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Universality, Quality & Economics: Finding a Balance in Ontario and British Columbia

Published online by Cambridge University Press:  24 February 2021

John D. Blum
John D. Blum*
Affiliation:
Notre Dame Law School, MHS, Harvard University School of Public Health; Loyola University Chicago School of Law
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Extract

National economies worldwide are in disarray, evidenced by escalating debts and growing deficits. As countries struggle with their faltering economies they are hard pressed to fulfill commitments of social programs made in more prosperous times, much less take on new government initiatives. The current experiences in health reform in the United States present an interesting example of the dilemmas governments now face when they embark on new ventures. While great political pressures have been launched and high expectations abound, the reality of American health reform quickly reveals that expanded access will come at a high price that won't be offset easily by conventional cost containment or market forces.

In the search for an acceptable model for health reform, it was popular for policy makers and academics to turn their attentions to the health systems of other nations. Recommendations were made that the US should adopt a German or Canadian solution for our health problems.

Type
Articles
Information
American Journal of Law & Medicine , Volume 20 , Issue 1-2: Quality of Care and Health Reform: Complementary or Conflicting , 1994 , pp. 203 - 229
Copyright
Copyright © American Society of Law, Medicine and Ethics and Boston University 1994

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References

1 Bruce Crumley et al., Farewell to Welfare, TIME, Nov. 22, 1993, at 51-52.

2 Cranford, Americans in Need of Help: A Look at the Figures, Cong. Q., Sept. 25, 1993, at 19-20.

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9 Id. at 50.

10 R.S.C, ch. C-6, §§ 8-12 (1984) (Can.).

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13 R.S.C, ch. C-6, §§ 18-21.

14 Fulton, supra note 8, at 38-39.

15 Id. at 38-39, 259.

16 Federal-Provincial Fiscal Arrangements & Federal Post-Secondary Education & Health Contributions Act, R.S.C., ch. F-8 (1985) (Can.). See also Fulton, supra note 8, at 29, 49-50.

17 See Paul Boothe & Barbara Johnston, C.D. Howe Institute, Stealing the Emperor's Clothes: Deficit Offloading and National Standards in Health Care, at 3 (1993).

18 R.S.C., ch. M-8, at §§ 3-6.

19 Id. § 5.

20 Federal-Provincial Fiscal Arrangements and Established Programs Financing Act, S.C. ch. 10, (1976-77) (Can.), amended by R.S.C., ch. F-8 (1985) (Can.).

21 See Boothe & Johnston, supra note 17, at 3.

22 “Transfer” is a term referring to the process of shifting federal monies from Ottawa to the individual provinces. Transfer occurs because the federal government, via taxation, has historically controlled resources beyond its constitutional responsibilities, while the provinces have had social responsibilities (covering health care, for example) which exceeded their own resources. To offset this imbalance, the federal government has pardy financed social programs by transferring funds to the provinces. Id. at,2.

23 Id. at 3.

24 Id.

25 Id.

26 Id.

27 Id.

28 Id. at 3-4.

29 Id. at 5.

30 Id. See also Ernst & Young, Cost to British Columbia of Measures by the Federal Government to Reduce its Funding Share of Social Problems (1993); Registered Nurses Association of British Columbia, Federal Transfer Payments for Health Care (1992); R.J. Van Loon From Shared Cost to Block Funding and Beyond: The Politics of Health Insurance in Canada, in Perspectives on Canadian Health and Social Science Policy: History and Emerging Trends, ch. 20 (Meiliche & Storch eds., 1980).

31 Barry Came et al., Sacred Trust?, Maclean's, Aug. 30, 1993, at 16-17.

32 Id.

33 Ontario Health Insurance Plan, Health Insurance-Ontario (1993) (an historical summary).

34 Id.

35 Fulton, supra note 8, at 1, 2.

36 Ontario Health Insurance Plan, supra note 33, at 1.

37 Id. at 2.

38 Ontario Health Insurance Act, R.S.O., ch. H-6, § 12 (1990) (Can.).

39 See also Ontario Trims Drug Benefit Program, Can. Health Facilities L. Guide (CCH) No. 108, at 1 (Aug. 31, 1993).

40 For a review of provincial health plan funding sources, see generally Boothe & Johnston, supra note 17.

41 R.S.O., ch. H-6, § 2(2)(a)-(b).

42 Nursing Homes Act, R.S.O., ch. N-7, § 21 (1990) (Can.).

43 See Public Hospitals Act, R.S.O., ch. P-40, § 5 (1990) (Can.).

44 Abebe Engdasaw, Will More Spending on Health Services Equal Better Health?, Ottawa Citizen, Mar. 5, 1994, at B7.

45 Premier's Council on Health Strategy, A Vision of Health; Health Goals for Ontario (1990). This Ontario report sets out a roadmap for reorienting the priorities of the Ontario health system. See also Albert Warson, Canadian Health System Running a Fever, Modern Healthcare, Feb. 14, 1994, at 78.

46 D'Arcy Jenish & Ann Walmsley, Tremors in the Heartland, Maclean's, Mar. 30, 1987, at 28

47 Paul Kaihla, Shell-Shocked, Maclean's, Dec. 7, 1992, at 12, 13.

48 William Walker, Ontario Deficit Soars: Higher Taxes Looming, Toronto Star, Feb 23, 1993, at Al. See also Maryjanigan, Demise of a ‘Fat Cat', Maclean's, Apr. 4, 1994, at 10-12; Clyde H. Farnsworth, Weak Canadian Dollar Raises Rates, Limits Jobs, N.Y. TIMES, Apr. 6, 1994, at Dl.

49 Boothe & Johnston, supra note 17, at 5.

50 Id. at 9-10.

51 See Warson, supra note 45, at 78-80.

52 See Premier's Council on Health Strategy, supra note 45.

53 Id.

54 See generally id.

55 Richard Mackie, Rae Says Social Contract a Prelude, Globe & Mail, Dec. 29, 1993, at Al.

56 See janigan, supra note 48, at 10.

57 See generally New Legislation Begins Reform of Long-Term Health Care, Can. Health Facilities L. Guide (CCH) No. 112, at 3.

58 See Warson, supra note 45, at 78.

59 Canadian Health Management Supplement, The Dispatch, Jan. 1993, at 85:7.

60 R.S.O., ch. 1-3 (1990) (Can.).

61 See Ontario Ministry of Health, Health Service Organization (HSO) Program Information Packace, at 1 (1990).

62 Hospital Funding Announced for 93-94, Ontario Ministry of Health News Release (Ontario Ministry of Health, Toronto, Ont., Can.), Nov. 26, 1992, at 1.

63 Berwick, Peter J. & Brown, Warren S., The Impact of the New Health Number on Office Practice, 57 Ont. Med. Rev. 9 (1990)Google Scholar.

64 Id. at 10.

65 Gordon Bagley, Delisting Rumors Denied, 11 Ont. Med. 1, 6, June 22, 1992.

66 R.S.O., ch. H-6, § 2(2)(c) (1990).

67 Ontario Restricts Drugs, The Dispatch, (Canadian Health Facilities Management), July 1992.

68 Paul, Rhodes, Most Doctors Honest, OHIP Says, Ont. Med. Rev., Nov. 1992, at 42Google Scholar.

69 See Bill 50, Legislative Assembly of Ontario, June 1993. “An act to implement the government's expenditure control plan and, in that connection, to amend the Health Insurance Act and the Hospital Labour Disputes Arbitration Act.” This act has not yet been enacted, but is now pending. Under Section 8 of Bill 50 the Government may assert control over the numbers and distribution of physicians. See also Derek Coomber, Medical Students Faced With a Bitter Pill to Swallow, Financial Post, Oct. 6, 1993, at C5.

70 Ontario Reforms, The Dispatch, (Canadian Health Facilities Management Supplement), July 1992.

71 Warson, supra note 45, at 78.

72 Rod Mickleburgh, Use of Nurse Practitioners to Rise, Globe & Mail, Feb. 11, 1993, at A-3.

73 Office of Economic Country Development (OECD), Nov. 1993.

74 Rod Mickleburgh, Cost Crunch Dictates: Hospitals, Heal Thyself, Globe & Mail, April 29, 1992, at A-l; Bruce Little, The $71-Billion System Seeks a Cure, Globe & Mail, April 27, 1992, at A-9.

75 Hospital Reform Update, Ontario Ministry of Health News Release (Ontario Ministry of Health, Toronto, Ont., Can.), Nov. 26, 1992, at 5.

76 Hospital Funding Announced for 93-94, supra note 61, at 1.

77 The Public Hospitals Act, 21 Geo. V, ch. 78 (1931). See also Steering Committee, Public Hospitals Act Review, Into the 21ST Century, Ontario Pubulic Hospitals, at 1 (Feb. 1992) [hereinafter Steering Committee] .

78 R.S.O., ch. P-40 (1990) (Can.).

79 Hospital Reform Update, supra note 75, at 5.

80 Steering Committee, supra note 77, at 28-39, 169.

81 Id.

82 Id. at 42.

83 Id. at 15, 16.

84 Id. at 173, 174.

85 Id. at 162.

86 Id.

87 Ontario Hospital Funding, The Dispatch, (Canadian Health Care Management Supplement).

88 Warson, supra note 45, at 78.

89 See Martin Powell, Toronto Hospitals to Woo Patients From United States, Globe & Mail, April 12, 1993, at A-l.

90 Id.

91 District Health Councils: Partners in Health Planning, Ontario Ministry of Health News Release (Ontario Ministry of Health, Toronto, Ont., Can.), Oct. 1989.

92 Id.

93 Id.

94 Id. at 31-34.

95 Id.

96 Health Services Planning Framework, A Tool For Planning, Ontario Ministry of Health News Release (Ontario Ministry of Health, Toronto, Ont., Can.), J a n . 1992.

9 7 Southwestern Ontario Comprehensive Health System Planning Commission, Working Together to Achieve Better Health for All (1991).

98 Id.

99 Id.

100 Id.

101 Id.

102 Long Term Care Statute Amendment, R.S.O. (1992) (Can.).

103 Canadian Health Management Supplement, supra note 59, at 85-87.

104 Nursing Homes Act, R.S.O., ch. N-7, §§ 105-69, 164 (1990) (Can.).

105 Id.

106 Redirection of Long Term and Support Services in Ontario: A Public Consultation Paper, Ontario Ministry of Health News Release (Ontario Ministry of Health, Toronto, Ont., Can.), Oct. 1991.

107 See Kelly Toughill, Province Plans Overhaul of Nursing Home System, Toronto Star, Feb. 21, 1993, at All .

108 New Research Institute to Improve Medical Practice, Ontario Ministry of Health News Release (Ontar io Ministry of Health, Toronto, Ont., Can.), Mar. 30, 1993.

109 Phillip, Hassen, Continuous Quality Improvement in Health Care: An Example, BUS. Q., Autumn 1991, at 34, 39Google Scholar.

110 Canadian Council on Health Facilities Accreditation, Acute Care Large Community and Teaching Hospitals (1992).

111 Id. at MED-26.

112 Medical Staff Privileges, Can. Health Facilities L. Guide (CCH) 3825.

113 Robert, MacMillan & Marsha, Barnes, The Independent Health Facilities Act: A First for North America, 11 Health Law in Canada 59 (1991)Google Scholar.

114 Id.

115 Id.; R.S.O., ch. 1-3 (1990) (Can.).

116 R.S.O., ch. 1-3, §§ 5, 6. See also Gary, Ollson, Quality Assurance and the Independent Health Facilities Act, 12 Health Law in Canada 46 (1991)Google Scholar.

117 R.S.O., ch. 1-3, §§ 5, 6; Ollson, supra note 116, at 46. The independent health facility quality initiatives are still being developed by the Ontario College of Physicians and Surgeons. Id. at 48.

118 See MacMillan & Barnes, supra note 113, at 62.

119 Id. at 62-63.

120 R.S.B.C, ch. C-28, § 1 (1979) (Can.).

121 Medical Service Act, R.S.B.C., ch. C-255 (1979) (Can.); R.S.C., ch. M-8.

122 See B.C. Ministry of Health, 1991-92 Annual Report (1992).

123 R.S.B.C., ch. C-255.

124 Id. § 8.

125 Medical Services Plan of British Columbia, Your Medical Services Plan (1992).

126 Id.

127 R.S.B.C., ch. C-28.

l28 The B.C. Pharmacare program is set up pursuant to the Guaranteed Available Income for Need Regulations, B.C. Reg. 479/76, § 30. This is subordinate legislation falling under the umbrella of the Guaranteed Available Income for Need Act, R.S.B.C., ch. 158 (1979).

129 Continuing Care Act, R.S.B.C., ch. 2 (1989) (Can.).

130 Special provisions for private health insurance are recognized in the Medical and Health Care Services Act, R.S.B.C, ch. C-76 (1992) (Can.).

131 It does not appear that the supplemental market in B.C. approaches that of Ontario in that the scope of coverage through the provincial plan remains very broad.

132 B.C. Ministry of Health, supra note 122.

133 Id.

134 Id. at 62-63.

135 Id.

136 Matt Borsellino, Union Call: Government Budget Prompts BCMA to Contemplate Unionized Status, Medical Post, April 13, 1993, at 1.

137 See generally Matt Borsellino, OMA Balks at NDP's Social Contract Negotiations, C.P. WIRE.

138 Robin Brunei, Medicare's Erosion, B.C. REP., Jan. 18, 1993, at 7-8.

139 Id. at 7.

140 Boothe & Johnston, supra note 17, at 2.

141 Ernst & Young, supra note 30, at 7.

142 Id. at 19.

143 Id. at 8-9.

144 Id. at 9.

145 See Id. at 10.

146 Hemeon, Recession in B.C. Cuts Deep, Fin. Times Can., Aug. 30, 1982, at 9. See Fennell, B.C. Outlook Dulls as Expo Glow Fades, Fin. Times Can., Oct. 6, 1986.

147 Valerie, Lawton, A Review of Peter Murray's Primer on B.C. Politics, C.P. Wire, Sept. 29, 1991.Google Scholar

148 NDP Wins Big in B.C. Election, C.P. Wire, Oct. 18, 1991. See Hal Quinn, B.C. 's New Era, Maclean's, April 15, 1991, at 12.

149 Steve Vanagas, A ‘Revolting’ Budget, B.C. Rep., April 12, 1993, at 6.

150 B.C. Ministry of Health, supra note 132.

151 For a discussion of budgetary pressures on t h e government, see Keith Baldrey, NDP Reels as Polls Match Socred Lows, Vancouver Sun, July 17, 1993, at A-l.

152 Robert Matas, Influx to B.C. Strains Welfare, Globe & Mail, June 3, 1993, at A-l.

153 See Medical Services Plan of British Columbia, supra note 125. THE COMMISSION summarized its findings in a report. See British Columbia Royal Commission on Health Care and Costs, Closer to Home, Vol. 2 (1991) [hereinafter Royal Commission].

154 Royal Commission, supra note 153, at A-7.

155 See generally id.

156 Id. at A4-5.

157 See id. at A6-7.

158 Id. at B-4.

159 Id. at v.

160 Id. at Part C.

161 Id. at A-15-16.

162 Id.

163 Id.at A-15.

164 Id. at B-37-40.

165 Id.

166 Id.

167 Id. atC-136-37.

168 Id. atC-132-33.

169 See id. at C-133-35.

170 See id. at C-153-61.

171 Id. at B-22-23.

172 Id. at B-26-29.

173 Id. at C-23-33, & 35-41, C-43-55.

174 See id.

l75 See id. at C-71-84.

176 Id. at D-3-22.

177 Id. at B-57-64.

178 Id. at D-4-7.

179 Id. at D-7-8.

180 See id. at B-77-114.

181 In Conversation With Elizabeth Cull: Reforms and Funding in B.C. Health Care, B.C. Health Mgmt. Rev., Spring/Summer 1992, at 9.

182 Id. at 9.

183 B.C. Ministry of Health, New Directions for a Healthy British Columbia (1993) [hereinafter New Directions]. Underlying the plan “New Directions” are four operating points: equity, partnership, financial responsibility, and sensitive implementation. Id. at 11. Of the four points, perhaps the most significant relates to finances. See Brunet, supra note 138, at 6. While the plan document didn't state that additional funds beyond those already expended would not be channeled into health, it stressed the need for fiscal conservatism. See New Directions, supra, at 1.

184 New Directions, supra note 183, at 5.

185 Id. at 11-17.

186 Id. For example, the plan called for the creation of the Provincial Health Council by the summer of 1993 and the creation of provincial health goals by the new Council in 1994. Id. at 12.

187 Id. at 13.

188 Id at 16.

189 Brunet, supra note 138, at 6.

190 See Royal Commission, supra note 153, at B-22-23.

191 See id.

192 See id. at B-23.

l93 See id.

194 Id.

195 It is beyond the scope of this article to review the details of all recent health law activity in the provincial parliament.

196 R.S.B.C., ch. C-76.

197 Health Authorities Act, 35th Parliament, 2d Sess., Leg. Ass. of B.C., 1993.

198 See Brunet, supra note 138, at 6.

199 See generally In Conversation With Elizabeth Cull: Reforms and Funding in B.C. Health Care, supra note 181.

200 See Royal Commission, supra note 153, at C-132.

201 Robin Brunet, The Dismantling of Medicare, B.C. Rep., Mar. 8, 1993, at 22, 24.

202 Royal Commission, supra note 153, at D-4-8.

203 Brunet, supra note 138, at 7.

204 Id. at 10-11.

205 R.S.B.C., ch. C-76.

206 Id

207 Id.

208 Id. at Part 8.

209 Id. at Part I.

210 Id. at Part rV.

211 Id.

212 Brunet, supra note 138, at 6.

213 Id at 7.

214 Id.

215 R.S.B.C., ch. C-255, § 9; see also]. Schreiner, B.C. Cuts Taxes, Shaves Deficit, Fin. Post, Mar. 23, 1994, at 3.

216 Schriener, supra note 215; British Columbia Doctors Settle, Montreal Gazette, Aug. 24, 1993, at Bl .

217 Brunet, supra note 138, at 6.

218 Borsellino, supra note 136, at 1. While the sentiment to unionize was strong, it did not carry with the BCMA membership. Medical Association's Doctor's Vote Against Becoming a Union, Vancouver Sun, July 31, 1993, at A-4.

219 Borsellino, supra note 136, at 1.

220 Steve Vanagas, Labor Peace We Can't Afford, B.C. Rep., Apr. 5, 1993, at 16, 17.

221 Id. at 16.

222 Id.

223 Palmer, 93 Hospital Accord, A Costly Operation, Vancouver Sun, Jan. 8, 1994, at A-10.

224 Vanagas, supra note 220, at 16.

225 Id.

226 Id.

227 Id.

228 Royal Commission, supra note 153, at B-37-40.

229 See generally Regionalization Working Group, Royal Commission Response Office, Decentralization of Health Services (Sept. 1992).

230 Id.

231 Id. at 3.

232 Id.

233 Id. at 9, 10.

234 Id.

235 Id. at 16-18.

236 Id.

237 B.C. Ministry of Health, A Guide for Developing Community Health Councils and Regional Health Boards (1993).

238 Id.

239 Id. at 5.

240 Id.

241 Id. at 5-6.

242 Id.

243 Id. at 21.

244 Id. at 5.

245 Id.

246 Id. at 6.

247 Id. at 11, 13-14,21-22.

248 New Directions, supra note 183, at 15.

249 See id. at 14-15.

250 Dibert Bhatia, Ontario Premier's Counsel on Health, Well Being and Social Justice, Devolution and Decentralization of Health Care Systems, 23-30 (1993).

251 New Directions, supra note 183, at 13-15.

252 Royal Commission, supra note 153, at C-154.

253 Elimination of Services, 35 B.C. Med. J. 219 (1993). To effectuate cost savings, and reduce unnecessary acute care bed capacity, the Ministry has ordered the closing of the 306 bed Shaughnessey Hospital, one of the oldest tertiary care facilities in Vancouver. Id. The closure, which will displace 2000 health workers, is also motivated by a realization that hospital beds will need to be increased in areas where the provincial population is expanding. Id. As might be expected, the medical community criticized the closure of Shaughnessey Hospital, arguing that the Ministry naively views hospital beds and services as fungible commodities that can be easily replaced elsewhere. Id.

254 Brunet, supra note 138, at 6.

255 Id.

256 See generally British Columbia Health Association, BCHA Response to Closer to Home: Report of the Royal Commission on Health Care and Costs (1992).

257 Vanagas, supra note 149, at 6.

258 Malcolm Gladwell, Failing Health, Globe & Mail, Oct. 1993, at 26; Clyde H. Farnsworth, Now Patients Are Paying Amid Canadian Cutbacks, N.Y. TIMES, Mar. 7, 1993, at A-l.

259 See Gladwell, supra note 258. See also Farnsworth, supra note 258.

260 See Gladwell, supra note 258, at A-10; Farnsworth, supra note 258, at 66. See also Brunet, supra note 138, at 6.

261 Students of health policy will undoubtedly take note of the developments in Canadian health policy on their own merit. Canada's health system, as noted Canadian economist Robert Evans has pointed out, was not created as a model for Americans, but, of course, as a system to serve its own national interests. Evans, supra note 11, at 362. It is a mature system, and as such one must expect changes will occur over time, as a result of a host of other factors in addition to pure economics.

262 Zwanziger & Anderson, Comparison of Hospital Costs in California, New York and Canada, Health Affairs, 138-147 (1993); Donald, Redelmeier & Fuchs, Victor R., Hospital Expenditures in the United States and Canada, 328 New Eng. J. Med. 772, 772-78 (1993)Google Scholar; Fulton, supra note 8, at 214-28.

263 See Zwanziger & Anderson, supra note 262, at 138; Redelmeier & Fuchs, supra note 262, at 772.

264 Jane, Fulton, A Canadian Takes on American Health Care, 9 Financial Executive 10, 10 (1993)Google Scholar; see also National Health Policy Reform Project, Canadian Hospital Association, An Open Future: A Shared Vision. OECD and WHO data cited in the Canadian Hospital study point out that the life expectancy in Canada is 76.8 years compared to 75 years in die United States. Also, Fulton notes that infant mortality is 10:1000 in the United States, as opposed to 6:1000 in Canada. Fulton, supra.

265 See H.R. 3600, 103d Cong., 1st Sess. §§ 1221-24 (1993); see Somerville, Singing the Praises of Single-Payer, A News, Dec. 6, 1993, at 9.

266 Royal Commission, supra note 153, at B-29.

267 Hospital Funding Announced for 93-94, supra note 62, at 1, 2.

268 In Conversation With Elizabeth Cull: Reforms and Funding in B.C. Health Care, supra note 181, at 11.

269 Evans, Robert J. et al., Controlling Health Expenditures -The Canadian Reality, 320 New Eng. J. Med. 571-77 (1989)CrossRefGoogle Scholar.

270 Lawrence, Brown, Some Structural Issues in the Health Planning Program, in Health Planning in the United States: Selected Policy Issues (Institute of Medicine, National Academy of Sciences, 1981)Google Scholar.

271 Boothe & Johnston, supra note 17, at 2; Royal Commission, supra note 153.

272 Willard Gaylin, Faulty Diagnosis: Why The Clinton Health Care Plan Won't Cure What Ails Us, Harpers, Oct. 1993, at 57-64.

273 Vanagas, supra note 220, at 16, 17.

274 More Budget Cuts Loom, Fin. Post, Mar. 10, 1994, at 51. This article talks about the new term for mandatory unpaid days off called “Rae Days,” named after the Ontario Premier Bob Rae who implemented this policy. See generally F. Dube, Unions, Hospitals Debate Cuts Effect: Deficit Driven Times Hurt Medical Care Workers, Ottawa Citizen, Dec. 23, 1993, at C-l.

275 Strikes Beset B.C. Hospitals, Facts on File, Inc. (1989). See also Laver et al., Temperature Rising, Maclean's, July 17, 1989 (detailing the widespread nursing union activity across Canada).

276 Fulton, supra note 8, at 214-28.

277 H.R. 3600, 103d Cong., 1st Sess. §§ 5001-13.

278 Fulton, supra at note 8, at 241-44.

279 The Institute of Clinical Evaluation Studies in Ontario is a good example of a major effort to improve the quality of clinical practice. Redirection of Long Term and Support Services in Ontario: A Public Consultation Paper, supra note 106.

280 Jcaho, Developing an Indicator Board Monitoring System (1993).

281 Id.

282 Canadian Council on Health Facilities Accreditation, Quality Assurance, the Future (Outcome Measures Project) (Sept. 1990).

283 See H.R. 3600, 103d Cong., 1st Sess. § 1341.

284 Fulton, supra note 8, at 258; see also Blendon, Robert J., et al., Satisfaction with Health Systems in Ten Nations, 9 Health Affairs 185, 185-92 (1990)CrossRefGoogle Scholar.