Melvin J. Howard’s determination vs Canada’s ambivalence

In their evident ambivalence about a publicly funded, semi-privately delivered health care system, Canadians and their politicians have given an opening to a manic businessman. Arizona health care entrepreneur Melvin J. Howard, who has alerted the world to his bipolar disorder on his Web site, is portraying himself as an underdog in the effort to establish commercial clinics in Canada. He vows to continue his fight “no matter what obstacles get in [my] way.”

In May 2008, Howard wrote on his blog that he would file an investor’s complaint under the North American Free Trade Agreement (NAFTA) because “municipalities or city officials can and have put up numerous roadblocks such as zoning and by law requirements” that prevented his company from establishing a clinic in British Columbia. He cites recent developments in Canada, such as the Supreme Court’s Chaoulli decision and legislation in Alberta, as evidence that the time is ripe for private health care investment in Canada. Who can blame him? The government of BC has all but cheered on the establishment of commercial clinics and for-profit surgical centres

Howard, however, is not content with using the leverage granted investors by NAFTA. In his September 20th blog posting, he wrote, “I am calling on the WTO [World Trade Organization] to wade in on our trade dispute with Canada. In arguing to keep health care off the table Canada claims to have exemptions on their public health care system. At the same time they demand the right to export their own health care services and not allowing any imports; is that sending a message of double standard? I think so.”

Howard is referring to the fact that Canada has included commercial health insurance in its commitment under the General Agreement on Trade in Services (GATS). Canadian multinational insurance corporations have access to foreign health care markets, but foreign insurers are excluded from insuring medically necessary services in Canada. He also points to the existing privatized aspects of the Canadian system including home care and long-term care, laboratory services, and dental care.

As some commentators have pointed out, including Luke Eric Peterson, who broke the story in Embassy newsweekly, Melvin J. Howard’s Centurion is not a huge U.S. health care corporation like Aetna or Tenet. But he’s surely not the only investor who has watched the hypocrisy and complacency unfolding in Canada. The result is murky and confused policy, which may be the intended effect. The province and the country are in the grip of politicians who believe that markets provide solutions; public administrators and governments are impediments, or at best, conduits for the flow of tax payer money to private enterprise.

Nearly every Canadian who advocates for more commercialization of health care also proclaims opposition to a U.S.-style system. U.S. entrepreneurs and investors backed by NAFTA and GATS, however, have no aim other than making money; why should they change their business to accommodate "Canadian values"? Canadians may not be able to have it both ways, and Melvin J. Howard seems to have a personal mission to teach Canada a lesson.

Montreal, Canada's commercial health care capital

In an opinion editorial published in the Toronto Star on September 3 http://www.thestar.com/comment/article/489323, Dr Robert Ouellet, president of the Canadian Medical Association, advances the idea that Canada can develop a European-style health care system with a public-private blend. This fallacy is promoted by politicians and pundits who are enamored of markets as the solution to our problems. But Canada is not in Europe, does not have a European-style social welfare establishment, and is party to a trade treaty with the United States. Once health care becomes a commodity in Canada, U.S. corporations will demand entry under NAFTA and the future of our health care system will be out of our hands, despite Dr. Ouellet's soothing rhetoric.

While it's frustrating for physicians to face an unresponsive bureaucracy, Quebec provides a cautionary tale of what may happen when entrepreneurs take matters into their own hands. Quebec radiologists established imaging clinics independent of the health care system, albeit with the province’s knowledge. The government then let itself off the hook for certain outpatient diagnostic exams, and these medically necessary procedures were delisted (which is illegal under the Canada Health Act). Patients now must pay out of pocket for these tests, and many buy commercial insurance "just in case."

Because markets and investors demand constant growth, established commercial clinics and health insurance will seek to expand into other areas. Dr. Ouellet is a manifestation of this—he is using his influence as the president of the Canadian Medical Association to advocate for more commercialization of health care.

Meanwhile, weeks after neurosurgeon Dr. Phillippe Couillard resigned as the Quebec minister of health, Persistence Capital Partners announced that he had accepted a position as partner. The Montreal firm is, according to its August 18 press release, “Canada’s first private equity fund dedicated to investing in healthcare businesses.”

When publicly questioned about the implications of his hopping from operating room to provincial cabinet to private investment firm, Couillard said, "It's perfectly in line with what I've been advocating for years - a strong public system, well-funded and well-organized." http://www.canada.com/montrealgazette/news/story.html?id=160dd9e1-5407-427e-86e3-6c3d55788825 As his legacy to the well-funded, strong public system, Couillard handed health care investors a gift in Bill 33, which promotes outsourcing to private clinics as a solution to excessive surgical wait times.

Both of these doctors insist that their efforts to commodify medicine demonstrate their devotion to public health care. Some physicians find this disingenuous. Medecins Quebecois pour le regime public issued their response to health care commercialization in Quebec during the August 2008 annual meeting of the CMA in Montreal http://www.medecinspourlacces.ca/position10.php Quebec may be different, but when it comes to health care opportunism in Canada, it is unfortunately not unique.

Randall White, M.D. FRCPC

Re: Betting your health on Canada's doctor lottery - National Post

Kelly McParland's August 7 editorial, "Betting your health on Canada's doctor lottery," suggests that doctors leave Canada because of the health care system. Undoubtedly some do, and some highly trained surgical specialists can earn significantly more in the United States. But what about U.S.-trained physicians who come to Canada because of the system? They exist and I am one of them.

According to the Canadian Institute for Health Information, more doctors returned to Canada than moved abroad in 2004, 2005 and 2006. Perhaps they were lured by low administrative costs, low malpractice insurance rates, and guaranteed payments. And if Canadian doctors think "government interference" is a problem in Canada, wait until they have to struggle with insurance companies for payment, have their patients' treatment dictated by insurance industry bureaucrats, or find they must treat patients for free. The U.S. is the only industrialized country that relies on charity care for a large proportion of its population. In Canada, I can treat all patients without having to worry about whether they have insurance coverage.

The assertion that all or even most U.S. physicians "practice the best medicine possible without government interference" is wrong. The U.S. government funds close to half of health care, and that money comes with many strings attached. The insurance industry has plenty of strings attached to the remainder of health care financing. I've been there, I know, and I'm glad I'm now in Canada.

Randall White, M.D., FRCPC

Re: Medicare debate under a cone of silence, Toronto Star, June 30, 2008.

By Dr Nan Okun, Maternal Fetal Medicine Specialist, Mount Sinai Hospital

As a practicing physician and a recently elected board member of Canadian Doctors for Medicare I struggled immensely with Ms Hébert’s editorial on the current state of health care in Canada. Medicare debate under a cone of silence

A relative newcomer to the politics of health care, I, along with the women I care for in my practice have been recipients of the inexplicable volatility in political decision-making that has defined how I am able to deliver care. From the heady 1980’s when the sky was the limit, to current times when “balanced budget” supersedes patient needs, I have wondered why politicians in this relatively rich country have had such difficulty delivering on a publicly funded medicare program that Canadians have repeatedly said they value highly.

Ms Hébert states that the departing Ontario and Quebec health ministers “leave behind a system whose root problems have ultimately defeated their efforts.” I would argue that it is not the system that has the problems; rather the problem lies with those that administer it being influenced by factors other than the vast majority of citizens that support the program and elect the governments.

Contrary to her assertion that “no federal party has ever had the courage to do for medicare what Stephane Dion’s “green shift” is about to do for climate change”, was it not the federal governments of the 1950’s onward that successively crafted the development of the current universal coverage that Canadians have the privilege to participate in, culminating in the Canada Health Act of 1984? Perhaps it is the lack of courage on the part of current governments to uphold it in the face of seemingly overpowering corporate pressure to reduce taxes at all costs, resulting in our perceived inability to protect and care for all Canadians in a publicly funded, single payer scheme of health care.

There have been commissioned and widely researched plans that would go a long way toward ensuring the sustainable future of medicare (eg Romanow Report on the Future of Health Care in Canada), but those in government appear not to be listening. Therefore we really haven’t given these plans a chance “to deliver truly sustainable results” that Ms Hébert refers to. That is different than saying that the plans themselves have not delivered those results.

She is right about escalating relative spending on health care. As many health care analysts and economists have pointed out, when overall social spending is drastically reduced as it has been of late, the relative proportion spent on health care will appear to be out of control. It is a true shame that we “devote twice as much to health as to education” as Ms Hébert points out. But the shame is in the relative decrease in proportional spending on education. This speaks volumes about the value that our governments place on two basic commodities that should be provided to all citizens in such a developed country.

Finally, I would love Ms Hébert to clarify what she means by the “different medicare mix” that no party has “had the guts to make the case for”. If she means the introduction of private for profit funding then we should hear one convincing piece of evidence that such a system would benefit all Canadians, not just those able to pay.

If there is doubt about what Canadians think about publicly funded health care, check out the recently published Dominion Institute survey (www.101things.ca) on the 101 things that we think define being Canadian. Whether categorized according to general public, immigrant, educator or order of Canada recipient, universal health care is in the top six.

The political cone of silence is likely not an accident. It allows the behind-the-scenes steady erosion of the Canada Health Act, created “to carry out the primary objective of Canadian health care policy, which is to protect, promote and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health services without financial or other barriers.” (Canada Health Act Annual Report, 2006-2007)

Doctors,nurses, perfusionists, and other personnel in short supply

By Randall F. White, MD, FRCPC
29 June 2008

At St. Paul’s Hospital in Vancouver, where I practice, 50 heart surgery cases have been cancelled since April 2008. The spokesperson quoted in The Province on June 26 said that the hospital sometimes lacks enough perfusionists to keep the cardiac operating rooms open. The opposition health critic in the legislature blames the government for its 2006 decision not to fund a perfusionist training program at Thompson Rivers University in Kamloops.

A few days before, The Province newspaper reported that BC Children’s Hospital in Vancouver has cancelled 50 surgeries since April because of a shortfall of at least 10 intensive-care nurses. The same week, The Globe and Mail reported that a small town in BC is so desperate for doctors that it is raising money to build a new health clinic for physicians who have yet to be hired. The public is painfully aware of the physician shortage. The 2008 Health Care in Canada survey found that 19% of people named it second only to wait times as the leading problem in our system.

In January 2008, the Canadian Medical Association launched a campaign to raise political capital for increased domestic training of physicians, an appropriate advocacy issue for Canadian physicians. But at the same time, the CMA leadership, including president Dr. Brian Day, advocates for a second tier of health care. They haven’t explained how this second tier would be staffed given the immediate need for 26,000 physicians to bring Canada up from a ratio of 2.1 doctors per 1000 population to 3 per 1000, the mean among OECD nations.

Doctors aside, private hospitals and clinics require nurses, perfusionists, and other personnel who are in short supply and who require expensive, lengthy training. These facilities would take such personnel from existing institutions, including St. Paul’s Hospital, BC Children’s, and the others that serve most Canadians. Wealthy people who can afford to pay a premium could avoid wait lists and cancellations while the rest of Canada would endure even more such failures of the public system.

This pattern occurred in Australia after the introduction of a privately funded, privately owned tier of hospitals. According to the Australian Medical Association, wait times and crowding in the public hospitals have reached a crisis. The same would happen in Canada; in fact, we have a crisis despite having no official second tier. So let’s forget tier two, train more health professionals, and make our existing system work better.

Sceptical Reflections on the BC Pharmaceutical Task Force

By Randall F. White, MD, FRCPC

9 June 2008

The BC minister of health, George Abbott, assembled a task force in 2007 to review policy on pharmaceutical coverage under the province’s PharmaCare program. According to the Web site http://www.health.gov.bc.ca/pharme/, the program “subsidizes eligible prescription drugs and designated medical supplies, protecting British Columbians from high drug costs.” Abbott’s appointments to the panel surprised even cynics.

Adrian Dix, the opposition health critic, called the composition of the nine-member task force “highly debatable” because five of the members had ties to the pharmaceutical industry. It included Russell Williams, the president of Canada's Research-Based Pharmaceutical Companies, a leading industry lobbying group. The conflict of interest was glaring, yet aspects of the province’s decision-making that displease industry were open for review.

Most provinces turn to the Common Drug Review that for decisions about covering medications. For therapies that fall outside the Common Drug Review, BC has an independent review process called the Therapeutics Initiative (TI), which also provides education for clinicians on its Web site Therapeutics Initiative The TI review process has been praised for outcomes such as preventing widespread use of COX-2 inhibitors in BC, medications which turned out to have a poor risk/benefit ratio.

The task force released its report in April 2008, and just as critics expected, the recommendations lean hard on efforts to protect tax payers and public health at the expense of Big Pharma’s profits. The report concluded, without substantiation, that the TI is “widely regarded as being in need of either substantial revitalization or replacement.” The panel even recommended that the TI cease educational activities, suggesting that they have not been “unbiased and evidence based.”

In barely concealed contempt for the TI, which is housed at UBC and is explicitly designed to keep the evaluation process shielded from industry influence, the panel suggested a new process that includes “disease-specific experts.” Although experts have a lot to offer, the fact is that many are involved in research and education funded by Big Pharma: more conflict of interest. In an egregious example, Dr. Joseph Biederman, a renowned child psychiatrist and researcher at Harvard, was recently found to have concealed a large sum of pharma income New York Times

What about a government’s conflict of interest in inviting industry to craft public policy? Big Pharma spreads its money around, including to Abbott’s party, the BC Liberals. The Pharmaceutical Task Force illustrates how commercial interests influence health policy, and why Canadians should hesitate to allow commercialization of other aspects of the health care system. Once corporate interests are let in, their lobbyists want a say in whatever government does.

CDM calls on BC government to reject two-tier health care disguised as "sustainability"

The BC government should remove “sustainability” from the proposed Medicare Protection Amendment Act, Bill 21, unless it unequivocally rejects private for-profit care for medically necessary services and commits to keeping the universal single-payer system, says Dr. Randall White, BC Chair of Canadian Doctors for Medicare.

“We all believe in a sustainable health care system,” says Dr. White. “We all believe in innovation, transparency and accountability – words the government wants to enshrine in the legislation. We all believe patients should have choice in the kind of care they get, that there should be personal responsibility. But we believe in these principles within the context of the public system because the evidence is that single-payer systems provide better value for money than private systems, with health outcomes that are as good or better.”

When governments enshrine these principles in legislation, they provide fodder for the supporters of for-profit care to argue that choice, personal responsibility, and the needs of other public programs require private for-profit health care, says Dr. White. This creates the impression that health care is siphoning funds from other programs, like education. “The reality is the health care budget has grown so much compared with other program budgets because the BC Liberals have reduced social spending and cut taxes.”

Alarmist rhetoric from promoters of commercialized medical care suggests Canada has a crisis that demands privatization, says Dr. White. For example, for-profit supporters use statistics stating Canada ranks 30th in the world in health care. This is from a discredited World Health Organization report that ranked Colombia as No. 1 in "fairness in financing" and the United Arab Emirates as No. 1 in "responsiveness". Meanwhile, favourable studies, such as a 2008 report showing that Canada ranks sixth in preventing deaths from medically treatable disease, are ignored.

Private for-profit care requires commercial insurance, which most Canadians will not be able to afford; or will not quality for. Studies elsewhere show the major beneficiaries of private insurance are investors in insurance companies, private hospitals, and specialist doctors who command high fees. Private clinics will take less complicated cases, leaving the more difficult cases to the public system – along with even longer waiting lists because the specialists will be busy in private clinics.

“We don’t need private for-profit care to have a sustainable system,” says CDM Policy Advisor Karen Palmer. “What we need are innovation and reform within the public system (see Successful Medicare Innovations). This means more surgical capacity in our public hospitals, queue management to reduce wait times, the most efficient use of operating space and staff; and systematic collaboration between generalists and specialists. We also need widespread efforts to prevent chronic diseases such as obesity, diabetes, and addiction.

“The path to sustainability is through a universal, single payer system, not through efforts to cap spending, outsource care to for-profit clinics, and shift costs to patients.”

For More Information:

Randall F. White, M.D. - BC Chair, Canadian Doctors for Medicare
Email: info@canadiandoctorsformedicare.ca
Phone: 604 221 2313 or 604 682-2344 x63966