Introduction
Canadian Pensioners Concerned Inc.(CPC) Ontario Division is appreciative of the opportunity to present a brief to the Commission on the Future of Health Care in Canada.

CPC, founded in 1969, is a national, voluntary, membership-based, nonpartisan advocacy organization of mature Canadians, committed to preserving and enhancing a human-centred vision of life for all citizens of all ages. Fundamental to a good quality of life is an integrated and comprehensive system of health care that is readily available to all "from womb to tomb." To this end, we support the principles of Canada's Health Act: universality, accessibility, comprehensiveness, portability and public accountability.
We further maintain that it is now imperative that the scope of the Act be broadened to include Home Care, Long Term Care, Denticare and Pharmacare, and that greater emphasis be placed on the determinants of good health, namely: income, nutrition, education, housing and the environment. In addition, adequate funding must be ensured, and a vigorous campaign undertaken to promote good health and the prevention of illness and disease.

We support A Call to Care, the joint statement prepared for the meeting in Ottawa on October 12, 2001 convened by the Canadian Health Coalition and the Canadian Labour Congress. (Attached)

Before Medicare
Seniors remember what it was like before Medicare, when we put off seeing the doctor as long as possible because our families could not afford to pay. Many of us bear scars from those days when we did not get appropriate and timely care. Families often experienced heavy debts from the costs of hospitalization for serious illnesses or accidents. In many cases, they were forced to sell their homes. Young people put off their extended education (sometimes indefinitely) to go to work to pay off family debts for health care.

There are many anecdotes from these times in "Life Before Medicare: Canadian Experiences" published by the Ontario Coalition of Senior Citizens Organizations, 1995. Seniors have no wish to return to the health care system of those times, nor to have their children and those who follow them, subjected to such conditions.

Seniors Not a Threat to Medicare
There is a popular myth that once you reach 65 years of age, you become sick, demented, helpless and dependent; you fold your hands and go on the dole. The much-maligned baby boomers are cited as a threat to all social programs because they will outnumber the wage earners and will presumably become dependent and contribute nothing to society. The truth is that the baby boomers have been the best educated, and, until recently, have had the best medical care of any generation yet. Like others already retired, they will continue to pay taxes, buy goods and services, donate to charity, help family members and do volunteer work.
Hopefully compulsory retirement will be dispensed with and those who wish to do so, will continue to be employed, perhaps in the training of less experienced workers. It should be recognized also that seniors have a wealth of knowledge and life experience which can be drawn upon in planning policy and programs at all levels of government and in their local communities. SENIORS ARE NOT A THREAT TO MEDICARE!

Sustainability of the Public System
With appropriate planning, Canada's public system of health care is sustainable.

• Canada is a country rich in natural resources and in its people and their skills.
• A fair and progressive tax system can take care of everyone's health needs
• If health care costs should rise incrementally because of population aging, costs in program serving the younger population will, concomitantly, drop.
• New technologies (e.g. joint replacement or cataract surgery) and medicines being used to treat seniors are instrumental in helping to preserve their independence and reduce demand for services such as Long Term Care.
• One of the highest costs of medical care is prescription drugs. Governments must not allow patents to be further extended. Provincial drug lists need to be coordinated and bulk buying by governments instituted. Many expensive drugs such as Visudyne for the treatment of macular degeneration are not included in the Ontario Drug Benefit Plan and hence are prohibitive for many seniors. The alternative is to not take the treatment and become blind, which leads to greater loss of independence and greater expense to the health care system.
• Medicare costs are not out of control; private expenditures are (i.e. health care costs paid for by the person receiving them). In Ontario "between 1980-1999 public expenditures on health care increased by 135%, but private expenditures shot up 333%". Health care as a percentage of GDP has remained relatively stable.
• More attention must be given to dealing with the determinants of health - income, housing education, nutrition, environment ( air, earth and water).
• The health system must be better integrated so no one falls through the cracks -, e.g., patients are often sent home sicker and quicker, because of hospital restructuring, and without adequate home care. Often health deteriorates further and the patient has to return to hospital or be institutionalized, at greater cost to both the patient and government.
• Inadequate supports to help people remain in their own homes leads to health breakdown and dependency and to increased demand for nursing homes, which are already in short supply. This leads to higher health care costs for society and the individual.
• Health promotion and disease prevention (eg. proper nutrition, exercise, social contacts etc.) receives less than 2% of health budgets, but are the most effective way to reduce the high mortality linked to unhealthy lifestyles - diseases such as heart attacks, strokes and high blood pressure. If we increase budgets for health promotion and disease prevention, then the far more expensive costs of health cure will drop significantly.

In an article on a web-site Dialogue on Health Reform, Monique Begin, former Minister of National Health and Welfare, maintains that real reforms, not simply more spending, are needed to heal and strengthen the health care system. "The letter and spirit of the Canada Health Act (1984) need to be implemented; the mode of remuneration of physicians must be changed from the perverse fee-for-service; the organizational and budgetary "silos" that evolve out of health ministries need to be replaced by disease management approaches and other models that enhance seamless integration of services; incentives must be offered to hospitals who can show improvements because of evidence-based best practices, and new federal legislation covering health care outside of hospitals needs to be created that provides stable funding."
"These reforms [she maintains] can only be realized through the cooperation of both levels of government, medical associations, unions and other players."

YES, CANADA CAN SUSTAIN A PUBLIC HEALTH CARE SYSTEM! IN FACT, WE CANNOT NOT AFFORD IT!

Managing Change
The Hall Commission Report in 1964 outlined the framework for a comprehensive medicare program for Canada. Unfortunately, only part of the system was implemented in the 1960s and we are now in desperate need of the completion of the project. This has become critical in the light of the rapid escalation of new technologies in the provision of healthcare. These new technologies have resulted in the rapid increase in:
a) the pharmaceutical approaches to illness, disease prevention, and the amelioration of illness, and
b) the drastic shortening of hospital stays for patients
c) the rapid rise in the need for and use of Homecare.

At this time in our history, the cost of healthcare is increasingly falling on the individual, either directly through out-of-pocket expenses for prescription drugs, Long Term Care and Homecare, or indirectly through taxation or escalating insurance costs. The public administration nonprofit approach to "medicare" shares the burden across all of society and contributes to social equity and justice. The private, for-profit approach does not. We therefore argue that we must recognize the changes that have occurred in the field of medical practice and treatment and at the least institute universal Pharmacare, Long Term Care and Homecare programs as part of the services covered under The Canada Health Act.

Healthcare as a "Public Good"
We see Healthcare as a "public good" and/or "public service" that must be publicly funded, administered and delivered. Health care cannot be, first and foremost, a "for-profit" industry. There are great pressures coming from the private sector (the for-profit sector) to shift from public administration to private administration. The argument is being made that "health care" is in financial crisis and that the only way to resolve this crisis is to turn to the private sector. This argument ignores the many studies that have been made, especially in the United States but also in Canada, that show public administration is far more cost effective than private; that more dollars go into actual direct care under public administration than they do in the private for-profit sector. Health care is the highest priority in the minds and hearts of a majority of citizens.

The issue is - how can we best manage the delivery of healthcare in a changing environment? The answer is clear. It is only through the expansion of the publicly funded, administered, and delivered healthcare services that the needs of all Canadians can best be met.

Financial Crisis
Business groups, politicians, academics and many others have been predicting doom and gloom concerning the financial crisis facing medicare in Canada. They assert that the "Baby Boomers" will break the system, and that the only solution is for a large infusion of private for-profit businesses to enter the system. This is a myth being perpetrated by those who want Canada to move to a private for-profit structure for those with insurance or who can pay, leaving the public nonprofit services for those who are poor. A two-tiered system is their vision. Change can be better managed, and we can and must do so, but not under the threat of the imminent introduction of a two-tiered system lead by private for-profit organizations and multinational entrepreneurs.

We do not face any crisis that compels us to adopt a private for-profit system. There is, however, an urgent need for better planning and administration of the current medicare system. We need to spend our public dollars more effectively and efficiently. If there is the will and clear commitment it this can be accomplished

Changes in Public Knowledge
Changes have also occurred in the public awareness and understanding of illness and of disease prevention, through the information available on the Internet, in books and magazines, and the press. Many more patients are now going to their healthcare provider with a reasonably good knowledge about their medical problems, and are in a far better position to decide what treatments they want or don't want. If circumstances were to change, and these were private for-profit managers who could ultimately have the power to decide what treatments the patient may be granted or not, then the patient would no longer a partner in his or her own health care; he or she would be simply a client/recipient (e.g., US Managed Care under corporate management). This would be a seriously regressive development, one that would deny our current understanding of the value of the holistic approach to healthcare and of the importance of the partnering of the patient with the healthcare provider(s) in improving his or her health status.

Public administration and delivery of services strengthen the role of the public whereas private for-profit administration and delivery of services weakens it.

Changes in Practice and Approaches
There has been a change in the approach to the delivery of healthcare, from the doctor-led model to a multi-disciplinary team approach - an approach that is inclusive of many skills and broader knowledge. The public is increasingly demanding to be a full member of the team and to participate in the planning of their personal health. The many health-profession schools must be required to instil in their students this new team-based approach to health care. This new approach is especially needed in the training and education of new physicians. We will have an approach that will respect the rights of the patient, maximize the skills of the professionals and lead to a more effective use of our human and financial resources. Community Health Centres in Ontario are good models for this approach.

The many health profession schools must be required to instil in their students the new team-based approach to health care.

Primary Care Practice
Primary Care has changed; however, the tools to manage this change are not in place. Healthcare providers, especially physicians, rarely make house calls, yet their offices are not open twenty-four (24) hours a day seven (7) days a week. Illness does not wait for office hours! Emergency Departments in Hospitals are neither designed nor intended for the provision of primary care, yet that is where people must go because little else is available much of the time.

We need to have available multi-disciplinary teams of healthcare providers accessible twenty-four hours a day, seven days a week, and these teams must have quick electronic access to patient records.

Primary Care - Patient Information
It is now commonly recognized that we must use the technology available to maximize our efficient use of resources to help those in need of healthcare. Electronic communication systems allow us to transmit detailed health information from one care provider to another within seconds when the need arises. The image of a patient walking their x-rays from one branch of a hospital to another is antiquated and just not acceptable. It is absurd to have physicians or hospitals or other care providers view the patient's records as belonging to the provider and not the patient! Patients are often required to pay for their records to be transferred! The record belongs to the patient and must be available to those needing access to serve the needs of the patient.

We must have electronically transmittable patient records. Patient privacy, however, is important. Three issues must therefore be addressed:
1. The right of the patient to determine what information will not be made readily available without their consent.
2. The use of an oath of confidentiality for all care providers accessing patient records. There must be clear penalties for those who break that oath.
3. A clear and effective role for the Office of the Privacy Commission in overseeing this area of patient information.

Human Resources
There are growing shortages of health care providers in all the health care professions. In the past, provincial governments have made short term, ill-advised decisions regarding the limiting of enrollment targets for these fields of study. Cuts have been made in the employment numbers or down-skilling of the labour force, especially in hospitals, in order to save money in the short term. We are now facing the consequences of those decisions - shortages of radiologists, of nurses, technicians, physicians etc. To compound this problem, we have made it nearly impossible for new Canadians who possess these needed skills to qualify for practice in this country. At present, there are human resources that are under-utilized or wasted.

We need a national Federal-Provincial task force to study the long term needs of the various health professions. We need a strategic plan to develop those resources so that citizens in need in all parts of the country will have reasonable access to the expertise they need.

Accountability - Performance Measures
New technologies, new treatment modalities are being developed at a rapid pace. In order to successfully manage and maximize the benefits from these new developments we need to have Federal-Provincial agreement with regard to the following:
1. Performance measures against which all current and new technologies can be measured. Patient outcomes should be the key element in the evaluation, as well as effective use of resources.
2. Public involvement in the accountability process must be present at all levels of decision-making. The public must be able to speak with its own voice.

Managing Change and the Canada Patent Act
The changing business environment towards medical discoveries which leads to private interests taking precedence to public interest must be critically reviewed. The changes that are occurring require immediate and strong action by the Federal government to defend the public interest above private profits and to preserve the viability of the health care system. Specifically, we call for the following:
1. Stop the privatization of human genes. We must join with other countries who reject the "right" of private companies to patent human genes. Genes are part of our humanity - not the private preserve of corporations.
Industry Canada and the Government of Canada must make it very clear that no patents on human genes will be recognized or allowed in Canada.
2. There must be a thorough review of, and revisions to, the Canada Patent Act and the Regulations specific to new patents for prescription drugs, to ensure that:
a) only new drugs that provide a new clear and distinct and cost-effective advantage (for the patient) shall be granted one patent
b) if new treatments are discovered which use an existing patented drug no new patents will be provided
c) no additional patents will be granted to cover drugs that are already patented
d) it prohibits the direct advertising of prescription drugs to the public
e) it facilitates the timely introduction of lower-cost generic drugs into the market

Cooperative Relations
We cannot hope to cover all the linkages that are central to an effective 21st century healthcare system, but we will argue that cooperation is essential at all levels and among all actors.

Federal-Provincial Relationships
The absolute necessity of Federal-Provincial cooperation is self-evident. In recent years, however, it has been more honoured in the breach than in the observance.

CPC is aware of the issues, history and tensions in the implementation of the Canada Health Act (CHA). Many of our members have lived long enough to know personally the struggles and debates preceding its adoption. Many rejoiced at the vigorous leadership taken by the Federal government of the day, at the behest of some of the provincial governments of that period.

CPC understands the constitutional ordering of roles and responsibilities of the respective levels of government and is aware of the need for cooperative federalism to address the changing needs and priorities of the Canadian people.

The Canada Health Act itself exists because of cooperative federalism. Strong Federal leadership and presence were critical in its adoption and implementation. Cooperative federalism is the strategy that has always made Canada work most effectively. All Canadians benefit when the Federal and Provincial governments join together in agreement on policies and programs. We take it for granted that cooperative relations between the two senior levels of government are essential. There must be agreements that bind all the governments, agreements that the public can use to hold their governments accountable; agreements that are not just "lowest common denominator" agreements.

The Canada Health Act is not simply an out-of-date, historical artifact. It is an important work in progress. Its essential principles remain entirely relevant, and we argue that the expansion of the Canada Health Act to complete the vision set out in the Hall Commission Report of 1964 is crucial. We must bring medicare into the 21st century. We must have legislation that recognizes and provides for the evolutionary changes in healthcare, and one that fulfills the promises and commitments made to all Canadians in the 1960s, regardless of their province or territorial place of residence.

Homecare, Long Term Care and Pharmacare need to be included under the Canada Health Act. We must have universally accepted standards of care, applicable to all care providers and services in Canada. We must have true portability - not a patchwork quilt of coverage that exacerbates differences of privilege and disadvantage between and among Canadians. We must have universal access to prescription drugs and other technologies at an affordable cost to the individual. None of these needs can be met without the cooperation of the senior levels of government and strong Federal presence and leadership.

To Canadian Pensioners Concerned, the expansion of the CHA in these two critical areas requires serious attention to Federal earmarked, targeted funding to ensure consistent cross-country standards, quality and accessibility for these services, irrespective of place of residence.

Block funding appears to have led to discrepant delivery of services currently covered under the CHA. The block funding approach does not appear to have ensured that such Federal transfer funding is necessarily and consistently used for its intended health programs and services. We believe the Federal Government has not acted sufficiently vigorously in defending and enforcing the underlying principles of the Canada Health Act. Cooperation is important, but not at the expense of the integrity of the Act. Clear, specific conditions are essential. Acceptance of targeted funds should be treated as a clear contractual agreement, with penalties for non-compliance.

Cooperation among Healthcare Providers
It is essential that there be close cooperation and active collaboration between the different levels of care (hospital, home care, institutions and primary community care) so that the patient can readily access the kind of care that will most effectively meet his or her needs. Patients should be able to move back and forth between these levels as their needs change.

At all levels, there should be every opportunity for input from the consumer of service and vehicles for registering concerns and complaints about services without fear of retaliation.

Provincial governments (Ministries/Departments of Health) are (or should be) the key to the tasks of planning, implementing and monitoring the effective meshing and interconnectedness of various programs and levels of care to ensure maximum seamlessness and continuity in the health care delivery system. People in need should not "fall through the cracks" of the system. Regrettably, at present, this occurs too often, and has serious human and economic consequences.

Cooperation Among and Between Health Professionals
We cannot countenance a continuation of the competition between professionals for power and prestige: physicians vs nurses, heart surgeons vs general practitioners, primary care providers vs audiologists, and so on. We need teams of people working together to help all Canadians regardless of their incomes or place of residence.

The professional colleges must be required to recognize each other's skills, and their respective roles in the healthcare system. Healthcare must become a true system, not just a patchwork of uncoordinated services.

The expertise and education of health professionals coming from other countries must be given fair and expeditious evaluations, and these potential resources must be provided with the opportunities and support needed to become full partners in the healthcare professions in Canada. Furthermore, inter-provincial barriers must be eliminated, if we are to benefit from all the expertise that is available in this country. Thus, inter-provincial cooperation is also essential as the provinces control the colleges of regulated professions.

A CALL TO CARE
A joint statement prepared for the meeting organized by the Canadian Health Coalition and the Canadian Labour congress, October 12, 2001, Ottawa

The public has an abiding sense of the values of fairness and equity and do not want to see a health system in which the rich are treated differently from the poor. The forum supports this view and supports necessary changes to our system only if we preserve the essence of medicare - universal coverage based on need, without financial barrier, portable across the country, to a comprehensive array of publicly administered health care services.

National Forum on Health, 1997

The peoples of Canada believe that health is a fundamental right of every human being without distinction of race, religion, political belief and economic or social condition. Organizations representing millions of Canadians will mobilize to defend this right and to ensure that the following principles shape the future direction of the health care system:
1. The recognition of health as a fundamental right throughout life and the necessity of preserving public health through active measures of promotion, prevention and protection, including such determinants as housing, income education, environment, employment and peace.
2. The reaffirmation of the original vision of a truly comprehensive public health care system for Canadians with a continuum of services. The next steps are the expansion of the public system to include a universal system of home and long term care services and pharmacare.
3. The need to move away from the fee-for-service model towards community based, multi-disciplinary approach to the management, organization and delivery of services and care. Levels of service must be sufficient so that the burden of care does not fall on families, mainly women.
4. The recognition that health care is a public good in which the few must not profit at the expense of the many. We affirm the need for a system of public health care which is organized on the basis of public administration, public insurance and the delivery of services on a public, not-for-profit basis.
5. The need for the federal government to fully assume its responsibilities in respect to health, particularly by restoring and increasing federal transfers to levels sufficient to secure the integrity of the Canada Health Act.
6. We oppose any commercialization and privatization of health. Therefore, the federal government must negotiate a general exclusion of health services and health insurance from all trade agreements.
7. We reaffirm the need to make health care accountable through democratic participation and governance throughout the health care system.
8. The recognition that health care workers are critical to the effective operation of the health care system and that decent wages, working conditions and training opportunities are essential to high quality care and the retention of health care workers.

Regardless of where we live, it is now imperative to reaffirm the values we all share. These values must guide our collective choices for the future of social services and public health care: universal coverage based on need throughout Canada.

We believe these values must be adhered to by all governments in Canada, even though jurisdiction is largely a provincial or territorial matter. Therefore, the principles of the Canada Health Act should be enshrined in the laws of each province and territory.

We come together to commit to direct political action to ensure that the governments throughout Canada protect and expand health care based on the foundation of the Canada Health Act.

What stands between Medicare and its destruction are the peoples of Canada. Future generations are depending on our vigilance.