Canadians with cancer, heart disease, diabetes and just about every other physical illness don’t think twice about going to their doctor for help. But, when it comes to mental illness just one in three affected adults and as few as one in four children seek and receive treatment.

For some, stigma and fear keep them from getting the medical care they need. Others desperately want treatment but can’t find the appropriate services in their community or face long waitlists. This is why Prime Minister Stephen Harper has called mental illness “a major national public health problem” and, in 2007, created a national agency to tackle it.

This week, the Mental Health Commission of Canada released its blueprint for a national strategy to properly treat and support Canadians with mental illness. The comprehensive document covers every aspect of what needs to change – from how employers and schools handle mental illness to the need for more affordable housing and a reformed justice system that doesn’t criminalize illness.

The danger now, though, is that rather than embracing the challenge, Harper may throw up his hands at the enormity of it all – and the seemingly high price-tag that comes with it. That can’t be allowed to happen. The status quo is not an option when one Canadian in five suffers some form of mental illness every year and it costs our economy more than $50 billion, according to the commission.

If Ottawa needs a manageable place to begin improving the lives of Canadians, why not start with our kids? In many communities, children and youth face the greatest shortage of mental health services. Resources spent on children have enormous impact. Early identification and treatment can save young people from a lifetime of challenges that come with untreated mental illness.

Without proper health services and community support, childhood mental illness can stress families to the breaking point. Children drop out of school, wind up in homeless shelters or, worse still, the prison system. Crown wards and First Nations youth are particularly vulnerable to this downward spiral.

Focusing on children will also teach everyone involved about the extraordinary level of cooperation and coordination that is required. This is not just a health problem. The solutions cross federal-provincial boundaries and run across multiple ministries, including health, education, social services, housing and corrections.

Breaking down those silos will require strong federal leadership. That, unfortunately, is not something this Conservative government has shown much interest in, especially in the health care.

When Prime Minister Harper launched this commission he promised “their work will improve quality of life for Canadians and their families dealing with mental illness.”

Whether that happens depends on what his government does now. So far, it isn’t looking promising. Health Minister Leona Aglukkaq welcomed the report and committed the government – not to action, but to yet more research.

The 6.7 million Canadians suffering with a mental health problem or illness deserve better than that.

< http://www.thestar.com/opinion/editorials/article/1175149–focus-on-children-first-in-tackling-mental-heealth >

Having won the Alberta election, Premier Alison Redford is now setting her sights on providing leadership in establishing the national agenda on health-care reform. In doing so, she won’t be able to ignore the issue of patient wait times. Wildrose may have lost the election, but it did propose some ideas in this regard that are likely to remain front and centre on the political agenda.

An important one that will have life in Alberta and beyond is a Patient Wait Time Guarantee, which would have allowed Albertans on lengthy waiting lists to seek care from independent health providers in or out of province with provincial public insurance coverage. Allowing such coverage is not merely Wildrose election rhetoric – basic elements of a plan to allow greater flexibility in provincial insurance coverage of services received out of province were contained in a leaked confidential Alberta Health and Wellness planning document in 2010.

Would such practices be consistent with the Canada Health Act or would they trigger financial penalties for the province? On this hot-button issue in health-care reform, Ottawa needs to clarify its position.

To comply with the Canada Health Act – to which Wildrose stated a clear commitment – independent health providers in Alberta wouldn’t have been permitted to extra-bill patients. But reimbursement for services provided elsewhere would have been at the rate provided for in the provincial schedule; if provided out of country, the patient would pay the difference between the Alberta rate and the fee actually charged – otherwise known as extra-billing.

Though detractors will claim that this violates the “spirit” of the act, the CHA allows this practice on out-of-country treatments. At the same time, it grants discretion to, but does not require, the federal minister to levy penalties for such practices should the minister determine they impede reasonable access to services.

The case is less clear for services provided by independent facilities in another province. The Wildrose proposal didn’t extend its restriction on extra-billing to independent providers in other provinces. While the CHA says there must be deductions from federal cash transfers for extra-billing “by medical practitioners or dentists in the province,” it’s unclear as to whether extra-billing by providers in another province automatically requires federal penalties.

This lack of clarity creates another grey zone, subject to the discretion of the federal minister. The minister also has discretion to levy penalties for such practices where the minister determines that reasonable access is impeded.

Wildrose said it didn’t “advocate” extra-billing; but its Patient Wait Time Guarantee certainly would have allowed it in these specific instances. But, then again, so does the CHA – unless, of course, the federal minister exercises the discretion granted in the act to say it doesn’t.

Should provinces wish to pursue reforms, they shouldn’t be hampered politically by a lack of clarity regarding consistency with CHA criteria. Rather, they should be able to make such decisions – and be forced to defend them on their merits – with relative certainty regarding consistency (or lack thereof) with CHA criteria. To help provide such certainty and clarity, the federal government should stop avoiding these public debates and, instead, clearly and publicly state its position on issues such as the proposed Quebec health deductibles or terms for out-of-province care as they arise.

Paradoxically, this might well place the CHA on a firmer political footing. The bias against reform generated by a lack of clarity has contributed to the sense that the CHA places a straitjacket on reform, which has resulted in calls for its suspension or repeal. Greater clarity and expanded political latitude for reform might well dull such calls.

Moreover, to the degree that providing such clarity is a key step toward meaningful public dialogue on health care in Canada, the federal government should do so. Clarity is one thing that’s clearly missing from current debates.

Gerard Boychuk is a professor of political science at the University of Waterloo and Balsillie School of International Affairs. His C.D. Howe Institute Commentary, Grey Zones: Emerging Issues at the Boundaries of the Canada Health Act, can be found at www.cdhowe.org.

< http://www.theglobeandmail.com/news/opinions/opinion/health-reform-ottawa-must-provide-clarity/article2414166/ >

Fast food is packed with sodium — a fact that’s no surprise to most people. But why here in Canada is our fast food even more sodium-laden than in other countries? According to a study published in the Canadian Medical Association Journal, McDonald’s Chicken McNuggets in Canada contain more than twice the amount of salt as they do in Great Britain. It wasn’t that long ago that Canada topped a world-wide list of the amount of sodium in products like breakfast cereals.

Meanwhile, Health Canada has indeed recognized that our sodium-rich foods are putting our health at risk. So what does this government agency do to help Canadians reach recommended targets?

Not much.

True, they did strike an expert committee to deal with our excessive sodium intakes and when the Sodium Working Group came up with hard hitting recommendations, Health Canada disbanded the committee. According to the group’s report, slashing our intake by 1,800 milligrams a day would prevent a staggering 23,500 cardiovascular disease events such as heart attacks and stroke per year. Many of the abandoned recommendations dealt with cutting sodium from processed food, which is where most of the sodium in Canadian diets comes from.

Consider that reducing our intakes would also lead to a whopping savings of $1.38 billion per year in direct health care.

The government’s latest blow for making smart food choices was the news from the recent federal budget that the Canadian Food Inspection Agency (CFIA) will no longer police food labels. It’s just the latest in a number of moves that appear to be putting corporate health before the health of Canadians.

As science shows the importance of healthy eating in both the prevention and treatment of disease, the government has taken away an important weapon in the battle against a variety of diseases. This at a time when the statistics link diet-related stroke, heart disease, cancers, diabetes and obesity to approximately 48,000 deaths annually in Canada.

With the government relinquishing its watchdog status, there is nothing to motivate companies to correct inaccurate and potentially misleading information that may make their products appear healthier.

Take, for example, what happened with a package of jumbo hot dogs brought to me by a client. It was a product with a label listing an incredibly low sodium content. She thought she had made a spectacular nutritional find. But to my expert eye, it made no sense that a hot dog (with added sodium in the ingredient list) could contain less sodium than a comparable amount of raw unseasoned beef. I contacted the company, which flat out denied that its label could be inaccurate. I then filed a complaint with the CFIA. The updated label that resulted from their investigation revealed that the sodium content listed was about 10 times the previous one.

Now there’s no longer anyone to hold companies accountable for providing Canadians with accurate information about the foods they eat.

The government says that it’s a cost-cutting measure but what about the fact that diet-related diseases cost more than $6 billion per year, a number that’s expected to keep rising.

This action is just the tip of the iceberg.

In February, Health Canada shuttered plans to regulate trans fats saying it would be a regulatory burden to food companies. This after their own expert committee recommended legislation, not voluntary action, to rid Canadian foods of this toxic ingredient. Consumption of trans fats is linked to heart disease, stroke, diabetes and more.

Health Canada also recently allowed caffeine to be added to non-cola soft drinks — an initiative that might yield more caffeine per can than the maximum recommended daily intake for some children.

Their inaction over the past five years in dealing with helping consumers select disease-fighting whole grains is another example. Because of outdated regulations that allow for whole wheat to be refined, yielding a product that is not whole grain, consumers are very confused. They logically think the word whole denotes whole grain, yet a bread that is 100 per cent whole wheat may not be a whole grain.

It’s time for Health Canada to get back to the business of safeguarding our food and health and protecting the money we spend on good nutrition instead of ensuring the food companies a healthy profit.

Rosie Schwartz is a Toronto-based consulting dietitian in private practice and is author of The Enlightened Eater’s Whole Foods Guide (Viking Canada).

< http://www.thestar.com/opinion/editorialopinion/article/1164814–health-canada-isn-t-helping-canadians-cut-salt-intake >

A series of stories in Thursday’s Star painted a sobering picture of how hospitals in the Greater Toronto Area compare to those in the rest of Canada. Data from the Canadian Institute for Health Information (CIHI), released via a great new online tool, indicate problems in 11 of 18 local hospitals compared to hundreds of acute-care facilities across Canada.

Sadly, these problems are not the only examples of how the GTA — and Ontario — lag behind the rest of the country when it comes to hospitals.

Ontario is also the only province whose ombudsman cannot investigate hospitals and long-term care facilities.

What’s the connection? Well, I’m not saying that the lack of ombudsman oversight means Ontario hospitals don’t perform as well as they should. But I am confident that they would perform better if they were subject to the scrutiny of my office, like virtually every other provincial ministry, agency, board, tribunal and Crown corporation.

Many of the problems identified in the CIHI survey — less-than-adequate nursing care, mortality rates, administration costs — are issues that Ontarians have brought to my office in the past. Every year, we hear from hundreds of patients and their loved ones who say they’ve endured inadequate care, unsafe conditions, even neglect and abuse in hospitals.

In the fiscal year just ended, we received some 375 complaints about Ontario hospitals that we were forced to turn away. I can only imagine how many we would receive if we were actually able to act on those complaints.

The Quebec ombudsman, for example, recently reported on several cases where her staff helped people struggling with poor care and maladministration in hospitals. A woman caring for her dying husband who was barred from hospital because of infection controls. A man whose wife died after childbirth because of inadequate aftercare. A woman with Alzheimer’s who was stranded alone in an emergency room because hospital staff would not let her daughter accompany her.

In each case, the ombudsman recommended policy solutions to prevent others from suffering the same treatment. My ombudsman colleagues in other provinces have similar stories. It’s tough to explain to them why we in Ontario are barred from helping people this way. The very first Ontario ombudsman, Arthur Maloney, asked that same question in 1979. I remain hopeful, but so far nothing has changed.

I’m often asked — especially now that budgets are so tight — how much it would cost to extend the Ontario ombudsman’s mandate to include hospitals. The naysayers envision a huge, expensive new layer of bureaucracy. But there’s no reason it can’t be cost-neutral. Indeed, that was the experience in Quebec — resources were simply reallocated from the health ministry.

And it’s worth noting that my office is already extremely cost-effective. In the past fiscal year, we handled about 18,000 complaints on a budget of about $11 million.

Speaking of money, the powers of the provincial auditor general were recently expanded to cover hospitals. This is often cited as adequate oversight. But we all know the impact of hospitals on people’s lives goes far beyond financial matters.

An ombudsman looks for administrative efficiencies in human terms — by cutting through red tape and rigid rules, by recommending ways to streamline processes and improve public service and governance. My office has helped countless Ontario agencies do this. We could do the same for hospitals.

The CIHI data and the Star’s reporting on it are an excellent illustration of how greater transparency can benefit the public. Making this kind of information available about hospitals allows patients across Canada to become better informed and engaged, and will contribute to better services all round.

Why, then, shouldn’t Ontarians with complaints about those hospitals be able to access the same independent, impartial complaint mechanism as other Canadians — their ombudsman?

André Marin is the ombudsman of Ontario

< http://www.thestar.com/opinion/editorialopinion/article/1157665–ontario-ombudsman-could-hold-hospitals-to-account >

Who is health care for?

The answer seems obvious: everyone. It’s a certainty based on the powerful utilitarian idea that public spending should provide the greatest good for the greatest number of people.

So what’s gone wrong with breast cancer treatment? According to the guidelines issued last month by the Canadian Task Force on Preventive Health Care, our extensive use of screening techniques provides only small benefits at a great cost.

The guidelines’ authors argue that more women have been harmed than helped by a public-health policy that has encouraged all women to see themselves as potential victims, even though the high-risk group is substantially smaller in number.

Critics dismiss the guidelines by pointing to the examples of women whose lives have been saved by mass screening campaigns.

The heated debate around cancer treatment has provoked a larger question: Should we be crafting policy and spending money on the basis of exceptionalism? But how do we begin to answer that question when there’s no public consensus on the exact point where the general good is no longer served by the benefits to a few?

“There’s a perverse lack of calibration between science and policy,” says Ross Upshur, Canada Research Chair in Primary Care Research at the University of Toronto. “And this rapidly turns into a classic conflict between the universal and the particular, because there’s always an exception to the rule, the patient whose tumor was found through screening.”

Exceptionalism is at the root of many public-policy issues where emotion, self-interest and personal experience conflict with the more dispassionate, evidence-based approach of science.

And with good reason: The individual story changes everything in how we relate to a prickly policy issue, whether it’s hunger in Africa made human through a famine-ravaged baby on a TV fundraiser, or the survivors’ testimony that has been marshalled to criticize the task-force report.

“If you put a face on a death, the argument for the other side is lost,” says McGill epidemiologist Abby Lippman.

Compelling exceptions are hard to counteract, especially for political leaders who can only look cruel by preferring abstract policy about death rates over individuals who share stories of pain and survival.

Those warring values were put to the test last year with the widely publicized campaign for funding of the controversial liberation therapy for multiple sclerosis. “The scientific evidence has been very weak to date,” says Timothy Caulfield, Canada Research Chair in Health Law and Policy at the University of Alberta. “If we made the science resource allocation the way we usually do, we’d have basic research first, try to figure out a mode of action and slowly move it into the clinical stage. But it’s the people with the disease who are driving the issue. And when the demand is so huge, there’s an impetus to take action.”

Last week, federal Health Minister Leona Aglukkaq announced plans for clinical trials of the treatment, reversing the government’s previous policy.

“The science is very thin,” says University of Manitoba bioethicist Arthur Schafer, looking for a way to explain this change of heart. “But the drug therapies we have are very oppressive, and you’re dealing with people who are desperate. So in the end, why not try it?”

When used as a policy tool, exceptionalism is understandable and even defensible. Israel trades 1,027 Palestinian prisoners for a single soldier held hostage by Hamas. The critics of that asymmetric deal take a position that is proudly detached: It’s wrong because it rewards hostage-takers, at the likely cost of future retaliations toward Israel.

But the payoff from the return of that single Israeli soldier goes well beyond the individual – other Israelis see themselves reflected in him and his suffering, and take collective pride in the protective patriotism that sees his life as so valuable. That compassionate sense of unity can be leveraged by politicians who recognize the overriding power of emotion, even when it seems irrational and potentially dangerous.

Likewise in Canada, a government that talks tough on criminals when crime rates are falling prefers the anecdotal concerns of its supporters to the collective power of statistics. Decision-makers who won’t let gay men make blood donations know the risk of spreading HIV is infinitesimal, but balance their bad science against the possibility of undermining public faith in the blood supply. Researchers tell governments that in-car headsets can be just as dangerously distracting as cellphones. Yet only the phones are banned, because the argument against a hand-held device is easier for the public to accept – public policy, much more than science, has to pass the popularity test.

The tensions in the breast cancer issue are even more divisive, for the paradoxical reason that the advocates for intensive mass monitoring of the population don’t accept that they represent an exceptional position. The treatment of breast cancer, like prostate cancer, like colorectal cancer, has been framed in general and universal human terms: If everyone should be tested at some point, even the non-symptomatic, isn’t that what preventive public health is all about?

The scientists on the task force challenge this belief simply by pointing to their seemingly overwhelming statistics: Screening 2,100 women aged 40 to 49 every two or three years for 11 years saves only one life. On balance, says the task force, that’s too much exceptionalism.

Of course in the real world, we don’t know whose life that is – it might be yours. And while science fixates on the mythical average woman, doctors see much more room for variation from the mean – especially in breast cancer, where family histories and genetic mutations can indicate a strong susceptibility to the disease.

“The tension in medical practice comes from figuring out how to translate guidelines,” says Neel Shah, who runs an NGO called Costs of Care. “The very best doctors look at patients and try to figure out how they could be different from the average. Guidelines aren’t gospel, they’re just a starting point.”

< http://www.theglobeandmail.com/life/health/new-health/health-policy/when-emotion-prevails-over-cold-hard-science-in-public-policy/article2259134/singlepage/#articlecontent >

It took six years, 60 researchers and $4.3 million.

Finally, the most comprehensive study of women’s health ever done in Ontario — possibly anywhere — is complete. The concluding chapter — a 10-point road map to health equity — was released last week at St. Michael’s Hospital at a celebration featuring speeches, congratulations and assurances by Ontario Health Minister Deb Matthews that the information in the massive tome would be put to good use.

There’s one problem: The POWER (Project for an Ontario Women’s Health Evidence-Based Report) study has received so little attention that most women don’t know it exists. Neither do their doctors.

That means too many women who suffer heart attacks will be misdiagnosed. Unlike men, they don’t typically experience chest pains or numbness. The most common symptoms of cardiac arrest in women are nausea, vomiting, shortness of breath and intense fatigue.

It means too many expectant mothers will undergo C-sections for low-risk births and unnecessary episiotomies for vaginal deliveries.

It means too many medical practitioners will ignore the strong connection between poverty and chronic ailments, such as obesity, hypertension, diabetes, arthritis and obstructive lung disease, which lead to foreshortened lives.

One of the reasons the 12-volume study hasn’t received much coverage is its heavy use of jargon. Here is an excerpt from last week’s release: “Health equity cannot be achieved without moving upstream and addressing the root causes of disease in the social determinants of health. A multi-faceted approach is required to tackle the many complex problems which contribute to greater chronic disease prevalence and poorer health outcomes in some groups.”

A second reason is that it has been released, chapter by chapter, over so many years that health reporters have lost track of the thread or moved on.

These problems could easily be rectified. The Ontario health ministry, which funded the project through one of its satellite agencies, ECHO, could assign a communications team to produce a user-friendly version of the report and develop an outreach plan. Or it could hire a public relations firm.

But Premier Dalton McGuinty is poised to cut spending and his budget adviser Don Drummond is urging the health ministry to streamline its operations. Both suggest that follow-up is unlikely.

This leaves women who want to take charge of their health with three options. They can read the 1,800-page report. With patience and persistence, they’ll get the gist of it. They can cherry-pick the topics that matter to them. Or they can lobby the government to finish the job.

For those willing to download the report, here are a couple of tips:

Some chapters are aimed chiefly at women, others at policy-makers. The written-for-bureaucrats chapters are distinguishable by their reliance on health/sociological jargon.

The most useful chapters for women seeking practical guidance are: cardiovascular disease, diabetes, depression, reproductive health and older women’s health. The chapters on cancer and musculoskeletal conditions (arthritis, osteoporosis) identify gender disparities, regional disparities and socioeconomic parities, but they don’t tell women much about how to improve their odds.

There is no question the study is a gold mine of information. Its website has attracted online visitors from 132 countries, 49 of the 50 U.S. states and 675 Canadian cities.

Taken seriously, it could be a catalyst for change. Its research team estimates that if Ontario had a truly equitable health-care system, there would be 230,000 fewer people with disabilities and 3,373 fewer premature deaths in the province’s big cities.

“We have more than enough evidence to make health equity a priority and more forward,” said chief investigator Arlene Bierman, a physician at St. Michael’s Hospital.

But the report could have done so much more. It could have alerted women to factors that raise their risk factor for various diseases. It could have helped them ask their doctors more informed questions. It could have led to public pressure for change.

< http://www.thestar.com/opinion/editorialopinion/article/1142057–women-in-the-dark-about-massive-ontario-study-of-female-health >

Last week, the premiers of all 13 provinces and territories gathered in Victoria. A key item on their agenda was to discuss the future of medicare in light of the federal government’s long-term take-it-or-leave-it health financing deal.

By now the details are well-known: Ottawa will increase the Canada Health Transfer – currently worth $27-billion in cash and $13.6-billion in tax points annually – by 6 per cent per annum until 2016 then tie the increases to economic growth (meaning they will be around 4 per cent a year) for another decade. In the future, Ottawa will dole out the money on a strict per-capita basis, with no adjustments based on the economic status or demographics of the provinces and territories. (There was an equalization formula in earlier deals.)

There will also be no strings attached, meaning the provinces and territories can spend the money as they see fit and that the federal government will no longer try to entice the provinces to tackle common problems like wait times or lack of electronic health records, nor will it use the money to ensure that provincial programs are equitable across the country.

Before the meeting there were dire warnings that drastic cuts to health-care delivery would be necessary in some provinces; others said it could spell the end of medicare as we know it, and so on.

What is certain is that Prime Minister Stephen Harper has fundamentally changed the federal-provincial relationship in the shared jurisdiction of health care, essentially relegating Ottawa to the role of disinterested benefactor of a decentralized system.

“The premiers were unanimous that the federal government’s decision to unilaterally decide funding was unprecedented and unacceptable,” said B.C. Premier Christy Clark.

A crisis requiring firm action indeed.

The premiers huffed about the lack of money Ottawa was offering and they puffed about the feds abdicating their responsibilities. And then they drew in a big breath and mightily declared that … more study was necessary.

Seriously?

By the end of the meeting, having tapped all their collective wisdom, political savvy, economic insight and social policy expertise, the cream of the crop of Canadian politics came up with a hard-hitting response … forming two committees.

Seriously?

Let’s pray there’s some secret plan they’re not telling us about because this is pathetic.

Mr. Harper took the 13 premiers to the woodshed – albeit with a velvet paddle – and their response was a vigorous bout of committee forming?

Mr. Harper is no Chuckles the Clown but he must be laughing himself silly at how easy it was to divide and conquer the provinces and save himself a few tens of billions in transfers in the process.

There was a golden opportunity here for the provinces and territories to say: “We have common interests and, despite Ottawa’s indifference, we’re going to ensure a semblance of a national health-care system remains.”

For example, the premiers could have agreed to a set ofcommon standards for reimbursement of prescription drugs, an area where there are gross disparities between jurisdictions. Creating this kind of national (not federal) program would be immensely popular with Canadians because it would be a de facto expansion of medicare. (Currently there are common standards only for coverage of hospital and physicians services.) The additional cost would be minimal and, with a united front, they could probably shame the federal government into paying for it.

The premiers could have shown leadership on a file that has festered for decades and started the process of dragging medicare into the 21st century.

Instead, we got a boatload of platitudes for public consumption and a new reality in health care where the rich provinces got richer and the poor ones got poorer.

With the fundamental principles underlying medicare – equity and fairness in health-care delivery and funding – crumbling, the premiers are fiddling.

We now have a new working group, chaired by Manitoba Premier Greg Selinger, to examine the federal government’s new funding formula (even though the federal government says it is not open for discussion). We also have a new Health Care Innovation Working Group, composed of all provincial and territorial health ministers and co-chaired by PEI Premier Robert Ghiz and Saskatchewan Premier Brad Wall.

This bold exercise in innovative thinking will focus on only three areas: the scope of practice of health professionals (important but hardly a task for premiers); human resources management (read: Hey guys can we stop stealing doctors and nurses from each other by co-ordinating what we offer them in collective agreements?) and encouraging the development of clinical practice guidelines (another triviality best left to professional associations.) That is work for bureaucrats, not premiers. When the first ministers meet, they should be articulating a vision for the future of medicare, not whimpering like snubbed school children.

We don’t need more studies or committees. Every royal commission, provincial inquiry, independent analysis for the past five decades has come to the same basic conclusions about what we need to do reform medicare:

* Control spending by limiting medicare coverage to essential treatments that work;

* Modernize primary care by moving away from solo physician practices to interdisciplinary teams;

* Create some kind of universal prescription drug plan;

* Shift money from institutional care to home care so we can look after people where they live, in the community and at home;

* Instead of spending obscene amounts of money to marginally extend survival of the terminally ill, invest it in palliative care.

The premiers have six months until their next meeting. In the interim they should be making plans, real plans, for improving medicare – with the money they have (which is about $141-billion in public funds and another $59-billion in private dollars.) There is no magic bullet, least of all more money. The improvement needs to be made, little by little, but that can’t begin to happen until there are specific goals and leadership from the top.

We don’t need more working groups. We need work to begin. Now. Seriously.

< http://www.theglobeandmail.com/life/health/new-health/andre-picard/the-premiers-want-more-health-care-study-seriously/article2312182/singlepage/#articlecontent >

A decade before medicare, the federal government financially supported hospitals across Canada; that came in 1957 under John Diefenbaker’s government. Ottawa used its spending power to bring in medicare in the late 1960s, negotiating conditions with the provinces for the money.

The 1984 Canada Health Act outlined five medicare principles that provinces had to respect; failure to do so could result in Ottawa’s withholding money. The prospect of losing federal money (and flying in the face of public opposition) enjoined provinces to end extra-billing by doctors and user fees for services.

In recent decades, Ottawa always tried to tie some of its health-care money to certain objectives, usually with only fitful success. The last major money-tying effort came under the Paul Martin government, whose $41-billion in transfers over 10 years, indexed at 6 per cent annually, had a welter of federal-provincial commitments. When Stephen Harper was campaigning for the first time, he proposed a Patient Wait Times Guarantee linked to federal money.

Now, however, Mr. Harper is going to give money to the provinces (they got federal tax points for health care a long time ago, a transfer they never mention) without any strings, conditions or demands. It’ll be the first time since medicare began that a federal government has handed money over carte blanche.

Broadly speaking, two reasons explain his decision – one theoretical, one political.

Mr. Harper believes, when it suits his purposes, in a kind of classical federalism wherein the two levels of government more or less stay out of each other’s jurisdiction. He thinks Liberal governments abused Ottawa’s constitutional “spending power” to intrude into provincial jurisdiction, especially in social policy such as health care and daycare. Conservatives would rather use the federal tax system, or unconditional grants to the provinces, thereby respecting classical federalism.

The politics of his decision have been almost completely ignored, but they’re important for those who think about political angles all the time.

Health care is a political hornet’s nest. Governments can never spend enough money to satisfy those who want more health care in the form of more doctors and nurses, equipment, hospitals, community care, drug plans, research and so on. The less Ottawa has to do with health care, the easier the politics. Moreover, Conservatives have issues they think they own (crime, the economy, defence) and issues owned by others (health care, the environment) on which they essentially play defence. In these areas, they do enough to protect themselves but expend no political capital trying to persuade people to their point of view.

By offering health-care increases of 6 per cent for five years to the provinces, Mr. Harper has provided himself with a strong defence. He can say right through the next election that his government is spending at exactly the pace of the Paul Martin government. Who can complain about that?

The anticipated drop in indexing from 6 per cent to 4 per cent or 5 per cent thereafter won’t figure in the next election, since the decline is hardly momentous. Put simply, Mr. Harper is trying – and he’s likely to succeed – to take health care off the federal political agenda for the next four years, or at least give himself a plausible line of defence should it unexpectedly arrive.

Mr. Harper’s view of federalism has a flip side: a stronger federal role shaping the national economy. This necessary imperative underpinned his government’s attempt to create a national securities commission of the kind other industrialized countries use.

Provinces, except Ontario, rose up against the idea. Their Little Canada view of such matters hardly surprised anyone. They preferred the defence of their jurisdiction above the good of the national economy. The Supreme Court, made up of lawyers, looked at the issue after a federal reference as one of jurisdiction rather than the functioning of the national economy, and agreed with the Little Canadians.

In the space of a few weeks, then, Canada got a political decision from Ottawa to abandon all attempts to influence the country’s most important social program, and a judicial decision to abandon an effort to improve the functioning of its internal economy.

< http://www.theglobeandmail.com/news/opinions/jeffrey-simpson/the-politics-of-harpers-medicare-decision/article2308425/ >

There’s an ominous new meaning for two-tier medicine in Canada: rather than one system for rich people and one for the poor, it will be one system for rich provinces and one for the poor.

Ottawa has unilaterally declared a new health-care funding formula that eschews the old prescription of giving poorer provinces proportionately more health-care dollars than richer ones, substituting a per-capita formula that removes the built-in penalty for economic growth. The result is a health-care fight at the Victoria meeting of the country’s first ministers that has become a proxy for the larger forces reshaping the balance of power in the country: a clash that pits the fast-growing, resource-rich West against the East.

Any doubt about this was quelled when Quebec Premier Jean Charest stepped to the microphone first thing Monday morning and talked about federalism’s new truth.

“There’s two realities in Canada,” said the Premier. “There are the economies of oil, gas and potash and the others. That’s the reality of Canada, and once we know that, we need, I think, to be able to make decisions accordingly.”

What Mr. Charest means, we assume, is that the West is richer than the East thanks to access to valuable raw resources. And this, he believes, needs to be taken into account in areas such as health-care funding. The wealthy should subsidize the less fortunate so our provincial governments don’t unwittingly create a two-tier health system of a different sort.

The Quebec Premier’s lament certainly echoed past complaints from the poorer provinces. And it was no surprise that his position wasn’t sympathetically embraced by Alison Redford.

Instead, the Alberta Premier again applauded a new federal “per capita” funding formula she says treats all Canadians equally. In other words, those living in her province don’t receive proportionally less for health care than someone living in Nova Scotia or Quebec.

All the premiers were saying what you might expect about the prospect of a two-tier health system in Canada, one divided along economic lines. Whether it was host Premier Christy Clark or Ontario’s Dalton McGuinty, the premiers insisted that every Canadian should have access to a comparable level of health care.

But “comparable” is a fairly vague term of measurement.

There isn’t a truly equal level of health care in Canada even now. Wealthy provinces have hospitals and programs that poorer ones can only envy. Wait times for certain procedures can vary widely between jurisdictions. There is a reason for that. The health budgets of some eastern provinces eat up their entire equalization payment. That is not the case for provinces such as B.C. and Alberta, where the economies are growing and the governments can afford to pour dollars into their health care systems.

The question is: will Ottawa’s new no-strings-attached funding proposal exacerbate the discrepancies in health care that already exist? And does Ottawa even care if it does?

Unless Stephen Harper and the Conservatives have an unexpected change of heart, it would seem this is going to be a problem the provinces are going to have to grapple with on their own. To that point, the sooner they begin sharing thoughts on how to start turning the health cost curve downward through innovation and best practices the better.

It will be savings made through these types of initiatives that will allow poorer provinces to stay in the health care game.

Moving ahead, it will be the provinces who make the health guarantees in Canada – not the federal government. It will be the provinces who will have to make themselves accountable to their citizens to deliver the same level of service across the country – not Ottawa. How they do that is something they’re just starting to figure out now.

“We don’t want 13 different health care systems in Canada,” Ms. Clark said on Monday afternoon. “And we don’t want different levels of care between provinces. Canadians expect the same care wherever they are.”

The challenge of delivering on that just got a whole lot harder.

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Dalton McGuinty joins his fellow premiers in Victoria on Sunday for a special summit to cure health care’s ills across Canada. But McGuinty’s mind will be elsewhere.

Fresh from his special guest appearance at the Liberal convention in Ottawa — where he renounced any federal leadership ambitions — Ontario’s premier will once again perform a delicate dance:

He must resist playing the role of Captain Canada rescuing medicare, avoiding any prime ministerial pretensions on the West Coast. And he dare not overdo his customary talk of fostering “national standards” for health care lest he lapse into the archetypal central Canadian patronizing other provinces.

But there is another reason for McGuinty to be more muted over the next couple of days of posturing with the premiers: The Great Game isn’t what it used to be.

The world has changed since 2004, when the provinces engaged in high-stakes negotiations with Ottawa that culminated in an accord to boost health care funding by 6 per cent annually for a decade. The premiers were caught off guard last month by federal Finance Minister Jim Flaherty unilaterally fixing future transfers at a rate decreed by Ottawa alone.

Flaherty’s diktat has sucked the air out of the premiers’ conferences because there is little left to fight about — except amongst themselves. A split has emerged between western premiers who deemed Ottawa’s offer reasonable and those who denounced it as wretched. Now federal Health Minister Leona Aglukkaq is trying to pick up the pieces, but the process is in limbo.

“This is a bit of an existential moment in the federation,” complains one official. “The feds are taking this goodbye-and-good-luck approach and yet still want to keep a foot in the door.”

Despite their internal divisions, the show must go on in Victoria. Yet McGuinty knows perfectly well that the real action isn’t at the conference table, comparing notes with premiers who are at cross-purposes.

The focus should be back home in Ontario, where the province’s finances are in a precarious state and the health sector is on a knife’s edge.

At $47 billion a year, the health bill takes up an unhealthy 42 per cent of Ontario’s spending. That’s why McGuinty has long made medicare a touchstone of his speeches, demanding that Ottawa sign another accord with national standards and clear objectives (like shorter waiting lists).

Now Ottawa is following its own script. Yet Queen’s Park tirelessly (and tiresomely) repeats its boilerplate denunciations of bad faith federalism.

It’s time to move on. Victoria can serve as a clearing house for “best practices” and interprovincial brainwaves on innovation, but it won’t provide any panaceas.

Like it or not (and I say this as an arch-centralist), the terms of the debate have shifted. The more interesting conversation is taking place back home, where the biggest brains are turning their minds to the bigger problems.

McGuinty needs to get out in front of the funding challenges in his own backyard: highly paid doctors, a poorly integrated health care system, modest community care and meagre home-care programs.

A report on Ontario’s public services, coming soon from influential economist Don Drummond, makes health care its major focus. Drummond points out that virtually all the major providers (doctors, nurses, pharmacists) are remarkably united with the big players (the Ontario Hospital Association and community care groups) in recognizing that delivery cannot continue as before — because funding cannot continue as in the past.

Drummond’s report will set the table for another major debate on front line challenges for health care in Ontario, free from pan-Canadian policy abstractions — and distractions. There is a perfect storm brewing on Ontario’s shores, and yet the stars are in alignment.

A draft of Drummond report’s is now in the premier’s office. McGuinty must know that Ontario will have to find its own way, and that the real work begins once he finds his way home from Victoria.

< http://www.thestar.com/news/canada/politics/article/1115720–cohn-dalton-mcguinty-can-t-play-captain-canada-to-rescue-medicare >