The House resumed at 8 p.m.
SELECT COMMITTEE ON HEALTH-CARE FINANCING AND COSTS
Consideration of the 1978 report of the Select Committee on Health-Care Financing and Costs.
Mr. Turner: I’m pleased and honoured to have the opportunity of leading off in this debate this evening to discuss the select committee’s report on health-care financing and costs.
Despite the inability of the members of the select committee to reach consensus, I believe our report indicates we have in fact discharged our responsibilities as outlined by the terms of reference.
I would like at this time to review with the members of the House what those terms of reference were and our response to them as a committee.
The first area for consideration was: to review Ontario’s health-care costs, health-care financing methods and services provided for that expenditure; and then to compare that profile with those of other provinces and countries as the committee may deem appropriate for purposes of providing a valid basis for comparison.
The committee found that we in Ontario have access to a comprehensive range of medically-necessary services at the highest standard of quality. In this respect Ontario compares very favourably with any jurisdiction, not only in this part of the world, but indeed around the world.
Though there is a theoretical universality of access, it must be qualified by noting some problems with the geographic distribution of physicians in Ontario. There are physician shortages in a number of areas in northern Ontario, for example, and even in some southern locations. Programs such as the under-serviced areas program and the establishment of district health councils to advise the ministry of local needs are aimed at an improvement in this area and a recognition of the problem.
Though the basic benefit package is comprehensive as far as medically-necessary services are concerned, there is scope for expansion of health services. For example, half the population of Ontario does not receive regular dental care. The committee recommends that high priority be given to consideration of a school-age dental program in Ontario as an extended health benefit.
On balance, it would appear that cost control in Ontario is relatively effective. On the basis of the evidence, however, there are no grounds for complacency. The elderly are on average the heaviest users of the health system in Ontario and naturally of course they are a growing proportion of the Ontario population. The aging phenomenon is but one aspect of the paradox of health care, namely that medical advances spur increased demand by enabling people to live longer and consume more expensive treatment.
Term of reference No. 2 called upon the committee: “To review alternative methods of financing the health care system and the impact of those alternatives on the fiscal and economic affairs of the province; and to make recommendations thereon.”
The committee was distressed to learn that only about one-third of those eligible for full premium assistance had applied for that assistance and that almost none of those eligible for partial premium assistance are currently taking advantage of this relief. Frankly, this is a rather difficult statistic to believe. I think all members of the committee expressed concerns, not only on the figures that were presented to us but perhaps the very validity of those figures. A lot of us have an instinctive feeling, if not evidence to support it, that the people who indeed qualify for those benefits must surely be receiving them through some other avenue.
Mr. Warner: No, we call it government failure.
Mr. Turner: That’s what you would call it.
Mr. Warner: That program has been in place for 10 years.
Mr. Grande: That’s what it is, pure and simple.
Mr. Turner: This observation motivated the committee to reach consensus on one major issue and to unanimously recommend that the current subsidy system be replaced by a tax credit system that would ensure, as the current subsidy system does not, that all those entitled to premium assistance in fact receive it.
While details of this proposal remain to be worked out, the format would involve retaining subsidies until the end of fiscal 1978-79, at which time those eligible for tax credits would receive them when filing income tax returns and would then apply those credits against premiums payable in the forthcoming fiscal year. The committee estimates that nearly half a million tax filers would benefit by such a system.
With respect to the means of financing the tax credit, there was majority support within the committee for the recommendation that as the tax credit results in a net additional revenue requirement, this be financed by reliance on progressive tax sources, recognizing that the ultimate responsibility for fiscal policy in this province must rest with the Treasurer.
Term of reference No. 3 required the committee: “To review existing reports which relate to methods and means of containing or reducing health care costs and to report its finding to the Legislature.”
There are many guises under which user charges may appear in the system. In addition to direct charges made to patients at the time of service, user charges can occur in the form of co-insurance or deductible payments in connection with insurance services; treatment of health services received as taxable income; supplementary charges by physicians under a balanced billing scheme; charges by opted-out physicians in excess of the OHIP benefit and so on. However, the problem with deterrent fees is that, in general they cannot be expected to deter very much, and in particular they may deter the very people who need that needed medical aid in the first place. The committee concludes that user charges for medical care are inappropriate at this time.
Since supplementary charges by opted-out physicians are a form of user charge, the committee is concerned about recent increases in the rate of opting out, particularly in a few chosen communities. The committee is sensitive to the underlying causes of the dissatisfaction of these physicians and urges the government to reconsider the mechanism for establishing the level of benefits under OHIP. In particular, it commends to the attention of the government a system of negotiating fees and utilization rates concurrently, so as better to promote the two objectives of quality care and cost containment without economically penalizing medical practitioners.
If, for example, the government was to negotiate a multi-year agreement with the medical profession, incorporating a substantial increase in fees in exchange for a commitment to hold constant the level of utilization and thereby decelerate the so-called revolving door practice, both these objectives, in the committee’s view, could be achieved. To ensure cost containment, the fee increases for subsequent years could be made contingent on the utilization performance in the first year.
In so far as hospital efficiency was considered, the committee agrees that some incentive should be offered to hospitals to encourage economy; not only to encourage economy but I think also to encourage innovative treatment as well. The committee further agrees that legitimate cost savings made through effective cost-control should not be appropriated completely by the ministry, but rather, at least in part, should benefit the particular hospital involved and perhaps be used to implement new programs within that particular institution.
Apart from the budgeting process, the committee was impressed by the cost saving potential of a number of innovative programs such as day surgery, peer-group monitoring and the parent-care program. The ministry should ensure that new programs which are effective are immediately and directly brought to the attention of all hospitals within the province. In addition, however, hospitals should be positively encouraged by the ministry to adopt effective programs and, if necessary, incentives offered through the funding mechanism. Money for new programs should be concentrated on those hospitals which have shown a willingness to develop and employ new techniques which have resulted in cost reduction.
What is clear is that the role of the emergency department within our society is changing, both in the eyes of the public and the medical profession. Policy should reflect that changing role and serious consideration should be given to expanding the role of the emergency department in some of our hospitals to that of a community health clinic service, offering a wider range of services. What was formerly seen as an abuse of emergency facilities may, in fact, be simply a more efficient use of existing expensive facilities at a relatively low marginal cost.
On the question of manpower substitution, the committee feels that the growing demands of older patients within the system increasingly can be met by introducing non-physician manpower, assuming an appropriate level of training. In the long term, desirable physician-population ratios could be maintained and the increased demands imposed upon the system could be met by less highly trained, but adequate, and less costly personnel.
The short-term problem of how to employ the graduating nurse practitioners should receive more intensive consideration than was possible for this committee to undertake this summer. In particular, it is recommended that the district health council be immediately petitioned for means by which these graduates can be properly employed so that the present program can be maintained and hopefully extended.
On the matter of public health and preventive medicine, the committee believes that while benefits cannot be measured in traditional cost-benefit terms, the people of Ontario will be better off with an increased emphasis on public health and preventive medicine. Areas which in the committee’s view should receive greater emphasis are fluoridation, immunization, elimination of junk food from school cafeterias, and treatment of alcohol and drug addiction.
The committee agrees that the discrepancy between subsidies and charges in various institutions for long-term patients constitutes a major disincentive to economy, efficiency and reduces costs, and in addition often operates unfairly. The committee recommends that moderate per diem charges be imposed upon chronic-care patients in hospitals so as to equalize the financial burden to those in chronic-care hospitals and nursing homes.
Finally, there is the issue of OHIP enrolment data. The committee supports the Ministry of Health policy of developing an individual approach to enrolment in OHIP as soon as possible, making adequate provision to protect the confidentiality of the information.
On the whole, Mr. Speaker, in this brief time I have taken to summarize our report, I feel the committee has done not only an effective job on behalf of the Legislature, but in fact on behalf of all people of Ontario to inform them of the high quality of health services which are available in this province.
Thank you very kindly.
Mr. Conway: I want to join with my colleagues, who will be here tonight to speak to the report introduced by the select committee on health-care costs and financing. I’d like to offer now, since my friend from Peterborough has given such an excellent abstract and synthesis of what it is we endeavoured to conclude, some general comments from my point of view as a member of the opposition and as someone who has had some involvement with the health-care policy field in the past year.
I think that from the opposition’s point of view, and particularly from my point of view, this has been an extremely important and very useful exercise in an area of public policy formation that I for one consider to be of very significant consequence.
Much has been said about this committee and its establishment, and more appropriately what it did or did not do. As one person who had something to do with its creation, I would be less than candid, Mr. Speaker, if I were to say to you tonight that what we have before us in this text of some 48 pages represents all that I had personally hoped for, because clearly it does not.
I began this process with the hope of doing a number of things. We all know the largely political circumstances which gave rise to this committee in March and April of this year. That, of course, was the budgetary initiative of the late Treasurer (Mr. McKeough), inasmuch as he endeavoured to increase OHIP premiums by what, for the opposition, was an unacceptable rate. As part of the compromise in April, it was agreed that not only would 37.5 per cent increase be scaled down to what in the end was 18.75 per cent, but that there would also be a commitment entered into by all members to initiate a select committee with the three specific terms of reference that my colleague from Peterborough has very properly drawn to our attention.
As the health critic for this party for the past 15 or 18 months, unlike the member for Oxford (Mr. Parrott) or the member for Hamilton West (Mr. S. Smith), I have not had specific expertise or experience in the health care field; I certainly am, and I think like the majority of members in this very technical field, largely a lay person. As a politician however, and as a member of this assembly for three years and some weeks now, one of the things that has always impressed me has been that we, as legislators, have been willing to dispatch ourselves a certain amount of the public revenue, to discuss in select committee such wide-ranging things as the after-hour use of schoolrooms and the very complicated and serious challenges in land drainage, to name but two. I think of the ongoing study of company law and insurance. I don’t for the moment suggest that these are inquiries that are not legitimate, but it really surprised me when I began initially in this field that not in recent memory, and certainly not in the period of 1968-78, had there been a select committee, or really any other special committee of this Legislature whose mandate it was to look at the general or specific areas of health-care policy and health-care planning. I found that to be quite interesting and somewhat alarming, in view of the fact that in the period I mentioned, 1968 to 1978, health care has come from a position of second or third in terms of public spending -- and always, of course, in terms of importance -- to a place today where it leads public expenditures in this province, as it does in many jurisdictions, in the amount of some $4 billion for fiscal 1978-79.
It’s an area where there was a serious challenge, particularly since 1975-76 when government felt, here as elsewhere, the requirement, and indeed the necessity, to deinstitutionalize by closing active-treatment beds and in some cases closing hospitals, suggesting that costs were indeed getting out of control. There was a growing alarmism; indeed many people began to feel that there were issues in the health-care field that certainly deserved the attention of the politicians.
I’m not suggesting this government or other governments have been insensitive to the need for that kind of inquiry, because one of the things in this Ontario jurisdiction that has impressed me is that just about everybody but the politicians have had some kind of special mandate to investigate the health-care field. I think of the Premier’s (Mr. Davis) joint committee of the OMA and the senior bureaucracy to look, as late as two years ago or a year and-a-half ago now, at methods of cost containment and whatever.
I know that the minister, who I am very happy to have with us tonight, would probably privately say to himself that’s just another oppositionist forgetting that we have an estimates process and other such opportunities. Indeed that’s true; but from my point of view as one private member, and I’m sure there may be more senior of my colleagues here who think this is not appropriate, by and large I find the estimates exercise to some considerable degree a waste of my time, but more important a waste of the minister’s time.
I think that’s important in one or two very central ways. I see developing in our system of responsible parliamentary government things that really do bother me. We have the growth now of systems and departments that are extremely wide-ranging and very technical, so the notion and the traditional concept of ministerial responsibility is significantly more difficult to defend than it was some years ago; to say nothing of the notion of legislative accountability.
I feel, in all my humility, very nervous and very unequipped to challenge much of what any modern government does, in so far as many of those initiatives are so complex as to be quite beyond the scope of my ability. I know there are others in the chamber who see their capacities as being far greater, and I defer to their intelligence. I’m just saying that from my point of view it certainly concerns me that we as legislators -- because we are accountable, as I see it, for what is done in our name.
Hon. Mr. Timbrell: You are uncharacteristically humble tonight.
Mr. Conway: I am. I guess I’ve had all the reason in the world to be humbled by experience in the not-too-distant past.
Hon. Mr. Timbrell: You should behave like this more often.
Mr. Conway: Well I have noticed a change in other personalities and --
Hon. Mr. Timbrell: For the better or the worse?
Mr. Conway: I won’t indulge myself in that. I must say that until I saw the appearance of Dr. David Surplis on the Minister of Health’s staff not so very long ago, I thought he had seconded my friends from Carleton East and Scarborough-Ellesmere to writing his speeches, at least where nursing-home care was concerned.
Mr. Warner: He writes them but he won’t follow through; man without action, man of words.
Mr. Conway: I’m glad to see my good friend, formerly of the government members services bureau, now surfacing and working in the employ of the Minister of Health. I just warn the Minister of Health that I hope his new helper doesn’t use the opportunity to write a post-doctoral dissertation that will surface 10 years from now in one way or another. However, it does concern me that we are, in this day and age, involved as legislators with areas of responsibility where we really cannot be expected to deal very effectively.
One small example that has been in the press very much lately has involved the Minister of Health. It’s perhaps a small point for some, but somewhere in the OHIP system we have had Ontario Provincial Police ensconced in an office looking, in an unsupervised way, at a considerable amount of confidential data. That in itself is important, but the fact that none of the senior ministry people, including the minister I understand, were aware of that is a good current example of the difficulties of our responsibility in this respect.
I guess I’m making this point in a rather windy and circuitous manner to get to the bottom line. For those people who felt, for whatever good or questionable reasons, the urge in mid-October to go forward to the media and say, “This OHIP select committee is an indefensible, unconscionable waste of thousands of the taxpayers’ dollars”, as one private opposition member, I repudiate that notion in its entirety.
Mr. Warner: The member for Armourdale (Mr. McCaffrey) uttered that. He’s not here tonight though.
Mr. Conway: Well, I must say to my equally good friend from Scarborough-Ellesmere that I don’t know what encouraged our chairman to say what he felt the need to say in mid-October. I sometimes, in my most cynical fit of partisanship -- and I’ll be public tonight and say this -- I sometimes thought that what was occurring in the last 10 days of that committee had much more to do with what was going on in Chatham and Wallaceburg than with the public policy formation in this area of health care.
Mr. Makarchuk: You won Chatham, we won Wallaceburg; and they won the riding.
Mr. Conway: That’s right; I appreciate what my friend from Brantford has offered.
Hon. Mr. Timbrell: We won Chatham by 200 votes.
Mr. Conway: I make no bones of it, I think there was an unhappy breach of confidentiality. I must say I did something I didn’t ever think I’d do and that was -- with the indulgence of my friend from Scarborough-Ellesmere -- I voted for having the report-writing stage of this select committee occur in public. I happen to think, generally speaking, that’s a pretty indefensible kind of doctrine. However, I had seen other things in this assembly’s recent past which indicated to me that the only thing worse than having it in public was having it in private but having certain people, nameless, carry a selected amount of information and dialogue to certain people in the media.
I don’t like being tried in absentia or being tried with only part of the evidence. So with my friend from Scarborough-Ellesmere, and with the strong opposition, at least by his vote, of my colleague the member for Huron-Middlesex (Mr. Riddell), I agreed. We lost the vote, but I did feel that I would agree to having the report writing occur in private, in camera.
I don’t have to tell you that I was, to some considerable degree, disturbed that the confidentiality, to which presumably all honourable members were committed, was broken. Indeed, it may have been some mysterious angelic force that was about and indeed nothing to do with those of us --
Mrs. Campbell: Psychic.
Mr. Conway: Some psychic force, rather, and I don’t wish to make allegations.
Mr. Ashe: Just look to your left.
Mr. Conway: I fear to make accusations because I’m not sure just where they should rest. But I was pretty irritated; I was, at times, hostile.
Mr. Turner: Were you really?
Mr. Conway: Yes, I was. I was hostile, as difficult as that might be for some of the members to imagine.
Mr. Breaugh: Did you stamp your little foot?
Mr. Conway: That’s right. I was hostile about the fact that what was being said in confidence, in camera, was not only appearing in the Globe and Mail at 10 o’clock that evening, but as being bandied about at an all-candidates meeting in Wallaceburg some hours earlier.
I just want to make that point. For those particularly -- and I hope there is no undue causal relationship affected here -- those who felt it their first responsibility, before the report was made, to tell the province, and indeed to that degree I think to abuse the privileges of this House; who felt the absolute necessity to run forward and indicate what was happening, what those wretched Liberals and what those horrible socialists were up to and just how this was all a total waste of time; I feel compelled for my own private purposes at least tonight to go on the record as deeply regretting that.
I must be specific here in adding that my good friend from Armourdale did feel a requirement to do what he did. It has not been an easy thing for me to accept, and it broke what I thought was a frightening conviviality among the eight members of this committee.
Mr. Mackenzie: He just got conned by a pretty face, that’s all; come on there, Sean.
Mr. Conway: It’s suggested to me by my colleague from Hamilton-East that we were conned, or I was conned, by a pretty face.
Mr. Mackenzie: No, no, I said the chairman of the committee; I didn’t say you.
Mr. Conway: Oh well, that’s an even more interesting sideline. I won’t touch that either.
Mr. Warner: He’s not sure what side you’re on.
Mr. Conway: I just want to say that for my purposes I think, as a member of this assembly who has some idea of the privileges to which we are all committed in a parliamentary context, what was done by this chairman in the last days of this committee is I think an example of how it is not to be done. I sincerely hope that never recurs. I’m sure that it won’t, but it’s something that I think we should make note of.
In that regard, I think one of the things I would certainly recommend to my esteemed House leader, who has arrived and who with the other two House leaders has --
Mr. Warner: Nobody knows who it is.
Mr. Conway: -- the order of these complicated committees, I would suggest with some support from others on that committee that this business of an eight-man committee was a very useful vehicle. We were an elite force with focus and mobility. I would recommend that this idea of a small committee be considered for select committees of this kind in the future.
Mr. Warner: I would have liked to have made it smaller.
Mr. Conway: I think the committee, if it did nothing else, educated eight members of this assembly in a good, honest and thorough way. We spent -- let’s make no apologies for it -- we spent $50,000 or more in that education.
Mr. Turner: Seventy thousand dollars.
Mr. Conway: My friend from Peterborough says it was $70,000. I was in Orangeville last night speaking to a group of nurses. One particular nurse of some advanced age was very exercised that we should have done this, spent this money and really not had much to show for it. I don’t know whether she accepted the argument that I want to make very strongly, which is that the private education members were able to gain in this process the public also got by virtue of very good press coverage. There are very few reporters who will be more remembered and appreciated for the way in which they stuck with us. I have to tell you, Mr. Speaker, and I know you have more considerable experience in these matters than I do, that there were times when one even wondered whether the 50 tax-free dollars a day made it worth it, but certainly it was a committee that was well reported in my view. I think the major metropolitan press here in Toronto did an excellent job. There was some misunderstanding sometimes about certain things, but I honestly felt that the reporting of that particular committee gave to the public a particularly good idea of what was going on in terms of the debate.
I well remember one specific example that my friend from Peterborough made some reference to in the early part of his remarks. That was the business of our coming to the conclusion that this $4 billion we’re spending is what we’re going to spend if we want the kind of system that I suggest all of us in this room want and will insist upon.
I can remember a front page story in a national newspaper, quoting among others the member for Armourdale and myself as suggesting that it was somewhat mythical for the Ministry of Health or the opposition or others to suggest that the health care spending in his province was not ridiculously out of control. I well remember a number of my colleagues, some of whom sit in front of me tonight, wondering whether or not I was quoted accurately, and wondering whether or not that was a statement that could be supported by the facts.
Mr. Nixon: We just didn’t want to get into any more trouble than we had to.
Mr. Turner: Did you question him, Bob?
Mr. Nixon: I never question him.
Mr. Conway: I must say it was a revelation -- to some of the committee at least -- that this $4 billion was, relative to other jurisdictions, a reasonable amount of money for what the society we politicians are part of had come to expect. I think that was important. That message had to be gotten across to people generally.
I want again to underscore that point about the educational process this particular committee enjoyed.
Mr. Mackenzie: You can take all of the rest of the night, Sean.
Mr. Conway: I may just do that. The Royal Winter Fair has depleted our ranks tonight, as the Prime Minister of Israel’s dinner has perhaps depleted the ranks of others.
Mr. Nixon: The Queen’s guinea night.
Mr. Conway: I want to make that point, because there were many who felt it was not the money or the time, and I for one felt very strongly that it was.
Mrs. Campbell: Definitely.
Mr. Conway: It has been said by some very prominent people in the government, with some wide reporting, that the Liberals particularly were the ones who wanted this committee, with the specific reference to major tax reform in the area of the premium. I think that’s quite fair and quite reasonable. I don’t for the moment back away from that. Let me just deal with that in a paragraph or two.
Those of us who are not tax experts went into this committee expecting we should be able to get as much data as would be required to make what we all understood would be a very tough and difficult decision. In the three-month inquiry in which we engaged it was, I think, a significant revelation for us all to find some things we had not expected to find, and some of them rather late in the process. I can well remember the late Treasurer from Chatham-Kent coming --
Mr. Breaugh: How sweet it is to say that.
Mr. Conway: The former, that’s more delicate -- the former Treasurer from Chatham-Kent telling us in the spring figures like this: that there were not fewer than 60,000 OHIP subscribers eligible for and taking advantage of partial premium assistance; in late September we were told no, that’s not quite accurate, the real figure is not 60,000 but 586.
I use that as one example of the order of magnitude of statistical error we, as a group of lay politicians, were confronted with in the last weeks of this inquiry. There may be those in this government who charge forward on their white horses, making wide-ranging decisions on that kind of data base.
Mr. Nixon: Margaret Birch.
Mr. Conway: I sometimes think that occurs. My brief educational experience was not of a kind to make me want to arrange decisions, and of a very important kind, on that sort of data base.
We came to a conclusion that I think is supported by the facts, and it is this: that in many of these health care matters poor old TEIGA for whom I -- it’s no longer TEIGA, it’s Treasury, TEA; only in Canada, what a pity.
Hon. F. S. Miller: Now I know what you do in your spare time.
Mr. Eakins: Frank, if it snows you’ll get the drift.
Mr. Conway: I was one of those people who for three years sat over here and watched TEIGA make their budget presentations. I sat in awe of their statistical capacity; I assumed they, unlike maybe a lot of others, really knew what they were talking about. That fast-talking posse led by Dunc Allan and company were a very able, a very dedicated, a very knowledgeable gang.
Well I must say this experience this summer indicates to me that where TEIGA’s relations with health care statistics are concerned -- and I am reluctant to say this, staring at the bald, or at least the balding, head of the Treasurer in front of me -- I am afraid TEIGA does not know what it is talking about.
Hon. F. S. Miller: I may be stupid but not bald.
Mr. Conway: That concerns me very much, because time and time and time again in late September we were led to believe that TEIGA just did not have the evidence we required, did not have the expertise and the kind of data that I at least wanted, and that my caucus insisted upon, before making a major tax change of the kind to which my caucus and I are still committed.
Mr. Grande: Quite right; TEIGA is a shambles.
Mr. Conway: It is said, and not improperly, shame on this health committee, shame on that opposition mob who had all the answers, who appeared to have all the solutions to the tax question in April; and in a six-month period, having spent $75,000, having sat for the grand total of 20-odd days, having interviewed a few witnesses, could not conclusively provide the course for this tax change.
I only say there may be some guidance for those of us on this side in another area. I have been told by senior colleagues of mine who have been here a lot longer than I, that this government has spent 15 years, millions of dollars, several commissions, countless committees and countless Treasurers dedicated to major property tax reforms.
I remember again the former Treasurer of this province being quoted in the spring as saying that this OHIP business is a diversion, that he really wanted to get onto the important business at hand, and that was delivering property tax reform, of the kind long-since promised, before this year was out.
I presume the former Treasurer is now happily ensconced in the oak boardrooms of the Canadian Imperial Bank of Commerce and his colleagues march on; but one thing we do not have is property tax reform, and that after 15 years of several cabinets, after expending several millions of public dollars --
Mr. Turner: Don’t be so self-righteous.
Mr. Conway: -- and after several other such committees. I make the point to provide some measure of context for my friend from Peterborough and others here. It is simply this: the kind of tax reform we are talking of here is, for me at least, major and significant and I want TEIGA to tell me the facts. I expect them to provide the data a committee such as ours requires to make that kind of a decision.
Mr. Grande: They don’t have it.
Mr. Conway: They don’t have it, that is right. I assumed they had if not all of it most of it, and that we would, in our imperfect way, get to it. We didn’t. I am sure it is partially my fault, and the fault of others who were less than totally alert when the committee began in July.
Mr. Turner: But you are committed to make the change.
Mr. Conway: We certainly are committed to make the change.
Mr. Grande: Hold on, Sean.
Mr. Conway: I want to make it perfectly clear, I will not support --
Mr. Samis: Where is Spiro Angew these days?
Mr. Grande: Careful.
Mr. Breaugh: Look what happened to Spiro.
Mr. Samis: San Clemente, Ontario.
Mr. Conway: I will not, as a responsible legislator, entertain the shift I was to make away from this ridiculous, regressive, administratively complex, costly, and worst of all wretched, Tory tax principle, to a more progressive --
Mr. Makarchuk: A just as wretched tax plan.
Mr. Turner: But it works.
Mr. Conway: -- a more efficient, a fairer and a more liberal tax principle, without having all the data as it reflects specifically and particularly to those groups, and I can mention two.
My colleagues on the committee will know we spent considerable time dealing with this, that is what the impact will be on senior citizens? How many senior citizen taxpayers have we got, TEIGA? We don’t know. How many low income tax filers have we got in these categories, TEIGA? We don’t know.
I’m afraid I’m simply not going to be able to make the kind of judgements and decisions I’d like without that. I suspect there’s no one else in this chamber who would want to make it in the absence of that kind of information.
Mr. Mackenzie: That’s quite a rationalization.
Mr. Conway: My friend and colleague on the committee, the member for Hamilton East, speaks of rationalization. I prefer speaking of rationality, a doctrine not too well known to certain people in that caucus -- and I can understand that. But I understand part of my mandate here, as one politician, to be to make judgements and decisions that can be supported on the basis of all the facts available. We did not have all the facts I wanted. I certainly hope we will be able, through one mechanism or another, to get to those before too much more time passes.
Mr. Grande: In the next 15 years.
Mr. Conway: Hopefully it won’t take 15 years. I must say that where the premium principle is involved, one thing became very clear -- perhaps it was obvious all along. The people of Ontario will not see a change in that tax policy unless and until they demonstrate the singular good sense of changing the government of this province.
Mr. Turner: And then their taxes will go up.
Mr. Conway: The member for Peterborough suggests their taxes will go up, perhaps they will.
Mr. Nixon: But they’d go back to work.
Mr. Conway: I’m sure even the people of Peterborough and Pickering and Muskoka understand that in the past 35 years their taxes have gone up, they’ve gone up a bit.
Mr. Mancini: A thousandfold.
Mr. Conway: I won’t comment on how much they’ve gone up --
Mr. Nixon: This government has been a disaster.
Mr. Conway: -- but they have gone up. I’m not prepared to deny that those taxes might increase to some degree. I just want to indicate that from our point of view that’s why we submitted the dissenting report we did in that connection. I stand by it, recognizing it’s not all I wanted. I make no bones about that.
Mr. Mackenzie: You looked like a whipped messenger when you came back from committee.
Mr. Conway: I may be a whipped messenger. I can think of worse things to be.
I just have to say that as far as I’m concerned that dissent is respectable in light of what happened. I must say as well that I look with interest at my friend from Muskoka who has been mandated, on the authority of his caucus colleagues, to repair the damage in that premium assistance area.
I think even the Tories, the most retrograde, regressive right wing lot of them over there, will be impressed by the need to do something about the abject, total, and now known, failure of the premium assistance mechanism which was for those many years held up as the progressive counterweight to this wretched, regressive tax system.
Mr. Nixon: Right wing.
An hon. member: But despite all that, it worked.
Mr. Conway: Enough said.
I want to snake one or two other general comments --
Mr. Nixon: That was point one.
Mr. Conway: -- for public consumption, if not others. If there was one thing I expected this committee to react to it was what we determined to be a tremendous feeling in the public -- rightly or wrongly -- that the time had come to introduce some measure of patient participation, some measure of deterrent fee, some kind of user charge into the system. While they never really said so, most people at least implied that should occur in the medical sector --
Mr. Makarchuk: The Tories suggested it in Saskatchewan.
Mr. Conway: I thought Ross Thatcher was a Liberal.
I don’t think it’s too much to say there were a number of committee members who went into these hearings not unimpressed by the obvious good sense of user charges, since there is an innate or natural gut instinct in many of us which leads us to believe that, like the Unemployment Insurance Commission which is being ripped off by everybody who can get within 10 feet of it --
Mr. Makarchuk: Prove it.
Mr. Conway: -- this health-care scheme of ours is being ripped off by just about everyone who can get near it. That’s the kind of allegation that often is levelled by a lot of people.
Mr. Makarchuk: Prove that allegation.
Mr. McClellan: Who are the terrible people who are saying these things?
Mr. Conway: I must say that I agree entirely with the member for Bellwoods who has interjected.
Mr. Nixon: He knows; he used to work for the old Indian Affairs Department.
Mr. Conway: I just want to say that we live in a society which has a certain moral bias --
Mr. Grande: Don’t let them stop you.
Mr. Breaugh: Someone should.
Mr. Conway: -- that is hopefully positive and in which we try to assume the best of our fellow man and neighbour. I must say it escapes me how we could organize or proceed with a society on the grounds of a more Hobbesian psychology, which would have us believe that everyone is pessimistic, negative, and worse than that perhaps. When you come right down to it, it seems to me that there is an incredibly punitive, nasty, miserable instinct in those people who would hang a big deterrent fee on a lot of people.
Mr. Mancini: That sounds like the Tories.
Mr. Conway: As the member for Peterborough says many of them would be very seriously affected. This committee’s unanimous recommendation, on the basis of evidence heard, was that user charges are unacceptable for a variety of reasons. I want to go into one or two of them.
The first is that the fundamental principle in a public health-care policy is that there is a commitment entered into by all of us that the well will subsidize the sick. That is one of the fundamentals that explains the kind of insurance scheme that I’m sure even the member for Muskoka (Mr. F. S. Miller) understands. Even some Tories have suggested that the insurance principle in that connection should be strengthened.
We had an interesting bit of evidence from one of our consultants. Staff on this committee, I suggest, was like the membership -- blue ribbon.
Mr. Nixon: Quote that one more time.
Mr. Ashe: Some of the members.
Mr. Nixon: It was all the membership.
Mr. Conway: I used a very ecumenical term like “blue ribbon” to explain your prejudice politically. Those members who sat on the committee will remember that we had a very interesting report provided to us by one of our consultants which went to a group known as physicians in this province who have certain things to say about user charges. I see my friend the member for Scarborough East (Mrs. Birch), who at least knows a certain individual who represents that point of view. The Ontario Medical Association wants us to introduce some kind of user charge. They are a fine, dedicated group of not-disinterested people. Those doctors in this survey -- and there were several hundreds -- were asked to quantify the amount of abuse they experienced in their practice. I stand to be corrected, but I think it was around the area of --
Mr. Warner: Ten per cent.
Mr. Conway: -- about 10 to 11 per cent; that was the quantifiable figure that they provided in that survey.
A second part of that question was asked and answered by those same physicians. How much under-use is there in the system? The answer there was 11 per cent to 12 per cent.
That’s a very interesting statistic to my mind, but the point that I think is even more important -- and the Minister of Health knows this only too well -- is that there is absolutely no evidence of any valuable kind to indicate that user charges bear a direct and positive relationship to the pattern of utilization. So you do not effect what most people who have this punitive instinct want to do when you nail people with a user charge.
I must say that I for one was not unmindful of that Taylor report which had the notion, and put it forward some months ago, that the best kind of user charge was one introduced in the hospital setting. How I as a hospital patient, even in Don Mills, have control over how I got in there is quite beyond even my comprehension. I intend to stay here until 11 o’clock or 12 o’clock tonight if anyone can explain that to me.
Mr. Mancini: More Tory policy.
Mr. Conway: I am prouder of nothing more than the fact that this committee of eight members, representing the three political parties, repudiated out of hand the doctrine which I consider to be wrong, miserable and punitive, that would have us introduce substantial or other kinds of user charges into the health care system which I think functions quite all right without them.
I may have exhausted a good part of the 40 or 50 minutes allocated to me, and in the interest of allowing certain of my colleagues a measure of time to add their words of wisdom to this debate, I want to conclude my remarks by simply reiterating again that I think this was a positive, productive exercise --
Ms. Gigantes: Exhausted all of us.
Mr. Conway: -- in which I, as one member of this Legislature, learned an awful lot more about a very complex and extraordinarily expensive system for which, in a bottom line sense, I have been elected to this place to be accountable. That is central to my duty and I am delighted to have had the opportunity to participate in that exercise.
Mr. Breaugh: Well, tonight is the night; tonight’s the night we are going to do away with the regressive, unfair, unpopular and untenable position of retaining an unfair taxation system in Ontario known as premiums for health care. I remember that from last spring when this committee was set up. I remember that from the urgent and dramatic call by the leader of the Liberal Party during the hearings in the social development committee in the spring session. I even remember seeing, for the first time in my life, an honest-to-God policy paper written by the Liberal Party.
Mr. McClellan: Whatever happened to that?
Mr. Breaugh: I found it a fascinating document, one in fact that even I could agree with. They wanted to get rid of premiums. I welcomed the opportunity to establish in this House a select committee to deal with this aggravating problem of financing a health-care system through a premium technique. I thought aha, finally a chance in a minority government to do something. I thought, here it is, clearly a consensus, formed early, that the argument will be how to provide for a better financing system, to look at the system in place and improve it, so that surely, tonight, we would have a vote at the end of this proceeding that would abolish a regressive system once and for all and we would get on to something better.
Well it ain’t here. It says in this little paper I have before me that there are a number of recommendations to be made; a number of careful observations taken and some rather nonsensical ideas that were put before the committee looked at, examined somewhat and discarded as they rightly should be.
How did all of this happen? How did we go from a position in the spring of this year when this select committee was set up where it was clear, party lines were staked out and party policies spoken that we would be rid of the premium system by now -- and yet it is still retained? Some of the damage was incurred by the person who ultimately chaired the committee, not the one who chaired the committee initially. Dr. Smiling Bob initially took it on and part of my faith in the committee was the fact that the member for York East (Mr. Elgie) was chairing it -- a fair, reasonable and honourable person, knowledgeable in the field. In my examination of the transcript of the proceedings and the documents put before the committee, that committee seemed to be perking along quite nicely, finding a few holes in the TEIGA ministry’s presentation of facts, finding out there was a bit of a shell game at work there. They weren’t quite as good with their hard numbers as they were with their hot rhetoric and there was a shortfall there. So I thought -- a chance.
Then the member for York East is elevated out of that role and into a more difficult one; in comes the Leo Cahill of the Legislature to lead the committee down the tubes. It is not surprising that he found the end result of the committee to be a disaster. I simply looked at who was leading the disaster. If accountability ever comes before this Legislature, you should take the chairman of a select committee who says he is not happy with what they did and ask him what he was doing in the chair while all of this was taking place, because surely he had a role to play which he certainly didn’t play.
Mr. McClellan: He isn’t even here.
Mr. Breaugh: Let me look at some of the difficulties.
Mr. Speaker, I don’t think we are really that surprised at the results. We looked at the terms of reference, frankly, in the setting up of his committee. We had a debate and I proposed an amendment dealing with the terms of reference which said we had a fourth term of reference, namely to review and recommend alternative methods in the delivery of health-care services. Obviously, Mr. Speaker, if you are going to look at the complex relationship involved in the delivery of health-care services in Ontario, and you want to talk sensibly and cohesively about the financing you must look at the delivery system as well. Otherwise we are simply being allowed to come up with $1.98 any way we want.
I think we made a fundamental flaw in this Legislature -- and I would remind the members that the amendment was put before the House and did not carry, and neither the Liberal Party nor the Conservative Party supported it. The reason, given quite eloquently at the time, is that “We want to do a good job. We have one object in mind here, to get rid of the premiums, and therefore in order to do that we’ll really home in on this financing system.”
Well, we didn’t home in. That didn’t happen either. I think that is important, Mr. Speaker, because if you look at that equation that is health care in Ontario you must look at how the services are delivered. That’s an important thing that’s left out of all the considerations.
Because I read the transcripts of the committee hearings, because I read the documents, I, for one, give full measure to those people who sat on the committee and slugged it out through the course of the summer dealing with some very complicated issues. I thought they did an admirable job at trying to hold their own in that league, because it’s a tough league. I’m happy that we served as a form of apprenticeship for the member for Renfrew North (Mr. Conway); perhaps that will be a useful thing.
I can’t take much exception to virtually anything that is written in this report. According to the terms of reference they did, I think, a noble job. They could not come to an agreement at the end and I think that that is tragic and unfortunate, but given the terms of reference to start with, and the role that the chairman of the committee played near the end of it, I think “understandable” is the politest way to put that.
Mr. Speaker, I think we should have looked at the delivery system because I want to point out to you that on a number of occasions as you read through this report you see the committee identifying parts of the delivery system, talking about the revolving door psychology of doctors treating as many patients as they can in a day, because they found that’s a way to generate profits, and being quite frank about that. I find that unfortunate. Let me suggest to you, Mr. Speaker, some other areas we would have well served had we looked at them.
I read with great interest that a colleague of mine this summer, the member for Scarborough-Ellesmere (Mr. Warner), spent an evening in an emergency ward. He points out in a small release which he issued afterwards, a totally unbiased, fair and objective mention of things -- let me quote you just a small line: “I witnessed not patient abuse but government abuse. Clearly the emergency ward was understaffed. I got the impression that this cheerful, hard-working staff of professionals was being pushed hard.”
Mr. Speaker, the committee addressed itself in great measure to the use of emergency wards in hospitals to provide services. I’ve heard on other occasions the Minister of Health say that in fact the emergency ward of urban hospitals really is the family doctor for a district. That may well be. That may be a very sensible way to deliver the health-care system, but as the member for Scarborough-Ellesmere experienced and pointed out in his release subsequent to that night, it’s a difficult one, and it isn’t working smoothly, not nearly as smoothly as we would like.
Let me bring to light another small matter that is of some concern to me. This one is from my colleague from Hamilton Centre (Mr. M. N. Davison), pointing out that doctors’ concerns about economic pressures are for real but the fees the doctors are charging to do a number of specialized services are causing financial hardships to many sick and disabled people.
One Hamilton specialist is charging up to $100 for medical reports needed by patients for Workmen’s Compensation Board appeals. A patient’s job or appeal hearing could be seriously jeopardized if he or she could not afford to pay the fee to get the report. Again, that’s a service provided in some instances by the province of Ontario under their medical-care scheme, but not in that one, and doctors of course are looking for a means to get around that.
Let me point out to you very quickly too, Mr. Speaker, an announcement that came across my desk from the Provincial Secretary for Social Development (Mrs. Birch). In this instance she is announcing that 1979 is the International Year of the Child. As I went back through this document, which I am always happy to receive, I noticed something that caught my interest. It is suggested in here that the Ministry of Health in 1979 will begin an intensive immunization and awareness campaign and a preventive dental care program that will begin this fall.
I thought aha, we’re finally moving to include dental care services in the medical system provided for by socialized medicine in Ontario. Mr. Speaker, I cannot give to you in words that this House would accept my disappointment when I found out that that dental care program turns out to be “Murphy the Molar” telling kids to brush their teeth. That falls a little short of the mark.
Let me deal with a couple of other matters that are of great concern to me concerning the delivery system that’s in place. One major item put forward in this part is a thing called the adult community mental health program, which I think a fine-sounding thing and which I also think to be a fine concept. I find, in looking through an application of that in a discussion of a specific one here in Metropolitan Toronto, that though the concept is there and though good ideas are present -- good and workable means of providing satisfactory health care to the people of Ontario -- the funding is not. The funding is not there because we have persisted in sticking to the one model that we have always used. Right or wrong, rationalized or not, that’s the one we’re with, in terms of a delivery system and in terms of how we finance it.
Let me put to you perhaps the most dramatic one that I would use this evening, and that is a report from a lady in Hamilton. She puts this as succinctly as anyone could.
“The Hamilton Spectator reports that this area is being used by the OMA as a testing ground for the destruction of universal health care in the province.”
Mr. Speaker, that universal health-care system is important. It is important in funding terminology because that’s one of the criteria used by the federal government to see that the funds they make available to provinces are used wisely and well, and that universal access to the system is guaranteed.
The committee in its deliberations this summer dealt with some of those matters. They were not directly within their terms of reference, that was clearly not the focus of the committee’s work.
The committee looked at some impressive reports, I grant you. It picked out in its several weeks of hard work some pretty serious inconsistencies in the numbers that were put in front of it by the government, by both the Ministry of Health and by the then TEIGA ministry.
It established clearly that there’s a good deal of bluff involved in all of this, that a government that has purported to be masters of financial handling often doesn’t know exactly what it’s doing. It pointed out that government programs designed to help those who need the help sound very good, but don’t deliver. The programs haven’t delivered for some time; and the committee detected that once again this government persists in putting forward fine-sounding programs with no realistic expectation of ever fulfilling those.
This document that is before us this evening is an examination of that to a degree. If I were to make a constructive criticism of the document itself, it’s simply that it didn’t stand much of a chance from its beginning. Clearly the government seized on an opportunity put forward by both opposition parties to get rid of the premium system, and said, “All right, but we want to restrict the terms of reference so that you really cannot do it.”
I don’t suggest for a moment that the change in chairmanship was really by design, but it happened to be an unfortunate coincidence that occurred at a very crucial stage in the committee’s deliberations, and I think it directly affected the end result, this report before the House.
I think we gave it to the government on their terms, and the government presented what numbers it chose to present. It presented them in a way that it wanted to present them. It only gave us, in my view, as much information as it was prepared to yield.
If we were to do this exercise again, and the purpose of the exercise was to conduct a hard-core examination of that financing system, I for one would not support the notion that the terms of reference would be as restrictive as this. I would not support the notion that you offer to the government the opportunity to present to the committee such information as it deemed suitable. I would be far more avid in having the committee subpoena documents on its own, using its own impartial staff to do the analysis.
I give full credit to those staff people who worked on this committee because, given the terms of reference, given the number of unfortunate incidents that happened in the course of the committee’s deliberations they came up with as good a document as anyone has a right ever to expect.
I find it unfortunate that the basic premise of the exercise was to do away with a tax system. I don’t want to get into the argument that my colleague from Scarborough-Ellesmere got into in the spring of this year about whether OHIP is or isn’t a tax. It takes money from people and in my view that makes it a tax. Whether that’s a parliamentary tax or some other form of taxation, I don’t care. If you take money from me, you’re taxing me. They got themselves to that point but no further.
There is a problem we all face here in terms of expectations of committees. We should pay far more attention to the terms of reference, to how committees are set up. I thought a clear consensus had emerged in the spring of this year over a debate about raising the OHIP premiums: that the premium system was not desirable and ought to be done away with. I heard that from spokespeople from the Liberal Party, from this party, and in fact in the committee sessions I sat in on, I thought I heard the Minister of Health say he wasn’t overly crazy about a premium system either, but it was in place. Basically the argument was, it’s a better system than something else because it’s there and any time you change, you give people the opportunity to squawk.
In one sense then, this committee report is a failure, It did not accomplish the basic objective that at least two of the three political parties had in mind when they started out down that long road. In other very real senses, I think it achieved notable successes for the first time. It unveiled some very glaring inaccuracies in the kind of statistics the government uses. It unveiled some serious problems in the delivery system itself. It found the tip of the iceberg, frankly, in terms of how practitioners view the system, how they finance themselves and their activities. It discussed in some completely rational ways, where the heavy costs in health care are. When it got down to that final point, through a series of problems with the terms of reference, the chairmanship of the committee and the political circumstances we found ourselves in in the last 10 days or so of the committee’s deliberations, it could not do what it set out to do. That is not to say that the report itself is a disaster, failure, or anything like that. It is a good, substantial examination of the health-care system in Ontario.
Mr. Speaker, I made a plea before the committee started and I will end this evening with the same plea. It is a shame that we could not have had a substantive, long-term investigation by a select committee of this House with independent staff on all aspects of the health-care system in Ontario. I want to put to this House tonight my own personal and heartfelt concern that the delivery system for health care in the province of Ontario is in tough times now and it’s going to get tougher.
No matter how nice and friendly and boyish-looking the current minister may be, and no matter how good his speeches might be on occasion, the plain fact is that those people who work in the health-care system are experiencing serious problems. In my personal view, the people who pay the shot and for whom that system is supposed to work, are being deprived of some pretty serious forms of health care in the province of Ontario; some shortages. In this transition period the government is supposedly going through, there are a great many rather sad and tragic shortfalls.
I think there is a need for the other members of this House, other than those who sat through the hearings of this select committee, to pick up this job where they left off, take the very valuable information they elicited from the government to establish their concerns once again, and see if we cannot renew ourselves and take up the challenge and get rid of a premium system that is regressive and unfair. Perhaps most important of all, it affects the delivery system. In the health-care field you are not often talking of inconvenience but rather of an individual’s opportunity to receive health care. No matter how you try to walk around the issue, it always means life or death.
Mr. Cureatz: Mr. Speaker, it gives me great delight to participate in my modest way in this debate regarding a committee I had the opportunity of sitting on. The unfortunate situation is that I was one of those subs.
Mr. Breaugh: You should be thankful you ever got that high.
Mr. Roy: Nobody ever noticed the difference.
Mr. Cureatz: In the hurry of cabinet shuffles, the member for York East (Mr. Elgie) was promoted and I was bumped from the company law committee onto the OHIP committee. It occurred to me that those other members who were sitting on the committee for some three to four months had the opportunity of finding out through in-depth investigation all the various ramifications and possible proposals alternative to the present system. I haven’t had the opportunity of having those investigations although I often, during the four weeks I was on the committee, listened to the members for Scarborough-Ellesmere (Mr. Warner) and Renfrew North (Mr. Conway) with great interest. They had the opportunity of listening to all the input and to all the factual data and information from TEIGA that would help them in coming up with possible alternatives.
I wasn’t there for that information. The parliamentary assistant to the Minister of Health was there and I think he very ably expressed some of his concerns when he started off this evening.
Interestingly enough, the member for Armourdale (Mr. McCaffrey) was there also -- not only as a member of a government committee but also representing the position as chairman. It’s interesting to note, if I can be so bold about it, that he’s not here tonight -- someone mentioned that from the other side of the floor. And --
Mr. Breaugh: That’s right, with good reason.
Mr. Cureatz: -- I can honestly say I’m a little disappointed. He was the chairman of, I think, a very important committee investigating the health insurance scheme of Ontario --
Mr. Breaugh: Go get him, Sam.
Mr. Cureatz: -- a multi-billion dollar operation. Do you think he’s over at Toronto General Hospital at the emergency ward checking out the program, Mr. Speaker or is he at Sick Kids --
Mr. Breaugh: I don’t think that’s fair.
Mr. Cureatz: -- checking out the third wing? I don’t think so. I think he’s off enjoying probably a very pleasant dinner, listening to one of the world’s leading premiers. I suppose there are priorities, but there are priorities in this House too. I want to let the record show how I feel about that chairman’s mood this evening. I’m a little disappointed at him not coming forward to bring forward in this House the things he did so well in the committee. Too bad he’s not here.
Notwithstanding that, let me in my own modest way review some of the thoughts I had and some of the concerns for the brief weeks I had the opportunity of sitting on the committee.
Mr. Mackenzie: Aren’t you shuddering?
Mr. Turner: No.
Mr. Cureatz: The relative superiority of our health insurance plan in terms of quality care, accessibility and portability has placed us in a model position for other jurisdictions. Most recently this superiority was portrayed in the United States. Testimony given by Ontarians before the human resources subcommittee on health, headed by Senator Edward Kennedy, left the Americans clamouring for a system like our own -- a system which the opposition have tried so hard to discredit.
It is our role as a government in this province to provide the high quality health-care system Ontarians have enjoyed and come to expect. It is also our role to search for and deliver our health program in the most efficient and equitable way. For this reason we must investigate alternatives and hear the views of the people to be sure these standards are being met.
The committee has heard four months of evidence, listened to people from within and without government and discussed the available alternatives. Throughout the deliberations it remains clear that the current premium method is the best financing method available at this time, although no system can claim perfection.
If the members recall, last April the Liberal Party called for an investigation to determine possible alternatives to the premium financing system. That study has been conducted at considerable cost in time and money and yet the Liberal position remains unchanged. They remain opposed to the premium system yet fail to come up with any new proposals. The Liberals have managed to once again fall squarely in the centre. Their recommendation is to extend the committee to March 31 -- in my opinion an attempt to buy time. The evidence has been heard and the time has come to reach a decision, based on what we know.
The NDP recommendation is to do away with the premiums either immediately or over a four-year period and to replace them with an increase in personal income tax. The far-reaching ramifications of a 13.5 point increase in income tax during the present period of economic strain received extensive attention in committee. Such a system would place an additional tax burden on those in the middle-income range. Seven hundred and fifty thousand senior citizens in this province currently receiving free OHIP coverage would be forced to pay. These are precisely the two sectors of our society most severely affected by inflation and the rising costs of living. Such a policy would be inconsistent with the general welfare of both these groups.
What would the implications of increased income taxes be for the business community? Perhaps most important, what effect would such a change have on labour-management relations? By what means could we ensure the working people whose premiums are presently paid by their employers would receive wage increases, or alternative benefits?
The premiums being collected currently account for almost $1 billion annually, or eight per cent of budgetary revenue. They cover almost 30 per cent of the money spent on insured services and about 25 per cent of the entire Ministry of Health budget.
Premiums are an established workable levy and a significant part of our entire revenue structure. Moving to an income tax system at this time would have an adverse effect on the total taxation system. An increase in income tax is not an appropriate alternative to the current economic period. The premium system of financing, while not without flaws, is a fundamentally healthy system. Working to improve the premium structure as it presently exists is preferable to a policy of uncertainty.
Perhaps the most important, indeed distressing, finding of the committee results from evidence showing that the current subsidy system, though well intended, is not functioning as effectively as it should be. Under the current premium assistance program, individuals with a taxable income below $2500 and families with a taxable income below $3,000 pay no premiums. Individuals earning less than $4,000 and families whose income is below $5,000 are eligible for partial assistance.
The committee has learned that of the 327,000 Ontarians eligible for full premium assistance, only 160,000, or about half, were receiving this benefit. Of the 160,000 eligible for partial assistance, just over 1,000 were receiving assistance. As a result of the publicity surrounding the select committee, a further 25,000 persons applied for and received full assistance by September 1978. By the same token the number receiving partial assistance increased to 2,000.
This observation moved the committee to reach consensus on one major issue and to unanimously recommend, and I quote: “that the current subsidy system be replaced by a tax credit system that would ensure, as the current subsidy system does not, that all those entitled to premium assistance do in fact receive it.
“If entitled, such people should take advantage of the assistance offered to them. If, due to lack of information or understanding, the disadvantaged in Ontario are not receiving relief, it is our responsibility to see that they do. It is estimated the tax credit would benefit up to 300,000 Ontario residents.”
The details of the proposal remain to be worked out and, again, there are implications to be considered. As the recommendation stands, senior citizens now receiving free OHIP would be required to pay premiums according to income.
Secondly, financing the tax credit would require an additional revenue requirement of up to $250 million annually. While reliance on progressive tax sources receives majority support in committee, it is, of course, recognized that fiscal policy ultimately falls under the jurisdiction of the Treasurer (Mr. F. S. Miller) -- so nice to see him here tonight.
Universal accessibility is the principle around which our entire health-care system is built. The tax credit would ensure those Ontarians eligible for assistance receive it without inflicting an unnecessary burden on middle income or elderly taxpayers in Ontario.
We are willing, after careful and responsible deliberation, to initiate change where the evidence indicates a need for such change. In responding to the changing needs and life styles of the people of Ontario, the Ministry of Health has set up district health councils to monitor these local needs.
In order to restrain costs, pilot projects such as in-home care for the chronically ill are operating across the province and reducing the burden of cost-intensive hospitalization. Educative programs to increase the public’s understanding of the proper role of the health-care system and the most responsible ways of using it will further contribute to the ministry’s successful efforts in restraining costs.
The hearings of the select committee confirmed OHIP as a sound health delivery system. The current premium system, while not without flaws, is fundamentally an effective system which continues to receive my support, and I believe the support of the people of Ontario -- and the member for Armourdale (Mr. McCaffrey), where are you?
Mr. Mackenzie: I personally found the hearings of the select committee on health-care costs to be useful and informative, albeit at times rather frustrating. I personally hope that the publicity and focus the committee brought to bear on health-care services in the province of Ontario and on the cost to the citizens of the province helped to trigger a little more awareness of the services that do exist in Ontario and on the need to preserve such a public service.
I think the restating of principles of the program -- universal coverage, comprehensive benefits, portability of benefits and public administration and accountability -- was both timely and of importance in clearing some of the fuzzy thinking that appeared to be infecting a cross-section of the public in the province, the members included, as to the purpose of a public health-care program in this country. It would be a tragedy if members were to lose sight of the long and difficult struggle in Canada to establish a program that covered all of the people in need without regard for the size of one’s bank account.
It was encouraging to find that we had a relatively good program in the province of Ontario, operating in most cases with justice and efficiency and operating at a reasonable cost when viewed in the context of today’s costs and in comparison with other expenditures, the gross national product, or almost any other yardstick one wishes to use. While the current price of health-care costs in the province is a little more than $4 billion and is a major expenditure for Ontario, I think the hearings debunked some of the scare stories of uncontrolled and runaway costs and services that might be lost to the people of this province.
It is a matter of record that we have a service that is one of the cornerstones of the good life in the province of Ontario. It is one that is accepted by the public of the province and one that the people did not want to lose and, in my opinion, were quite willing to pay for. Because it is a service that people perceived as a real value, it is one that I feel should be expanded rather than one that should be cut back.
The committee had clear evidence of both the quality and the saving resulting from a comprehensive public system when compared with the private approach, such as the current system in the United States. One could even detect a measure of shock evidenced among some of the members of the committee when they realized that not only were our services more comprehensive and universal, but that generally they were of higher quality. Our costs in Ontario were escalating at a slower rate than in the private system in the United States, and our percentage of gross national product spent on total health-care costs was considerably less under our public system than that under the private system of our neighbours to the south.
It was encouraging to have the recurring arguments for user or deterrent fees exposed and rejected to the point where the committee was unanimous in reaching agreement on this particular point, unanimous on user fees in terms of their unfairness and their counter-productivity.
The many suggestions made by hospital and medical delegations and by others in the health-care field should certainly provide additional ideas and information for ministry personnel to use in planning the more efficient use of our health-care dollars in this province.
On balance, I want to say I was impressed with the Ministry of Health personnel who worked with our committee with what I perceived to be a genuine awareness of the importance of our plan to the people of the province. I hope this expertise will give a fair evaluation to the many ideas that were presented.
I do have some criticism of their approach to one particular issue, that of nurse practitioners. Both the ministry people and the Treasurer insisted that if the current program of training nurse practitioners ended, it was McMaster’s fault, since they were the final decision-makers in terms of whether or not we continued such a program.
That was not true. I think McMaster effectively refuted the charges and in fact it is the cutbacks, in this case I think ill-advised, that will likely lead to such a cancellation if indeed it happens.
I could relate to the fact, and I think most members of the committee could, that there was a problem in terms of quality of service and remuneration for some doctors, general practitioners in particular, because of the OHIP payment schedule and the additional case load undertaken by many of them to maintain take-home pay.
My only negative reaction in this area was the tendency of some members of the medical profession to take out their frustrations on the health-care plan itself and therefore on the people it covered. This in my mind was manifested by the argument for user or deterrent fees, which were shown to be unfair and regressive, and the opting out of the plan, which to my way of thinking is a serious threat to the very principle of universal health coverage in our country.
It was encouraging to find a concern over opting out on the part of the minister and the ministry and a willingness to take action, if and when necessary. The “if and when necessary,” however, does disturb me, simply because of its vagueness and the uncertainty I think it created.
An area of concern was the apparent lack of consistent and accurate figures from both the Ministry of Health and from TEIGA; although I have to acknowledge that the requests we made for a variety of combinations of increases and tax credits over a very short period of time probably presented difficulties, given the lack of any accurate individual identifier in our health-care system in this province.
If there was a shock to every single member of the committee, and I believe to the ministry itself, it was the rather startling information unearthed in terms of the lack of full and partial premium assistance take-up. It is nothing less than ludicrous in my opinion to find that only approximately $50 million of a potential $200 million cost was being used to bring about a measure of equity in the plan. It is even more unbelievable that the ministry was not aware of the extent of the failure of this equity weapon.
I think the extent of it should be put on record because it’s of some importance. We found that only 162,000 out of some 487,000 eligible for full assistance appeared to be receiving it. We found that considerably less than 1,000 out of some 160,000 entitled to partial premium assistance were receiving it.
I said “equity weapon” earlier because one of the most consistent early arguments made by government members in defence of premiums to pay for health care was based on the argument that the resulting premium assistance brought some progressivity to the current method of paying for the plan. I might say that this argument was quickly and almost completely destroyed with the information that in fact equity was not being delivered through premium assistance.
This revelation also added a totally new dimension to the committee’s deliberations in terms of paying for the current system. We were faced with the need to find $150 million for the government to bring their own plans up to their own standards. This was a problem that should have been the government’s problem and not the committee’s responsibility. At best, it displayed shocking ineptitude on the part of this government.
My biggest disappointment, or the biggest disappointment to the New Democrats, was the failure to reach agreement on more equitable funding of our health-care plan. On reflection, I now believe that there was to be no agreement, regardless of the merits of the arguments made in the committee.
There was certainly clear evidence that premiums were not an equitable method of payment. None on the committee could refute the arguments of experts or staff as to the lack of equity in premiums, though not all would accept some of the arguments. Nevertheless, there was a clear majority opinion in that committee that premiums were not equitable.
In spite of this, and in spite of efforts by myself and my colleague to explore a variety of combinations of premium and personal income tax, extended over a number of years if necessary, and in spite of one such suggestion from one of the government members to which we responded with more than a little support, it was simply not to be.
I regret, as others have said, the change of chairmanship from the member for York East (Mr. Elgie) to the member for Armourdale (Mr. McCaffrey), I regret even more his absence from the debate here tonight, but what I will say is nothing I haven’t said to him in the course of the committee hearings.
I found him to have almost a total lack of interest -- as a matter of fact, he stated it very clearly in the committee -- in terms of reaching a consensus or a compromise in methods of paying for health care, and his attitude in the final week of the committee clearly resulted in a disintegration of the debate within the committee. A committee that was charged with a major responsibility and which started out in a very positive way and spent many hours listening to good witnesses and trying to digest volumes of printed material was turned into a bit of a joke.
I want to say that once we got involved, all of the members were aware of the magnitude of the subject and knew there were no simple or easy answers. That was clear from the very beginning. We did not need a chairman who made it very clear that he was not the least bit interested -- to use one of his quotes -- in “wasting his time in looking for any consensus or compromise.” He also made it clear that he considered the efforts of members of the committee to be a waste of time. The chairman also accused New Democrats on the committee --
Mr. Cureatz: That was in the heat of the debate.
Mr. Mackenzie: -- and one of the Liberal members of being interested only in shifting the costs from the lower-income person to the higher-income person. He made it clear, in his argument with us, that he was there to look after the interests of those higher-income people who would have to bear more of the tax burden. I think the members know that’s clearly on the record as well.
He said that we were already taxing the higher-income groups too much and when we said, “You’re talking about the $40,000-and-up-group,” he said: “Yes, and I’m here to represent them.”
I found the argument rather a sorry one --
Mr. Renwick: That is his minority.
Mr. Mackenzie: -- because there was no intent, as I thought, of anybody on that committee to get that $40,000-and-up income group. There was an intent, and a genuine feeling, that we should be trying to finance the health-care costs in this province in a more progressive way and if that resulted in extra costs to the $40,000-and-up, so be it, no argument. What’s more, I suspect that most of them would probably accept it. That is, all but the rednecks in our society.
I want to make it clear in this debate in this House that I was proud to be the target of the kind of hyperbole that we got from the member for Armourdale, his blind allegiance to the high-income earners which did deny justice to the vast majority of our people, particularly to those on lower and fixed incomes in our society.
Mr. Lawlor: Who represents the 90 per cent of people in his riding?
Hon. Mr. Walker: He does and he represents them well. He represents all of them well.
Mr. Mackenzie: The chairman went further and stated, at the end of the hearings and in the press shortly before we released our approach for all to see, that the whole exercise was a waste of time and money. The waste of time and money was that expended on the chairman of that committee.
Mr. Cureatz: You see, he shouldn’t be here.
Mr. Mackenzie: Further, I consider his statement an insult to the sincerity and integrity of every member of that committee and I consider it an insult to this House which, in its own good judgement, initiated the committee itself.
I have to wonder, and I wondered as we went through what I took to be an unbelievable performance whether indeed it was the blockheadedness of the member himself or whether word was being passed down from the cabinet or the Premier (Mr. Davis) to somehow or other screw the committee.
Hon. Mr. Walker: Other members didn’t think that.
Mr. Mackenzie: I never was quite sure.
Hon. Mr. Walker: Bob, you are just exaggerating.
Mr. Mackenzie: In the key area of financing, we were able to reach an agreement on only one item: the necessity of rescuing the government from its own folly by recommending a tax credit to assure coverage of those at the bottom end of the income scale, a measure necessary to provide coverage for those --
Hon. Mr. Walker: Is that a consensus?
Mr. Mackenzie: -- who were already supposed to have it. Beyond this, our efforts to bring about a more progressive tax base funding in place of the premium was totally rejected.
Hon. Mr. Walker: Bob, I just think you are exaggerating.
Mr. Mackenzie: I say totally, in spite of the clear stating of party policy by the Liberals, a policy which clearly called for the replacement of premiums, when we offered a number of options and indicated a willingness to make a change over a number of years, the Liberal members would not go along with us. Indeed, when a Liberal policy paper was finally produced in the last three or four days of the committee, a paper which froze premiums at the current level but which went on to say that the policy was to work to replace them, we quickly backed down a considerable degree from our position and offered to support their paper with one small change in the interests of reaching some kind of a majority report.
A very hurried Liberal meeting sent a dejected messenger back with the answer, “No.” I say dejected, referring to the member for Renfrew North (Mr. Conway) for, I believe, he agreed with us because he had joined with us in many of the arguments. I can’t leave that, although I’m near the end, Mr. Speaker, without quoting just two lines from that paper, presented to the committee in the last week.
Hon. Mr. Walker: Pay attention to what he says.
Mr. Mackenzie: “The Liberal caucus remains persuaded that the OHIP premium must be supplanted by more progressive forms of revenue raising. The premium system obviously cannot be abolished overnight.” It goes on a little later to say: “We remain adamantly opposed to the premium system,” and I ask you to listen to this, “and a Liberal government would move in its first term of office to abolish the system and replace it by a more adequate and progressive one.”
We offered to buy their recommendations if they would add the provision, the one provision that it would be over four years and they wouldn’t do it. What does this tell us, Mr. Speaker? It tells us that a Liberal position isn’t worth the paper it’s written on and it is a clear reason to expect no more than that, if a Liberal government was elected.
Mr. Foulds: Cowardly.
Mr. Mackenzie: Either they or their policy is a piece of hypocrisy and they are shown for just exactly what they are.
Mr. Makarchuk: They put in a deterrent fee.
Mr. Mackenzie: In winding up, Mr. Speaker, I will not try in this short time to go into details. But I want to make it clear that we argued from day one of the committee for a more equitable method of financing that portion of our health care costs, now collected through premiums in this province. We showed the utmost flexibility in terms of phase-in time, or combinations of personal income tax, tax credits or corporate income tax, any of which could be phased-in to coincide with the most appropriate period economically.
This would not have been easy. We recognize it. It did present some problems and it would have cost some more. But it is the honest approach. It is one that accepts fair equity and it would in fact help more than it would hurt. It would help those who have the least disposable income. For that kind of justice, New Democrats would take any flak that comes from those who disagreed.
It’s a sorry time in Ontario when that kind of progressive thinking is scuttled by the fear of those bowing to the screams of those in support of the current establishment-oriented tax system in this province. I think it was a sorry day when we couldn’t reach agreement. I think it surely exposed both the immovability of the government and the hypocrisy of the Liberal Party.
Finally, I would like to comment briefly in one paragraph on the committee staff itself -- the total staff of the committee and in particular on the counsel, Don Rogers, and the consultant, Dr. Allan Wolfson, who worked hard and with understanding and expertise under the handicap of partisan political positions which did not always make their job easy. I for one appreciated their efforts. Thank you.
Mr. Warner: Mr. Speaker, I wish to say at the outset before beginning my comments on the committee’s work that I appreciate the efforts by quite a few people including our legal counsel, Don Rogers, Dr. Allan Wolfson, who was our consultant to the committee, who was assisted by a very good assistant, Dr. Greg Stoddart and Susan French who was a researcher. We also had some expert advice from Merv Hanna and Yale Drazin who came to us from the Ministry of Health and who provided some excellent backup help. They were very useful and helpful people.
The clerk of the committee, Doug Arnott, I thought did an absolutely superb job for us in trying to arrange everything and make sure that everything flowed smoothly and ran on time, as well as Franco Carrozza who was general administrator and did a fine job. Quite frankly, for the first part of our hearings, from July and August through to the appointment of our chairman, the member for York East (Mr. Elgie), I feel the committee members benefited quite a bit from the wisdom and experience of the member for York East. He provided a very objective viewpoint as the chairman and he was most useful. He assisted the committee in trying to go about its work in an orderly and objective way, giving us each an opportunity to make our points both political and otherwise.
Unfortunately, that good kind of assistance was not followed by the next chairman. That’s where, as has been brought to our attention by several members, the committee got into some difficulties. It’s unfortunate, but that’s life I suppose, at least around here.
Since we do have a fair bit of time and some of the members who served on the committee are not present this evening, I would encourage the Minister of Health (Mr. Timbrell), if he has not already considered doing so, to enter into the debate, to lend his remarks and his comments upon the report to us. I imagine he has read the report by now and has considered it. I would appreciate hearing from him.
The government faces, as do people in Ontario, a very serious problem. It is a problem which the committee was confronted with and a problem over which the committee anguished for some considerable length of time. It is a problem which obviously the government has had at its feet for some time and not been able to solve. The problem is getting worse instead of better, and there is not at this point any conceivable answer to the problem, at least as expressed by the government.
The committee has addressed the problem in quite a few pages and has come up with one solution. I would expect that the minister could tonight enlighten us as to whether or not the one concrete proposal put forward by the committee will be adopted. I put it that straightforwardly because I fear that like so many reports this one will be shelved and this one will be collecting dust. As the minister leaves the chamber, I will outline for him the problem which he is already aware of, that is, the problem of doctors opting out of OHIP.
This problem is something which has been brought up in the House during question period. The committee dealt with it. We have an increasing number of doctors in the province of Ontario opting out of OHIP to the point where obviously the universality of the program is threatened. I might read a section which was noted by the committee. It is this particular section which obviously the government is concerned about because if the universality is eroded, the government of Ontario stands in jeopardy with respect to its arrangements with the federal government for funding.
The Medical Care Act of 1970 reads in part: “The plan provides for and is administered and operated so as to provide for the furnishing of insured services upon uniform terms and conditions to all insurable residents of the province, by the payment of amounts in respect of the cost of insured services in accordance with the tariff of authorized payments established pursuant to the provincial law or in accordance with any other system of payment authorized by the provincial law, on a basis that provides for reasonable compensation for insured services rendered by medical practitioners and that does not impede or preclude, either directly or indirectly, whether by charges made to insured persons or otherwise, reasonable access to insured services by insured persons.”
It is that last part of the sentence which causes alarm in some communities around Ontario and causes alarm for me -- “reasonable access to insured services by insured persons.” In other words, if we reach the state where in a community most or all of the doctors opt out of OHIP, I would put to you, Mr. Speaker, that we no longer have that reasonable access to insured services by insured persons and that the plan is threatened.
The Minister of Health came before the committee and put it to us that he was concerned about this problem and that if the problem reached a certain magnitude he was prepared to act. He didn’t bother to tell us what magnitude nor how he was going to act. There was some suggestion by the minister that, if necessary, the government could be the provider of last resort, but it wasn’t specified under what precise conditions that would occur. That bothers me as well.
I would assume that, like any impending natural disaster, the government has a plan to put into place. We have assumed in this House for some time that if a flood occurs the government has a plan of action; if a bridge is washed out there is a plan of action to replace it. We find out now, of course, that about a third of the bridges in the province may in fact be washed out. We’re not sure whether the government can replace those. What is the government’s plan of action? What is the Minister of Health prepared to do? And at what point in time will he act?
I’ll wait for the minister, if he returns, to enter the debate and tell me whether or not we now have 17 per cent of the doctors in Ontario opted out of OHIP. If so, is that the magic number? Do we wait until 20 per cent have opted out? Or 25 per cent? What is it? How far do we let OHIP erode before the government is prepared to act? If they are prepared to act, precisely what is it they’re going to do?
That brings me to the one concrete suggestion the committee arrived at -- and I must remind you -- in unanimous agreement. That is that the system of payment, the fee for service, be linked to the utilization.
This plan is in place now in the province of Quebec and the reports we received in the committee were that the plan was working quite well. It works in this way: the government negotiates with the doctors, as they have been doing. They negotiate a two-year fee increase -- for example, as in Quebec, seven per cent the first year, seven and a half per cent the second year. But the second year is dependent upon the utilization rate not being increased. If the utilization rate increases overall in the province, then the fees are decreased -- the percentage is decreased.
What this does is keep that utilization in line. Why do we have to do that? Because it’s been the experience in this province and others that where fees are held in check doctors simply increase the number of patients they see. They run a revolving-door practice, and that isn’t good medicine. Some doctors will candidly admit that to you, but they feel it’s necessary in order to maintain their incomes. So you hold the fees in line and they will simply see more people. That’s what’s happening. Any studies that were done and so presented to the committee indicated that’s precisely what happens. So the one concrete suggestion which the committee came up with and agreed to unanimously would prevent that revolving-door syndrome from recurring ever again.
I’ll be very candid about it, and I still feel this way: I don’t think it’s unreasonable to expect that if a person is going to practise medicine in Ontario, he or she belong to OHIP. It’s simply a requirement. We’ve provided the public buildings for that person to receive training. We’ve provided the equipment. We’ve provided the instructors. We’ve probably spent the best part of $250,000 on that person to become a doctor. Is it unreasonable to expect that person will be part of our public health care system? I don’t think so. I think it’s entirely reasonable.
But being a conciliatory person by nature, and wanting to come up with a good, solid, unanimous report, I agreed with others on the committee we should try the negotiation method. That’s what we’ve stated. My fear is, as I stated before, that this suggestion by the committee, like so many other suggestions, will be filed somewhere and we won’t see any action. The situation in Ontario will continue to deteriorate. That’s why I hope the minister will return tonight and will answer the questions I have posed.
I must say it was refreshing for me to find, as we deliberated through several months, that our public health-care system has been successful, and for many reasons. We are able to deliver a fairly decent level of health-care services in Ontario. There are flaws and the committee noted them. The committee did a comparison of various provinces in Canada and other jurisdictions outside of Canada. We’re missing a dental-care program for children, for example, and the committee unanimously recommended that the government get going on a dental-care program for children. But overall it’s a good system and the citizens of Ontario are able, for the most part, to partake of a good health-care system.
When we examined the costs we found that our costs are in line with other jurisdictions. In fact, they were considerably less than the costs experienced in the United States of America. The committee further found that the reason was that we have a public health-care system whereas the Americans are saddled with a private-public health-care system, and the private system of course, as usual, is more costly. It was reassuring to us, I guess -- and this is a very personal comment. I take some pride in noting that in 1978 I can stand up and talk about a public health-care system in place, which I know Tommy Douglas fought so hard for in Saskatchewan and of which we in Ontario are the recipients. I appreciate that and I feel very grateful for it.
Mr. Conway: Long live the Socialist International.
Mr. Warner: We touched on quite a few matters in the committee, matters which I suppose are going to be buried. We talked about preventive medicine to a great extent. We realized, and the committee openly admitted, that the largest single cost to our health-care system is attributable to alcohol abuse. Admittedly, candidly, we don’t have any more definitive answers on how to solve that problem than others who have come before us.
The government sporadically has made attempts to curb alcohol abuse, and other governments in other places have tried as well. We should underscore to the public at large that alcohol abuse has contributed extensively to the cost of our health-care system. If we had some answers to alcohol abuse we would probably be able to lower the costs of our system dramatically, as well as, of course, providing the social benefit of people able to lead healthier and longer lives.
We had suggested in the report that the government take an active part, and by that we mean curbing the ads on television for the consumption of alcoholic beverages and providing alternative ads. We noted, for example, that in the United States when they started cutting back on the ads for smoking cigarettes they countered with ads pointing out the evils of smoking cigarettes. When those two were put into place, when they were balanced, there was a drop in the use of cigarettes. What we’re suggesting here is that the same approach be taken by the government and directed towards alcohol abuse.
I realize the government has a conflict of interest. Its revenues each year are about $400 million -- last year it was $385 million -- from the sale of alcoholic beverages in the province. That sizeable revenue can’t be ignored by the Treasury. I put to you, Mr. Speaker, that if the government were to find a way to curb alcohol abuse it would end up saving money in the health-care system. The revenues would be down, obviously, but they would save enormous amounts of money and the social benefit far outweighs whatever dollars they collect from the sale of alcohol.
We talked also in the committee about the use of emergency wards. I say that the six hours I spent on the emergency ward in Northwestern General Hospital were a revelation to me. I enjoyed it. It was a learning experience and it confirmed to me that the allegations made by Dr. Aitken, who was then the registrar for the College of Physicians and Surgeons, were utter nonsense. He came in and made the outrageous claim that two-thirds of all the people were ripping off the system. I challenged him on it. I went with him to the hospital and I served a six-hour stint. Lo and behold, as I had anticipated, his claims were absolutely unfounded. What was unfortunate about it was that because of his position his statement received some treatment and some notice by the press. I must say -- and it’s noted -- that he is no longer the registrar of the College of Physicians and Surgeons.
Emergency wards are serving a different function now I suspect from what they did 20 or 30 years ago. They are more ingrained in the communities. They are more a community clinic. They are a place of trust for the people in a community. That evening when I was there I found that most of the people who came in did not have a doctor or their doctor’s office was closed for the evening or the doctor had referred them to the hospital. In some cases, the doctor had gone on holidays and hadn’t bothered to make arrangements for his patients.
In all instances, there was an absolute need for the person to be at the hospital rather than at the doctor’s office. I suspect that is a different situation today from what it was 20 or 30 years ago. I guess the end result of that is that the Ministry of Health perhaps should take a look at a different funding mechanism for the emergency wards and hospitals because they are serving a different function today than they were previously.
Manpower substitution is a big word. It means we start using people other than doctors to make the health system function. That is extremely important but, make no mistake about it, the day the government decides to embark on it, it will be into a fight with the OMA. They know it because that was the experience in the province of Quebec. Community clinics came along with the use of nurse practitioners and people other than doctors. There was a considerable struggle with the doctors in the province. The province eventually won that one.
I wonder if this government is as courageous. I don’t know. I have nothing to date to show that they are, but perhaps there will be some new-found courage. That has to be a better way to start delivering services. I’m not sure whether it’s cheaper or not and I don’t make the claim that it may be cheaper. Maybe it is or maybe it isn’t I don’t know, but I do know one thing. That is, that manpower substitution may be extremely crucial in terms of reaching the aging population.
One thing which was noted by this committee, as has been noted by other committees is that our aging population is presenting some unique problems for us. Unless we start doing the planning now, we may not have any of the answers that are required. For example, the whole area of gerontology and geriatrics is one which requires a great deal of attention. Traditionally in this country we’ve done very little about it. Then again we haven’t had a very big elderly population, but we are getting a larger and larger elderly population. Are we ready for it? No, we’re not ready for it. In terms of counselling services or homecare services or visiting services, or whatever it is, I would suggest that we don’t necessarily need doctors, but we do need people who are trained in the area of gerontology. We’re not doing that.
Earlier today, Mr. Speaker, you will recall a question during question period about the nurse-practitioner program in Hamilton. The Speaker recalls that, as he recalls every question that is asked and the answers that are given, if answers are given. One of the comments which the committee made about the nurse-practitioner program in Hamilton was to get on with the program, get the people graduated from that program, turn to the district health councils and get some suggestions from them as to how they’re going to employ those people.
Mr. Conway: What was the Minister of Colleges and Universities (Miss Stephenson) trying to tell us today?
Mr. Warner: I’m never sure what she is trying to tell us.
There’s a section -- if members will just bear with me for a moment while I find the page -- yes: “The committee feels that the growing demands of older patients within the system increasingly can be met by introducing non-physician manpower, assuming an appropriate level of training. The Ministry of Health presently has targets for doctor-population ratios and has initiated a freeze on immigration and medical school places to reach their general goals. This program could be maintained in the face of increased requirements associated with an aging population by substituting paramedical personnel, trained in gerontology and other related disciplines. The committee is aware that the institutions are not presently structured to provide such training. Consideration will also have to be given to defining the roles and the responsibilities of these complementary disciplines and the medical profession.
“The short-term problem of how to employ the graduating nurse practitioners” -- and this is the Hamilton program -- “should receive more intensive consideration than it was possible for this committee to undertake this summer. In particular, it is recommended that the district health councils be immediately for means by which these graduates can be properly employed so that the present program can be maintained, and hopefully extended.” Perhaps when the minister responds he can answer that one as well.
I understand that at least one member from the Liberal Party wishes to use the remaining 10 minutes and that should also leave some time for the minister to respond. In closing, I echo many of the sentiments put forward earlier by my colleagues from Oshawa and Hamilton East. There are important items in this document. We could have solved the problem, which had been first put by the Liberal Party, about how to better pay for the system, but they weren’t willing to do that. So we fell upon stones. That’s unfortunate.
The issue isn’t over. It’s going to come back. Six provinces in this country do not have premiums, so eventually Ontario will sharpen up. It may take another government to do it, but nonetheless we’ll sharpen up sooner or later; the fight’s not over.
What I would like to know from the minister, as he meanders around some more, I would like to know whether or not he can solve the problem of opting-out physicians. That’s the key to our health care system in this province right now; and that’s a problem which he has not answered and I don’t know that he can.
The committee has put forward a suggestion, and I think a workable one. Is the minister prepared to meet that? Will he implement the suggestion put forward unanimously by the committee? Well it’s his chance to tell us.
Mrs. Campbell: Mr. Speaker, I will watch the time very closely.
I had not intended to participate in this debate because I wasn’t a member of the committee and I felt that there were others who were better able to address the report than I. But you know, Mr. Speaker, in the course of a career one does learn a few things, and I feel that one of the things that I learned, having had the advantage of being the budget chief for the city of Toronto, was to investigate very carefully all of the data which pertain to any kind of reform that one wants to achieve. While I was not a member of this committee, I was very much a part of the consideration and analysis of the data which were before us as we tried to reconcile the figures which we had, and which in this case I have to say were far more accurate than the figures which were coming to us from TEIGA in this particular situation.
Unlike the statements, or some of them, which have been made by the members of the third party, the thing that caused me concern was that from the figures that we had to study, we found that unfortunately some of those at the lowest end of the scale were those who would be hit by the various suggestions brought forward as alternatives to the premium system.
It is funny that we have a rule in this House about not ascribing motives to members, but we can ascribe motives to a whole party in discussing what is said to be an hypocrisy. I have been committed as the members of my caucus have been, to changing the premium system.
Mr. Warner: But not today.
Mrs. Campbell: I will tell you that I don’t intend to make a change that will, as far as the figures available to me are concerned, affect those who can least afford that change. Condemn me if you like for not making that decision but don’t call it an hypocrisy. I have always, and I think my record is clear, stood for those who are least able to afford some of the changes that are made.
The other point that I want to make follows very much along the lines of some of the latter remarks of the member for Scarborough-Ellesmere except that mine I think are somewhat mere generalized. I have a concern, and I am sure the minister must, in looking at and analysing the statistics before him. He must have concern about the growing older age group in our society. Obviously they are by their very nature calling on the health delivery system.
I don’t think the answers are exclusively as the member for Scarborough-Ellesmere puts them. I have in my riding as many as, perhaps more than, some members have in that particular age group. I think it is an over-simplification to talk about nurse practitioners or some of the paramedics exclusively as being necessary in this area.
Loneliness itself is a very difficult thing for people to live with as they grow older. Many of the people in my riding are people living very much unto themselves. For that very reason they develop problems related to health, but which don’t really come under the heading of health but rather under the heading of a lack of social intercourse in the community.
For a long time when I was at Metro I was one of those staunch advocates of the building of the homes for the aged and senior citizen apartments and the rest, and I think it was necessary. But I also think that in doing that and leaving it there we made a very serious mistake, because those very people who are in small apartments, as many of them are, really are almost condemned to live alone and to live segregated. So it seems to me we have to look a little deeper into that kind of situation to try to ensure that those people are enabled to live in the community, with the kinds of assistance that are available and should be increasingly available to them, rather than looking to the paramedics and others strictly in the health field.
I suppose I’m addressing my remarks at this time basically to the Provincial Secretary for Social Development (Mrs. Birch). It seems to me this is an area, a very large area, but one which is not to be exclusively in the health field, but rather, to be a combination between the health field, the Community and Social Services field and those people in the public at large who are trying to bring services to make life a little more enticing to older people who, regrettably, often seem to be divorced from their family for whatever reason. Perhaps only because of our more mobile kind of lifestyle, for whatever reason, they are isolated, lonely and do develop the problems which cause them to seek help in the health field because it seems to be the slot that they can get into.
I have talked before about our computer type of mentality, where people must conform to a slot in order to get care. Often the slot is the wrong slot. It needn’t be an expensive kind of operation, but in the interests of looking at the whole health field, it is urgent that we start now with a real thrust in this area if we are not going to face, down the road, very appreciably increased costs in the health field.
I want to say one other thing. In my riding I do have numbers of people who require very sophisticated health services because the medical profession has been so successful in prolonging life in so very many ways. I’m thinking of those on dialysis; people with other diseases which would have been fatal some years ago but are no longer fatal because of the advances in medicine. I don’t think we should always have a one-sided approach to the importance of those engaged in that field. I’m very grateful to them for the kinds of research they have done and I don’t for one moment begrudge the sophisticated care that goes to making life richer for those who are able to be treated in these sophisticated ways.
If the minister is going to respond to this, as he has been invited to do, I would very gladly yield to him at this point. If there is some indication that he is not going to respond --
Mr. Warner: You’re kidding. You’ve got to be kidding.
Mrs. Campbell: Is there no way we can invite or entice the minister to address himself, at least briefly, to some of the very real questions which have been posed?
Hon. Mr. Timbrell: On that may I say, given the hour, within a matter of a couple of days we have 11 hours of the estimates of my ministry. I thought it best not to try, in a very brief time, which couldn’t possibly do justice to the variety of issues raised. It’s not my intention to respond this evening but to do so in committee where we have all that time to explore a variety of issues, many of which I have already explored, in my appearance before the select committee.
Mr. Warner: I just have one brief point of privilege before I go on. I am in error. I forgot to pay tribute to and compliment the poor working persons of Hansard who lost numerous hours of sleep and acquired several additional grey hairs in order to accommodate the horrible hours that the committee sat. I regret having left that out of my earlier commendation of those people who assisted the committee.
Could the minister not answer the one question which I put to him about the opting-out doctors? Perhaps it’s not important to him but it is important to me and the people in Ontario. We have 10 minutes; isn’t that a sufficient amount of time to answer the question I put to him or is he just not interested? Is that what it is?
Mr. Peterson: Is this question period or what?
Mr. Sterling: That’s what the question period is for.
Mr. Warner: I’m glad it’s noted, Mr. Speaker, that the minister isn’t interested in the serious problem --
Mr. Speaker: Order.
Mr. Warner: -- of opting-out doctors. Thank you.
Mr. Sterling: That’s your conclusion.
Mr. Speaker: Are there any other members who wish to address themselves in the remaining time?
Mr. Peterson: It would be a terrible shame to adjourn this Legislature 10 minutes early. I’ll share a few of my reflections and I did not have an opportunity to sit on the committee although I know it was interesting and the members worked very hard, as did the Hansard people. The member for Scarborough-Ellesmere, in giving credit to people in Hansard, obviously would like a little credit for himself for sitting on the occasional evening. That isn’t the usual NDP style, because they get very upset if they’re a minute late for dinner or if the House sits a minute after 10:30. However, I give them all credit.
In my judgement, they collectively tried to attack probably the most serious problem that we are going to be facing in this province over a period of years. I think my colleague from St. George alluded to this when she talked about the percentage of elderly people, retired people now in the community. As I recall the number, something like 16.8 per cent of the people in the community now are at a retirement age. That will go up to about 18 per cent or 19 per cent by the end of the century and by the year 2031, something like 33 per cent.
We are a rapidly aging community. We are old by the UN standard, which says that we became old by their definition in the year 1971. We’re becoming progressively older given the present demographic trend, the changes in the birth rate and all of the other contributing factors. What that says is that there are going to be, in the future, increasingly heavy demands on an already and, in some respects, overburdened system.
Let me say personally, I have infinite respect for the health system in this province. I just had a personal experience last week. My little 14-month-old baby was sick. We were here in Toronto. We don’t have a doctor here in Toronto. We took him down to Sick Children’s Hospital and there is no institution in this country which could have been more sensitive, more intelligent or more efficient in the treating of my little baby as well as treating my wife and I very sensitively.
For that marvellous privilege of having that facility at 2:30 in the morning, I am grateful as a taxpayer. I am grateful as a citizen and in my emotion of the moment I would pay anything for that particular kind of service. I know we all feel that. We all feel the similar kind of response when we are in need of those services. When we are, there is no price that is too great individually or for society.
The question is going to be, however, one that will become more serious over a period of years. We have, for want of a better word, a pooled-risk system. We have the healthy look after the poor, and the non-user or the little-user looks after the heavier user. As these demographic changes come about and bring a myriad of social problems to this community, to the province of Ontario, to the country of Canada, I am not sure that we have given sufficient kinds of attention to the kind of planning that we need in the long term.
I think the systems that have evolved are working reasonably efficiently now. When one runs into a period of economic restraint, one puts on the brakes. If it eases up a bit, one loosens up a little bit. But I have the feeling that not enough serious thought has been applied to the problems as they are going to affect us in the next 10 or 20 years.
I think that is a perspective that is going to be increasingly important. I know that those aren’t the usual prerogatives or perspectives of political people. We are collectively trained to think in four-year cycles, and some of the great political evils have been because we have not, collectively as legislators -- and I don’t blame just one party -- been able to elevate our sights out for 10 or 20 years. It is my belief that we have made a great number of mistakes collectively and we are, daily, monthly and yearly, infringing upon the legacy that we are leaving to the young people behind us.
I think that the world my child grows up in, financially and in every other way is going to be a far more difficult and far more complicated one than the one I had the privilege to grow up it.
Mr. Foulds: Only if you blow the family fortune, David.
Mr. Peterson: Yes, that’s true, the member for Renfrew North is still going to be around; he will probably still be in college with my kid another 20 years.
When I look at the impact of these demographics on some of the great issues facing us, like the pension crisis when a higher percentage of our productive capital is going out into retirement incomes, when you extrapolate those same figures into the health system, we are probably going to find far fewer productive workers having to pay a much higher percentage of their disposable income to sustain health services for an older population.
I can understand the complexities of this issue to some extent and the difficulties of a committee dealing with this matter in the short period of time they have had. I respect the fact there is a dramatic difference of opinion, basically revolving around the issue of health-care financing as it exists at present. I would respectfully say to you, Mr. Speaker, that the questions 10 years, five years or 20 years from now are going to become increasingly more complicated.
I share from a philosophical point of view many of the views expressed by my colleague from Renfrew North. I happen to be far more attracted to a progressive kind of taxation system than I am to a regressive taxation. But I also understand the points of view expressed essentially by the Conservative Party.
Mr. Foulds: Yes, you would.
Ms. Gigantes: You can afford to.
Mr. Peterson: It is very difficult for any government to vacate a major revenue field today. We are going to see such extraordinary pressures on the progressive tax system, not only in health but in pensions, education and in all sorts of other areas, that there is a limit to how much we can load up the progressive taxation system. I don’t know where that magic balance is. Perhaps it’s a matter of political philosophy, perhaps it’s a matter for the day.
But when we are facing and seeing on a daily basis our previous hopes for sustained and large economic real growth on an annual basis in which we were used to six, seven or eight per cent real growth and we are now settling into two, three and four per cent real growth -- with no immediate prospects for changing that -- when we look ahead and we’re facing the new economic realities, increased energy prices; when we’re facing increased commodity prices and world-wide, very high inflation -- it’s an extraordinarily difficult problem for governments to handle -- then we see that we are going to have to look at some major restructuring of this problem.
I don’t think personally that it’s going to be able to be loaded completely on to the progressive tax system. We are already seeing examples of how our tax climate in this province is not necessarily competitive with some of the more aggressive or some of the luckier provinces.
Ms. Gigantes: Some of the smarter provinces.
Mr. Roy: The only reason they are smarter is because they hit oil.
Mr. Peterson: We are seeing investment fleeing this province on a daily basis. There is a limit to how much we can load that system before we kill the golden goose, before we kill that productive driving part of our economy that is in fact paying for the luxuries and the marvellous health systems that we here enjoy.
That is why I would like to see two things. I would like to see some more attention given to the matter of long-term financing -- and I am talking about 10 years from now, I am talking of a time when the demographic changes come to bear.
What we are talking about now, what essentially the committee dealt with was one issue, and that is how to extract $4 billion out of the Ontario economy in the fairest, most rational way. There are various different political points of view on that particular subject, all of which I respect, but I think that maybe some of the systems that we have in place aren’t going to serve this province well in another 10 years.
There is another issue I would like to have seen dealt with, Mr. Speaker. Even though there was some attention to cost efficiencies and to administrative efficiencies in the system, if I was drafting the terms of reference of that committee I personally would have liked to see more attention directed to that aspect of the problem. It is almost impossible, in the short life of a committee such as it was constituted, to do that kind of work, and I respect that; but I can think of no more worthwhile task for a committee of this Legislature, or members of this Legislature, than to look in great detail into the administrative efficiencies in the system, because we all know specific examples where we think they could be improved upon.
So these are just a couple of reflections I want to make in this debate. I have enjoyed it; I enjoyed reading the report and I compliment the members on undertaking a gargantuan task. I am sorry, in a sense, that we couldn’t get to a common resolution; maybe that’s the nature of the political process, particularly on a very contentious issue. But it was, I agree, a worthwhile exercise.
Hon. Mr. Timbrell: Mr. Speaker, before I move the adjournment of the House, I want to thank those members who have been so generous in their comments about the members of the staff of the Ministry of Health who assisted the select committee. I am pleased to say that Dr. Eugene Leblanc and his wife -- Dr. Leblanc being the head of our strategic planning and research branch -- were in the House the whole evening. I would only like to repeat to him, and those who assisted him in the ministry, my appreciation for the tremendous amount of time and work they put into the ministry’s presentations and the ongoing activities of the committee. Even though this is the largest ministry in the government, it still comes down to a small number of people who are the key decision-makers, and players as it were, in the process. Dr. Leblanc is certainly one of those people and I accept, on their behalf, the kind remarks of the members.
On motion by Hon. Mr. Timbrell, the House adjourned at 10:33 p.m.