Better Treatment, Better Care (2)

are because the principle on the surface if it's interpreted right doesn't have

to be a straightjacket it actually can can be

the aspirational goal all of us want to achieve do you think the way it's

written is it prevents it creates a barrier to some of the reforms we'll be

talking about i don't know the the universality term

specifically does but there's an interesting thought that we can have

what canadian would live without a universal access healthcare system what

canadian province would say to its population we're no longer going to have

universal access healthcare in this country healthcare is a matter of

provincial jurisdiction the canada health act is an exercise of the federal

spending power that is the federal government taxes more than it requires

for its own responsibilities and then redistributes that money as an exercise

of the spending power and the canada health act is one of the governing

conditions for it why have the term at all no province is

going to move away from it no sensible government will move away from it the

federal government to my mind when it comes to the canada health act needs to

enforce portability the ability for people to move freely from one province

to another and still be covered for a universally accessible health care

system i think makes a great deal of sense when it comes to labor mobility

when it comes to flexibility in the economy but does it really need to

enforce universality when we know no province is going to back away from

that that's a good point so it's there's al

there's sort of a populist holding their governments to account on that principle

so you don't really need the heavy hand of the federal government coming in that

makes some sense let's talk about comprehensiveness i've never really

understood what comprehensiveness means in the context of the canada health act

because there are a lot of services that are not covered by the canada health act

and there's a lot of services you can pay for out of pocket you can co-pay for

and so when we talk about comprehensiveness

what what it doesn't seem to me like it is a barrier but i'm wondering what what

what is it supposed to cover when we're talking about federal legislation and

the federal spending power you just spoke about there's almost a historical

component to comprehensiveness comprehensiveness defines what is to be

covered and it is the the health care system

that a province sets up in order to have access to its federal transfers must

cover physician services and hospital care medically necessary physician

services and hospital care this is where this term medically necessary originates

it really is around comprehensiveness in the canada health act uh and so

now we've got a healthcare system that has to be universal it has to cover

everybody it has to have these particular services covered in it but

it's this is where the tweet comes why we don't necessarily have drugs or

dental services or other services within the universal construct because they're

not really defined in by the canada health act so they're not a necessary

requirement but the other parts of the canada health act that do force

provinces to go down a less efficient policy approach that is a policy

approach that is going to cost more and deliver less as a result of what's

required by the canada health act in a manner might be considered to be

tied to that other requirement where provinces are saying well

we know we have to be inefficient because the federal government forces us

to be so we're only going to cover what they say we have to you know i i wonder

if an error was made in choosing physician services to be under that

umbrella because not not every time you go to the doctor is it essential

sometimes you're getting a renewal of a prescription sometimes you're just doing

a basic checkup on an annual basis i mean you could probably argue

that um that vital pharmaceuticals are more essential once you've been

diagnosed with a disease you need to manage or if you've got some kind of

severe toothache going to the dentist is more essential than that than that

physician visit uh what do you do does that exist elsewhere in other in other

jurisdictions where only the government can pay if you go to the doctor no that

that is a very uniquely canadian canadian experience where you don't have

an alternative for your medically necessary care and we do see provinces

tweaking with this term medically necessary all the time trying to balance

budgets defining what is and what is not medically necessary is what you do pay

your doctor for and what you don't we know now when you go to the doctor in

alberta you're going to pay for your doctor's note for your work because

that's no longer a medically necessary service there's a little sign on the on

the door in the exam room this is what you're going to pay for that service

please one problem per visit because that's how the medically necessary

government operates it really all does come back to cost

efficiency there's a very interesting tweak that occurs here though uh as we

go through the canada health act sections 18 through 21 disallow cost

sharing and extra billing that is we cannot have patients sharing the cost of

care consumed and we cannot have any private top-up to services that are

funded by government any funding by government must be complete it can't be

partial when you take that and combine it with medically necessary we now

create a system where the pharmaceutical has a copay because that that is

reasonable based on how the insurance system is structured but the physician

does not so we go to the physician with no copay the physician prescribes the

drug that is actually going to do the healing and now there's a copay but

provinces have no way of addressing this under the canada health act because the

physician must be copay free okay

and copay is going to be a pretty important aspect for us to to discuss

when we start talking about the other systems let's talk about accessibility

because when when you talk about accessibility

you would think that this aspect of how long you're waiting for medically

necessary treatment would factor into it i years ago when this was litigated at

the federal level and the shoutly decision came about the decision was

access to a waiting list is not access to health care sadly that seemed to only

apply in quebec it didn't apply to the rest of the country i never quite

understood why that was but what does accessibility mean in this context when

we're talking about the canada health act because it means something different

than i than i think it should accessibility it reinforces a lot of the

other principles we come back to ensuring everyone has access to health

care but this is where we come into section 12.

section 12 is is the problematic section healthcare because it requires that

patients have reasonable access to medical services and that is entirely up

to the federal government's discretion what that term means and so we have

interpretation letters that have come from the federal government federal

health ministers over time that have said private clinics providing surgical

services may impede reasonable access to

healthcare in the opinion of the health minister sounds like a very benign

statement but it's not that is a direct assault on the province's freedom to

determine its own policy structure because the federal government said

section 12 might come into play section 12 a violation of that means we pull

back all of your cash transfers and so the federal government can at any time

say under this under this particular principle we think what you're doing to

your province is impeding reasonable access to health care services it could

be as simple as saying alberta saskatchewan we know you're contracting

out some services to private surgical facilities we appreciate the evidence

that says this is a more efficient way to deliver more health care services but

we think it impedes reasonable access and and all of a sudden now the

prevention the federal transfers are under threat so this is the section

where we really run into where the canada health act poses a barrier but

but it's an it's an almost undefinable barrier because it's an undefined term

in the act itself and so there's no definition to fall back on just as

important this is not a justiceable act this is not an act that can go to court

to be challenged this is an exercise of the federal spending power so it is

entirely the federal government's discretion what this act says and how

it's enforced wow let's and we'll talk about how significant those factors

those um transfers has have become which is why i think there's a reluctance for

provinces to to to try to push the envelope i was using the word trans

transferable the actual word is portability the idea that you should be

able to travel anywhere in the country and and get coverage now do we do we

succeed in that is our system portable if i

broke my leg in quebec would i be able to get services there if i needed to get

my gallbladder removed if on a trip to saskatchewan would i be able to get it

removed there i guess i don't i don't even really know how portable the system

is yeah it is reasonably portable there are some issues with how some provinces

are paying for care in other provinces which has created some barriers for

patients on an ongoing routine basis but we do have a healthcare system where

while you're traveling in canada the provinces are funding healthcare in the

in the alternate province it also protects patients moving from province

to providence so for 90 days your province of origin will provide for your

healthcare services while you meet the eligibility in the next province so it's

set some terms around that in many ways i think this is actually a

very important part of the canada health act because it does ensure labor

mobility in the country it does ensure that when you have a recession or an

economic event in one province that canadians can move within their own

country to another province without being locked to a health care policy in

a province without being locked to a province because of their health care

needs and i think that's an important thing to have for canada's economy

generally and for canadians generally okay so let's just do a summary here

public administration we can live with that although we would get a better more

tailored system if we allowed for some competition so people could tailor the

program to what they actually need universality great principle

and but it can be implemented in a way that's different than how we've

implemented it here comprehensive we've already created the flexibility it seems

to me within that interpretation so that we can start looking at things that are

covered 100 and things that are that you have a copay for

accessibility if we can get that redefined around talking about

accessible healthcare being access and wait times then we might be able to make

it somewhere and portability we'd keep so my general view is that there's

nothing really in the canada health act that is preventing that is absolutely

putting a stop on on any transformation am i being too optimistic

i think you're being optimistic on two terms section 12 of sections 18 through

21. section 12 is is the reasonable access term the undefined term that has