people need to have something there in the community for them.
Second, we are concerned that the community-based mental health sector should be more accountable and a greater percentage of its funding must be tied to acceptable outcomes. For example, there should be an evaluation process, an external evaluation process, placed on all the different mental health programs. We want to make sure that they're effective, that they're doing the job they're supposed to do and that the people who are using the services are benefiting. It's not enough to say that someone likes the program to consider that to be effective. They have to benefit from it. They have to show that they are coming along in their problems and their recovery. They have to show that they are able to go back to work, or live on their own, or whatever the goals are that were set with their therapy. It's very important to have program evaluation from external evaluators with the proper skills in order to do it.
For example, many of these mental health programs do not have a clear statement of purpose, goals or objectives. Some people are there forever and they never get a discharge from the program. I think there should be some kind of way where there is a link between these programs and then the person in the community so that they cease to become just consumers of mental health services and become citizens. There has to be a stage between one to the next stage. You can't just have somebody that, just because the program is there, they can go there every day for the rest of their lives. We don't particularly consider that to be helpful.
If an agency is supposed to help survivors find work, for example, I think we have a right to know how many survivors actually got jobs out of it. If an agency is trying to get into crisis management, if you're in a hospital situation or outside a hospital setting, we want to know how many people were averted from going into the hospital, and therefore we can probably realize what cost savings we actually have.
Also, we want to know what people want. There is a very high demand for employment services. When mental health reform was put into place, employment was given the back burner. Nobody considered that to be a priority. They just listed case management services, housing, self-help and programs of personal support. Those types of programs would be a priority, but when it comes to employment, they put that at the back burner.
So they formed a working group. We're not interested in working groups, we're interested in seeing what action there is, what actual programs there are, how people can access funding and create programs, businesses or whatever, to create jobs for people to help them get off the welfare rolls or disability rolls, for those who want to. It should never be a mandatory thing, but for those who want to, to help them get into the community, be reintegrated.
We also recommend some form of professional association or body or something governing mental health workers in the community mental health field to ensure continuing education and standards for all mental health workers and all mental health programs. At the present time they're unregulated. You don't know who you're hiring or what's going on in the services or in the agencies. Some of them have very good people. The majority of them in fact do. But there may be a few of them that may not, and we have to be very careful about that. We want to make sure we're getting the best services we possibly can for our dollar.
In addition, programs that have been proven to be ineffective and unrepresentative of the people they work with should be cut, if you're going to be cutting anywhere. And there's a lot of unnecessary duplication in some of these areas, and that should be examined, but not without community input and consumer input, other people's input. You don't just go in and say, "We're just going to slash this one and that one," and then end up seeing the consequences afterwards. It's always good so that people know what's happening, what's coming down the pipe, so they know and they can prepare for it adequately for the future.
An emphasis on community care models would be cheaper than encouraging people to continue using hospitals. I noticed some little bit there in Bill 26 about how doctors would only be allowed to bill OHIP for their services if they had connections to the hospital, something like that. I find that sort of against the whole principle of moving people out to the community. It doesn't create a big incentive, because some doctors may want to get involved in innovative community-based health care, whether through community mental health programs, through a health centre in Parkdale or something, maybe form a community clinic. Actually, those are a lot cheaper to deliver. Whether a medical association might be willing to go with it or not I don't know, but I think some of these models should be tried, pilot programs set up. I think that would be very effective. You'll see how the cost savings would be developed from there.
Also, the other thing is, a continued balance of representation from survivors, survival organizations, because not all survivor organizations have the same perspective. I think there is a need to have a varied perspective on various things. You can't just have one group because it claims to represent a whole geographic area when it possibly doesn't. You might want to have people who are having different perspectives and kind of get them around the table and try to develop some kind of consensus about how things can be developed so that everybody is happy, or at least nearly everybody. You're never going to get everybody happy, but at least nearly everybody.
Family members need to have a say in a lot of these things because family members do not have services. There's very little support. Peter Kormos has made a mention about Stella May Williams. The fact is that family members in that situation do not have a lot of support in the community, even though they get support from us, and our hearts and souls are with them, but it's just that it's very difficult for a person who's going through this for the first time -- what to do, where to go. A lot of education is required in this area.
We also need to maintain the balance on the community mental health boards so that we can ensure that the services that are being delivered are being delivered to people who want them and being delivered in a way that people want them.
Mrs Betty Ferrish: Good afternoon. I'm Betty Ferrish and I welcome you to the Niagara region. We represent the Niagara South Social Safety Network, which is a broad-based community group of people who work towards social justice and community development.
We regret the urgency and tight time frame we had to prepare our presentation. We work from a collective approach in our group and it was difficult to include all our points and all our people and to do this in a succinct way; however, we present our position and the wisdom contained within. We have approached our presentation section by section.
Ms Mary Beth Anger: I'm Mary Beth Anger and I'm from Community Legal Services of South Niagara and I'm a member of the Niagara South Social Safety Network. I thank you for the opportunity to allow the Social Safety Net to participate here. We are certainly pleased to make this presentation to you.
Ms Anger: We, as citizens, believe in the right and responsibilities of a free and democratic society. We, as voters, have entrusted this government to act in a democratic process and protect the rights of all citizens whether they are rich or poor.
A democratic society respects, considers and shares with its citizens the power to make or change laws and regulations. Too often, we have not been consulted about changes and this amounts to the weakening of our democracy that citizens are entitled to have through consultation, debate and discussion. Anything less is a denial of natural justice for the members of this society and our rights to freedom.
We agree that citizens from the province have the right to be heard and we understand that change is inevitable given the debt and deficit that our province has encountered. We have been living in a dream world in our inflation system and using credit financing that we never have been able to repay. Before us lies the challenging task to work towards a healthy financially secure society in Ontario.
We do not agree with one person or one office in this government having an excessive amount of power which reduces the power or input of citizens in this province. We see that abuse could arise from either the Minister of Health or the Minister of Transportation having the carte blanche power that is being suggested in Bill 26.
In addressing schedule F, that's the amendments to the Ministry of Health Act, the Public Hospitals Act, the Private Hospitals Act, and the Independent Health Facilities Act, we support the right of input into the changes of legislation by citizens. We disagree with the amount of authority that Bill 26 suggests be given to the Minister of Health. We have medical experts and authorities, knowledgeable in the decision-making process, to work for the best interests of that medical community and the users of that service. Partnership decisions allow for ownership of the decisions and that the best consideration has been given to reach the solution to the problem. The closing of hospitals deserves to be studied to allow cooperation with the shareholders without holes in service while the changes are made. Often, better solutions appear to resolve the problem other than the closure of an important service. Brainstorming issues often result in solutions once the knowledge of the problem, the budget, and the discussion is known. The transition for that hospital may be to a different and better service. The community can build itself from the inside out, but the facility closure needs early discussion to prevent the loss of the service while providing financial options that may work towards a successful future.
A debate surrounding transition for hospitals in the Niagara area is the discussion of closure of hospitals and building a megahospital. When we look at these issues we see we need major hospitals in Niagara Falls, Welland and St Catharines. The other outlying hospitals could be trauma centres and provide local rehabilitation and chronic care. This would allow a person, once they are past the acute stage, to be closer to family and friends. There are problems with some emergency department services, but these need to be resolved locally by the boards of hospitals. We have too many walk-in clinics that end up costing more money to our system, as they most often just refer you back to your own doctor. This results in two charges. We see that effective emergency departments with minor and major departments would service the community better and that hospitals would be used as intended. This is in the best interests of the taxpayer and public interest. Communities that are set apart from hospitals could benefit from walk-in clinics.
One central administration for all the hospitals in the Niagara area would be cost-effective, with a confederated board of directors. Transportation to the services of different hospitals is also a problem here in Niagara and the ability of doctors to be tied to all hospital services in the new structure would need change of policy and regulation. All these issues would need to be considered in the regional plan. These changes would promote better health care services in Niagara.
"Public interest" is not defined and we do not know what the government means by this term. We question the intention of section 5 of the Public Hospitals Act and what the government definitions surrounding grants, loans and financing mean. We disagree with the power of the ministry requiring a security agreement of repayment and the power to reduce or terminate grants and loans. All this recourse without a right of appeal or negotiation would lead to arbitrary decisions. The power of the minister is too far-reaching when the minister can deem any matter to be in the public interest. Section 8 sets the investigator up in the role of good guy, bad guy or as the benevolent dictator, which is not democratic.
We understand some budget cuts we've been given. Hospitals where the buildings are not cost-effective could be closed. As the building becomes older and needs repair and falls below building codes, is it better to look at the financial advantages that a new hospital could offer? The major concern is servicing the medical needs of the community. We see this as public interest. Broad public input is important to the closure of any hospital. People not residing in that community would not understand what is being lost. Written financial reports do not always tell the whole story.
The excessive amount of power given to the Ministry of Health contradicts the community control process that this government advocates. The government has said that it wants to put more control in the municipalities to make these decisions more locally palatable. Will the financial means also be given with the responsibility? The local taxpayers are already overburdened by excessive taxes. This kind of municipal power may result in large shifts of citizens if one area has the type of services they desire and the service is better than in the area where they reside.
In the Niagara region, we are fortunate we have to a particularly effective district health council which is committed to community consultation. However, we see the district health councils as extended arms of the government and therefore believe that their recommendations have the ability to be slanted and not truly representative of the people in that community. We believe that the health councils and hospital boards can again be a viable working process, with some housecleaning and new innovative ideas that can be found among the vast resources of over 10 million people in this province.
To believe that the Health minister has all the knowledge that is available would be rather shortsighted. A recent example of this can be seen in Toronto with the Women's College Hospital where the decision to amalgamate the hospital was changed after the public forced the ministry to consider public input. The amalgamation of this hospital apparently may have been a mistake. Without community input, changes would have happened that were not in the best interest of the public. Learning from this event is a lesson to remember.
Changes need to take place in hospital boards. This community board needs to be a greater representation of the community, of single parents, mothers raising children, injured workers, disabled persons, senior citizens and different levels of various aspects of medical services in the community. All the players need to be represented and not dominated by the well-known, well-established professional people on the board. A viable cross-section of the community is necessary. The decisions that were not made caused patients to suffer from the lack of a needed change and decision.
Some board members around the province are professionals who use their board position for personal status and political reasons. They have very little concern about the wellbeing of the community. To become a member of some hospital boards, it is expected that the new board member will make a financial contribution to the hospital before they are admitted to the board membership. This looks like the person bought their position on the board, and it denies low-income people the ability to participate on the board.
Too often board members do not have the time and interest to commit to the board. We are not saying that all board members fall into this category, but certainly there are some, which causes large gaps in the process that comes from healthy debate surrounding the day-to-day workings of a board. In our area, we see that tough decisions needed to be made surrounding personalities or changes in staffing but were avoided. A mechanism is needed in these cases for an outsider to make changes when the hospital board will not do the work that is needed to be done.
We do not support the broad sweeping powers for the Health minister as suggested, or that they need to be time-limited. We believe this power planned to be given to the minister should not be implemented.
The suggestion that hospital boards of directors be taken over by an appointed supervisor for matters relating to the hospital in the public interest is a very broad statement that needs to be defined if this section is implemented. We find it difficult to understand how the minister or the Lieutenant Governor in Council would know what is in the public interest without some public input.
We state that the current system with a few changes to the broad structure has the potential to do the job of making the best decisions in the public interest. The board of directors is very accessible to the public, therefore making it easy to obtain public input to determine what will benefit public interest.
Subsection 9(1) raised the issue of accountability. The denial of accountability throughout the bill leads us to believe that the government itself does not know the extent of the change that this bill will create. Our health care system, one of the best in the world, is too important to start changing without first looking at all the possibilities that the 10 million people of this province have to offer. We realize that this would be a large undertaking, but what is important? Is it the efficient care of the community or privatization? Is this again only a corporate agenda, controlling the life of people in Ontario? Effective, efficient health care ought to be the goal.
Within the changes proposed in schedule F, we do not see any recurrent pattern of principles. People will likely die due to these changes unless community input is considered and other paramedical services are first developed. For-profit services cost more money. With the numbers of people presently unemployed or those designated as working poor, the privatization of these services will increase costs to the taxpayer. Who else is going to pay for these increased costs? Under privatization, many necessary services will be gone.
The health management organizations in the United States did pursue some of these some of these changes and the result was the loss of empowerment by the community. The result was that two tiers of service, for those with money and those without, developed. Many free street clinics have been opened in the US to care for persons not able to access the medical system. Do persons in Ontario truly know the outcome for low-income families and singles? It is also unreasonable to allow the cabinet and the minister to be free of any legal liability for any decisions as a result of direction or level of funding. Is this proposed legislation due to the expectation of serious problems arising that may warrant legal action?
Section 32 has some merit when we have seen that hospital services feel that they are services with a doctor who does not provide the quality of care they believe that the community is entitled to receive. Most often, hospital boards do not act around these issues, for they fear legal retaliation. We believe that the connection to a hospital needs to be reviewed on a yearly or bi-yearly basis through evaluation. A hospital needs to have the strength and power to end a relationship with a doctor when it believes the need is present. We see that this is one of the areas of weakness in community hospital boards of directors.
When hospital services are below standard, we agree that there needs to be a mechanism to revoke the licence of that private hospital. We still support that a right of appeal is inherent in this type of process.
The Independent Health Facilities Act would allow a facility fee that we disagree is a reasonable charge. We further disagree with the ability to charge this fee on top of the insured services cost. We do not agree with the change of the definition of the term "facility fee." There is the issue of privacy of information, as the bill gives the power of the minister to collect and disclose patient information. We have an Information and Privacy Commissioner in Ontario to conduct the legislation and concerns surrounding privacy and freedom of information.
Ms Mazzuto: Schedule G, amendments to the Ontario Drug Benefit Act, the Prescription Drug Cost Regulation Act and the Regulated Health Professions Act, 1991: Medication for people of this province is a necessity. Like food and shelter, medications for many people are life-preserving. The lives of many could be endangered without the proper ability to have the exact drug or service required. According to London Life, one of the province's largest insurance firms, the deregulation of drug prices will cause drug prices to rise. Rising drug prices will affect seniors, women, children and the working poor in this province. This government is intent on attacking the most vulnerable in our society. Without medication, many people cannot function. Many citizens do not have the availability to shop for the best drug prices. The best drug prices may also be increased with the travel costs added to get to the location of the cheaper product. The alternative is that we will be forced to pay whatever the local pharmacy charges.
This could lead to some serious increases for the pharmacies that happen to find themselves in an ideal location, eg, adjacent to a seniors' building or hospital. Drug pricing at a reasonable rate is not guaranteed. This leaves the fate of these prices in the hands of the large corporations and drug manufacturers. Most corporations do not have the public interest as their primary goal. Profit is their goal. We do not support putting the health care programs on the chopping block at the expense of increased costs and inability to pay costs to the health care consumer.
Poor seniors and persons on public assistance have to stretch their dollars to an impossible extreme. With dispensing fees, someone supported by social assistance will not get the medication they need. Will the result be hospital confinement a few weeks later? Will it result in family and children's services needing to be called as the child is not having its medical needs met? There are many resulting problems that will likely arise that will cost the taxpayer a greater cost when we put in place dispensing fees. This is an unfair, risky burden left on a patient.
Generic drugs will also be used and a local pharmacist advised that persons requiring the non-generic drug will have to pay the difference. This is unfair, given that many persons do not get the same medical benefits they need from generic drugs as they would from the brand-name. This will again only cost more when the person has to return to the doctor when they are again not well. Many persons can take generic drugs, but there are also those who cannot. The money spent on the generic drug is wasted. We believe that it is important to try the generic drug, but it is imperative that if the name-brand drug is required, it can and will be given. The wrong drug prevents the person from proper function and often increases the side effects of the medical problem, incapacitating the patient. Therefore, all drugs need to be covered.
The Ontario drug benefit plan covers 2.4 million people, of whom 1.2 million are on social assistance. The Ontario drug plan covers over 2,000 drugs at present. Many drugs are used for medical problems other than for the primary diagnosis for which the drug was developed. Iatrogenic medical problems will result in greater costs. Alternative health care and other disciplines need to be covered, as they are often cheaper and work more effectively than drugs without side effects.
A method of saving many dollars in the drug care system would be to have a central provincial or regional purchasing service to provide the medication of all persons on social assistance or using the Ontario drug benefit program. The ODB program could use one contracted drugstore chain. This would encourage competition at the renewal time of the tendering of the contract.
The Common Sense Revolution stated that there would not be any cut in health care spending. What was stated was that the health care system was too important. We agree that we do need to root out waste, abuse and health care fraud, mismanagement and duplication. The Common Sense Revolution went on to say that "Every dollar saved by cutting overhead or by bringing in the best new management techniques and thinking will be reinvested in health care to improve services to patients." This is an excellent approach and we suggest that providing preventative programs is where the savings need to be put. We suggest that a vitamin therapy program for all those persons in the optional Ontario drug benefit plan be provided. This could assist with the lack of nutrition of persons on social assistance.
Schedule H, amendments to the Health Insurance Act and the Health Care Accessibility Act: The changes of schedules H and I put in place extreme powers over doctors. We do not agree with the power, although we do see that when an area has several poor doctors practising in the same area of medicine and the patient leaves the area to find better doctors farther from home and the services of distant hospitals, this does not support the local medical economy. Therefore we see that the present system has inherent problems. We believe this is a problem that hospital boards fail to address. We support medical teams under good medical supervision from well-known, qualified doctors appointed or elected by the OMA.
Another plan to ensure quality care to outlying or northern areas would be to require doctors to serve three years in rural areas before they can locate permanently. This is part of the practice for theology graduates. We support this type of process. We support the OMA taking action to retrain doctors who have failed to keep up with the new trends in up-to-date medical practice or to limit the area of practice when a doctor cannot meet the standard.
The OMA ought to be able to review doctors who have received several complaints of concern, and not necessarily complaints that are pursued by the College of Physicians and Surgeons. Sometimes doctors or other medical professionals may become careless in their daily routine recording or prescribing practices. In life-threatening situations that can arise, a doctor needs to be able to withstand scrutiny. Good doctors do not fear standards of practice and are not afraid to be evaluated or reviewed.
Section 17 of the Health Insurance Act that approves in the government the ability of setting out criteria for necessary services and the basic fee payable for any insured service. This can result in some doctors cutting their services when they are not paid adequately for the service that is requested. Again, there is no mention of an appeal process to negotiate any of these issues. The OMA and the government have cooperatively defined the services covered under OHIP and rate of payment for various services. We support the continuing of this practice.
The government could make decisions based on the age of the patient, the type of medical condition, the severity of the illness, the ability of the patient to pay, top-up services and any other criteria that the government decides to use to remove services from the list of covered services. This could open up a two-tiered method of delivery for medical services to patients that could lead to discrimination against the elderly, the disabled and unprotected children.
We're going to the next page, third paragraph. In the Health Care Accessibility Act, we disagree with the minister extending to hospitals the ability to charge fees for services to insured persons. This contravenes the Canada Health Act, and we believe that this is one more penalty for being poor. It is the poor people who will not have the money to pay for the services requesting payment for food, accommodation, toiletries and operation room costs. This is in direct conflict with the statement above regarding the Common Sense Revolution of Mr Harris.
Mrs Ferrish: Schedule I, the new Physician Services Delivery Management Act, 1995: We support a strong relationship between the Ministry of Health and the OMA and do not agree with the stripping of the agreements that have been made between the OMA and the government. This act voids these agreements without any negotiation rights. This will make the OMA of little force or effect in our province.
The HMOs, the health management organizations, in the US are similar, but they have the ability to make important decisions, and sometimes not wise ones. Community legal services works closely with a similar body in the working of law in Ontario with the Law Society of Upper Canada, and we support the same process, working with the OMA.
In conclusion, as Canadians we are proud of our health care system and our concern for our fellow citizen and their best medical care interests. We have not supported some in our province having the ability to receive greater services whether they are rich or poor. The same basic medical care is administered to all in Ontario. We cannot support any change that would deny even the poorest medical services and care. We cannot accept user fees. We see that many of the cost-saving suggestions will only make money for those corporations in this country, which are already receiving most of the wealth in Canada, and we will not accept the Americanization of our province's health care. We are Canadians, and around the world we are set apart. We are truly a distinct society and culture. We want this and the Canadian way of life to continue. We can work towards a better, more efficient system, but we do not want to be Americanized. Those making the decisions in Bill 26 can hardly know the effect of these changes. We state that privatization of more medical services will destroy the quality of medical care and health care that the people in Ontario have enjoyed in the past.
Mr Larry Butters: I made a presentation kit, and I'd just like to go through. We got notified at the last moment that we had a time to make a presentation. I'm very happy we can, because we feel that as ambulance officers in Ontario we serve the province, and we feel that our jobs are in jeopardy from this bill. So we're very glad to be here.
I have been an ambulance officer for 24 years in Port Colborne. My involvement in the labour movement includes being president of our ambulance Local 264 of OPSEU, I'm a region 2 director of the ambulance division of OPSEU and I'm co-chair of the provincial negotiating team of the ambulance division. I'm a member of the Port Colborne and District Labour Council, and I served as a member on the health team for OPSEU during the social contract negotiations. I feel that my experience and history in the industry qualifies me to speak on behalf of my fellow ambulance workers, and I strongly urge this committee to pay close attention to our concerns.
Over the past 10 years, there has been a number of comprehensive reports concerning the provision of ambulance care in the province of Ontario. They are: the Windsor study in 1985 done by the Ministry of Health; the Shapiro report in 1989 done by OPSEU; the McLeish report, which is an inquiry into the air crash where some of our brothers were killed; the Swimmer report, done by the previous government, and it was quite in depth about what should be done with the ambulance services; and just recently the Donner inquiry, which dealt with some deaths.
Every one of these reports over the span of the past 10 years has come to the same conclusion: that the present system remains fractured and convoluted and, if the best interests of the public are to be served, it would be best to have one rationalized ambulance service.
Right now, service delivery is done in a number of ways: by the ministry, which is this area and Niagara Falls, Welland and Fort Erie; hospital, which is St Catharines and Niagara-on-the-Lake; and private services, which include myself in Port Colborne, west Lincoln and the outlying Dunnville area. We have no municipal services, of which the biggest is Metro, but there are some smaller ones; also, volunteer services throughout the province.
The volunteer services, of which there are approximately 13, is $337 per call. The reason it's the highest is because for the volunteers -- they're not really volunteers; they do get paid -- the number of calls are far between and they have standby rates. They're in rural areas and their calls are usually long; their average calls go from 45 minutes to an hour and a half to transport somebody. Volunteers are costly; there's not that many of them and their call volume is very low.
The private services, of which there are approximately 69, run a close second at $258 per call. Municipal-based services, of which there are approximately 17, Metro being the biggest, is $229 per call. For the hospital services, approximately 16 of them, the cost is $173 per call. Last but not least, the ministry services run at approximately $150 per call.
This sort of tells us that maybe the private is not the best way to go in terms of being cost-efficient. The difference of over $100 per call between the privately and ministry-run services can be explained by the following:
(4) There are 67 different benefit plans because of the private operators, not one central plan, and that's a higher cost. The figures show that could be as much as $6 million in savings to the government.
(5) The private operators also have a higher rental cost. Most of the ministry services and the hospital services are run out of a hospital. What the private operators do is have a limited company to run the ambulance service; they also have another limited company where they rent to the government. The facts and figures prove that in some of the smaller areas they charge the same rent as if you're in downtown Toronto. So some of the figures are expanded, and the difference between hospitals and private is almost $6 million. There's an extra cost of over $6 million that could be saved.
All these facts and more came to light during the process of negotiating the social contract. The government of the day agreed that one provincial service would be cost-effective, but were reluctant to implement it because of the initial cost of the buyout from private operators; the private operators' compensation package would have been approximately $2.5 million. The government, if they had paid that out, in two and a half years would have got that money back and would have been saving money from that point on.
This scenario brings me to Bill 26. The government's title for Bill 26 is the Savings and Restructuring Act, 1995 -- major changes to fix a system that doesn't work; redesigning the public sector to improve productivity while delivering important services more efficiently and at less cost.
It should be obvious to anyone that to further privatize ambulance services is not cost-effective. Niagara region has a ministry-run service, private and hospital-based systems. By far, I have demonstrated that ministry or hospital-run services are less expensive than any other.
I have seen first hand, as a front-line worker, how quality care to our patients is the obvious primary goal. Just as obvious is the need to deliver the public services in a cost-effective manner. I encourage the revolutionaries of Mike Harris's government to listen to the care providers. We know how money is wasted. We have some answers. We have seen the fraud. We know the cost of strikes, the cost of poor labour relations -- the list goes on and on.
Bill 26 invites profit-making corporations, private American companies, to convolute this system that is already fractured and struggling to work efficiently. If you are truly interested in common sense, let us participate in really fixing the delivery of ambulance services. One of the "fixes" could be a two-tiered system of delivery.
Mr Lowell: My name is Mark Lowell. I'm a provincial employee; I work in the ambulance service in the Orillia-Haliburton area. I was the three unions' representative on the Swimmer committee and basically lived and breathed the system for some five years to see it end up in obscurity, the way all things seem to end up in obscurity when the government doesn't really put a commitment into where it wants to go.
I would hope this government would look at the ambulance service as the first link in pre-hospital care, look at that linked with some kind of vision as to what they would like to see happening in the communities they represent.
I would hope that the politicians in general would see that with deteriorating finances and closing of hospitals, reorganization and restructuring of hospitals, the redirection of long-term care, a vast number of people is being put in situations at home that used to be common in hospitals, and when they call for an ambulance and an ambulance arrives at their door, they should be getting the same care regardless of where they live. I don't think people need to be penalized because they happen to come from a rural or northern environment.
It's quite interesting to see at least two previous Health ministers at the table today. I know they both had a shot at fixing the ambulance service when they were in power. Before the government of the day beats its chest about what it's going to do, it should remember -- I've been around since Frank Miller was the Minister of Health and I've seen governments make attempts -- feeble, some very grand -- in fixing the system.
I want to take you on a quick walk through history back to when the Conservatives, the Big Blue Machine, was running the province of Ontario. A gentleman by the name of Dr McNally got it in his mind and was able to convince the Davis government of the day that he was going to create a province-wide paramedic ambulance service that was going to be the example for pre-hospital care in the world. Had he been able to fulfil his agenda, we wouldn't be here today because the job would have been done, although he did it a little too expensively and it was canned. That was in the early 1970s.
His idea was to take ambulance workers, put them in university courses in Kingston, train them through the hospitals in Kingston, kick them back out into the local communities as paramedics. They would be trained as respiratory techs, IV techs, they would be able to do manual defibrillation -- a wonderful array of skills. They were, I guess, the arms and actually had part of the mind of the physician.
Unfortunately, when they sent these workers back out to places like Peterborough and ambulance attendant X showed up at the Peterborough hospital and said, "I'm a paramedic now, I'm going to do all this stuff on the road," the doctors in those communities said: "Under whose authority? Who gave you the right to do this?" And it never happened. It was a very expensive waste of time, with good intentions.
Because I'm a civil servant, I'm certainly not happy with Bill 7 and what it could do to workers should this government attempt to fix the ambulance service. But because you have that hammer, you can get around some of the things that possibly caused the previous government some concern in fixing the ambulance service. You don't necessarily have to be nice people about what you're doing. It gives you an opportunity to go in and say to the private operators, the hospital operators and the Ministry of Health, "We have a vision of how we want to provide ambulance service in this province and we're going to go ahead and do it."
And you can say to the unions, regardless of who they are: "If your members want to work in this system, they're going to work in this system under this vision. There are going to be province-wide paramedic ambulance services, so when you respond to that call in Moosonee, or in Longlac or in Metropolitan Toronto you're going to get the same care." Granted, because of the geography involved, the travel time is going to be different, some of the skill levels are going to be different, but there has been study after study after study.
You're the government of the day, you have the majority, you have the ability to make change. The other parties in opposition to this government have been in the position to try to make change. I think everyone knows what needs to be done. We need to have a province-wide paramedic ambulance service, period. British Columbia walked down that path some 20 years ago, and it's taken them up until two years ago to actually have every ambulance service in the province under one roof, with one direction providing a standard of care that's equal across the province. It didn't happen overnight, and I don't expect it to happen overnight in Ontario, but it would certainly do my heart good to see a government take it on and turn it into something.
I would hate to see a return to 35 years ago. I do have to say up front that I find a lot of the legislation from this government is very regressive. In the wrong hands, if you march down the road of privatized health care and private ambulance services, as an example, you'll be taking us back 35 years. And 35 years ago in this province, when someone was hurt on the street, out in front of this building, a private ambulance service rolled up to the door and, if you had money, they'd take you to the hospital. Chances are that if you had money, there'd be two ambulances from two different companies rolling up to the door and they might even go out behind the ambulances and have a little fistfight to decide who was going to take you. When in doubt, if you thought the people you were picking up might not have money, you tried to take the dead person to hospital because you knew the coroner's office was going to pay you. I don't want to see it turn into that again.
I worked in a private ambulance service in the early 1970s, just as the government funding was evolving. I will tell you, and if you ask the private operators around in that day, they were going bankrupt in a very big way. What the private operators want the government to do this time around is open up the purse, hand it to the private operators and they're going to make the system better. I'm sorry. They're not. It just is not the way to run health care in a progressive, democratic society like the province of Ontario.
Mr Bradley: With the provisions of Bill 26 giving more power to municipalities to impose user fees, although the Ministry of Health now sets the rate, a user fee, for an ambulance, we could in theory, unless the Minister of Municipal Affairs were going to amend the bill yet again, have a situation where a municipality that operates an ambulance service could charge more than when a private operator or the Ministry of Health operates an ambulance service. Is that a concern?
Mr Lowell: Yes, that is a concern. That's why I would like to see it looked at on a provincial scale as opposed to ever entertaining municipalities. Metro may offer a fine system in one municipality, but the community of Fenelon Falls, where I live, doesn't have the financial ability to offer a similar service.
Mr Bradley: If we're going to provide services across the province, we're going to have to have the resources to do so. The government is concerned about the deficit, and understandably so, but is also going to be calling for a tax break which will cost the province $20 billion in new money to be borrowed -- $5 billion in interest. Do you believe, in your discussions with various people whom you encounter, that they would prefer to have a diminishing of the services or higher-cost services of the essential nature you're talking about, or would they rather have a 30% tax break on the provincial income tax?
Mr Lowell: I hear you, but I think you're making it harder than it has to be. In my industry, when someone calls for an ambulance service, they want the best they can get, as when someone shows up at the hospital with a sick relative, they want the best they can get. At that point in time, money isn't the object; it's what's there and the quality of what's there.
Mr Butters: And it has been shown that paramedics being able to defibrillate has saved lives; being able to intubate does save lives. If we're going to go to full paramedics, I think we have to look at what we're going to get. Do you want to save lives or do you want to save dollars?
Mr Lowell: If you close the hospital down in my community, in Minden, where I work, which is half-closed now, you've taken the golden hour of trauma away from every person in that community. In a critical trauma situation without paramedic intervention, which we're not able to do, the golden hour is gone, because we're over an hour from hospital if they get hurt right on the main street.
Mr Lowell: Yes, it is. There's $330 million that goes into ambulance, roughly, in Ontario. Since the social contract came in, bureaucrats in the ministry services have added two layers of management without adding a car to the road. There are some options there to streamline. Those added jobs are regional dispatch managers and operational managers, who provide no form of patient care and do nothing to enhance the service to the public.
Mr Butters: We think that to rationalize the system under one provincial ambulance service would be cheaper. We've sat through the social contract and negotiating with the NDP on some cost savings, and that was done. We showed the facts and figures where we could save money and have better care. It's there if it's rationalized.
Mr Bradley: Would you be of the opinion that with a bill this complicated, changing 47 different acts of the Ontario Legislature in some way or another, it would be advantageous not to proceed to a final vote on January 29 but rather to have further hearings so that representations can be made from various communities across the province, and then when the Legislature returned for its normal session, it would deal with the legislation?
Ms Lankin: I appreciate the documentation you supplied with this. Taking a look at the Swimmer report, it was a very comprehensive piece of work done recently looking at all these issues, and it came to the same recommendation you have been making for a number of years in terms of moving to one provincial service and that that be provided in the public service, not through private operators.
One of the things we're worried about in this bill is that it actually does open up the door for more for-profit delivery of health care services. Government members have said that shouldn't bother anyone as long as we've got our quality controls in, that we shouldn't worry about that aspect.
I recall a lot of stories about the for-profit ambulance services over the years in this province. I remember thinking it was a bit of a conflict of interest to be running both a funeral home and an ambulance service. It didn't give me a lot of confidence in the service I might be getting, but there are a lot of other things: the Alexander case, and perhaps you could talk about duplication of private services in Belleville and other communities. Could you tell us a little about the state of affairs with the for-profit delivery of services that exists?
Mr Butters: When you mentioned Alexander, that used to be the private operator in Welland. He was charged with fraud. He spent two years less a day in jail. They could only nail him for just under $300,000 that he milked taxpayers for. After that, the service was taken over and they became ministry, and that's why Niagara district now is Niagara Falls, Welland and Fort Erie.
Where I worked in 1985, we were on strike for 144 days. After that strike, one of the deals was that our private operator was to sell the service. I have a new operator since 1995. What we used to do was drive tow trucks, fix snowmobiles, pump gasoline. If I were driving the tow truck and went on a tow call, I'd come in and submit my timesheet as if I were working on the ambulance. I did that for 10 years. That was fraud. Our employer was just told to sell the service: "You're out." That still happens today; it's out there. If you think privatization is going to be any different from a few years ago, the crooks are smarter now than they were before.
Mr Lowell: It also leaves questions like, why does Mr Ross in Hamilton own two separate ambulance services with two separate ambulance licences as one owner? Why is the community of Belleville serviced by two completely different ambulance services, workers organized by two completely different unions, dispatched by another private entity in the way of a dispatch centre? Why does Stratford have two ambulance services in the same community running out of two different bases with two different management compensation packages? The craziness continues.
Mr Lowell: Reprivatizing or increasing the privatization is only going to add to the problem. We'll be here -- I'll hopefully still be around -- when another government comes in another day, and we'll try to do it again if this government doesn't get it right.
Mike Harris has always said we are always interested in how to deliver the best quality to the consumer or taxpayer at the best available price. Sometimes that means government doing it, sometimes it means the private sector doing it, sometimes it means a mixture of the two. We enter into any field looking for the best for the taxpayer. I want to make that assurance to you.
With that in mind, I have taken the liberty of trying to go through your numbers a bit. I confess I don't understand them all yet. There are a lot of numbers on this spreadsheet about the relative costs for the various parts. I did have one question you might be able to help me with. Part of any cost is overhead, your fixed cost. If you deliver something as a government or as a municipality, you can shield out some of your overhead cost, because that's part of your infrastructure as a government, whereas private operators don't have that advantage. Are overhead costs included in this?
Mr Lowell: Those are, I believe, total budget costs. In Swimmer, we discovered, or we came to a consensus agreement, that about 85% of the cost is the cost of delivery of the service and 15% is the arbitrary amount that's out there, because of wages, gas, oil, vehicles, things like that. That's not to say that better vehicles couldn't be purchased cheaper. There are things that can be done there.
Getting back to your earlier statement, I would like to advise you that your minister, Mr Wilson, has met several times with the private operators and scheduled one meeting with us, at which he didn't show up. We haven't had any opportunity to speak with the minister.
Mr Lowell: That is certainly the direction to go in. The only thing that again adds to this patchwork and causes concern to communities and to workers is: Why is Ottawa getting paramedics? Why does Hamilton have paramedics? Why does Toronto have paramedics? Why are they going to Peterborough? Why not to Barrie? Why not to Orillia? Why not to Minden? Why not to Haliburton? Why not to --
Mr Lowell: Port Colborne, sure. I understand why it started in Ottawa-Carleton. It was by a community group called Action Paramedic and a group of physicians in that community who brought extreme pressure to bear on the government. They squeaked and they got greased, but you shouldn't have to do that.
Mr Butters: One of the things we believe is that the paramedics should be across the province. It's fine for paramedics to be in the cities. Their response time to a hospital is less than eight minutes, and that's great. But what about rural Ontario where paramedics setting up IVs and having their skills expanded in rural Ontario would serve us better? They have a longer distance to the hospital. With intubation, IVs, they would stabilize a patient. But what they're doing is going to the big areas and leaving the little areas. I think it should be province-wide, and hopefully that will be there.
Mr Lowell: I'd like to add just quickly that when you look at money, when you fall on the sidewalk in Toronto, why do they send a police officer, a pumper truck and a station wagon? Why send nine other people when all you need are two workers and a van? I mean, that is the answer, and they say, "Well, the fire departments have better response times." Why is that? Because geographically ambulance services have never been located where they should be, I think is the point.
Mrs McLeod: Mr Chairman, you'll appreciate the fact that because we've not had anybody with the subcommittee who's responsible for carriage of the bill, and in fact the Minister of Health has not been present for even a portion of any one of our hearings of the health subcommittee, so we've not been able to place questions directly to the Minister of Health, I would wish to place a further question on the record.
We have had numerous presentations that have indicated that the deregulation of drugs will in fact drive drug prices up. We've had considerable evidence presented to back up that case and virtually no evidence presented -- I think two opinions that have been offered in total that have suggested drug prices could decrease, or at least ultimately decrease after perhaps five to 10 years.
I would like therefore to have the Minister of Health's rationale as to why they would be deregulating drug prices, which will clearly, as prices are indicated to increase, not provide better health care to individuals at less cost. I would like to ask whether there's any rationale other than the ideological commitment to deregulation and privatization.
Mrs Caplan: Following the last presentation -- and I will only take a couple of minutes -- what we heard, I thought, was quite an astounding admission from the last presenter that he had been forced by his employer to participate in fraud over a 10-year period, employer fraud. I had expected that the government members might have said something about that since we've heard that this government has a zero tolerance for fraud and that many of the policies of Bill 26 recognize that. I'm also aware, for example, that the Minister of Community and Social Services posted offensive posters saying if you even suspect anybody of fraud, call this 1-800 number. That was their snitch line.
I know the reason that employee wasn't comfortable to snitch on his employer was because he'd lose his job if the employer found out. I'm wondering whether or not the Minister of Community and Social Services and the Minister of Health contemplate employees such as that being able to use the snitch line anonymously to be able to report ambulance employers who are committing fraud, or what the government would intend to do. We've heard today testimony that this practice continues today. The government should be concerned if that kind of fraud is being perpetrated. I want to know whether they are suggesting to this person that they call the welfare 1-800 snitch line or if they have some other mechanism to deal with that kind of fraud contemplated in Bill 26.
Dr K.N. Reddy: Chairman and distinguished members of this committee, thank you for the opportunity to express my personal views about Bill 26, referring to schedules F, G, H and I. I'm a specialist in urology, practising in the city for over 20 years.
All of us would like to see that the health care costs are brought under control and to live within our means. Successive governments have failed to recognize the major contributing factors for escalating costs, such as consumer demand for the services and the defensive practice of medicine.
Ministry of Health officials will have the power to seize medical records from the doctor's office. This is unthinkable. The ministry can ask the physicians to repay the cost of service if they think it was not necessary. So are we to take permission for each service provided, or will the ministry give us a list of tests and procedures allowed for each clinical condition? This will create a bureaucratic nightmare.
It is time for the honourable Minister of Health to sit down with the representatives of our medical association and work out a plan to achieve the common objectives of cost containment and manpower distribution.
Mr Clement: As you know, the committee, both the opposition and the government members of the committee, are considering amendments to this legislation as part of what a committee does, and we've been hearing presenters over the past three weeks. If we did entertain that as a committee that would strengthen the ability to maintain the anonymity of the names involved in medical records but still allow investigative powers to occur, so that if there is any misuse of the medical system -- we don't want to be, as taxpayers, spending dollars in a way that is a misuse of the system when there are so many crying needs in the system in other areas. But if we could alter our plans to provide for the proper balance between confidentiality and an ability for investigation of misuse of the system, would that go some way to addressing your concerns?
Dr Reddy: With due respect to your comments, already we have an existing system of peer review. I do not mind the peer review person from the college coming in and investigating my office. We are open for that. But a bureaucratic person from the Ministry of Health is unthinkable. I think this is the most objectionable legislation which you have created. I think this is unacceptable.
Mrs McLeod: If we are planning to have the time of the physicians shared in terms of presentation and then share the question time with all of them, I would hope we're going to have still an equitable distribution of time.
Mrs Pupatello: Thank you, doctor. We heard a presentation from a doctor who was from Leamington but who at one time practised in California, and because he saw so many similarities to the American system now being allowed to come into Ontario, he gave us an anecdotal case where a surgeon was just about to pry into a patient for a particular procedure -- it was a tube of some sort -- and the phone rang and it was a clerk from one of the HMOs. The clerk reviewed the file and saw that this patient wasn't covered. The events leading up to the surgeon preparing for the incision were that there were several emergencies that had precipitated immediate surgery and this sort of thing. When the phone rang, the surgeon was told to stop because the patient was not covered. This is the kind of event that will be allowed to happen because there are provisions in this bill that will allow for American companies to come in, that will allow for this kind of thing to happen, which has to date never been the case. Do you have any comments about that?
Dr Reddy: As you know, Canada and Canadian physicians are very compassionate. We may be prepared to do the service free if the operation was necessary, if it's covered or not covered. You must understand that we are very compassionate people. That's important.
The second question: If somebody asks me to stop the operation, if the patient requires it, I'll still go ahead and do it, free of my cost. But if it's not needed, then it's obviously my fault. But certainly I do not like to see the government take the steps to tell me to do this operation, not to do this operation. I think this is totally meaningless, senseless legislation to bring out, saying that the ministry will decide if this procedure is covered or not covered, this test was required or not required. Let us decide. Let the professional and provider decide what is necessary and what is not necessary. Let my peer committee like the college of surgeons decide if my decisions were appropriate, not the ministry. I think this has gone too far.
Mrs McLeod: Mr Chairman, can we just determine exactly what we're about to do, because I see the last presenter is leaving. I think we want to be clear. We want to use the full time that the committee has until 5:30. Is that correct?
The Chair: If everybody's in agreement, why don't we have all three doctors? Dr Makerewich and Dr Smith can make their presentations, and all three of you would be available to answer questions. Is that okay with everybody in the committee?
Mrs McLeod: And can they all remain until 5:30, which is the time the committee has? We would certainly take all the time until 5:30, should that time be available to us. So we would be happy to have an in-depth discussion of the issues affecting physicians, and this may be a unique opportunity, with three physicians here, to have an intensive discussion about the issues in Bill 26. So if the physicians who are here can join us, that would be highly desirable from my perspective.
Dr Leonard Makerewich: I'm Dr Makerewich. Nice to meet you. Dr Kevin Smith and I actually will be presenting on behalf of the Greater Niagara Medical Society. I am an otolaryngologist, or ear, nose and throat specialist, and president of the medical society. Dr Kevin Smith is a dermatologist, or skin specialist, and he's vice-president of the society. Today we're here as Team Niagara. We'd like to make a few points and we'd certainly welcome your questions.
The doctors of the Niagara region would certainly like to welcome the members of the committee to Niagara Falls and we'd hope that if there was any possibility of any free time, you'd take advantage of that and go down and see one of the wonders of the world here, especially its winter coat. It's quite nice, and if you did have any time we'd certainly think that would be nice.
What we want to say here, and I'll go through this probably as briefly as I can, is that coming into the last election certainly the doctors in the Niagara region were very impressed with the sincerity of Mr Jim Wilson prior to the election in terms of his proposed cooperation with physicians when he met with the Ontario Medical Association. He came with an outstretched hand. He came and made a presentation to the OMA stating that he really desired to heal the wounds that had been created with some of the former governments. Certainly since then and since we've heard about this proposed legislation, we've not only been shocked, we've been dismayed at some of the draconian proposals that have come through in this Bill 26. These proposals are going to affect every physician in this province and every patient in this province.
When we went into medicine -- I can speak personally and I can speak for my colleagues as well -- we went into this with a purpose. We wanted to work hard. We wanted to serve our patients. We wanted to make a decent living that recognized our training, our workload and our heavy responsibility, and the hours that we spend after hours and midnight away from our families. Little did we realize we would have to start learning how to practise politics just to be able to survive in the practice of medicine in the 1980s and also in the 1990s.
Had the government come to the OMA in private with the draft legislation prior to introducing Bill 26, these public hearings wouldn't be necessary. Doctors, like other independent business people in this province, fully support the fiscal objectives of the Harris government to reduce and eventually eliminate the deficit. The deficit, both at the provincial level and at the federal level, is probably the scariest thing that we have now in terms of downloading all the things that we were supposed to have had for free over the last 15 or 20 years to our children and our grandchildren. It's quite frightening, and we strongly feel that this has to be dealt with. The problem is that we feel more can be accomplished with cooperation with the medical profession rather than the confrontation that's going to occur with the medical profession if Bill 26 is passed in its present form.
We feel that many of the proposals in schedules F, G and H relating to privacy of information and examination of health care records assume that physician fraud is a major problem in the current system, and it's not. I think that if there was a very close audit of everything that would be done here in terms of looking at physician fraud, it would be a very, very minor part of the problem, an extremely minor part of the problem. I think most physicians bill honestly and they work very hard. I think, really, that the major cause of spiralling health care costs in our present system is the lack of patient or consumer accountability for the use of the medical services that are out there now.
Most physicians' telephones in this day and age are ringing off the hook, and we're so busy trying to satisfy the insatiable demands of our patients for so-called free medical services and high-tech investigations that we're doing everything possible not to encourage repeat or follow-up visits unless absolutely medically unnecessary.
Many patients feel that they have an unlimited right to three, four or five medical opinions at government expense until they hear what they want to hear or until they get the prescription that they were really after in the first place.
If we don't satisfy our patients' demands for timely access to our offices, they usually go down the street to the walk-in clinics or to the emergency department, and if they're referred to specialists after hours, this ends up billed to the system and sometimes ends up in after-hours premiums. There's no savings in the system. There's no savings in our rationing care and cutting back our services to our patients. They go elsewhere, and when they do go elsewhere, it costs us even more. It costs the entire system more.
Doctors are presently providing the medical services that the citizens of Ontario are demanding, and we're being financially penalized for doing so and we're being accused of overbilling the system when the level of physician payments exceeds a predetermined government cap. This government cap was so-called negotiated with the last government, with a gun to our heads.
The major problem with our present system of universal access to health care and total first-dollar coverage under the terms of the Canada Health Act is that it's unaffordable. It was unaffordable and was paid for with borrowed money back in 1984 and it's unaffordable today. The problem is our fiscal reality and the sad state of our provincial finances now.
With continuing cuts in federal transfer payments for health care to the provinces, the Canada Health Act will shortly become an irrelevant document, and it's going to lose its financial control over the provinces, which are already shouldering the major burden of health care costs in this country.
Doctors have already absorbed 30% to 40% cuts to 1991 level fees because of billing caps and because of social contract reductions, and we've done this in the face of ever-escalating office and practice costs and we've maintained service in spite of all that. We're getting to the point where we cannot tolerate any more, both fiscally and realistically.
We've done our share and many of us are at the top of our credit lines. Many of us are starting to have problems meeting our expenses. Most people feel that every dollar that we take from the ministry is a dollar that goes into our pocket. Some of us only get five cents out of that dollar after we've paid our overhead costs; some of us more, depending on the level and the size of the facility that we've developed, the salaries that we have and so forth, the rents that we pay. We're small, independent business people and we have expenses as well, and this all comes out of our OHIP billings. We're working as hard as we can now to satisfy our patients' demands and we can't continue to provide the high-quality medical services that we've been providing in the past with the present level of fees, and certainly if they should go down even further.
Many of us have spent anywhere between seven and 12 years in training at little or no pay prior to entering the profession, and we continue to work between 50 and 90 hours a week serving our patients, away from our families, after hours, in the middle of the night.
We can't look to government for additional funds. The government doesn't have those additional funds, and we understand that. We feel that the consumers of health services finally have to become accountable for their own health care costs and that the government and the medical profession both should ensure that no one should suffer financial disaster because of a need for expensive health care services.
The proposed restriction of billing numbers for new medical graduates will send even more of them out of the country. A carrot has always been more effective than a stick. The OMA's proposal for rural and underserviced long-term financial incentives is far more realistic in solving the problem than what the government proposes.
Significant savings can be made in the system not only by downsizing and some of the measures that are being taken now, but by defining core services and knowing which ones are essential services, by delisting non-essential services in cooperation with the OMA.
When we look at some of the terms and conditions of the proposed regulations in Bill 26, we think to ourselves of the size of the bureaucracy that will have to be created to micromanage the doctors under this new legislation. I thought the Harris government was into downsizing. Am I wrong?
Dr Kevin Smith: At the outset, we've been focusing for a number of months now, ever since the election, on the cost of medical services. I want to mention the value of the medical services that are provided and the value of the medical care system we have here in Ontario.
We do as good or better a job than the Americans and we only spend about 10% of our GNP on health care, while they spend 14%. We care for all the people in this province and we provide a very good quality of care for all the people of this province, while in the United States, considerably more money is being spent and many people are being left out in the cold. An increasing number of people, I think, have inadequate access to care or hardly any access at all.
The doctors, the nurses and the other members of the medical community are very proud of not only the quality of our system, the quality of the work we do, but also the efficiency of our system, the fact that we're able to obtain good results, give good care to all the people and do so at a considerably lower cost than our friends just right across the border.
Moving on from that, there is concern that people are sometimes afraid that we're going to develop a two-tier medical system. We already have a two-tier or multi-tier system for access to medications and medical devices. For example, people covered by the government-funded drug plan have access to a limited range of medicines and medical devices, while those with private coverage or cash have access to a broader range of products.
Another example would be that people covered by workers' compensation in some cases have preferred access to certain specialists, to diagnostic procedures and to medications which are not available to people who are covered by the OHIP pool of resources. The reason for that is simply that because of capping, an increasing number of specialists, are reaching their fee limit within the OHIP pool and they have to ration out the number of consults they can see every month to make them last all year long. So if a patient calls for an appointment and it's a workers' compensation case, of course there's no waiting list for them because the limiting factor is not the availability of my time; the limiting factor is the availability of money to pay for the services and investigations that are required to take care of these people. So if it's, for example, a WCB patient, they can get seen much more quickly in some cases than exactly the same person with exactly the same problem who has OHIP coverage.
Another example would be somebody from outside of the province, either from outside Canada or from another part of Canada, somebody coming in who is going to pay cash. Again, there's no waiting list for people who want to pay cash because the availability of physicians and operating rooms and other resources is not the limiting factor. That's not the bottleneck; the bottleneck is the availability of money from OHIP to pay for all these good things.
People in this province are free to spend their money on cigarettes, liquor, lottery tickets, lap dancers, so it seems strange that the people of Ontario are forbidden to spend their money on a higher standard of convenience or a higher standard of medical care than that dictated by the government from time to time. As I mentioned earlier, Americans and other people from outside of Ontario are free to come to Ontario and spend their money for medical services while the people of Ontario are forbidden to do so and must leave the province to purchase medical services. In this respect, outsiders actually have more freedom in Ontario than the people of Ontario do.
Just in yesterday's newspaper there was an ad from an American company that is offering joint replacement therapy. A person in Ontario would have to travel down to Virginia and spend their money in a strange place where they don't know anybody to have this done, but they're forbidden to spend their money to have this work done at their own expense here in Ontario, and that would be one less case sitting on the waiting list to be covered by the OHIP pool. I find that very difficult to understand, especially when these same people are, as I said, free to spend their money on liquor, lottery tickets, cigarettes, all manner of things which are probably less desirable than medical services and probably less beneficial.
The government has progressively narrowed the definition of what is a medically necessary medication in the government-funded drug plans over the past several years, and in many respects this has been a good change. Patients have accepted this change with very little complaint. There hasn't been any political backlash. When I explain to patients that the people of Ontario, through their elected representatives, have decided that we simply can't afford to pay for certain items, most patients are very understanding. They're grateful for what the government does provide them with, so the cutbacks that have been made so far really haven't had a lot of political consequence, nor should they. I think the patients are very reasonable in many respects.
The previous administration, under the NDP, started to take some steps with the encouragement and with the cooperation of the OMA to narrow the definition of what are medically necessary, core physician services. About $20 million worth of items were, in one way to say it, delisted. A number of those items were in dermatology and again, the patients have accepted these changes with essentially no complaint. They understand that we've got serious problems. They understand that we can't pay for everything for everybody and that we must draw the line somewhere. So at least in my own personal experience, people have accepted these changes and they really welcome the changes. They think this is timely and appropriate, that there have to be some restrictions.
I know that you're looking for practical suggestions on what can you do to reduce the amount of money being spent. We know that you're going to have to spend less money. You want to do it in a way that's going to be effective and that's going to minimize the impact on health care outcomes in Ontario.
In Manitoba, a utilization reduction experiment was done a year or two ago where they identified the 100 patients in Manitoba who were consuming the greatest amount of outpatient resources. In some cases, these individuals were having more than 500 physician visits in a single year. All 100 individuals were contacted and surprisingly, as I understand it, all 100 agreed that in the future they would get all of their medical care through a single physician. They could pick the physician, but then they would have to stick to that physician for all their care and all their referrals.
That group of 100 people in Manitoba was spending more than 1% of the entire health care budget in Manitoba. So this small experiment not only gave these people better medical care, because their care was much less fragmented -- if you're seeing more than 500 physician visits a year, you're probably being exposed to a lot of diagnostic and therapeutic interventions which are doing more harm than good, so by forcing these people, this tiny subset of people, to stick to one doctor, they saved a lot of money and I think these people got much better care too. That's something that could certainly be tried here in Ontario, and if it's successful it could be expanded to some extent. It would be in the public interest and it would be in the interests of the patients.
As we look at the legislation that's before us, one point, on page 112 of your book in section 7, where it says "Classes," I'll read into the record. It says, "A regulation may create different classes of persons, facilities, accounts or payments and may establish different entitlements for or relating to each class or impose different requirements, conditions or restrictions on or relating to each class" of person.
I wonder, are some animals going to be more equal than others when you're finished? Why are you creating separate classes of persons? What's the intent of this legislation? Perhaps you could tell us, why are you putting this in here? This seems to be something that will divide and fracture the population of Ontario. I know we have the class of persons who are covered by workers' compensation, but I wonder, are there other classes you have in mind who perhaps deserve a higher or lower degree of access to care? Perhaps you can comment on that during the question section.
A major concern to the physicians which Len alluded to is uncertainty about chargebacks for the costs of tests, referrals and medications. As I understand it, there will be no hearing, no right of appeal and, the most dangerous of all, the minister's opinion is law. Since the Magna Carta almost 1,000 years ago, a basic principle has been that the law must be knowable; it must be published so that we can read and follow the law. In this case, the law is whatever the minister says it is, from time to time. I don't know what's in the mind of the minister today and I have no way of knowing what will be in the mind of some future minister, but I'm liable. If that minister decides that a certain set of procedures or investigations was unwarranted, even though they might have been ordered in good faith and for good reasons, I can be, as I understand it, required to pay back thousands of dollars, and interest and legal costs.
Now, my take-home pay for seeing a follow-up patient, after taxes and expenses, is around $5.50. In the course of that visit I might, in good faith, order thousands of dollars worth of investigations, medications and referrals for a certain patient. For the $5.50 I am being paid, I can't really afford to expose myself and my family to the open-ended financial risks that this legislation may create, and other doctors can't afford that degree of risk in addition to the risks that we already accept and face. In some cases, it may be necessary for the patient to get prior authorization from some micro-manager in the government before they can find a physician willing to order investigations or treatments. In other cases, the patient may be required to agree to be personally responsible for the costs of any investigations or treatments which the minister subsequently decides not to pay for, because I simply can't accept that risk.
Because emergency physicians do not have the opportunity to obtain prior authorization from the government, and they may not be able to negotiate "hold harmless" agreements with the patients in the emergency room, it may be necessary for hospitals to agree to be responsible for any costs which the minister tries to recapture at some point in the future, or it may be very difficult for them to recruit emergency physicians. Again, the emergency physicians may not be willing to accept the risks that are associated with practising in this environment in the absence of those guarantees.
Moving on to a different subject, reduced availability of hospital resources has increased and will continue to increase the demand for and the complexity of outpatient medicine. One of the flies in the ointment here is that walk-in clinics, in particular those which are staffed by doctors who are not on staff at the local hospital and who are not members of the local community, may be consuming resources out of proportion to the incremental benefit of the services that they're rendering. Of particular concern to the hardworking family doctors in our community is that these walk-in clinics, by skimming off the quick, easy, lucrative work, are leaving the proper family doctors with an increasing concentration of difficult, complex, poorly paid work, caring for people who have chronic problems, caring for hospital and nursing home patients and doing unpaid work on hospital and community committees. Virtually every physician who is a member of the hospital staff does unpaid work to keep the hospital functioning, sitting on tissue committees and medical record committees and other things.
Reduced prices for services will, to some extent, limit the availability of those services. Caps on incomes may also reduce the availability of certain services, and the combined effect of these two things may make it very difficult for the most demanding patients, the ones with the most complex and difficult problems, to get the kind of care they need. So if you could do a little bit to help give the OMA the tools it needs to rein in the walk-in clinics and perhaps the house call services and the GP psychotherapists and a few other things, that might go a long way towards solving your problem and improving the bottom line for the health care consumer, giving the people of Ontario better care, less fragmented care.
Another suggestion which has come forward from a number of the family doctors and other physicians whom I've spoken with, and which would be very useful in my personal practice, would be if you would put in place an information system which would contain the laboratory results and prescriptions which have been given to the patients. If this information were available, it would provide you with an excellent statistical database and it would increase the efficiency and quality of care. I could simply swipe the patient's card into my computer, find out what tests have already been done, what medications they've had. It might also give me a sense for, "Well, gee, you've seen four other dermatologists in the last three weeks; what's going on here?" or, "You've seen 14 doctors in the last two months."
That would change the complexion of the dealing with the patient and it might, again, help to limit wastage. Instead of my having to order redundant tests or repeat something someone has already done and have the patient back in two weeks, I could see what's been done, I might be able to give them better care quicker, reduce the number of follow-up visits and reduce the number of needle pokes and other investigations. Okay?
Another advantage there is that part of the cost of setting up such a system might be recaptured by selling the system to other provinces and in other countries. It seems like an idea whose time has come, and we have the computer expertise. We have the people here in Ontario who could build and maintain that kind of system and sell that kind of system. Places like the University of Waterloo and some our major software developers, I'm sure, could make a major contribution.
The laboratories are largely computerized already and they're already in the process of feeding this information over computer networks to the physicians. It wouldn't be a big step for you to make a central database of all this information so that it would be readily available throughout the province. If somebody had a heart attack in Ottawa and they were from Niagara Falls, their medications and lab records would be available instantly. It could be a big advantage; it could be a life-saver in some cases, avoiding drug interactions and providing higher quality treatment at lower cost to you. We'd all be happy.
Finally, I'm uncomfortable sitting here publicly chastising and correcting a government which in many ways I support. The public interest is not served by the ill-considered proposals in Bill 26, and much of this unpleasantness could have been easily prevented if the ministry had consulted with the OMA or with any physicians. You could have rounded up the people at this table and we could have probably told you most of what you need to know. We would have been happy to point out some of the more glaring problems in private and so expedite the changes to the health care system which the people of Ontario, through their elected representatives, have decided are necessary and which I think we all agree are to some extent necessary and desirable.
I should at the beginning state the obvious, which is, on some things we hold a different position, particularly with respect to opening the system for those who choose to pay to get quicker service and user fees, and I think we know those discussions --
On the other hand, I'd like to say that many of the concerns that you raise with respect to this legislation I share with you, and I believe that some of the changes that the OMA is looking for are ones that I and my colleagues would be able to support as we go through the amendment process.
I do want to ask you some specifics about the legislation, but let me touch on a couple of things that I have heard OMA representatives say, which I think is an evolution in the thinking of the OMA or in the preparedness to deal in different ways with some issues.
I have heard representatives of the OMA say that you are prepared to deal with differential fees to look at resolving the issue of maldistribution of practitioners, as opposed to a billing fee restriction approach that is being talked about. I've heard you, Dr Smith, and others talk about being willing to deal with walk-in clinics, and I welcome that. I would say a couple of years ago -- it was more than that when I was Health minister and wanted to deal with walk-in clinics -- that wasn't the position then. But then we were doing other things the doctors didn't agree with, and that's always the case, the to and fro in negotiations, so that might have just been at the moment.
Those are important changes, I believe, and if I've heard those correctly, I think that indicates, much like we've heard from many other people in the health care system, that doctors are also supportive of and understanding of the health reform that is taking place and that is required to take place and, within the publicly funded system we currently have, the need for those resources to be used in a wiser way.
I say that just to get a quick response from you to make sure I haven't misread some of those things, and because the government needs to hear that you are in fact willing partners in health care reform and restructuring and not just defenders of the status quo, which is what they seem to accuse people of if they oppose the government's measures in this bill.
Dr Makerewich: I think that's a fair understanding. We're willing partners in the entire situation. There's more to be gained here by cooperation than there is to be in confrontation, but let me make it very clear: Beds are being closed and doctors are heading for the border. There is a problem. What's out there now isn't working, and there's a reason it isn't working, but let's agree to disagree.
Ms Lankin: The question is, will the proposals in this bill make it better then? If you've got problems with what's there now, will this make it better? I've heard very clearly from doctors that, no, it won't.
I have questions in a number of areas. Let me just start, though. Dr Smith, you raised a regulation-making power under the Health Insurance Act relating to different classes of persons and facilities and different classes of accounts or payments. I'm not sure exactly what that means, and that's not something that's been touched on in depth in the presentations thus far. I don't know if you have any response. I know you asked the question, but have you any thoughts of what that means?
And let me ask you, given that the government is eliminating the role of the OMA as a negotiating body and is going to move to unilateral setting of tariffs under the health insurance scheme, and has indicated that it will negotiate with individual doctors or groups or classes of physicians, does this reference to classes of payments mean that we could see differential payments being unilaterally set as a result of one-off talks as opposed to negotiations with the OMA? I don't know; I'm asking.
Dr Smith: I think the government is building itself the best possible toolbox. They're acquiring every possible power. Whether or not they're going to proclaim these pieces of legislation is another issue entirely, and what happens in the regulation-writing stage is going to have a lot of bearing on that. But I was just struck by the reference to different classes of persons. I thought that was a bit strange, and I find that a little worrying. I thought we were all the same and we're all equal, but now some animals are going to be more equal than others maybe.
Ms Lankin: One aspect that concerns me greatly is the process by which the government can revoke hospital privileges for doctors, particularly given that it is restricting access to a billing number to those who have a relationship with a hospital or a facility. I have a problem with that to begin with, but if that's the case and your hospital privileges can be unilaterally revoked and there is no appeal, many doctors have said that really means their role as patient advocates within the hospital system will be -- not challenged, but they will feel threatened to provide patient advocacy for their own area of specialty of practice and/or budget areas of the hospital.
There's been one amendment that has been made which actually narrows the application of this right to revoke privileges without appeal, and now it's clear that the government intends that to be the case in hospital closures and/or ceasing to provide services.
But I ask you, if you're a troublemaker doctor in terms of being an advocate for your patients and the service happens to be being rationalized over to another hospital, what right do you have to follow your patients with that service to the hospital, without a right of appeal? Does this fix the problem that your profession has identified for us through the earlier weeks of hearings?
Dr Smith: It narrows the scope of the problem considerably, but it's important for physicians who find their hospital closing or find their department closing that they and their patients can move to a different hospital. It's not just a case of the doctor being able to set up shop at a nearby hospital, but his patients also need to have access to that hospital. We may see that a little bit in some regions where people will say: "Well, this is the Niagara Falls hospital. Our taxes are paying for it, our donations paid for the CT scan. We don't want those folks from all around the countryside coming in here and consuming our resources."
I don't think that's the way that health care should evolve here in Ontario. I want the physician and the physician's patients to be able to move to another facility within a reasonable distance, and there's no provision for that and there's no mechanism for that. I think the addition of that by way of an amendment would be very helpful, both from the point of view of the physicians and also from the point of view of the patients of the physicians who are being affected.
Dr Makerewich: Could I make a comment too? You said earlier that the government then would have the unilateral right to restrict privileges and close down and so forth, and also to negotiate with different classes or different people or different physicians. The example was given of the obstetricians. The obstetricians had a meeting and are willing to tell government or anybody else to get stuffed. You either talk to us all or you don't talk to us at all. That's one point.
This is, "We will dictate, we will dictate, we will dictate." You're assuming that doctors are going to continue to obey the law. We've been held hostage by legislatures on three occasions in the past, starting with the Canada Health Act. You're assuming that physicians are going to continue to obey the law. We're that far away from starting civil disobedience.
Mrs Johns: I'd like to thank you for your presentation today. Unlike Ms Lankin, and that's probably because she's been in the health field a lot longer than me, I'm somewhat confused by the OMA presentations over the last few days. She's got a vision that things are continuing on the same line, that you're saying the same things every day. I'm having trouble with that, so I just need to check a couple of things and go back to a presenter we had yesterday.
Dr Makerewich: I'm not sure of the relevance of the question. How do you mean? Do you mean in terms of fees? Each of us has our eight hours working and some of us share on-call responsibilities and some of us do shift work in the emergency department and voluntarily will cover a 4-to-12 shift or a midnight shift or whatever else. I think we all work pretty hard.
In this community here in Niagara Falls we have a very inadequate supply of family doctors. It's the same in St Catharines. It's very hard for many people to find family doctors, yet within the last year two walk-in clinics have set up in this community which are staffed by physicians from out of town. They work their hours doing the light cases with low acuity, high volume, and cases which need more work -- the mentally ill, the geriatric folk, people who are dying at home and need house calls, are seen by the rest of us. If the government is wanting a way to weed out walk-in clinic problems, then for urban centres like Toronto the simple way, in my estimation, would be to say walk-in clinic doctors who don't have hospital privileges don't get paid.
Mrs Johns: I guess I didn't do a good of it last time, but I came through that part of it and I understand what you were saying. The Scott report suggests there should be a different fee schedule in different areas, given the fact that they provide different services, if you will, and suggests that would entice doctors to rural and northern areas. What I heard yesterday from the OMA was that that is one of the processes they would recommend. The minister has asked that all presenters give us their opinion so we can try and resolve this problem. Have you an opinion on whether they deserve that differentiated fee and if the OMA will be offering that?
Dr Nicholson: Absolutely. I can't speak for the OMA, but it certainly has been discussed within the OMA and it has been agreed upon that it is much better to entice doctors with carrots than to beat them with sticks, and if you pay enough money as a premium to get people up to the north or an underserviced area, you will get people.
Dr Nicholson: The whole question of allocation is a different process altogether. At present, of course, the physicians are being asked to subsidize the expansion, on a year-to-year basis, of the system, and that's quite inequitable, so I don't think we can use the present system as a starting point. But the answer to your question, can more money affect the distribution of doctors, is yes, obviously.
Dr Smith: I'd like to introduce Dr Alison MacTavish, a family physician here in Niagara Falls, who has a very active obstetrics practice. She may be able to comment with respect to obstetrics in particular.
Mr Clement: If we have time, Mr Chair, sure. First of all, Dr Makerewich, I'm just going to raise something you said on page 2 of your brief, that if the government had talked to the OMA in private before, these public hearings would not be necessary. I think what you mean is that it would not be necessary in terms of the OMA's concerns but they still would be necessary for other people's concerns.
Dr Makerewich: Perhaps, but we as physicians are just absolutely shocked. What is trying to be accomplished here? The privacy and the confidentiality reek of a major physician fraud going on and I don't think that's the case.
I'm sorry, physicians are not unique. Everybody's angry at the government at this point. The teachers and labour unions and everybody else have been equally affected, so I don't think we have exclusive rights in that regard. When it comes down to it, many of the concerns here seem to have been -- we don't know where they came from. Did they come from faceless bureaucrats? Did they come from people who have had an axe to grind in the past? What is trying to be accomplished here?
We're supposed to have a tool box. The government says they want to have a tool box. What are they fixing? What do they need to fix? Why do they need the tools that they say they need to fix this? Isn't a handshake and cooperation and co-management the way to go?
Mr Clement: I'll do a preface, because there is some reference to what you have said as doctors. We've heard a number of times from a number of different doctor presenters about how you are really life givers, no question about it. But you're also business people. You have to run an office; you have to pay the bills.
Mr Clement: Sure, and you give something very important to the community but you have to do it in a context that makes sense for you as an individual, you as a family person, you as a practitioner. I think we all understand that.
Are we coming to the point that there is some inherent tension in the way we have constructed our health care system in Canada, which is, I would say, a unique system but it's not the only system in the world? Is there an inherent tension there between doctors as life givers? We would like to have that service available to everyone through a socialized system of some sort. It's not like British health care but it is something --
Mr Clement: That's right. Sorry, that's true, but national health in its original incarnation. We've got that on the one hand. We want those services. We want them available to everyone at any time of the day or night in every community. Is there an irreconcilability of that concept with the concept that we've tried to inject into our version of the health care system in Canada where doctors are not employees? That was the original incarnation. They're not employees. They provide a fee for service. Is there an irreconcilability there that you're sensing?
Dr Makerewich: With all the cutbacks that have occurred, I can assure you, sir, that doctors have been the only thing that has continued to make this system work. It would have collapsed years ago had we not gone the extra mile and done what we're doing now and not being paid for what we used to be paid for five years ago. It's not just about money. We love our work. We love serving our patients as well.
That seems to suggest to me that there is a bit of tension there. Maybe there always was and it was up to government to grapple with that inherent tension in the system to ensure that doctors felt a part of the system, that they felt they were not just employees of the state. But at the same time government had a mandate to provide as many services as possible in the health care field to as many people as possible as many times as possible.
Mr Makerewich: When medicare was introduced into Ontario -- and correct me if I'm wrong; I believe it was Mr Robarts -- I don't think he was a willing participant at the beginning, but when he finally got into this, I believe the term or phrase that was given to doctors was, "You practise medicine but just send us the bill." I think things have changed since then.
Mrs McLeod: One of the presentations began by suggesting that if there had been consultation with physicians before this bill was presented, we would not have the bill in front of us. It would be nice to think that might have been true. I think in fact it would not be true, because this bill is not about restructuring health care. There was no desire to seek rational and logical discussion about how we can manage to provide health care in the most cost-effective way. This bill is about cuts. It's about finding precisely $1.5 billion in cuts in health care and finding it as quickly as possible.
I respect that one of the solutions you offer as an alternative might be a charge to patients. It's not one I happen to agree with. I think you would find that even if that had been proposed before Bill 26, the government might have been reluctant to accept it. If in fact the government is prepared to go that route or would be prepared to go that route, I suggest that we step down and let them say that now, because we'll have a really good debate and they will indeed make news by the end of the day.
But I don't think they would go that route. Therefore, I think we're back to discussing how we can provide health care in a way that allows us to offer that health care, quality health care regardless of ability to pay, and to manage that even in difficult financial times.
The government's toolkit is what they've offered -- Bill 26. One thing they've done, they will continue to delist but they will set physicians' fees at zero -- delisting by another name -- and there will not be consultation with the OMA. We've seen the evidence of that.
One of the other tools, and there are many of them in here, is not just to take away the ability to appeal if you have been denied payment for a service rendered, but in fact for the government to prescribe the conditions under which health care can be provided, to prescribe what's medically necessary and at what terms and conditions.
I would ask you how comfortable you are with those kinds of powers being exercised by a government whose goal is to make cuts, to find savings in the system, and whether you think the government can exercise a judgement after the fact about what was medically necessary, and what that does to your clinical judgement when you're in the office with a patient.
Dr Smith: This could amount to Mike Harris's Vietnam. If he picks 20,000 fights with 20,000 doctors, they're going to bog down so fast that it'll be a nightmare for them. It's just not a practical approach. I have trouble micromanaging myself. I'm managing my practice, one doctor. It's tough. You try to manage 20,000 of us and you're going to have more headaches than you know what to do with.
Dr Reddy: I answered that question. This is a very objectionable part of the legislation. It is totally inequitable, the ministry giving us the guidelines for treatment, our clinical conditions, where and what to treat.
Dr Makerewich: Could I make a comment as well? You asked for a level of comfort. I think our presence here bespeaks that, otherwise we wouldn't be here sharing this lovely time with you. I'm sure you're tired just like we are.
We all keep talking about preserving the system. I'm sorry there are shrinking finances; I'm sorry we have a federal problem, we have a provincial problem. There are decreasing funds. The bankers are starting to call their loans and get very worried about how we're going to manage economically and whether our Canadian dollar is going to collapse or not.
We've got to do something about the deficit. There's no problem in that way, from physicians certainly, but I think for us to continue the dream and the social experiment of the Canada Health Act, and what T.C. Douglas and Emmett Hall started, I'm sorry, but you have to look at the experiences elsewhere in different countries and see how they've dealt with it. They've had different solutions as well. I'm sure we're going to agree to disagree, but the way it's going now I see nothing but a slope downwards.
What is your end point in terms of rationalizing the efficiency of the system as the feds continue to cut back? What is the end point? Where do we stop before people say: "Finally we've gotten as efficient as we can. We can't afford any more"? Unless we start injecting some private money into the system and making patients more accountable -- there is terrific patient abuse out there. Just talk to any emergency physician who has somebody come in looking for some aspirins because it's cheaper to come to emergency than to go to a drugstore and buy some. There's terrific abuse out there. I can assure you that it's not the doctors who are abusing the system, but there is a problem and we'd like to help.
Mrs McLeod: There's no question that there's a challenge to be able to preserve a system that we consider to be at this point in time one of the best in the world, and the challenge could only be met in a collaborative way.
Mr Bradley: Speaking of borrowed money, I see on page 2 of your brief, "Doctors...fully support the fiscal objectives of the Harris government to reduce and eventually eliminate the deficit." Are you aware that this government, while they're cutting health care services, intends to borrow $20 billion more over the next five years, paying $5 billion in additional interest to give you and me a 30% tax break?
Mr Bradley: -- additional dollars, in order to finance a tax cut. Do you think that is as productive a use of the finances of this province as either addressing the deficit or reducing the cuts to the health care system?
Mr Bradley: I appreciate that answer. It is something I'm hearing more and more, even from people who, as you point out here, in many ways support the thrust of the present government of Ontario. When they find out that the government is going to have to borrow money -- add to the debt -- to be able to give you and me a tax break, they often say, "I would either like you to address the deficit or I would like you to not cut as deeply in our health care system." Comment?
Dr Makerewich: We all have problems with the debt. I have problems with this so-called beautiful Canadian universal access system that was financed by our grandchildren and our great-grandchildren. That's fiscal reality for you.
Dr Reddy: Certainly what you said, that they have to borrow the money to pay the tax refunds, we were at least not aware of this fact. I think this is a matter of concern, as I see it. Certainly, we would like to see deficits reduced, but not with borrowed money to pay a tax refunds. This needs further clarification by the present government, I suppose.
Mrs Caplan: I'd like to address the Americanization aspect of Bill 26. You compared, I thought very accurately in your presentation, the fact that the United States spends 14% of their gross domestic product; we spend 10%. The United States is categorized by insurance companies that have managed-care organizations, fee-for-service. They also have copayment, user fees, deductibles, and patients pay if they have money; if they don't, they either don't get service or they go to emergency. That's one of the reasons it's so wildly expensive there.
One of the features of the American system that I'm very concerned about that Bill 26 will permit, and I'm not sure that we really are aware of the implications -- Dr Reddy, your initial presentation I think alerts us to that -- is that in this bill the cabinet defines "medical necessity"; the minister has the power to share patient records and information and the additional powers allow them to come in after the fact to say that they will not pay for anything that wasn't "medically necessary."
All those features are features of American managed-care organizations that require advanced approval before you do anything. "We don't pay you if you didn't get advanced approval or if we deem it wasn't medically necessary," is American managed care. They determine what is "medically necessary." They have to share information in order to be able to do that and there's a 1-800 number that you call to get that advance directive. It's exactly the take that my colleague Ms Pupatello addressed. There's actually an article from the New York Times, and I read this quote in that says, "They're basically moving to a US managed-care model." Who said this? Peter Coyte, professor of health administration from the University of Toronto. A spokesman from the ministry confirmed and said, "Some very basic management is finally being incorporated into the way we're spending our money."
Dr Makerewich: I have a unique perspective. I'm New York state licensed and I practise in the United States as well as in Canada. I've seen the system over there and I also know that the CEOs of some of these HMOs are making $3 million and $4 million a year. It's a for-profit system, thank you. Yes, I've been through the billing restrictions and I've seen a lot of that. I'm still practising in Canada. I love this country, I choose to stay here, but I have a foot in the door over there and I practise in both places right now because I happen to live in a border town. None the less, I'm not sure about that comparison to a managed-care system. I don't think there's anybody in the government who's going to be making $3 million or $4 million a year. I think that's a very unique way of looking at that situation.
The way that the American system works now is the competition, the overpopulation of doctors, is so much that physicians, number one, are bound by anti-trust legislation. They can't even talk to each other over there; it's illegal. They can't form an OMA over there. They have an American Medical Association, they have a New York State Medical Society, but for them to talk about fees is illegal. If a lawyer found out about that, they could be in big trouble. Even just talking about fees is anti-trust.
Secondly, if they don't take the fees, then there are four others behind them who will take less and less and less. They're at each other's throats there. Physician competition there is very keen and it's responsible for the fees ratcheting down over there. There have been major, major cuts in fees in the American system, and I'm seeing that over there now. In fact, I've offered some of my colleagues jobs in Canada if things get too tough.