In the early 1980s a patient who needed surgery at an Ontario hospital very often had to pay an extra fee to the anesthesiologist, even though that same doctor would be paid a negotiated fee by the universal health insurance system, OHIP, the Ontario Health Insurance Plan.
When this writer required emergency surgery in Ottawa during that period, an anesthesiologist bluntly told him: "We run a closed shop, here. If any anesthesiologist wants to practice in this hospital she or he must extra bill. Otherwise we'll see to it that they don't work here."
This practice of extra billing had become very widespread in a number of provinces by 1984, though it seemed obviously unfair to a great many people.
Doctors had the right to collect their negotiated fees from the provincial health insurance plans (supported by federal transfer payments) and then turn around and force patients to pay them an arbitrary extra amount. They had sick people over a barrel.
Some described the extra billing practice as "Having your public medicare cake and eating your private fee too."
The provinces were not, however, interested in tackling the extra billing problem, least of all such Conservative run provinces as Ontario and Alberta.
And so Trudeau's Health Minister, Monique Bégin, decided to weigh in to stop what she saw as a rapidly accelerating erosion of the universal health care system.
Thus we got the Canada Health Act, which imposed conditions on federal health transfers to the provinces.
Bégin stopped extra billing and the growth of two-tier
The five big principles of the Act are:
- Public administration, which means that any provincial health care system has to be managed on a non-profit basis by what the Act calls "a public authority."
- Comprehensiveness, which means that the health care plans of the provinces have to cover all necessary care.
- Universality, which entails that 100 per cent of the population must be covered by the health plans, "in a uniform way."
- Portability, which requires that Canadians can move or travel from province to province and still have health coverage, without gaps.
- Accessibility, which means that everyone, rich and poor, rural as well as urban dwellers, should have "reasonable access" to services on "uniform terms and conditions."
The Trudeau government enacted the Canada Health Act in 1984. It put an end to extra billing, and discouraged the development of two-tiered parallel public and private systems.
Stealth attack on a political sacred cow?
Although subsequent governments unilaterally slashed federal-provincial health transfers -- notably the Liberal government of Jean Chrétien -- none tampered with the Canada Health Act.
The current Conservatives' ideological soul mates at the Fraser Institute have been actively advocating a two-tiered system, and effectively scrapping the Canada Health Act, for quite a while.
Many worry that, as part of its master plan to re-mould Canada in its own image, the Harper government has its eyes on the 1984 Act.
Harper and his colleagues are unlikely to proceed with a frontal attack on Bégin’s landmark Act, which has become something of a sacred cow -- at least rhetorically -- to all federal parties.
But many worry that the current federal government will seek to undermine the broad principles of the Act in a myriad of ways that may not be immediately obvious.
What concerns the Official Opposition the most is the posture of not-necessarily-so-benign neglect that Harper and his team have assumed with regard to health care.
Last winter the Finance Minister announced that federal health transfers to the provinces will continue to rise by six per cent per year until 2017, at which time, until 2024, they will be pegged to inflation, but will not fall below increases of three per cent per year.
The NDP argues that, in effect, what the federal government is planning to do is take $36 billion out of federal health transfers.
The federal government would not be reducing health funding in absolute dollars. But were it to maintain the six per cent per year increases after 2017 the federal contribution would be richer by $36 billion.
A bit of complicated math, perhaps -- but a plausible case nonetheless.
A sit-on-its-hands federal government
But what is almost more worrisome to the NDP than the federal cash contribution is the Conservatives' apparent lack of interest in working with the provinces to improve delivery of health services and achieve better health outcomes.
On that score the math is not very tricky and the facts are pretty clear.
The current government, NDP Deputy Leader and Health Critic Libby Davies notes, has dropped the ball on a number of the big health care challenges. These include a national prescription drug strategy, home care, electronic health records and reduced wait times.
The provinces are now working together to find practical and innovative ways to deal with all of the above and to re-invigorate health care across the country. However, the NDP argues, the federal government is failing to play an active and engaged role, and that could jeopardize any progress.
The NDP's response is a Canada-wide consultation on the future of the public health care system, to be led by Davies and fellow MP Djaouida Sellah (herself a medical doctor).
Although the Official Opposition is not providing the answers ahead of time, it has outlined broad health policy goals for this consultation.
Chief among those goals are better access to prescription drugs, better and more widely available home care, reduced wait times for essential care and procedures, and a serious and meaningful disease prevention strategy.
The last of those goals would link health to social and economic policy, by bringing in matters such as diet, income disparity, housing and the all-too-often grim conditions on aboriginal communities.
Are the feds only good for writing cheques?
The federal government does not manage health care, by and large. That is a provincial responsibility.
But from the beginnings of universal health care in Canada, in the 1960s, the federal government has leveraged its financial clout in order to play a key role.
That financial clout is not what it once was, relative to total health spending; but it is not negligible, and the provinces couldn't manage without it.
And, apart from the billions in transfers to the provinces, the federal government directly spends hundreds of millions on health, in a variety of ways.
The feds spend on everything from food inspection (not always doing that very well, according to the latest news from Alberta), to research, to health statistics, to a federal agency (Canada Health Infoway) whose role is to foster the implementation of fully electronic health records nationwide (only seven per cent of Canadians have those now).
And then, of course, there are federally funded health services for aboriginal communities, about which the previous Auditor General had some fairly withering observations.
The NDP MPs leading the consultations will want to make sure to take into account all of those aspects of the federal policy, as well as the federal transfers. There is much more to the federal health role than merely writing cheques to the provinces.
Karl Nerenberg covers news for the rest of us from Parliament Hill. Donate to support his efforts today. Karl has been a journalist for over 25 years including eight years as the producer of the CBC show The House.