We measured this Bill against our list of what should be in a piece of legislation that carries the title "Commitment to the Future of Medicare" and found it to be lacking. For eg. there is no increased democratic control or accountability to the people of Ontario; there is no prohibition of further delisting, two-tiering that is happening in the MRI/CT clinics, service charges that are occurring throughout the system or P3s; there is no provision for democratic input, whistle-blower protection or consultation with the people of Ontario prior to changes in the health system; there is no provision for a democratic, accountable health council that reports on how the system measures up against the principles of the Canada Health Act; there is no extension of Medicare; there is no major initiative to strengthen Medicare aside from a weak and undemocratic health council. Most worrisome is what the Bill does: it gives the Minister huge powers to restructure the health system without telling anyone what is his intent; it allows block fees by physicians; it allows the potential for extra-billing to be put into the regulations; it sets up a health council that could be used by a government unfriendly to medicare to aide in privatizers' campaigns against public health care. The good things: it brings physicians' block fees into the purview of the government and out of "self-regulation" by the College of Physicians and Surgeons but it fails to ban them. It tries to ban doctors from opting out of OHIP. It tries to prohibit extra billing (but then leaves an opening to put it into the regulations).

The Minister announced amendments this afternoon. I will send them out as soon as I get them. I will also send out an analysis of them as soon as I can.

Please do join the hearings in your town. Our brief follows and below it are the hearing dates and deadlines.

Introduction

Bill 8 is titled the Commitment to the Future of Medicare Act. It was introduced in the autumn as the fulfilment of the Liberal Party’s promise to enshrine the Canada Health Act (CHA) in Ontario law, create a Health Quality Council to monitor and provide accountability, and prohibit two-tier healthcare. As it stands, the Bill does not further the implementation of the principles of the CHA, does not provide improved democracy, transparency and accountability; and does not prohibit the further erosion of the scope of Medicare, the increasing problems of privatization and profit-taking, and two tiering for those services that have been delisted. Further, it gives the Minister of Health sweeping powers without clear intent or democratic control.

This brief is an attempt to compare the act to what could and should be the province‚s commitment to the future of Medicare:

1. Rebuild a Commitment to the Universality, Comprehensiveness and Accessibility of Medicare.

Ontario’s public health system has been seriously eroded by years of cuts and delisting.

A few examples: (insert local examples here)

- $100,000,000 in OHIP services have been delisted over the last decade.

- The Ontario Medical Association reports that a record 900,000 Ontarians have no access to a family physician

- We have approx. 5,900 fewer hospital beds and fewer staff than in 1995

- Homemaking and home support services have been virtually eliminated across the province - lowering caseloads from 2002-2003 by approx. 115,000 people, often the frail elderly

- Long term care facilities hours of care per resident have shrunk

- Drug costs are prohibitively high and inaccessible for a growing number of Ontarians

- Reductions to funding for assistive devices leave many unable to access the tools they need to live to their potential.

Bill 8 incorporates the principles of the Canada Health Act in its preamble, but provides no concrete initiatives either to ensure access to these services that have been cut or to implement the sentiments outlined in the CHA. As noted in the preamble to the Bill, homecare and pharmacare are key components of rebuilding an accessible, comprehensive, universal public health system. So too are homemaking and support services, access to primary care, access to drugs and assistive devices, and a comprehensive OHIP list covering the services that people need. The intent of the Canada Health Act was to ensure that Canadians have access to a comprehensive range of medically necessary health services. Real concrete steps are needed to fulfill this vision.

2. Prohibit Two Tier Medicine and Extra Billing

Fundamental to the universality of the public health system are the prohibition of two tier medicine and extra billing. The threat of two tier healthcare has grown significantly with the privatization of the health system.

For-profit health corporations see user fees, service charges and two tier access as potential new revenue streams and are pursuing these in a much more aggressive way than their non-profit and public counterparts ever contemplated. In addition, the delisting of services and procedures has allowed the growth of two tier access for uninsured services.

Some examples (insert local examples here)

- Private laboratories now charge fees for pick up and delivery which used to be provided without charge. This affects long term care facilities and homecare patients.

- Private MRI/CT clinics are allowed to provide scans to those who pay out of pocket for so-called "medically unnecessary" scans. Therefore, those with the least medical need can jump the queue.

- The proportion of beds in long term care facilities held for those who can afford to pay a premium for a semi-private or private room has gone up to 60%, reducing the number of basic ward beds available.

- Service charges and fees for a whole range of services throughout the health care system are becoming a growing concern.

- Access to publicly funded physiotherapy, rehabilitation therapy, speech pathology and a host of other medically necessary services has been severely eroded.

- Inadequate staffing in long term care facilities is forcing families to pay for their own caregivers if they can afford to do so. Otherwise, residents go without even basic care as hours of care have been reduced while acuity has increased.

- Inadequate homecare budgets have led to massive cuts to home nursing, homemaking and personal support services. Those who can pay can get service. Those who can‚t go without and end up with preventable injuries and illness.

- Doctors are charging "block fees" for patients and patients don't know whether or not they have to pay to get onto the doctor's list.

Bill 8 must be changed to stop the two-tiering for so called "medically-unnecessary" scans that is allowed in the private MRI/CT clinics. There is no public-interest justification either in providing scans to people who don’t need them (and, not incidentally, exposing them to radiation in the process) nor in shuffling the queue to allow those with no medical need to get service before those with medical need. Bill 8 must also anticipate and prohibit increases in fees and charges levied by the for-profit corporations in search of new revenue-streams as they take over more health facilities. The government campaigned against P3 hospitals and private clinics.

They should fulfill their campaign promises to stop and reverse these privatizations. In addition, as the scope of Medicare has been reduced through delisting and underfunding, the Bill should protect against two-tiering for all of the services that have been delisted and any further erosions of this sort.

3. Create a Health Quality Council to report on Compliance with the Principles of the CHA

Given the CHA principles enshrined in the preamble to this Bill, it is surprising that the Health Quality Council outlined in Part I does not ensure reporting on the extent to which the health system conforms with those principles. Further, it is not required to report on issues relating to two-tiered medicine, extra billing and user fees.

No person who has a financial interest in for-profit health care corporations should be allowed to sit on the Council.

The appointment of the Council by the government is inappropriate for a body that is supposed to increase accountability and objective reporting. Rather than an appointed body, this Council should be comprised of a democratically selected group - appointed by all parties - who represent patients, advocates workers as well as so-called experts. The Council should include representatives from diverse groups, as well as geographically remote areas, and equality-seeking groups.

The Council should be required to investigate how the health system conforms with the principles of comprehensiveness and universality as well as accessibility. It should be required to report on two-tier access, user fees and service charges, and extra billing. Further, this democratic and representative Council should have the power to make recommendations regarding these issues and should be required to conduct its operations in a completely transparent manner.

4. Prohibit Block Fees and Charges that Create a Barrier to Access

We support and applaud the prohibition against physicians and other practitioners opting out of OHIP. However, we are concerned that the wording of the Bill allows this protection to be reversed in the regulations to the Bill therefore providing less protection than we already have in Ontario law. Government should not allow physicians to extra-bill by regulation.

Physicians across the province are charging patients for non-insured services by use of a block fee in which they set out a specified price to cover all services provided during a year. These services might include telephone advice, telephone prescriptions, medical assessments and notes, and other professional consultations. Some of these services have been de-listed. Some were never listed. To date, the regulation of this practice, such as it is, has been governed by College of Physicians‚ policies.

However, getting information on what charges are allowed, at what levels, and whether a physician can force patients to pay block fees is very difficult. We have been unable to get a list of services for which physicians can charge from the College.

We can get the list from the Ontario Medical Association if we pay a fee of more than $100. Technically, the College requires that physicians allow patients to make the decision about whether or not they will pay block fees and cannot refuse a patient who will not pay in this manner.

Bill 8 brings the regulation of Block Fees under the control of the government. We applaud this. However, it allows the regulations of the Bill (which are unspecified) to determine whether and how block fees can be charged.

We oppose Block Fees. We believe that Bill 8 should simply ban the practice. It violates the principles of the CHA as it creates a barrier to accessibility. It is unnecessary as physicians can charge on an item by item basis for those uninsured services. It is potentially a barrier to access as patients are unlikely to make complaints, or to know that they can make complaints if compelled by their physicians to pay the fees or if they are being charged inappropriately. In a context of a severe shortage of doctors, a system that allows block fees is open to abuse and patients have few choices to leave a physician since they cannot find another one.

Further, the preamble of the Bill sets out a commitment to primary care. This section of the Bill should address the transition to a team-based, salaried, reformed primary care model such as that used in Community Health Centres.

5. Ensure Public Accountability, Democratic Control, and Transparency

Part III of Bill 8 sets out far-reaching powers of the Minister to order individuals and organizations to comply with seemingly unfettered ministerial initiatives. Under the provisions, the Minister can direct any health resource provider, person, agency or entity to enter into accountability agreements ordered by the Minister those under his direction. There is little limitation on who might be required to enter into such an agreement.

There is limited guidance in the legislation regarding what might comprise an accountability agreement, and the Minister can vary, terminate or issue a new agreement at will. The Bill specifically refers to "value for money" and "fiscal responsibility" as well as "transparency", "quality improvement", "public reporting" in the list of matters this section covers. However, it can cover any other matter at his discretion. Further, the Bill allows the Minister to enforce compliance according to consequences that are left to the regulations (unspecified).

The Bill provides, in s.27, that the Ministerial orders can cover reduction or variation in a person’s terms of employment including compensation, and where this is contrary to his or her contract, the Bill determines that such change will be deemed to have been mutually agreed upon. Similarly, the Minister can reduce funding and vary any contract or agreement, and again, the Bill deems such unilateral orders to have been mutually agreed upon.

This section allows the Minister to order fundamental changes in the health system with little if any public consultation, procedural safeguards, transparency or other checks and balances.

We believe that the health system should be accountable to the people of the province, not to the Minister in such a top-down unfettered fashion.

This section provides no public accountability for the Minister or the health system. It does not provide democratic control and diverse representation on boards and governing bodies. It does not provide public access to financial information about the health system. It does not provide for whistle-blowing protection for healthcare workers who complain about poor practices by their managers or company owners. It does not provide for public consultation and meaningful input prior to changes in the health system. It does not provide for democratic consultation prior to cuts. It threatens free and open collective bargaining. It does not challenge the increasing "commercial secrecy" pervading the privatized parts of the health system. It does not ensure democracy and transparency with respect to defunding and delisting. It does not commit the Minister to improve his accountability for providing stable, predictable, multiyear funding prior to the end of the fiscal year. This section of the Bill must be changed to ensure accountability to the people of the province who pay for and use the health system. If the Minister is comtemplating another health restructuring exercise, he must conduct meaningful consultation with the people of the province and undertake any actions in a democratic, transparent and accountable manner.

An accountable health system must include:

- democratically elected boards, open memberships, and diverse representation on boards governing health care sectors

- whistle-blower protection

- transparency regarding delisting and defunding

- democratic governance of the OHIP list

- meaningful restrictions on commercial secrecy, and full public reporting on finances within the health care institutions and sectors

- public consultation, meaningful input and public debate about changes to the health system

- full public disclosure of fees, services charges and other out-of-pocket costs

- duty of the Minister to provide stable, multi-year funding

- representation of diverse populations, equality-seeking groups, and geographic diversity on all boards and other governing bodies

- meaningful input of healthcare workers and users at every level

6. Stop Privatization and Ensure Democratic Public/Non-profit Delivery of Service

The threat to the future sustainability of Medicare posed by private for-profit corporations is critical. P3 hospitals put billions of dollars of public funds into the hands of profit-seeking corporations for whom a veil of "commercial secrecy" obscures public scrutiny over profit-taking and misuse of public funds. The imposition of two separate sets of management under the same roof - one with a goal of providing a public service, the other with a goal of maximizing profit and growth - is fraught with problems.

The higher borrowing costs, consultant fees, inevitable legal fees, outrageous executive salaries, fraud and profit taking drive up health care costs, making competing claims on scarce resources. In their endless search for profits, corporations seek new sources of revenues, imposing fees and service charges wherever they can. The motivation and means for increasing two-tier healthcare are increased. The result is that the scope of services offered under the public system are reduced. Beds and staff are cut; patients face a barrage of new fees; two-tiering increases; public accountability and access to information is reduced; democratic control is reduced; advertising, consulting and legal costs go up; fraud goes up; executive remuneration goes up; more and more of the health system is governed by a bottom line of profit margins and rates of return for investors. We can provide masses of evidence from around the globe to substantiate these claims. (Insert stats here if you have time)

Further, the trend towards hiving off the so-called "non-clinical" services and privatizing them in facilities must be stopped. It must be made clear that medically necessary services include those services that support patients‚ daily living including food, laundry, maintenance, record-keeping, lab tests, diagnostics, therapies etc. These services are not second class to patients ˆ they are essential to infection control, nutrition, diagnosis, and recovery. They should all be provided on a non-profit basis.

Similarly, the creation of private for-profit clinics to deliver hospital services poses serious threats to the sustainability of Medicare. Access to diagnostics is limited by the supply of equipment (scanners) and trained personnel (radiologists, technologists). While private clinics provide machines - for which we ultimately pay - they do not increase the number of health professionals. The private clinics find their staff by poaching them out of public hospitals leading to staff shortages in public facilities. In addition, they seek new revenue streams out-of-pocket payment for so-called "medically unnecessary" scans - a trick to get around the Canada Health Act. A person who pays for a medically unnecessary scan therefore jumps the queue, using up scarce resources for no reason, and pushing back those with medical need on the waiting lists. In addition, the private clinics take the less risky and less costly scans, leaving the heavier burden scans to the public system which has been deprived of personnel. They also take the third-party billing patients and those on WSIB, depriving hospitals of this revenue. These clinics make profits at the expense of the public health system.

One only need look at the whopping increases in costs of drugs - the area of the health system most dominated by transnational profit-seeking corporations - to see the high costs and threat to public access by privatization. Fundamentally, the motivations of the profit-seeking corporations fly in the face of the principles of comprehensiveness, accessibility, universality and the single-payer system.

The Canada Health Act calls for public administration of the health system, recognizing the inherent threat posed by private insurance corporations. Similarly, private hospital corporations, private long term care corporations, private labs, private homecare corporations are a serious threat to the future sustainability of Ontario’s health system.

The current government ran on a platform of stopping the "Americanization" of our health system. The pre-election promise was very clear: they opposed creeping privatization and committed to rebuilding Medicare.

Any legislation purporting to show this government‚s commitment to the future of Medicare must include concrete initiatives to roll back privatization and prohibit future for-profit control of our health care institutions.

Sudbury, Ottawa and Windsor on February 17, 18 and 19;

in Toronto the week of February 23;

and in Niagara Falls on February 26, 2004.

Interested people who wish to be considered to make an oral presentation on Bill 8 must contact the clerk Susan Sourial at tel: (416) 325-7352 by the deadlines set out here:

in Sudbury, Ottawa or Windsor should contact the Committee Clerk by noon on Monday, February 9, 2004 .

in Toronto should contact the Committee Clerk by noon on Monday, February 16, 2004.

in Niagara Falls should contact the Committee Clerk by noon on Thursday, February 19, 2004.

Those who do not wish to make an oral presentation but who are interested in commenting on the Bill may send written submissions to the Committee Clerk at the address below by noon on Friday, March 5, 2004 .

Copies of the Bill may be purchased through Publications Ontario at 1-800-668-9938, or at 416-326-5300 in Toronto. An electronic version of Bill 8 is also available on the Legislative Assembly website at: www.ontla.on.ca .