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37th PARLIAMENT, 2nd SESSION

Standing Committee on Health

EVIDENCE

CONTENTS

Wednesday, April 2, 2003

1545

The Chair (Ms. Bonnie Brown (Oakville, Lib.))

Mr. Roy Romanow (Former Commissioner, Commission on the Future of Health Care in Canada)

1550

1555

1600

1605

The Chair

Mr. Rob Merrifield (Yellowhead, Canadian Alliance)

1610

Mr. Roy Romanow

Mr. Rob Merrifield

Mr. Roy Romanow

Mr. Rob Merrifield

Mr. Roy Romanow

1615

Mr. Rob Merrifield

Mr. Roy Romanow

The Chair

Mr. Réal Ménard (Hochelaga—Maisonneuve, BQ)

1620

M. Roy Romanow

Mr. Réal Ménard

Mr. Roy Romanow

1625

The Chair

Ms. Carolyn Bennett (St. Paul's, Lib.)

Mr. Roy Romanow

Ms. Carolyn Bennett

Mr. Roy Romanow

1630

Ms. Carolyn Bennett

Mr. Roy Romanow

The Chair

Ms. Judy Wasylycia-Leis (Winnipeg North Centre, NDP)

Mr. Roy Romanow

1635

The Chair

Mr. Jeannot Castonguay (Madawaska—Restigouche, Lib.)

M. Roy Romanow

1640

Mr. Jeannot Castonguay

Mr. Roy Romanow

The Chair

Mr. Greg Thompson (New Brunswick Southwest)

Mr. Roy Romanow

1645

The Chair

Ms. Hélène Scherrer (Louis-Hébert, Lib.)

1650

Mr. Roy Romanow

1655

Ms. Hélène Scherrer

Mr. Roy Romanow

The Chair

Mr. James Lunney (Nanaimo—Alberni, Canadian Alliance)

Mr. Roy Romanow

1700

Mr. James Lunney

Mr. Roy Romanow

Mr. James Lunney

Mr. Roy Romanow

1705

The Chair

Ms. Carolyn Bennett

Mr. Roy Romanow

Dr. Gregory Marchildon (Former Executive Director, Professor and Canada Research Chair in Public Policy and Economic History, Faculty of Administration, University of Regina, Commission on the Future of Health Care in Canada)

1710

Mr. Michel Amar (Former Director, Communications and Consultations, Commission on the Future of Health Care in Canada)

The Chair

Mr. Rob Merrifield

Mr. Roy Romanow

Mr. Rob Merrifield

1715

Mr. Roy Romanow

Mr. Rob Merrifield

Mr. Roy Romanow

Mr. Rob Merrifield

Mr. Roy Romanow

Mr. Rob Merrifield

Mr. Roy Romanow

The Chair

Mr. Jeannot Castonguay

Mr. Roy Romanow

The Chair

Ms. Judy Wasylycia-Leis

1720

Mr. Roy Romanow

1725

The Chair

Mr. James Lunney

1730

Mr. Roy Romanow

Mr. James Lunney

Mr. Roy Romanow

Mr. James Lunney

Mr. Roy Romanow

The Chair

Mr. Roy Romanow

The Chair

Mr. Roy Romanow

The Chair

CANADA

Standing Committee on Health

NUMBER 028

2nd SESSION

37th PARLIAMENT

EVIDENCE

Wednesday, April 2, 2003

[Recorded by Electronic Apparatus]

¹ (1545)

[English]

The Chair (Ms. Bonnie Brown (Oakville, Lib.)): Good afternoon, ladies and gentlemen. It's my pleasure to welcome you to this meeting of the Standing Committee on Health, and on your behalf, to welcome our key witness, Roy Romanow, the former Commissioner on the Future of Health Care in Canada. He has with him Dr. Gregory Marchildon and Michel Amar.

We congratulate Mr. Romanow on his report, which the whole country welcomed, I think; certainly, this committee did. It's a few months ago now, so we would invite you to update us on where you think the results have led us and where you would like to see us go.

Mr. Romanow.

Mr. Roy Romanow (Former Commissioner, Commission on the Future of Health Care in Canada): Thank you very much, Madam Chair.

I'm not sure I'm going to be able to enlighten very much. Maybe the committee members will be able to enlighten not only me, but the Canadian public on this very important subject, even though we're living in very trying times.

I want to thank you for introducing my two colleagues, Dr. Greg Marchildon, who is the chief executive officer for the royal commission and lead pen for the report, and Michel Amar, who is the commission's director of consultations and, I would argue, the architect of our strategy for engaging Canadians in this process. With your permission, Madam Chair, and the permission of the committee members, if I run into any rough spots in questioning, my rule is that I answer all the easy ones and these two guys answer all the tough ones.

[Translation]

Madam Chair, it is a privilege for me to appear again before the Standing Health Committee. I know I am here to answer your questions and I will therefore be brief with my preliminary statement.

[English]

Over four months ago the final report was submitted--it just seems like yesterday when you're having fun--and it's just over two months since Canada's first ministers came together to achieve an important 2003 health accord. The health accord is a major first step, in my judgment, in fixing medicare, for a number of reasons. I would just briefly outline the positive reasons.

[Translation]

First of all, the First Ministers have renewed their commitments on the five principles of the Canada Health Act.

[English]

Second, they recognized that reform and new public investments are required to meet Canadians' desire for a sustainable health care system that provides timely access to quality health services. Third, they took a solid first step, in my judgement, towards reform by not only reaching consensus on a number of targets and objectives for improving health care, but also agreeing to report publicly on their individual and collective progress in meeting them. Fourth, they accepted the imperative to improve transparency and accountability in Canada's health care system. Fifth, they recognized the urgent need to better monitor population health and to address health disparities, directing Canada's health ministers to “continue to work on healthy living strategies and other initiatives to reduce disparities in health status.” By the way, the FPT symposium on healthy living scheduled for the end of April in Toronto is one example of the new spirit of collaboration on health care, and I think this will serve Canadians very well indeed. Finally, and perhaps most significantly, the first ministers agreed to work together with each other, with the health care providers, and with Canadians, the public at large, in shaping the system's future, agreeing to the creation of a Health Council of Canada. I'll have more to say on this towards the end of my remarks.

Again, these are very notable achievements, and first ministers deserve credit for their efforts, for their flexibility, and for their leadership. Canadians should be very pleased that the first ministers agreed to embrace a reform agenda that goes beyond a simple focus on hospitals and physician services. The ambitious and explicit targets that have been established for ensuring 24/7 access by Canadians to front-line primary health care are another important and positive development. We should also welcome the collective commitment by first ministers to set certain national objectives in regard to home care, and especially for community mental health services, which I have described as one of the orphaned children of health care. This is a praiseworthy step forward, as are, I would argue, the recognition by the first ministers of the need for action to provide catastrophic prescription drug coverage for Canadians and the decision to allocate $1.3 billion for first nations health.

At this point I want to congratulate Minister Anne McLellan and her provincial counterparts for their excellent work in establishing criteria and public reporting mechanisms that will apply to the $1.5 billion medical equipment fund just announced. This is, in my view, a very positive evolution from the general, open-ended approach that characterized and marked the failure, I think, of previous accords, like the September 2000 accord--maybe failure is overstating it, but at least, it was less than satisfactory.

Finally, the agreement to replace the current CHST, the Canada Health and Social Transfer, with a dedicated CHT, a Canada Health Transfer, I think is a very important accomplishment. It will improve transparency and accountability in regard to what each level of government is contributing to the health care system.

Those are the positive things, amongst others, but I also have some observations and questions about the adequacy of the dollars on the table and where and how they will be spent to improve and strengthen the health care system for Canada and Canadians. Let's make no mistake about it, there is a lot of taxpayer money on the table in this current accord, and depending on the assumptions used--and I think it doesn't help us very much to get drawn into sterile debates about whether it's new or old money--there is somewhere between $30 billion and $35 billion at stake over the next several years.

But I do have four major concerns with the money issues. First, there is less money than the Senate committee report on health suggested was necessary, less money than our own commission recommended, and most importantly, less money in the immediate term, in any event, than is needed for Ottawa to contribute its historical federal share of the medicare bargain.

¹ (1550)

Second, while first ministers accepted allocating some $16 billion over the next five years to a health reform fund, there are still too few details available to know what the health reform fund will actually achieve, what conditions if any will apply, or what criteria will be used to evaluate its effectiveness. This is a lot of work yet to be done.

I have similar concerns about the immediate $2.5 billion top-up that has been agreed to, ostensibly for assisting provinces to address urgent immediate priorities like attacking the wait list problem and improving timely access to care. If the $2.5 billion is spent wisely--and here's the important part, in my view--and according to a coherent plan, it can make a very real positive difference. However, so far the only real guarantee that the additional $2.5 billion will in fact be devoted to health care in this area will be an effective and transparent accountability framework that allows Canadians to see exactly how their governments are using this money. That's good, we want the accountability and the transparency, but there also needs to be a coherent plan.

Third, much of the money available within the health reform fund will be loaded towards the end of the term of the 2003 accord. This may end up delaying needed reforms in a number of areas. Under the health reform fund less than $1 billion will be available in year one for transforming the system, and funding increases will rise only gradually thereafter. Change will still occur, let's give the government and the first ministers credit, there's no doubt about that, but it should be understood that it'll occur more slowly than should be the pace ideally, the pace I think Canadians and the system demand.

And as I will explain shortly, the lack of stable and predictable transfers will hamper our ability to support longer-term planning, while encouraging federal-provincial bickering in the short to medium term.

Madam Chair and members of the committee, I do not want my comments to be construed as critical or as damning the accord with faint praise. As a former premier, I can personally attest--boy, how I can attest--to how difficult and politically fraught the federal-provincial arena can be. The health accord is, I repeat, a first major step, and we should acknowledge that. It provides a strong foundation for revitalizing our system. It will allow us to take the further steps necessary in the coming years to build the most effective public health care system in the world or the vision statement to make Canadians the healthiest people in the world.

¹ (1555)

This committee knows better than most there is no shortage of areas in our health care system where we can and must do better. For example, we need to better coordinate and support the expansion and alignment of health care professionals and our health infrastructure, making sure plans in all jurisdictions can keep in step with patient needs and expectations. Second, timely access to quality care has to be made a reality. Third, we need to focus more on preventing chronic diseases, investing more in population health and wellness initiatives that make the system more sustainable and promote self-reliance and our own responsibilities for health care. Fourth, we need to upgrade our national capacity in health research, especially as it applies to population health and health informatics. Fifth, we need more collaborative initiatives, like the common drug review process that came on stream earlier this year, to help us get a handle on containing ever increasing rises in drug costs. And we need to ensure that we have a regulatory system that is more responsive to public policy imperatives in this area for safety, affordability, security of supply, ethical standards, and competitiveness.

I believe only limited progress can be made in tackling these problems anywhere in this country in the absence, again, of a coherent and coordinated national plan of action. This presupposes that the conditions exist for the federal and provincial governments to move forward together. I say we're getting much closer, but we are not there yet. To make headway on this problem, I believe we must continue to make progress in three key areas.

[Translation]

First, I believe that we have to change the way the system is funded not only to make it more stable but also to reduce tensions between the federal and provincial governments.

[English]

Second, I believe we need to modernize the Canada Health Act to reflect the reality of how health care is delivered in Canada today. And finally, we need to establish an effective Health Council of Canada, to make the system more accountable to taxpayers and to give patients and providers a stronger voice and a greater say in shaping their future directions in health.

Let me just summarize my views in this regard before I close. In my final report, talking about the health system and the CHA, I recommended that by 2005-2006 Ottawa cover a minimum of 25% of provincial health spending for Canada Health Act expenditures and that this be provided in the form of a dedicated cash-only transfer. I also proposed an escalator clause within the transfer to allow the federal share of health spending to track inflation and adapt to changing patterns of provincial health care spending. Taking account of tax points that were permanently transferred to the provinces way back in 1977 in addition to the 25% cash transfer would restore Ottawa's share of CHA-covered health spending to historic levels.

What would this new funding mechanism achieve? For one thing, it would remove an ongoing irritant, which I fear is still there, from the already volatile intergovernmental relations mix, while simultaneously improving transparency and accountability. The federal and provincial governments would be working together from the same numbers, and they would not be continually negotiating the size of the federal transfer, the growth of the federal transfer, or both. In short, the result would be a more positive federal-provincial dynamic and adequate stable and predictable funding for the system. That stability, that tranquility in the federal-provincial wars over health care, is desperately need.

I also linked the 25% federal funding floor by 2005-2006 to targeted funding, on the argument that the funding should buy change in a number of specific areas over the next two fiscal years. The targeted funding was to focus on key short-term priorities of Canadians, such as timely access to care and advanced diagnostic services. It was also intended to kick-start the revitalization of medicare by providing federal funding to support home care and prescription drug treatment as integral components of a modern-day health care system in Canada.

To entrench these changes, the report recommended that the Canada Health Act be amended by statute to include priority--note the word priority--home care services and prescription drug coverage. In my view, this would acknowledge that health care today is about more than just doctors and hospitals, which is all the Canada Health Act, as important as it is, currently covers. Given that prescription drug coverage and home care are the fastest growth areas of health care spending, this would also ensure that Ottawa is financially responsible for paying its share of the system's expansion and bring it into the basket of services under the CHA.

º (1600)

As this committee knows, one of the real barriers to improved cooperation and coordination in our health care system is that the different levels of government and sometimes different provincial governments begin from very different starting points on simple issues of fact. Thus, the report suggested the creation of a Health Council of Canada, whose membership would be broadly reflective of the various interests at play in health care, patients, providers, and officials. It would promote collaboration among the governments, and it would also make sure they would be reporting to those who utilize and own the system, ordinary Canadians.

The Health Council would incorporate the following features. It would bring together under a single roof a number of existing federal and provincial advisory structures and agencies and provide an objective and neutral forum whose expertise governments and the public could draw upon, as required, for support. Second, it would give patients and providers a more direct say in how the system operates and the means to monitor its performance. If there's any message I got from the royal commission hearings, it was those two for sure. Third, it would serve as a focal point for gathering health information, for setting common health data and informatic standards--something towards which we've made some progress with CIHI, but frankly in my judgment, there's a long way to go--and once we get the common health data and standards, for interpreting and reporting to Canadians how we're making out in achieving those standards, the outcomes. Fourth, in time, as trust is gradually built, the council would become a trusted source of advice for governments on how best to discharge their individual and collective responsibilities for the system and assist in fact-finding and in resolving disputes over the interpretation of the Canada Health Act.

I note that the 2003 health accord commits governments to establishing a Health Council of Canada, right around the corner, by May 5, 2003. Obviously, the council's eventual terms of reference and governing structure, the autonomy, the quality of those selected to serve on it will determine its effectiveness. I remain hopeful that first ministers will create an effective, inclusive, and independent health council that will do more than focus narrowly on the implementation of the accord. Properly structured, it will mean less bureaucracy, not more. May I just repeat that, because I think there's been a lot of misinterpretation. This is not an extra bureaucracy. It should mean less bureaucracy, streamlining it, and not more. And it will speed up the pace of innovation and reform, not slow it down.

Madam Chair and members of the committee, whether or not we as Canadians and governments of Canada succeed in establishing an effective Health Council of Canada will prove to be, in my judgment, a litmus test of whether or not the governments of this great nation of ours have listened to Canadians in respect of what they told me they wanted the accomplishments of the council to be during the royal commission hearings.

I would, therefore, also like to draw to the standing committee's attention a March 21, 2003, workshop in Toronto that was organized by Professor Colleen Flood of the University of Toronto, funded with the support of the Atkinson Foundation of Toronto. The workshop brought together some of the foremost health policy minds in the country, who have been active and vocal advocates for a national entity that would have roles and functions similar to those I have just outlined. The stature and the calibre of the participants is eloquent testimony to the interest that has been generated in the health council and the proprietary sense that flows with that for ordinary Canadians about accountability and transparency.

I repeat again, in my judgment, Canadians will be watching extremely carefully, this being probably, after the budget and the accord, the first major act to determine whether or not the council is set up, has the appropriate mandate, the appropriate resources, independence, and leadership to make a real and positive difference in influencing the future direction of health care in Canada. With respect, we cannot fail Canadians.

º (1605)

In closing, let me say the past 18 months or so that I spent as commissioner were among the most exciting and challenging, and I might add most rewarding, in my public life. The process renewed my faith in Canadians, in their maturity, in their capacity to understand and to make tough choices, in their faith in the democratic system, that politicians and governments will listen and still can listen, and in the common values that unite us as a country. I believe absolutely we can make our health care system the very best in the world--and it's very good now--if we're prepared to heed the advice of Canadians and to respect their wishes, and I believe the health accord is a very important first step to getting there, but there's much work yet ahead of us.

Thank you very much.

The Chair: Thank you very much, Mr. Romanow.

We'll move to the question and answer session, and we'll begin with Mr. Merrifield representing the Alliance Party.

Mr. Rob Merrifield (Yellowhead, Canadian Alliance): Thank you.

I appreciate your coming in again, Roy. You were here last time, and I challenged you, I think, when I chatted with you about your commission. I certainly applaud the work you've done, I think you've given it your best, but what I said to you back then was that the report will be either a success or a failure determined not by how good or how bad the report is, but by how much is actually accepted, complied with, and implemented. You obviously have seen the health accord and what has come out of that. Some you could say is perhaps a step towards some of the things you recommended, other things are not.

I have a number of questions. I know I'm not going to get at them all, so what I'm really wrestling with is which ones I should ask first.

º (1610)

Mr. Roy Romanow: The easiest ones.

Mr. Rob Merrifield: Yes, the easiest ones.

What was frustrating to, I think, many Canadians was the dollars coming out of the accord. If you didn't like the numbers, you just read a different paper that morning and you got a different rate of numbers. It seemed there was much confusion, and I think there is still a little confusion as to the number of dollars, because some of them, as you have said, have been previously announced, so which were actually new dollars and which were not? Nevertheless, let's forget about the numbers, because we could get into a long debate about that, and it's not worth it. The reality is that the provinces stepped away from that table and agreed to the arrangements with the money that was on the table, and so did the federal government. So I guess my challenge to both the provinces and the federal government is to stop the squabbling and start performing and moving ahead on health care reforms.

My first question to you is on the strings attached to that money. You recommended some fairly stiff strings. I believe that was the approach of the federal government going into the accord. Nonetheless, the provinces held on and said a lot of this was their jurisdiction. As a premier of a province, if you, let's say, have been provided, as in New Brunswick, with a very comprehensive home care program, if there are strong strings attached to that money, would you forgo having that money, or would you want the flexibility the provinces have achieved through the accord? Are you pleased with that or not?

Mr. Roy Romanow: Well, Mr. Merrifield, if I may say so, as usual, that's a very tough question to answer, but an important one.

To be very succinct, I believe the accord improved, in a way, on the commission's recommendations by putting into the medical reform fund three of the five specialized funds I advocated, and in doing so, it provided some flexibility for the provincial governments to use those sources that were applicable to their individual jurisdictions. New Brunswick has a pretty good, if I may say so, home care plan, and their priority may be in another area. I think in that regard there is some improvement with respect to the accord. The key question, however, remains for me. The devil, as we know, resides in the details. How one gains access to the medical reform fund, under what terms and conditions, the coherent plan, the degree of flexibility that is going to be involved are still being worked on and need to be determined. I don't dismiss this as an improvement, I think it is an improvement, but I think more needs to be worked out before I can comment particularly on that.

Mr. Rob Merrifield: So what I'm hearing you say is that you're okay with the flexibility under the fund, and I would agree with that.

I would agree with your other comment with regard to the rest of the health reform fund. The catastrophic drug plan is supposed to be worked out over a two-year period. I know you're recommending that the provinces ante up 50-50 on that fund. That is yet to be worked out, and it really will be interesting to see how that's worked out. I don't know if there's any point in commenting on that, but it is going to be interesting.

When it comes to the strings attached, would it not have been wiser and less confrontational to have challenged the provinces--and you are an ex-premier--to come up with ideas on where they would apply the money to retain the values Canadians hold so dear in their medicare system under a single payer? Would it not be a better way to have them come forward with their recommendations on where they would apply the money, then holding them accountable for where those dollars go to achieve the goals? Would that not have been a much less confrontational approach, respecting their jurisdictional provision of health care under their constitution and their authority? I'm just a little confused as to why that didn't take place, having their electorate hold them accountable.

Mr. Roy Romanow: I'm not saying you're saying this, Mr. Merrifield, but I'm not sure the recommendations we set out had a confrontational element. If we're having a national system, one that recognizes that health care is not an exclusive provincial jurisdiction, although there would be an argument given to me perhaps by members of the committee, it is a shared responsibility, a primary responsibility of the provinces, but it also involves the federal government. How else can one conclude that it involves the federal government? Under what authority would the federal government get into an exclusive provincial field of activity? It gets into it because of the federal spending power, which is a constitutional authority Ottawa has. So we have to decide, as Canadians, whether we come to this cooperatively. The primary delivery of the health care system and other powers reside provincially, the federal spending power, with its sources of money, contributing to that, and I argue that it's got to be done cooperatively.

The strings that are attached really are the result of what I felt was an accurate assessment of what Canadians told me they wanted by way of transformational change in the areas that were important to them. But I heard from every provincial government, either a premier or a minster of health, in every territory as well, during the course of the public hearings, setting out their shopping lists, if I can describe it that way. There were some common themes, and they boiled down to the five specific fundamental categories. We need to have a flexibility, because one size does not fit all, but we also need to compromise that flexibility with a platform that is common to our Canadian citizenship and needs of Canadians across the country.

º (1615)

Mr. Rob Merrifield: Isn't it very easy for a premier or a province to just come to the federal government and say they need more money, as we have seen in the history of the provinces? That's what they've said, and I tend to agree with them, because I think there was a reneging of the original agreement, and I think you concur with that. But isn't that letting them off the hook somewhat, by not suggesting to them that the federal government is there to make sure national values remain from coast to coast to coast in this country in health care, to force them to come up with some of where they would apply these new dollars to achieve the values and the goals for efficiency and sustainability of our health care system into the 21st century? I just would suggest that this would be much more difficult for them to approach in a confrontational way, as they might with Big Brother saying, I want you to put it here, here, and here in specific dollars.

The other quick one is on the drugs. You recommended a national drug safety agency. We haven't seen that in the accord. In fact, it was rather mute as to what would happen in that area, and it's an area that we're very concerned about. As a committee, we're about to go into a major study on prescription medications. I wonder what your comment is on that.

Mr. Roy Romanow: First, I'm not advocating a Big Brother or Big Sister approach from Ottawa. I repeat again, the only way this country can work, in my judgment, is through collaboration and cooperation. One can disagree on whether this commission report captured the areas where I think the vast majority of Canadians think some form of collaborative, conditionalized--that's a bad word to use perhaps in some minds--action and program should be undertaken, but I do not believe it should be top down. I simply think the health care needs in Saskatchewan are different from those in Nunavut and in B.C. So it's collaborative, but I think we don't disagree in very substantive terms, maybe in nuance.

On the drugs, could you just repeat the question very briefly for me?

The Chair: I think it's actually too late. Mr. Merrifield is well over his time, and it's now time for Mr. Ménard to have the floor, Mr. Romanow.

[Translation]

Mr. Réal Ménard (Hochelaga—Maisonneuve, BQ) : Thank you, Madam Chair.

My first comment on your report is that it is somewhat a mirror image of your political career, which means that there are some extremely attractive elements and some that are absolutely terrible. You know that the Government of Quebec has rejected the Romanow Report. It seems to me that there are two biases that are wrong with your basic philosophy.

First, you seem to believe that the provinces do not yet have any accountability system, as if there were no Question Periods, as if there were no Regional Boards, as if there were not many ways for the provinces to explain to their citizens how they spend the money.

Secondly, your most serious bias is that you're trying to use health to do nation-building when the federal government is the level that knows least in that field. When you look at its performance relating to the Armed Forces and the Aboriginals, even at a time when [Editor's Note : inaudible] this does not lead us to trust them for an expanded role. That was my first comment.

I will now ask a question on the cost of drugs. For the first time in our history, the cost of prescription drugs is higher than the whole compensation of doctors, and I agree with the analysis stating that that is the main reason for the increasing costs of our health system. However, you were quite vague on the way to limit the increase in the cost of drugs.

When one reads your report, one does not find any correlation, for example, between the patent protection provided by Canada for 20 years and the cost of drugs. Does that mean that you did not want to deal with that correlation or that you think there are other ways to limit the increasing cost of prescription drugs?

We have some proposals to submit to the Committee. I have provided a mandate which we could discuss but I would have wanted you to be a bit clearer.

º (1620)

M. Roy Romanow : Thank you very much, Mr. Ménard, for your question.

[English]

With respect to accountability, I understand the argument you advance. In my province we have regional health boards, and provincial governments--I suspect I even did so myself as premier--argue that there's accountability through the department of health provincially and through regional health boards and the like. The issue here, however, is $30 billion to $35 billion of federal funds to buy change, with a guarantee that the money advanced--this has nothing to do with any particular province, but I'll use it as an example--isn't used to buy lawnmowers, as opposed to putting it into medical equipment. That's why I gave credit to Minister McLellan with her announcement of a few days ago. That is the context of accountability, but it's more than that. It is, I think, and with the greatest of respect, this is what I even heard in Quebec, in two large meetings in Quebec City and Montreal, the desire of the vast majority of the people in Canada.

[Translation]

Mr. Réal Ménard : Do you understand that there are already some mechanisms?

Your reasoning is dangerous because, pushed to the extreme--and that is somewhat similar to your political career--one rips the Canadian Constitution. The federal government's responsibility in the field of health relates to the Aboriginals, the Armed Forces, quarantines, and epidemics and patents. That's all.

What right does the government have to tell people providing services to Canadians that they should be accountable? Is that because you have obvious examples, in Quebec perhaps--I know the situation in Quebec--where the funds that have been provided have not been used to do what they had been provided for?

[English]

Mr. Roy Romanow: Well, first, I think we have to agree to disagree, Monsieur Ménard, about whether it is an exclusive provincial jurisdiction for health care or whether it is a shared jurisdiction. May I also say that the Government of Canada is the sixth largest provider of health care services on the front lines, which is not insubstantial when you consider the other provinces and the territories.

On the key question of patents and drugs, I haven't seen your proposal, I'm sorry. I look forward to studying it. The issue of drugs and their increasing costs is a complicated one. There are some arguments that the cost factor of pharmaceutical prescription drugs is due to prescriptions. We have 10.1 prescriptions for every man, woman, and child in Canada, which is surely either the right number or huge overprescription. There is a question of whether or not generic drugs are any kind of relief here. If my memory serves me correctly on the report on generic drugs, Canada now ranks third highest in the OECD, so it could be argued that they're pushing the price right up at the top.

The question of the patents raises a recommendation I made in the report, which is that we should look at at least two aspects of patents, something called evergreening, the extension of 20 years to 20 years by changing, and the issue of notice of compliances, allowing generics, once a patent runs out, to move into this area.

Finally, the recommendation in the report said you almost need another royal commission to examine the detail of these very complex issues. What we also said was, in the meantime let's decide that over a certain dollar value, if you require drugs, you're in a catastrophic category, $1,500 or more. It is the principle of value, solidarity, the business of equity that kick in at that stage of the game, and we couple that idea with what we call a prescription management program, namely using drugs in an appropriate way, to take a look at this 10.1 figure.

º (1625)

The Chair: Thank you very much, Mr. Ménard.

The next person is Ms. Bennett.

Ms. Carolyn Bennett (St. Paul's, Lib.): Thank you, Madam Chair.

Obviously, you think the accord has been an important first step. You've also called upon Canadians to be vigilant in keeping up the momentum for what they said they wanted to see. What would you say Canadians should be watching for with the next steps? There were some pretty tight timelines in your report? I guess we're all curious about your role with the Atkinson fellowship and whether you'll be helping coach Canadians on what to be watching for.

Mr. Roy Romanow: I think the next immediate first step is the one I mentioned in the opening remarks, the Health Council of Canada. I know you particularly have been doing a lot of work in this area and thinking about it, which I think is very valuable. And it's part of that Colleen Flood study I mentioned on March 21. I think that's the first important litmus test. If this is not achieved, without repeating myself at length, I think it'll have an extremely negative impact, not only on health care reform. Again, I don't want to be too gloomy about it, but it could have a very negative impact in whether or not the political system listens. I think that's the next first step, but we have to start our reforms now on primary health care, we have to start our reforms now on wait lists and timely access to health care. All of these will need immediate attention, but will take some time for actual implementation. I would put those as the top priorities.

With respect to myself, I'm on the lam, looking for a job, so thanks for inviting me and allowing me to put forward my views. I think at this stage of the game it's in the hands of parliamentarians, and I think parliamentarians will not take offence when I say, as a former politician, it's really in the hands of the public to push all of us along to make these reforms. That's how I'd see it.

Ms. Carolyn Bennett: As to the council being a trusted body and earning the trust of the players, some of us were pretty concerned after the December 6 health ministers meeting. Some of them came out, went to the mike, and said we don't need a council. How will we know on May 5, when the council's announced, or when would Canadians know, whether this is a real council or not a real council and whether it has the heft you'd hoped for in your report?

Mr. Roy Romanow: That is a very tough question. I think one test will be the personnel appointed, making sure they are of integrity and ability and enjoy the confidence of Canadians. Another is the mandate, although the accord says the mandate is the accord itself, which, frankly, may not be the end of the world, because the accord is certainly porous enough in its wording that it might allow, over a period of time, confidence building. Over a little longer time will be the matter of trust, which has to be earned by the members of the health council. Almost immediately there is the spirit, coupled with the words and actions, in which governments accept the health council. If this is a grudging acceptance or if it's something that is imposed--talking about Big Brother--I think we have ourselves another dimension to the federal-provincial squabbling, which would not be very helpful. However, if we make the proper appointments, with the proper mandate, and gradually grow over time--I don't know what that means, but it will be defined by Canadians--that would probably be a modest, but pretty good start.

º (1630)

Ms. Carolyn Bennett: And the money?

Mr. Roy Romanow: I can only repeat what I said in my opening statement. I think the certainty of money, the floor, needs to be achieved, for all the reasons I articulated. It avoids ongoing battles, and it avoids the kind of statements we saw at the last first ministers meeting--I'm coming back to see you a year from now. Everybody has to be in this together. The caregivers have to know how much money is available, because they're going to be making demands, the managers have to know how much money is available, the provinces, the federal government. I think the way to do that is in historical terms, with that 25% portion of the insured, provincially delivered CHA services, when you take into account the tax points transferred. The sooner the better.

The Chair: Thank you, Ms. Bennett.

Ms. Wasylycia-Leis.

Ms. Judy Wasylycia-Leis (Winnipeg North Centre, NDP): Thank you, Madam Chairperson.

I'm certainly glad that our new health critic couldn't be here today, so I could come and at least complete a chapter in my life with the Romanow commission. I wanted to publicly take the opportunity to say thank you to you, Mr. Romanow, and all the staff for your great contribution to the whole question of the future of health care. I think, for most Canadians, you reflected their values and you backed up your recommendations with solid research. I think the disappointment of Canadians now, though, is that they feel it's been sidelined by the federal government and there has been no sort of outright acceptance by the federal government of the Romanow blueprint. Although there's some progress on different fronts, that failure has been noticed by Canadians, and I think they're counting on you to continue the fight for the recommendations you've given to us.

I have three quick questions. I'm going to start by dealing with the whole issue of privatization and for-profit delivery. In your report you indicated that for constitutional reasons, you couldn't recommend an outright prohibition on for-profit delivery. However, your recommendations throughout seemed clearly to be based on the evidence that for-profit delivery could, in fact, harm medicare. So given that the health minister, the Alliance, and others have said it really doesn't matter who owns the institutions and how the services are delivered, what would you say in response, based on the evidence you gathered and in light of the trade implications noted in your report?

Mr. Roy Romanow: That's a very difficult question. I see the accord as the product of federal, provincial, and territorial governments. Again, I do not want to deviate from my opening statement: these are not easy agreements to arrive at. I want to repeat again, I think it was a pretty important first big step, and it cannot and should not be classified as a failure. It's got to be classified as a good stepping stone to move forward. All governments are involved in coming to that accord, and I commend them for it.

On the issue of privatization and profit, I simply would say to you that the evidence has not yet been contradicted, to my knowledge, by comparable studies showing that it is either more cost-efficient or more efficient in respect of health outcomes to have anything but, for core services--note the words I use, core services--a single-payer, publicly administered system. The public administration as being some sort of a banker only--I'll write the cheques--does not speak to the problem. If you look at the American models--and people ask why we are concentrating on the American models, not looking elsewhere where's there's been experimentation, the evidence is quite clear. Our system is cost-effective, and the outcomes are very much better. The report documents this.

Two researchers from Harvard, Woolhandler and Himmelstein, Americans, in 1991 studied just the administration costs and the overhead costs of the American system compared to the Canadian system. It was audited by the GAO, the General Accounting Office of Congress, which approved their numbers. They did an audit 10 years later, which is about to be published, if it is not published already, and there are the same numbers. What does it amount to? In America $1,150 U.S. overhead and administration costs per person per year, in Canada $325 U.S. One of the ironies of it all is that 60%, in one way or another, of the American health care system is financed by American taxpayers, with Medicare, Medicaid, and tax breaks, which they don't account for, for individual people to buy into a private insurance and tax breaks for private for-profit insurance companies to get me insured. The net result is that nearly 100 million people are either uninsured or under-insured, and with the 26 categories of the OECD, their heath outcomes in at least 24, if not all 26, are significantly worse than in Canada. What am I saying? I'm saying, look at the evidence, and I'm open, even at this late stage, to any study that disputes that.

The federal government has no power to pass a law, the delivery is a provincial responsibility. The constitutional hook for the federal government to get into this is the public administration hook. That's why it's principle number one of the Canada Health Act and why I recommended it should not be changed. That is their hook, and the federal spending power, the Canada Health Act. I think, if the evidence is there, it only makes sense, ideology aside, for all governments, provincial, federal, and territorial, to give the cost dollar and health dollar outcomes that work.

º (1635)

The Chair: Thank you, Ms. Wasylycia-Leis.

Mr. Castonguay.

[Translation]

Mr. Jeannot Castonguay (Madawaska—Restigouche, Lib.) : Thank you, Madam Chair.

Thank you, Mr. Romanow, for being here and for your excellent report.

I have spent more than 25 years as a doctor in New Brunswick and I have been saying for a long time that we should de-politicize health because that is one of our major difficulties. People will keep pointing fingers, exchanging accusations and bickering, as you mentioned. If we want to go forward, we will have to stop this kind of attitude.

When I see your recommendations, especially the Health Council, I have the feeling--and you can correct me if I am wrong--that this might be a useful tool to de-politicize the issue. I have been here for two years and I see that the system is still as politicized as before, and I find it disgusting. It is as simple as that.

I know that you have crossed the country and I wonder what kind of feedback you received. How did the various provincial governments react to the Health Council idea?

You also mentioned that this would lead to less bureaucracy rather than more, whereas people keep saying that it will be another bureaucratic layer in the system. Could you explain your answer on this issue?

M. Roy Romanow : Thank you, Dr. Castonguay.

[English]

When I say this about our commission report, I want to stress that while I support everything that's in here, obviously, maybe somebody can come up with a better idea, and when I make a defence, it's not because I'm saying it's this or nothing, not at all. But in our report we said bring in CIHI, the Canadian Institute of Health Information, bring in CCOHTA, the technology assessment agency, currently existing bureaucracies, and put it all under a Health Council of Canada, made up of eminent Canadians, involving caregivers like yourself, the public, specialists in the field, and government people, and streamline the bureaucracy. One of the things that astounded me was that there were five, I think, federal-provincial-territorial committees of health, each one of which had six task forces--30. Nobody knows what these studies are all about. I'm sure Judy, as a former Minister of Health in Manitoba, will know that's the case. You have to streamline and prioritize. So there's where the argument is about no bureaucracy.

On the reaction, the provinces' reaction, I think, is well covered in the newspapers. Some think, as we heard Monsieur Ménard say, it's an invasion of provincial jurisdiction. I must remind the committee that when the Social Union Framework Agreement was written in 1999, there was a specific paragraph headlined “Accountability and transparency related to health care and future health care programs and reforms”, to which all the premiers and the Prime Minister signed on, with the exception, to be fair, of Monsieur Bouchard, who was then the Premier of Quebec. This is not new. So the provinces vary. I don't understand why it was acceptable in 1999, but is not acceptable today.

As for the public, I'm sure there are some who don't agree with it, but I can tell you that very early in the public hearings, and even before that, in the consultation and in the citizen participation, in the decision-making, two different concepts, but related, there was overwhelming support for accountability. Canadians are simply seeking it, they're demanding it, to be blunt about it. That's my assessment of it. Why? Because they want to know, they want it depoliticized, though it'll always have an element of politics to it, and they want to make judgments based on solid facts and data.

º (1640)

[Translation]

Mr. Jeannot Castonguay : Would you go so far as saying that, if we do not manage to set up this Health Council, it will be difficult to de-politicize the health debate?

[English]

Mr. Roy Romanow: If the health council does not see the light of day, I think, mixing metaphors, the heart and soul of health care reform, which has been so well started by the first ministers, will have been removed. This is all a package: a health council monitoring how much money is spent, for what purposes, to buy change, not more, more, more money--that hasn't worked. When I was Premier, we picked up $24 billion in 2000, and one year later the Prime Minister set up a royal commission. Here we are after the royal commission with $30 to $35 billion, I think. That's the amount of money overall. If it just goes into straight circumstances without any conditional changes, it isn't going to work. The answer, for me, is obvious.

The Chair: Thank you, Mr. Castonguay.

Mr. Thompson.

Mr. Greg Thompson (New Brunswick Southwest): Thank you, Madam Chair.

Mr. Romanow, it's nice to have you with us. I think we've all read Romanow cover to cover, to go by the quality of questions being asked.

One difference between your royal commission report and the senate committee report is that Kirby recommended a national insurance premium. He called it a variable premium, and hidden within the bowels of your report, there's a very slight reference to that. I don't have the report with me, but if my memory serves me correctly, you said it was something that might be considered in the future, but we probably wouldn't need it at this point. I do know you took the opportunity to examine some of the European models that have successfully used premiums over the years. So perhaps you could comment on that, sir.

And I don't want to get away from Mr. Menard's point on catastrophic drugs. The cost is something I've personally experienced. At what point do these catastrophic drug prices become catastrophic for the state, with the ability of the government to pay? In some cases it's up to $10,000 for a month's supply, and some are even more outrageous than that.

Mr. Roy Romanow: First of all, the Senate report is a very good report. As I recall, there were a number of options set out for financing it. The premium was one that was raised by Senator Kirby. Premiums exist, as we know, in Alberta and British Columbia, and they've existed in a number of jurisdictions, including my home province of Saskatchewan. There are at least two problems with the premiums, as I see it.

First, you need a very high premium in order to get real money to finance the health care system. Thus you'll see in Alberta and B.C., in my judgment--I don't want to get involved in political fights with my former colleague Ralph Klein and Premier Campbell--fairly substantial increases in the premiums. I know governments that have not had premiums have looked at them, and they've decided that the big barrier is that you would need to have something in the neighbourhood of $1,200 for a family of four, which on top of drug costs is pretty expensive.

The second argument is one of principle. Is it a fair tax? Because that's all it is, a tax. Some people in Alberta, my friends, say it's not a tax, it's a premium. It's a tax. If you're making $100,000 a year and you're paying $1,200 as a premium, that's one kettle of fish. If you're making $45,000 a year and you're paying $1,200 as a premium, that's an entirely different kettle of fish. It's not geared to ability to pay. As much as we may have reservations about paying taxes, I think the only fair method is based on ability.

So I think those are two show-stoppers on premiums. The best method of financing still is a progressive income tax system, in my view.

Your point on drug coverage I think is excellent. That is why in our report we recommended entering into this very cautiously, catastrophic to begin with, and limiting that by tying it to what we call prescription management with certain diseases. Roughly 5% of Canadians consume 40% of the drugs. The average cost per family is $1,200 a year. We need to make sure of the combination of prescriptions, the kinds of drugs, and the kind of diseases to which they're addressed. There are five categories that account for about 60% of the illnesses, psychotropic, heart disease, cardiovascular, high blood pressure, with various drugs underneath them. These are the bulk. You have to manage that very carefully. You cannot just move into a universally covered drug care plan. I want to see that as an eventual goal, but only after there is fine calibration, including prescription policies, including the actions of everybody from the pharmacist to the doctor to the patients and their demands. In the meantime what I think is important is to save catastrophic costs. I heard case after case of people saying they have to pay, if I'm right on this, for rheumatoid arthritis $20,000 on Remicade a year. If you have cystic fibrosis, it's incredible. This can't work in a country like ours, so we have to start with some catastrophic care, and then very delicately move into the question of possible universal expansion, but only after we get the data to match the prescription with the need.

º (1645)

The Chair: Thank you, Mr. Thompson.

Madame Scherrer.

[Translation]

Ms. Hélène Scherrer (Louis-Hébert, Lib.) : Thank you, Madam Chair.

Thank you very much for your presence, Mr. Romanow. I glanced at your report, I would not say that I read it from cover to cover, but I read enough to see that you have done a good analysis of our health system. I believe that you have clearly identified the weaknesses of the present system, and your recommendations are aimed at filling those needs. However, I have the feeling that the recommendations were more aimed at short-term needs rather than major weaknesses of the system in general. You have very clearly identified the reasons why the costs are increasing in a quasi-exponential manner.

For example, when one talks about the cost of drugs, when one talks about the cost of equipment or the cost of human resources, and each of those factors could perhaps be controlled by a dollar sign, that is to say by a financial investment.

I always come back to this issue, because it is important, I believe. I did not find in your report any strong recommendation relating to investing for prevention. But, to my mind, prevention remains a way to reduce costs in the long run and, when I talk about prevention, I talk about changing directly the lifestyle of Canadians.

When one looks at the recent statistics, one sees that the percentage of obese people is becoming obscene. Tobacco use remains a major problem for youth, as well as the lack of exercise. And when we look at the budgets established in those fields, by the provinces or by the federal government, one sees that those established for health promotion and prevention are absolutely ridiculous.

Is it because this is not saleable, politically-speaking? As a politician, you know that it is not easy to plan for investments that will produce results in only 10, 15 or 20 years--or is it a thing that people did not refer to at all during your consultations, or because you, personally, did not feel that it would be a very important way to reduce long-term health costs?

º (1650)

[English]

Mr. Roy Romanow: You're right, Mr. Thompson, it seems everybody has read the report. I hope you haven't fallen asleep in the middle of the night doing so.

Again, without any defensiveness--I'm here to try to help the committee and provide the best advice and knowledge and experience I've garnered--with respect, I don't agree with you on the contention that we don't talk about the role of prevention. One could argue that maybe we should have devoted more pages to it, but on pages 128 to 134, within the chapter “Primary Health Care and Prevention”, we stress the need for prevention in population health, but as a part of primary health care. One of the problems of medicine, so doctors and others tell me, is the stovepiping. There is the primary, there is the acute, there is the tertiary, there is the wellness, and it's got to be an integrated approach. Second, so much good work has been done in this area by people like Marc Lalonde and Jake Epp, others who have studied wellness, that we could only add to it by way of some modern additional information, as I did by noting, for example, the federal-provincial-territorial ministers on sport, recreation, and fitness.

So we recommended the need to really pump money into prevention and population health, going so far as to recommend a national immunization strategy for children, which I think everybody says makes good common health sense and saves money down the road. And there is the need to deal with obesity, which is identified at page 129. Smoking, we say, costs more than $16 billion a year to our economy, including $2.4 billion in health care costs. You and I agree on these figures. And on it goes.

So I would argue that we did try to focus in on it, but we did not want to put it into an isolated category. I think the best way to do it is to put it in the primary health care model. When I go to my doctor, at first point of entry he or she is going to ask me about my lifestyle, my intake of food, my physical exercise, whether I smoke, whether I drink, etc. Then comes some analysis and an attempt to reorient me in this regard. I didn't think it would do anything but stovepipe the demarcation, and we don't need that. People were saying to me at every stop, prevention and population health. Dr. Bennett was talking about the Atkinson Foundation, and this is one of the areas I'm going to at least be trying to look at to further augment the report. I don't say that defensively, I simply say it's there.

º (1655)

[Translation]

Ms. Hélène Scherrer : I only want to mention that, when one looks at the provincial or federal budgets, one finds that this is all pious intentions but not much else. When one talks about making an investment or providing a budget, the amount is always minimal compared to the whole. If you look at the money provided for physical exercise or any prevention program, you will find that the amounts are not very significant.

That is why I am happy to find this but I feel that there should be much stronger recommendations on this issue, so that governments be ready to invest much more money in this.

[English]

Mr. Roy Romanow: I don't disagree with you about focusing more and more, but I do disagree with you about our not focusing on it. “Primary Health Care and Prevention” is the title of chapter 5, and you've read this:

Integrate prevention and promotion initiatives as a central focus of primary health care targeted initially at reducing tobacco use and obesity and increasing physical activity in Canada.

Implement a new national immunization strategy.

Then we enveloped the primary health care fund with $2.5 billion targeted--you've got to make the change to achieve these. I agree with you, we need more, but I think it's in there.

The Chair: Thank you, Madame Scherrer.

Mr. Lunney.

Mr. James Lunney (Nanaimo—Alberni, Canadian Alliance): Thank you, Madam Chair.

In the same vein, Mr. Romanow, when you concluded your remarks to us, you expressed the hope that this agreement will help to restore the health care system in Canada as the best, with Canadians as the healthiest people. You went on to express there that Canadians expect the government to invest more in wellness and prevention and to promote self-reliance. Madame Scherrer just brought up the prevention issue, but there is an inverse relationship between remediation and prevention and the disease management system we have in Canada. Largely, our medical model is one of disease management. Many of these remedial interventions are on the side that is outside the public investment domain, chiropractors, of whom there are about 7,000 in the country, naturopaths, of whom you have about 1,200 in the country. Canadians are paying out of their pockets to secure these services. You seem to understand this, but our governments are so strapped with the disease management side that the more money we put into disease management, the less money provincial governments have to invest on the remedial management side. That's certainly true in British Columbia, where they just cut the $50 million they were investing in chiropractic, for example. As I'm sure the commissioner knows, health care economists have shown that chiropractors alone could save up to $2 billion in managing low back pain.

In chapter 4 you talk about allied health professionals. In recommendation 15 you talk about the need “to improve the supply and distribution of health care providers, encourage changes to their scopes and patterns of practice, and ensure that the best use of this is made in the mix of skills of different health care providers.” Earlier you say specifically, “While much of the focus is on nurses and doctors, there are numerous issues that affect other health care providers as well”. My concern is that while your report does this lip service, the recent health care accord does absolutely nothing to tip that equation between remediation and prevention.

Mr. Roy Romanow: With some modification to your comments, in my view, I say the primary health care model and the special targeted $2.5 billion, which now is part of the reform fund, do not prohibit the inclusion of people who are in naturopathic work or chiropractic work. In my province of Saskatchewan, long before this royal commission was set up, we covered a lot of the chiropractic work. It's a question of primary care and primary care teams. It's up to the provinces to take up the money and say, this is where the appropriate interdisciplinary mix of professions will work or not work. I'm not writing prescriptively what should be the one size to fit all for every province or for every jurisdiction. It may be something entirely different, say, in Nunavut. They need to develop their primary care and their wellness models on an entirely different basis. In Nunavut, just to give you an example, their biggest problems are mental illness, alcoholism, suicides, housing, which is in the realm of health care and may be not in the realm of health care. They have to see to primary health care needs to deal with those problems. I'm not going to say to them, you need to have a naturopath--maybe in B.C. or in Saskatchewan. Nothing prevents the provinces from picking up on it if they want to.

» (1700)

Mr. James Lunney: Money spent on remediation reduces the burden on the disease management side. I think that's becoming better understood, though it's certainly been obvious for years. Roughly, you've got over 8,000 practitioners out there who are qualified and who could take quite a bit of the burden off the disease management side if their services were better secured. What would you recommend can be done to encourage provincial governments to take seriously the benefits of remediation and prevention in using that $2.5 billion?

Mr. Roy Romanow: I think it's there in the report, flexible wording and options that permit the provincial governments and the provinces to tailor their programs according to their needs--the Nunavut example I gave you. I say team work, interdisciplinary collaboration, by which I don't mean doctors and nurses. There are people who will go to chiropractors, we all know that, or naturopaths and use them. It is a matter of all health care providers and devising a 24/7 program to see that it's achieved. That may not be specific enough, it may not be motivational enough--if that's your point, I certainly get that very clearly--but it was my intention to say, I'm not going to cross every t and dot every i for a province, I'm going to simply say to you, you've got the right, and that fund is going to be targeted for you to be motivated to use this kind of interdisciplinary collaboration.

Mr. James Lunney: I appreciate that comment. We need to see more of an emphasis, I think, in that direction.

The last one has to do with catastrophic drug costs. I was at a function recently that the health minister attended. She was asked how this would be implemented, how the dollars would be secured, and how this $1.5 billion for catastrophic drug costs would be administered. Frankly, she didn't really have any idea. Where do you draw the line? My colleague here raised the issue. Are you aware of any parameters that are being discussed on catastrophic drug management at this present time, or other models across the country?

Mr. Roy Romanow: I don't know what the federal government's approach is or what their studies show, but we based our recommendation on the evidence and the research we uncovered. The Manitoba Health Centre was our primary research area, but we also tried it out on two other provincial drug plans. Manitoba taught us that the average cost a year for drugs is $1,200. So we assumed, that being the current cost we all carry ourselves, unless we're covered through a private insurance plan, an employer plan of some nature, we would leave it there, and anything over that, by definition, becomes catastrophic. I won't repeat my answers to Mr. Thompson with respect to disease management and the like. You can model it any way you want to. Senator Kirby, I think, recommended that the line should be at $5,000. I chose the $1,500, because it was above the $1,200 average for Canadians. I felt it was akin to what the actual needs were.

Work has to be done, and you'll notice that the key of this recommendation was that we would not pump in money, if they adopted our recommendation on catastrophic drugs, until 2004-2005--do the preliminary work carefully. The provincial drug plans are up and down. Some coverage is wider than others, some are limited to social assistance. You need to somehow get all these data before you start moving tentatively into a national program.

» (1705)

The Chair: Thank you.

We'll start into the second round, Ms. Bennett.

Ms. Carolyn Bennett: Some people have thought one of the main jobs of the health council would be transparency and accountability. Would you see that it has to be a sixth principle of the Canadian Health Act, or would you think you could do it through some sort of legislative framework setting up the council, with transparency and accountability as part of the reporting structure, maybe not voluntary, but in effect?

Also, you mentioned the Social Union Framework Agreement, which did talk about transparency and accountability, allowing Canadian to set priorities, reporting to Canadians on an annual basis. One of the interests to me was your consultation with Canadians, which I think most of us feel was the best that's ever been done. Would you or Michel or Greg have any comment on the capacity of the council to keep having a conversation with Canadians? If it's about the trust Canadians have in the system, how would you see this council's ability to continue with the deliberative democracy? How would you see that look so that we didn't need to have a commission every five years?

Mr. Roy Romanow: On accountability, I'd simply make a very brief comment. I felt the legislative amendment was a statement to Canadians generally, as opposed to governments or caregivers, in compliance with their clear request to me that it be set out. I thought it was a clear-cut sixth principle. Can it be done otherwise? Maybe. With respect, I'm not sure it can be done through a Health Council of Canada, this being dependent upon the people who make up the health council, and it may be up and down, but some statutory base would clarify it.

I'd like to call on Mr. Marchildon and Mr. Amar, who were very helpful in the citizen participation consultation, to make a quick comment on your second part, which I think is very interesting.

I think there are two ways in which the Health Council of Canada can play that role. One, obviously, is through representation on the governing council, if I can call it that, direct public representation, and those individuals should be feeding back to the general public. A second way is through the health council itself having citizen engagement exercises on particular issues, adopting a similar methodology, so that the very difficult trade-off issues are dealt with properly. In addition, as you would expect, there would be feedback through annual reports and occasional discussion papers, the more passive forms. But I think there could be very much a role for this very active citizen engagement process, done appropriately and in a way that will get the kinds of rich answers that are needed.

» (1710)

Mr. Michel Amar (Former Director, Communications and Consultations, Commission on the Future of Health Care in Canada): I think Greg has pretty much covered it. There is a real distinction between consultation and engagement that I think the health council has to take account of. One of the reasons our public consultations and our engagement strategies were successful was that we did a significant amount of public education before going out into the public. I think there are opportunities for the council to use the periodic reports as the basis for a good public education campaign. The council should do more than just issue a report and leave it at that, it should use the report for the basis for educating Canadians, consult on what the report means and what to do about it, and provide opportunities for Canadians just to feed in their views and perspectives on the health care system.

The Chair: Thank you.

Mr. Merrifield.

Mr. Rob Merrifield: Thank you, Madam Chair.

Why don't we pick up on that a little while we're in it, with the health council? I see the potential for it to be a good thing. Not to be negative about it, I see a government that has a history of studies and not a very good history on accountability or best use of dollars. This government has spent $243 million just studying health care since it has come to office. Nonetheless, when you say, Mr. Romanow, this federal government and this health council would actually save money and not be an addition to bureaucracy, but actually a limit to it, I would say, what is it going to replace that it is going to save a significant amount of dollars?

Second, what kind of cooperation do you expect from the provinces with regard to the aggressive nature you perceived the committee might take on?

Mr. Roy Romanow: First of all, I would stress again that my vision of the Health Council of Canada is as an intergovernmental body, not the federal government's alone. It would not work as a federal government institution, and I did not recommend it as such. It can only work if the federal, provincial, and territorial governments, as part of our federation, buy into it, and if, I would argue, it is bought into by the caregivers and the citizen groups. If that buy-in is achieved, we've reached a huge plateau from which we can build.

On the issue of the saving of money, as I said in response to somebody else earlier here, we have a dizzying array of advisory committees doing very good work, but this is work that in some ways is simply lost. It's just too wide and diffuse and needs to be somehow more focused. I argued that it can be made to save money, it being an intergovernmental body. My idea is not getting very far when I talk about bringing CIHI into it. CIHI is a wonderful database, but it doesn't take the data to policy. A health council might bring it to policy. You have CIHI already, bring it in, bring in CCOHTA, the technology assessment--is it good technology or not?--and maybe trim some of these ministerial committees. My argument is that it can be done, and I think it can be done without an additional wallop of taxpayers' money, if it is done this way.

Mr. Rob Merrifield: There are lots of ifs there. If we have full cooperation with the provinces, there may be some economies of scale. That's a very noble idea, and hopefully, it could be achieved, but when I hear some of the premiers' comments coming out of the accord, I suggest to you that perhaps the idea of this health accord and the vision you have is significantly different from theirs. We have this report card process actually happening--I think the first one was last September--and really, the provinces are saying, they're doing this now, and they're just going to give it to the federal government, so they can do what they like with it. I don't know how you take those comments, but I certainly don't see the cooperation there. Am I reading it differently. Do you still think there's a dream there?

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Mr. Roy Romanow: I just don't think we know yet about the Heath Council of Canada. We have until May 5. I think we have--I mean this is in non-partisan terms--a very effective Minister of Health, who has experience in intergovernmental affairs, a non-health-related area in which she has to work with her colleagues. Let's see what happens. It may very well work out that some combination of appointments and mandate will work. There are ifs, there's no doubt about it, but I think those ifs are perfectly manageable, given political will and leadership.

Mr. Rob Merrifield: There's been a lot of talk about who is going to chair this council--Mazankowski, Kirby, you. Is that something you'd like? If it were offered to you, would you chair the council?

Mr. Roy Romanow: Would you nominate me, Mr. Merrifield?

Mr. Rob Merrifield: I would if you would work collaboratively with Mr. Kirby and Mr. Mazankowski on that same council.

Mr. Roy Romanow: Leaving the council aside, I'll get this off my chest. I've had a very good working relationship with Senator Kirby and with Mr. Mazankowski, with whom I go back a long way--actually, Kirby and I go back even further, back to 1980, the Constitution days--so there's no problem agreeing where we can agree and disagreeing where we disagree. But the ministers of health are charged with this task. I'm out of the picture. They have to make their choices in the best interests of the provinces and the country.

Mr. Rob Merrifield: Was that a yes or a no?

Mr. Roy Romanow: I'm out of the picture.

The Chair: Thank you, Mr. Merrifield.

Mr. Castonguay.

[Translation]

Mr. Jeannot Castonguay : Thank you, Madam Chair.

You mentioned a while ago that the Health Accord that was signed or not signed by the First Ministers in February 2003 was a first major step, which leads one to believe, obviously, that there should be other steps in order to fulfill the recommendations of your report.

Practically speaking, what do you think would be a reasonable period of time to implement such a program? As you see, I am not getting any younger and I would like to be able to benefit one day from your recommendations.

A voice :You will get to be a hundred, Jeannot.

[English]

Mr. Roy Romanow: I'm with you on the latter sentiment.

It is not a flippant answer when I say my reasonable timetable is the one we set out here, which is two years. Some don't agree, obviously, but I'd like to think it's a correctly analysed and well-argued case. I can't deviate from that, because I'd be deviating from my report. Maybe five, ten, fifteen years from now, when you and I are around somewhere, we'll be able to say this was wrong and this is right, but I think it could be done and should be done. Although it would a pretty impressive achievement, that's my timetable, two years.

The Chair: Thank you, Mr. Castonguay.

Mrs. Wasylycia-Leis.

Ms. Judy Wasylycia-Leis: Thank you, Madam Chairperson.

I'm going to ask three questions, all unrelated, but I'm going to get cut off. Maybe the chair will give you some leniency in answering them.

First, back to the privatization issue, I appreciated your very thorough and clear answer. It seems to me that with threats to medicare, commercialization in diagnostic services is probably the greatest area for concern right now, given what's happening in some of the provinces. In your report you recommend that there be a clarification to ensure that diagnostic services are covered under the Canada Health Act. I'd like some comments on that. What do you think it would do in this whole area? What we can do to advance that issue? What benchmarks would you suggest to guide the current experimentation in the whole area of for-profit delivery of publicly paid for services?

Second, with respect to the national drug agency, which I think is probably one of the most important recommendations of your report and probably the one that hasn't received enough attention, it seems to me that the provinces have already agreed to collaboration in sharing of information and admission of new drugs into the health care system. Your proposal seems to build on that. Do you see any obstacles from the provincial side to advancing this proposal? How do we, in fact, do as you've recommended, get the first minsters to delegate the authority to ministers of health to pursue this on a priority basis? I'm referring to your February 19, 2003, speech.

Third, with respect to the health council, I'm glad you've reminded us that there's only one month before the deadline for the establishment of this council. I don't think we've heard anything from the federal Minister of Health about developments in this area. In fact, I think the health committee--although I'm not a permanent member--should actually be pushing the health minister for a status report on this matter. I was going to ask what you would recommend as critical components of this council, but you've already answered that in part, so I'm more interested in how you think we can kick-start the process and get this deadline achieved by May 5, but along the lines you've recommended, in a much broader way than appears to be the case with the federal minister or the first ministers accord.

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Mr. Roy Romanow: Those are three very tough questions. I'll try to be very brief, although they really require more length in explanation.

On the MRI diagnostic services issue, there are those who argue that this is covered currently by the Canada Health Act under the diagnostic provisions, which are related to hospital care through MRIs. “Diagnostic” doesn't necessarily mean advanced diagnostics only, it means blood tests and things of that nature, all of which are covered by the insured services, but it is clear that there is a grey area when it comes to advanced diagnostics, outside hospitals in particular. We also note that Canada now has fallen below the OECD countries' average of advanced diagnostics like MRIs and CAT scans. Everything abhors a vacuum, and so that vacuum is filled outside hospitals, and perhaps even inside hospitals. It's filled for sure outside hospitals by the private, for-profit sector. People demand access to advanced diagnostic equipment. By the way, one of the biggest sources for wait lists is getting that MRI or the CAT scan.

The answer for us is to clarify the problem by legislative amendment and invest money, and I am pleased again to commend the Minister of Health for her announcement on the MRI program, which speaks to much of the issue of private versus public. It needs to be carefully analysed, in my view, but that's another discussion. That is the rationale. We're behind, we need to catch up, and the way to do it is to clarify it under the publicly funded service, because if it's true that diagnoses are best carried out, efficiently and for health outcomes, through the single-payer public system, the very heart of the 1984 Canada Health Act, it must be equally true that MRIs are part of that as well. It's a natural extension.

You could put guidelines in there. You could say, if they're outside the hospitals, in other sectors, you can't jump the queue, you can't bill extra, and you've got to be CHA-compliant. That's a level playing field, and anybody in the private, for-profit sector would have to follow that. Then there would be a real question on the private, for-profit side whether or not they could make a go of it if the field is equal with the public sector. That might help, and I know it's the Ontario government's approach to it.

On the NDA, I'll only say this. On page 202 of the report we set out in detail what it should be responsible for:

Establishing and managing a common national drug formulary to ensure that decisions on including or excluding particular drugs are based on the best available clinical, pharmacological and economic evidence.

There are many more issues. From my personal experience as a premier, there's one I didn't mention, but perhaps I should have, political pressure. Under the current system, if Manitoba adds something to its drug list that Saskatchewan does not have on its formulary, the pressure immediately mounts. It's the breakdown of the national system, Mr. Merrifield, that worries me a little in our discussion. If you leave it strictly to the provinces, it depends upon capacity. Some drugs are covered to a larger extent in some provinces than in others, and you have a patchwork quilt of 13 or more regions. Thus the need for the national standard. It won't be easy, but it can be done, and I would argue politically that it makes sense to do it, because then the premiers aren't blackmailed--that's a hard word to use--politically, because one province does it and you haven't done it.

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On how to kick-start the HCC, I think there's only one way, and that's to get it done. I'm less concerned about its having an extensive mandate, about many aspects of the report or other reports as to how it's done. My main concern is that there be men and women of quality who get going, even limiting themselves to the accord as the mandate in the first instance. You can expand it through trust and through confidence over the long term.

By the way, Mr. Merrifield, I didn't mean to be critical and argue with you. I know what the rules of the committee are. You can come back at me, if the chair will allow. I didn't want a debate.

The Chair: Thank you, Ms. Wasylycia-Leis.

With your indulgence, Mr. Romanow, I'd just like to tell the members of the committee who weren't here on Monday, it was a meeting to review a report. We cannot review a report without nine people being present. There were not nine people, so I had to cancel the meeting. That has been referred to an extra meeting next week, which will be Tuesday morning at 9. I am hoping most people will be able to be here, so we can proceed. In addition to the report, there is another matter, which has to do with having witnesses on a different topic, witnesses who seem to be rather recalcitrant, and I may have to get your permission to use the power of the committee and the House to make sure those witnesses will come. That will require votes also. We have a motion from Madame Scherrer we might want to vote on. So Tuesday morning I will require at least nine people, and preferably the whole committee. Monday afternoon we will be hearing witnesses, and three members will be sufficient for that.

I'm sorry to have interrupted, but I had a feeling people were about to leave.

Mr. Lunney will be the last questioner.

Mr. James Lunney: Thank you, Madam Chair.

I wanted to pick up on the question about privatization, this terrible dragon that's been creeping in. Perhaps the reason Canada falls outside the accepted OECD levels for diagnostics is that we're one of the few countries trying to carry on a single-payer system, and where there's no competition, costs spiral out of control. There's no incentive in our system for cost-effectiveness, and that seems to be one of the big problems. For example, I'm sure you heard about Sunnybrook Hospital and cancer therapy. The public sector could not get anybody to work after 6 o'clock. They'd shut everything down in their cancer clinic, and the wait list was huge. This program, I believe, was shut down recently, but there was a doctor with an MBA who took this on to look at efficiencies. He said, turn it over to me in the evenings, and we'll run it with the same equipment and the same protocols. Over the course of a year they were able to treat 1,000 people with the same time and cost that the public system would take to treat 600, and that's with a one-week waiting period, rather than six weeks. This is the dreaded private system people are worried about. The people getting the treatment didn't seem to object, other than in having to come in the evening for the treatment, and the people working were not paid less, they were paid a premium for working in the evening hours. It was publicly paid for. I'd like to hear your comment.

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Mr. Roy Romanow: I'm not sure what comment I can make. Are you asking me whether this is an efficient way, are the health outcomes better, is there more choice? What is it you specifically want me to comment on?

Mr. James Lunney: Why is this model so scary to some people, when there clearly are efficiencies that are escaping the public system with the present model? These are public dollars being spent in a private environment, as it were.

Mr. Roy Romanow: I don't think the evidence is there that there are efficiencies that are escaping the public system and only the public system. I think there are efficiencies that escape public and private systems, whether in health care or otherwise. It's the obligation of everybody to be as efficient as they can be.

I think the other issue is whether or not, as a matter of values and principles in this country, we believe the provision of health care.... And this has been tried elsewhere, by the way. The U.K. tried it, and they're reversing it. In Sweden they've tried it, and there are no more private hospitals. It doesn't work because of the simple fact that if you have extra ability to pay money, you're in there, if you don't, you're not in there.

Mr. James Lunney: They were not paying extra. The public system simply wouldn't work in the evening.

Mr. Roy Romanow: I don't want to get into a debate. My only comment would be, Mr. Lunney, that if we pay, as a society, X dollars from 6 p.m. to midnight to what I would call, just for the lack of a better name--I don't mean to be pejorative about this--a privately functioning system such as you describe, why wouldn't we be prepared to pay X dollars for a public system? There's no change in the money factor.

The Chair: Thank you very much, Mr. Lunney.

I believe there could be some very strong clarifications on the example he chose to use. I think Dr. Bennett is much more up-to-date on that particular Toronto experiment.

However, on behalf of all the committee members, I would very much like to thank Mr. Romanow for coming back. I was going to ask what we could do to push forward the agenda you outlined, but I think the answer came up through the questions of my colleagues. It seems to me the first thing we should be doing is looking at that May 5 date and putting some pressure on our own minister to make sure the health council, which seems to be crucial for the forward motion of all this, is coming together in good time, by which I mean on or around May 5, as opposed to six months from there. Thank you for your guidance.

Mr. Roy Romanow: Thank you very much.

The Chair: Any time you want our help and would like to drop a note to me, I know my colleagues would love to hear what you have to say. If you think there's something else we can do in future to push the agenda forward, please do not hesitate to use us as you observe what's going on from your very unique viewpoint, having been the author.

Mr. Roy Romanow: You're very kind. Thank you very much, Madam Chair, and thanks to all the committee members.

I will simply say in response to your request that I have every confidence in this committee and this House of Commons, I really do. You folks will sort it out. I've done my bit, and now it's up to you. So good luck and God bless you.

The Chair: Thank you very much.

This meeting is adjourned.