ROY ROMANOW SPEECH TO THE COOPERATORS APRIL 15, 2003 HALIFAX, NOVA
SCOTIA
Speech for The Cooperators

Halifax

April 15, 2003

I am very pleased to be here with you. I am pleased to have the
opportunity to talk about the future of our health care system. It's
also nice to be with friends who understand the power of cooperation
and the creative expression of its principles in community based
cooperatives and entrepreneurial business versions as well. And
frankly, given the chaotic world in which we live, I am pleased to be
anywhere!

It's been just over 4 months since my final report was submitted, and
just over 2 months since Canada's First Ministers came together to
achieve the landmark 2003 Health Accord.

I must say that I take no small amount of pride in the fact that First
Ministers agreed to act as quickly as they did to give effect to many
of the key recommendations included in my Commission's Final Report.

Pride, not because the Accord's proposed directions are a vindication
of what I recommended; after all, even a cursory review of the myriad
of recent task force and special committee reports on the future of
health care will reveal broad consensus already existed on most key
issues. Rather, pride because First Ministers clearly listened to
Canadians' urgent plea for fundamental changes to the health care
system and for governments to work collaboratively to strengthen it.

Indeed, I referred to the Health Accord as a landmark for a number of
reasons.

First, the first ministers have publicly confirmed their commitment to
the five principles of the Canada Health Act.

Second, they recognized that reform and new public investments are
required to meet Canadians' desire for a sustainable health care system
that provides timely access to quality health services.

Third, they took a solid first step toward reform by not only reaching
consensus on a number of targets and objectives for improving the
health care system, they also agreed to report publicly on their
individual and collective progress in meeting them.

Fourth, they accepted the imperative to improve transparency and
accountability of Canada's health care system.

Fifth, they recognized the urgent need to better monitor population
health and to address health disparities by directing Health Ministers
to "continue to work on healthy living strategies and other initiatives
to reduce disparities in health status."

Last, and perhaps most significantly, they agreed to work
collaboratively with each other, with providers and with Canadians, in
shaping systems future, by agreeing to the creation of a Health Council
of Canada. I'll have more to say on this issue shortly.

These are not insignificant achievements, and First Ministers deserve
credit for their efforts, for their flexibility and for their
leadership.

Over the past number of weeks, I have made a number of presentations in
which I commented on specific aspects of the Accord. Let me briefly
summarize the gist of my comments. I will then outline for you what I
believe to be the critical next steps on the journey toward reform.

In doing so, I will focus specifically on the need for a strong and
effective health Council of Canada.

The 2003 Health Accord

In addition to the points I have already covered, there is much to
commend the 2003 Health Accord.

For example, Canadians should be pleased that First Ministers agreed to
embrace a reform agenda that goes beyond a simple focus on hospitals
and physician services. The ambitious and explicit targets that have
been established for ensuring 24/7 access by Canadians to frontline
primary health care is an important and positive development.

Canadians should also welcome the collective commitment by First
Ministers to set certain national objectives in regard to home care,
especially for community mental health services.

This is a praiseworthy step forward, as is the recognition by First
Ministers of the need for action to provide catastrophic prescription
drug coverage for Canadians and the decision to allocate $1.3 billion
for First Nations health.

Finally, the agreement to replace the Canada Health & Social Transfer
with a dedicated Canada Health Transfer will improve transparency and
accountability in regard to what each level of government is
contributing to the health care system.

However, I also have some fairly strong views in relation to the
adequacy of the dollars on the table and where and how they will be
spent to improve and strengthen the health care system for all
Canadians.

Make no mistake: there is a lot of taxpayer money on the table in the
current Accord. Depending on the assumptions used - and I don't care to
get drawn into sterile debates over what constitutes "new" and "old
money" - there si somewhere between $30 and $34.8 billion at stake over
the next several years.

But I have 4 major concerns with the dollars.

First, there is less money than what the Premiers were seeking, less
money than what the Senate Committee report suggested was necessary,
less money than what my own Commission recommended and, most
importantly, less money than is needed for the federal government to
contribute its historical federal share of the medicare bargain.

Second, while First Ministers accepted allocating some $16 billion over
the next 5 years to a Health Reform Fund, there are still too few
details available to know what the Health Reform Fund will actually
achieve, what conditions, if any, will apply, or what criteria will be
used to evaluate its effectiveness.

I have similar concerns about the immediate $2.5 billion top-up that
has been agreed to, ostensibly for assisting provinces to address
urgent priorities-like reducing waitlists and improving timely access
to care, especially advanced diagnostic services. If the $2.5 billion
is spent wisely and according to a coherent plan, it can make a
positive difference.

However, unless the federal government is prepared to step up to the
plate, the only real guarantee that the additional $2.5 billion monies
will in fact be devoted to health care will be hard public scrutiny.

Third, much of the money available within the Health Reform Fund will
be back-loaded, and this will delay urgently needed reforms in a number
of areas.

For example, my report recommended an additional $3.5 billion in
federal health funding in 2003/2004 and a further $5 billion in
2004/2005- all of it specifically targeted in 5 priority areas to
kick-start the process of transforming the system.

Thats $8.5 billion over 2 years, all targeted toward change.
Thereafter, federal funding would be fixed at 25% of provincial
CHA-related spending. Under the Health Reform Fund, less than $1
billion will be available in Year 1 for transforming the system, and
funding increases will only rise gradually thereafter. This doesnt mean
change will not occur, only that it will occur more slowly than would,
in my view, be desirable.

Last, the inability of First Ministers to agree on a method for
financing health care that results in stable, predictable funding that
supports long-term planning, is frankly disappointing.

The Path Ahead

I do not want my comments to be construed as damning the Accord with
faint praise. As a former Premier, I can personally attest to how
difficult and politically fraught the federal-provincial arena can be.
The Health Accord is, I repeat, a landmark achievement that provides a
strong foundation for revitalizing our health care system. It is a
strong step forward, not a step back.

Now, as you know, there is no shortage of areas in our health care
system where we can do better:

     We need to better coordinate and support the expansion and
alignment of health professionals and of our health infrastructure,
making sure plans in all jurisdictions can keep in step with patient
needs and expectations.

     We need to much more to make timely access to quality care for
all Canadians a reality.

     We need to focus more on preventing chronic diseases and invest
more in population health and wellness initiatives that make the system
more sustainable and that promote self-reliance.

     We need to upgrade our national capacity in health research,
especially as it applies to population health, and in applied health
informatics.

     We need more collaborative initiatives, like the Common Drug
Review process that came on stream earlier this year, to help us to get
a handle on containing rising drug costs. And we need to ensure we have
a regulatory system that is more responsive to public policy
imperatives for safety, affordability, security of supply, ethical
standards and competitiveness.

However, I believe that only limited progress can be made in tackling
these problems anywhere in this country in the absence of a coherent
and coordinated national plan of action. This presupposes that the
conditions exist for the federal and provincial governments to move
forward together.

We are getting much closer, as the restraint exhibited by First
Ministers throughout the meetings leading up to the Health Accord
indicates, but we are not there yet.

To make headway on this problem, I believe we must continue to make
progress in three key areas.

First, I believe we must change the way we finance our health care
system, not just to provide the necessary stability, but to reduce the
unproductive tensions between the Federal government and the provinces.

Second, I believe we need to modernize the Canada Health Act to reflect
the reality of how health care is delivered in Canada today.

Last, we need to establish an effective Health Council of Canada to
make the health system more accountable to taxpayers and to give
patients and providers a stronger voice and a greater say in shaping
its future directions. Permit me to summarize my views:

Permit me to summarize my views:
Funding the Health System & the CHA

In my final report, I recommended that by 2005/06, the federal
government cover a minimum of 25% of provincial health spending for CHA
expenditures and that this be provided in the form of a dedicated
cash-only transfer. I also proposed an escalator clause within the
transfer to allow the federal share of health spending to track
inflation and adapt to changing patterns of provincial health care
spending.

Taking account of tax points that were permanently transferred to the
provinces in 1977, the 25% cash transfer would restore the federal
governments share of CHA-covered health spending to historic levels.

What would this new funding mechanism achieve? For one thing, it would
remove an ongoing irritant from the already volatile inter-governmental
relations mix, while simultaneously improving transparency and
accountability. The federal and provincial governments would be working
from the same numbers, and they would not be continually negotiating
the size or growth of the federal transfer.

In short, the result would be a more positive federal-provincial
dynamic and adequate, stable and predictable funding for the system.

I also linked the 25% federal funding floor by 2005-2006 to targeted
funding in a number of specific areas over the next two fiscal years.

The targeted funding was to focus on addressing key short-term
priorities of Canadians, such as improving timely access to care and to
advanced diagnostic services. It was also intended to "kick-start" the
revitalization of Medicare by providing federal funding to support home
care and prescription drug treatment as integral components of a modern
health care system.

To entrench these changes, I also recommended that the Canada Health
Act be amended to include priority home care services and, over time,
prescription drug coverage. In my view, this would acknowledge that
health care today is more than just about doctors and hospitals.

Keeping in mind that prescription drug coverage and homecare are the
fastest growth areas of health care spending, this would also ensure
the federal government was financially responsible for paying its share
of the system's expansion.

I do want to clarify that my preference for a fixed federal funding
floor does not mean carte blanche for provinces to spend health dollars
as they see fit. I absolutely recognize that under our constitution,
provinces have primary jurisdiction for health care.

But they do not have exclusive jurisdiction, and the federal government
has a legitimate and constitutionally recognized national interest
responsibility for ensuring the integrity and effectiveness of the
system. The need to encourage and facilitate coordinated action to
reduce health disparities among the poor and our First Nations is only
one example.

Should the funding approach outlined in my report be accepted, it will
make all the more important the need for an inclusive, objective and
effective Health Council of Canada.
A Health Council of Canada

One of the real barriers to improved cooperation and coordination in
our health care system is that the different levels of government, and
sometimes different provincial governments, begin from very different
starting points on simple issues of fact.

Hence, my report suggested the creation of a Health Council of Canada
whose membership would be broadly reflective of the various interests
at play in health care: patients, providers and officials.

Its main purposes would be to provide clear, accurate, and transparent
information to the public and the providers regarding both expenditures
and results and to promote collaboration among governments.

This would incorporate the following features:

     It would being together, under a single roof, a number of
existing federal and provincial advisory structures and agencies and
provide an objective and neutral forum whose expertise governments
could draw upon as required for support.

     It would give patients and providers a more direct say in how the
system operates and the means to monitor its performance.

     It would serve as a focal point for gathering health information,
for setting common health data and informatics standards, and for
interpreting and reporting to Canadians on health outcomes.

     And in time, as trust was gradually built, the Council would
become a trusted source of advice for governments on how best to
discharge their individual and collective responsibilities for the
system and assist in fact-finding and in resolving disputes over
interpretation of the Canada Health Act.

I note that the 2003 Health Accord commits governments to establish a
Health Council of Canada by May 5, 2003. Obviously, the Councils
eventual terms-of-reference and governance structure, and the autonomy
and quality of those selected to serve on it, will determine its
effectiveness.

I remain hopeful that the First Ministers will create an effective,
inclusive and independent Health Council that will do more than just
focus narrowly on the implementation of the Accord.

Many experts, and Canadians generally, will be watching carefully in
hope that the eventual Council has the mandate, resources, independence
and leadership it requires to make a positive difference and to
influence the future direction of health care in Canada.
Conclusion

The 18 months I spent as Commissioner were among the most exciting,
challenging and rewarding of my public life.

The process renewed my faith in Canadians, in their maturity, in their
capacity to understand and make tough choices, and in the common values
that unite us as a country.

I believe absolutely that we can make our health care system the best
in the world if we are prepared to heed the advice of Canadians and to
respect their wishes. And I believe that the Health Accord is a good
starting point for getting there.

Before I conclude, I would like to note that, while our health care
system will always be central to ensuring a healthy population, it is
also important for us to remember that it is not the only factor.

Income, the quality of our air and water, early childhood education and
development opportunities, the security and availability of affordable
and nutritious food, adequate shelter, and recreation, are among the
other critically important determinants of the health outcomes we seek
as individuals and as a nation.

If we reform and stabilize our health care system but neglect these
other factors, we will not achieve our health goals nor will we be cost
effective.

Our vision of becoming the healthiest nation on Earth requires a
coherent and integrated approach.

Permit me one final observation... this time not as a former Health
Commissioner, but as an individual with a profound respect for
democratic institutions and processes and a deep love of this wonderful
country.

It will be for political scientists and historians to assess the
significance of that remarkable six-month period last year when
Canadians came out in massive numbers to participate in the debate over
the future of their health care system. When they came out to try and
make a difference.

I don't think anyone ever expected- I certainly didn't- that our
processes would have so galvanizing an effect.

I'm acutely aware that over the past decade, public opinion polls have
ranked health care the foremost issue for Canadians.

I know too that the extent of what I would characterize as "health
literacy" among ordinary citizens was one of the most eye-opening
aspects of our consultations.

And yet now, in the aftermath, when I reflect upon all that I heard,
and all that I learned, I am left with a clear sense that it was not
just health care people were talking about when they came to our
meetings, or wrote, or e-mailed or called to share their views. It was
also the health of our political institutions and of our democracy.

I think that a fair number Canadians saw in our consultations an
opportunity to participate in a direct way in the democratic process.
That their contributions could make a difference.

That for once, they were not powerless. That the demise of a program to
which they were profoundly attached, and which appeared under threat,
was not necessarily a foregone conclusion.

I am proud and relieved that through the Health Accord, Canada's First
Ministers chose to respect the wishes of Canadians.

To be sure, there is still some distance to travel before we achieve
the type of health care system Canadians expect and deserve.  But we
are certainly a lot closer to our destination today than we have been
for some time and I am more convinced than ever that it is within our
reach.

The vision is clear, the pathway set. All we need to move ahead is
uncommon cooperation and you folks know all about that.

Thank you.

~~~~~~~~~~~~~

NOW'S THE TIME TO STAND UP FOR MEDICARE, SAYS ROY ROMANOW FOLLOWING
COURT RULING (JUNE 10)
Now's the Time to Stand Up for Medicare
By Roy Romanow

Op-ed Published in Globe and Mail, June 10, 2005

Canadians should be optimistic that the nation-building values of
Canada's public health system were reaffirmed by yesterday's
Supreme Court ruling, with all of the court's contributing members
recognizing the need to maintain the integrity of our public medicare
plan.

That said, the decision certainly creates the appearance that the slide
to privatization has increased in the province of Quebec. It is also
fair to say that evidence of creeping commercialization is showing up
in other parts of our country as well.

All of this means that the not-for-profit debate that has been around
since the beginning of medicare has picked up impetus once again.

There are those who have already seized on aspects of the court's
decision to claim victory for selling something old as something new.
They advocate for a return to pre-medicare days and, with their strong
advocacy for a pure market approach to health care, they have gleefully
proclaimed the death of medicare just has they have done in the past.

Not so fast.

The evidence is overwhelming and clear: The two-tiering of health care
represents a march backward in time, to when good health care depended
on the size of one's wallet - to a situation like that which
currently prevails in the United States, where last year, more than 50
per cent of all personal bankruptcies were due to health care expenses.
They just eliminated 25,000 jobs in the United States, largely due to
the company's burden of health-care costs.

Cherry-picking great examples of American health care practices while
ignoring the millions of the uninsured who get sick just worrying about
getting sick does not make the case.   It is a false economy to
advocate for transferring the costs of health care from the public
purse to the private purse.  We will pay one way or the other.

The simple fact is that the yearly percentage of GDP spent on total
health care in Canada is at about 9.6 per cent as compared to nearly 15
per cent the United States.  That's more spending in the United
States, yet the result is less coverage and worse health outcomes.

Because the U.S. model is so unacceptable to Canadians, modern day
advocates of privatization are now cherry-picking various bits and
pieces from Europe.  But their concocting European/Canadian hybrids as
just the latest Trojan Horse for treating health care as a commodity.

The Supreme Court has provided a wakeup call to all of us, especially
those charged with fixing our single-tier medicare program.  This
judgment must serve to hasten the progress of real reform.  As a result
of last September's first ministers' health-care deal, money is no
longer an excuse.

Many elected officials say "they are standing up for medicare".
They understand the clear evidence regarding the cost-effectiveness of
a "public good" approach over the "market" alternative. And
perhaps some leaders also publicly extol the virtues of our single tier
approach because they know that's what an overwhelming number of
Canadians want.  Either way, the rhetoric must be backed up by more
urgent and tangible progress.

The blueprint for change is there - it's just waiting to be put
into practice.  But we must apply the entire blueprint: An integrated
approach is critical.  To take on the problem of wait times in an
isolated way without implementing reforms to primary and home care,
will not work over the long haul.

Dealing with some wait times may pay dividends, but other serious
problems, such as acute care, will keep popping up if an ad hoc style
rules over an integrated approach.  What's vital to real progress is
investing more money in health promotion, increasing the role of nurses
and other health professionals, and committing to the kind of rigorous
and transparent accountability that remains elusive.

Medicare needs fixing, not scrapping.  Canadians overwhelmingly favor
this approach over one (however disguised) that allows those with
wealth to purchase health care, draw off doctors from our universal
system and, at the same time, does nothing to reform, strengthen, and
sustain the system for all Canadians.

The progress and pace of health care reform will either prevent or fuel
a myriad of further court challenges. It will take strong, determined,
and visionary leadership to achieve a modernized medicare system, and
in doing so, a better nation.

This is one of those moments when Canadian people need to stand up for
medicare and declare that reports its death have been greatly
exaggerated.

Roy J. Romanow led the Commission on the Future of Health Care in
Canada and is an Economic Justice Award Recipient of the Atkinson
Charitable Foundation.