SAVINGS AND RESTRUCTURING ACT, 1995 / LOI DE 1995 SUR LES ÉCONOMIES ET LA RESTRUCTURATION
ONTARIO HOSPITAL ASSOCIATION, REGION 1
OGDEN-EAST END COMMUNITY HEALTH CENTRE
THUNDER BAY AND DISTRICT LABOUR COUNCIL
LAKE NIPIGON REGION HOSPITAL ASSOCIATION
CANADIAN UNION OF PUBLIC EMPLOYEES, LOCAL 1409
THUNDER BAY COALITION AGAINST POVERTY
SERVICE EMPLOYEES INTERNATIONAL UNION, LOCAL 268
CONTENTS
Wednesday 10 January 1996
Savings and Restructuring Act, 1995, Bill 26, Mr Eves / Loi de 1995 sur les économies et la restructuration, projet de loi 26, M. Eves
Thunder Bay Regional Hospital
Dave Ringius, chair of the board
Gaston Levac, president and CEO
Ontario Hospital Association, Region 1
Bob Muir, executive director, Lake of the Woods District Hospital
Andrew Skene, chair, OHA region 1; CEO, Dryden District General Hospital
Ogden-East End Community Health Centre
Joe Devlin, executive director
Thunder Bay and District Labour Council
Judy Monteith-Farrell, delegate
Richard Armstrong, second vice-president; member, health committee
Lake Nipigon Region Hospital Association
Donald Ross, CEO, Nipigon District Memorial Hospital
Dr Mary-Lynn Jackson-Hughes, chief of staff, Lake Nipigon Memorial Hospital; coordinator, FamilyMedicine North
AIDS Committee of Thunder Bay
Michael Sobata, executive director
Thunder Bay Medical Society
Dr Gordon Milne, president
Dr John Fernandes, representative
Dr Walter Kutcher, vice-president, medical staff, Thunder Bay Regional Hospital
Dr Jim Stamler, president, medical staff, Thunder Bay Regional Hospital
Canadian Union of Public Employees, Local 1409
Jules Tupker, CUPE national representative
Thunder Bay Coalition Against Poverty
Christine Mather, representative
Constance McKnight, representative
Jaroslav Kotalik
Service Employees International Union, Local 268
Jack Drewes, president
Glen Chochla, organizer
STANDING COMMITTEE ON GENERAL GOVERNMENT
Chair / Président: Carroll, Jack (Chatham-Kent PC)
*Carroll, Jack (Chatham-Kent PC)
Danford, Harry (Hastings-Peterborough PC)
Kells, Morley (Etobicoke-Lakeshore PC)
Marchese, Rosario (Fort York ND)
Sergio, Mario (Yorkview L)
Stewart, R. Gary (Peterborough PC)
*In attendance / présents
Substitutions present / Membres remplaçants présents:
Johns, Helen (Huron PC) for Mr Danford
Miclash, Frank (Kenora L) for Mr Sergio
Clement, Tony (Brampton South / -Sud PC) for Mr Kells
Ecker, Janet (Durham West / -Ouest PC) for Mr Stewart
Lankin, Frances (Beaches-Woodbine ND) for Mr Marchese
Also taking part / Autre participants et participantes:
Gravelle, Michael (Port Arthur L)
McLeod, Lyn (Fort William L)
Pouliot, Gilles (Lake Nipigon / Lac-Nipigon ND)
Clerk / Greffière: Grannum, Tonia
Staff / Personnel: Campbell, Elaine, research officer, Legislative Research Service
The committee met at 0900 at the Airlane Motor Hotel, Thunder Bay.
SAVINGS AND RESTRUCTURING ACT, 1995 / LOI DE 1995 SUR LES ÉCONOMIES ET LA RESTRUCTURATION
Consideration of Bill 26, An Act to achieve Fiscal Savings and to promote Economic Prosperity through Public Sector Restructuring, Streamlining and Efficiency and to implement other aspects of the Government's Economic Agenda / Projet de loi 26, Loi visant à réaliser des économies budgétaires et à favoriser la prospérité économique par la restructuration, la rationalisation et l'efficience du secteur public et visant à mettre en oeuvre d'autres aspects du programme économique du gouvernement.
The Chair (Mr Jack Carroll): As is our custom, we're going to try to get started on time, if I could get you all to take your seats, please.
To everyone in our audience, we're delighted you're here. We appreciate your interest in the process. I'd just like to remind you that the dialogue is between the presenters and the committee members and we'd kind of like to keep it that way.
THUNDER BAY REGIONAL HOSPITAL
The Chair: Our first group this morning represents the Thunder Bay Regional Hospital: David Ringius, chair of the board, and Gaston Levac, president and CEO. Welcome, gentlemen. You have a half-hour to use as you see fit. Questions, should you allow time for them, would begin with the New Democrats. The floor is yours.
Mr Dave Ringius: Thank you. I am Dave Ringius and I will make the presentation and both of us will answer questions.
Thunder Bay Regional Hospital is pleased to present our corporation's comments on Bill 26. We commend the finance and economic affairs standing committee of the provincial Legislature for providing interested groups and individuals with the opportunity to present their views on this proposed legislation.
A little bit of background: Prior to commenting on Bill 26, we believe it is important to provide the members of the committee with a brief description of the new Thunder Bay Regional Hospital Corp.
The Thunder Bay Regional Hospital Corp was established on April 1, 1995, through a voluntary amalgamation of the former Port Arthur General Hospital and the former McKellar General Hospital. The establishment of this new corporation was totally compatible with the Thunder Bay Hospital Services Review Report (1993-94) which recommended the creation of two hospital businesses for Thunder Bay. One business focus would include all acute care services, with the other being responsible for comprehensive chronic and rehabilitation services. The Thunder Bay Hospital Services Review Report recommended that all institutional hospital services be contained within these two businesses. It was further recommended that these distinct organizations be governed independently by their own boards with separate management structures, a vast improvement to a system previously comprised of five hospital corporations, each with its own board and management structure.
With a mandate to be the only acute care regional referral hospital corporation in Thunder Bay, the board of directors, the management, the medical staff and the employees of Thunder Bay Regional Hospital have the following goals:
-- To consolidate all institutional care services under one corporation, with one management team, one medical staff and, in the medium term, on one site; there are currently three sites.
-- To utilize the achievement of increased efficiencies to enhance the quality of institutional care in our community and our catchment area.
-- To work cooperatively with other health care providers, including our district health council, to ensure that our actions continue to be consistent with the Thunder Bay Hospital Services Review recommendations.
-- To decrease the overall cost of providing institutional care services in Thunder Bay.
-- To reinvest part of the savings accrued through this restructuring of acute care services in enhancement of weaker programs, such as our trauma program; establishment of non-existing services -- several home support services; improved recruitment and retention of health care specialists; consolidation of all institutional acute care on a new hospital site within five years.
We'd like to highlight the progress achieved in just a few short months, the magnitude and pace of which we believe were only possible because of a true amalgamation. With widespread community support for the need for change and by starting quickly to implement change, our initial steps in reorganizing to increase efficiency, improve quality and reduce operational costs have already resulted in an annual decrease in operating expenses of $2.1 million on a total budget of about $95 million. Discussions on plans for further changes are well under way. Obviously, the recent funding reductions announced by the Minister of Finance will add significantly to our challenges.
We believe that similar opportunities are available to all multihospital communities if meaningful restructuring occurs. We also hope that communities that have shown and indeed have taken the initiative to implement changes such as we have done at Thunder Bay hospital will not be penalized down the road.
We also make the following observations:
Many communities or transfer payment agencies currently opposed to Bill 26, in some way, contributed to the province's financial problem.
Many communities/TPAs have been unwilling or unable to achieve consensus on the measures which must be taken to assist the government in balancing the books. On the contrary, almost the entire public sector, including transfer payment agencies and many special-interest groups, has continued to lobby governments for more transfer payments or for the status quo over the years.
Most communities/TPAs currently have no concrete proposals to assist the provincial government to balance the budget and to significantly reduce the level of existing transfer payments.
The provincial government has a responsibility to the electorate to make significant changes in legislation that will empower it to impose measures, when necessary, upon communities and transfer payment agencies to achieve a balanced budget.
Our position on Bill 26:
Firstly, we support the government's agenda to balance the provincial budget within its first term. We believe that the long-term viability of our province, of our country and of all our public services depend on it.
Secondly, we support the government's agenda to reorganize the entire public sector service delivery system to make it more efficient and to provide public services within our ability to pay and within our ability to sustain them within a balanced budget.
Thirdly, we support the government's thrust to divest itself of the direct responsibility for delivery of services wherever it can do so to save tax dollars.
Fourthly, we wish to indicate our general support for Bill 26 giving the Ontario provincial government the powers and the tools to achieve its stated agenda, for which it was elected. We acknowledge that the government's primary mandate of balancing the provincial budget cannot be realized without appropriate changes in legislation to allow the government to take dramatic measures when they are clearly required to be taken.
However, the powers to be assumed by ministers, the civil service and boards that may be appointed to implement or enforce actions taken under the bill are overwhelming and somewhat frightening. Therefore, in requiring Ontarians to accept this legislation and its inherent powers, the government, its ministers, civil services and boards must strive to attain much higher standards than we historically have seen from them in the past. Parochialism can have no part in implementing this bill if this government expects the people of Ontario to readily accept the provisions of Bill 26.
Some proposals to improve Bill 26:
We believe that most Ontarians support the intent of Bill 26, and such support should be enhanced with the following considerations. Our suggestions focus on conditions for utilizing the powers outlined in the bill, on sunset clauses and on the role of the civil service in the implementation of the act.
We recommend that the provincial government provide written descriptions of the conditions which will need to occur in communities or with the various transfer payment agencies prior to implementing the new powers in the proposed legislation. Examples of such conditions may include:
-- When consensus has been achieved that communities or TPAs are incapable or unwilling to meet provincial goals or norms which are being created by or progressively agreed upon by other Ontario communities or other transfer payment agencies -- "consensus" could be defined as agreement reached in communities by a majority of stakeholders and the appropriate minister of the government upon advice of any commission he or she may establish;
-- When there is consensus that communities or transfer payment agencies are unable or unwilling to achieve goals within reasonable time frames coestablished with their respective ministers;
-- When there is consensus that the measures being taken by communities or TPAs to meet provincial financial goals are being implemented in ways which compromise the quality and/or the long-term viability of those services or the desired increased and sustained efficiencies.
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We recommend that the provincial government provide pre-established sunset clauses as to how long a minister may assume extraordinary powers through legislation, such as:
There should be an overall sunset clause to the legislation itself subject to the province's financial goals having been achieved and/or subject to a broad provincial evaluation process of the effectiveness/need for such legislation once a balanced budget has been achieved and the appropriate structure to sustain it is in place.
A minister would only assume extraordinary powers over a community or a transfer payment agency for a maximum of six months, after which time the responsibility/authority and accountability would revert back to the community or the transfer payment agency via a community board or a body established by the minister in consultation with appropriate local stakeholders.
We recommend that the provincial government provide safeguards to ensure that civil servants from the various ministries respect the intent of the legislation by:
-- Providing interpretations that respect the spirit of the legislation.
-- Not providing interpretations that strive to protect their own status or promote their agenda.
-- Preventing civil servants from implementing the legislation whereby the responsibility and accountability for implementation of the government's agenda is removed from the appropriate communities or transfer payment agencies and retained by the civil servants. Communities or transfer payment agencies are much more likely to be successful in their support for the government's goals if the ways and means of doing so are retained by them rather than vested in the civil service.
In conclusion, the Thunder Bay Regional Hospital supports the need for a balanced budget in Ontario:
-- Encourages the provincial government to proceed with legislative change and to utilize these powers prudently as recommended above;
-- Encourages the government to resist being influenced by the doom-and-gloom rhetoric of communities/transfer payment agencies/special-interest groups. We all share the responsibility for our current financial problems and we all must be an integral part of the solution.
-- Emphasizes the need for the government to ensure communities/transfer payment agencies which have already initiated the process of restructuring that they will not be penalized down the road.
The Thunder Bay Regional Hospital will continue in its efforts to contribute to a balanced provincial budget.
Respectfully submitted by the Thunder Bay Regional Hospital Corp.
The Chair: You've allowed about six minutes per party for questions, beginning with the New Democrats.
Ms Frances Lankin (Beaches-Woodbine): I must say, as a former Health minister, it warms my heart to hear a hospital board chair and CEO -- and we've heard it in other communities -- come forward and be so supportive of the need for restructuring. Would that I'd had that kind of cooperation a few years ago. But I have to say that M. Levac was always one, in my dealings with him in Sudbury, to be very supportive of the need for the change and the restructuring. I appreciate your comments on that.
I'm particularly interested in the conditions that you've set out as examples of what should be put in place prior to some of these extraordinary powers being used by the minister. I think that is very helpful. I also note that you're saying you want to see a sunset clause to the powers, and I heard you say, I think, to the legislation overall once the goals have been achieved. This is a pretty simple question, but I assume from that that the minister's commitment to sunset the restructuring commission doesn't go far enough for you at this point in time, that you think the sunset clause needs to be more broadly applied.
Mr Ringius: I think we have to make sure and be aware that as we progress, the accomplishments that have happened should vest in the community and not with the central powers. So we would like that to have a sunset clause so we can determine when they're no longer involved.
Ms Lankin: Just in terms of some of the powers that you're talking about, I would assume the appointment of a supervisor and the supervisor's powers and those sorts of things, but what about the ability of the minister to impose a physician human resource plan on the hospital? I've heard that referred to by some other hospital representatives as they fear the potential for micro-management and they would like to see that sort of power sunsetted as well.
Mr Gaston Levac: I think the overwhelming or fundamental approach to the comments that our chairman has just made is that obviously, if a community is able to resolve restructuring issues on its own and that restructuring effort is compatible with the overall provincial goals of balancing the budget and doing things differently in a way that we can sustain in the future, then the commission would have less of a role and our discussions on the fine print of sunset clauses and conditions of using the powers would be less important. However, the experience in Ontario has been that such a commission is necessary, because many communities cannot achieve consensus, and even where there has been consensus, such as Thunder Bay, there are still unresolved issues that may well require the intervention of a central body with the power to say, "This is what we would like to see, based on the overall provincial framework and the overall provincial goals."
The long answer to your question is, the sunset clauses and all of the peripheral elements to the initial intent of the legislation are less important than a clear, sound judgement about when it's appropriate to use the powers and in what circumstances.
Mr Gilles Pouliot (Lake Nipigon): Welcome. I listened -- we all did -- intently. No less than five times, with respect, David, you have mentioned the need to balance the budget grosso modo. The province takes in some $47 billion per year. The province spends $10 billion more, some $57 billion. You have also mentioned that it must be done within a term of office. With the tax cut, for we have to believe what has been said, you add another $5 billion. So are you suggesting -- because I did not, with respect, hear anything about the tax cut, which is another $5 billion, but I heard five times the need to reconcile the books, to balance the budget -- would you subscribe to $15 billion less money being injected in Ontario society when you, sir, provide the most essential of services, that of health care, not only for Thunder Bay, but for the region?
Mr Ringius: I believe that we're all responsible for the deficits, because of demands we've made on governments in the past. We at some point have to recognize that there is a need for change. The time frame that we're recommending here, because of the sunset clauses, has to be within the term of the current government. It is our hope that they will balance the budget in that time frame, and we will also make the appropriate accommodations in health care restructuring services. We have an aggressive agenda in Thunder Bay to make sure that we have health care at the bedside, that we will continue quality care. We have a history of getting things done voluntarily in Thunder Bay. We believe that is accomplishable within that time frame. Whether or not that includes tax cuts, that's not my determination; that's up to the government. We're here to make sure that we deliver the best possible health care for Thunder Bay.
Mr Pouliot: A 30% tax cut -- if I had the choice, and I'll be candid with you, I could forgo that, providing that your doors, for the people I represent and me also, remain open. It's a choice I have to make. I too wish to balance the budget, but what we have here is a supplementary burden of some $5 billion because someone, simply put -- and I know you don't wish to say this, but I can and I will -- went out on a limb to gather votes, and why not? -- and now is stuck with a 30% tax cut, and the economy isn't growing, plus the determination to impose another $10 billion, all this in a very limited, very systematic and deliberate time frame. We say it can't be done because we begin to dislocate.
The Chair: Thank you, Mr Pouliot. For the government, Mr Clement.
Mr Tony Clement (Brampton South): Thank you very much for your presentation. I was avidly listening to your suggestions for improvement because we are looking for improvements to the bill as we go through our hearings process. I just wanted to come back to a couple of the points that you had mentioned and to draw out a bit for the purposes of our committee some of the conclusions that we can reach together.
I take it then that the hospital's position is that there has to be an ultimate decision-maker and that ultimate decision-maker is the minister. Is that fair to say, where you're talking about hospital restructuring?
Mr Ringius: Where the community has been unable to reach consensus in an appropriate time frame, we believe that there needs to be a global body that makes these decisions, to get on with the change and restructuring that's required in order to balance the budget.
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Mr Clement: So it's almost like a hierarchy, then? The first stage of the process would be a local process, a community process. That would then be part of the district health council, presumably, and the hospitals would have input into that and community stakeholders. Then it goes, I guess, under our proposal, to the restructuring commission, but it would have to be cognizant of what's going on in the community and the community's, I guess, wishes, if it can be discerned what those community wishes are. Is that fair to say?
Mr Levac: The short answer is yes, but if I may be permitted a few additional comments, I have the privilege of wearing another hat in my current role. I currently chair the Canadian Health Care Association, which is the former Canadian Hospital Association, so I have a fair perspective of what's going on across the country, having the 11 provincial associations for hospitals as our members.
I can say pretty definitively that most provinces where there has been some form of legislation providing a provincial framework for change in order to meet the provincial government's goals have initially resisted that and found those pieces of legislation to be offensive. But what I'm witnessing over a period of three or four years since this type of legislation has been introduced in various provinces is that in retrospect people feel it was the best thing that ever happened to their provinces, because it did provide a sense of direction, a sense of leadership and a sense of provincial goals.
The providers, or at least the managers and the boards of most hospitals that I'm familiar with in this province, have been saddened to see over the years that we've waited too long for providing that kind of final authority that would make decisions and not let communities dangle in a Never-Never Land of not being able to reach consensus and do the things that everybody knows need to be done.
I think I can represent fairly the views of a lot of my colleagues and other people in the health care sector by saying that fundamentally people welcome this kind of legislation and the opportunity for the government to have a tool to impose change when it's not coming.
Mr Clement: Thank you. I respect your view on that. I just want you to clarify, if you could, in your methodology to improve Bill 26 you mentioned in the latter part of your recommendations safeguards with respect to the civil service, so that they respect the intent of the legislation. Can you give me some examples or elaborate on how you'd like to see that work?
Mr Ringius: We certainly know that there are entrenchments in organizations, in bureaucracies, in corporate, private and public, where the need is for direction from the minister to make it clear as to what is expected of the civil service, that there isn't the opportunity for the silos to say don't touch my area and look for areas not to make improvements and efficiencies. We need that communication. I think that takes a strong direction from the minister. I think we've had some experiences with that in some of the roadblocks that were happening in the Thunder Bay area and were not moving along because there isn't a clear understanding of governance models that were agreed to and then made changes to.
Mr Frank Miclash (Kenora): During your presentation, Dave, you talked about savings within the system and the reinvestment of these savings in non-existing services, and you mentioned recruitment of health care professionals, retention of those professionals in the north. I guess what I'm wondering is, what assurances do you have that those savings will remain here in Thunder Bay?
Mr Ringius: Previous communications with ministry officials under the hospital service review indicated that where savings were needed and there was not the delivery in the sector outside of the hospitals, they could be allocated until those services are filled, because you can't do all of the work inside the institutions, some of these services need to be put outside. So that's where the savings should go initially, and then any further savings would go obviously to deficit reduction.
Mrs Lyn McLeod (Fort William): I'll follow up. There's a whole host of areas in Bill 26 and even those aspects of Bill 26 that only affect hospitals that I'd like to ask you about. I'm not going to because I think we have an opportunity here to learn a little bit from the Thunder Bay experience, so I'm not going to get into issues like whether supervisors should be able to take over hospitals without any inspectors' reports, whether or not the Minister of Health should have the power to act unilaterally without regard to the Public Hospitals Act or any regulations under the act -- I suspect you'd have some concerns about that -- or whether the Minister of Health should have no liability at all for any decisions that are made, including funding decisions. I'm going to set those aside for now, because I want to pick upon the fact that, as Dave said at the very end of his presentation, we have a strong belief in this community about community resolution to problems, and we take some pride in our record of having been able to resolve issues locally and sometimes come up with creative solutions.
I have been pretty close to a full arrival at a voluntary resolution of a single amalgamated board, as you know, over a period of time. I guess one of the things that concerns me about this legislation as it applies to other communities and perhaps in the future even to our own, because we have some unresolved issues, is at what point, at what time and in what way does the Minister of Health come in and have that involvement?
I think there is always need for a facilitating role in order to help a community arrive at decisions. But if a Minister of Health had come in -- and, Dave, as you know, it took 10 years, a heck of a long time, to get to the voluntary agreement to bring about a single board. But if the Minister of Health coming out of Queen's Park had at any point in time come in and said, "Thou shalt do it this way," and the community wasn't convinced this was a good decision, I'm not sure that would have been well accepted in this community, just knowing what this community is like. I guess that's what's worrying me.
Maybe if we can build on the point Thunder Bay is at, and the experience we've had here, the question of how do we define community, how do we ensure that we've got community support -- do you have some recommendations in that regard?
Mr Ringius: Certainly I've been involved for quite some time in the Thunder Bay experience through the chamber of commerce, which has looked for a single acute-care facility here. It was not until 1991 that we had some direction from a former Health minister, Frances Lankin, who had given some direction for that hospital services review. That review, in my mind, had a broad constituency from all stakeholders at that table and we had community input on a regular basis, continued to receive reports, and then sent the report in.
Even though it seems like 10 years, I think since that task force was established, we've accomplished a lot. There was not a whole lot of discussion around governance. It was fairly well accepted that there are basically two businesses in Thunder Bay: acute care and chronic. One of the areas that was not totally resolved was the mental health issue and that again was because of the way it's structured. We need to address that.
The time frame I think is much shorter now. I think we're in a more critical area. I think we've been around. Positions change, individuals change, jobs change, but I think overall the community is looking for the momentum to continue for Thunder Bay. It's been a good experience. All of the stakeholders are still there wanting to proceed. I believe we can accomplish our goals in a much shorter time frame than previously done in Thunder Bay.
Mrs McLeod: In part I think because there is an increasing recognition that the dollars aren't there, as you've noted in your brief -- and I think everybody who's involved in providing health care understands that, and I think communities understand that, one of the reasons there's going to be a lot of concern about the exercise of decision-making power by the minister under this bill is that the powers are much more sweeping, because there is no clear requirement for the community involvement, there's no clear guidelines set out for that community involvement or community agreement to be sought.
There is also a driving force, as you've noted several times in your presentation, of balancing a budget, and in fact balancing a budget, as Mr Pouliot said, with some additional financial requirements the government needs to meet in its April budget. So you worry whether or not what's going to happen here is not guidelines and facilitation from the Ministry of Health for community resolution of problems, but a minister who needs to drive a decision whether it's right or wrong for a community.
I guess it comes back to Frank's question. Unless there's some commitment of dollars to a community it will be very difficult for the Thunder Bay model, which has been achieved with a lot of sweat and a lot of hard work, to actually be carried through successfully, because you need the commitment of dollars. This can't be a way of saving money for the minister to balance the budget; it has to be a way of controlling the health care costs and keeping dollars in the community. I'm not sure whether you want to comment on that.
Mr Ringius: That's why we put in place here when consensus is not maintained -- that's when we expect that there would be some, as you say, facilitator. The Thunder Bay experience worked well with a facilitator and we continue to use that method to resolve issues. Hopefully that will continue. If that can't happen within the time frames established by the community and the ministry, we need to step in.
The Chair: Thank you, gentlemen. Thank you, Ms McLeod. We appreciate your presentation this morning and your interest in our process. Have a good day.
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There are a few chairs still at the front -- it's kind of a church setup here -- for some of you folks standing at the back. I did neglect to say on behalf of the committee that we're delighted to have an opportunity to be in Thunder Bay. For some of us, it's our first trip, but it's great to be here. We didn't get much chance to look around last night, we didn't get in till 10 o'clock, but we are happy to be here.
Ms Lankin: Mr Chair, I almost got sidetracked by your little dialogue.
The Chair: I was hoping you would.
Ms Lankin: I know. I'd like to place a motion before the committee, please.
The Chair: Yes, Ms Lankin.
Ms Lankin: My motion is as follows:
Whereas there has been overwhelming public interest in Bill 26 and that 33 groups and individuals have requested to appear before the standing committee on general government today in Thunder Bay, which far exceeds the 10 spaces available today for hearings;
I move that this committee recommends to the government House leader that when the House returns on January 29, 1996, that the order with respect to Bill 26 be amended and that the bill be returned to the standing committee on general government so that further public hearings can be arranged for the community of Thunder Bay;
Further, that this committee recommends that the three House leaders meet as soon as possible to discuss this issue.
The Chair: As previously, I'd ask for unanimous consent to discuss that motion at our break at 12:30 rather than interfere with our presenters.
Mrs McLeod: I would like to acknowledge that as this motion comes forward repeatedly, we could solve a lot of the time problems if the government were to propose the motion and recognize that we have a lot of presenters, including people in this room today, who are not being heard. It's one out of four or one out of three who's going to have an opportunity to be heard in Thunder Bay.
The Chair: We'll talk about that at 12:30.
ONTARIO HOSPITAL ASSOCIATION, REGION 1
The Chair: Our next group represents the Lake of the Woods District Hospital. Sue Straight is obviously not here. Bob Muir is the CEO and chair of the Lake of the Woods hospital, and Andrew Skene is the chair of OHA region 1 and the CEO of the Dryden hospital. Welcome, gentlemen. You have a half-hour of our time. Questions will begin with the government.
Mr Bob Muir: I'm Bob Muir, and not, as you've correctly pointed out, Sue Straight. I'm director of the Lake of the Woods hospital in Kenora, a little under 400 miles to the west of here. This year, fortunately or unfortunately, I'm also chair of the Ontario Hospital Association and co-chair of the JPPC. We've agreed that for this time slot -- although I would like to answer questions as well -- Andrew Skene, chair of region 1 of the OHA, which represents all of northern Ontario, will make our presentation.
Mr Andrew Skene: I would like to thank you, Mr Chair and committee members, for allowing me to present on behalf of OHA region 1 council to the committee concerning the recently introduced omnibus legislation, Bill 26. I'd also like to thank Bob Muir and Sue Straight from Kenora for allowing us to have this time slot to make this presentation.
Region 1 covers northern Ontario, and we go from Bracebridge, just north of Toronto, through to James Bay to the Manitoba border, so it's a fairly large area. The council takes a leadership role on matters of northern concern and regional consultations and advice and education for our members, and we've got about 48 hospitals in the region.
Bill 26, as you know, is a very complex package of legislative change and raises a number of concerns and questions for our hospitals in region 1. On December 18, the OHA made a presentation to this committee, supporting certain sections and not supporting other sections, and we're not going to go over what the OHA presented. The synopsis of what I will be doing today -- you will be receiving a full brief, so I'm not going to read the whole brief.
During the process for the OHA submission, our region was involved and we held teleconferences to go through the OHA brief. For making this presentation, we had the region agree to one presentation, and the executive worked very closely together to make sure we brought a package for you.
We'd like to say that inequities exist in delivery of services in the north. Service gaps in the provision of health and social services general infrastructure have been well documented, and many studies are out at the moment -- on the shelf -- that can be looked at. We also note that first nations have their own distinct health care needs and requirements, and we must not lose these in any processes.
We believe that the policymakers and politicians need to understand and realize the northern problems of delivering health care before sweeping changes could be made.
Northern Ontario is 80% of the land mass and 9.2% of the population, so that leaves its own demographic problems. Often we don't have the critical mass to maintain full programs and not necessarily in all areas. In isolated areas, some programs can't be run and you rely on regional centres.
Statistics show that there are fewer social services and health care professionals in the north. Also, in terms of health status, we have a higher infant mortality rate, a higher morbidity rate and a higher motor vehicle accident mortality rate, which can be attributed to the roads and the distances of travelling.
The role of the hospitals in the north: Many were initially built by religious groups or private companies in the past who were committed to community development, and they continue to play a vital role in the community and in the economics of the community. The community hospitals are governed by volunteer trustees, and they have ensured accountability both to their communities and to the health care system to provide viable and affordable health care. We have some strong concerns over the application of Bill 26 that could lead to the undermining of the volunteer community trustee governance of our hospitals.
The hospitals in northern communities are sometimes the only 24-hour health care facility -- and that's a very important thing -- and they've become the sole provider of services within those communities. Significant downsizing of hospitals will have a proportionately much higher impact than those in the southern communities. Instead, maybe these organizational structures should be strengthened.
Various documents -- Small Hospitals in Ontario: Towards the Year 2000 -- define some of the roles that hospitals can have in the health care setting in communities, and this works for northern and rural communities as a whole. Some of the traditional models of hospital care are not really carried out, because the hospital is not just a hospital, it has various other aspects -- running ambulance services, mental health services -- built on to the scale of economy.
The minister, in November at our annual meeting in Toronto, acknowledged that he needed an affordable and sustainable health care system, and that the government is going to focus on creating appropriate, accountable, integrated and cost-effective health care services.
We're supportive of changes in legislation, but it should be enabling to the northern remote hospitals. Horizontal integration, ie, mergers and amalgamations, may not be feasible in many communities, but a vertical integration of health care services within that community may be the way to go.
Most of you have probably heard of Access to Care in the North, a document derived by northern health care professionals that dealt with many aspects and came out in 1992. The process was based on the desire to be positive, innovative agents for effective change in the delivery of health care services for the northern region. Since its release, it has received widespread support. We're pleased to see that some recognition to the north has come from that in the travel grant program, the delivery of the appropriate service or procedure happening in the nearest locations; that was tightening up the money being spent. And we have other areas, the underserviced area program, moving to Sudbury, which was a good move. So we're getting the northern flavour.
We acknowledge the intent of the government to make available the appropriate tools to restructure health care, but these tools cannot replace the need for the development of strategy, and we would like to see a northern health care strategy, as we outlined in Access.
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We often assume that all communities have comparable health and social services infrastructures. This is not true. History has dictated. Guidelines for allocating resources to hospitals have to be relatively uniform throughout the province, essentially population-based. We know that in the north the population base is not always there, but we have to develop flexible guidelines in order to deliver health care.
Funding of the northern hospitals: We're pleased to see that there is a multi-year funding proposal before us now, and that's useful so we can see what's going to be happening in the future.
There have been some unprecedented funding reductions, and we can see the challenges to be faced in the future by the health care areas and other areas, but we trust that these allocations and reductions will not be applied across the board. We need an approach to ensure that there's fair allocation of resources among hospitals. We have to recognize that there are different circumstances faced by the northern, the rural. We have seen that the Ministry of Municipal Affairs is cutting less deeply in terms of some of its transfer payments to some of the northern communities, so there has been a recognition. We would recommend that there not be that across-the-board cut that would result in a substantial reduction and maybe elimination of total services and programs in certain communities.
We have to look at, with the major shifts of funding support from the institutional, that any changes out of that shift of funding from the institutional sector should be accompanied by clear plans and commitments to reinvest those savings in areas of crucial and urgent health care needs. We have to make sure there's a proper reallocation of funding. This is particularly necessary where the hospital is the sole provider of some health care services in the north.
Physician services: Shortage of medical human resources and the lack of viable coordinated medical service plans have been documented as major obstacles in the provision of adequate health services in northern Ontario. It might be from not having enough permanent physicians in a community to cover emergency services or not having enough specialists, whether they be general surgeons, psychiatrists etc. There have been many measures over the years, but we still have unrealized goals in fulfilling the medical needs.
The medical needs for physicians in communities vary from one community to another -- they're not all cut from the same cloth -- and the standard, traditional physician-population ratios are not relevant, especially in the northern rural communities.
The recent incentive with respect to the approval of guaranteed minimum payment for physicians providing on-call services in low-volume departments is welcome, but other measures may be required in the long term.
There is the ability to manage very directly the supply and distribution of payments to a physician in Bill 26.
The ability to restrict billing numbers and privileges and place moratoriums: This will resolve a problem maybe in the short term, but will it resolve the long-term problem which we have to really look at? We have to look at the enhancement of recruitment and retention and advocate in order to prevent further migration of physicians from northern Ontario.
Limited options are presently available in the system for financial recognition of the greater breadth of responsibility physicians have in northern rural Ontario. Fee differentials may be required here. We look at what a physician has to do in a smaller community, and his skill level has to be far greater than that of a person at a walk-in clinic that has got a teaching hospital next door. We have to recognize that.
The third-year residency program is good and we need to see that enhanced even further, and that the people coming into the north have got the necessary skills.
We recognize that the government doesn't license physicians; that's the college's duty. However, when we cannot get people into the north, maybe we need to look at foreign graduates. Experience has shown that specialists and general practitioners who have graduated from other countries can make valuable contributions in the north, as they have in the past and as they are doing in other provinces now.
The Health Services Restructuring Commission under the Ministry of Health Act: Given that the members of the commission shall be appointed by the Lieutenant Governor in Council, region 1 council hospitals would like to see some provision made for representation from rural northern areas and small hospitals to be considered members of that commission so that the members of the commission will have a good understanding of the northern health care delivery system and be sensitive to the many issues that we have identified now and that have been identified in the past. Also, the council believes the commission's role should be to implement the plans either developed voluntarily by hospitals or developed by DHCs and approved by the minister. The minister, not the commission, should make the decisions relating to closures and amalgamations.
Region 1 agrees that effective mechanisms are needed to implement the structures. The Public Hospitals Act, section 6, provides the minister with new and sweeping powers. We understand that the minister, in his presentations to this standing committee on October 8, announced that he will be recommending sunsetting the proposed Health Services Restructuring Commission. We agree with his recommendations but believe it is even more important that the sweeping powers vested in the minister under section 6 are also sunsetted.
In conclusion, I would like to reiterate that while region 1 council agrees with the government on the direction and scope of many aspects of Bill 26, there are areas that need further consideration, not to say changes. We are willing to work with the government and our partner agencies.
The Chair: Thank you, gentlemen. We've got about four minutes per party for questions, beginning with the government.
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Mrs Janet Ecker (Durham West): Thank you very much for coming forward today. I think one of the helpful things we've had over the last several days of hearings is that so many hospitals and representatives of the hospital community have come forward with what I think are some excellent suggestions for ways to continue the restructuring exercise and at the same time improve the way that we may be able to do that.
You make a very valid point about the difficulty if cuts are across the board, and I think our government has certainly recognized to date, with the way the municipal transfers were made, that there are unique needs in regions. That's an important point to make.
The second issue is that, again, you made the point about the importance of voluntary boards, the importance of community involvement in the restructuring process, which is something that Minister Wilson has stressed he believes in. He believes that the commission and the whole restructuring has to depend on that.
What I'd wonder is how we can ensure in the legislation that the principle of volunteer boards is being respected, because some provinces have chosen, frankly, to basically abolish hospital boards in their restructuring exercise, just sort of make everybody part of one regional board and things of that nature. We rejected that. We don't think that's appropriate, because we do believe the volunteer boards are important.
But at the same time there are also examples where, for whatever reason, the consensus that has been reached in some communities is that the restructuring exercise is not possible, that the board doesn't function or there are difficulties in the hospital, the quality of care or whatever, so that there was a need to somehow have authority for the ministry to act and in some cases, if quality of care is being threatened, to act quickly.
How do we balance that need to act in extreme circumstances with the importance of the volunteer boards and making sure that is there and that is respected and that the boards feel that is there and that is respected?
Mr Muir: I think part of the answer to that is to ensure, as we've said, that there are sunset clauses, not only for the commission but for other parts of the act as well that deal with the powers of the minister. We've also said, out of respect for voluntary boards, that, for example, hospitals that perhaps are in danger of being taken over should have the opportunity to at least put their case, to deal through the health councils and to use those mechanisms and to balance it. In the Public Hospitals Act at the moment there's a certain balance. The minister can act, the minister can do certain things; there are certain powers there that the minister has.
It is true that hospitals are also independent, and I know there was a concern about being able to deal with closure of hospitals. If that's the issue and if restructuring takes four years, I think there are ways, and we suggested ways, in which you can do that while at the same time recognizing voluntary governance, because if that doesn't happen, it will be voluntary governance in name only.
Mr Miclash: Thank you for the presentation. I agree with Mrs Ecker that we're certainly going to have to take a close look at the volunteer boards, especially in small northern Ontario hospitals. I know in both your communities they play a very important role in terms of fund-raising and ensuring the operations of both facilities. But I think something of greater importance is that we're often hearing about the cut in transfer dollars. I'm interested in hearing from the administrators of two very small hospitals as to what effect that will have on your operations in both Kenora and Dryden.
Mr Muir: Let me address that first. I represent a hospital which is an amalgamated hospital, 26 years ago, one of the first in Ontario. Those funds have obviously gone through the system already. I also represent a hospital which serves -- 35% of its patients are first nations. In most of those communities primary care systems are rudimentary.
I know the funding formula. I've supported it in the work I've done. But I also know where the formula ends and policy begins. I know that the northern factor was taken out of the formula. I know that we can't come up with criteria around socioeconomic conditions, which everybody recognizes is a problem in some northern areas and certainly adds to the cost of providing care. We can't do that; it's not currently recognized in the formula.
I should also say that outside the city of Thunder Bay there's one resident pathologist, one resident radiologist, two resident internists -- I hope I'm correct on that -- three resident psychiatrists. In our area there are three general surgeons, two of whom are in Kenora. I began the conversation by saying I live 400 miles west of here. All of the specialists I talked about -- and that's pretty thin gruel in any area of the province -- are in Kenora.
The issue for us, when we look at the provision of care to first nations people, the type of work we do, the way in which we're funded, the fact that the formula doesn't include these other things -- and I'm not criticizing the government for that; I'm saying it's a fact -- I think if there isn't special recognition, the underpinnings of the thin secondary care system that we have outside Thunder Bay are going to be severely damaged.
I'm not going to talk about things I know about in some other areas, but if they're talking about a range to even 5% for some of these hospitals, it simply undermines the basic level of service that can be provided in those areas. We've made some suggestions to the government. I think, certainly from people I've spoken with, there's an understanding of that, but the size of the mission is so great that obviously, in some areas of the province, cuts of the magnitude of even 5% are going to have be dealt with in terms of public policy and not the funding formula.
Mr Skene: To go on with what Mr Miclash asked, to Dryden 5% would be nearly half a million dollars. That is over twice what we had to take out in the social contract. That was after we had to kick in an extra $100,000 for pensions, the employer health tax and things over the last few years. Therefore, we would have to be looking at serious program cuts, and that would happen with many of the northern hospitals.
Ms Lankin: I'd actually like to make a couple of comments on some of the things I've heard. I don't have a specific question. I think you've been very clear in your recommendations about what areas of the legislation you think should be amended.
One of the things that has interested me -- and Bob, I think your comments were a bit different -- over the course of the hearings so far is the hospitals that have said, "We think the minister needs these extraordinary powers essentially to force us to restructure." Yesterday it was interesting in Sudbury. We heard two different presentations from the same hospital corporation talking about how in that community there had been a real problem with people moving ahead and getting the job done, and in fact it took the minister five times to tell the DHC to get the sole governance issue off the table, and therefore the government minister really needed this legislation.
They couldn't tell me how a restructuring commission was going to solve the problem that had been there and they didn't tell the committee that the previous minister had given a very clear direction that the governance issue was on the table and that the lobbying they'd referred to was, in some part, their own lobbying of government to change the consensus that had been arrived at through the DHC.
I think that while we hear from a lot of hospitals that hospital CEOs and boards are ready to move on with this and ready to get these things done, it really is a perspective. If it's not your hospital that's being touched, then perhaps you're in support of it; if you get the decision changed by the minister, the new minister, or whatever, then maybe you're in support of it.
What I have a problem with is understanding how the hospital commission, with no terms of reference and no mandate and no linkage to the local DHC and local restructuring planning that's been going on, is ever going to solve that. In the end, it comes down to a minister's decision, the minister is accountable, and I don't see how the legislation is going to provide anything more than the power the minister already has to step in and to facilitate when communities need that and request that.
Mr Muir: I'm not sure if that was a question, but I think the OHA presentation has said that while we support the idea of a commission -- in fact we had some conversations with the ministry -- the fact is that we haven't seen the terms of reference. We are interested in the linkage between the commission, the health council and the boards which are going through restructuring. At the end of the day, though, you cannot come up with $1.3 billion in this province in cuts over three years unless you close some hospitals, you amalgamate hospitals, you restructure, and the government has said that. In order to do that in three years, you need a mechanism other than the process we have now.
The OHA is on record in saying that we support that, but with conditions. But we are also saying that we want to see the terms of reference. We are also saying that at the end of the day, both as citizens of this province and, obviously, as a lobby group, we would like the minister to make the final decision. We think it's important that the minister closes hospitals. We think it's important that the minister, on behalf of the people of Ontario, through the process that we respect, does those things, and not some commission that would have these extraordinary powers.
Ms Lankin: Just so you know, we'll be seeking some amendments from the government to try and achieve those terms of reference in the legislation.
The Chair: Thank you, gentlemen. We appreciate your presentation this morning.
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OGDEN-EAST END COMMUNITY HEALTH CENTRE
The Chair: Our next group is the Ogden-East End Community Health Centre, represented by Joe Devlin, the executive director. Good morning, Mr Devlin, and welcome to our committee. You have a half-hour to use as you see fit. Questions would begin with the Liberals if you leave time for questions. The floor is yours.
Mr Joe Devlin: My name is Joe Devlin and I am the executive director of the Ogden-East End Community Health Centre, or as we like to call it, a CHC. Our CHC serves two neighbourhoods in Thunder Bay: Ogden and the East End. The total size of our catchment area is about 10,000 people and includes many of those who need health care the most: seniors, natives, low-income families and the homeless.
Our CHC began offering programs and services in June 1992. Today, we serve over 2,000 clients, and the demand for our services is continuing to grow at the rate of 60 new clients per month. We employ a range of health care professionals to meet the needs of our community, including a family physician, nurse practitioner, registered nurse, registered midwife, health promoter, outreach worker, counsellor, registered dietician and chiropodist. All our staff, including the physician, are on salary. We maintain our accountability to the community we serve through our community board of directors elected annually by the Ogden-East End community membership.
The Ogden-East End Community Health Centre is one of over 50 CHCs in the province of Ontario. While each CHC is unique, we all share a commitment to the fundamental principles of providing accessible, comprehensive primary health services with an emphasis on health promotion and empowerment.
We believe that the government also supports these principles because we find them articulated within the Progressive Conservative Party's document called The Mike Harris Forum on Bringing Common Sense to Health Care, which was released on December 2, 1994.
For this reason, we urge the government to ensure that the goals and commitments outlined in the Bringing Common Sense to Health Care document are incorporated into Bill 26. Allow me to give you some examples of what we think this means:
A commitment to public involvement: In the Common Sense Revolution, it was stated that:
"We are ready to listen, to learn and to work with anyone who wants to join us and who can show us more creative, more effective ways to end waste and duplication.
"Our commitment is carved in stone -- a 20% cut in non-priority spending in three years. But how we get there will be discussed in partnership with all Ontarians."
As a community health centre, we are also committed to working in partnership with others to create positive changes in the health care system. We are very concerned, however, that the size and complexity of Bill 26 and the speed with which the government is moving to introduce this into legislation does not allow for adequate public involvement. If the government is still committed to working in partnership with all Ontarians, then we would request that you do the following:
(a) Break up Bill 26 into reasonably sized, coherent packages of legislation which can then be properly assessed by those Ontarians affected.
(b) Allow more time for public hearings in order that the many groups which have expressed a keen desire to speak to the issues in this bill will have a chance to be heard by the government.
A commitment to universal and equitable access to health care: The recent reduction in social assistance has had a major impact on many members of the Ogden-East End community. Already some people are unable to cover the costs of the basic prerequisites of health, such as food, clothing and shelter. Bill 26 heightens this inequity. The imposition of copayments will have a greater impact on social assistance recipients and low-income seniors. The deregulation of drug prices and the imposition of a wider range of facility fees are all going to increase the hardship on our low-income populations. These sectors already bear an enormous burden due to the battle against the deficit.
The imposition of user fees in the past has not been successful in lowering costs and reducing the overall utilization of the health care system. What it has been successful at is reducing accessibility for low-income groups. Saskatchewan provides a good example of this. That province tried charging user fees for physician and hospital services during the period between 1968 and 1971. What that experience showed is that when user fees were in place, utilization of physician services by the elderly and the poor decreased by almost 18%, but overall physician and hospital costs remained virtually unchanged. That's from an Ontario Council of Health report in 1979.
For these reasons, we regret the implementation of user fees into a health care system that is based on the principle of universal access. We also note that you said, "Under the Common Sense Revolution plan, there will be no new user fees." We would urge the government to maintain its commitment to not introduce new user fees, and therefore to remove those sections of Bill 26.
The specific sections we refer to are the imposition of copayments in schedule G, part I, the deregulation of drug prices in schedule G, parts I and II, and the imposition of a wider range of facility fees in schedule F, part IV.
A commitment to the individual's right to privacy: Bill 26 contains provisions that would allow the government to gain and use personal information in an unprecedented manner. Clause 6(2)(d) of the Ministry of Health Act currently provides the minister with the power to "collect such information and statistics respecting the state of health of the public, health resources, facilities and services and any other matters relating to the health needs or conditions affecting the public as are necessary or advisable, and publish any information so collected."
Bill 26 proposes to further extend these broad powers to provide the government with the authority to disclose personal information to any party it enters into an agreement with.
The highly confidential nature of health records requires handling with the utmost care. While the information medium, be it paper, electronic or whatever, may be owned by the respective health provider or facility, the actual personal health information belongs to persons referred to in the respective health records.
The Progressive Conservative Party's commitment to a health care bill of rights identifies, among other rights, the "right to participate in decision-making regarding one's own health and the right to treatment free of discrimination and which recognizes one's privacy, dignity and individuality." We are concerned that, unless amended, the relevant Bill 26 provisions will put at great risk the privacy, dignity and individuality of Ontarians.
Our recommendation is that you ensure that Bill 26 adequately provides for the protection of patient-client confidentiality.
A commitment to fostering community involvement: In Ontario local public hospital boards of directors are incorporated under the Corporations Act. In addition, specific corporate powers are provided under certain sections of the Public Hospitals Act. This approach ensures that a local facility or agency is subject to appropriate lawful checks and balances contained in the respective legislation.
At the same time, this approach allows community input and local autonomy and authority in decision-making. Bill 26's provisions to amend various portions of the Public Hospitals Act have the direct effect of undermining and nullifying a local board's authority and autonomy. In concert with other provisions of Bill 26, these amendments eliminate the capacity of local boards to ensure that communities have a say in establishing their health priorities.
In addition to giving the Minister of Health the power to make decisions on hospital amalgamation and closure without community consultation, these amendments render local community boards of directors instruments of the minister. Through the appointment of a hospital supervisor, the minister can assume all the rights and authorities of a local community hospital board of directors. This means that, effectively, the minister has the power and the authority to manage the health care system at the local level without community input.
In Bringing Common Sense to Health Care, you said that your goal was "to give communities more say in establishing their local health care priorities, as well as how and where they want health care services to be provided."
You further stated that: "We believe the public should be a key player in determining local community health care priorities. By enabling communities to determine their health care priorities, we acknowledge the need for flexibility in the local health care mix."
It would appear to us that Bill 26 will need to be amended to ensure consistency with your earlier statements regarding the pivotal role of the community in local decision-making.
Our recommendation is that you add provisions to Bill 26 which allow for public consultation before major decisions are made.
A commitment to bringing common sense to health care: As you can see from what we have said, we believe that Bill 26 needs to affirm a basic set of goals and principles for positive health care reform. We see many such goals and commitments articulated in the Progressive Conservative Party's document called The Mike Harris Forum for Bringing Common Sense to Health Care, which was released on December 2, 1994.
Our recommendation is that you ensure that the goals and commitments outlined in the Bringing Common Sense to Health Care document are incorporated into Bill 26.
On behalf of the Ogden-East End Community Health Centre, I would like to thank you for this opportunity to address some of the health issues arising out of Bill 26. I trust you will see our comments as constructive.
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The Chair: Thank you for your presentation. We've got about six minutes per party left for questions, beginning with the Liberals.
Mrs McLeod: I appreciate the fact that you've touched on a broad number of the issues that are of concern in Bill 26 and that you've also reminded the current government of some of their past commitments. I thought you missed one, though, which was the commitment that we thought was pretty clear about no cuts to health care, and what this bill is all about at the bottom line is finding $1.5 billion in the health care system for deficit management. So that creates a part of the problem.
One of the areas, of course, in which they looked to find some dollars is in the copayments, which you've addressed quite clearly. By the way, I think all of us on this side of the table completely agree that this bill should be broken up so that we're not jumping from the powers of the minister to close hospitals to the issue of copayments to deregulation of drugs and what that's going to do to pricing to billing numbers for a physician and whether that's going to drive more physicians out of northern Ontario.
On the issue of copayments particularly, and knowing that you work with a large senior population at Ogden-East End, one of the things we've been hearing from pharmacists is that there is a particular problem for senior populations if you prescribe large volumes in your prescription; that it's better to break it into more frequent prescriptions of smaller volumes, that seniors can manage that better, and there's actually less wastage of the drug and less cost; that if you bring in a copayment, seniors are likely to be, in order to try and save them the cost of that copayment repeatedly, given larger and larger quantities of their prescription at one time.
I just wonder if you'd comment particularly on your concerns with the senior population about this impact of copayments.
Mr Devlin: I think that's just one example of a broader issue of where economic goals and health goals may not be in sync, and that is an example of one of the impacts that this bill will have if it's not amended. You'll see situations like that where people will try to save money because they have other things they have to try to spend their money on, some of their basic needs, and that will have a detrimental impact on their health in some cases.
Mrs McLeod: Do you think it will actually force people into choices?
Mr Devlin: And sometimes poor choices in terms of their health.
Mrs McLeod: On page 3 of your brief you make very passing reference to the imposition of a wider range of facilities fees. You've obviously taken time to read Bill 26 and the health care provisions. Would you like to expand on that? This is one of the issues that doesn't come up very often in our presentations, that this bill does open up the possibility for hospitals, for example, by regulation, to charge fees for services they don't now charge for.
Mr Devlin: I wish I could speak in more detail about that, but I have to be honest. The speed at which we had to react to this didn't really allow me to do my full homework and get a full set of footnotes for every piece. I found the legislation rather mind-boggling. When we looked at it, we could see some of those references, but I don't have them at hand.
Mr Michael Gravelle (Port Arthur): You're not alone, Joe, in finding it mind-boggling. Thank you very much for your presentation. I want to pick up on your comments about the individual's right to privacy. Obviously, great concerns have been expressed since the bill came out, the concept that indeed people's personal health records can be made public and used in a manner that obviously would be a tremendous infringement. Can you give me your take on what the implications are if that aspect of the bill is not amended?
Mr Devlin: One of the biggest impacts is somewhat hard to document, and that's the undermining of the trust between the recipient of care and the provider of care. We rely very strongly on a bond of trust. That's sacrosanct, the doctor-patient confidentiality. This has the potential to undermine that. It means that information can be released to other agencies, it can be released to the police, it can be released to other bodies. I think people might be reluctant, in some cases, to be forthcoming with information that's very important for those making decisions about what they need in terms of their health care.
Mr Gravelle: Something you didn't necessarily refer to directly but that I'm interested in, in terms of the impact of this bill on the people who use your services, is the community response to this, the awareness of the bill itself and some of its implications. Have you had people coming to you expressing concerns about the scope of the bill, that it is mind-boggling, as you put it, in terms of the people you provide services to?
Mr Devlin: We haven't had a strong reaction to the bill, and that's probably due to a couple of things. One is that a lot of the people we try to place an emphasis on serving are the marginalized, the disempowered. They feel they've been screwed by the system for a long time so they don't feel they ever have a chance to make a statement, or that it will make any difference. People tend to just try to survive as best they can. As I said earlier, many of them have now experienced social assistance cuts. They're just struggling to make ends meet. Finding the time to get hold of a bill and read through a lot of legal mumbo-jumbo is not on their priority list.
Mr Pouliot: A comment, perhaps, and a couple of questions in this six minutes allocated to our party. You represent the human dimension, in my opinion what is best about people.
We'll call him Harry Smith, though it could be Ms Jones. Harry comes to see you, Joe, and he's one of the marginalized; he's not very rich. He wishes to be like the others. Harry needs care. You mentioned at the beginning that the client group of people who seek that essential service is growing. You anticipate that the money available to provide that service, to tell Harry he's going to be okay, that he too is taken care of -- well, you'll have more Harrys and less money.
I have a $5 bill here. With the highest of respect to Harry, would Harry understand the complexities of this side of the $5 bill being a user fee, and this side here being a copayment? If Harry used a service last week and it didn't cost him anything, and he uses the service next week and it's costing him his last $5, to him he's a user of the service. He shall pay, and he shall pay big-time, I can assure you.
Let's make no mistake about this. In terms of consultation, these people were dragged into this thing, screaming and kicking until the last second. That's why we're here. The compliment of your visit is not because of the house of benevolence, and I want to make this very clear.
You will get less money. There has been some rumour that the money saved will be rededicated, put back into the system. We don't know when, we don't know whom. Have you been consulted? Do you have the ability and the desire? What does your gut feeling tell you? Will you be consulted to make sure the money is dedicated so that the Harry Smiths of this world, the growing number of Harry Smiths, will have their rightful place under the sun? First tell me about user fees -- take his last $5 -- and then tell me about consultation in the future.
Mr Devlin: To quote an earlier person, I'm not sure if that was a question or not. A couple of comments in response to what you've said, and one is about user fees. That's not the only barrier that many people in our community face. I mentioned that we serve a homeless population. That they may not even be in possession of a health card, though they're fully entitled to have one, can be a barrier to access for many services. It's not for us; we don't require that somebody have a health card to receive services. We're very much dedicated to trying to overcome whatever barriers exist for people in receiving the health care that's a right of every Canadian to have, so any time something's proposed which is going to be a barrier, we have a concern about it.
In terms of your comment that there will be cuts, that's why we are trying to emphasize to the government that we would like to see its position paper Bringing Common Sense to Health Care incorporated into Bill 26. They made a number of goals and commitments in that which we found very reassuring; we found much in there that we could identify with. But if that's not incorporated into Bill 26 our fear is that the overwhelming preoccupation with the deficit will overwhelm any other consideration.
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Ms Lankin: One of the things I have been concerned about in the legislation is that the powers of the restructuring commission, for example, aren't linked in any way to local community consultation. The government actually has said in these hearings that it is the intent, but I would like to see that linkage in the legislation.
The other thing is the reinvestment of these dollars saved by hospital restructuring into the community. While again they say that's their goal, in communities like Windsor, with the restructuring proposals ready to implement there, they've actually taken the operating savings away and have said, "No, you can't have that to reinvest in the community."
If you have comments about those two areas and what it would mean in terms of gaps in services at the community level if we don't have that reinvestment, it would be helpful. I think the government needs to hear that.
Mr Devlin: Once again I would say that we would like to see their position in the document incorporated into Bill 26, because they do talk about reinvesting the savings within health care.
But I'd like to step back and say that sometimes we make the mistake of saying that health is health care, that health is doctors and hospitals. It's not. It's a broad set of things, and already we're seeing the impact of government actions. We try to work in partnership with many other organizations. Quite a number of those are funded through social services, and they've experienced cuts, so our ability to work in partnership with other groups in the community to maintain and improve the health of our community has already been jeopardized.
If there are going to be savings through hospital restructuring, we need to look at how best to reinvest that. It may not be the case, necessarily, that reinvesting it in capital projects is the best way. It may be that basic things, shelters for women and things like that, are what's really needed.
Mrs Helen Johns (Huron): Thank you very much, Mr Devlin, for your presentation today. I appreciate all the time you've put into it. I just have to clear up a couple of things before I ask some questions, if you don't mind.
This government made a commitment that we would maintain $17.4 billion in health care, and we will do that over the time we are in power. The commitment we didn't make was that we would maintain the status quo in health care. We have to make some changes to make the system a better system so that the money is utilized better by the consumer -- the end user -- and by the community. We're doing some of those things in this bill to try to manage the system and to try to better get money down to the end user, we believe.
I can in some ways prove this in the fact that people are coming out of hospitals much sicker and quicker, as we've closed 6,700 beds in the system, but we've closed no hospitals at all; that's the equivalent of 30 medium-sized hospitals. At the same time, long-term care, especially in the north, is growing by at least 13% per year and we haven't been able to give it the money it needs to be able to grow.
We will have heard, by the time this committee is over, from about 750 different people throughout Ontario, so we believe we're hearing from a number of people about what we should be listening to, what they like about the bill, the things they're having problems with. We think we are listening and we are hearing what people have to say.
In terms of the drugs, I want to comment that with the copayment we have put in, we intend to have 140,000 working-class people able to get on the Trillium drug plan that they have never been able to have before. I think that having health care for 140,000 working people in Ontario is an important aspect.
You talked about consumer and community involvement. We haven't touched the process whereby the district health council looks at the planning, decides what the community needs are for health care in the community. Is that not the good community involvement that you would like to see maintained?
Mr Devlin: One thing that's not clear to us is what the relationship would be between the hospital restructuring commission that you're proposing and district health councils. It would help to have that clarified.
Mrs Johns: As long as the district health council is involved in the planning process of what happens in the community, that's basically what you were looking for in section 5.
Mr Devlin: If we understand the bill -- and I'm not sure that all of us do completely understand it -- it's proposing that the minister could, with pretty broad discretion, step in at any point and pretty much do anything the minister so chooses in terms of that restructuring. That, I think, can undermine any process of community consultation. When you consult with people, they're looking at you to say, "Are you really interested in what we have to say and are we really going to have an impact on what's going to happen, or are you just going through the motions?" That's what we find in our own work, that our credibility with people in terms of our intentions is very important. What we've been trying to say this morning is that that's just not clear enough in the bill.
Mr Clement: Mr Devlin, I take it from your discussion about the disclosure of confidential information that you don't like a bill or an act that says that the minister may enter into agreements to collect, use or disclose personal information relating to eligibility. Is that the major concern you have?
Mr Devlin: One of them, yes.
Mr Clement: I hate to be disingenuous and I don't want to put you on the spot, but I just read from the old act. That power was there in the old act. What the new act does is say that the minister must use that information "for the effective management of the health care system and the delivery of health care services." What's so scary about that?
Mr Devlin: I'd have to say that we're not the only ones who are concerned about that. The privacy commissioner, a whole range of people, have said --
Mr Clement: I just read you the act, though, sir.
Mr Devlin: It's not just in that portion. There must be about a dozen places in Bill 26 that talk about additional powers for the minister to collect the information. All we're recommending is just ensure that Bill 26 provides provisions for the protection of confidentiality.
Mr Clement: I just want it on the record that there were provisions in the old act that relate to disclosure, what the minister can and can't do, and in some cases the new act is more specific than the old act.
Mr Devlin: I actually had the chance to watch the current Minister of Health on TVOntario speak to that very point and he seemed to give a very coherent, intelligent answer to it. All we're saying is please make that clear in the bill. If that is the case, please make it clear in the bill, because it's not.
The Chair: Thank you, Mr Devlin. We appreciate your presentation here this morning and your involvement in our process. Have a good day.
Mrs Ecker: Mr Chair, I just want a clarification from Ms Lankin. I wasn't sure if I understood when you were talking about the savings from some of the areas not being allowed to go back in. My understanding is that those savings are going back into being reinvested in programs where there's a priority, like cardiac, paramedic, kidney dialysis.
Ms Lankin: Mr Chair, is this in order? I would love to enter into a debate with Ms Ecker. You know I've been dying to have this opportunity. If she's opening up the door, this is the moment for it. I'm ready.
The Chair: We got into this particular situation yesterday and I would just as soon we not do it today. We are here to listen to the people of Thunder Bay and district make their presentations to us, not to argue with one another.
Mr Pouliot: We're being provoked.
Mrs Ecker: I wasn't arguing. I asked for a clarification.
The Chair: If we could leave it at that, I think the people in the room would appreciate it.
Ms Lankin: If you would allow your parliamentary assistant to the Minister of Health to answer the questions I've tried to put on the record on a number of occasions, we could have a very constructive debate, Ms Ecker.
The Chair: Thank you, Ms Lankin.
THUNDER BAY AND DISTRICT LABOUR COUNCIL
The Chair: The Thunder Bay and District Labour Council is represented by Richard Armstrong, the second vice-president and member of the health committee, and if the lady would introduce herself, we'd appreciate it. Welcome to our committee. You have a half-hour to use. Questions would begin with the New Democrats. The floor is yours.
Ms Judy Monteith-Farrell: I'm Judy Monteith-Farrell, a delegate to the district labour council.
Mr Richard Armstrong: On behalf of our affiliated members, the Thunder Bay and District Labour Council welcomes the opportunity to present our concerns over Bill 26, the Savings and Restructuring Act, 1995.
At the same time, we express at the outset our disdain and opposition to the undemocratic manner in which the Mike Harris government attempted to sneak Bill 26 into the Legislature on November 27, 1995, while the opposition and the media were preoccupied with the economic statement. It is clear that the government's intention was to ram the bill through before Christmas and make it law, a bill that would impose the most sweeping, fundamental, irreversible changes in the history of Ontario, and without any public debate. We now have public hearings, but the government intends to pass this draconian bill by the end of January 1996.
The passing of the bill is undemocratic. No one, including members of the public, the media, the opposition parties, perhaps even the government itself, has had an adequate opportunity to study the bill or adequately speak together as a community about the changes it brings to our fundamental social values or the democratic process for decision-making within our society. Every day, new information is discovered on how this bill will affect our lives. The Minister of Health and the Minister of Municipal Affairs and Housing are unable to explain the meaning of very important sections of the bill for which their ministries are directly responsible.
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It is clear that the direction of the bill will move Ontario towards an American style of government which is based on the hedonistic individual and the free market. This will not build a healthy society. It will destroy the distinctive Canadian society which we have experienced over the years.
Every union, every worker, every disabled person, every senior citizen and every child will come to learn how this bill hurts them. As their frustration grows to anger and rage, the government will experience protests and strikes as never before, a reaction that will equal the extreme action of the bill. This bill will destroy local democratic institutions, devastate public services and impose hardships on all but the richest Ontarians. It is especially hard on those who are most disadvantaged. Bill 26 is nothing short of a naked grab of power by an extremely authoritarian, autocratic and undemocratic government.
The bill creates three new acts -- the Public Sector Salary Disclosure Act, 1995; the Ontario Loan Act, 1995; and the Physician Services Delivery Management Act, 1995 -- it totally repeals two acts -- the Public Halls Act and the Bread Sales Act -- and it amends a total of 44 other acts.
Given the massive nature of this bill, there should have been a process which provided more time to review the full document. Given the significance, the process should allow for the democratic input of all concerned, not the limited few of us who are fortunate enough to have slots at these hearings.
As an overview, some of the substantial changes to the bill include:
-- The rollback of pay equity for women.
-- The deregulation of drug prices and the introduction of user fees for the drug benefit plan.
-- The enormous power to the Minister of Municipal Affairs to unilaterally restructure, amalgamate and dissolve municipalities.
-- The gutting of laws governing cleanups when mines are closed.
-- The increased power of the cabinet and the Minister of Health over hospitals and doctors. Under this bill, the Minister of Health will be able to close hospitals, appoint a supervisor to take over hospitals and tell individual hospitals which services they can or cannot provide.
-- The repeal of existing laws giving preference to Canadian-owned, non-profit health care providers and the removal of a public tendering process. It ensures that the door is open to the American for-profit companies to set up clinics.
-- The opening of the door to new user fees for a wide range of health care services, including hospital services.
-- The rewriting of rules for bargaining with hospital workers and others within the broader public sector, including police officers and firefighters, forcing them to consider the possibility of service cuts when they decide wage levels.
-- The limiting of access to government documents and increases in fees under the freedom of information act.
-- The sweeping immunity of government at all levels from legal challenges.
-- The absence of any appeal process for health care providers or citizens.
No sector is as significantly affected by Bill 26 as the health sector. Bill 26 will impact on the quality of care. It will encourage privatization of health care. It will direct attacks on the elderly, the poor and all those who need quality care. The primary objective of health care should not be profit; it should be quality of care. The bill will permit and even encourage extra-billing and entrench two-tiered medicine. It in fact violates the Canada Health Act.
Bill 26 will put our health care system in a critical condition by granting omniscient powers to the Minister of Health over hospitals, physicians and patients' confidential records; by repealing provisions that give preference to Canadian-owned, non-profit health care; by deregulating drug prices, introducing copayments and deductibles for prescription drugs and opening the door to user fees for all kinds of health care services. The only winners in this bill are the US health care firms and multinational drug firms.
The balance of this document will provide a more detailed analysis of the schedules that affect health. It is our hope that you will have a better understanding of our concerns about the impact of this bill.
Ms Monteith-Farrell: Schedule A, the Public Sector Salary Disclosure Act, 1995: This is a new law requiring public sector employers to make public a list of all employees who earn $100,000 or more, including position, salary and benefits. It applies to the Ontario public service, municipalities, universities, boards of education, Ontario Hydro and basically everything considered broader public sector. It includes non-profit employers receiving $1 million or 10% of gross revenues from the Ontario government, with one exception: It does not apply to for-profit enterprises; for example, for-profit nursing homes. This initiative was announced by Ernie Eves on November 23, 1995.
Schedule F: Our review of this schedule leads us to the conclusion that this is a direct attack on the principles of the Canada Health Act. It has the arbitrary power to close public hospitals and/or to invite private American or other profit-making corporations to open licensed fee-charging facilities in Ontario. It also permits user fees, extra-billing and firmly establishes a two-tiered medical system.
Schedule F amends the Ministry of Health Act, the Public Hospitals Act, the Private Hospitals Act and the Independent Health Facilities Act.
Amendments to the Ministry of Health Act. Facts: Bill 26 establishes the Hospital Services Restructuring Commission whose mandate is to implement the government's agenda on hospital restructuring. The commission is totally protected from any liability in implementing hospital restructuring, and section 8 of the Ministry of Health Act deletes any references to the district health councils. Bill 26 repeals section 8 of the Ministry of Health Act.
The changes to the Ministry of Health Act create a new Health Services Restructuring Commission, which one suspects is designed to provide a vehicle to cover for the government on unpopular decisions like hospital closures. The new section does not mention district health councils. Health councils should be strengthened to provide greater community input.
The proposed changes to the Ministry of Health Act make it clear that the needs of the people of Ontario are secondary to the needs of the government. The Minister of Health is not as concerned with supporting and assisting communities as he is with devising and legislating ways to force this government's solutions on to communities without regard for the consequences.
Mr Armstrong: In fact, Bill 26 says the Minister of Health can make "any direction related to a hospital" that he wants to as long as he considers it to be "in the public interest to do so." According to this bill, the public interest is defined as what is in the interest of the Minister of Health.
Public interest is used throughout schedule F. The definition of "public interest" is added to the Public Hospitals Act in section 9.1. The clause states that the minister and cabinet are not limited by these matters and can consider "any matter they regard as relevant." The list includes (a) the quality of the management and administration of hospitals; (b) the quality of the care and treatment of patients in hospitals (c) the proper management of the health care system in general; and (d) the availability of financial resources for the management of the health care system and for the delivery of the health care system.
The availability of resources is entirely a matter of priority. The Minister of Health may well find fewer resources available for health care because more is needed to cut the income tax of the well-to-do.
Bill 26 changes the fundamental relationship between the public hospitals and the government. The minister and his cabinet can override and/or replace the independent decision-making of hospital boards and the community the board members represent. The act grants the minister the power to virtually dictate any aspect of the operation of public hospitals.
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Under Bill 26, a supervisor can be imposed at the Lieutenant Governor in Council's discretion, with no connection to an investigation. The supervisor has the power to take over a hospital, to exercise all powers of the board or corporation. In fact, the supervisor has any and all powers the government specifies. The supervisor is dispatched by the government, reports to the minister, responds to the directions from the minister and carries out "every direction of the minister."
The protection for the supervisors and investigators from personal liability is further extended to anyone assigned ministerial power. That means that the bolstering commission set up by the minister, acting on behalf of the minister, can order a hospital to cease operating or stop providing service with immunity.
Amendments to the Private Hospitals Act. Facts: The minister has the power to close or terminate any grant of any private hospitals without notice. Hearings or rights of appeal will be repealed. The minister is protected from liability.
In schedule F, the minister amends the Private Hospitals Act to give the minister the power to revoke a private hospital licence at any time and to reduce or terminate any grant, loan or other financial assistance without notice where the minister considers it in the public interest.
No hearings or rights of appeal presently provided under the Private Hospitals Act would apply. Again, the minister is immunized from any legal liability as a result of the closure or funding decisions according to the bill.
Ms Monteith-Farrell: Amendments to the Independent Health Facilities Act. Facts: Bill 26 expands the definition of independent health facilities to include any facility or service that the minister defines through regulation. It allows for the expansion of independent facilities licensed to charge a facility fee over and above what they receive from the government for insured services -- this is called extra-billing. It repeals all preference to non-profit or Canadian operators, thus opening the door to private American or profit-making corporations to open licensed, fee-charging facilities in Ontario. It removes the requirement for public tenders and allows the minister to send a request for a proposal to one or more specified persons.
In the Independent Health Facilities Act, it becomes evident that the government is trying to facilitate the privatization of health care. The bill gives the minister broad new powers to designate new services and facilities to be covered by the act.
The omnibus bill proposes changes to sections of this act which are crucial to our maintaining a universal, accessible, not-for-profit, publicly administered health care system in Ontario. In Bill 26, the terms "facility fees" and "independent health facility" are redefined to allow for a charge or fee to be made for any service designated by the minister and includes any facility the minister defines through regulations. Independent health facilities can be expanded far beyond their present use in the system and will be permitted to charge fees to insured persons. This, again, is called extra-billing.
The definitions of "health care" and "health record" are repealed in subsections 3(2) and (3). "Insured service" is changed to just "service." This allows for deinsuring services and implementing user fees in other parts of Bill 26.
The bill repeals existing subsection 6(3), preference for non-profit facilities and for Canadian ownership. This is an obscure section worth emphasizing. If the government's intention is not to encourage American for-profit companies to take over more of Ontario's health care, then what is its intention?
Schedule G amends the Ontario Drug Benefit Act, the Prescription Drug Cost Regulation Act and the Regulated Health Professions Act, 1991. Facts:
Bill 26 introduces copayments and deductibles for seniors and social assistance recipients. Cabinet has the power to increase these user fees at any time.
It also deregulates prescription drug prices. Ontario will be the only province that does not regulate drug prices.
It repeals the process to negotiate dispensing fees between the government and the Ontario Pharmacists' Association.
The minister also unilaterally determines which drugs will be listed and delisted in the formulary.
The minister has the power to overrule the decision of a doctor or pharmacist as to what is appropriate medication by refusing to pay and by requiring the patient to bear the full difference in the cost between the approved drug and the prescribed drug.
As advertised, this introduces copayments and deductibles for seniors and social assistance recipients. It also deregulates drug prices. The new name of the act is the Drug Interchangeability and Dispensing Fee Act, since it no longer regulates costs.
Mr Armstrong: Ontario will become the only province that does not regulate drug prices. The government will say deregulated drug prices will go down, but there's no reason anyone should believe this; or perhaps Ontarians with health problems will be expected to haggle over prices with pharmacists, as they have to do with grocers for their tuna.
All recipients of the Ontario drug benefit plan will now pay a minimum $2 charge per prescription. In addition, where an individual's income exceeds $16,000 or family income exceeds $25,000, a $100-per-person deductible per year will be instituted. Furthermore, once the deductible has been reached, the full cost of dispensing the prescriptions will be borne by the individuals and families.
These changes not only represent a power grab but a fundamental shift in principles and values for Ontario. They do nothing to improve the health care system.
User fees, deductibles and copayments for prescription drugs will not reduce the need for prescription medicine, but it will reduce the number of prescriptions filled by seniors and families with limited incomes. It will increase the need for crisis intervention, hospitalization, long-term treatment and other social services.
For example, patients who have been released from psychiatric facilities often need tremendous community support. Monitoring their medication compliance is crucial. A user fee will restrict their access to the drug therapy programs that make them well and keep them well. Introducing a $2 prescription fee to patients who may require as many as a dozen prescriptions will put them at risk to do harm to themselves and others. More likely, they will end up on the street, in jail or back in the hospital.
User fees shift the blame for the high cost of the drug program on to the victims -- senior citizens and those on social assistance -- when the responsibility lies mostly with governments, doctors and the drug companies.
The existing act requires the Ontario drug benefit plan to reimburse an eligible person for the full costs of the drug where a physician has specified that no substitutions are to be allowed. Under Bill 26, the eligible person would be responsible for paying the pharmacist for the cost of the difference between the specified drug and what is deemed by cabinet regulation to be an interchangeable product.
This bill gives cabinet virtually unfettered power to enact regulations establishing user fees and copayments, which could lead to charges that differ substantially in method and amount from those that have been recently announced. It also gives the Minister of Health wide power to collect, use and disclose personal information for purposes related to this act or for any other purpose defined by regulation.
All of these regulations seriously impact on the universality and accessibility of health care services, of medically necessary medication and treatment, for people who need support.
Ms Monteith-Farrell: Changes to the Prescription Drug Cost Regulation Act: The name of this act is changed to the Drug Interchangeability and Dispensing Fee Act because the Minister of Health will lose the power to regulate the price of drugs for anyone not covered by the ODB. Some 60% of all prescription products sold are for people who are paying on their own or through an insurance plan.
Manufacturers will be free to determine the price for drugs, other than for drugs provided under the ODB, and prices will certainly go up. As well, there will be impacts on the uniformity of pricing, particularly in remote locations, where they may seriously escalate.
In the multinational world of drug manufacturing, competition will not be a control factor in keeping prices down because of the patent protection of Bill C-91.
People fortunate enough to find or keep employment that pays well enough for them to be exempt from the Trillium program will pay more for their drugs. Those who benefit from insurance plans which cover drug costs will have to deal with the impacts of increased premiums, employers as well as employees.
It is easy to see who will benefit and who will lose under the amendments to these acts.
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Schedule H amends the Health Insurance Act and the Health Care Accessibility Act.
Bill 26 removes all references to "medically necessary" services and substitutes a broad power in cabinet to decide which services will be insured. This opens the door to establish delisting of services. The government will be free to determine whether medically necessary services are insured services or not.
The cabinet has the power to determine the types of services provided to persons in a prescribed age group. The intent of this clause is unclear, but there is nothing in Bill 26 that would prohibit persons in their 60s to be refused open heart surgery, based on age.
Cabinet has the power to determine if the services are medically or therapeutically necessary.
Cabinet has the power to unilaterally establish the basic fee payable for insured services.
Bill 26 gives the minister and general manager of OHIP the power to collect and disclose patient information for any purpose that may be prescribed. This opens the door to privatizing OHIP administration and giving personal medical information to private corporations.
Bill 26 amends the Health Care Accessibility Act to apply to hospital insured services. It gives explicit statutory authority to cabinet to make regulations that would permit hospitals to charge patient user fees for any hospital-based insured services, including those presently covered by OHIP. Examples of user fees would include accommodation and meals, necessary nursing services, laboratory and other tests, drugs and emergency room visits.
Mr Armstrong: Schedule I, Physician Services Delivery Management Act, 1995: This is a new act introduced in Bill 26. Bill 26 grants the cabinet power to extinguish contractual rights or obligations contained in various agreements entered into between the government and the Ontario Medical Association. These include the various existing alternative payment plans or non-fee-for-service agreements.
It strips the OMA of any negotiating rights and says the judge's ruling, decision, award or order "shall be of no force or effect."
Together they provide the government with enormous powers over doctors. The Minister of Health can restrict the number of eligible physicians, determine that a particular area is oversupplied and impose a moratorium on new physicians in that area.
The amount paid for services will be varied, depending on the geographic area or other factors.
One amendment to the Health Care Accessibility Act, subsection 2(3), may open the door for hospitals to expand their user charges for such items as toothpaste.
The Physician Services Delivery Management Act treats doctors like the Leamington mushroom workers, who were decertified with the repeal of the Agricultural Labour Relations Act. It voids the OMA's agreements, strips the OMA of any negotiating rights and says any judge's ruling, decision, award or order to the contrary "shall be of no force or effect."
The Chair: Excuse me, I'll just make you aware of the fact that you're down to three minutes.
Mr Armstrong: Okay. There are schedules I, J, K and Q that we had wanted to speak about, but you can read them at your leisure.
During the 1995 election we heard promises from Mike Harris and his Conservative cronies. The promises on health care are in print and were said to be sacred. The promises voters heard were clear. The Conservatives said, if they formed the government: "We will not cut health care spending," that "health care spending will be guaranteed," that "health care funding won't be touched," that "aid to senior citizens and the disabled will not be cut."
"How we achieve the savings," they said, "will be discussed in a partnership with all Ontarians. Our four-year plan is based on four years of study, analysis and consultation with workers and ordinary Ontarians through extensive public hearings. We've looked at user fees, copayments and delisting but decided the most effective and fair method was to ask individuals to pay a fair share based on income. There will not be user fees. We will work with OPSEU members, listening to their ideas and eliciting their help in taking action."
Bill 26 breaks each and all of these promises. It will destroy Ontario's health care system and it will put people at risk.
In conclusion, Bill 26 represents the most authoritarian power grab in Ontario's modern history. It is an affront to democracy and a disgrace. It follows the same course of action the government followed in Bill 7: a swift introduction and passage of the legislation with little opportunity for public input and hearings. It verges on fascism with its sole discretion of the minister and immunity to any court processes.
Bill 26 is the thin edge of the wedge to Americanize our health care system. It repeals the Independent Health Facilities Act language which gave preference to our Canadian-style non-profit operator. It gives the minister singular power which raises the real possibility that for-profit US health care providers will be licensed to provide health services in Ontario. Studies I have read and comments from our American sisters and brothers show us that the American corporations are extremely interested in our health care system. These corporations call our health care system the "unopened oyster" and they refer to the elderly as "mining grey gold."
I am old enough to remember my grandparents and parents talk about families becoming destitute when a family member became ill before we Ontarians and Canadians had universal medicine. No one wants to go back to those times.
The only positive comments we have heard in northwestern Ontario are from rural communities which are desperate to get doctors. We support that need. However, the end does not justify these means.
Bill 26 should be withdrawn. The government should conduct extensive hearings and produce changes desired by the populace. The majority of Ontarians did not vote for this government. It should not rule like a dictator.
Bill 26 should be withdrawn. If it is not, it will become the rallying flag for the citizens of Ontario. It is already the rallying flag for the Thunder Bay and District Labour Council and its affiliates.
The Chair: Thank you for your presentation. We appreciate your interest in the process. You did not leave any time for questions. Good day.
Mrs McLeod: I'd point out that a number of people have been standing for some time. Could the hotel be asked if there's any way to put a few more chairs in the room?
The Chair: I don't see a lot of room to put any but in the corners.
Mrs McLeod: I don't think we're at capacity in terms of numbers of people. It's just a place to find some chairs.
The Chair: Okay, we'll ask the question. Thank you very much.
Ms Lankin: Mr Chair, may I place some questions on the record, please?
The Chair: Yes, you may.
Ms Lankin: Thank you very much. I think, because there are so many aspects to this bill, we haven't been able to have presenters focus on certain areas, and I'm concerned that we may not get full information, particularly with respect to the Independent Health Facilities Act. These last presenters raised some important issues. So I'd like to place some questions to the ministry.
The changes to the Public Hospitals Act and other areas in this bill allow the minister to determine what services will or won't be provided in any particular hospital. Is it possible that services that the minister determines will no longer be provided in a certain hospital will be moved and/or provided through an independent health facility?
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Is it possible under this new legislation that a profit-making American company could become the owner and/or operator of an independent health facility?
Is it possible under this act, as you will be amending it, that the minister could contract directly with such a for-profit American company without going through a tendering process?
Is it possible that that company could be the likes of an American for-profit health maintenance organization, or HMO as they are better known?
The Chair: Ms Lankin, this is beginning to look a little bit like a speech.
Ms Lankin: No, it's not. These are questions. I have specifically written them down. They are questions that I want answers to and this is an appropriate process, Mr Chair, and I'm not abusing it.
The Chair: Okay.
Ms Lankin: Could you indicate to me for such a for-profit company where in the margins of operation the profit would be found? Specifically, I'd like information on the use of facility fees and the OHIP billings.
I would be interested in having a list, if there are any, of any American for-profit companies or their Canadian subsidiaries, I should say, that the minister has met with or spoken to. If I cannot get the information provided through this process, I will file an FOI. I know it could be made available through that process, so I'm trying to short-circuit it and ask you to cooperate on that.
The Chair: Is there some end to this list, Ms Lankin?
Ms Lankin: Yes.
The Chair: We do have people waiting to make a presentation.
Ms Lankin: Mr Chair, you know the only way that questions can be asked of the ministry and put directly on the record is to be done this way. I'm doing it very quickly. I have two other questions on another matter, and it'll be very quick, and that's with respect to the concerns raised around the privacy of information and the use of such information.
Would those provisions, as they're being changed in the act, allow for, as the speakers indicated, the privatization of OHIP management and that information to be therefore managed by a private firm, and/or the production and management of the health card, particularly if we moved to smart card technology? Would these changes pave the way for that kind of event?
That's it. Thank you very much, Mr Chair.
The Chair: Our next presenters are the Lake Nipigon --
Mrs McLeod: Mr Chair, I'm sorry to do this to you. I'll ask Lake Nipigon to have 30 seconds' more patience. As you're aware, there are a number of people who had wanted to make presentations to the committee and are not able to. I assure you I'm not about to ask for further consideration, but there's at least one individual here who had hoped to make a presentation and has a written brief. I'm wondering if the clerk could make this written brief available to each member of the committee.
The Chair: I would be more than happy to do that. Anybody who has a written brief, the committee would be happy to entertain it.
Mrs McLeod: This is a brief from the executive director of the Atikokan General Hospital.
LAKE NIPIGON REGION HOSPITAL ASSOCIATION
The Chair: The Lake Nipigon Region Hospital Association, represented by Judith Harris, the CEO of the Manitouwadge General Hospital. I'm sure I don't have the other names. If you could introduce yourselves, we would appreciate it. You have 30 minutes to use as you see fit. Questions would begin with the New Democrats. The floor is yours.
Mr Donald Ross: Hello. My name is Donald Ross and I am the chief executive officer of the Nipigon District Memorial Hospital. Dr Mary-Lynn Jackson-Hughes is the chief of staff of the Nipigon hospital as well as the coordinator of Family Medicine North. Judy Tinnes is the chairman of the Nipigon-Red Rock Healthy Communities Committee.
Thank you for the opportunity to appear before the committee to discuss the Lake Nipigon Region Hospital Association's concerns regarding the Savings and Restructuring Act, Bill 26.
The Lake Nipigon Region Hospital Association is comprised of five hospitals located in the Lake Nipigon riding. They are Geraldton District Memorial Hospital, representing Geraldton, Nakina, Longlac, Caramat; Manitouwadge General Hospital, representing the Manitouwadge-Hillsport area; Wilson Memorial General Hospital, representing the Marathon-Heron Bay-Mobert area; Nipigon District Memorial Hospital, representing the Nipigon-Red Rock-Beardmore-Dorian-Hurkett area; and the McCausland Hospital, representing the Terrace Bay-Schreiber-Pays Platt-Rossport area.
To give the committee some idea of the land mass of the Lake Nipigon riding, it could easily fit in the area from Toronto to Chatham and north to Owen Sound. It has a population base of approximately 30,000 people.
Like the Ontario Hospital Association, the Lake Nipigon Region Hospital Association cannot support those sections of Bill 26 concerning certain amendments to the Ministry of Health, the Public Hospitals Act and other health acts. The Lake Nipigon Region Hospital Association fully supports the concerns and recommendations provided to you by the OHA and OHA Region 1. Rather than reviewing with the committee the details of these concerns already placed before you on other occasions during your hearings, please allow me to tell you about a success story.
Lake Nipigon Region Hospital Association has been in place in one form or another since 1978. The purpose of this association is to:
(1) Provide advice and recommendations to each member hospital board of governors on issues of common concern and interest to improve the efficiency, co-ordination and quality of services provided both individually and collectively.
(2) Strategically ensure that the members of the Lake Nipigon Region Hospital Association can proactively respond to changes in the delivery of health care services on a timely basis.
(3) From time to time, recommend to member hospitals the need for studies to address specific issues.
(4) Communicate and share pertinent information that will assist member hospitals either individually or collectively.
Given the geographic and climate conditions experienced in the Lake Nipigon riding, you can appreciate the deep commitment required by all the communities to ensure the success of this association. The association shares four major programs on a global basis within our association: laboratory, pharmacy, dietitian and occupational therapy. The association also assisted and promoted the development of a vertically and horizontally integrated health care system in each of our communities.
Our institutions are not traditional hospitals but are community health care centres which support a significant number of community-based programs. A list of the services and activities of the Nipigon District Memorial Hospital, attached in appendix I, is provided to you to further emphasize this community's attitude, supported by its own dollars, towards an integrated health care system. We use Nipigon as an example only; all five communities have similar systems in place.
In our communities we also have in place healthy community committees consisting of intersectoral, interdisciplinary and volunteer public members who work together addressing health, social, environmental and economic health issues for our communities. This integrated community model of services and programs provides coordination of community and institutional services, focuses on health promotion and disease prevention, and at all times encourages public participation and commitment in the planning process.
These committees look for and monitor both duplication and gaps in services and then jointly try to find solutions. Specific programs and services are rarely planned in isolation, even though many of our agencies and institutions are operated and funded independently. Appendix II demonstrates the comprehensive membership of these committees.
We are concerned that the three-year hospital funding reductions do not take into consideration the comprehensive nature of our health care systems. If I could ask the committee to turn to appendices Ia and Ib, you will see that Nipigon District Memorial Hospital delivers a comprehensive range of patient services. They range from acute care to nursing home beds to ambulance services to home care programs to Handi-Transit services. They are integrated and administered by a common hospital support system. Hospital funding reductions will impact not only on traditional hospital services but also on a variety of community-based programs, and a reduction of community-based programs will, in turn, increase institutionalization.
Secondly, in all of the association's committees, community-based programs are of low volume and rely on the support services of their local hospitals. If funding reductions force hospitals to cut back, limit or suspend community-based programs, they simply won't be delivered, or they will be, at a much higher cost, by a distant central agency.
The association requests that the government understand this unique system and be sensitive to it when considering funding reductions.
We have achieved these successes in spite of the barriers placed before us, such as the silo structure of government and its agencies, funding constraints, lack of physicians, as well as geography and climate. We suspect our health care system in our Lake Nipigon riding is closer to the concept of one-stop health care than any in the province.
I would like now to ask Dr Mary-Lynn to make some comments on the physician shortage.
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Dr Mary-Lynn Jackson-Hughes: I'll just tell you a little bit about myself. My husband and I are in practice in Nipigon, which is a small community of 2,500 people. It's 100 kilometres east on the Trans-Canada Highway. We came up through the underserviced area program to stay two years and we are now in our 20th year of practice in Nipigon. We very much have enjoyed living there, raising our family there and we would like to continue to practise there.
I personally have been intimately involved in all the problems associated with physician recruitment over the whole 19 years. In fact, I've met a lot of you on recruitment tours where we go stomping down in southern Ontario to all the major cities.
You know and you've heard and you're very, very aware of the problems in these small communities, and it was recognized with the $70-an-hour sessional fee -- absolutely fantastic and we thank you in the small communities because it is going to make a difference. It is time now, though -- I think the studies are all completed, the rest of it -- for implementation of recommendations that I know are before you, specifically the Scott report and especially the alternative method of payment.
Another solution I feel to the problem is support of the NOMP undergraduate and graduate training program through Family Medicine North. It has been well documented that physicians who train in the north stay in the north. We have been involved, and I personally have been involved, for 19 years. The program has been involved locally here for 25 years. We're doing a good job and we want recognition that we have done a good job, and please let us go on and continue. Thank you.
Mr Ross: We in the Lake Nipigon riding have never accepted the status quo and we are always continuing to re-evaluate our service and ensure they are in concert with those of the Ministry of Health and government. In December, the Lake Nipigon Region Hospital Association initiated a comprehensive re-evaluation of the region's health care system to further identify savings and improve efficiencies. This study is funded by the member hospitals.
Although supportive of the need for significant changes, our association is concerned that some of the new powers given to the ministers and civil servants under Bill 26 may not enhance our association's work and could potentially impede it. If changes are not made to Bill 26, or if its power is inappropriately exercised, it may (a) undermine volunteer governance of health care; (b) allow for the micromanagement of front-line operations; (c) restructure services, programs and institutions in an irrational manner; and (d) minimize due process and fairness.
Our association agrees with the Ontario Hospital Association's five goals:
(1) To preserve and enhance the system of volunteer governance of health care by community representatives;
(2) To maintain and improve the quality and accessibility of the health care system and to increase accountability for the public dollars expended;
(3) To ensure that regionalization initiatives are based on population needs and the creation of systems of care which reflect delivery capabilities and effective referral mechanisms;
(4) To maintain the hospital system's ability to manage human resources effectively; and
(5) To develop new approaches to funding hospitals and related physician services in order to improve health services across the province.
I have attached for your review the OHA recommendations that were provided you to on December 18, 1995.
In summary, the Lake Nipigon Region Hospital Association is aware that bringing the deficit and debt under control is a requirement and we are pleased to contribute our energies towards that effort. We applaud the intent of Bill 26 to facilitate change but are concerned that in its present form it may endanger the most positive aspects of our health care system. Appropriate safeguards are required to prevent that.
The Lake Nipigon Region Hospital Association opinion is that most of the problems facing small hospitals are well documented. Many of the solutions to these problems are identified in numerous reports: The Scott report; the OHA rural study, Small Hospitals in Ontario: Towards the Year 2000; Access to Care in the North are just a few I could name. The evaluation process should now be over and the implementation phase begun. It is the association's hope that government will be sensitive to the north's solutions to its unique problems and funding requirements and act on them accordingly. Thank you very much for listening.
The Chair: Thank you. We have about five minutes per party left for questions, beginning with Mr Pouliot.
Mr Pouliot: I thank you very kindly, Mr Chair. You will allow me perhaps a departure from form to say briefly -- however, sincerely -- how pleased I am when I see the heading of Lake Nipigon, but more importantly, I see Mme Tinnes, Dr Jackson-Hughes and Mr Ross, who have been closely associated. We have fought many battles of many kinds over the years.
I'm a little surprised, having said this, to find my three most distinguished constituents sounding a lot more moderate than their representative. You'll hear. My first question will be directed at Don -- Mr Ross.
Mr Ross: Not moderate, wiser.
Dr Jackson-Hughes We've learned over the years. Is that what we're saying?
Mr Pouliot: Mr Chair, will you please assert your authority?
People will do that, and I'm sure the members have been blessed with synonyms or words that are often repeated, such as "Our situation is unique," "Oh, but we're more special than others." Suffice it to say the riding of Lake Nipigon certainly has a claim, and you've mentioned it, and very well indeed: 26% of the overall land mass of the province, the size of Germany. I live in Manitouwadge and I'm closer to Toronto than I am to some parts of the riding of Lake Nipigon, and when in Toronto closer to Miami. One can go on to illustrate about, if not its uniqueness, the fact that ridings such as Kenora, with my good friend Mr Miclash, are dependent. There's really no alternative here. And people have been very, very cognizant. They've acquiesced readily the time to change, because we change just to survive.
You've mentioned about three years' funding. You've shown a concern. I was watching you carefully and listening intently indeed. Can you give me in your own words, Mr Ross, an example of what would happen if funding would be negatively impacted? You're a hospital administrator. You know first hand. You see those things on a daily basis.
Mr Ross: And Mr Pouliot will want a straightforward answer. If we were to receive, in our small hospitals, an 18% across-the-board decrease, it would literally destroy the network that we have spent the last 15 years developing. I have some doubt, and I have not worked through the process in my own hospital, I'm not so sure that we can survive the 5%.
Our problem, I think, in terms of funding is that the funds we receive are based on traditional hospital methodologies, and we are no longer a traditional hospital. Our system has developed into an integrated one.
Let me give you an example. We have a Handi-Transit program in Nipigon which is solely funded, totally, 100% funded by the community, through Lions clubs and volunteers. That program is extremely important to support our medical day care program, because the greatest barrier bringing people in for medical day care is the transportation.
If one of those two programs were not be funded, for whatever reason, what would occur is that those people would have to go somewhere, and I can tell you where they'll end up. They'll end up in the acute care portion of our hospital, which will then just force up costs, greater than they were in just subsidizing the other two.
We also, through our hospital budget, make the conscious decision at times to fund non-traditional services. If we need to expand home care a little bit, we as a hospital will contribute money to keep this very important program going.
We receive our funding based as a traditional hospital. We have developed over the last 20 years, I think developed in the direction Mrs Lankin had wanted us to go and Mrs Caplan had wanted us to go and Mr Timbrell had wanted us to go over the last decade and a half. I have a great fear, unless somebody pays attention to this problem, that our total network could be destroyed, and I think the ultimate end goal will be increased costs.
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The Chair: Mr Pouliot, I'd love to listen to some more questions from you but your time is up.
Mrs Ecker: Any riding that can produce a representative as unique as my honourable colleague across the way is indeed unique.
Ms Lankin: Wait a minute here.
Mr Miclash: Was that a shot?
Mrs Ecker: It was a compliment, without at all wishing to be provocative.
Thank you very much for taking the time to come today. We've heard, I think, some very useful input from the hospital sector, as we've done in these hearings, and I think the other thing is that most of the presenters have taken the time to provide some very useful educational information to make sure that we all are very familiar with the concerns and the needs that are here.
I would share with you your urging to get on with implementation, that the time for studies is over. We've read them, we've seen them; they're all very consistent in some of the recommendations that they make.
I guess when we talk about underserviced areas and getting physicians attracted to the north, retaining physicians in the north, it's a problem that all three governments in the past have wrestled with. I think that some of the past governments' representatives here might find it a tad ironic that they had actually looked at things like fee differentials, fee discounting. There was great angst about that, and that wouldn't work, that was a problem, and yet we've had presenters come forward who say, "No, no, no, don't do billing numbers, do fee differentials," or discounting in fees.
There are lots of suggestions that have been played around with, and I'm sometimes left with the impression that without some kind of big stick, without some kind of need to push the change, it's not going to happen, the problem is not going to get solved, because we've seen it not being solved despite a lot of good efforts by a lot of people from many, many stakeholders.
We had PAIRO, the interns' group, presenting to us. They're launching what sounds to me to be a very good initiative, working with the communities and their colleagues and the graduates to try and get physicians in there. I was left with the question about, this sounds really good, this sounds like it might really work, but where was that a year ago or two years ago or three years ago when the problem was just as severe?
I get the sense that we've run out of time, that it's getting worse, and that without some power, some push, some stick, something that gets it solved, it's not going to happen. With your great experience that you've had in this field and wrestled with and everything else, do you have any comments or suggestions or advice for us as we continue to try and resolve this problem?
Dr Jackson-Hughes: I personally think that you can't have a stick, you have to offer a carrot. To me, you have to have the incentive. You have to have people wanting to come to these communities. You can't have them forced there because of billing numbers and the rest of it.
I don't want someone to come into Nipigon who couldn't practice in Toronto or Chatham or whatever. I want someone there because they want to be there, because they want to raise their family in a small community. You need to have -- and unfortunately, financial incentives help. It's not the only answer. You have to look at spousal retainment and lots of other problems involved in retention.
But I can't agree with the stick. I'm sorry, it's my own personal --
Mr Ross: I would also add to that, probably one of the best government reports I've read in 20 years is the Scott report. The Scott report really says there is no one single solution to this problem. In order to solve it, you have to have whatever number there are, the six or seven or eight major prongs to that report must be in place all together at the same time to attempt to solve this problem. You can't take just one of the areas out and say: "Hey, I've done my thing. Things are going to go along." You have to take the whole package and implement the whole package if we ever hope to solve this problem.
I can tell you, a great deal of my time over the last 20 years has been spent in recruiting physicians, and it has never been so difficult as it has been in the last four years.
The Chair: Mr Miclash -- oh, Mrs McLeod.
Mrs McLeod: I'll lead off because my point follows on the issue Ms Ecker was raising. I have repeatedly expressed my frustration at the suggestions of the government that it now needs to come in with the threat of billing numbers and coercion because nothing is working. Obviously, you've been very involved in the underserviced area program and some of the frustrations in getting it enhanced and improved, because it can be made to work. The residency training program which you've talked about this morning is recent in terms of its graduates. I just checked, and the retention rate for that training program is 67%. That is unheard of in terms of our ability to use a training program to retain physicians in northern Ontario. So there are programs that are working.
What we heard in other communities was that we need a comprehensive program, which is the point that Don Ross is making, and there are ample recommendations. In fact, we had an outstanding brief in Sudbury yesterday presenting a complex set of recommendations and following up on the Scott report.
We also heard that the threat of billing numbers, combined with other interventions of government, or threatened interventions of government in the way in which medicine is practised, will set back the positive process of recruitment significantly and holds the threat of both new graduates and established physicians leaving northern Ontario. I guess I would just ask for your further comment on that.
Dr Jackson-Hughes: I wholeheartedly agree with you, Lyn. Personally, if things like that, billing numbers, came in and they were imposed, it just takes away any freedom you have of where you want to practise medicine, and it's wrong. It's not right.
I keep emphasizing that you have to want to come. Part of it is, train in these small little communities. Get over your fear of what's going to happen medically in the emergency department.
All those things are working right now, and you add a few more of the Scott report recommendations and I think your problem's going to start being solved.
Mr Ross: That's why you have to pay close attention to the Scott report, because if that Scott report is not implemented, or some form of it, you may find yourself using the worst tool possible, and that may be billing numbers. That's how important that Scott report is.
Dr Jackson-Hughes: You're going to have a revolving door of physicians in these small communities. They come in, they spend their two to three years and they're right out again. I want people there. Our retention rate in Nipigon is one of the highest in the area. We have five, eight, 10, 15 years, and my husband and I 19 years, because of what we have to offer: our lifestyle.
Mr Miclash: We've been hearing that the government has suggested that hospitals such as the one that Don runs should earn revenues through the assets of the facility. I would just like to ask for some input from Don. Earlier today we heard from two other administrators from small hospitals who were concerned, as you were, about funding cutbacks. But what do you feel about this whole idea of the earning of revenues through your facilities?
Mr Ross: We do it. We do it very actively. We run, I've forgotten the number now, five or six businesses, with gross expenses of somewhere between $600,000 and $700,000 and a net profit of about $140,000, but I think we're at the maximum. When I hear that hospitals should get into this business and they can earn more revenue, I say, "My goodness, I'm already there."
I've got to tell you, as a hospital administrator, I don't like it. I seem to be spending less time as a hospital administrator and more time as a private business. I have to be concerned, in a small town, that I'm not in competition with the only dry cleaner. Is it my objective to put him out of business?
Mr Miclash: I hope the government's listening.
Mr Ross: A whole slew of problems associated with it, but at the same time for small communities that have not participated in this, there is room to move. But I'm concerned that in our particular area we're very active right now. On the other hand, I have to tell you that I'm a hospital administrator; I'm not a small businessman.
The Chair: Thank you very much, folks. We appreciate your presentation this morning. Have a good day.
Mrs McLeod: Can I take 30 seconds to provide the committee with some information? I think it's of interest. We've had several regional hospitals present today and the OHA District 1 chair brought along what is the sole map that has the entire province of Ontario on one page other than an MNR map of provincial parks.
It's yellow with age. I wanted to just present it to the committee. I think it dates back to about 1926, but it does show you, I think graphically, what we're talking about today. We leave northern Ontario this afternoon, as you know, and fly to Ottawa. We have been discussing for the last three days this entire region of the province of Ontario, and I think what every presenter has said is that you've got to understand the geographic realities of the province of Ontario to know what unique northern health care needs are.
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AIDS COMMITTEE OF THUNDER BAY
The Chair: Our next group is the AIDS Committee of Thunder Bay, represented by Michael Sobota, the executive director, and Robert MacKay, a member of the board of directors. Good morning and welcome to our committee. You have a half-hour to use as you see fit. Any questions that you leave time for would begin with the government. The floor is yours, sir.
Mr Michael Sobota: My name is Michael Sobota. I am the executive director of the AIDS Committee of Thunder Bay. Mr MacKay is unable to co-present with me due to personal reasons.
I feel, as I sit here, that I've just won Lotto 6/49. Being able to be in this chair is an extraordinary privilege. I am aware, as I sit here, of the people behind my back, not just in this room but outside of these walls, who don't have this privilege. I feel their tension, I feel their presence and I feel their pressure as I'm about to speak to you. Thank you for allowing me this time to be here.
You have my brief in front of you. I'm going to quickly scan the executive summary with you. It is not possible in a half-hour to talk about all of the things we want to talk about. We would like to speak to you next week on the non-health issues as well because they do impact on our work, but we opted to attempt to get into this round of the deputations.
If you'll quickly look at my executive summary, I would like to just put on the record the topics that are covered in the brief. The subjects we look at are economics rather than health; community consultation and building on past work; a concentration of powers and authority; the removal of liability or appeal; privatization of Ontario health care; privacy and confidentiality of medical information; authorization to municipalities to dissolve boards of health; direct costs to people living with HIV/AIDS; and an atmosphere of insecurity, fear and polarization.
It's been paramount in our analysis of the bill to look specifically at how Bill 26 impacts on the lives of people who are living with HIV or AIDS and also how it impacts on the work of community-based AIDS organizations.
You need to know quickly a couple of other hats that I wear. It's been my humble privilege and honour to serve under five different ministers of Health as an adviser to them on the subject of AIDS, spanning all three major political parties.
I was pleased to be appointed the co-chair of the minister's Advisory Committee on AIDS under then-Minister Frances Lankin and I'm currently sitting on the Honourable Jim Wilson's Ontario Advisory Committee on HIV/AIDS. He acknowledged my work on the floor of the House last October during AIDS Awareness Week. It's a context you need to know as I begin this.
Economics rather than health: Right from the first paragraph of Bill 26, the language and its objective is economics. Subsequent sections grant the Minister of Health and other ministers sweeping powers to act when the minister "considers it in the public interest to do so." But public interest is seen as singularly economic. Fiscal issues are important and even critical, and we acknowledge that, but within this legislation they're the only criteria for action.
There are clear dangers that the Minister of Health may be forced to make decisions that are economic only and not related to the health of Ontario citizens. The Minister of Health needs to be an advocate for health at the cabinet table. The bill makes the minister a financier first and foremost, almost subservient to the Minister of Finance. The bill embraces an extremely narrow view of reform, restructuring and change, that of economic restraint.
Community consultation and building on past work: We acknowledge there's a need to get the province's fiscal house in order, but in the desire to fix fiscal problems this legislation creates more problems. We believe that both health and fiscal responsibility can be achieved. There have been numerous previous studies and consultations that have addressed these issues. Many people who spoke to you here before me have already addressed that. This bill demonstrates little of what we have already learned.
A primary example is the general recognition that we need to shift health more to the community to provide a continuum of care from hospital care to home care. Each health agency or institution has an integral role to play, as restructuring occurs to shift the balance from higher-cost institutional care to lower-cost community support. This shift is already in process. Community-based AIDS organizations, community health centres and community mental health organizations are all examples of this shift in process.
There has been important recognition of community involvement in setting direction, and there needs to be more of this. An example is the previous consultation process and review of the Public Hospitals Act, where many people spoke of the need to make hospitals more accountable to their communities. This bill makes them accountable to the minister and to cabinet. This is moving backwards.
Concentration of powers and authority: If passed in its present form, Bill 26 will vest in cabinet and ministers the unconstrained power to make decisions affecting the delivery of public services -- in the instance of health, what kind, how often, at what cost -- together with the operation of public health institutions -- whether hospitals will stay open, boards of health will reduce or change services or simply cease to exist. In most cases these decisions can be made by regulation, ministerial direction or administrative order without parliamentary debate or meaningful opportunity for public scrutiny and without community, local or stakeholder input.
Let's establish clearly here that these remarks about the concentration of powers are not personal to Mr Wilson or to other ministers. The powers granted in the bill are generic and that's what we are reacting to.
The serious dangers of decision-making by one individual, the minister, or a small group of individuals, cabinet, in isolation, should be obvious. Bill 26 moves us backward to a system of dictatorial authority and imposition of decisions rather than consultation in partnership. At the least, this fosters an atmosphere of tension, frustration and distrust; at the worst, people's lives may be at stake from uninformed or mistaken decisions. The central question here is how can a single individual, or even cabinet, possibly understand the full impact on the personal or community level of health care matters without meaningful community input?
Removal of liability or appeal: In the complexity of Bill 26, by my analysis there appear to be at least 13 areas where the government is giving itself the right of final appeal, thus removing any possibility of review by independent third parties, the Legislature or the courts. This, coupled with the concentration of powers previously mentioned, is very troublesome and doesn't make ethical sense.
If the government is convinced that these unilateral powers will be used justly and fairly -- if you believe that, what have you to fear from third-party review? What is there to be afraid of in letting the Legislature debate your decisions before they're implemented, if you really believe that? This too contributes to a generalized atmosphere of distrust and insecurity that Bill 26 engenders.
Privatization of Ontario health care: The changes to the Health Care Accessibility Act, section 22, remove the preference given to non-profit Canadian sources or institutions. Our fear is that this is a clear shift towards an American medical model. One characteristic of that model is the belief that the market brings out the best in everything. We fundamentally disagree with this philosophy in application to health care. In health care the market does not produce the best for the greatest number of people.
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An example exists currently in the public insurance industry. This example relates directly to the field of HIV/AIDS. If you wish to take out life insurance of a certain threshold amount, usually anything above $100,000, you're required to submit to a number of health tests, including the antibody test for HIV. In Ontario HIV antibody testing is done by a blood test processed through our provincial laboratories. The public insurance industry, which is essentially self-regulated, allows a required HIV antibody testing to be done from a urine sample rather than blood for economic savings.
Ontario, together with eight other Canadian provinces, does not allow urine testing as it's far less reliable than the basic blood test. The insurance industry gets around this ban by shipping urine tests for processing to the only province where it is legally accepted: Quebec. This process is notoriously flawed and has resulted in unnecessary stress and anguish for people who access our services, who have received false or otherwise inaccurate test results because of insurance-mandated testing and the private system they use to get around our provincial testing laboratories.
We are very worried about the potential reduction or loss to our regional public health laboratories. The for-profit motive of commercial laboratories does not operate with the interests of patients as its standard for existence. While commercial laboratories are generally competent businesses capable of carrying out a range of professional services, there are none the less well-documented problems of consistency, standards and processes.
Let me share with you a local example. In more than one instance our clients have reported to us that they've had to go back and duplicate blood samples drawn at a private medical lab, as the lab's transportation procedures could not deliver blood to the nearest equipped centre for its processing in time for it to be usable. Essentially it was wasted, and our clients had to go back to the lab and have blood taken a second time. People living with HIV require more than usual testing, many requiring blood to be drawn. For them to have their blood wasted, and that's the net result of what this private laboratory processing procedure was, was unconscionable, adding unnecessary stress to already burdened immune systems.
Our provincial laboratory system, specifically in terms of HIV surveillance, is one of the finest on the continent, if not in the world. It is the envy of the Centers for Disease Control in Atlanta. I know this from feedback at international AIDS conferences. Ontario has been a leader in building one of the earliest and best systems to get hold of this epidemic, to be able to bring into focus what's now called "the natural history of HIV."
This is accomplished within our public laboratories through years of dedicated experience and expertise, through systems and data collection improvement, through enlightened government and public support, and here I include the utilization of the provincial anonymous testing system. Ontario's anonymous testing system collects the most comprehensive data and has been the envy of American and other centres for AIDS control.
HIV surveillance, that is, testing, data analysis and report-generating, is simply non-existent within the commercial laboratory system. An example here is the Western Blot test, used as the standard for confirmatory testing to determine a positive HIV antibody test. It's not done commercially, and that's probably because the test is labour-intensive and expensive.
The costs of shifting this to a commercial system would be prohibitive. It will cost you more to do that. A comparable test also would be hepatitis, and please check these figures out for yourself and do some research about this. Our public laboratories can do this for approximately $5 or $6 per test. Private laboratories cannot deliver it for this amount. Check this out and verify it.
Proponents of Bill 26, in their intention to drive decision-making on economics, should tread cautiously when addressing the complex services of our public laboratory system and on the exemplary record they've compiled over a decade of working with HIV surveillance. This is so crucial, that this could be lost in our struggle with HIV in the province.
Privacy and confidentiality of medical information: It has been elementary to Ontario citizens from the time we were kids and we first went to the doctor, our first access to health care, that our personal medical information was private. We were told that. That's part of how we get to feel okay about going to the doctor, that you can talk to your doctor, that it's a safe place to be. Privacy and confidentiality of medical information is a basic, sacred trust between governments and its citizens. Bill 26 is a breach of that trust.
This section alone has raised acute fears and questions from people living with HIV and AIDS. A prominent person living with HIV put it most simply and eloquently. He said, "What does the minister need my medical information for?" This, coupled with the protection the bill provides from damages caused by the release of medical information, is causing a profound sense of insecurity and an atmosphere of fear within our work. It particularly damages our ability to gain and maintain the trust of young people and others already marginalized by mistrust of institutionalized care and bureaucracies.
This single element does profound damage to years of hard and dedicated work towards attracting people living with HIV into the health care system. It destroys all the principles with which we encourage people to seek anonymous testing, counselling and, where appropriate, connecting up with a primary care physician. Anonymous testing was built on the principle that you'll be treated with respect and utmost protection. That sense of protection and respect is violated by the legal authority to breach confidentiality and make public what was private medical information.
If we lose the momentum we've worked so hard for for over a decade towards bringing people who are infected with HIV into our health care system, you can expect two practical and direct results. There will be increased transmission of HIV and there will be greater, not lesser, health care costs.
Again, we reaffirm our respect for the present Minister of Health. He has gone on the record saying that AIDS is a priority within the ministry, but structures and policy should not depend on any single individual. This section of Bill 26 may be the clearest example of where the legislation is motivated by economic considerations, to the neglect of other profoundly damaging implications.
I want to jump to my section 8, the direct costs to people living with HIV. The imposition of mandatory prescription user fees, the moves to restrict and reduce drugs available on the formulary list, the imposition of user fees by municipalities -- which you'll hear a lot about next week -- all add direct dollar costs to people who are already struggling to make their financial ends meet every month. The impact on people living with HIV is to add stress and expense to their daily living, which is already complicated by maintaining a delicate balance of quality of life with a terminal illness.
One of the primary stressors to people living with HIV is whether new treatments, those chemical equivalents of hope, will be accessible and affordable. We expect the measures in Bill 26 to add pressures to our agency's emergency financial assistance program, which are private, fund-raised dollars that we raise ourselves to assist people facing emergency financial needs that are not met from any other source. This is already happening.
An atmosphere of insecurity, fear and polarization: Taken as a whole, the sweeping nature of Bill 26, coupled with its concentration on unilateral decision-making and its startling authorization to breach patient-physician medical confidentiality, has created a charged atmosphere of tension. For people living with HIV, there is a genuine concern about what this bill means in their daily lives. A bill that runs to 211 pages and affects some 40-odd different pieces of legislation is incomprehensible to somebody living with HIV. It's just one more mammoth problem dumped on their backs to figure out and cope with. There is tension all around.
Physicians are unhappy. Labour organizations are unhappy. There is a realistic fear that we may lose physicians and, in particular, that we could genuinely lose much-needed specialists -- I think this is a really practical and realistic projection, not a theoretical one at all -- who will leave the province because of Bill 26. The natural history of HIV clearly shows that we need dedicated, HIV-aware physicians who are crucial for the people living with this illness, and physician referrals to specialists are vital to managing patient care and providing a minimum quality of life.
The basic social safety and basic health care for people living with HIV appears to be shrinking or becoming more expensive, without viable --
Failure of sound system.
The committee recessed from 1150 to 1153.
The Chair: We've got our power back on, so we can reconvene. Okay, Mr Sobota, you can carry on.
Mr Sobota: Thank you. The basic social safety net and basic health care for people living with HIV appears to be shrinking or becoming more expensive, without viable alternatives being either offered or explained. The fear is real. The insecurity is genuine. This atmosphere of tension is a legacy of Bill 26 that we will live with for a long time, no matter what form you pass it in. We acknowledge that you will pass it. We hope that you will amend it. But there is a legacy already generated of fear and tension and insecurity just by what has already been introduced.
In summary, Bill 26 is legislation that sees Ontario's health care primarily as a financial matter rather than one of people's health. It's driven by (a) provincial cost-cutting and (b) offloading of costs to municipalities and individuals. We don't believe for a second that costs to us as individuals will be less. They may be to your level of government. Municipalities will pick up these costs and charge us more for services. The bill doesn't start from what the needs are; it doesn't even address the subject.
The sweep and the breadth of this legislation is staggering. We've been able only to comment on those few sections we could analyse and understand now in the brief time available to prepare for these hearings. We've not had sufficient time and opportunity to review this bill in terms of all the implications for people living with HIV. We are raising what stands out for us, but we're genuinely concerned that there are areas that will be missed. We question how this committee can work through all the implications for every issue in so short a time frame.
At its core, Bill 26 is writing a lot of blank cheques and asking us to trust how they will be cashed in. It visibly demonstrates a lack of trust in due process and checks and balances by removing the government from review or penalties should the blank cheques bounce down the road. As a simple but revealing comparison, we would never be allowed to operate in this manner. You wouldn't let us. Bill 26 has engendered a complex world of fear and insecurity within people who do and who don't understand its implications.
We very much hope the government is considering amendments to Bill 26 and that they will be tabled for public review and discussion before passage of the bill is sought. There's a long-standing history of partnership between government and its citizens, between ministries and community groups, that should be taken advantage of. So much is at stake, so many lives are affected.
The Chair: You've left the committee with the challenge of three quick questions, one each. We'll start with the government.
Mrs Johns: I'd like to thank you very much for coming today. We appreciate the presentation. I know you've put a lot of thought into it. Since I only have a quick question, I want to talk about the drug issue. As you know, with HIV especially there are needs for new therapies all the time, and new therapies are being delivered all the time. There's so much pressure to have new drugs available to people with HIV. In order to be able to add new drugs to the ODB program, it must be made more sustainable and affordable. It's grown by a huge percentage in the last 10 years. Can you comment on how you could see us doing that, what the problems are with the drug benefit formulary?
Mr Sobota: To people who have fixed and reduced incomes, it's not an issue for them about whether the drug formulary has increased by 10% or 15% or 20%. These are people who may be facing two or less years of their lives. That's not their concern. Their concern is: "How do I get through next month? The government licenses and says 3TC is going to help me, it will sustain my life, it will give me a quality of life. But it will not pay for it and I can't pay for it." The equivalent of that is, "I'm going to die because of the government's action." It's not their issue about how to make that affordable. It's the government's responsibility to find where that money can come from.
Mr Gravelle: Michael, thank you very much for your presentation. You touched on just a number of areas that I wish we had more time to get into. There just are several, but if I may, I think I'll focus on the whole aspect of voluntary testing in terms of confidentiality of records.
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I know that the AIDS committees across the province and across the country have worked for years on education and awareness to try and get people to understand and have built up a certain trust. The implications of voluntary testing falling as a result of what's happened already just in terms of what's been proposed in this bill are I think extreme, but if you could just amplify a little more what you think the implications, the worst-case scenario, would be if the amendments are not made in terms of the confidentiality provisions.
Mr Sobota: It is so difficult to draw into the health care system people who are scared and frightened, and people who have HIV or AIDS are scared or frightened for a range of societal stigmatizations. We've worked on that for 10 years and we've had multiple layers of government support to do that for 10 years. If I'm living with HIV and know that I need to access a physician, but I go to that physician and he may be being scrutinized so that they can have their costs reviewed or reduced or eliminated, I'm not even going to come forward. I'm not going to go into the system. I'm going to be scared out of my mind to have what's already a scary thing for me to live with analysed and scrutinized by larger officials and/or then made public.
Ms Lankin: Let me say on behalf of all former Health ministers and, I truly believe, the current Health minister, how much we thank you for your past and your ongoing work, things like anonymous testing and treatment guidelines and treatment standards and the Trillium drug program. You and others you've worked with have really brought about those changes in this province and we lead in many policy areas as a result of that work.
There's so much I want to ask you and can't. You've covered a lot in your presentation. Some of it we've had a chance to talk to people from other communities' AIDS committees about, so I'll leave that.
There are two things I want to ask you to expand upon. We have not before heard the concern about a provision in the other section of the bill of municipalities' ability to do away with local boards and local boards of health. I'd like to hear about that. Secondly, on the independent health facilities option of opening up for for-profit American firms, do you have any knowledge of, in the United States, what kind of treatment HIV/AIDS patients receive under HMOs in the private sector delivery of service that would be of interest to us to know?
Mr Sobota: The first piece: I was astonished when it was drawn to my attention -- I believe it's under schedule M -- that municipalities will be given the power to alter their arrangements with local boards of health or dissolve boards of health. I couldn't believe that authority was going to be given to city councillors, and the linkage here is again economic. The linkage is about funding, because there's a statutory relationship between municipal councils funding a portion of the operating budget for boards of health.
You'd better believe that municipalities won't increase that relationship. So what they're likely to do is decrease it or, if they don't want to do it any more, simply absolve themselves of the responsibility to carry that portion of those budgets.
The Chair: Unfortunately, I'm going to have to cut you off. We've used up all the time. The question was just a little bit too long.
Ms Lankin: That was a short question.
The Chair: I realize that, but everybody was asked to have a short question.
Ms Lankin: I'm beginning to think that every time I mention for-profit American HMOs, you get a little touchy. There's a pattern here.
The Chair: I just think we've got a challenge with 15 minutes for lunch and checking out. We need to keep on schedule.
Thank you very much, sir. We appreciate your involvement in our process.
THUNDER BAY MEDICAL SOCIETY
The Chair: The last group this morning is the Thunder Bay Medical Society, represented by Dr Milne, Dr Fernandes, Dr Stamler and Dr Kutcher. Welcome to our committee. We appreciate your being here. You've got a half-hour of our time. Questions, should you leave any time for them, would begin with the Liberals. The floor is yours.
Dr Gordon Milne: Good afternoon. I'm Gordon Milne, a general practitioner in the city of Thunder Bay. I'm president of the Thunder Bay Medical Society, a delegate to council of the OMA, chairman of the ethics committee of the medical association and long-term care representative on the Thunder Bay Regional Hospital MAC.
My co-presenters today are Dr Walter Kutcher, a gastroenterologist in the city of Thunder Bay; Dr John Fernandes, an obstetrician-gynaecologist in the city; and Dr Jim Stamler, president of the medical staff and a member of the executive of the board of the regional hospital. Dr Kutcher is the vice-president of the medical staff and a representative on the board of the regional hospital.
You'll also meet three of our general practitioners, and I thank the Chairman for allowing them to give a short presentation on how we see problems arising from the act, if passed in its present state. I'd like to thank the committee for hearing our concerns and also thank those who helped ensure that our concerns were heard today.
Those present represent both the 263 physician members of our society and also physicians who are not members of our society. Our city's physicians are widely represented on boards and advisory councils and are active in sports, cultural and community activities. Hospital reorganization has been actively supported by physicians through their participation in the hospital planning council, the one hospital committee and latterly in the amalgamation of medical staff of all acute care hospitals in the city.
We, as Ontario physicians, have great concerns regarding the implications that the proposed changes will have on health care across the province. We are particularly concerned regarding the effects that the proposals will have on the availability of health care in our city, our district and the region. We're also concerned that statements by the Health minister show a lack of understanding of health care processes.
While all physicians practising in Ontario are members of the OMA, some physicians would prefer to be represented in government discussions by other groups. We, however, feel that health care can only be provided with input from physicians and that the government must hear the concerns presented by an organization or organizations approved by the province's doctors.
Now we'd like to give a short presentation of about 10 to 15 minutes by the three family physicians who are here today: Dr Martha Stong, Dr Pam Johnson and Dr Janet McLeod, who are better known as the Buck Stops Here Family Practice Group.
The Chair: This part of the presentation is not on the record.
Mrs McLeod: On a point of order, Mr Chair: May I ask why?
The Chair: Because they're not at microphones.
Interjections.
The Chair: Excuse me. I don't want to turn this into a charade. The protocol is that we --
Mr Miclash: It's their time.
The Chair: Mr Miclash, we have four people making a presentation. I told them ahead of time this would not be on the record. They agreed to that.
A skit was performed.
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Dr Milne: Dr John Fernandes would now like to give a short presentation.
Dr John Fernandes: I want to address the committee's attention directly to the state of obstetrical services, particularly as it relates here in northwestern Ontario.
I'd like to remind you that in the past few years, with the number of family doctors leaving smaller communities in the peripheral areas around Thunder Bay, it is not uncommon for me to see in my office, on a daily basis, women who have driven four hours in to see me in my office for routine prenatal care and who will be driving four hours home. If you think driving on northern roads is an easy process, I've got news. I've had, as recently as two weeks ago, one of my pregnant obstetrical patients, at 28 weeks, end up in a ditch in an overturned truck. This is not exactly easy access to health care here in northwestern Ontario.
In Thunder Bay itself, between our two hospitals, we do approximately 2,000 deliveries. We are eight obstetricians servicing everywhere from Wawa basically to the Manitoba border. As a result, our offices are quite replete with patients. We're very busy, working very hard in order to keep up with the pace. The 2,000 deliveries that we do locally are not just divided, fortunately, between the eight obstetricians. About 1,200 of those deliveries are actually performed by obstetricians here.
If you divide that 1,200 by eight, you will come up with the number of 150. If the current legislation goes through as it stands, it would mean that those 150 deliveries physically performed by each individual obstetrician will not be remunerated to that obstetrician whatsoever, because all of the income from those 150 deliveries will go towards paying malpractice premiums in order to just perform the service. As a result, I am anticipating -- and we have had discussions about this -- that if this bill goes through as it stands, without any adjustment for this malpractice situation, I fully expect that you will be having eight obstetricians resign their obstetrical privileges very shortly.
We have been told by CMPA and by the college that should we not have obstetrical coverage with malpractice premiums, given that situation, should we, in an emergency, perform any obstetrical procedure, we will not be covered, and in fact the college will come down hard on us. As a result, there will be no obstetrical coverage from a specialty point of view in northwestern Ontario. All 2,000 deliveries as a result will have to head to southern Ontario. I hope that somewhere the government is willing to and expecting to be able to fund that transport of 2,000 patients a year down to southern Ontario for delivery. From a very practical point of view, that's what we're facing.
The situation that is going to also develop in the area of orthopaedic surgery will be the same. With orthopaedic malpractice premiums increasing at the rate at which they are currently increasing, also up to the equivalent of what obstetricians are performing, with our shortage of the current number of orthopaedic surgeons in town here, I fully expect that we are going to start to see an exodus of physicians from this part of the province. From a purely economic point of view, you can't afford to continue to practise where all of the income is going towards paying the premiums just to be able to practise. It's not practical.
In the long term, our concerns are that with all of the changes that are being proposed with this, it is going to make obstetrics and gynaecology a very unattractive area for physicians to enter into in the early stages of their careers, when they're making career choices. As a result, our residency programs are going to fall apart, the educational aspect in obstetrics and gynaecology and any research that is currently going on will eventually come to a halt and women's health care issues are going to be ignored once again. It's taken years and years to get women's health care issues recognized and attention being drawn by various governments; to do this at this point would be an enormous step backwards, and I suspect a detrimental one not only to women's health but also to children's health in this province.
Afterwards, I'd be quite willing to answer any questions specifically around obstetrics and gynaecology in this region.
Dr Milne: Dr Kutcher will now give his presentation.
Dr Walter Kutcher: I've enclosed a handout of things I wanted to cover, so I'm going to briefly highlight a few points.
I fear that the adoption of this bill may hamper our ability to provide quality medical care to patients in northwestern Ontario. Allow me to outline several areas of concern to me. I'm going to skip number (1), because I think timewise we're running a little long. I'll leave that for you to read, if you wish.
(2) Under schedule H, new physician billing numbers will only be issued in undersupplied regions of the province, and doctors will not be allowed to move within the province without ministry approval. I applaud the government's stated desire to address the shortage of physicians in underserviced areas of the province. The estimates I have read suggest that 200 to 400 doctors are required to fill these important spots.
Several areas are of critical importance to us in Thunder Bay and northwestern Ontario. For example, at present we have no tertiary trauma service because of our shortage of orthopaedic surgeons and neurosurgeons. I don't believe that Bill 26 will force these types of physicians to underserviced areas. Furthermore, the ones it does force here may not be the physicians who are best for our patient care. I believe it's the wrong approach to take. For instance, when I came to Thunder Bay six years ago, I planned it to be for a couple of years. However, my family and I have found we like it here and plan to stay. If six years ago I didn't have the later option of moving in Ontario, then I would have opted for a job in the United States.
I believe that doctors should be enticed to underserviced areas with incentives. Incidentally, the incentive hasn't changed since 1980, I believe. Some will choose, as I have, to stay in these areas. This surely provides better-quality medicine to our patients than we would expect to have by forcing doctors to work here against their wishes. Furthermore, specialists such as orthopaedic surgeons and neurosurgeons, who are still in great demand in the United States, will surely move there rather than to Thunder Bay.
I also believe there are other ways to limit physician numbers in overserviced regions of the province. This could include differential billing fees for new physicians in the areas, alternatives to fee-for-service practice, a limitation on the number of medical school graduates and foreign doctors as well.
(3) Schedule H also gives the general manager of OHIP powers to unilaterally reduce or refuse to pay claims and may require a physician to repay the plan for services deemed not medically necessary. Inspectors will be given wide new powers of inspection and entry for examining patient and physician records.
I understand the government's need to make the health care system more efficient and effective. I also believe that almost all doctors are fair and honest. I don't believe the government should have the right to decide whether a particular service I require for my patients is medically necessary, and further have the right to penalize me without the right of appeal. If physicians begin to second-guess their clinical skills, patient care will suffer due to inadequate diagnostic testing and care. Furthermore, the potential for confidential patient information being disclosed may also result in poor care, as patients may choose not to report information about abortions, drug history, psychiatric history etc, in the fear that it could be disclosed at a later date.
If the true reason for these powers is to catch the few Ontario doctors who may act fraudulently or refer excessively, this can be done by expanding the powers and penalties already in place by the College of Physicians and Surgeons of Ontario Medical Review Committee. This desire to reduce fraud will come with a huge cost both for the freedom of our medical profession and potentially the care we can now give to our patients.
(4) This has been covered by Dr Fernandes.
(5) Schedule I also cancels all agreements between the government and the Ontario Medical Association. This will make it impossible to establish new health care initiatives, such as the proposed nursing station in Armstrong, Ontario, a northern Ontario community near us which traditionally has had great difficulty in providing adequate medical care to that region.
In summary, as a concerned citizen of Ontario, I appreciate the need to get Ontario out from under its crushing deficit and debt load. I understand this will require a fundamental restructuring and rethinking of public services as part of balancing our provincial budget. However, I believe Bill 26 is an unnecessary intrusion into the workings of the medical system that will have adverse consequences both for our profession and, most importantly, for our patients. I believe the needed changes can be achieved using the mechanisms already in place, with the continued partnership between government and local institutions. At best, the bill should be delayed several years to allow the local solutions to occur. At worst, as it applies to health care, it should be scrapped. If this bill is enacted and the powers in it utilized, I predict that in several years we will look back and see that it really created quite a mess.
Thank you for the chance to speak.
Dr Milne: Thank you for your attention. We would be happy to entertain questions.
The Chair: We've got just basically a minute each, time for one quick question each, beginning with the Liberals. We have to get on with that other debate, so we'll limit it to the minute.
Mrs McLeod: Yes, indeed. I would have asked what the effect of Bill 26 would be on your patients. You've already demonstrated that, I think, very effectively in just for the record reiterating the fact -- and I'm going to do this in less than a minute -- that there is no appeal from a revoking of a physician's privileges. You could have gone on to quote section 26 of the same schedule, which would say the general manager of OHIP decides who is an eligible physician, and there is no appeal of that decision either.
You also indicated that there can be a refusal to pay for a referral to a specialist if it was considered not medically necessary. There is at least some form of physician review of that, but if there is a decision by the general manager of OHIP or the minister that what you did as a physician was not medically necessary, you can be denied payment for that service, and that would have to be referred by the physician himself to get any kind of appeal of that.
The third one you were pointing out was that virtually everything else in Bill 26 gets in the way of a patient's relationship with the physician. I would specifically ask you perhaps to address the fact that it's new and significant in this bill that it gives the government the power to decide what is medically necessary.
The Chair: Thank you, Mrs McLeod. Ms Lankin.
Ms Lankin: Thank you very much. You've covered a wide range of areas.
I want to ask you a question about the proposed billing number restrictions. We heard yesterday that not only new physicians but existing physicians who realize that if this bill becomes law their billing number might be frozen in this area, even though they've been here and they are committed to practising here, because they can't see into the future, what might happen with them is that they might leave and establish southern practices now, before this comes into effect, and that in spite of the OMA having now put an offer on the table to pay for the incentives out of the physician pool and all those other solutions that the government says it's going to give a chance to let happen, we may not have an opportunity to see the benefit of because doctors might leave in advance.
I want to know: Is that an empty threat?
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Dr Milne: We've already had one emergency physician leave town this week to move to southern Ontario to make sure he can get a licence in southern Ontario. We have just been told this in the last two weeks, that we're losing a urologist and a nephrologist.
The Chair: Thank you, doctor. For the government, Mr Clement.
Mr Clement: Thank you for your presentations and for the graphic demonstration of your point of view. You gave us a lot to think about and I appreciate the time that you've put into all aspects of your presentation.
In the limited time I have, I just wanted to turn to the definition of "medically or therapeutically necessary" and who gets to decide. Do you think that there is a way, from your perspective, to improve the unconscionable wait that sometimes occurs with the Medical Review Committee to improve that committee, to make it do the job that it's supposed to do on behalf of the taxpayer, and not overturn that balance in favour of the bureaucracy? Is that something that you're willing to work towards?
Dr Jim Stamler: I think definitely there's a wide body of knowledge across the border, and insurance companies are using this knowledge regularly in the private industry. In fact, physicians are human and what they need is guidelines to practise. If it's defined what we need to do for our patients, we can look at what the patient needs, make individual decisions, and there are probably some areas that at this point may not be necessary. It may be deemed for society's good that we should not be doing these things. But we're human beings and we need to know that we are following a set of guidelines that will help the patient and make us feel better as we do it. If we feel like we're frauds every time we do something, you're going to get some really strange behaviours coming out of doctors.
The Chair: Thank you very much, doctors. We appreciate your presentation here today.
Mrs McLeod: On a point of information, Mr Chair: Yet another of the groups that had hoped to make a presentation today was the Thunder Bay Pharmacists' Association, and they have provided a written brief. I appreciate that being tabled for all members of the committee, but I did want people who are attending to know that the pharmacists have also made representation.
The Chair: Just a couple of points: we have to check out by 1 o'clock, and the 3:30 pm pickup for MPPs.
Mrs McLeod: Is it also appropriate to recommend and perhaps to move that we allow for a half-hour break at lunch? We are only 10 minutes from the airport and it is not snowing, and I do think that, given the power of interruption, we could afford to take a reasonable break of 20 minutes or 25 minutes for lunch and still get to the airport on time.
Mr Clement: We'll be finished by 3.
The Chair: Yes, that's all we have. Out of respect for the people who came to present, we're going to stick to the schedule. We're going to deal with Ms Lankin's motion.
Interruption.
The Chair: We still have some unfinished business. If you wish to stay you're welcome to, but we need to be able to hear.
Ms Lankin: Just to let people know what is happening, we're debating a motion which would have this committee recommend to the government House leader that we consider coming back to Thunder Bay to be able to hear from those people who didn't get a chance to get on before this committee today.
Mr Chair, I know the committee members know my very strong feelings on this issue. We went through some raucous times in our relationship in the Legislature and in the end determined, collectively among the three parties, a process that we would adhere to which included three weeks of public hearings, but for the opposition gained us the very important aspect of being able to travel outside of Toronto to hear from people.
None of us at that time knew the overwhelming public response that we would receive. While there is some dispute around the numbers and how groups are counted, no one can dispute that in the two weeks we're out travelling right now, the two committees, there are over 1,000 groups or individuals who have applied for somewhere just under 300 available spots. The number that I have been given is 274 available spots. The government disputes that and thinks it's closer to 300. I don't care. That is still astounding: over 1,000 people for just under 300 available spots.
Here in Thunder Bay, even with the accommodation to get on an extra group that we've just heard -- and I'm glad we heard from them -- there are three times as many people who have applied as there are spots available. Only one third of the people or groups who've applied to be heard by this committee have been able to be heard.
I have to say that we know that it's up to the group if they want to leave time for questioning, but there's such in-depth information and the breadth of the bill that people want to be able to comment on and the opportunity for dialogue and to be able to pursue some of those things would only improve the legislative process. I'm sorry we didn't get a chance to have a full discussion with some of the participants today, and it's not their fault. You can't physically address all of the areas of concern in the bill to many of the groups or organizations or individuals in half an hour and still have time for questions.
There are many groups who are not even being heard. I appreciate the written submissions, but I want to be very honest with people. I think I'm a very conscientious, hard worker, but I am sitting on committee from morning to evening, leaving, getting on planes, going to the next community. I have a meeting all day Saturday to try to go through developing amendments that we're going to be tabling the following Monday. I travel all next week, I come back, I go into clause-by-clause analysis, and I want to be honest with you, although I will try, I know I will not be able to read all of the written submissions that people are being encouraged to apply. So I feel sorry that people are being led down a garden path, that they think this committee -- and I challenge anyone on this committee to tell me that they will be able to read every word of all of those submissions.
All I'm asking the government members is to please recommend that the government House leader look at this issue again, look at passing the things that they need to pass on the 29th, but let us deal with some of the longer-term, bigger policy areas that are not necessary for your immediate fiscal agenda. Please, just make this recommendation from the committee. Let the House leader make the decision, but let's have this committee at least acknowledge the number of times you heard today in Thunder Bay people saying they needed more time and they wanted more people to be heard and that the bill should be dealt with in a different way.
The Chair: For the government, Mr Clement.
Mr Clement: I will speak against the motion. I feel that the premise of the mover of the motion is flawed. The process that we have undergone has been a worthwhile, extensive process. We have had a diversity of points of view in Thunder Bay this morning so far -- we haven't even got into the afternoon yet -- where a lot of different points of view have been able to be expressed, many of which have been critical of the government's position on either the entire bill or specific portions of the bill. Where people are unhappy, they have been given an opportunity to suggest amendments. We are listening to those amendments, at least on the government side. I can't speak for the other side. I'm sure they are too.
Mr Pouliot: Come on. You're lying through your teeth. Be fair.
The Chair: Mr Pouliot.
Mr Clement: I'm sorry Mr Pouliot feels so strongly about this, but I can assure him that I am listening very closely to the presenters in Thunder Bay, as in the other cities that we have been to. In fact, both sides of this committee, the health and the non-health side, will have had 750 slots, by my personal calculation, for presenters to express their views. I think that will provide for the diversity and multiplicity of opinion and views held by people in all corners of Ontario. So I think it's a fair process that is giving good input, and I guess I disagree with the mover's premise from that point of view.
Ultimately, the job, the obligation of legislators, is to have a period of time where we consult with both our own constituents but also with the wider public, and then ultimately to act. We must act as legislators. We must legislate. That period was agreed to by all three House leaders -- NDP, Liberal and PC -- to be on Monday, January 29, 1996, and I am sticking to that agreement.
I must put on the record yet again that this bill is receiving more time in committee than any bill in the previous two parliaments -- in the previous two parliaments. Even extending the hearings --
Ms Lankin: That's not true. That's incorrect.
The Chair: Excuse me, Mr Clement has the floor.
Ms Lankin: That's factually incorrect, though.
Mr Clement: I put it to you that that is in fact true. I've said it on many other occasions and you have not objected.
Let me add this one point: We heard from deputations today and yesterday about the need to proceed with restructuring, the need to get on with the job, to reallocate some of the resources into areas where perhaps we are spending without regard to whether it is money well spent and to put it into areas such as HIV, such as long-term care and such as community-based health which genuinely need the funding. The only way we can get from here to there, the only way, is to move ahead with the legislation. If we hold off for yet another month, that will cost, by my calculations, at $1 million an hour, $720 million going to the interest on the debt rather than to our hospitals, rather than to our community health centres, rather than to our HIV patients. I think that is unconscionable. I will not let it happen. I will vote against this motion.
The Chair: Mr Pouliot, just as a point of order, I believe I heard you say something that is rather against the rules, and I would ask you to withdraw that.
Mr Pouliot: If I mentioned in a fit of passion that a member opposite was lying through his teeth, I will withdraw this and substitute it by saying that he was shying away from the truth.
Mr Gravelle: If there's one thing that's become clear, and I think Mr Clement knows this, as he brings out the argument that indeed it's costing $1 million or whatever amount it is in terms of interest payments, the fact is he knows full well that extension of the hearings --
Interjection.
Mr Gravelle: Whatever figure they keep using. The extension of the hearings is clearly what is needed. The fact is that by allowing the public to have real input -- I've been sitting in my constituency office this past week talking to people who were not able to get on to this committee list who want very much to make presentations, and he admitted earlier that it is indeed one of the responsibilities of the legislative process to have committees go forward. There is absolutely no truth to the fact that extending the hearings -- allowing people to have more input into February would not by any means change the process in terms of the debt. Things can still be put forward. Things can still be passed. You know it's true.
The fact is that hearings are what people want and need. I think it's the height of arrogance to say that there's no time for more hearings when indeed throughout whatever community you've gone to and certainly Thunder Bay is one of those communities, there are a variety of groups who very much have a great deal to add to the possible list of amendments that need to go for this bill, and I think it's clear that certainly we in the loyal opposition support Ms Lankin's motion and find it astonishing that the government cannot at least bring forward, as you did say when you were speaking just now -- if there are some things that have to go forward on the 29th, fair game, let's talk about it with the three House leaders. We would be willing to talk about those options, but give the people of Ontario and the people in Thunder Bay a greater opportunity to make their points of view about this bill, which is mind-boggling and frightening to a lot of people.
We completely support the motion.
The Chair: One minute to sum up.
Ms Lankin: A very quick wrapup: Mr Clement, you heard many concerns raised today and many of the issues, in fact in the last presentation -- let's just take that -- they raised that you know when that bill's passed on the 29th, on January 30, not one cent is going to be saved against the deficit, and your numbers of $720 million in a month is like the deficit will be eradicated by this budget bill. That is so misleading.
The other thing I want to say is, you said you're here and you're listening to people. All the way through the Toronto hearings and many of the presenters in the last three days in northern Ontario have said, "Break this bill up and slow down some of the bigger pieces." If you're listening, why aren't you prepared to pass on that recommendation to the House leaders and let the House leaders figure it out? You don't need to stand in the way of that. Let the House leaders figure it out.
The Chair: It's time to vote on the motion.
Ms Lankin: A recorded vote, please.
The Chair: Ms Lankin has requested a recorded vote. Those in favour of Ms Lankin's motion?
Ayes
Lankin.
The Chair: Those opposed?
Nays
Clement, Ecker, Johns.
The Chair: The motion is defeated three to one.
We'll recess for 15 minutes.
The committee recessed from 1244 to 1303.
CANADIAN UNION OF PUBLIC EMPLOYEES, LOCAL 1409
The Chair: Our first presenters this afternoon are from the Lakehead and District Council of the Canadian Union of Public Employees: Jules Tupker, Alan Black, Darrel Williams, Lois Vanson and Connie Leblanc. We'll beg your indulgence. We didn't have time for lunch, so some us may be grabbing a sandwich as we're going through here, but we're still paying attention. The floor is yours. You have a half-hour. Questions, if you leave time for them, would begin with the government.
Mr Jules Tupker: My name is Jules Tupker. I'm the national representative for the Canadian Union of Public Employees. I represent bargaining units in Thunder Bay, Atikokan and Fort Frances, hospital locals, homes for the aged locals, municipal and so on. The original seating was for the district council. A number of the executive are in Fort Frances and they were unable to make it today so we've asked Local 1409 to sit in on the hearing. I'll just go through my presentation for you.
The Savings and Restructuring Act, Bill 26, is one of the most devastating pieces of legislation ever brought forward by any government. This bill, disguised as a money-saving venture for all of Ontario's citizens, is going to lead to unprecedented hardships for all the citizens of Ontario who are least able to fight back -- the sick, elderly, poor, disabled and unemployed.
The implementation of Bill 26 is a major step for the Harris government towards the creation of a totalitarian state. As extreme and bizarre as this statement may sound, anyone who takes the time to look into what powers Bill 26 takes away from the citizens of Ontario and gives to a few power brokers in the government soon realizes the seriousness of the situation.
Today we are here to look at the effect Bill 26 will have on health care. The changes contemplated in the bill will give the Minister of Health unrestricted authority to enact changes to the delivery of health care that will be catastrophic to not only health care workers, but to any citizen who relies on publicly funded health care and who could never afford to pay for the care they need. These changes will lead to the Americanization of our health care at a time when Americans are trying to Canadianize their health care.
The health care system in Ontario is indeed in need of reform. No one wants to see the debt of this province continue to rise. However, the massive cuts and control measures that are proposed in Bill 26 will do much more harm to far more people than any savings derived from Bill 26 can justify.
Schedule F of the bill amends the Ministry of Health Act, the Public Hospitals Act, the Private Hospitals Act and the Independent Health Facilities Act, resulting in changes in many areas.
Bill 26 will give the Minister of Health virtually unlimited authority in respect to the funding, operation, amalgamation and closure of public hospitals. The minister can ignore the needs and desires of a local community in the operation of its hospital and the minister has the power to close hospitals simply for financial reasons. The current Public Hospitals Act does not allow the ministry to stop funding for budgetary reasons without taking into account the effect the closure will have on patient care.
The effect that this power will have on northern Ontario's remote communities with their small hospitals could be devastating. Patients could be forced to drive hundreds of kilometres in severe weather conditions to receive basic health care, and, I might add, on highways that we feel will probably be maintained at a lower level than they presently are.
Schedule F of the bill also provides the Minister of Health and the cabinet with protection from any legal liability with respect to any direction issued to a hospital and with respect to the effect of any funding decision. The minister and cabinet will have been placed above the law.
Changes to the Independent Health Facilities Act will eliminate the tendering process and will also eliminate the requirement that any preference in the tendering of services be given to non-profit Canadian operators.
The minister will be able to handpick companies and individuals that follow his wishes in regard to health care. The minister under Bill 26 even has the power to prevent physicians presently providing services from continuing to do so.
These changes open the door to private companies determined to make a profit. Undoubtedly, these companies will be large, multinational organizations that have no interest in preserving Canada's health care system.
The loss of confidentiality of personal medical information also becomes a reality under this bill. The minister will be allowed to collect, use or disclose personal medical information for any purpose he or she feels is necessary.
Schedule G of Bill 26 will introduce the citizens of Ontario to a user fee for prescription drugs. Also, a $100 deductible charge will be implemented. These charges may seem insignificant to us, but to the poor, disabled and seniors, all trying to survive on fixed incomes, these fees will be devastating and will in some cases restrict the ability of these people to obtain the drugs necessary for their wellbeing.
The deregulation of drug prices for drugs not covered by the Ontario drug benefit plan that Bill 26 allows will encourage drug companies to increase the price of drugs substantially. Under schedule G of the bill the minister's power to regulate the price of drugs will be removed. This change will be significant in northern Ontario, where the remoteness of communities will surely result in significant increases in drug prices.
The removal of public input into the setting of drug prices and the determining of issues under the Ontario drug benefit flies in the face of two court rulings that went against past government decisions. The government is in fact putting itself above the law by enacting this section.
Bill 26 under schedule H will authorize cabinet to implement user fees for any hospital-based insured services including those covered under OHIP. The government has already announced that daily user fees for patients in acute care beds awaiting placement in chronic care facilities or nursing homes will be implemented. Patients placed on waiting lists for critically underfunded facilities will be penalized while they wait for placement.
The Health Services Act that is in effect now requires that OHIP cover all medically necessary services provided by physicians. Bill 26 removes any references to medically necessary services and authorizes the cabinet to decide which medical services will be insured and under what conditions and limitations. Further, cabinet is also given the power to determine that certain services will not be treated as insured services unless they are provided in or by designated hospitals. These powers could have serious implications in northern Ontario where remote hospitals can be told what services will be covered in a particular hospital, and patients requiring treatment in a community hospital not covered under OHIP will be forced to travel great distances to another hospital.
In conclusion, the changes to hospital and health care services proposed in Bill 26 will seriously damage if not destroy the publicly funded medicare system that is in place today. The passage of this bill will result in a decline of health care that is absolutely unacceptable to the citizens of Ontario and a decline that the Conservative Party and Mike Harris promised the people of Ontario would never take place.
Bill 26 will encourage the privatization and corporatization of health care, which will result ultimately not in cost savings but in ever-increasing costs to the citizens of Ontario. Reform of Ontario's health care system is necessary, but it is essential that any reforms that are enacted do not lead to the destruction of a health care system that is the envy of the world. Bill 26 will destroy that system and that cannot be allowed to happen. Bill 26 must be withdrawn.
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The Chair: That leaves about six and a half or seven minutes per party for questions, beginning with the government.
Mrs Ecker: Thank you very much for coming forward today and taking the time to bring forward a presentation with suggestions for Bill 26.
One of the things I just wanted to clarify, if you will, is that as far as I know, Bill 26 doesn't remove references to "medically necessary." I think that's something that is very important in terms of the judgments that have to be made and allowing physicians to make those decisions. That is something in there, in the process, and I think we will make sure it stays in the process because I think that's a fundamental principle.
Secondly, the Canada Health Act is very clear in terms of what we can and can't charge for insured services, and certainly the province is not planning on violating the Canada Health Act. That is something I'd like to assure you of, because that is, as you point out, a very important factor.
The other point that I think is worth making about independent health facilities is that the Independent Health Facilities Act, which is a regulatory act and is designed to promote quality assurance within licensed facilities -- and there has been a serious problem over the years with many facilities providing various kinds of medical care that do not come under that legislation.
There have been serious questions raised by physicians who practise there, patients who receive care there, about the quality of care in those facilities. As a matter of fact, there is one famous death of a patient in one facility where the coroner, as I recall, was recommending that something be done about that.
One of the things I think it's important to remember is that anything that is licensed under the Independent Health Facilities Act, regardless of the ownership, regardless of whether it's profit or non-profit, it's important to point out that there are for-profit IHFs out there now, so they're already there. Quality is the main thing about that legislation, so I think that, regardless of who's there, that is there for the protection of the public.
You mentioned about Bill 26 taking away the public process for setting of drug prices, and I'm not clear what you mean by that.
Mr Tupker: When I read the act, I read that to say the government is going to be able to set the prices for the drugs, and there's not going to be any input. In other words, there's going to be undue influence put on the government by corporations in drug prices, and that's going to be a problem.
Mrs Ecker: I think what I read, and I just want to clarify it, was that there was some public process for setting drug prices that was being removed by Bill 26, and I just wasn't clear what you meant by that.
Mr Tupker: There's not a public per se input into that, but all drug prices are controlled by the government and we feel that the bill will change that. The private corporations will have more input into the establishing of drug prices. That's going to be a problem. Obviously they're in the business to make a profit and we feel that any input that the public or public institutions have in establishing prices should be maintained.
Mrs Ecker: I think the government, as one of the biggest customers of drug companies, has much clout. I would line up against some of the drug companies any day on this.
One of the things we've talked about is the attempt to try and restructure the health care system. We've heard people come forward from all across the system who said we need to restructure the system. We've also heard people say that there is a need for an authority, a power -- whether it's the minister or a hospital restructuring commission is a point that some people disagreed on -- but there is a need for something to do that restructuring, to make that happen. Do you have any response on that? Do you think that's a good thing or a bad thing? How would you advise the government to do the restructuring that the experts in the field say needs to be done?
Mr Tupker: That's an interesting question. As I said in the report, we understand that there has to be reform. There's no doubt that we can't go on the way it's been going. The fear we have in this bill is that it's going to be done by a small group of individuals within the government, and the smaller group of individuals you have, the more influence large corporations are going to have on those individuals.
We see this bill as taking the power away from the larger government body and instilling it into a smaller group, and that group will be influenced by private sector organizations and corporations and public influence will deteriorate under this bill. That's what we're concerned about. I guess time will tell whether decisions made under this bill are correct. We just see it heading in a direction we don't like, and that's why we're opposed to it.
As to what changes we'd like to see, again I'm not an expert in the health field, but I'd like to see experts from all walks of life help to establish a plan that would see reform in health care that would be fair to all people. At this point, we feel the changes are going to affect the people who are least able to defend themselves. Canada is premised on helping each other, and we feel this bill is going to take that opportunity away. People will be hurt by this bill.
Mr Gravelle: Thank you for your presentation. Obviously, there's a number of areas I'd like to ask you about, but the aspect that concerns most people is the sweeping powers the bill gives the minister, and you've made some reference to that in terms of making it into a small number of people who have some control. One of the overall aspects of Bill 26 is that it essentially removes the ability of the legislative system to be part of it and moves everything into regulations. You look at the bill in various aspects and find that the minister has the final say and in fact the crown is not liable for anything.
I presume you see that as a concern in the health areas, but I wonder if you've looked at other aspects of the bill and have the same concerns, the fact that the minister will have final authority, the fact that ministers and the crown will not be held responsible for some of the actions they take.
Mr Tupker: You're absolutely right. Government is elected by the people, and what we see here is that this bill is just taking power away from the people and concentrating it into a small group. The whole Legislature, the people we elected, are going to have very little say in any action this government takes, and that's not acceptable to us.
Mr Gravelle: I asked a question earlier of another presenter about awareness of the bill by the people they serve. One thing we've discovered is that because of the short time frame and the complexity of the bill, there is not yet the awareness of what's in the bill and how it's going to affect people. I think there is a gathering awareness, and that's why we've asked for more time to have more public hearings, so that people have an opportunity to look at it more closely.
I presume your membership was keen to have you come forward and make a presentation, and I suspect they'd want you to do so on the other aspects of the bill as well. What is the awareness level of your membership? How large is your membership?
Mr Tupker: Local 1409 at McKellar hospital has only about 90 members. In the health care field in northwestern Ontario, there are probably a few hundred in CUPE. We're not a great, large group.
In terms of awareness, these four people on the union executive who are here don't know what's happening. It's as simple as that. They're not aware of what this bill entails; they haven't seen a copy of it. I have it in my briefcase, but I haven't had a chance to go through the whole package. I pick out highlights, and we've had legal people give us the highlights and try to pick out some things. The vastness is just phenomenal. The powers it gives the minister and a few people are unbelievable, but the membership knows nothing of what's going on. I know, because I've spent some time reading the document, but to ram this thing through in the matter of a month is just phenomenal, absolutely unheard-of, and it should not happen.
Mr Gravelle: That really is one of the points we want to make so strongly. Your union is terribly interested in what implications it has for you as employees, obviously, but at the same time, with the complexity, it's very difficult to be able to get into it. We're discovering new aspects every day that people aren't familiar with in terms of the powers in it. If there were anything you could say or do, besides what you've got in your presentation, one piece you would want to have taken out, one element, what would that be? The bill appears to be going through in some form.
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Mr Tupker: I don't think I could name one element. The immunity from the law is a scary situation. They're putting themselves above the law in a couple of areas. The invasion of privacy is very scary. I deal fairly regularly with invasion of privacy: employers trying to find out medical information about my members. It's totally unacceptable that this bill takes that privacy away. A number of issues in here are of very serious concern to my members and to me.
The seriousness of the whole process is that there's just no time to discuss it. There's no input from the members, from my members of Parliament, to have an opportunity to oppose this bill that's been introduced. We're going through this process now for a month, and from what I understand, it's going to be passed at the end of the month. It's absolutely ludicrous. This is supposed to be a democracy where issues are discussed and debated openly in Parliament. It's not being done here. We're given an opportunity here to the best of our ability to put our opposition forward, but there's just not enough time to present a proper opposition to this whole package. That's a major concern.
Ms Lankin: I appreciate your presentation and all of you being here today. Your last comment that there hasn't been the time to do the full analysis and to consult with your membership is something we have heard from other groups and organizations. Earlier this week it was a group of seniors who, on behalf of the seniors' co-op, came in and said, "But we haven't talked to our membership yet about this." Yet if you were here before the break, you would have heard Mr Clement say: "There's nothing wrong with the process. The process is fine. We've got lots of presentations, lots of time." It makes you wonder if they're listening to your comments about the bill, if they're not listening to the comments about the process and how prepared people are.
I just wanted to make one comment. Ms Ecker said the government will be the biggest purchaser of drugs and therefore will be able to get a good deal. What she didn't comment on from your presentation was the deregulation of prices that's going to affect everyone else outside the government plan, and that's you and I as consumers and our insurance plans etc. That's what's being deregulated. You were talking about the government, being the representative of public input into that process, being gone.
I wanted to spend most of my time with you talking about the problems and concerns you raised around the development of a two-tier health care system and concerns about violations of the Canada Health Act.
Ms Ecker said that the brand-new provision in this bill which allows the government to prescribe certain insured hospital services for which there could be a copayment or a user fee -- that they won't do that in any way that would violate the Canada Health Act. But I can point to several places in the old legislation where any regulation power the government gave itself had a condition on it right in the legislation that it had to be in accordance with the Canada Health Act. This new provision they've put in is absent that condition.
Let me give you one other example. In the old Health Care Accessibility Act, in the regulation-making powers under section 45, there was a provision for some services to be prescribed by age. For example, breast screening programs are generally available to women over the age of 55. So that happened, but again it was in a section that had a condition on it that it has to be done in accordance with the Canada Health Act. They've taken out that section of prescribing by age and put it in another section of the act where it now has no protection of the condition "under the Canada Health Act."
Minister Eves went to Ottawa, met with finance ministers and said, "What we want is some flexibility under the Canada Health Act." When you put that all together, I think you've got something when you raise these concerns. Could you comment on what gave rise to these concerns for you in reading the bill and where you think it might take us?
Mr Tupker: Yes, I can comment. Where it's leading us is to an Americanization of health care. It's going to lead to a health care system that only rich people can afford. It's taking away the whole concept of medicare, of equal opportunity for health care for any citizen in the country, in the province. Only the rich can afford it; only the people who can afford to pay for medically necessary procedures are going to be able to have those procedures. It defies imagination that Canada is moving in this direction. That Ontario is leading Canada in moving in this direction is totally obscene.
Ms Lankin: We are asking the government to make amendments in those areas to put the protection of the Canada Health Act back in. We'll see what happens with that.
Another area we're asking for amendments in is on public process and input -- and you raised that -- specifically the hospital restructuring commission. Currently, as it's set out in this legislation, there are no terms of reference, no mandates, no limits on the power, and nothing to connect it to the work of locally led planning studies, local DHC restructuring studies, or any of the local processes that are taking place around the province. The government says, "Of course that is what would be intended," but the legislation doesn't say that. We're asking for amendments to set out terms of reference, mandates, limits and relationship. Would you be supportive of those sorts of amendments, and what does that mean for you as a community member?
Mr Tupker: Obviously, we're in support of any opportunity for general public input into the process in the reform of health care. It's necessary. It has to be there. Reforms have to be brought about at the request or with the approval of the citizens of the province. To deny us that opportunity is ludicrous -- absolutely unacceptable, from where I stand. There's just no way we can accept that.
The Chair: Thank you very much for your presentation this afternoon. We appreciate your interest in our process.
For those of you who are standing at the back, there are seats scattered throughout, if you want to make yourselves more comfortable.
THUNDER BAY COALITION AGAINST POVERTY
The Chair: Our next group is the Thunder Bay Coalition Against Poverty, represented by Christine Mather. Good afternoon. Welcome to our committee. You have a half-hour to use as you see fit. Questions, should you allow time for them, would begin with the Liberals. The floor is yours.
Ms Christine Mather: Thank you. Good afternoon, ladies and gentlemen. Before I begin, I'd like to introduce the other people of our delegation. They're all members of the Thunder Bay Coalition Against Poverty. With me are Len Maki, Katja Maki, Delores Ponych and Connie McKnight. My name is Christine Mather.
The Thunder Bay Coalition Against Poverty -- we call ourselves T-CAP, for the purposes of brevity -- is a grass-roots organization of people concerned about the depth and extent of poverty in Thunder Bay. Our primary purpose is to provide support to and advocacy for low-income people. We are a volunteer organization which has no paid staff and which receives no funding other than private donations. We have about 80 members, of which approximately 75% are themselves low-income people.
Before we begin our examination of some of the specific schedules of this piece of legislation, we would like to draw attention to two facts which underlie, and we believe support, any further points we will make this afternoon.
The first fact is that women, senior citizens, people with physical, psychiatric and/or developmental disabilities, visible minorities and immigrants make up the majority of the low-income population. They are also the primary consumers of health care services.
The second fact is that low-income people, historically and currently, do not have much say within the policymaking and legislative processes. This lack of political and economic power makes it all too easy for decisions which affect them to be made without soliciting, listening to, let alone taking into account, their opinions. T-CAP believes that this is particularly true of low-income people in the north.
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Having presented these two basic facts, we will now address some of the specific schedules of Bill 26. Concerning schedule F, we will first comment on the new section 6 of the Public Hospitals Act. We have two points to make about this section.
Point 1: This section allows the minister to close or amalgamate hospitals without reference to the wishes of the communities they serve. Given the lack of political clout of poor people, we are concerned that this section could result in hospitals being primarily located in areas containing residents who have political and economic power. We mean by this, of course, wealthy neighbourhoods.
Point 2: This section also allows the minister to decide what services a given hospital may provide. Poor people have mobility problems. Most don't have cars. In the north, it can be many miles to the nearest hospital. Therefore, giving the minister this power could result in poor people not being able to obtain needed services. It is already easier for a rich woman to obtain an abortion than it is for her poor sister.
Still with schedule F, but now concerning the Independent Health Facilities Act, T-CAP has two points to make.
Point 1 is concerned with the redefinition of the term "facility fee" to include any service so designated by the minister. This could result in a facility charging for a currently insured service. Low-income people's budgets are stretched so far already that such redefined facility fees could exclude them from obtaining health care.
Point 2 concerning the Independent Health Facilities Act is in regard to the minister's power to collect and disclose patient information through this act and through the Health Insurance Act and/or the Health Care Accessibility Act. It is difficult for us to discuss this issue without becoming either hyperbolic or disrespectful. However, we will state that we view this as having the potential to completely change the doctor-patient relationship, a relationship which up to this time in Ontario has been characterized by high levels of trust. This trust has been grounded in the safeguards of confidentiality.
We believe that all sections of society should be alarmed by the minister being given such access. There are, however, some issues specific to low-income people. There are several social workers in our coalition. Their combined experience is that the status accorded to GPs allows them to act as extremely effective advocates for their low-income patients. A patient may confide private familial information to their doctor, who is then able to advocate for the patient to receive quick access to social services which have long waiting lists. Poor people cannot afford private counselling.
We believe that the possibility of ministerial access to confidential information will dissuade low-income people from enlisting their GPs as advocates. Further, when we consider that psychiatric consumer-survivors are a large subset of poor people, our concern rises. Psychiatrists are privy to the most intimate details of their patients' lives and illnesses. This level of trust is considered a necessary component of treatment. We believe that the possibility of the minister having access to psychiatric case notes will profoundly interfere with the psychiatrist-patient relationship, and hence, with the treatment process itself.
Finally on this issue, the committee should be aware that in the north, especially in the smaller communities, the lack of resources results in GPs functioning as front-line mental health service providers. They often act as de facto psychiatrists.
Concerning this schedule in general, we dislike the use of the somewhat vague term "public interest" in many of the new or amended sections. T-CAP believes that too often "public interest" is interpreted by governments to mean the rich public's interest.
Taken as a whole, the changes and new provisions of schedule F leave us profoundly concerned that they will result in a two-tier system of health care based upon ability to pay and ability to travel. This is not to the benefit of low-income people, this is not the platform upon which the current government was elected, this is not just, and this is not what most Ontarians want.
Turning now to schedule G of Bill 26, we have five points to make. Point 1 concerns the copayments for prescriptions for seniors and social assistance recipients. This will cause hardship to both those groups. Research has indicated that copayments of this type can deter people from having their prescriptions filled. It is not hard to see how this can eventually lead to higher health care costs through hospitalization and/or the worsening of the original condition. It can also lead to an increased usage of social services. This is particularly true of people with psychiatric disabilities. T-CAP views these user fees as discriminatory and as an illusory cost-saving measure.
Point 2 is that we have heard the government quote the figure of $2 for this user fee. When people live below the poverty line, even $2 counts. There is also no guarantee that a future minister will not raise the amount.
Point 3 is that psychiatric consumer-survivors, people with developmental disabilities and some senior citizens are often prescribed several medications over a long period of time. This user fee, therefore, represents a particularly onerous burden for people who are already disadvantaged.
Point 4 is that T-CAP believes it is unfair for the government to no longer pay the difference in cost between a generic drug and its brand-name counterpart when the latter must be substituted to treat a person on the Ontario drug benefit plan. As noted in the previous point, certain groups within the low-income population often have to take a lot of medications. Much manipulation of dosage and brands takes place until a hopefully ideal mix of drugs is reached. Doctors should not be hampered in this process by concerns about costs.
Point 5 is concerned with the deregulation of drug prices. Relying on the workings of the free market economy to protect low-income people has never worked; quite the reverse, in fact. T-CAP, therefore, anticipates that drug price deregulation will not work in the interests of the poor but rather in the interests of the pharmaceutical companies.
Now concerning schedule H, we have four points to make.
Point 1: The changes to the Health Insurance Act appear to give the minister the power to delist services based upon criteria other than their medical necessity. We strongly object to the proposed subsections 11(4) and 11(5), which could allow age to be used as a criterion in the definition of "insured service." Excluding a class of persons from service based upon a blanket criterion is surely the very definition of discrimination.
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Point 2: The changes also appear to give the minister authority to delist a service based on geographic availability. We cannot stress too strongly that low-income people have difficulty in travelling to obtain services.
Point 3: The changes also appear to give the minister the power to delist a service based upon the experience of the physician. Here in the north, especially in smaller centres, doctors are often young or intend to practise in the north for only a short period of time.
Point 4: We believe that the last three points add weight to our earlier-mentioned concern about the establishment of a two-tier health system. If certain services in Thunder Bay, provided by certain doctors for certain groups of patients, become uninsured, it is not low-income people who will be able to pay for services in an alternative location or through an alternative physician.
Concerning the Health Care Accessibility Act now, it appears that the bill gives the government the power, through regulation, to allow hospitals to charge fees for services to already insured persons. We are worried about how poor people will pay for things, such as operating room costs, meals etc. We thought the government promised no new user fees. We also believe that this contravenes the Canada Health Act.
In summation, the Thunder Bay Coalition Against Poverty has grave concerns that the health care provisions of Bill 26 will prove to be disastrous for low-income people. We find it astonishing and contradictory that a government which states that it wants to get government out of the lives of Ontarians is willing to ascribe to itself so much new authority and so many new powers.
We wish also to comment briefly about the process of bringing Bill 26 into law. We have already stated that low-income people do not generally have a loud political voice. It is not to this government's credit that T-CAP's ability to present at this hearing is the result of actions taken by the opposition parties.
While we are grateful that those actions were taken, we are still not satisfied with the level of public input allowed into Bill 26. This is a highly complex and physically large piece of legislation which will bring many important changes to Ontario. Too little time has been allowed for the public hearings. Too few groups have been allowed to present. Too little time for analysis has been allowed to the groups who are presenting. At T-CAP we have no secretaries, no lawyers, no policy analysts. We only heard that we would be presenting five days ago and therefore we have not been able to do as competent a job for the government as we would wish. We still have not heard if we will be allowed to present on the other schedules of the bill.
This is a government which talks a lot about efficiency. Giving too few people too little time to do too much work is not our idea of efficient governing.
Thank you for your attention to our presentation this afternoon.
The Chair: You've left about four minutes per party for questions, beginning with the Liberals.
Mr Miclash: Thank you very much to the coalition for your report here today. I'd like to read from the Report of the Mike Harris Northern Focus Tour. This was a report done back in January 1995, and it was certainly floated around in June 1995. I quote: "We need answers, not made-in-Toronto policies but solutions based on input and ideas from the people who live and work in the north."
I think your presentation today has highlighted the fact that there was very little input into the drafting of Bill 26. Were you or do you know of any group that was consulted during the drafting of Bill 26?
Ms Mather: We were not consulted and we know of no group that was consulted. That doesn't mean there weren't some, but we don't know of them.
Mrs McLeod: Thank you for the presentation. You have very clearly covered so many of the areas of concern. I'd like to ask you about each one of them, but you've done it so clearly that maybe I'll try and take you the next step or two.
Ms Mather: Don't do that, Lyn. I'm nervous enough as it is.
Mrs McLeod: You note, as well as the impact of copayment on those who are on the drug benefit plan, that the deregulation of drug prices could also be a problem for those who aren't on the drug benefit plan but are still in a low-income group. One of the things the Minister of Health has said is that they think the way drug prices will actually come down is that some pharmacies will drop their prices, and others of course may not drop them as much, so the sick individual should go from pharmacy to pharmacy bartering for the best drug price.
I wonder if you'd like to comment on the people you work with and how feasible you think it is for a single mom with a sick kid to go bartering for the best price.
Ms Mather: Certainly. First of all, I'd like to say that bartering seems to be a very common strategy this government suggests for low-income people, isn't it?
Low-income people, as I have pointed out over and over and over again in our presentation, don't have cars. The very work of T-CAP is hampered because, among the 80 of us, there are six working vehicles. If you're a single mother with a sick child, you are not going to be able to go from pharmacy to pharmacy seeking out low prices.
I would like to reiterate that a free-market economy does not work in the best interests of low-income people. It doesn't. The facts are there. We don't have to guess. We know that.
Mrs McLeod: I know Mike has questions, but I have to make the point that with every presentation we learn something new. You've made a point here, and it had come up yesterday and I hadn't fully understood the new point, about delisting of service based on the experience of a physician, and how in northern communities often a physician may be doing an area that looks like a specialized area; they may be trained to do it. We could really risk losing the services, so thank you for that.
Mike, I hope I've left you some time.
The Chair: Not much.
Mr Gravelle: I want to publicly pay credit to the Thunder Bay Coalition Against Poverty for the work you've done in giving a voice to people who are not normally well represented. You've done some remarkable work and I've certainly enjoyed working with you.
You've brought out some other interesting things in terms of potential age discrimination in 11(4) and 11(5).
Could you tell us about the human dimension, how the people you represent and speak to are feeling? I know there's a level of fear with the social assistance cutbacks that happened earlier. Could you just tell us and the people in this room something about how people are feeling as a result of the actions this bill may be bringing forward.
Ms Mather: Constance McKnight works very closely with one of the most disadvantaged groups of low-income people. I'm going to ask her to answer that question.
Ms Constance McKnight: There's just so much fear and anger, especially among our psychiatric community. I do a lot of work with the coalition, but I especially work with psychiatric persons, and there's the fear of our records being made public. It's already hard enough to go out and ask for the help, but to go to a pharmacy and try to barter for something when you can't even walk into a store because you're isolated and fearful and just so scared, to go in and try to barter for something you need and there are so many other people who have psychiatric disabilities and who don't come out and talk about them.
A number of social service people, maybe counsellors and stuff, are psychiatric survivors and already can't get the help they need because if they disclose they are psychiatric survivors, they feel they will be in jeopardy of losing their jobs. I used to be a social service person and now I'm working in the psychiatric community, and it was a very hard thing for me to do. There is that level of fear.
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There is the issue of medications. That makes me very angry, because there is a number of people with concurrent disorders, meaning they have addiction problems and psychiatric disabilities. For them to go to a pharmacy four times a week and pay $2 every time they go to the pharmacy -- they can't afford that. Neither can the seniors. There are so many people being let out of the hospital already, and how many people are going to lose their beds and how many people are going to be discriminated against because they are low-income people, because they do have psychiatric disabilities?
The Chair: Thank you very much. Ms Lankin, you won't mind if Mr Gravelle used a couple of minutes of your time, will you?
Ms Lankin: Of course. I object absolutely, fundamentally -- loudly, if you make me. Actually, I will try to keep my questions brief.
Thank you for your presentation and for your contribution in response as well. It's very important to hear from people in terms of how they view it's going to affect their lives and the clients they work with. You've done an excellent job, so you shouldn't be nervous at all, Christine.
I want to read you something:
"The people of northern Ontario have given us a clear message: Their needs and concerns are not being met by provincial government. They feel left out of the decision-making process. Inappropriate and unnecessary laws and regulations, designed to meet the concerns of the urban south, are being imposed on them....
"This report outlines the ideas of the people of northern Ontario for the real change needed to accomplish these goals in the north and the commitments we are prepared to make on their behalf."
The very first commitment is, "Giving northerners a greater say on policies which affect them."
I am reading from the Mike Harris Northern Focus Tour and his comments on health care. Do you feel the government has lived up to that commitment with the introduction of this bill?
Ms Mather: Most definitely not. There doesn't seem to be anything we can find in the health schedules that recognizes the difficulty that everybody in the north faces in travelling for services, and certainly it doesn't recognize the difficulties that low-income people face. In Toronto, you go to the subway station; every 10 minutes there's a train. It isn't like that here. On the bus route I live on it's every 40 minutes and on the weekend it's every 80 minutes, and on statutory holidays there's no bus service. If you live in Nipigon, it's an hour's car drive from here, and if you have no car, there's a Greyhound or a Grey Goose bus schedule you can use.
This legislation does nothing, talks not at all, about the difficulties that low-income people in the north face accessing services simply because of geographic considerations. It doesn't, like all this government's actions, recognize that the cost of living is a great deal higher than the cost of living in the south. The 21.6% cuts to social assistance recipients' benefits have brought increased hardship up here because our food costs more and we have the third-highest cost of housing in Ontario. Those two factors put together mean that low-income people in the north are affected to an incredible expense.
Ms Lankin: And in terms of determinants of health, this is a very, very big blow.
Ms Mather: Absolutely. Thank you, you added my point.
Ms Lankin: I wanted to ask you about a couple of other areas in your presentation; I'm going to fold them together. In terms of determination of medical necessity and copayments for hospital insurance, basically your concern was around a two-tier system and the Canada Health Act. We've heard the government say it's not its intention to use those sections in any way that violates the Canada Health Act, and we're asking them to make amendments to put that protection in.
You've also raised your concerns about the privacy of health information. Ms Johns will tell you they intend to amend that section. Mr Clement, if he were here, would argue with you and say the bill doesn't violate your privacy at all. Would you like to hear Ms Johns today put on the record that they intend to amend that section in accordance with all the recommendations of the best expert in this province, who is the privacy commissioner? If we could get that commitment from her, we wouldn't have to argue about this in community after community.
Ms Mather: I have two responses: Yes. The second response is that you asked me so many questions that I can only remember the last question, to which the answer was yes. If you want to go back to the first question, I'll try to --
Ms Lankin: Maybe we'll just let Ms Johns respond with whether she's prepared to make that commitment.
Mrs Johns: Thank you again, Frances, for your continual efforts to put things in my mouth.
I'd like to thank you for your presentation. I appreciate a number of the comments you made. I was going to say, before Ms Lankin said it for me, that the Minister of Health will make sure we stay within the guidelines of the Canada Health Act, just as she suggested I would say, so she is becoming part of my mind.
I want to talk about page 2 with respect to points 1 and 2. You're talking about people's ability to have a say in how their health care is distributed. In point 1 you're talking about institutions: hospitals, for example.
With this bill we've amended a number of sections, but we haven't in any way touched the district health council, at this particular point. Is the district health council not meeting the needs of a certain segment in the community? That's maybe what you're suggesting in point 2; I'm not sure how I'm to understand that.
Ms Mather: First of all, we are not asking the district health councils to hear our concerns, we're asking the provincial Conservative government to hear our concerns.
Mrs Johns: But we're using the district health council to be able to decide how hospitals should be restructured. That's the vehicle for public input.
Ms Mather: Here and now I would like to focus on getting across to the government's representatives what we feel. I can explain these points in more detail, if that's what you're asking me. I don't want to be laying any blame on our local Thunder Bay District Health Council.
The point we're trying to make in point 1 and point 2 is that we feel it would be very easy for wealthy citizens to do effective lobbying with the government to have hospitals stay open in their areas and that it would be harder for low-income people to do effective lobbying to have hospitals stay open in low-income areas.
Point 2 says again that most poor people don't have cars. The minister is being allowed to decide what services a given hospital may provide, so say T-CAP or another group like us lobbies like crazy and we manage to save a hospital in a low-income neighbourhood and the minister decides that hospital will not provide such and such a service, low-income people would have great difficulty travelling from their low-income area to the more fully serviced hospital within a rich neighbourhood.
That's our concern about the potential of those sections. Is that clearer now?
Mrs Johns: I'll talk to you after and go from there. I'll talk about the direct substitution. I don't think I got the answer I wanted to hear, but maybe you want to tell me outside so I can understand it better.
Ms Mather: Maybe I can explain it better.
Mrs Johns: Okay, go ahead.
Ms Mather: When I was saying we're concerned about talking to the government's representatives, it's because this legislation appears to give the minister some kind of all-inclusive power. The DHC may produce some massive reports -- I used to work for the DHC as a mental health researcher, and I've done them myself, this thick -- and the minister can turn around and say, "Whoops, don't like that one." That's our concern. Is that clearer now?
Mrs Johns: Yes, that's clear. Thank you very much. I appreciate that.
The Chair: You have about one minute for a quick one.
Mrs Johns: Yesterday we heard from someone, it must have been a pharmacist, talking about substitution, that a lot of people can take -- in the particular example they gave us, 6% of people couldn't take a substitute drug. There are such demands on the ODB plan right now and on our need to keep as many drugs on the plan as we can. Do you feel from your recommendation that there should be no substitution?
Ms Mather: I think people are poor because of characteristics of our society. The way our economic and social system works is that there is a group of people in society who are poor. If our society works so that there are poor people, our society has the responsibility to provide them with necessary medical care, therefore -- to get to the end of that long, complex preamble -- doctors should be able to prescribe the drug the person needs regardless of that person's income.
The Chair: Thank you, ladies. Not "ladies" -- I'm sorry.
Ms Mather: Women and man.
The Chair: Thanks very much. We appreciate your interest.
Ms Lankin: I was just wondering if I could place on the record, in case there was anyone in the room who didn't notice, that Mrs Johns did not give the commitment on the amendments to the privacy information.
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JAROSLAV KOTALIK
The Chair: The next presenter is Dr Jaroslav Kotalik. Welcome, Doctor, to our committee. You have a half-hour. Questions will begin with the New Democrats, should you allow time for them. The floor is yours, sir.
Dr Jaroslav Kotalik: Thank you. Mr Chairman, ladies and gentlemen, I should state at the beginning that I am perhaps the only one today who is not speaking on behalf of any particular organization or profession or group. I'm really making these comments as an individual. Of course my remarks will be coloured or formed by what my background is, undoubtedly, and I feel I have to reveal that to make my comments understood.
I am a physician who has practised in this community as a cancer specialist for over 20 years. For over a decade I had the responsibility for administration of regional cancer services. I have for the past several years concentrated on the study of biomedical ethics and medical law. It is strictly from the perspective of bioethics, of bioethicists, that I am going to address to you some of the remarks today. Obviously, I will be referring to the sections in schedules F, G, H and I in Bill 26.
Ethics is a discipline which looks at the question of how we recognize, articulate and then treat the things that are of value to us. An ethicist examining Bill 26 will recognize that the bill does not define values in health care but in many of its provisions actually tends to negate, threaten and ignore the values which we, until now, have taken for granted and which created a common base and underpinning of our health care services. There are four areas where it is most obvious and I want to make basically four comments of that type.
The first one relates to the obligation of our society for health care. For the past 40 years we have built and perfected the notion that our society will provide health care to all our citizens, regardless of their condition and their ability to pay. You could argue that this responsibility for the access to and cost of health care initially started to cover the necessary medical interventions. Later it was extended to the interventions that could be potentially beneficial and eventually started to mean that all kinds of health care interventions desired by the user or by the provider should be given free to the user.
You could say that we now have proven that our society cannot afford this, that we have to roll back such generous privileges. You could be right in making that conclusion, but the ethical issue here is that when you suddenly pull the carpet of values from underneath our elaborate construct of health care services, the whole building may collapse. Before making organizational and financial changes which may be necessary, we have to carefully examine and redefine the values that are valuable and should be retained, and those which are no longer useful and should be discarded.
In such a public discussion, both the health care providers and the health care users need to be involved and should lead to a creation of a new consensus. It could happen with an introduction of a new bill to Parliament, but I'm afraid it's not going to happen with this bill, given the fact that it's an economic bill and given the time constraints which we have at the present time.
The bill seems to be concerned with economic criteria and wants to apply strictly economic criteria without evaluating how these will impact on the health of the population, what values are being promoted, what values are being tossed aside and the consequences of all those actions.
The second point that I wish to make concerns the new level of decision-making in health care, which Bill 26 promotes. You probably will agree with me that part and parcel of our ethical notions about what is proper health care in Canada has been that the actual content of the health care, the particular intervention for a particular patient, has been decided between the patient and the health care practitioner. Of course there were always local and regional boards which made this or that available or unavailable, and the Ministry of Health which funded it or created various guidelines. There was always that macro and meso-allocation decision made outside of the caregiver-patient relationship. However, the actual concrete decisions were always made in this context.
When you read Bill 26, you cannot fail to see a bureaucrat sent by a big government sitting right between the caregiver and the user or the patient listening to every word and being prepared to block or veto anything which is being decided in that relationship, and stop the whole process or make the caregiver ineligible at any moment of the time to terminate this relationship. The last couple of decades we were strengthening the position of the patient in that relationship. His autonomy and self-determination are important values that bioethics is trying to defend and also expand.
I believe that with Bill 26 both user and provider will lose the ability to determine which person, which drug, which facility to use. We would like to see that the people of our province, better than ever informed and sophisticated about health care, can take increasing responsibility for their health. But Bill 26 seems to suggest -- not desiring so but nevertheless seems to suggest -- that the government or bureaucrats should have all the responsibility and that neither citizens, as users, nor the professionals can be trusted. I believe that this cannot but undermine the sensitive relationship of trust and confidence between the patient and the caregiver, which is essential for healing and recovery.
My third point is about fairness. Let us assume that the structural and fiscal changes or the harsh prescriptions which the bill contains, all the changes in the health care delivery, are necessary to make the public sector solvent again. But if this is the case, should the bill not allow sufficient space, sufficient mechanism to alleviate some of the adverse effects to mitigate some of the unfairness and injustices which may appear in individual cases?
A typical situation would be this: Let's say that the minister will decide that for certain medical problems only a particular intervention can be available. The health care provider, keeping in mind the special bond of fiduciary trust and responsibility to the patient, nevertheless must inform the patient about various alternatives which are available. The health care provider will have to indicate at that time that some intervention which he would recommend is not an insured service, yet it may be more advantageous for a patient, given his particular situation. Given this kind of information, should a patient not be able to decide if additional services are worth the cost which he will have to pay from his own pocket? If this would be the case, the patient would have to turn to the private sector for such service.
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Given the realities of health care in Ontario, is it fair to enact a law which places severe limitations on the kind and volume of health care services paid from public funds without assuring that facilities, staff and necessary infrastructure are available to provide additional services to be paid by the patients?
Is it not offensive to our sense of human dignity and liberty that no appeal mechanism will be put in place that will arbitrate cases where denial of public funds for certain interventions could be seriously unjust to the patient? Is it not unfair that private insurance is not available for a full range of services that can become uninsured for those who would wish to buy such additional protection?
I am putting those comments in questions because, as you probably realize, there is a great deal of division, for people who are examining the ethical issues and underpinning of our health care, if in fact a two-tier system is ethically proper and justifiable. The fact is that until now this has been a theoretical discussion, but now we're coming to the situation that that actually is going to happen. The same as I've started to publicly speak, asking those questions I would not have probably asked six months ago, I suspect that the others are having similar concerns.
One of my colleagues put it in a way which perhaps expresses this very well. If you are a captain of a ship and that ship is sinking and you don't have enough boats for all the people, are you ethically correct if you prevent people from swimming ashore just because some people can swim better than others? These are the kinds of questions which will have to be asked with Bill 26.
My final concern is about infringement of our established standards of confidentiality of personal information which is given by the users of health care services to their health care providers. Such information about one's private affairs is given explicitly to facilitate personal care, and the law and customs prevent care providers from releasing the information to anyone without consent of the person. For example, data of this type can be ethically used for research only if the identity of the person involved is hidden.
Situations where the disclosure of such confidential information from health care records could be ethical without consent and without a court order are very rare instances, where important public interest, particularly the life of a person, is at stake. This is how the courts in common law are looking at questions of the public interest. As far as I can say, there's not been public interest in the sense of release of information interpreted that represents possibility for economical savings or improving efficiency.
A bill that would allow release of personal confidential health information to the minister because of the fiscal concern and without proof of important public interest may have a serious effect on the way people relate to health care providers and how they share their information. I think we have to be aware that besides how the confidentiality and privacy of information of health care speak a lot about how we value privacy and how we value respect for persons, it also has important practical implications. People will not share their confidential information which is essential for decision-making in the health care sector unless they will be assured about the confidentiality, and if they don't share, then you will be making wrong decisions. So the cost and economic impact of not protecting the information in the health care sector could be also significant.
Given this level of complexity of the bill, I may be perhaps misinterpreting some of the provisions and I will be glad to be corrected. Nevertheless, I believe that a bill that seeks to achieve fiscal savings will in fact change the moral values that are underlying our health care and will do so without trying to carefully reformulate those values, redefine them, create a consensus which would be then in fact binding on both users and providers of the health care. It may cut citizens off from health care intervention which their care providers may consider appropriate and will do so without opportunity for appeal or for purchase of the health care desired.
It promotes such centralization of health care decision-making that it in fact allows the Minister of Health to practise medicine without a licence and will likely seriously undermine that important patient-caregiver relationship which is essential for healing and recovery.
It raises serious concerns about privacy and confidentiality of personal information, both for providers and users. The bill may enforce saving and may mandate efficiency, but for an unknown and unexamined cost of human health.
The Chair: We've got about four minutes per party left for questions, beginning with Ms Lankin.
Ms Lankin: Dr Kotalik, thank you very much for your presentation. You are the first person who has come forward to provide the committee with this type of analysis from your perspective and from your expertise. I think it is very important and I think it's an area that we need to explore.
I believe you've hit the nail right on the head in terms of the concern that I and a number of people have with the bill. There is a set of values inherent in our system today, and while I know that the government members have said and would say that basically we all still share those values, the problem is, the bill is not reflective of that.
The bill provides incredible powers for decision-making to be undertaken which, at the very basis of it, leads to some of the concerns you've raised about cutting out certain areas of activities which will necessarily lead to a demand for those to be picked up by the private sector, for those who can afford to purchase to do so. That will be the result. That's why many of us have talked about leading to a two-tier system, to privatization. Sometimes that sounds rhetorical, but it's an inevitable result.
The problem I have is that we've not had a discussion that that's the direction we want to go. The bill takes us in a direction that we haven't debated and the bill doesn't set out the values or the intentions of the minister and how he is going to use the powers. We hear assurances but we don't see it in legislation.
I am just so profoundly moved by your presentation and feel that it should be compulsory reading for every member of the Legislature at this point in time.
Could you tell us the state of debate with respect to these changed values that you are aware of within the Canadian jurisdiction or in other jurisdictions? What do you think we would need to do to have an appropriate debate to reach a societal consensus on whether these are the kinds of changes that we would want to undertake or not?
Dr Kotalik: I'm not probably an expert of the type you would need to make such a recommendation to your committee, but for one thing, obviously, it would need time. That's the first thing, which we don't seem to have in this instance.
It would need really a major effort from all levels of government and need activation of all the mechanisms which we have in our society which can relate to health care. The fact is, we have a professional group which is perhaps well organized and has been able to articulate its values and its positions and so on. On the other hand, we don't have organized patients or users of the system in some way, so you have to find some mechanism to bring that into the discussion.
I would think that discussion should really take place at multiple levels. You really need a resolution that there's a field of academic ethics, bioethics, which I am sort of getting some information on, and there you need certainly much more debate and you need the opportunity for people to meet. You have to ask those people. I don't think they have been really asked, the people who are dealing with it, how they would approach the situation. But I think you need to have a discussion at the community level, and here by "community," I mean the one like Thunder Bay or one in northwestern Ontario, even a small one. You really need to bring that down to the basic level.
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One thing that is happening with the ethics of health care is, it seems to substitute almost for all the ethics in our society. It's becoming kind of a lingua franca -- what's the better term? -- of the ethical confirmation in our society. We're sorting out who we are as a society quite often, publicly and privately, the way we handle ethical issues in medicine and associated biological sciences. When you look at the daily newspapers, the ethical issues which most commonly come up are related to the review of health care. I would think that the effort that would be put into formulating such a consensus in health care would be very important, not just for that one field but also for society at large.
The Chair: For the government, Mr Clement.
Mr Clement: Thank you, doctor, for your presentation. It certainly was mind-expanding. I want to assure you that this bill is not the alpha and the omega of discussion of health care in Ontario. It may be the alpha, but it's not the entire picture, and I expect that we will have numerous discussions in the Legislature and in society as a whole where we can flesh out some of this.
Let me turn to the question of values and how public policy and legislation ultimately reflect those values, because I want to add an addendum to your theory. This is, I guess, my theory as opposed to your theory, but I want your reaction to it, and that is that the current system, the so-called status quo, which is in fact a deteriorating status quo, was creating de facto rationing, two or more de facto tiers of health care delivery, de facto waits and queues in the system, de facto to keep doctors in northern and rural Ontario.
That is a shift of values, but there was no discussion about that. There was no possibility of discussion because that was the status quo. So can I put it to you, if I can look at the glass half full for a second, maybe Bill 26 at least allows for these discussions to be held, for these issues to be addressed?
Interjection: Before the end of the month.
Mr Clement: No, not at all. The whole idea is that now we start the process. This is not the end of the process, just the beginning.
Dr Kotalik: I agree with you on the first point you made. I certainly was unhappy also, as many of us were as citizens and users and as the providers, that the many things which happen in our health care were a quick, rapid improvisation of trying to fix the situation fiscally without actually looking at the health consequences, without a long-term view of how it will affect the health care status, what's going to happen to the relationship within society and so on. So I fully agree with it.
If we would have a health bill to discuss, and with appropriate analysis and with an appropriate white paper, whatever it would be, I think we would probably be having a different discussion. But the fact that I am the first one who is raising this question, it seems to me it is going to happen that people do concentrate on the things which are more immediate, which are more practical, which affect the actual treatment or the way health is remunerated, but we will not be getting to discussions of those values even with this bill.
I agree that the bill is doing openly many of the things which previously were happening in our health care and were covered by pretending that it was just extending the old 1985 idea of health care which is available to everyone everywhere without any cost.
Mrs McLeod: I too want to express my appreciation of your presentation, both because of a thoughtful theoretical analysis and also because I can tell members of this committee that it comes from somebody whose practicality and perseverance has almost singlehandedly ensured that we can provide a quality of care to cancer patients in northwestern Ontario. I think that lends weight to the theoretical concerns that you've expressed to us today.
I'm glad you began with the premise that one of our values has been to provide quality care regardless of ability to pay. Unlike Mr Clement, I'm concerned that this bill is the omega and not the alpha. It is certainly not the alpha, the beginning of discussions. It could lead to a serious erosion of that basic value that we have held so strongly.
I wish this discussion was about preserving health care. It's about finance, as you have noted, and that's why this is a Ministry of Finance bill. I wish too that the discussion that you've suggested needs to be held -- and you're not actually the first to suggest it. A physician in Sudbury also said yesterday that we needed to begin the discussion about limitations on our access to medically necessary in order to determine what we can afford, that that discussion needs to take place in a forum where it can be thoughtfully considered by everybody affected. Unfortunately, we won't even get to debate those kinds of issues. We won't even get them in the Legislature because "medically necessary" will be determined by regulation.
It's in that context that I want to place one specific question -- only one; there could be so many -- and I'll ask this question because I think it is a totally inappropriate question to ask in this forum. The only reason I ask it is that it's the kind of question that we're driven to ask because of this bill, and it's the fact that age can be a criterion for determining what is considered medically necessary. I understand that that is not an entirely new piece of legislation, but it becomes new in the context of a bill that says, "We will pay for services in the public health care system that are prescribed" -- and that is new -- "services prescribed for conditions under terms and conditions determined by regulation." All of that may be a contravention of the Canada Health Act as it now stands.
A terrible question to put before you and yet a question that's raised by this bill and I wonder if you would comment.
Dr Kotalik: There are probably hundreds of books and thousands of articles in bioethics which are looking at the possibility or impact or meaning of discrimination by age, and the debate, as far as I know, is by no means closed. Obviously some countries which we consider very civilized, like Britain, have been using it for years.
I think probably there will be no sacred cow in the discussion which we'll have to make, and age may not be necessarily the one which we will always protect. But it seems to me that what I only advocate is that the values which we want to change really have to be very carefully articulated and looked at.
I must say I'm not aware that age is actually an issue in the bill. I haven't noticed it, but there are probably a number of other things I haven't noticed in the bill, given the complexity and the effects on the statutes, which I am not familiar in any detail with. But you could probably single out a number of other similar factors which may need to be considered.
I cannot give you a definite answer, but I would only say these are the types of issues which really need to be brought out into the open before we actually decide on some sort of structure or procedural changes which will lead to either dismantling of certain values or instituting totally new values into our health care.
The Chair: Thank you, doctor. We appreciate your involvement in our process and your presentation this afternoon.
Ms Lankin: Mr Chair, I was wondering if I might make a request, and I will understand if my request can't be met.
Dr Kotalik did not have a written presentation that could be distributed and in fact some of his comments, I think, also would be helpful. If there is any way, recognizing that we're travelling, that Hansard could attempt to provide committee members with a transcript of his presentation -- and if so, also the questions and answers -- but most importantly the presentation, I would find that very helpful. There are some points in there that I would like to review and be able to ask questions of other presenters as we continue.
I recognize it's a difficult request and if it's not possible, fine, but as soon as would be possible, that would be very helpful to me as a committee member.
The Chair: Normally, when would we get that? Monday?
Mrs Beth Grahame: Friday or Monday. I'll put in a special request.
The Chair: Fine. All right. Thanks, Ms Lankin.
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SERVICE EMPLOYEES INTERNATIONAL UNION, LOCAL 268
The Chair: Our final group is the Service Employees International Union, Local 268, represented by Jack Drewes, the president, and Glen Chochla as a member. Welcome, gentlemen. You have half an hour of our time. Questions, should you leave time for them, would begin with the government. The floor is yours.
Mr Jack Drewes: Good afternoon. My name is Jack Drewes and I'm the president of Service Employees International Union, Local 268. To my immediate right is Brother Glen Chochla. He's Local 268's organizer.
Our Local 268 stretches, and our jurisdiction, from the Manitoba border to approximately the Algoma border near Thessalon. We have right now 1,700 members in Thunder Bay and district hospitals. We have another 1,000 in the Thunder Bay district health care system. We have a total of 800 members in Sault hospitals as well as 200 in other health care systems in the Sault. This adds up to a total of 3,700 members in our local, based in Thunder Bay, in the health care field. I believe we are the largest health care union in the Thunder Bay and Sault Ste Marie areas.
SEIU members and all Ontario workers owe a great debt of gratitude to the members of the Legislature who had the courage to fight for public hearings on this legislation. The contempt and disdain this government showed to all Ontario in a vain attempt to hide this legislation and ram it through the Legislature during the day of the financial statement shows the true colours of this government and what we are in store for. I think the government members should be ashamed of themselves and apologize for this breach of public trust. More hearings are needed due to the vast number of groups that did not have the opportunity to exercise their democratic rights.
Mr Glen Chochla: I'd like to talk a little bit about collective bargaining rights and how they're affected by Bill 26. It's probably a bit of an unusual place to start, but I want to talk about physicians. It's a bit of an unusual place for our union to start because our people, our members, are really at the low end of the health care pyramid and physicians are at the top. It's an unusual situation where those at the top of the pyramid and those at the bottom have so much in common in terms of their basic collective bargaining rights.
What Bill 26 has done to doctors has extinguished the contractual rights that they have through their agreements through the Ontario Medical Association with the Ontario government. The bill also gives the government the power to decree, amazingly enough, that interest arbitration awards by arbitrators in favour of -- not in favour of, but in terms of what goes into an agreement between the OMA and the government -- are of no force and effect.
Why are our members so concerned about those at the top of the pyramid? The basic reason is that collective bargaining rights, whether we like it or not, are a cornerstone of a free and democratic society. They're one of the things that distinguish our society from a more totalitarian form of government, and historically those totalitarian governments have been of the right-wing nature. When I first heard about the stripping of physicians' collective bargaining rights, I thought to myself other workers are close behind, and sure enough when Bill 26 came out, we saw what it did to hospital workers.
What Bill 26 does particularly to hospital workers is it amends the Hospital Labour Disputes Arbitration Act and it attempts to strip arbitration boards and arbitrators of the independence to determine what goes into a collective agreement. It tries to turn them into head waiters for the government.
The way it does that is that prior to Bill 26, arbitrators had complete independence. What Bill 26 does is it says that whatever economic or financial situation the government wants to create, arbitrators have to bow down and worship that financial situation, have to remain constrained within that financial situation.
Prior to Bill 26, what arbitrators said under the Hospital Labour Disputes Arbitration Act was: "Look, the government creates its own financial situation. It makes decisions on taxation. It makes decisions on spending. Because it has that incredible power, what we are going to do as arbitrators is we're going to look at what the norm is out there in the private sector and we're going to base public sector settlements on what the norm is in the private sector."
The government has taken that away and that seems a bit odd to us because this is a government that is very much wedded to -- and I don't think it's overstating it -- worships the notion of private sector and private sector businesses and what's good for business in the private sector and so on and so forth. What we don't understand is why in the world the government wants to restrict arbitrators from doing what they normally have done in deciding what goes into collective agreements for hospital workers.
We're also very concerned that it would appear very much that this government is bent on creating a crisis within the public sector. What they're doing is creating a revenue crisis. They're going to give huge tax breaks to the very wealthy in this province, and they're also going to create a revenue crisis by getting rid of, believe it or not, an organization like the LCBO. It looks very much like they're going to do away with three quarters of a billion dollars of revenue every year by privatizing the LCBO. So you're going to create this revenue crisis and then you're going to tell arbitrators that they have to remain within the bounds of that crisis you have created. That does not make any sense to us; it doesn't make any sense to our members.
You've done the same thing to hospital workers that you've done to physicians, and that's really a concern to us, because the reason we have binding arbitration in the hospital sector and for physicians is that health care has been deemed to be, by the people of Ontario and the governments of Ontario prior to this government, extremely important, and we've decided that we don't want labour disruptions, we don't want withdrawal of services.
If you throw the arbitration system into disrepute the way you're going to, two things are going to happen. First of all, as far as physicians are concerned, you're going to lose physicians to other provinces and to the United States. The second thing is that physicians are going to have to go on strike if they can't come to an agreement with the government on fee schedules. Why are you planning on doing this? It doesn't make any sense.
For hospital workers, our fear in our union, the leadership and staff of our union, is that our rank and file is going to get so discouraged by an arbitration system that does not work that we're going to start having, down the line at some point, wildcat illegal strikes in the hospital sector. I would remind you that just a couple of months ago in Alberta we had exactly that, and that was a situation created by a government that has very much the same kind of philosophy as this government. We're very concerned about that.
The other thing we think may also happen, and it's just as discouraging, is that arbitrators who are used to acting independently, good arbitrators who have done interest arbitration for years, are going to say -- I certainly actually hope they do this, because it might stimulate a bit of thinking on the part of government -- they may well say, a good number of them I think will say: "We're not going to get involved in interest arbitration. We're just not going to do it, because we don't have the discretion that we need to have in order to make fair decisions on interest arbitration hearings."
Similarly, with respect to pay equity, we have a lot of concerns that the government has done away with the proxy system effective January 1, 1997. The pay equity system, and in particular the proxy part of pay equity, really benefited the lowest-paid workers, most of them in private nursing homes -- in our union anyway -- female employees, again working at the bottom of the pyramid of the health care system.
Those who did not have male comparators within their workplace could go outside of their workplace to find a comparator in a similar type of institution. That's going to be gone as of January 1, 1997. That affects our members very directly and we're very concerned about that. We think that part of Bill 26 should be struck as well.
In addition, we're also of course very concerned about the reduction in pay equity payments that Bill 26 is going to effect for pay equity plans and the proxy system that have already been posted. There's going to be quite a significant reduction in the payout under those plans, most of which have been freely negotiated between unions and employers.
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Mr Drewes: With Bill 26 Ontario also becomes the only province in Canada with no government regulation for prescription drug costs. Our members have fought for decent benefits at the bargaining tables for years. They and the employers they work for will now have to deal with sharply escalating benefit premiums for the drug plans, especially now that the federal government has given such strong patent protection to drug manufacturers. At the bargaining table now, we can expect our workers to pay for this gift from Harris to the drug manufacturers.
Bill 26 is a power grab by an extreme right-wing government from the communities that our hospitals serve. It gives fantastic powers to the Minister of Health to shut down hospitals or take over their operations. Community workers need more say in their hospitals, not less. This applies also to other health care sectors. It effectively closes out district health councils from the process of hospital rationalization and it makes it impossible for citizens to sue the Minister of Health or any of the other folks he gets to do his dirty work.
All this so that Harris and his fellow political allies can give huge tax breaks to the wealthy of the province and hand over a profitable and publicly owned enterprise like the LCBO to his friends in the business sector. They are also now creating opportunities for the American health care system. Before, it was only Canadian non-profit health facilities that had the opportunity to mine our grey gold. Now the Americans are going to be doing that as well.
In conclusion, two presenters, I believe, yesterday, called this government in Sudbury -- I think the word was "fascist." The head of the CAW said something similar two months ago when he said that this government was the closest thing to fascism that he'd ever seen. I'm not going to use that language, but I think the government should think long and hard about why so many people are using this term to describe this government -- ordinary working people in this province. In the words of a member present here, the government has declared war on many, many Ontarians.
I say to you, go back to the big business backroom boys and tell them that the people of Ontario will not stand for this type of leadership. If you do not stop this right-wing behaviour, the province will be split into two warring camps: the haves and the have-nots. I think you've already woken up the sleeping giant known as the Ontario worker.
The Chair: We've got about four or five minutes per party left for questions, beginning with the government.
Mrs Ecker: I think anybody who uses the term "fascism" to describe what is happening in this province does not know history very well, sir, and I will take great issue with the use of that term for you and anybody else that has used it. I think it does a serious disservice to the many individuals around the world over the past several years who have fought fascist governments and died in the cause and I take great offence at the use of that term.
However, I would like to thank you for coming. I would like to thank you for putting forward your views and your concerns about Bill 26.
One of the things I was interested in is your description that we are somehow manufacturing the economic crisis. I would suggest that at the rate of $1 million an hour going into debt, which is what this province is doing -- $1 million every hour we spend more than we take in -- I'm not an economic genius, but that strikes me as being a pretty serious crisis for taxpayers in this province. I am a taxpayer and I have a concern about that.
The other thing that I think is worth mentioning is that you talked about what's good for business and that somehow or other you think this government should be worried about business and link that to arbitrators losing their independence because they're being asked to take into consideration the economic reality of what a public sector employer can pay.
I guess, to me, that strikes me as being common sense, because if there's one message we've heard from people, if there's one message we heard during the last two or three years of consultation with the public, it was that government had forgotten what all of the hardworking families out there knew, that you have to live within your means. That is one of the things that we are attempting to do, and many public sector employers, who, I would suggest, I don't believe are motivated by the profit motive, since they're in the public sector, non-profit, have expressed concern about the fact that arbitrators had made awards that were not paying attention to the economic realities of what was there.
I guess what I would like to ask is, how do you believe that the government -- the experts in the health care field have said that the system needs change, the system needs reform, the system needs structure. They've said we don't have time any more, they've said we must move. They've said there have been many, many studies, there have been many, many recommendations. The district health councils have done recommendations, the steps that need to be taken are very clear, and it is time to take those steps.
I guess if we don't take those steps, how do we address the reforms that are urgently needed in the health care system? How do we address the reforms that are urgently needed to protect the taxpayers of this province?
I think it is worth mentioning that 79% of the taxpayers in this province who will benefit from any tax cuts that are brought in by this government make under $40,000, and I would suggest that $40,000 in any community is by no stretch of the imagination rich.
So I would ask how you think we should be proceeding with addressing these very real concerns, which the voters have told us are very real concerns.
Mr Drewes: One of the issues you touched on was the lack of funds for the health care system, and I heard it previously, at a previous speaker. That just speaks right to I think the largest issue we have here, and that is, where does the money come from? Where does the money come from, when how many banks made billions of dollars in profits and paid no taxes? How many profit-making corporations make money and pay no taxes? Perhaps we should tax fairly and equitably in those sectors as well, and perhaps we could then afford the health care system that we deserve as Ontarians.
You stated the system needs change, and I don't think anybody disagrees with that, but it doesn't require change on a bill that comes before the Parliament in one day, to be voted on a week later. To me, it constitutes a type of change, but the type of change this province and the workers need is a consultative process. I think we've had our share of dictators in history, and I guess my history is a little bit different. If you talk about fascisms and people who die, I've seen some people on Toronto streets who aren't too far away from that, if that's what you expect from a fascist government, that you have to die for them.
Mrs Ecker: They were there before June 8, sir.
The Chair: Thank you very much, Mrs Ecker. The Liberals.
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Mrs McLeod: It strikes Mrs Ecker that with the deficit adding to the debt on an hourly basis we have a financial crisis. It equally strikes me that it makes no sense to add $5 billion more to the financial crisis with an income tax cut, which is most certainly driving the $1.5 billion in health care cuts, which is why we're at this table today talking about fundamental changes to our health care system and the way we're governed.
A couple of things, one in your presentation and one not in your presentation, just to keep us specifically on the issues you've raised. I was interested in your comments about the arbitration and also in your suggestion that arbitrators might have some real reluctance to follow terms and conditions so closely set out by the government.
I happened to run into somebody from the arbitrators' association the other day, and they, lo and behold, are one of the groups that has not been consulted nor heard from on the issue. I think your suggestion that we might want to hear from the arbitrators is a very good one.
The question I have is an issue that you didn't touch on and I'm wondering if it's perhaps because your immediate members would not be affected by it, but there's a provision in Bill 26 to allow for a clawback on public sector pensions in the event of layoffs and hospital closures. This is a provision which then deprives public sector workers of the protection that is available to private sector workers. I'm not sure if your immediate members are affected by it, but I'd appreciate your comments.
Mr Chochla: As far as I know, and I haven't looked at this in any depth, the clawback of pensions applies to members of the public service, I believe.
Mrs McLeod: Yes, and a few others.
Mr Chochla: Not the kind of members that our union represents, which is primarily hospital and health care employers in the broader public service. So I really can't speak to that issue, and this bill is of course so huge that we tried to zero in on a couple of issues that were of most concern to our members.
If I may just say a couple of things about collective bargaining, I think that's a very good point, Ms McLeod, that you need to hear from arbitrators, because I can bet that there are going to be some very good arbitrators who are going to be very reluctant to do interest arbitrations, and may even refuse. I think you need to talk to them. I think you should invite them, if you haven't already heard from them, to come and speak to you in some kind of forum.
In terms of a comment that was made about looking to the private sector in collective bargaining, perhaps I didn't express myself well enough, but that's precisely what arbitrators have done under the Hospital Labour Disputes Arbitration Act. They have said: "Let's look at what is going on in unionized private sector workplaces. Let's look as well at the financial constraints that governments are under. Let's take that into consideration as well." But primarily they said, "What's the going rate out there?" and if private sector employers are coming in at 0% or 1%, that's generally what arbitrators have done.
The reason they did that -- and this is absolutely critical for you to understand, and I urge you to take the time to try to understand it; I think it's a question of understanding -- what they said was: "It is impossible for us to take for granted the economic situation that the government says it has before it. That is impossible for us, to just take that as a given, because" -- and please listen to this: Because you control how much revenue you bring in. You decide whether to give a tax cut, who to give it to. You decide whether to increase taxes. You decide whether to forgo three quarters of a billion dollars a year by privatizing something like the LCBO. You decide how much spending you do. And you do all of this with a great deal of power. So it's fundamentally unfair for you to create a situation and then expect arbitrators to make a decision within the walls that you have created.
That's not to say that arbitrators have never given any consideration at all to the government's fiscal situation. But they have said that's not the only consideration.
What you're doing effectively is saying to arbitrators, "You're going to have to deal with the situation that we've given you, and that's it." I think any fairminded person would have to agree that that's outrageous, in the same way that it's outrageous that you're taking away collective bargaining rights for doctors, because that was a good system. Now we're going to get into labour disputes and work stoppages for doctors. Why?
Ms Lankin: If I can just continue along the theme of the importance of the arbitration process and let folks know, because we haven't talked about this here -- that clause is actually before the other subcommittee -- this affects hospital workers, certain police forces in the province, firefighters.
Mr Chochla: That's correct.
Ms Lankin: There's a broad range of groups that are being affected by this. I'd love to hear from the likes of the Owensheims and the Swans and the Kennedys and the Pichés and the Martin Teplitskys on this. It would be interesting. There would be some fireworks, I'm sure.
In fact, I remember a time when a previous Conservative government introduced wage controls, which was time-limited, wage guidelines, and the arbitrators said no. In fact, they would not allow their decision-making to be fettered in that way, because they understand that public sector arbitration in fact is to replicate the effects of free collective bargaining, and to fetter the decision-making of arbitrators in that way -- and you're right, they have taken all these things into account. But to try and put those kinds of guidelines in place and try and fetter their decision-making in fact leads to the situation where public sector workers will necessarily, by lower wages, subsidize the cost of the delivery of public services.
If you recall before the Hospital Labour Disputes Arbitration Act was in place and the large CUPE hospital strike and the Johnson report, all of these issues were well explored and I really urge the government members please to look at that and to look at the history and how this system evolved.
I just want to ask you one question. Ms Ecker went on at great length about change needed in the system and all these reports and nothing's happened, and if I hear that one more time, I don't know what I'll do, because I'm constrained by parliamentary behaviour.
Mrs Ecker: When did that stop you?
Ms Lankin: So much has happened in terms of changes that are taking place in communities: in communities that are leading reform processes themselves and coming to conclusions and implementing them, in communities like Windsor, in communities like Thunder Bay. Can you talk about what you've seen in your own community in terms of communities grappling with change and being prepared to move ahead and to implement that change? I just hope it will impress itself upon the government that they are not the beginning, the alpha, of the debate on the need for health care restructuring.
Mr Chochla: In this community, for the last three years we've been struggling and the district health council has been struggling with the question of what to do with the four hospitals we have in the city, plus the provincial psychiatric hospital. It's been a long process. The district health council came out with some recommendations about three years ago that were tabled before the community and the community had a very strong reaction against them.
So the district health council went back to the table and has come up with other proposals and we're continuing to work through the process.
The other thing that has happened in the community is we've had a lot of consultation, and I think some very good consultation, about long-term care reform. That's a critical area to look at when you're talking about hospitals, because if we can care for people in the community, we can do it cheaper than we can in the large institutions like the hospitals.
We frankly don't understand why the concept of a multiservice agency and the labour protections that were in there, which were pretty fair, and the concept that the NDP government was putting forward has been discontinued, and we'd urge you to get that back on line.
I have a lot of criticisms of the previous government, but there were a lot of good things it was doing in health care, and it was getting a grip. I think it was the first government to really get a grip on hospital and health care finances at the same time that it was doing fundamental reforms of the system. I think they were doing it a lot more sensibly than this government, which just announced pulling I don't know how many billion dollars out of the hospital system. The old system, for all the criticisms that I sometimes had of it, that the district health councils were not consulting enough and so on and so forth and weren't listening to us, was much better than what we're getting right now.
The Chair: We appreciate your presentation this afternoon. On behalf of the committee, to the people of Thunder Bay, thanks for hosting us. We enjoyed our stay here. We adjourn now to the Delta Hotel in Ottawa at 9 am tomorrow morning.
The committee adjourned at 1459.