Assemblée législative de l'Ontario

SAVINGS AND RESTRUCTURING ACT, 1995 / LOI DE 1995 SUR LES ÉCONOMIES ET LA RESTRUCTURATION

NORTH EASTERN ONTARIO PHARMACISTS ASSOCIATION

MICHEL LABELLE

POVERTY ACTION COMMITTEE

CANADIAN MENTAL HEALTH ASSOCIATION, TIMMINS BRANCH

CANADIAN UNION OF PUBLIC EMPLOYEES LOCAL 1140

PORCUPINE DISTRICT MEDICAL SOCIETY

ONTARIO PUBLIC SERVICE EMPLOYEES UNION NORTHEAST AREA COUNCIL

ONTARIO PUBLIC SERVICE EMPLOYEES UNION, LOCAL 645

CANADIAN UNION OF PUBLIC EMPLOYEES LOCAL 1214

PATIENT ACTION

CONTENTS

Monday 8 January 1996

Savings and Restructuring Act, 1995, Bill 26, Mr Eves / Loi de 1995 sur les économies et la restructuration, projet de loi 26, M. Eves

North Eastern Ontario Pharmacists Association

Kalvin Brown, president

Sandra Hutty, member

Michel Labelle

Poverty Action Committee

Suzette Courtemanche, executive director

Carl Warren, communication director

Canadian Mental Health Association, Timmins Branch

Catherine Yard, president

Judy Shanks, executive director

Canadian Union of Public Employees, Local 1140

Brenda Cooper, representative

Porcupine District Medical Society

Dr Claude Vezina, representative

Dr David Huggins, representative

Ontario Public Service Employees Union, Northeast Area Council

Helen Riehl, chair

Ontario Public Service Employees Union, Local 645

Douglas Heath, representative

Canadian Union of Public Employees, Local 1214

Nichole Daggett, representative

Patient Action

Ginette Lafond, founder and executive director

STANDING COMMITTEE ON GENERAL GOVERNMENT

Chair / Président: Carroll, Jack (Chatham-Kent PC)

*Carroll, Jack (Chatham-Kent PC)

Danford, Harry (Hastings-Peterborough PC)

Kells, Morley (Etobicoke-Lakeshore PC)

Marchese, Rosario (Fort York ND)

Sergio, Mario (Yorkview L)

Stewart, R. Gary (Peterborough PC)

*In attendance / présents

Substitutions present / Membres remplaçants présents:

Johns, Helen (Huron PC) for Mr Danford

Miclash, Frank (Kenora L) for Mr Sergio

Clement, Tony (Brampton South / -Sud PC) for Mr Kells

Ecker, Janet (Durham West / -Ouest PC) for Mr Stewart

Lankin, Frances (Beaches-Woodbine ND) for Mr Marchese

Also taking part / Autre participants et participantes:

Bisson, Gilles (Cochrane South / -Sud ND)

Brown, Michael A. (Algoma-Manitoulin L)

McLeod, Lyn (Fort William L)

Ramsay, David (Timiskaming L)

Wood, Len (Cochrane North / -Nord ND)

Clerk / Greffière: Grannum, Tonia

Staff / Personnel: Campbell, Elaine, research officer, Legislative Research Service

The committee met at 0900 in the Senator Hotel, Timmins.

SAVINGS AND RESTRUCTURING ACT, 1995 / LOI DE 1995 SUR LES ÉCONOMIES ET LA RESTRUCTURATION

Consideration of Bill 26, An Act to achieve Fiscal Savings and to promote Economic Prosperity through Public Sector Restructuring, Streamlining and Efficiency and to implement other aspects of the Government's Economic Agenda / Projet de loi 26, Loi visant à réaliser des économies budgétaires et à favoriser la prospérité économique par la restructuration, la rationalisation et l'efficience du secteur public et visant à mettre en oeuvre d'autres aspects du programme économique du gouvernement.

The Chair (Mr Jack Carroll): Good morning, everyone, and welcome to the standing committee on general government hearings on Bill 26 and to Timmins. We're delighted to be here as a committee.

A couple of housekeeping things before we start. Summaries have been handed out to those members who were part of the hearings in Toronto before Christmas. You've been handed those by the research department.

Secondly, as far as time goes, every presenter has half an hour of time. They can use that time as they see fit. Any time left over at the end of the presentation for questions is divided evenly among the three parties and we start in rotation. We would start with the Liberal Party for the first set of questions. We tend to hold a fairly tight time line on the 30 minutes, so please don't be offended if the Chair happens to cut you off. We do have a lot of hearings and we are on a fairly tight time schedule, so those are the rules we play by.

As well, for those people who are here to listen to the hearings, we appreciate your attendance. It's nice to see you here. I'd just like to make you aware of the fact that the dialogue is between the people sitting at the table. I'm sure you will appreciate that and adhere to that.

NORTH EASTERN ONTARIO PHARMACISTS ASSOCIATION

The Chair: Our first group this morning is from the North Eastern Ontario Pharmacists Association, represented by Kalvin Brown, the president, Nancy Meyer, the secretary, Rachel Pineault, the private sector benefits manager and Sandra Hutty, a member from Sudbury. Welcome to our committee. The floor is yours.

Mr Kalvin Brown: Our association over the past year has been working with local employers to achieve sustainable, long-term cost savings. This initiative is known as the Timmins project. In dealing with the private sector in ongoing cooperative efforts, we have together developed unique ways in which to control and reduce drug plan expenditures. Some of these techniques are applicable to ODB, or Ontario drug benefit, and may lead to savings in that area. We would like to share our experience in the Timmins project and the success we have had in controlling and reducing drug plan costs for these employers.

We are not here to complain about the need for cost containment; rather we are here to offer concrete and workable applications to render long-term savings for the province we all live in. With the aforementioned goals in mind, we will look into four areas: days supply of medication, rational prescribing guidelines, deregulation and copayments.

The concept that must be understood and agreed upon by any group dealing with drug plans is that the overriding bulk of the prescription dollar is spent on the drug itself. For the private sector, this total is somewhere around 70% of the cost of the prescription. For ODB that percentage would be even higher.

This being the case, it makes common sense to target the cost of the drug as the main mechanism to achieve long-term savings. The government has made a start in this direction, but we see further opportunities to achieve savings and reduce wastage.

Several studies have recently pointed out the potential savings in reducing waste. In fact, an article in the last issue of Pharmacy Practice points out the huge savings to be had by reducing non-compliance by consumers. The study was conducted by the University of Toronto, the Addiction Research Foundation, the University of Guelph and the Toronto Hospital.

For example, assume the cost of Losec for one month is $88. This medication should be dispensed only monthly. Currently the medication can be dispensed up to 100 days or three months. Thus, if three months were handed out and the patient for any reason changed medications or stopped using the Losec 10 days after getting the prescription, the loss to the Ontario taxpayer is $234. The professional fee is the only variable in this equation and can in fact be used to determine the price breakpoint. If the medication were a new prescription, it should be given out only for 10 days in order to allow for an adequate trial. If the patient for some reason could not continue, the savings would be $58.67. The savings on reduction in wastage would more than compensate for the small amount in increased professional fees.

We propose two things: First, if the cost of medications exceeds the professional fee for a year, dispense the medication in a monthly supply. Second, new medications which are expensive be given out in a trial prescription to evaluate side-effects. This is one of the mechanisms we currently use to determine the number of days supply for those employers involved in the Timmins project.

Rational prescribing guidelines: The actual cost of medication and not the professional fee makes up the largest part of the average prescription. Over the last 10 years the cost of medication has increased at a rate of 18%, compared to the professional fee, which has been cut by 5.5%.

Perhaps we should be legislating the manufacturers of medications to post the actual cost of making a product and what markup they are placing on the product. This would allow all parties to know exactly where their money is going.

To attain real cost savings the focus should be on the drug entity itself. Pharmacists are the best source of unbiased drug information for both patients and physicians. This places pharmacists in the pivotal role of being able to recommend rational medications which are cost-effective.

For example, the cost of two capsules of Prozac 10 mg is $3.27 while the cost of one capsule of Prozac 20 mg is $1.67. If a prescription for Prozac 10 mg, two at bedtime, were written by the physician, you can see the vast cost savings which a pharmacist can generate by dialoguing. The pharmacist is probably the only health care professional who would be aware of this type of saving.

Prescribing guidelines which have already been set up for anti-infective and anti-hypertensive drugs should be looked at as a means of cost saving.

An example from the Anti-infective Guidelines for Community Acquired Infections follows: Otitis Media: Acute drugs of choice. As you can see, first-, second- and third-line antibiotics are listed as well as their cost per day.

In general, the older antibiotics should not be discarded for newer drugs unless efficacy is substantially improved, toxicity is reduced or overall effectiveness is greater. If there is no rational need to use Biaxin but the physician chooses the drug anyway, the cost would be 18 times more than either the first- or second-line choices.

We propose a tiered system of rational drug prescribing that can be guided using software that pays for the right drug at the right time in consultation with the patient, physician and pharmacist.

The guidelines we are speaking about are already in place and supported by ODB, family physicians, specialists, pharmacists, drug manufacturers and associations. All that is needed is a mechanism to ensure the use of these rational guidelines.

We feel this system can yield rational drug utilization as well as cost saving in excess of any proposed by the current changes.

Deregulation: Larger multinational drug companies with long patents remaining will likely raise their prices to the international standards, which are much higher than have been allowed in Ontario since 1986. The BAP, or best available price, system has worked effectively to keep drug prices down. Its destruction will mean higher costs for drugs. For a lot of businesses the increase in drug costs may lead to cancellation of drug plans. The result may be increased enrolment in the Trillium drug plan. In turn, this will lead to increasing future costs for the Ontario taxpayer.

The following is a direct quote from a local employer in Timmins:

"We believe the present BAP system for non-ODB patients should be left in place. Our insurance carrier has already promised higher premiums for our employees' drug plan due to these anticipated higher wholesale drug costs. When our renewal comes up in February, we will cancel our drug plan component and have our employees apply for the Trillium drug plan. This will also apply for my wife's store as well as my partner's delivery company. If thousands of small employers across Ontario take this same route, it will raise the costs of the Trillium drug plan into the millions more than projected.

"It is this kind of flawed logic which permeates Bill 26. In order to save taxpayers from a financial fiasco, the bill should be taken back and reworked."

The new legislation will kill Bills 54 and 55, and some pharmacies will bill higher copayments to seniors than the currently negotiated professional fee. This will be especially true in towns with only one pharmacy and in northern communities where access is limited. The bill also opens up questions in terms of buying. If employers can negotiate directly with a drug company, only the largest will get a good price. The smaller companies will pay more, in order to subsidize deals for large employers. The Ontario taxpayer gains lost drug plans and small business closures. If we attempt to control drug use based on price competition, we are recreating the American system of health care. Perhaps before we do this we should have a close look at the per capita expenditures in the American system.

We propose that the BAP system is cost-effective and maintains an even playing field and therefore should remain unchanged.

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Copayments: Currently the OCP, the Ontario College of Pharmacists, a self-regulating body, sets standards of practice. What these standards do is ensure documentation of pharmacists' professional functions. This has put in place a mechanism to make our role as essential health care providers transparent. It has taken the recommendations of the Lowy commission and made them a reality. As pharmacists, we now document what we do for the Ontario taxpayer. This has put in place a mechanism to allow constructive dialogue with the OPA, the Ontario Pharmacists' Association, and government on reimbursement for the professional services we provide.

Deterrents created to limit access to pharmacists will potentially increase costs. Pharmacists are the most accessible and trusted health care professionals. If people can no longer afford to get their prescriptions filled, the increase in hospital costs could be staggering. We need rational use of the resources we have. Pharmacists are a cost-effective way to ensure understanding of prescriptions and to work with patients in getting the greatest benefit from all medications. We have the ODB plan in place because it is a very cost-effective way to reduce health care expenditures. In creating cost penalties for utilization of this cost-effective service, we are defeating its essential goal.

With respect to copayments for seniors over the income threshold, we believe there are other ways of implementing effective cost-sharing. As one example, the cost-sharing component can be set up as a monthly insurance plan, much like an insurance plan you buy when you travel out of province.

To summarize, we propose:

First, if the cost of medications exceeds the professional fee for a year, dispense the medication in a monthly supply.

Second, new medications which are expensive be given out in a trial prescription to evaluate side-effects.

We propose a tiered system of rational drug prescribing that can be guided using software that pays for the right drug at the right time in consultation with the patient, physician and pharmacist.

We propose that the BAP system is cost-effective and maintains a level playing field and therefore should remain unchanged.

The Chair: Thank you. We have about five minutes per party for questions, beginning with the Liberals.

Mrs Lyn McLeod (Fort William): I appreciate your presentation, and you've addressed two of the key concerns that we have as we look at the aspects of this bill that affect prescription drugs, one obviously being the deregulation of drugs and what that is going to do to the cost of drugs and the other being the whole question of the copayments. There are a number of questions around the ultimate cost of copayments and the effect that will have on access to pharmacists and to the drugs that are needed.

I'd like to then see if you've had a chance to look at some of the other parts of the bill that relate directly to pharmacists and the professional work of pharmacists. I'll just mention three areas, and if you've had a chance to look at any of the three, you might comment on it. In the interests of time, I won't make them separate questions.

One is that, in our reading of the bill, and it's actually section 23, the bill appears for the first time to give the cabinet, the politicians the ability to set conditions on the prescription of drugs, and as I understand it, this would be setting essentially government in place of the professional judgement of pharmacists and physicians as to what the appropriate prescriptions are. If you have any comment or concern about that, I'd appreciate your comments.

There is also the section of the bill that if there is any substitution for those who are on the Ontario drug benefit plan, the cost of the substitution would have to be paid for by the patient. I wonder, as pharmacists -- and you've indicated in your brief that there are some situations in which an alternative to the least-expensive drug would be preferred for a patient -- whether you would want to see some process in place to be able to provide a substitution for certain individuals.

Third is the fact that there are considerable powers to disclose information about the prescriptions you're giving to patients in order to implement the user fee program, whether that causes you concern as professional pharmacists.

So any or all three, if you have comments in the few minutes we have.

Miss Sandra Hutty: All of these areas cause us considerable concern. First of all, by the cabinet taking over the power to decide what is or is not possible, by writing out any consultation, what they have done is remove any possibility of consultation, of advice. We have proposed in the past many ways of saving money for the government and they have just said, "No, we just don't want to listen to you any more." What they're doing is closing the door for any possible dialogue.

That causes great concern to us. We feel the patient should be able to choose or have some option for getting a product; for instance, if you have a patient who's allergic to some of the ingredients that hold a tablet together, even though the active ingredient may be the same as the product prescribed by the physician. They're not going to have that option any longer, so they will be paying out of their pocket, usually the poorest and least able to pay in most cases.

Freedom of information: Obviously, we feel that is a matter between the pharmacist and the patient, the physician and the patient, that there should be no way of identifying any information about a particular patient. That has been removed from the regulation so it causes us a great deal of concern.

Ms Frances Lankin (Beaches-Woodbine): Thank you very much and welcome. We appreciate your presentation. I have questions in three areas, so I'll try and go through them one at a time, but fairly quickly.

First of all, on your proposal with respect to a tiered system of rational drug prescribing, I can't tell you how much I agree with you. A lot of work has been done in the last number of years coming out of Lowy and a number of other studies, as I understand it from the time when I was Minister of Health. Everyone has said that the way to control the number of drugs, particularly that seniors are getting, is not by putting the user fee on, but by having good prescribing guidelines affecting the prescribing practice of physicians, so that they better understand and there's a closer link with pharmacists so the pharmacological expertise you have can be brought to bear in the patients' goodwill.

Can you tell me what effect you think the copayment will have, because we've heard members from the government say that too many seniors are getting too many drugs and that this $2 copayment will help discourage that? Is that your understanding of the effect the copayment will have, and could you comment on that versus prescribing guidelines?

Mr Kalvin Brown: Currently, copayments do exist in other provinces, and we've had a look at the effect it has had on utilization in other provinces. The most recent data come out of BC, and when they jumped their copay up, in fact it increased utilization, that they supply the medications, it went up, not down, so it didn't really do anything to discourage utilization; it just increased the amount of medications people were getting. So we don't really see any benefit to putting a copay into place.

Ms Lankin: If I can continue on with respect to copayments, the last day of hearings in Toronto we asked for a ministry representative to come forward, and Mary Catherine Lindberg, the assistant deputy minister, came forward. When I asked her if she would explain to us how the copayment was going to be collected -- we thought this was interesting -- it seems as best I could understand the answer that that hasn't been worked out yet and there are a lot of details that are very, very sketchy, but it sounded like one of the ideas was that it would all be up to the pharmacist, and there was a suggestion that for those over the threshold, on the dispensing fee, the professional fee that you charge, some of you may waive $2 of that in order to make up for the copayment that seniors would have to pay; it seems to me that then the burden falls on pharmacists to make up the money for the government as opposed to anybody else.

Have you been given any information or have you been told you're going to be responsible for collecting this? Have you thought about what it means in terms of administering this at the pharmacy level?

Miss Hutty: We have been given absolutely no information at all. That concerns us because we're getting a lot of questions from the public. What also concerns us is the fact that somebody at $15,500 per year, for instance, will be paying $2 a prescription, which in many cases will be difficult for them if they have 10 or 12 prescriptions a month. But then you jump to somebody who has an income of $16,500 and they will be asked to pay the $100 per year plus $6.11 per prescription.

What we would like to know from the government is how it decides that $1,000 difference in income decides that the patient has to pay several hundred dollars more per year. When you look at somebody who is paying $6.11 per prescription and has 10 or 12 prescriptions a month, they're looking at something like $74 per month as a deductible. Not only do we have no idea how we will be expected to go about collecting the deductible, but we would like to know how the government decides the income threshold and how it's going to go about determining that.

0920

Ms Lankin: My last question is with respect to the government's plan to deregulate the price controls on drugs for all the rest of the people in Ontario who aren't on the Ontario drug benefit plan. There's two parts, I guess, to this question.

The pharmaceutical industry says that competition will bring down the price of the drugs. You indicate you think if large companies and large purchasers and even large pharmacy chains negotiate a good deal, someone else has got to make up the difference. They point to pharmacists and suggest that the markup is an area that should be public, because the markup could be an area of differentiation. The pharmacists I've heard come forward before have said, "No, it wouldn't be us; it would be the drug companies." In fact you actually, I think quite fairly, say that in small towns with one pharmacy with a monopoly, that could be a problem too.

I just wondered if you could comment on that, because as someone outside the industry, I worry about both parts of this. I worry about the pharmaceutical industry price they charge and about what the pharmacist does with the markup and particularly in small, rural Ontario and northern Ontario.

The Chair: Unfortunately, there's no time left to answer the question.

Ms Lankin: Maybe you can answer in response to one of the government's questions.

Mrs Helen Johns (Huron): Thank you for being here today. We appreciate your time and obviously the thought that went into your presentation.

I'd just like to follow a different line of thought from what the previous two parties have been talking about. The Ontario drug benefit program has tripled in the last 10 years. Spending that the taxpayers of Ontario are paying for the ODB has moved from $375 million to $1.2 billion. It's really increased in the last 10 years, to the point that some people, taxpayers of Ontario, are wondering how we can control this.

Obviously, our reason for initiating Bill 26 is to try to manage the health care system. We believe that the only way we can do that is by some of the things we have proposed in Bill 26 when it comes to the ODB program, when it comes to copayments, elimination of no-substitute claims.

You basically have said you don't agree with any of those. Tell us how you would better manage the system to stop these escalating costs that are growing at the kind of rate they are, because we know they have been for the last 10 years.

Mr Kalvin Brown: As we've already indicated, we had a number of proposals, the first being using the right drug at the right time for the right patient. That alone, as we indicated, with the overhead yields tremendous savings. In fact, we went through this proposal with a number of private employers in town and they agreed with us. We instituted those kinds of savings and we have generated reduction in costs for a number of employers.

It works. It's been put in place. We just need the consultation with the pharmacists, the physicians, and we need the patient in the loop as well. It's not that people are unwilling to look at alternatives; it's just that nobody has had the chance to propose them.

Mrs Johns: I guess I misunderstand you, because when I was reading along with you, I thought you were saying that was already in place, and we know the costs have been escalating up until this day.

Mr Kalvin Brown: No, I said the system was already potentially in place. We have the information out there. What we need is a mechanism to use it. What we're doing is working with private employers at this point. We have had very little contact with the government. Any of the changes we've instituted locally are with private employers.

Mrs Johns: You talked about copayments and you basically said you didn't think that would stop the increase in dollars being spent in drugs. Can you talk about something that you think may help, or are we back to the bad example again?

Miss Hutty: As Kalvin has already indicated, we have been working with a number of private corporations and the kind of things they have been using that have been used by the governments in British Columbia and Quebec, things like trial prescription programs. When a patient gets a new prescription for one of the more expensive products, it's given for a limited period of time, for instance, seven to 10 days, and then if that is the appropriate medication for the patient the rest of the supply is given.

It was found in Quebec that in 50% of the prescriptions that second quantity was not picked up by the patient, which indicates that if, as happens here in Ontario at the moment, we give a three months' supply they use it for seven to 10 days and then throw away the rest. Medicine cabinet cleanups in various cities have demonstrated that very clearly. So the trial prescription program is one example.

Another one is that as indicated in antibiotic guidelines printed by the provincial government, you use the antibiotic in a certain sort of step method. You start with sort of an antibiotic that generally functions for these -- in pneumonia, for instance, if there is an antibiotic-resistant pneumonia, then you go to a second level of antibiotic which is generally more expensive, but in 75% of the cases the initial antibiotic is the effective one, and you're saving $60 to $70 per patient per prescription by following the currently printed guidelines.

The Chair: We thank you for your presentation and your interest in our process.

Miss Hutty: We thank you for the opportunity.

Ms Lankin: Mr Chair, I'd like to place a motion before the committee.

Whereas there has been overwhelming public interest in Bill 26 and that 1,026 groups and individuals have requested to appear before the standing committee on general government for the out-of-town hearings which far exceed the 274 spaces available for hearings; I move that this committee recommends to the government House leader that when the House returns on January 29, 1996, that the order with respect to Bill 26 be amended and that the bill be returned to the standing committee on general government so that further public hearings can be arranged out of town; further, that this committee recommends that the three House leaders meet as soon as possible to discuss the issue.

I have copies available for the clerk.

The Chair: Out of respect for the people who are here to make presentations, do I have unanimous consent to deal with this at lunchtime?

Ms Lankin: Absolutely.

Mr Tony Clement (Brampton South): Mr Chairman, I'm wondering, have you made a ruling yet as to whether this is in order, given the motion that was passed by the Legislature to deal with the time allocation with respect to this committee and its position on January 29?

Ms Lankin: If it's of any assistance, Mr Clement, I was very careful in checking with the clerk's office to ensure that this motion was in order, as the previous ones that I moved in the first week of hearings, and that it was substantially different from those so that it wasn't a motion that this committee had already dealt with.

Mr Clement: Well, my question --

The Chair: Excuse me. The decision on the motion and the debate on the motion will take place at lunchtime out of respect for the people who are here being given their time to make a presentation. Can everybody agree with that? Agreed.

Mr Clement: Mr Chairman, by virtue of the committee, I also have the responses from the Ministry of Health with respect to Ms Lankin's questions on December 21 and 22, 1995, including the copayment issue that she raised in her discussion with the former presenters. I'd like to table those.

The Chair: We'll have the clerk distribute those.

MICHEL LABELLE

The Chair: Our next presenters are from the Canadian Auto Workers, Michel Labelle. Welcome to our committee. You have a half hour to use as you see fit. Any time you leave for questions would begin with the NDP and be split evenly. The floor is yours, sir.

Mr Michel Labelle: First, I'd like to welcome you all to Timmins and maybe give an introduction of who I am and what I do. I'm an electrician. I'm a rank-and-file person who has taken an interest in Bill 26. I'm married, I have three children and we are also users of the health care system in Ontario. The brief that you have in front of you was prepared by myself and my wife, and the way it's laid out is that we've just looked at all the different acts that have been amended and we've basically broken them down into sections, looking at each amendment and coming up with interpretations.

The first amendment, in subsection 8(2), appointments to commission by Lieutenant Governor, is part of part I of schedule F, "Health Services Restructuring." It goes to the sixth amendment, sections 5 and 6, and the interpretation that we've come up with is these sections replace previous legislation and give the Minister of Health sole authority in the distribution of provincial aid to hospitals. He may unilaterally decide, at his discretion, which hospitals or medical facilities will receive grants, loans or financial assistance. He may impose, amend or remove any terms and conditions he considers appropriate in respect of the distribution of funds. The minister also determines the manner in which grants or loans are secured. He may reduce, suspend, withhold or terminate any grant, loan or financial assistance if he considers it in the public interest to do so. The Minister of Health may direct the board of a hospital as to what services they will provide, and increase or decrease these services. He may close or amalgamate any hospital or make any other direction related to a hospital that he considers in the public interest. These amendments also ensure compliance to the directions of the minister by the hospital boards.

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The seventh amendment: The interpretation is that investigators appointed by the Lieutenant Governor in Council report to the Lieutenant Governor or the Minister of Health and have the authority to investigate management and administration of a hospital, quality of care and treatment of patients or any other matter, again, the Lieutenant Governor deems relevant.

Section 9 is the directions to be followed. Again, like investigators, a hospital supervisor is appointed by the Lieutenant Governor in Council, is bound to carry out every direction of the Minister of Health, and reports to the minister. He has the exclusive right to exercise all the powers of the hospital board whether the hospital is public or is privately owned. He has unrestricted access to documents, records and information of the board and the hospital. He has the same rights basically as the hospital administrator and the board.

Subsection 9.1 deals with public interest and no proceedings against the crown. We couldn't find anything in the document that defines what public interest is in the sense of the act. I guess it's left to the minister to decide what's in the public interest.

Interpretation: This amendment is one of the broadest in the document. It affords the Lieutenant Governor and the Minister of Health the right to consider "any matter they regard as relevant" in making a decision in the public interest regarding hospital or health care services. This amendment also specifies that no one has legal recourse against the crown or the Minister of Health in respect to sections 5, 6, 8 and 9 of this bill.

The 10th amendment deals with bylaws. We interpret it as such: It requires hospital boards to pass bylaws in line with the new legislation.

If we look at the 11th and the 13th amendment, it amends section 32. It gives supervisor powers over hospital boards and bylaws.

We interpret it as such: Section 32 gives the Minister of Health new powers to regulate the appointment of physicians. He requires hospital boards to submit their physician human resource plans to the ministry for approval. They must amend their plan as required by the ministry and are restricted to appointing physicians to the medical staff only in accordance with the approved physicians' human resource plan.

The 14th amendment: Where hospitals cease to operate, there are no hearings or protection from liability.

We interpret it as such: In cases where hospitals cease to operate -- a decision of the hospital board or the Minister of Health -- the minister reserves the right to reject the application of a physician for reappointment, to revoke the appointment of any physician or to cancel or alter the privileges of any physician. Doctors are barred from legal action against owners or operators of hospitals in subsection 44(4). We have to wonder exactly what that's going to bring to the quality of health care, especially in areas like northern Ontario, should the minister decide to exercise some of these wide-sweeping powers.

Section 15.4 goes from notice to no right to appeal, temporary control, authority of the minister, appointments; it talks about termination of order, repairs and recovery of costs.

Interpretation: The Minister of Health may at any time unilaterally revoke any private hospital's licence. He may make this decision based on financial considerations or any matter he deems relevant, with no prior notice to the licensee. He is protected under section 15.4 against any legal recourse for his actions. He also has the right to temporary control of any hospital for which he has revoked a licence and legal access to payments for repairs to the hospital from any person or persons to whom the licence was issued. Again, there are ample provisions for legal protection for the Minister of Health.

Part IV is Amendments to the Independent Health Facilities Act.

Interpretation: I will not list all of part IV but comment on it as a whole. The act broadens the term "facility fee" to include any segment of service that the minister redefines. Independent health facilities would be allowed to charge fees over and above what is now covered by insurance to certain persons defined by regulation. The minister could, through regulation, include any for-profit independent facilities and effectively open the door to a two-tiered system. Extra billing for insured persons could result if the present uses of independent health facilities are expanded.

That concludes schedule F.

Schedule G: There are some amendments to the Ontario Drug Benefit Act, the Prescription Drug Cost Regulation Act and the Regulated Health Professions Act.

Part I is amendments to the Ontario Drug Benefit Act, and there are various amendments there. We've just interpreted all the way through schedule G. Although schedule G is not listed in its entirety, I will comment on many parts of the schedule. It amends the Ontario Drug Benefit Act, the Prescription Drug Cost Regulation Act and the Regulated Health Professions Act, 1991. This legislation takes the words "user fees" and spells them "copayments."

Part II is the Prescription Drug Cost Regulation Act. The 19th amendment: "The title of the Prescription Drug Cost Regulation Act is repealed" and substituted with the "Drug Interchangeability and Dispensing Fee Act."

Interpretation: This is an example of this government's feeble attempt to disguise new pieces of legislation by changing the name of an old one. The cost regulation of drugs no longer exists; it is gutted. This means that Ontario will become the only province that does not regulate drug prices. Schedule G allows for the substitution of brand-name drugs with generic drugs. Should a generic drug not be available to a patient where the Minister of Health has accepted it as a substitute for the name brand, the patient will be required to pay the difference between the price of the generic drug and the brand name. The minister will abolish the 10% to 20% markup on drugs and the Ontario drug benefit dispensing fee and set new regulations not yet disclosed. We have no part of knowing what the regulations will be.

If we go through the rest of the amendments, which are many, it brings us to the interpretation of those regulations in schedule H. Schedule H gives a new definition to the term "eligible physician." It gives the minister powers to restrict the number of eligible physicians in any areas of the province and imposes a moratorium on new eligible physicians.

Schedule H also redefines "insured services." It allows the Minister of Health to dictate insurable medical services with no consultation with medical professionals. Medically necessary services are also not spelled out in this bill. The minister is allowed to establish the conditions and limitations for insurable services and set levels for OHIP. There are factors such as geography and the physician's experience that will determine the fee payable.

The regulation system has dangers of delisting medically necessary services in attempting to find cuts. These decisions should be left in the hands of the Ontario Medical Association through a negotiation process with the government. The unilateral powers this legislation will give to the Minister of Health are undemocratic. He is in no way qualified to make such decisions. It is an insult to our health care professionals to attempt to strip them of the consultation process. This legislation could open doors to a two-tiered health system in Ontario.

Schedule I kind of backs up what I said on schedule H. This new law strips the Ontario Medical Association of all its negotiated agreements and negotiating rights. It also overrules any judge's decision, award or order if it is contrary to the law.

In summary, the "common sense" government, with its Common Sense Revolution, states, in the introduction of your CSR: "It's time for us to take a fresh look at government. To reinvent the way it works, to make it work for people. While many goals remain important to us -- creating jobs, providing safe communities, protecting health care...." etc -- I'll just go from quote to quote. "Total `non-priority' spending will be reduced by 20% in three years, without touching a penny of health care funding," page 3, item 2. "We will not cut health care spending. It's far too important." That's on page 7 of your CSR. "For the professionals within our health care system, this means freedom to find more efficient ways of spending without worrying that government will siphon their savings off into other programs," page 8. "Health care, law enforcement and classroom funding won't be touched"; that's on page 19. "We are ready to listen, to learn and to work with anyone who wants to join us and who can show us more creative, more effective ways to end waste and duplication." That's part of the summary of the CSR. "We will provide the people of Ontario with better for less," page 3.

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Are copayments and user fees better or less? Already we have seen massive cuts to our health care system. And to top it off, this promise: "Under this plan there will be no new user fees." Lies again, and again, nothing but betrayal of trust and lies.

It took years of painstaking work, trial and error to formulate legislation, with changes and amendments coming slowly. Progress takes time. When you rush, you make mistakes. It is irresponsible at best and dangerous at worst for any government to attempt to bring massive changes to our health care system without consulting health care professionals as to what impact it will have on the quality of that care.

What concerns me most, and I think I speak for many people, is the dictatorial nature of these amendments. This bill is an attempted assault on Ontarians. It threatens our rights by giving potential access to private information. There is a blue blanket that covers our province today. We have felt it smothering us under unworkable labour legislation. This blanket is hand-woven, and it's hand-woven with threads of dictatorship.

In closing, if this is an exercise in futility, if these hearings are only to appease the outcry, if despite these hearings the PC Party follows through with this omnibus bill without listening to Ontarians, take notice all the way to Queen's Park that we will start a revolution, a true "common sense" revolution, to educate the people of Ontario. We will work in earnest to thwart your efforts at changing our province from a place to grow to a place where no one wants to go. We deserve better than your government is telling us is a "common sense" approach to good health care.

Thank you for your consideration.

The Chair: Thank you very much. We've left just under five minutes per party for questions, beginning with the NDP.

Mr Gilles Bisson (Cochrane South): Mr Labelle, I just want to pass on the comment that there's an extreme amount of research in this document and I would thank you and whoever helped you, because there's a lot of detailed look at the actual legislation and amendments. I think I would want to first of all speak on behalf of at least our members of the caucus here who were looking at it, saying, "Thanks for the insight into this."

I want to go to one point really quickly, and I'll pass on to Mr Wood here from Cochrane North. One of the things that you allude to in your presentation -- you go through a whole explanation of basically what the bill does in regard to the health care sector -- is to take the power out of the hands of local decision-makers, be it hospital boards, hospital administrators etc, the model of where we try to put decisions at the local level in order to respond to what's happening within our communities, to where it is possible that a minister can take over complete control of a hospital or a hospital board.

You talked about dictatorship. I'd like you to maybe expand on that a bit. The government is saying it needs the tools. They've got to be able to balance the budget; they need to eliminate the deficit. They're saying this bill is all about tools in order to do that. Is the toolbox needing, in your mind, to be that heavy, giving that kind of power to the minister, or should we be trying to find a way of working with communities?

Mr Labelle: I think that Timmins may be a good example of the way the system does work. We've had two hospitals that the district hospital councils here have closed on their own. They didn't need interference from the provincial level to do it. They saw the need, they saw that these hospitals were redundant in nature, and they amalgamated them on their own with the Timmins and District Hospital.

Right now we're just looking at the health part of the bill. If you take a look at all of Bill 26, it doesn't just include health, now, does it? It goes into municipalities, it touches all kinds of different areas that are also trying to bring these same wide, sweeping ranges of powers to different ministers with portfolios. I don't believe Ontarians need to have that kind of interference in their municipalities, in their health care system or any other system for that matter. We elect officials, boards are appointed by those officials or elected by the people, and I think that process works fine. I don't think we need to fix anything that's not broken.

Mr Bisson: One of the things you alluded to -- you pointed it out, and it's not one of the things a lot of people talk about -- presently, if I'm unhappy with the decision made by my local board, I can go and talk to my local board member, the administrator etc. One of the things this bill does, in the event that the minister takes over the running of the board, is that he or she is immune to any kind of action by a community and can't even be sued. How do you feel about that?

Mr Labelle: In my mind, what it brings to mind is that this is a kind of bullying tactic, that next thing you know, we're going to be told unilaterally how to do things, and if you don't play the game the way the minister may want it to play, it can open the doors to discrimination, it can open the doors to making decisions that are not necessarily in the public's interest. There's no definition of what the public interest is in the bill, to begin with. I believe that's something that should be looked at and definitely outlined, because people have the right to know what is in the interests of the public. That's a pretty broad term and easily misinterpreted or misused. The thing just gives too much power to one man or a series of people who can decide unilaterally what they're going to do with communities or health care and so on and so forth.

Mr Len Wood (Cochrane North): Thank you very much for an excellent presentation. On your last half of the page you're saying that it took years of painstaking work and trial and error to develop legislation, whether it be the health field or whatever, and by rushing through with the bully bill we see here, there can be a lot of mistakes. From what I can gather, the government is saying that it needs Bill 26 and it needed Bill 7 and it needed this to pay down the deficit. But in reality what they're looking at is a 30% tax break that they want to give to the people, and they're saying that's going to create employment. Do you see any employment being created with Bill 26?

Mr Labelle: I know there's some restructuring that is mentioned that's part and package of the bill. The restructuring may be necessary, but the biggest thing I see are some measures like files disclosed, personal files disclosed to whoever, the minister, and the minister can use them as he sees fit. Where does that save money? Where does that happen? What happens there?

As far as saving, the CSR always promised there would be no cuts to health care, there would be no spending cuts at all to the health care system and they were going to look at other avenues on saving this money.

Now, if you're going to be cutting a total of $6.7 billion to the deficit, or the deficit spending, in the next three or four years to have to borrow another $6 billion to give us a tax cut, why don't you just quit the running around and forget the tax cut and maybe concentrate on employment? Because I think the real problem in Ontario is not so much our health care, and it's not so much some of the social programs we enjoy. I believe the reason we see deficits going up is because of unemployment in Ontario. If you want to take people off welfare or reduce their benefits, how about you reduce them all the way, 100%, by supplying them with a good job?

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The Chair: For the government, Mr Clement.

Mr Clement: Thank you very much for your presentation, Mr Labelle. You've obviously spent a lot of time, and your wife has, going through this legislation --

Mr Labelle: That's right.

Mr Clement: -- which I think is illustrative that people can come forward and speak to this committee and have time to dissect the legislation, as you have. It won't come as any surprise that you and I disagree on some of your presentation, and in fact it's funny how things work, but I don't think the CAW, at least the union leadership, has agreed with the government much since June 8, although I had a number of CAW voters in my riding who seemed to see the need for some real change from the status quo, which wasn't working for anybody.

Some of the generalizations you engage in in your presentation do concern me a bit, because I think they're leaving an untoward impression for this committee. You just finished saying that personal files under our section can be used by the minister and disclosed as he sees fit. In fact, if you read the legislation, there are constraints on the minister's power to disclose or use that information, just as there are under the current legislation.

You mention the Common Sense Revolution document and the fact that you interpret it as meaning that somehow we're going to keep the exact status quo in health care when in fact our commitment was to keep the funding the same at $17.4 billion but there have to be some, in some cases, radical changes in the health care system, just as there have to be some quite extensive changes in other parts of the way we govern ourselves and participate in this province.

Let me ask you this question: Do you think your colleagues in the CAW, your neighbours, your friends, your relatives, are absolutely satisfied with the status quo in health care, the way it's delivered in Timmins and the surrounding area?

Mr Labelle: I hope not. I hope that everybody would work towards making things better, using smarter ways to get them accomplished.

But what we see here is, I don't think my friends at the CAW would think the dictatorial measures that this bill allows ministers are such a good idea either. I don't think our buddies at the CAW would say it's okay for a minister to be able to have the unilateral power to shut down any hospital he feels is necessary to shut down in the public interest. First off, I think my friends out there and anybody who knows me would know that we definitely want a definition as to what public interest would mean in such a case, and Bill 26, the omnibus bill, is absent of that.

And as far as when you made reference to the Common Sense Revolution, I'm sure the promises were made that not a penny would be cut. In your last budget, there was a fair amount of money cut from the budget.

Mr Clement: And a fair amount of money reinvested as well, so the whole idea is to --

Mr Labelle: Over the four years, right?

Mr Clement: The whole idea, sir, just so you know and are aware of what the government's intentions are --

Mr Labelle: Oh, I know.

Mr Clement: The whole idea is to restructure the health care system so that we can give value to the taxpayers and also assist patients in need, and that means you have to rejig things. You can't keep spending on the things that don't make sense and then increase the spending on things that do make sense, because we'll all be in the poorhouse. So I think that's the government's intention, but I want to assure you that that's the way we're going on this.

In terms of the minister's power, because you spent a lot of your time in your presentation on that, if you look at some of the other provinces, and we've had some evidence to this effect, in New Brunswick they completely shut down all of the hospital boards and ran them out of the Ministry of Health. We're not proposing that. We're proposing that the boards should stay in place unless there are very, very extraordinary circumstances, and we want to work with the boards, but, ultimately, somebody has to make a decision. If no one gets to make a decision, then everything stays the same and we continue to pile up expenses and costs which are costing us but aren't delivering the health care that we need.

Don't you agree that ultimately it should be the elected person, the Minister of Health, who ultimately has to be accountable for the decisions on behalf of Ontarians?

Mr Labelle: On what level? You mean to tell me that the Minister of Health in the province of Ontario becomes the sole owner of all the hospitals or the sole facilitator of all the hospitals in Ontario? Is that what you're saying?

Mr Clement: Not at all. That's exactly what I'm not saying.

The Chair: Okay, thank you very much, Mr Clement. Just before we go to the next question, I would appreciate it if the dialogue between the questioner and the answerer be left just a two-person dialogue, mutual respect for one another, so we all hear the answers. Okay, the Liberals.

Mr Frank Miclash (Kenora): First of all, Mr Labelle, thank you very much for a very comprehensive presentation to us this morning. You quoted a number of times from the Common Sense Revolution. I have another document in front of me. It's called A Voice for the North, and it's a Report of the Mike Harris `Northern Focus' Tour. It suggests, "We need answers -- not made-in-Toronto policies, but solutions based on input and ideas from the people who live and work in the north." This is a document drafted in January 1995 and it was floated around northern Ontario quite a bit in June 1995, during the election, of course.

It goes on to say, "Recognizing the special needs of people in the north, we will give northerners a direct say in changing the Ministry of Health's planning and resource allocation so that it includes more consideration for northern priorities and conditions."

Mr Labelle, do you know of any group or organization that was consulted during the drafting of Bill 26?

Mr Labelle: Not to my knowledge. I don't even know of any group that was consulted or even brought in when it came to changing the labour legislation either. All the bills that we've seen this government do have been done unilaterally on its own, and hopefully it'll fly and, "We'll deal with the protest," and "We'll do this and we'll do that." "We'll always try to appease those who are upset, and it's a minority."

The CSR talks about the groups that are against the government are special-interest groups, you know: "Our political system has become captive to big special interests. It is full of people who are afraid to face the difficult issues, or even talk about them. It's full of people doing all too well as a result of the status quo."

These kinds of statements fly in the face of ordinary Ontarians, because we know that maybe the party that is in power now has special-interest groups of its own. I think the legislation that we see, as far as labour legislation, omnibus bills, all the next legislation that they're tabling, kind of reflects exactly who their special-interest groups are, and there's no doubt to most Ontarians. That's not just an insult but a very big concern.

As far as a hearing, we talk about the hearing, we have the opposition of the government to thank for that. We would never have had these hearings. You tried to blindside this legislation, you tried to blindside the people of Ontario, blindside the opposition. The first reading of the bill was when everybody was in lockup. I was watching the proceedings through the Legislature that day. I didn't understand what was going on till the next day when the press got a hold of it and got more informed, but I'll tell you what, it's made me more informed Ontarian as far as the way the Legislature works and the procedure in the House.

The Chair: Mr Ramsay.

Mr David Ramsay (Timiskaming): Michel, I'd also like to congratulate you and your wife for your presentation.

The Chair: Is this a Liberal member?

Mr Miclash: Yes. He's a Liberal.

Mr Ramsay: Okay, thank you very much.

Mr Clement: He just lost his moustache.

The Chair: Without the moustache, I didn't recognize him.

Mrs McLeod: We allow change.

The Chair: My apologies.

Mr Ramsay: Michel, you just referred to the action that took place in the House before the holidays, and why that had to take place is also reflected in Frances Lankin's motion today that we need more time. When you read through this, I'm discovering every day new things. I want to bring one to your attention and get your opinion of it, because it worries me very much.

In regard to health care and in regard to insured services, insured services can be also such services as may be prescribed are insured services only if they were provided to insured persons in prescribed age groups. So I think what I'm seeing here is the potential for starting to rationalize certain procedures for certain age groups of men, women and children. I'm just wondering what you would think of that sort of rationalization.

Mr Labelle: Again, I believe that we have a health care system that was built by the determination of people like our former generation. What happens oftentimes is this new-wave thinking that takes over that says, to be competitive, we have to be reduced to the survival of the fittest. I believe that piece of legislation is dangerous because it starts reflecting those thoughts in our laws in the way the health care system is delivered in Ontario. I don't agree with it. I believe that health care is for everybody. It should be universal, regardless of age or financial standing.

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The Chair: Thank you, Mr Labelle. Thank you, Mr Ramsay. I will never again make that mistake, just as I will never call Ms Lankin by the wrong name. Thank you for your presentation. We appreciate your interest.

POVERTY ACTION COMMITTEE

The Chair: Our next group is the Poverty Action Committee, represented by Suzette Courtemanche and Carl Warren. Good morning and welcome to our committee. You have a half-hour to use as you see fit. Any question time would begin with the government at the end. The floor is yours.

Ms Suzette Courtemanche: Thank you. I hope you can bear with us. We're new at this. We've not been around for that long.

The reforms contained within Bill 26 are not the product of a natural democratic process, nor are they the result of evolving trends in the medical profession -- that for years doctors, patients, hospital administrators and ministry officials have consulted with one another and agree that the government should be able to divulge medical records and allow the minister to unilaterally close hospitals. It would also be progressive to treat doctors like insubordinates within the health care system and grant absolute immunity to the government for any malpractice it may inflict upon the health care system. The outrage within the medical profession clearly demonstrates that this is not the case.

The proposed omnibus bill does not stem from the input of either the practitioners or the consumers of medicare. In reality, Bill 26 is a correlate to the ideology set forth in the Common Sense Revolution and one that has underscored most of the government's actions since taking power last spring: ideological opposition to the idea of, the plight of or the situation of low-income people. Bear in mind that low-income people are more than just women on social assistance. They are unemployed parents who have seen their training programs and day care slashed. They are women and students working in the service sector who have had their right to unionize denied through Bill 7. They are first nations people who have had their community development projects and youth programs dismantled. They are abused women who have had their shelters savagely cut. And now, despite the pre- and post-election pledge to not touch health care, the Conservative Party is encoding the ideology of the Common Sense Revolution in the laws governing medicare.

The Poverty Action Committee would argue that ideology has no place in the health care system and that Bill 26 will have a disastrous impact on low-income people. If passed, Bill 26 will further centralize the decision-making process in the health care sector and weaken the voices of low-income people into the system that they entrust their lives to. Those people include seniors, the disabled and chronic care patients. Bill 26 is a crude attack on these people who are not just disadvantaged due to economic circumstances but also because they are physically less able to speak for themselves. The government has clearly exploited this power dynamic in order to grant itself much of the authority outlined in section 6 of the new hospital act. Section 6 gives the minister the power to close or amalgamate hospitals. Already there is a lack of communication between the patients and those creating policies and writing directives that will affect their lives.

Last fall, at an in camera meeting, the Timmins and District Hospital health board voted to close South Porcupine continuing care facility and move patients to the Timmins and District Hospital. Patients were not consulted and discovered through a leak that their facility was closing. Sections 5 and 6 will exacerbate the kind of élitism which already exists by giving the minister even more direct influence, therefore reducing grass-roots input into how the system should operate.

Mr Carl Warren: The omnibus bill drastically thwarts the principle of medical need as one of the underlying principles behind hospital funding and supplants it with the minister's discretion. The new sections 5 and 6 no longer require that the minister fund hospitals in accordance with regulations and gives him the power to suspend, reduce or eliminate funding to a hospital altogether. It allows him to set the terms and conditions for repayment. It redefines the term "financial aid" and once again injects the minister's own ideology into this principle.

Although the term "public interest" is flaunted throughout the document and is intended to reassure us, it is empty without the process of consultation and regulation which existed in the former legislation and which will be removed in the new legislation. Even in section 9.1, where the bill defines the four elements of public interest, its tenets may be superseded by "any matter" the minister considers "relevant." The legislation is also a gross violation of people's privacy by allowing the government to divulge medical records.

Furthermore, the legislation has granted the government absolute immunity from liability in sections 9.1 and 13. These sections indicate to me the minister's and the Premier's willingness to act upon the power granted to them by sections 5 and 6. In doing so, the government has already predicted some of the damage that it is going to inflict on the health care system. If the government does close hospitals and reduce services, it will create a more two-tiered health care system in Ontario, which already exists pretty much in the north. Low-income earners will have to rely on local services and wait longer for treatment as waiting lists grow. Middle and upper-income earners can choose to dodge waiting lists and fly to any clinic or any hospital or see any specialist anywhere in Ontario, or check into an expensive American clinic.

The proposed changes to the Ontario Drug Benefit Act and the Prescription Drug Cost Regulation Act will have a major impact on three groups of vulnerable low-income people: seniors, the mentally and physically challenged, children and people on social assistance. Changes to the drug laws which introduce copayments on prescription drugs do not take into account the fact that many of these people rely on multiple drugs, sometimes up to 10 or 12.

While the government has downplayed the cost of individual prescriptions for low-income people, it ignores the compound expense of multiple prescriptions for a family living below or straddling the poverty line. As the government knows, because it has already cut back social assistance dramatically, some recipients are already suffering due to these cuts and they will be forced into the awkward situation of having to choose between medicating or feeding their families. Some may forgo doctors' visits or misuse prescriptions and make them last longer. The problem will get even worse if low-income people are forced to make up the difference between generic and name-brand drugs or bear the cost of an exorbitant pharmacist's markup.

Despite the fact that the government has reassured Ontarians that deregulated drug prices will not result in drug price increases and may actually result in a reduction, the profit motive will certainly drive prescription prices up. Again, this provision has little to do with providing the best, the most progressive and affordable treatment for Ontario's citizens and has all to do with the government's prevailing ideology, which is the Common Sense Revolution and complete disrespect for low-income people.

In conclusion, although the focus of this presentation has mainly been on how Bill 26 might affect low-income people, this legislation must be viewed as an affront to universal health care which benefits all Ontarians, poor or rich. If the government attacks our health care system, it is jeopardizing the productivity of its citizens. The Poverty Action Committee strongly urges the Conservative government to repeal this regressive legislation and build upon the accomplishments of the past, instead of creating more inequities and more social havoc in the present.

The Chair: Thank you. We have about six minutes per party for questions, beginning with the government.

Mrs Janet Ecker (Durham West): I'd like to thank you very much for your excellent presentation and for coming today to participate in this. We've found the input that we've received from many of the groups to be very helpful and very useful as we go into detailed analysis of the legislation.

A couple of points I'd like to get on the record, both in response to some of your comments and some comments that were made just previously. In regard to regulation-making powers about different classes of age, if you will, there has been no change. The Health Insurance Act as previously written had that regulation-making power. There has been no change there.

The other point is that, on the hearings, the government had been quite prepared to have public hearings before Christmas, but with the deal that was negotiated with the opposition, we basically split. So we've got half before and half afterwards in terms of public hearings to give people more time to prepare.

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The other thing is that the northern health report which has been quoted also had a great litany of the problems with the health care system in the north. We had consulted quite extensively, and there are many comments about medical professionals concerned that the fee-for-service system, as it exists under previous government-OMA agreements, was not meeting their needs. We've all heard about the problems in Red Lake. That's one of the reasons why the government has decided to move on the recommendations of the Scott commission to help try and solve some of those problems in underserviced areas.

Also, the underserviced area program itself wasn't working. The problem in fact has been getting worse, which is why the minister has brought in steps in this legislation to try and fix those problems but has also given the medical profession additional time to say if there are solutions out there that a government hasn't tried in the last 15 years. None of them have worked, but if there are new ones, let's talk about them.

The other point is that we agree that local input for changes in the health care system is very important. That's why what this bill does is allow the power of the minister to implement the recommendations of the district health councils, who quite appropriately will be making the planning recommendations to the government, as they have done and are doing in many regions of the province.

Finally, this legislation does not give the minister the power to run around willy-nilly dropping patients' records in public. It expands the current information used to manage the system. There are confidentiality protections in place, and we are meeting and discussing with the privacy commissioner. If they need to be improved or tightened, we're certainly prepared to do that.

About the copayment, the drug situation that you have talked about, one of the things that we have been trying to do is to protect the ability of the government to pay for the full cost of the drug. As you know, many people, if they're on an employer drug plan, for example, or do not qualify for drug benefits, have no way to pick up their drug costs. What we've been trying to do is to make sure that for those who qualify for drug benefits in Trillium, we can afford to do that. My colleague Ms Johns mentioned the expansion of the drug costs in the last couple of years, so many provinces have gone into copayment mechanisms, as we have.

With those savings, what we've been trying to do is also to extend drug benefit protection through the Trillium for 140,000 additional people who didn't qualify for drug benefits, so we've been able to do that. How would you suggest that we protect the drug plan, protect the ability of people to have the full cost of the drug paid, be able to extend it to further people who've needed that support and also be able to bring on new drugs, more expensive drugs which previous governments have had difficulty getting on the system? How would you propose that we are able to do that if we don't start changing the system and follow the copayment mechanism which many other provinces have done?

Mr Warren: I don't deny that there are certain elements in the health care system that have to be reformed and that were addressed in the omnibus bill. I think it's quite plain that there are very contentious aspects of it, like the powers that the minister is given, the centralizing power, unilaterally closing hospitals. Those kinds of things are very contentious, obviously, and basically those are some of the things that we're addressing today.

In terms of copayments, I understand that other provinces do other things. They may be draconian, but I don't think that Ontario should be following the same example. I don't think that just because they are doing that necessarily means that we should feel as though we should be doing the same things.

I'm not too familiar with all of the aspects of Trillium and how that works. I don't believe that copayments are a good idea, for the same reason I have mentioned before, that many families have multiple prescriptions and the expense compounded with several can be a lot to bear for a family on social assistance or for a senior or for people who are living below the poverty line. I would suggest that it is the government's responsibility to come up with more constructive alternatives than slapping user fees on people who are living below the poverty line.

Mrs McLeod: I do have a couple of questions, but if you'll bear with me for a moment, since the government wants to use some of the time to set the record straight, I think it's important that we make sure it's set a little bit straighter.

I first want to ask the government to recognize the fact that the raising of the concern about age as a criterion in determining what is medically necessary becomes very important when you have a new provision in an act that says the cabinet, by regulation, will set out under what conditions medical services will be paid for.

Up until this act's proposal, the decision about what would be paid for as medically necessary was determined by a committee of physicians. When government is going to determine what's medically necessary and when that is clearly going to be driven by the cost concerns that the government keeps expressing, you do worry about whether we're going to get a rationing of health care based on age as a criterion.

The second part of the record I would set straight is that you're absolutely right to be concerned about the disclosure of personal information. The privacy commissioner has made it very clear that he feels the provisions of this act constitute a serious consequence for the invasion of personal privacy, and I believe this act will have to be amended in accordance with the privacy commissioner's concerns.

Last, I wouldn't in any way feel that you should be apologetic to the government about your concern about copayments. An earlier presenter to this committee this morning indicated that the experience of at least one province in introducing copayments was that the utilization went up, and therefore the cost to the government of the drug benefit plan would go up with the introduction of copayments.

Those are all very legitimate concerns to express, and that does take me to my question. I just want to ask you to expand a little, because I think you see the face of poverty in your communities, and there are many aspects you've touched on that relate to the price the poorest in our communities will pay for the changes in this act.

One of the things that worries us is the deregulation of drug prices themselves and the fact that we don't know what that's going to do to drug prices. For those who aren't on the drug benefit plan, that could mean they're facing increased prices for drugs, and in smaller communities that may be a particular problem.

One of the things the minister has suggested in the past is that people will have to barter for drugs, find where the cheapest drug is. I wonder if you might comment on whether you think the people you see in your communities who need access to a drug can go out and barter for it. And in a small community, where are they going to go to barter? How many different places can they go to find the cheapest drug?

Ms Courtemanche: I think everyone knows that accessibility here in the north is limited. Also, we've had calls coming in right now because a lot of people are worried about this, especially low-income, especially social assistance recipients. Now they want to introduce a $2 copayment. Social assistance recipients have already been cut by 22%. They have to make up the difference, which hasn't been implemented yet.

Now, on top of being cut, they're going to have to decide whether they're going to feed their child one month or whether they're going to buy him drugs because it's a necessity in his life, which amounts to sometimes $100 or $200 a month. If that child needs a special drug which is not on the list of generic brands, that means they have to pay the difference.

For example, someone right now is using antibiotics for their son. This won't be on the list, as he's been told by his pharmacist, so that means he has to pay the difference of $40 a month to get that drug because the child is allergic to all other drugs that could benefit him.

You're starting to run into a lot of problems which the government won't be able to handle on an individual basis. Some of these people are really going to be paying for those mistakes.

Mr Ramsay: Thank you for your presentation. Governments have always tried to grapple with poverty. Today, we have fewer and fewer tools, but three main ones that remain would be looking at the income tax system so you could take low-income people off the tax rolls so they could at least retain the money they are earning. That's something I think we need to be pursuing, and I would say to this government that if you are to bring in a tax cut, that's where you should be bringing in the tax cut, to low-end people. The other is a public school system so there's universal access for everyone for education. The third is why we're here today, and that is a universally accessible health care system.

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It seems to me that when you look at the changes through schedule H, and you've mentioned many of them, a lot of these changes are going to impact very harshly upon low-income people. Why do you think this government is mounting this attack on people in poverty? Why do you think this is happening when over the years we've all tried to work together to alleviate this inequity as much as we can?

Mr Warren: As Suzette said at the beginning of the presentation, Bill 26 is not the result of years of consultation nor is it the end result of progress within the medical profession. It was created in a vacuum, and it's puzzling to know why we have this bill. But when you look at some of the sections and when you look behind the fine print, it's very much in keeping with the ideology of the government, which has been a total disregard for low-income people.

We've seen that in terms of cuts to low-income people, their day care and their training programs. First nations people in the city of Timmins, who are low-income people, have seen their youth programs obliterated and dismantled. The Timmins Native Friendship Centre has been cut to the bone; they've had to lay off several people. Of course, directly with this, low-income seniors, the physically and mentally challenged, all these low-income people, are being targeted through this legislation.

By encoding this ideology into the health care system and allowing themselves to close hospitals and do things unilaterally, they're giving themselves the leverage to give the richest citizens in Ontario a tax break.

Ms Lankin: I want to take a moment to put a couple of things on the record in response to Ms Ecker's comments, and then I'll turn it over to Mr Wood, who has a specific question for you.

One of the things that has angered me the most going through this process are the myths and the misinformation that the government puts out with respect to what's in this bill. Ms Ecker said to you very specifically, in response to your concern about the provision of services to prescribed age groups, that that was in the old bill, that nothing's changed, that there was always that power and nothing's changed. Let me tell you what has changed, because she is absolutely wrong and that is not correct information that she's given you.

In the old bill, under the regulation-making section, section 45, there was a similar provision, but there was a proviso at the end of that section that said, "no service or age group shall be prescribed under this clause that would disqualify the province of Ontario under the Canada Health Act," a very specific reference, and it goes on to talk about consideration by the government of Canada because the plan would no longer satisfy the criteria under the Canada Health Act. You have a protection there in the old legislation that these provisions must be done in accordance with the Canada Health Act.

That particular clause about prescribing by age group has been plucked out of that section with the protection of the Canada Health Act and has been put in another section of the legislation with no reference at all to the Canada Health Act.

Anyone who looks at legislation, if you ever had a case on this and went before a judge of some sort, has to interpret: What was the intent of the Legislature? Why would they move it away from the protection of the Canada Health Act and put it without the protection of the Canada Health Act? It has to be somehow different, or why would they have made the amendment?

The government has never answered the question why they are moving that section. The only difference, and it's a big one, is that it's taken out of the protection of the Canada Health Act. When she says to you, "There's no difference," she's not telling you the complete story. I find that very upsetting, and we went through this on a number of occasions in the first week of hearings.

Privacy: She said to you, "There's no difference between the old act and the new act." Why are they making amendments, then? And why did the privacy commissioner, who is the person most knowledgeable about these issues in the province of Ontario, come before us and present us with pages of amendments that he said were necessary to protect private information, health records? He said the government's amendments from three various sections, the multiple acts that are amended, when put together constitute a grave breach of privacy. Again she said: "There are no changes. There's no problem." The privacy commissioner says no, and when you read the words you can see that's not true.

In terms of the excuses they use, on copayments, for example, it's that every other province has copayments so we should have them too. Well, they're also deregulating drug prices. You know what? Every other province regulates drug prices. It's okay for Ontario to deregulate there and do something different, yet that's the excuse they use for copayments.

You don't get the whole story when you listen to those comments. I just wanted to get that on the record and assure you that the points you raise are very valid.

Mr Len Wood: Thank you for coming forward with your excellent presentation on the poverty groups. As you're probably aware, I have a lot of first nations, aboriginal people within my riding and lot of poor and low-income people. Even this bill's title says "promote economic prosperity" and "streamlining and efficiency."

Throughout your presentation, what you're telling me is that it seems to be an attack on the low-wage earners, the people who are living below the poverty line. What would a family with a couple of children, even if they're just on minimum wage, who don't have money to pay a $2 prescription fee -- let's say there is a number of prescriptions; that they have pneumonia or this and that. It's going to mean an awful drain on the hospital system. Where a simple prescription was being fully covered before, now they're going to end up hospitalized as a result of the parents or parent not having the money to pay prescriptions, whether it be in the aboriginal communities or people on social assistance or welfare, as a direct result of the 20% they've already cut. Now they're being penalized again in order to give a 30% or a $6-billion tax break to the wealthiest people in this province. I just want to get your comment on that.

Ms Courtemanche: First of all, I'm not aware of everything that's being done with Bill 26, but there is one thing I know for sure in looking at everything that's been going on since last August, and that's the fact that, yes, people are saying they will be getting a tax break. I can't see that tax break coming through in the first place, because if we're getting it back at the top, we're going to be paying it at the bottom somewhere along the way.

Furthermore, the ministry keeps saying they're cutting everywhere and there are going to be jobs available to people. In December, we sent out letters to the businesses here in Timmins, non-profit and profit, asking businesses to please hire people who were on social assistance so they could make up the differences of their cheques. We didn't get one response, not a single response.

If the government is saying there are jobs out there, I wish they could produce them because I've got a lot of low-income people right now who are asking me for jobs -- not that they want to be on social assistance, either. They just want to get off, but there are no jobs out there for them. If there were jobs and they could be earning some kind of money, they could pay for their drugs.

The Chair: Thank you. We appreciate your attendance here this morning and your involvement in our process. Have a good day.

Ms Lankin: Mr Chair, while we are exchanging groups, could I place a question on the record for the ministry? It's with respect to the amendments to the Health Insurance Act, specifically subsection 18.2(2). Section 18.2 is the provision in which the general manager now gets to make a decision to refuse a payment to a physician or any other health care practitioner, and subsection (2) is if the general manager has reasonable grounds to believe that all or part of the services were not medically or therapeutically necessary.

I asked a question with respect to that in the first week of hearings and the response that has been tabled by the ministry indicates that two sections of the previous act have been amalgamated, which I think we as a committee discovered during that first week. But they say specifically that the therapeutic necessity which is included is in reference to the services of practitioners and health facilities, while the reference to medical necessity is included with reference to physicians' services.

I would like to ask the ministry, particularly the ministry lawyers, for an interpretation. As I see it, it simply says the general manager can apply these tests and they are all included. There's no reference, no way of insisting that medical necessity be applied as the only test to physicians' services. So my question: Is it not the case that the bureaucrat applying this test will have, necessarily by the legislation, the opportunity to apply a test of therapeutic necessity and medical necessity to any doctor or health facility or practitioner and that in fact there's nothing in the legislation that structures it, that says one test is applied to one group and one test is applied to the other? I think in a sense that might be sloppy drafting in the way in which that has been put together, and that gives me concerns.

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The other question I have is, in reading the old bill, there is no definition of "medical necessity" or "therapeutic necessity." In the past, under the old legislation, it was a Medical Review Committee, which was a doctor's peers, and it was a peer committee of health practitioners for the particular profession involved that would apply those tests of medical necessity or therapeutic necessity. Now it is a bureaucrat in the Ministry of Health who will do it, who is not a professional in these fields. I would like to ask the question, what test are they going to apply, what definition are they going to use and how they are they going to make that judgement, given that it is not any longer a peer review group?

The Chair: Does the ministry staff have the question sufficiently? Okay.

CANADIAN MENTAL HEALTH ASSOCIATION, TIMMINS BRANCH

The Chair: Our next group is the Timmins branch of the Canadian Mental Health Association, represented by Judy Shanks, executive director, and Catherine Yard. Welcome to our committee. You have half an hour to use as you see fit. Questions would begin with the Liberal Party. The floor is yours.

Ms Catherine Yard: Good morning, Mr Chair and fellow committee members. I am the president of the local mental health association board of directors, and Judy Shanks is the executive director of the agency.

The Canadian Mental Health Association, Timmins branch, appreciates the opportunity to present a response regarding Bill 26. The CMHA, Timmins branch, is involved in health care in the province of Ontario and in particular in mental health and family violence. We appreciate the opportunity to express our views on the future of health care in the province and, in particular, northern Ontario, which we see as a major difference in the province.

Recently, our Canadian Mental Health Association provincial office made a presentation to your committee in Toronto. In order not to be repetitive, we would simply like to emphasize that we support that presentation. However, we do feel that it is imperative to add a northern perspective which more specifically reflects the issues of the north and in particular the Timmins branch views.

The Canadian Mental Health Association, Timmins branch, is an incorporated, registered, non-profit organization chartered since 1962; 100 volunteers are active in direct board and committee service in the Timmins district. CMHA, Timmins, is one of 36 branches of the Canadian Mental Health Association, Ontario division. The branch is a strong advocate for the rights of adults and children with mental health difficulties, as well as for women and children and victims of family violence.

Timmins branch programs are funded through government transfer payments -- in the amounts of 56% from the Ministry of Health, 34% from the Ministry of Community and Social Services and 6% from the Ministry of Housing -- the local United Way and supplementary funding activities.

Ontario's current economic environment is burdened with a high budget deficit, mounting public debt and continually accumulating interest. CMHA acknowledges this environment and understands the government's need to act to reduce the debt and the interest we pay on it as an important measure of fiscal responsibility in order to create a better future for growth and opportunity in this province. The CMHA, Timmins branch, acknowledges the necessity for the government to act and to act quickly.

We do not wish to portray the message that we are in disagreement with the government of the day, but there are certainly various changes we hope can be instituted in the north to ensure that northerners are adequately provided for.

The distribution of mental health services is fraught with inequities. We realize that the government must take a stand to adjust these inequities but must keep in mind the northern uniqueness. The north covers a large geographic area, sparsely populated except for a few urban areas.

We have always had difficulty in the recruitment and retention of mental health staff such as psychiatrists, psychologists, social workers etc. More than ever, we are once again at a critical stage in the recruitment and retention of professional staff in northern Ontario and attempting to overcome the problem. The government must look at various options such as a regional approach to the mental health care delivery system, utilizing existing dollars and human resources in a much more effective way than is presently being done.

Prior to enacting legislation, the government should look into the following areas:

(1) The distribution of psychiatrists, psychologists, physicians and social workers. Fair and equitable criteria for balancing the distribution of mental health care professionals in Ontario should be developed, particularly in the north, where we are very underserviced.

(2) Incentives and improvement in working conditions, differential remuneration, brief stay etc for professionals who work in areas which are historically faced with low supply should be considered. For example, in the north, a strong mental health support system would support psychiatrists and physicians and aid in their recruitment and retention.

The Minister of Health and his deputy minister and ADMs had a number of meetings with a variety of groups and individuals prior to the release of the fiscal and economic statement. In some of these presentations and discussions, several messages were being brought forward. At this time, I would like to highlight a few points that were brought forward.

(1) The Ministry of Health is reviewing the business it is in and does not intend to be in direct care in the future. CMHA, Timmins branch, is in agreement with this and would like to be one of the key service providers.

(2) The ministry lacks an adequate data and information base upon which to make the best decisions. CMHA would be willing to take a lead role to assist in developing an information system.

(3) The ministry is determined to have restructuring in health care occur to provide a better continuum of care. CMHA feels we could assist in this planning. One suggestion that we hope would be given consideration is looking at the delivery of mental health services in the north in a regionalized delivery model.

(4) The budget will include the largest reductions ever in Ontario government spending. Redistribution of dollars may be one of the best cost-saving measures.

(5) The ministry is considering reviewing all of its agencies, boards and commissions with a view to having fewer of them. CMHA believes that the end result would be a better utilization of volunteer time on boards and committees if such a move was enacted.

(6) The government has indicated that the information systems will be dramatically improved. We applaud this comment; however, we hope that action, and not more consultation, will be the end result.

We believe that in the mental health field this cascading process, if handled properly, will likely see the current $1.5-billion system need little or no more funding to cause it to operate more effectively for the consumers of services, not to mention the staff and volunteers involved with them. The approximately $385 per day cost to care for individuals in provincial psychiatric hospitals can be much better utilized in many instances either to retain individuals near their homes or to return them to their community at a much more rapid rate. Outfitting the general hospital psychiatric units to provide emergency backup when cyclical crises occur will be fundamental to permitting this change to happen.

In the community agency component of the mental health and addiction fields, the great proliferation of small agencies begs to be part of an organizational solution. Fortunately, the multiservice agency model does not appear to be in favour with this government for the long-term care field, so presumably it will not be found acceptable in the mental health field either. However, we need a structure which will allow funders to deal with community agencies in an efficient and effective manner in terms of initial funding; as well, concerning accountability/evaluation, it will require some sort of massification, or organized approach to pooling resources.

The creation of mental health and addictions network organizations could be the best transitional solution for the mental health field in the north. In the Timmins area, for example, very large as we are, a mental health services network organization linked to a district health council or a similar planning body or group from a policy planning/definition of service perspective and linked to their funders for financial support would be a definite asset. The funder, of necessity, would set general parameters for the services they want to see provided with these funds. In this model, the network organization would be responsible to ensure evaluation of service quality and outcomes. This model would place the mental health network organization in a position to secure services needed by consumers from any entity in the spectrum of available services. The model would be client-centred, holistic and based upon the psychosocial rehabilitation approach and not fragmented.

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It is well known that systems, as they grow and develop powerful entities within, can easily become self-absorbed and lose sight of the central purpose for their existence. We need strong leadership in the various elements within the system, but at the same time there must be mechanisms in place to balance those strengths. We encourage members of this committee, as you examine Bill 26, to ensure that the processes are in place to provide balance and to ensure a consumer focus, which we must not forget.

The current model with Queen's Park as the government core causes loss of time and inefficiencies. A regional-based model would recognize the specific needs for a particular area.

The district health council areas could assist in defining the administrative and geographic size of any particular mental health services network.

Reduction of services is not the answer. We need to look at the redistribution of dollars that are already in the system. It is important that we look at delivery of health care services in the north much differently from those in the south and the larger areas.

In the past few years, a number of health programs have been implemented on a regional basis in the northeast. In 1985, cancer became regionalized; 1989, dialysis; and in 1993, diabetes. Regional programs have proven to be cost-effective when you are dealing with a sparse population scattered over a large geographic area with limited resources.

In discussions with my Canadian mental health colleagues throughout the northeast -- Timmins, Sudbury, North Bay, Sault Ste Marie and Kirkland Lake -- there appears to be a genuine interest in pursuing this concept further. For example, we have had some serious discussions around a generic community support worker. This concept would not only serve the psychiatric population, but as well could be utilized to work with brain injury, developmentally challenged, dual diagnosis, concurrent disorders and forensic groups.

The philosophy and training for the generic community support worker is based on the psychosocial rehabilitation model. This model refers to a client-centred approach to working with the disabled population, seniors and youth. It can be adapted to cross over with all ministries and is in fact already present within the approaches utilized by services funded by various ministries. Some of the target populations already using this type of approach are those from the Cochrane-Timiskaming Resource Centre, Community Living Timmins, South Cochrane Addictions Services, Adult and Family Services-Northern College of Applied Arts and Technology, and the Timmins and District Hospital.

In the north we feel that the services should be very comprehensive, consistent, coordinated and cost-effective. You may ask, how do we come up with cost-effectiveness? If each agency is trained under one model, then whether you are a community worker or an institutional worker, people would have the same goals and the best interests in mind to work with the client or consumer. This would also make the transfer of institutional worker to community worker quite smooth and effective.

All levels of government need to work in a collaborative and cooperative manner. For example, in the Timmins area a group of approximately 25 local agencies has formed the Timmins Health and Social Service Coalition. Currently, the group is meeting to share information about support services and to develop short-term opportunities for collaboration. Examples of common support services are: (a) purchasing of equipment and supplies, photocopying etc; (b) group employee benefits -- employee assistance programs, human resources, health and safety; (c) information systems, education and training; and (d) public relations and information dissemination to the public. The group is also looking at opportunities for creating additional revenue.

We ask that you review our response carefully. The Canadian Mental Health Association, Timmins branch, feels that with changes brought about through co-operation and collaboration and reflecting a northern perspective, we would support the government's actions in this section of Bill 26. We ask that you take time to consider the uniqueness of the north and consider the concept of regionalization. If we all work together with the common interest of our consumers and clients in mind, the battle can be won. Thank you.

The Chair: Thank you. We've got about four minutes per party left for questions, beginning with the Liberals.

Mrs McLeod: I appreciate the fact that you wanted to bring a northern perspective to the presentation. I think that's going to be important to our committee as we travel across northern Ontario. I do want to just touch base, though, because you've indicated your support for the presentation that the Canadian Mental Health Association had already made. One of their very real concerns was about the increased access to patients' medical records. This was a particular concern for patients with psychiatric records in a doctor's office. I assume that in supporting that presentation, you share that concern.

The other concern, and I appreciate your comments on it, is with the whole aspect of copayments for people who have a psychiatric disability -- and obviously not all people who are facing some mental health challenges would be psychiatrically disabled and therefore be facing a copayment; others would have to pay the full cost of their drugs -- those who are on a disabled pension. The cost of the copayment and the fact that there's a concern that with psychiatric patients often they're not only on four or five prescriptions, but they get very small amounts and have to have it renewed repeatedly -- the cost of the $2 copayment might not seem like a lot, but it could be punitive for psychiatric patients. Do you have any further comment on that?

Ms Yard: One of the areas that I touched on briefly was the community support worker program that we are involved in and would like to increase our involvement in, and that certainly would assist our clients in formulating a more effective plan for their life in terms of assisting them with budgeting and that kind of thing. Part of their role is to consider the entire entity of our consumer group and look at how we can -- we certainly don't agree with the $2 copayment, but if we need to look at assisting our clients in dealing with that copayment, then we will certainly do that.

Mrs McLeod: Yes, that's right. There's a lot of community support needed in terms of management, lifestyle, housing, which leads me to my next question, which is: In the consultations that you mentioned the government had prior to the release of the fiscal and economic statement, are you aware of any commitment that the government has made that any dollars saved in health care would come back into the northern Ontario communities?

Ms Judy Shanks: We haven't heard that directly from them, but it's certainly an argument that we continue to hammer away at. We hope that consideration would be given, and I think that's the way it's been left with us in any of our discussions or dealings with the respective ministries.

Mrs McLeod: I would urge you to continue to hammer away at that, because one of our very real concerns is that with the size of the cuts in health care that the government has to realize over the next little while to meet the Finance minister's bottom line, the dollars that are saved, if in fact there are any savings through the components of Bill 26, are going to be lost to communities, certainly in the immediate term.

Ms Shanks: I guess one of the frustrations for us in the mental health field is that over the last number of years we've talked about the restructuring of mental health in particular and looking at the psych hospitals, and there doesn't seem to be any real, significant movement in that area. When you look at, for example, our local psychiatric hospital, North Bay Psychiatric, which 10 or 12 years ago was operating on a $34.5-million budget with almost 900 patients, they have less than 250 patients and they're still operating at $34.5 million, and there's been no movement. So I guess that's one of the things that we still argue. And it's not just our psych; I think it's psychiatric hospitals across the board.

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Mr Bisson: I've listened quite intently to your presentation, because as people here might know or may not know, I was part of that coalition and did a lot of work with Judy and yourself in regard to a lot of the issues you talk about.

I guess I'm a little bit puzzled, listening to the presentation -- and I don't mean to be argumentative here -- but where do you see, in Bill 26, regional planning being enhanced through the bill? Just to put it in perspective, because I agree with you: We need to have more regional planning, not less of it, and when you say that you're in favour of Bill 26 because it promotes regional planning when it comes to not only mental health but our health care system overall, where in the bill does it allude to that? I've read it and I haven't seen that.

Ms Shanks: I don't think we were wanting to be as specific as that, Gilles. I think what we were saying is that we have to look at issues differently in the north.

Mr Bisson: Yes, completely.

Ms Shanks: Certainly, by being able to give a solution to the problem, hopefully in looking at Bill 26, consideration to some of the solutions and not just antagonizing the problem further may assist us in moving towards that direction.

Mr Bisson: But is there anything specifically in the bill that would allow that to happen?

Ms Shanks: I'm not convinced that there is, but at the same time I haven't read -- it certainly wasn't a short time frame. If you look at the presentation done by our provincial office, I think they alluded to some of those areas. That's why I'm saying we certainly agree with that. What we're trying to do is get a northern perspective to reinforce where we see that some of the solutions are and not just create more problems.

Mr Bisson: I wanted to make sure I understood your position. I didn't want to see it changed, because I always agreed with it.

The other thing is that you make the comment, on page 6 of your submission, that we need strong leadership, but you need a mechanism to balance off those strengths. Are you talking about strong local leadership or strong central leadership, just to be specific?

Ms Shanks: I guess, again, I'll challenge you by saying that in the north, for example when we have had any kinds of supports, its always been from Toronto that we have to get a program supervisor or whatever. We're saying if we could decentralize that and make it local -- by the time I get an answer back from Queen's Park, I've already done the deed and taken my chances that it's going to work for the best, and to this point it has.

Mr Bisson: So you still support regional planning as a concept?

Ms Shanks: Absolutely.

Mr Bisson: Do you see this bill enhancing regional planning?

Ms Shanks: Let me clarify something. I don't support regional planning for the entire province. I'm saying that I think in the north we have been trying to cry out for a number of years to say that we are unique, and I would still argue that our uniqueness is created because of the geographics, because of the limited resources, because of the difficulties. And we've tried how many different ways to look at recruitment and retention of individuals? But I think once and for all we've got some leaders within the north that -- if we can have the opportunity to bring those people forward in order to develop and work on their own, with some guidance but also some direction from the ministry so that we're not being pulled back by Queen's Park to say, "Well, this is the way we do it in Toronto, so therefore you have to follow the lead from Toronto."

Mrs Johns: I'd like to thank you for being here and for your presentation today. We appreciate all the help we're getting from many organizations. I just want to thank you for recognizing that the bill is about trying to look at the best ways to provide health care services, and that redistribution may have to take place to allow us to get the best health care system that we can in the future.

I want to comment just for a minute on the fact that the intent of the bill relating to your parent or umbrella firm was that privacy and confidentiality of health records were never to be, willy-nilly, allowed out to the public, so we will be making amendments that will close that down. It wasn't our intent to do that. We felt we were providing a bill, but if there's public concern about it, we'll do something about that.

We are putting money back into the health care system, and I want you to know that. As you know from some of the things I've been doing, there is money going back into long-term care, for example. We have been making investments in dialysis; we're talking about long-term care; we're talking about a number of areas that we will be reinvesting in. I don't think your assumption is incorrect that there will be money that will be allocated to different areas of health care as we find the community need. We believe we have to find the savings first and then reallocate, so it's a little different than has happened in the past, but we believe that's the way it has to happen.

I was interested in your comments about the psychiatric hospital and the dollars in North Bay. Why would so much of the service be taken away, so many people be taken away and not dollars taken to follow into the community at the same time or to follow the people who were being helped somewhere else? Do you have any ideas about that or comments about how that system evolved, why dollars didn't move or why they weren't taken back into the public purse or back to the taxpayers if they weren't being utilized?

Ms Shanks: It was our understanding over the previous governments, going back even to all three previous governments, that eventually that was to happen. I've been in the mental health field for 20-some years and it hasn't happened. I hope we would certainly work towards that, but I think we've consulted this whole process time and time again. I've got documents in my office about this high as to how many times we've got consultation on it and I think the plan is there. Putting People First, the last document around mental health reform, is certainly the one that I hope continues on, because it's a 10-year document and we're in our fourth year of planning for that. It specifically states how institution dollars would be sent back to communities or moved in that direction. Why it hasn't happened I'm not sure, but at the same time I'm hoping we can advocate to make sure it does happen.

Mrs Johns: The doctors' distribution, as you talk about psychiatrists and not being able to get doctors in the north: Given that you have 20 years of experience, is the problem getting worse? Better?

Ms Shanks: The problem's getting worse, and I don't want to speak for the doctors, but one of the things we have at hand now that can resolve some of this, for example, especially in the psychiatric area, is to look at the whole issue of video-conferencing. We can't get the doctors. There are 15 doctors, psychiatrists, sitting in North Bay and it's four hours away. Somehow that highway only goes one way and it's not coming back up north. What we're hoping for is that the technology that's coming into place -- if dollars were allocated to these kinds of resources, possibly that would assist in keeping some individuals here, or at least getting some individuals here with the various professional disciplines.

If we are able to look at utilizing all of our resources, but I'm saying there may be some initial dollar input to start with, to kick the system into start, then we can certainly look at how we can keep doctors. Isolation certainly is a big factor here, and if you don't have anyone to consult with, then it really does become a little bit mind-boggling, to say the least, and quite lonely when it comes to trying to make some decisions.

That's why we're talking about the regional model; that's why we're talking about networking. With those people who are staying, the front-line workers who are staying, if we can utilize some of the training and support of dollars to make sure that video-conferencing is going to be a reality for us and financially available, then we hope we can maintain some kind of system on a long-term basis.

The Chair: We appreciate your attendance this morning and your interest in our process. Thank you.

The next group is Local 1140 of the Canadian Union of Public Employees.

Mrs McLeod: Mr Chair, while they're coming forward, could I also table a question for the ministry staff? It's a follow-up to the question Ms Lankin asked, and the response was tabled today, on the way in which the copayments for the drug benefit program would be implemented. I'm concerned, quite frankly, in the ministry's response, that there will be no implementation plan in place until June 1.

If there's to be a cost saving for this measure, there has to be some indication of what the cost of putting the program in place will be. I would like at least an estimate at this point of what the cost of the billing will be for administering the copayment. It's apparent from the answer that it will be a retroactive billing that is put in place since the decision about whether to charge or not charge can only be made after the claim has been filed. I'd like there be some estimate of the cost of this system.

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The Chair: Is the question understood? Thank you.

CANADIAN UNION OF PUBLIC EMPLOYEES LOCAL 1140

The Chair: Good morning, and welcome to our committee. We appreciate your attendance here. You've got half an hour to use as you see fit. Questions would begin with the NDP party. If you'd identify yourself for the record, we'd appreciate it. The floor is yours.

Ms Brenda Cooper: Good morning. My name is Brenda Cooper. I've been employed in the health care field for the past seven years, and as a public worker I'm very concerned about the effects of Bill 26.

The majority of changes that will affect hospitals and the delivery of institutional services are contained in schedule F, Health Services Restructuring. This portion of the bill gives the Minister of Health unlimited authority to enact the onerous cutbacks announced in the government's economic statement. The elimination of funding to the hospital sector could result in the layoff of up to 26,000 workers and will severely restrict access to health care services.

Bill 26 will surely accelerate the decline in the quality of care that has occurred as the result of years of underfunding to the hospital system. In addition, it will profoundly damage publicly funded medicare and encourage the privatization and corporatization of health care. It is an attack on the elderly, the poor and all those who are most in need of compassionate, high-quality care. If this legislation is enacted, we will see rapid encroachment by the private sector, whose primary objective is to capitalize on illness and disability.

A key goal of the government, reflected in the legislation, is the realignment and rationalization of hospital services in Ontario. One mechanism for this restructuring will be the creation of the Health Services Restructuring Commission. This group will be appointed by order in council and can be assigned duties by regulation, under terms and conditions determined by cabinet. The minister could delegate his authority to the council, which will be empowered to carry out restructuring in whatever he deems appropriate.

Schedule F will give the minister virtually unlimited powers with respect to funding, operation, closure and amalgamation of public hospitals. Like many other portions of the bill, these provisions represent a fundamental change to the relationship between public institutions and government. It allows the minister to ignore the needs of the local communities who access hospital services, and gives him unlimited control over all hospital matters.

The minister will be able to reduce, suspend or terminate hospital funding at will if he deems his decision to be in the public interest. Currently in the Public Hospitals Act, funding is allocated by specific criteria and regulation. The minister cannot terminate funding simply for budgetary reasons; his decisions must take into account their effect on patient care. Under Bill 26, the minister can select the criteria he regards as relevant when making funding decisions, including, specifically, the availability of financial resources.

The minister also has the unlimited authority to close hospitals, force mergers between institutions or order hospitals to change or eliminate the types of service they deliver. An acute-care hospital may be directed to eliminate all its chronic-care beds or shut its emergency room. Since the government has made it clear that too much money is spent on inpatient services already, it can also use this bill to compel hospitals to contract the volume of acute care they provide. This will result in patients being forced out of the system much too quickly or even denied appropriate types of care when needed.

Since the government has also stated that up to 38 hospitals in Ontario must be closed, the legislation has provided it with the necessary mechanism to achieve this goal quickly and aggressively. No public consultation will be necessary even on a superficial basis.

Rural Ontarians will be particularly hard hit by closures. As small local hospitals are shut down, users will be forced to travel greater distances to access even the most basic services.

As well, the minister will be given the power to make "any other direction related to a hospital that the minister considers in the public interest." This potentially has the effect of giving the minister the power to dictate virtually any aspect of the operation of hospitals.

The bill will also provide sweeping powers to the minister to appoint a hospital supervisor whenever he deems it appropriate. If a hospital board were to resist a restructuring direction from the minister, he could appoint a supervisor who would have the exclusive right to exercise all the powers of the hospital board. Community control of hospital services would be completely taken over by a supervisor who is required to follow any direction issued by the minister with respect to hospital operations. The bill states that the supervisor's powers are virtually unlimited.

When hospital boards do comply with the ministry directives, the bill will provide them with unrestricted power to carry out these orders, regardless of the provisions of any other legislation or the hospital's own letters patent or bylaws.

The bill also will give the minister the ability to write regulations concerning the disposal of hospital assets and capital funds in the event of merger or restructuring. Potentially, he could establish regulations that shift assets allocated or reserved for specific purposes, like foundation money, to different parts of the health care system.

Finally, the bill provides tremendous levels of liability protection to the government and to the boards of hospitals during the restructuring process. They cannot be sued or held accountable for virtually any action they take under the authority of the new legislation.

One of the aspects of Bill 26 that really concerns and upsets me deals with the loss of confidentiality of medical information. Confidentiality of personal medical information became a thing of the past under this legislation. The Harris government clearly -- and mistakenly -- feels that bottom-line economic considerations should override the right of citizens to have their personal medical histories held in confidence.

Schedules F and H of the bill will open the door for the minister to collect, use or disclose personal medical information for the proposes of the administration of the Independent Health Facilities Act, the Health Insurance Act and the Health Care Accessibility Act.

The act deems that every insured person under the Health Insurance Act will have authorized his or her physician or hospital or health facility to provide information to the general manager of the insurance plan. The rationale for this disclosure is that it is necessary for the "effective management of the health care system or for the delivery of health care services." Those who are most vulnerable in our society could find themselves the victims of a campaign to deprive them of adequate and necessary levels of care.

Citizens will have no recourse or protection when personal information is disclosed. The bill provides that no action can be brought against the minister, the general manager or any other member of the staff for disclosing information.

The bill provides for the minister to appoint inspectors to act under the direction of the general manager. These inspectors will have considerable powers to access and reproduce health records, books of account, correspondence and records, including payroll, employment, patient and drug records.

As if these provisions aren't cause enough for concern, the act actually opens the doors wide open for potential misuse and abuse of confidential information. Schedule H permits the minister to enter into agreements to collect, use and disclose information. We fear that these functions will be contracted out to private companies which will not be held accountable and which will be more concerned with profit-making than with the protection of the public interest through maintaining confidentiality.

We note that Ontario's Information and Privacy Commissioner has already expressed concern that the privacy of individuals will be compromised under Bill 26. We also note that the Health minister has agreed that changes would be forthcoming to ensure that the rights of the public with regard to privacy are respected. We hold the minister responsible to make such changes immediately.

Anyone who sifts through this enormous piece of legislation quickly learns that "restructuring" really means massive downsizing of the public sector.

What about the "savings" part? Obviously the government saves by cutting its spending by over $6 billion, without even tabling a formal budget for debate in the Ontario Legislature. But what about individual Ontarians and their communities? Will the Harris government's spending cuts and the promised tax cut give us more money in our pockets?

The direction set out Bill 26 is very clear. While many of the details will not be known until regulations are in place, the bill makes it plain that Ontarians will soon pay fees and other charges for numerous services which until now have been supported out of local or provincial taxes. Even if the government is able to introduce its proposed tax cut, the saving for most Ontarians will likely be outweighed by these new charges. Inevitably, these charges will prevent many lower-income Ontarians from using services which are now universally available.

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It is difficult to predict the precise impact of many sections of Bill 26, because it will give very wide discretion to government ministers to enact regulations prescribing what other levels of government can and cannot do. While it delegates power in some areas to hospital boards and other bodies, this is invariably matched by giving sweeping powers of regulation to provincial cabinet ministers.

By attempting to pass Bill 26 before putting these regulations in place, the government wants to write itself a blank cheque. Once passed, Bill 26 will allow government ministers to make up whatever rules they see fit without having to debate them in the Legislature.

As a member of the Canadian Union of Public Employees, I say scrap this omnibus bill which will destroy local democratic institutions, devastate public services and impose hardship on Ontarians, especially those who are most disadvantaged.

The Chair: Thank you. We've got about five minutes per party for questions, beginning with the NDP.

Ms Lankin: Thank you for your presentation. It's helpful to see this bill through the eyes of a health care worker and someone with the experience on the ground that you have.

There are a few areas you've touched on. If I were to try and wrap it all up and describe the concerns you've raised and the concerns that other groups have raised, it's that the bill centralizes bureaucratic power in a very significant way and in a sense undermines the role of volunteers.

You talked specifically about the role of supervisors in hospitals, for example, and I find that one very interesting. When the Minister of Health presented before this committee on the first day of public hearings, we asked him some questions about that. He referred to the section in the old act where a supervisor could be appointed -- it had a lot of process things in front of it, but the process things had been taken out -- but he said that's hardly ever been used; once or twice in the history of the act. He said: "I really believe it's an extraordinary circumstance. It's rare that it would be used, and it's not likely to be used." That really makes you question, why is he changing it, and why is he increasing the power if he doesn't think he's going to use it?

Like you said, a supervisor now can take over the day-to-day operation of a hospital. In the past, the board still ran the hospital; in major decisions, they'd have to check with the supervisor. Mr Clement, from the government, has pointed out in the past that there's really no difference. Again, if there's no difference, why are you amending it and why are you changing it? We never get any answers from them on that.

Do you have any sense of why these kinds of changes are being made? What do you expect is going to happen with those new powers the minister has taken on to himself to take over a hospital, to appoint a supervisor, to undermine the local volunteer board and to run it? Why do you think he's doing that?

Ms Cooper: First of all, I want to say that I do work in a long-term-care facility; it's not a hospital. We've already seen changes in our facility even without this bill. Our workload has become increasingly heavier. There are no more residents than there were before, so because the workload is much heavier, the type of patients we are getting are heavier.

They're not getting the quality care that they were getting before because we are doing more and more with less staff. That really concerns me because most of our residents in this long-term-care facility are the elderly, and I just wonder where we're going to go. Is it going to be less and less for this section of society?

Ms Lankin: I think you raise a very important concern that is quite general across the province in terms of what the potential for cuts to health care spending would mean. The government promised there wouldn't be cuts and they've said that any cuts they make are going to be reinvested. We'll see. I hope that's true, and we'll see on that point.

In your presentation you touched on some areas where you feel that there will be amendments necessary; one of them, for example, around the privacy area. The minister has indicated he'll consider amendments; in fact Ms Johns today said there will be amendments in this area, and we're pleased to hear that. My frustration is, given that the minister has already said there will be amendments and he has said that about a couple of other areas of the act, it would be very helpful if they were tabled.

I asked the minister that at the first day of hearings when he talked about certain amendments and I asked for a commitment that he would table them before we got on the road for these hearings. He said, "Absolutely," because he always found that frustrating when he was in opposition if the government waited until the last moment to table amendments. It seems to me if he'd table the amendments that he knows he's going to make to this health privacy area, and if they were sufficient, we wouldn't have to be talking about that today and the groups coming forward could be concentrating on other aspects of the bill.

I agree with your call for amendments and I echo your call, and I reassert my statements earlier and my plea to the government to table the amendments they know they're going to make so that the public who are coming forward in the hearings and the opposition members know, at least thus far, what their intentions are, and granted there will be more as we hear more presentations. With that, let me just say thank you very much. I assume that's the end of the time. I appreciate your presentation.

Ms Cooper: I just would like to reiterate I really feel that loss of confidentiality is an overwhelming invasion of my privacy. I feel very strongly on that.

Mr Clement: Thank you for your presentation and let me reiterate, as I have to Mrs Lankin before, that we will table amendments once we've heard from the people. We've heard from Torontonians, and that's all great, but I'd like to hear from people in Timmins and Sudbury and Thunder Bay as well. That's why I don't think any amendments have been finalized to this date in time.

There are a couple of things in your presentation where I share your concern, but I think some of your concerns are based on what I perceive to be misconceptions, and maybe reasonable people can differ on that. For instance, you've got some great concerns about disclosure. Of course, under the old act there was disclosure and there were limits to confidentiality under the old act, so we all know that. But I read to the privacy commissioner earlier the new section directed to disclosure of confidential information which prescribed four sets of circumstances, how disclosure should take place.

Under the old act there were no limits on how disclosure should take place, so in fact the new act is more particular and more specific than the old act. The privacy commissioner had no reply to me and still hasn't given me a reply as to how my reading of the act is misinformed. I would just like to put that on the record. But if there is a way that we can amend the act, as Mrs Johns has said, to make that even more clear, I think we are quite willing to do that.

If I put it to you that way -- you don't have to take my word for it; read the act and read the old act -- would that allay some of your concerns on disclosure?

Ms Cooper: No.

Mr Clement: Well, I tried anyway, I guess.

Ms Cooper: Not at all.

Mr Clement: I'm telling you that the new act is more specific and more directed than the old act, and that doesn't allay any of your concerns?

Ms Cooper: No.

Mr Clement: I'm sorry we can't help you on that one, I guess.

Let me just talk then more generally about the powers of the minister. You're involved in a long-term health care facility?

Ms Cooper: Yes.

Mr Clement: You agree that your particular sector within the health care sector needs more resources?

Ms Cooper: Yes.

Mr Clement: What we're doing is allowing the minister, the publicly accountable person in this whole system to the people of Ontario, to make some decisions after listening to the district health council, after their planning reports, after their community outreach has been done, to actually make some decisions and maybe reallocate some resources so that other needy sectors within the health care sector have some more resources in their area. Would you not be in favour of that if that benefited the long-term health care sector?

Ms Cooper: I would but I don't see that happening. I have some pretty definite opinions on this whole thing.

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Mr Clement: That's fair, but if that's the net impact, if we can redirect some resources to some areas where we're not saving any money and where patients are not well served and can direct that to long-term health facilities, I think that's a win-win situation, isn't it?

Ms Cooper: Yes, it is.

Mr Clement: Gives them the power to.

Ms Cooper: But I don't see that happening. I don't see the Common Sense Revolution doing that.

Mr Clement: You're a tough person to mollify, but let me give you my assurance then in wrapping up that that certainly is our intention.

Mrs McLeod: Perhaps I can use a moment to share what I'm sure is your frustration with the comments that Mr Clement has just made on behalf of the government, because there are some ways in which we could be provided with some assurance including, I guess, the six northerners who happen to be sitting on this side of the table who would not take any offence at all if you were to table amendments to provide assurance that you will not be invading personal medical records in the very specific way in which this act indeed sets out.

It's the specificness of what this act allows the minister and the minister-appointed inspectors to access, to remove from doctors' offices, to copy and to disclose without penalty, that very specificity is what has everybody alarmed, and I think not only the presenter today but every presenter to this committee would be reassured by the government tabling the amendments that the minister is committed apparently to tabling so that we will know it will be made much clearer that the government does not have these kinds of powers.

By the same token, I think in regard to the concerns you're expressing, you would not be reassured by the statements of the government's good intention. You've done a very thorough brief in recognizing the way in which the powers become very unilateral and very dictatorial, and I obviously share your concerns. You mention on page 2 of your brief, and I was interested to see that you recognize that one of the significant changes in this bill is that the Minister of Health is no longer even governed by regulations set by cabinet when it comes to making decisions about operations of hospitals, that he doesn't have to work within the regulations under the Public Hospitals Act.

This makes the Minister of Health, for the first time ever in the history I think of any province, able to make unilateral decisions about hospitals and to give the responsibility for making those decisions to a commission or indeed to a hospital supervisor. In the case of a hospital supervisor, there's no longer any requirement that there even be an inspector who comes in and makes a public report as to why the minister is exercising those kinds of powers. So I second wholeheartedly the concerns you're raising.

The other thing you mentioned, I think quite appropriately, was the whole question of whether or not there are going to be savings that are ever seen by individuals when there's a whole host of new fees proposed. Other sections of the bill deal with that in municipal areas, but in terms of hospitals there's not only the copayment but the possibility for additional hospital fees being charged to patients.

I wanted to ask you one specific question, realizing that you're in a long-term-care facility, one area you didn't touch on in your brief, as thorough as it was, and that's the whole question of copayment. If you haven't had a chance to look at this I'll certainly understand it. I don't know whether you work in a facility where the individuals receive a comfort allowance as sort of a spending allowance, but one of the concerns that has been raised is that a copayment for drugs, even as little as $2 per prescription fee, would be really punitive for anybody who is in a long-term-care facility and is existing on a $30-a-month comfort allowance. I don't know if you have any experience of that.

Ms Cooper: Some of them don't have any money left now, so that is a concern. If there's a copayment, then they can't have any of the luxuries that they do now at this facility -- go get their hair done, or whatever. There just won't be the money. There goes their quality of life in other areas.

Mrs McLeod: The other thing you point out in your brief, and I think it's an important point, is that in setting out, as this bill does, the ability of government and the minister to look at terms and conditions, one of the terms and conditions that the minister can be guided by in making decisions is the availability of financial resources. Does it seem to you that that is no longer cost-effectiveness but actual rationing of health care because of dollars, and do you see a difference between the two?

Ms Cooper: I think "cost-effective" is just a nicer word to put on it, rationalizing everything. It's cuts, whichever way you look at it, and who's going to suffer?

The Chair: Thank you for your presentation. We appreciate your interest in our process here this morning.

PORCUPINE DISTRICT MEDICAL SOCIETY

The Chair: Next is the Porcupine District Medical Society. Good morning and welcome to our committee. You have a half-hour to use as you see fit. Any time left for questions will begin with the government party. The floor is yours, sir. Please introduce yourself to us for the record.

Dr Claude Vezina: My name is Dr Claude Vezina. I'm a radiologist in Timmins, a native of Timmins, having returned here approximately a year and a half ago from Ottawa. I'm also expecting Dr Dave Huggins. I'm told he's on his way from his office, so hopefully he'll join me as I present.

I would like to thank you, Mr Chairman and committee members, for the opportunity to present on behalf of the PDMS, the Porcupine District Medical Society, and also as a radiologist who serves nine hospitals.

We are a group of four radiologists who serve the Timmins and District Hospital, but I would like you to note the geography of the hospitals that we also serve in the district. I will list them for you, since I think geographically this is probably the greatest section of patient care that you have in this province. In addition to Timmins, we serve the hospitals in the communities of Hearst, Kapuskasing, Smooth Rock Falls, Cochrane, Ansonville, Matheson, Kirkland Lake and Englehart. Those are a lot of miles, and in the weather of today, very dangerous miles.

In this presentation, which I will try to keep as brief as I can, I will try to wear these different hats in delivering my thoughts.

The Porcupine District Medical Society fully agrees that changes are required to solve the local and district drastic and acute manpower shortages that exist in various specialties. I heard someone else speak just previously about psychiatry, and hopefully the continuing contract discussions will come to fruition very quickly. This is an absolute must. Other needs also exist in obstetrics and gynaecology, orthopaedic surgery, and we need more family physicians. There's no doubt about that.

But let me stress to all of you right now that conscripting a physician to come to northern Ontario is only a forced, unilateral, short-term solution, if any solution at all. I've seen over the last 15 years, through various friends and family members, speak to me when I was in the capital of Canada about how their family physician turnover was happening so frequently. That's what you're going to get, nothing more, and that is not a solution. People will not stay. They'll come but they'll go. To continue in the solutions that you're suggesting of conscripting a physician to do so is to me unacceptable.

Incentives, however, or differentials, we believe, are more suited to such an end point. We have always supported locally and congratulate the government on actions guaranteeing minimum payment for physicians providing emergency on-call services in low-volume departments. But let us not stop. Long-term solutions must be developed. We need highly trained and skilled physicians who want to be in the north. We do not, I think, need to have physicians who have to be in the north because of a piece of legislation.

To do so, we would certainly encourage physicians in training to have rotations in northern communities during their training. This, I believe, and we all believe, will have a positive impact in the long term of attracting more physicians locally.

At this point I had hoped to have Dr Huggins present a summary of the OMA solutions on this topic, and I think you're pointing to him now. No? I'll leave that for now.

Let me go back to a local solution which is a physician-driven solution that has been put into practice only a week or so before Christmas. Over the last year we worked hand in hand with the hospitals of the district, and I'll be specific by naming them: Hearst, Kapuskasing, Iroquois Falls, Cochrane and the Timmins District Hospital. We realized we had to find a solution to being able to give our opinions on various images, X-rays or ultrasounds on patients who are at a remote distance to us, sometimes three to four hours. To do so, we took the time with consultations with various companies to look at what we can do with teleradiology. This is not telemedicine, per se, but it's similar to it. It's basically sending an X-ray image over a telephone line with a software package in a computer. Therefore, this in place now between these five hospitals.

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In addition to that, we have met with the vice-president of the Toronto Hospital and Dr C.S. Ho, the chairman of imaging of the Toronto Hospital, and they have supported and have agreed to buy the same technology we have. I stress that this is a physician-driven solution, not an imposed one. We have been able therefore to develop a computer linkup with software and telephone line between various cities in the community here, that I've just listed, to Timmins and from Timmins to Toronto. The logic is very simple: We will look at the images and we will talk over the phone and we'll come to solutions and differentials. That I think is the type of end point we should be aiming for in the problems we have to solve in the health care matters here today.

More specifically, I'd like to address a few points as they relate to the Public Hospitals Act and also the Independent Health Facilities Act, because as a radiologist and having colleagues that have private imaging clinics, I think these points also have to be discussed.

Firstly, the Public Hospitals Act: The delicate balance on Ontario's public hospitals between physicians and hospital administrators has been an important component behind the excellent level of care received by patients for decades. The Public Hospitals Act has served the interests of all concerned well by ensuring that the administrator's goals of efficiency and cost-reduction have been balanced against the physician's role as patient advocate.

It is the permanence of the physicians' appointments, subject to the very well-defined exemptions, that has enabled the physicians to play this role and to ensure that quality assurance and patient care are maintained at the highest possible level. It has also ensured that financial and other pressures are not improperly brought to bear upon physicians in an attempt to influence their clinical judgements, which must always be kept free from undue influence, so that only the best interests of the patients are considered.

Never in Ontario's history has this balance been more critical. In the face of the need to reduce costs in Ontario public hospitals, the need to have the physicians continue to act as the advocate of his or her patients is imperative. To disturb this balance and tip the scales heavily towards hospital administrators is to expose patients to the bottom line without any level of safeguards.

Once physicians may have their privileges revoked without cause, due process or recourse, there is nothing to stop any hospital administrator from exerting whatever pressure is necessary to ensure that any physician does as the administrator sees fit. Physicians may be told that they must discharge patients earlier, clinical judgment notwithstanding. Physicians may be forced to make a financial contribution to the hospital out of moneys paid by the Ministry of Health to the physician, even though the ministry paid such moneys in the expectation that this was intended as compensation for medical services. Besides being potentially a breach of professional conduct, regulations known as fee-splitting, it opens the door to all sorts of potential abuse.

In order to avoid the potential consequences of this destruction to the physician-hospital administrator relationship, the power to terminate physician privileges without statutory due process and without recourse has been reduced only to be applied where a hospital is being closed and only to become effective upon closure. Specifically, such power will not be available where two hospitals are merged or otherwise integrated and it will certainly not be available in any other circumstances.

At this point, I'd like to make comments as they relate to the Independent Health Facilities Act. The main reason for the introduction of the IHFA was to ensure a high standard of quality assurance in facilities governed by it. Through the joint efforts of the college, the ministry and key stakeholder organizations, the quality assurance program that has been developed is exemplary and a model to be replicated elsewhere in the health care system.

Concern has been raised, however, about the government's ability to enforce the same level of quality assurance against foreign-owned entities and to enforce rules protecting patient confidentiality against such foreign entities. In addition, concern has been expressed with respect to the college's ability to enforce a high standard of quality assurance in non-physician-owned facilities or to enforce patient confidentiality requirements against non-physician owners.

Therefore, to ensure that the college has the necessary power to sanction those who do not comply with quality assurance standards or patients' confidentiality requirements, the ownership of those facilities, such as diagnostic imaging facilities, that provide medical services should in the future be restricted to those physicians with the specialized expertise in this area. This is consistent with the approach taken towards professional practices generally in Canada.

Existing licensees who are not physicians or physician-controlled will be permitted to continue to operate their already licensed facilities. However, any new licensees, including purchasers of existing licences and purchasers of the shares of a corporate licensee will have to meet the new criteria. By limiting ownership to physicians, it is expected that less emphasis will be placed on marketing and generating profits, and consequently it should lead to lower utilization.

Furthermore, most facilities which have been the subject of sanctions based upon poor quality under the act since its proclamation have been physician-owned.

Finally, it should also help to ensure patient confidentiality by guaranteeing that the college will have the necessary authority to enforce the relevant rules.

Dr Huggins has arrived.

Dr David Huggins: My apologies, folks; a sick child and a sick adult.

Dr Vezina: Good morning, Dave. I've left a few paragraphs for you as it relates to the OMA proposals to government to solve the problem of physician needs in northern Ontario.

Dr Huggins: My pleasure. Good morning, all. There were some concerning things actually that the minister stated some several weeks ago concerning the lack of the OMA's positive suggestions to influence life in the north as a physician. As you're probably well aware, we have proposed a number of proposals, including a northern incentive program to be funded out of the global budget of the OMA. We have proposed, since 1993, direct contract proposals. There certainly was some concern over the past several years as to who might pay for this.

The ministry's position has changed. The OMA's position has changed. We believe it's a valuable program. We believe it should have been initiated several years ago. However, we're still hoping that it will be initiated. Just for example, in this town we've got one psychiatrist. There's virtually no child psychiatry in northeastern Ontario -- virtually, because I think there may be one and a half in Sudbury; I believe there are 50 in Ottawa.

We at the ministry -- the ministry? God, it's been so long talking with them. We at the OMA do believe that we have some positive programs that are going to be much more successful than what the minister has suggested. I don't think we in the north really are interested in having doctors conscripted to come to the north. We think they may be poorly trained and ill equipped and not interested in coming here. We do recognize there's a problem in the provision of services in northeastern Ontario and we think we have a better solution than has been suggested to date.

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The Chair: Okay. We've got about five minutes per party, beginning with the government.

Mrs Ecker: Thank you very much for coming here and taking time out of a very busy schedule to provide us with some good suggestions. I have two questions, one concerning the Independent Health Facilities Act.

I think Dr Vezina made a good point about the fact that if there's physician ownership, it might well provide a better way for the College of Physicians and Surgeons to police the quality of care and confidentiality. One of the things I'd be interested in your input on is that one of the concerns CPSO has had with physician ownership of things like the Independent Health Facilities Act is conflict-of-interest problems. I wondered if there is a way that could be better addressed, because I gather that has been creating a lot of concerns. It's a minority, it's not the majority, but there are some apparently who are creating some difficulties because of conflict of interest. Is there a way to address that?

Dr Vezina: I don't have the solution clearly in front of me to deliver this morning. I could agree with you that it is firstly a minority of situations, of imaging occurring in this way in the province, in fact the whole country. It has been much a bigger problem in the United States, as you can certainly understand.

Certainly as it relates to Ontario, I think if we agree that this is an objective we should aim for and if we agree there is a problem or a potential problem, we should sit down with the people who will be providing it with the CPSO and develop some guidelines to prevent this happening.

We have computers everywhere now. The ministry has computers everywhere. We can easily backtrack or look back or provide ways of perhaps monitoring that and minimizing it, if not removing it.

Mrs Ecker: Is there any way to do that sort of sharing of information and that kind of thing without getting into the sharing of patient treatment information among the ministry and the committees and that in order to try to go after that abuse and fraud?

Dr Vezina: I'm not sure of a yes or no to that. I would suggest that the OAR, the Ontario Association of Radiologists, as the leading group of imaging in this province would be able to provide sufficient suggestions to you or to anyone else who would like to look at that matter, but I agree with you that should be clarified, if that's the objective down the line.

Mrs Ecker: Just on the underserviced area, which I think we all recognize has been a serious problem that a lot of governments have tried to wrestle with, the difficulty is that of course specifically in the last four or five years the number of underserviced communities has increased something like 40%.

The minister has proposed financial incentives, enhancements to education and training, increased professional support. There's certainly a recognition and an acknowledgement that many of those recommendations that help address the isolation and the lack of support for physicians in the north might well be of assistance, and that if that doesn't work, if there's not some time here, then billing numbers may well need to be looked at.

Given the fact that we've all wrestled with this, governments, the OMA and local communities over the last several years, is there anything new and different in the proposals that you've talked about that haven't been tried before?

What we're trying to wrestle with is that there have been things like incentives and things that haven't worked before, and I guess what we're trying to get at is what will work now that didn't work before. Was it just that there were recommendations there which previous governments didn't enact or are there things there we should be enacting and what can we do to make sure it helps so we don't need to use things like billing numbers, which I think everybody agrees is not the preferred option to go here? But communities are losing physicians at a great rate and we have to address that in some manner.

Dr Huggins: I'm encouraged to hear that the government is going to follow through with the incentive program. The incentive program was one that was initiated by the OMA, as was the CME program for physicians in the north. It was introduced under the 1993 agreement, as you're well aware. We're hoping that will continue to happen.

We're also very much involved in the production of the northeastern-northwestern family residency programs, which we think are excellent programs and need to be augmented. We have suggested since 1993 that there be increased circulation and exposure of specialists in their post-grad training programs to the north so they get exposed to what life is like and it is not all that terrible up here in the north. They actually come prepared perhaps.

Why hasn't it worked in the past? We think the incentives have been lousy. They haven't been changed since the UAP program was initiated back in the 1980s. We think it was inappropriate, inadequate. We think there are many things we can do to improve it.

Mr Miclash: I'd like to thank the doctors for appearing. I think what you've done here in your presentation this morning is just sort of extended what we heard earlier, that being the uniqueness of practice here in the north, that we do need some physician-driven solutions to the problems. We need a commitment on behalf of those who wish to practise in the north, who wish to come to the north, to remain and that commitment coming directly from them.

My question to you this morning is, being that we've had the present government indicate in a number of documents, and I quoted from a few of them this morning, that they would have consultation from people in the north, do you know of any individuals or groups that were actually consulted in the drafting of Bill 26?

Dr Huggins: The short answer is no.

Mr Miclash: Okay.

Mr Vezina: My answer is a big zero.

Mr Miclash: Thank you.

Mrs McLeod: Following that, I've been directly and indirectly involved in the whole question of physician recruitment and retention in northern Ontario for a long time now and I get more than a little frustrated at suggestions that there have not been creative solutions that have been put in place and that are, in some measure, working, and you mentioned a number of them.

The residency program: Somebody says, "Well, why hasn't it produced results yet?" I think this is the first year that the graduates have actually been out in the field and the retention rate from that program is remarkably high. I think there is considerable encouragement from the incentives and, as you've indicated, there is sufficient encouragement that we need to look at enhancing the programs that are in place now.

I'm prepared to say that my anecdotal experience is that the biggest problem in retaining physicians in northern Ontario has been the outflux of physicians when doctors see the government stepping in to control health care. I'm wondering whether or not you are concerned about surveys of the University of Toronto medical school class, for example, where they said 80% of them would leave if the kinds of measures proposed in Bill 26 were brought in. Are you concerned that Bill 26, billing numbers notwithstanding, may in fact create an even greater problem for recruitment of physicians in the north?

Dr Huggins: Aside from the anecdotal, and the one comment we heard from the chair of general practice at U of T that a significant number of his grads were going to walk, in our community I believe that at the last count we're up to six physicians who have left within the last six months in this community, and I don't believe we have any sign on the horizon of a single replacement for any one of them.

Anecdotally is the best I can give too, but I believe there is a significant disinterest, if Bill 26 continues, in young physicians continuing to practise anywhere in Ontario, let alone where they might be conscripted to work.

Mr Ramsay: I would just like to say that about a year and a half ago, Dr Vezina, I was through your radiology department and was very impressed with what you've done here. It's a very good example of how not only physician-driven solutions but locally driven solutions and, in this case, a regional solution for northeastern Ontario, or at least a good part of it, seems to be the way to go, rather than the government from up on high, and especially from the minister's office, dictating policy. I think you're a very good example of how, when the pressures and needs are there, we in the north can come up with solutions and I'd just like to congratulate you for that program.

Mrs McLeod: I'll come back to the independent health facilities, which is another issue you raised, and since we're not in a court of law, we're allowed to make attributions. I wonder if you would comment on why you think the government would be dropping the Canadian preference in looking at who should manage independent health care facilities.

Dr Vezina: Probably opening it up to more people and liberalizing the use of that particular industry. If you open it up to more doors, in my mind, if this is what you're questioning, to me, it is a step in saying that maybe more of our health care will be opened up to US markets. Isn't that the way you read it?

Mrs McLeod: Yes, that's the way I read it.

Dr Vezina: That's quite simple.

Dr Huggins: The only other read is that it seems this is the only example in Bill 26 where the PCs are at all interested in free and open markets.

Mr Bisson: Just a couple of quick questions here. We heard some comment a little while ago by the Conservative member, Mr Clement, that they're waiting to hear what the hearings have to say in regard to the whole issue of releasing of confidential medical information. I would just remind people here and yourselves that if it hadn't been for the work of both the Liberals and the NDP in forcing this into committee hearings, we wouldn't even have the opportunity to do that, so I think it's a bit of a moot point that the member is making.

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The question I'm asking you is this. There are two parts. In schedule H of the act it says, "The minister may enter into agreements to collect, use and disclose personal information concerning insured services provided by physicians, practitioners or health facilities." Do you have any concerns as a professional in regard to what that might mean and where that might lead? And if you can, be a bit specific.

Dr Huggins: Obviously, we do. I think the average patient should have more concerns than I as a professional have. I don't think any government should have the right to know what your private medical file says. I think there is no question that governments need increased information in terms of managing the system. Providing there are absolute guarantees of anonymity, I think improved information accessing is useful, useful to government, useful to the provision of health care in the longer term. Currently, the way it sits, it doesn't give me much assurance, nor can I give my patients much assurance, that there is any degree of anonymity, in spite of the fact that it comes under the aegis of the privacy commissioner.

Mr Bisson: The second very quick question is that under the act there's going to be more of an ability for the government to decide what treatment that you decide that you want your patient to follow, based on the medical situation of that patient, or how you can treat them. Any comments on that, in regard to trying to find savings; in other words, delisting unilaterally certain services?

Dr Huggins: I'm not sure that just delisting unilaterally is the implication. What more of the implication is to me is that somebody may make a bureaucratic decision as to what is appropriate. What's even more appalling and more absolutely absurd in the legislation is that after the fact, after a service has been delivered, somebody can make a decision that it was not medically necessary to do so, in which case, according to the legislation, I would be responsible for having ordered the test, made the consultation referral etc.

On what basis can one, in any legitimate real world, have somebody, presumably a physician but there's no reference to a physician, making a second guess as to what it is that a service is going to be provided? It's absolutely nuts.

Ms Lankin: Just to follow up on that point, in the previous legislation if there was a review, if there had been a concern raised about some aspect of practice of the physician, it was a Medical Review Committee, a peer review, that would look at that and exercise that judgement around medical necessity, in consultation with the physician. Now it is somebody at the Ministry of Health in Queen's Park, not a physician, not a qualified peer review. Those concerns are very appropriate.

I have to tell you that last night I sat in the hotel room here reading through all of these, which are letters from physicians to their MPPs, the Minister of Health and the Premier. The concerns that they set out in there and their fear that there's a bureaucracy that's going to be making medical decisions and reaching in and the intrusiveness of that, instead of those decisions being made by patients and doctors together -- even if that's not what the government intended, that's how people understand what is happening here, and what the impact of the actual words in the legislation are.

I just wanted to add some other information from your colleagues who have written here, because in fact many of them indicate that there is a growing sense that physicians are going to leave, not just the graduating physicians that you talked about.

This letter here from a dermatologist talks about -- in fact, he's the representative for the section of dermatology for the OMA -- and he says that he's received five phone calls in the last week from colleagues with seven to 10 years' practice experience who've begun an extensive search for relocation outside of Ontario.

There's another letter in here -- I don't have it in front of me -- where the physician has talked to a physician headhunter in Phoenix, who indicates that since Bill 26 has been tabled, the number of Ontario doctors that have contacted them and they're talking to has just blossomed, and that's one headhunter in one US city.

I don't have a specific question for you. I just think that the concerns that you've raised we're hearing from physicians right across this province. I feel in many ways like physicians have been scapegoated through this process and that it's almost like a divide-and-conquer, because many of the letters from physicians now sort of turn on patients and say it's patients who are driving increases in utilization. We're all being divided in response to how this government is behaving instead of trying to find common solutions, which would be a better approach.

The Chair: Thank you, doctors. We appreciate your interest in our process and being here this morning.

We have a motion to deal with at lunchtime that is in order. Just a couple of things before we get to that. Number one is we do have to check out at lunchtime; number two, there are some tables set up for us to have lunch. It is snowing heavily outside. The last plane out to Sudbury is the one we're scheduled on. In view of those issues, can I have unanimous consent that we will limit the discussion on the motion to one five-minute conversation per party and then vote on it?

Mrs McLeod: What's our time frame to get to the airport?

The Chair: We've got an hour.

Mrs McLeod: From the end of the committee hearings until the flight leaves?

The Chair: Right.

Mrs McLeod: And it's what, a 20-minute trip to the airport under good conditions?

The Chair: It's snowing heavily outside. We do have to get to Sudbury.

Ms Lankin: I will agree to that. I'd just like to split my five minutes to an introduction and a wrapup.

Mrs McLeod: I'm not sure that we need to curtail the presentations. I think we should perhaps check with norOntair as to whether or not --

The Chair: We do have somebody scheduled at 1 o'clock. We do have to check out, we do have to have lunch, and I think it's important that we do those things. I'm just talking about the debate on the motion that Ms Lankin introduced.

Mrs McLeod: But not on the presentations after that.

The Chair: Oh no, no. I'm sorry, my mistake. One five-minute conversation per party on the motion. Everybody agree with that? Okay. Ms Lankin.

Ms Lankin: Thank you very much. I have moved this motion today because I think it is important that we continue to drive home to the government the concern of people in the province of Ontario with respect to this bill and the concern with respect to the process and the fact that many, many people who have put forward their names to present before this committee and the other committee that is travelling in these next two weeks won't be heard.

Prior to Christmas, when we discussed the concept of whether or not there should be more hearings and whether the bill should be split etc, the government members simply said that they didn't think there would be that much of a problem, that people would have an opportunity to be heard and that it was premature. Well, let me say that since that time the numbers of people who have applied to be heard have increased. In my motions before Christmas, we were referring to hundreds of people who had applied to be heard. Now there are 1,026 groups and individuals who got their names in and applied before the deadline and before the cutoff, and we've received numerous calls from people who missed the deadline and the cutoff and were still trying to get on. That 1,026 number is just for these two weeks of out-of-town hearings, and -- I have alluded to this earlier -- there are only 274 spaces that are available for people to be heard. So you can see by how much the demand outstrips the time available.

Particularly as we're travelling in the north, you can see that -- for example, you mentioned the last flight out of here is at 4:30 today. We've had to cut the day short and stop at 3 o'clock in the afternoon, whereas in Toronto, for example, we would have gone on till 6 or till later into the evening. So northern communities, when we're only here for one day, are not getting the same kind of access as other communities are. We're cutting short the north in terms of the amount of time available. When we go into communities like Sudbury tomorrow, there are 13 spots available. There is something like 56 or 58 people who have applied to come forward. This is just not acceptable in terms of a democratic process.

I know the government members know that I believe the bill needs further consideration and that it should also be split up so that we deal with it adequately, and that we're prepared to pass the parts that are urgent and need to be passed on the 29th. I would urge them, after having heard over the break the number of people who are wanting to come forward, to reconsider the position they've taken on this motion in the past and to support it so that we can at least simply ask the government House leader to meet with the other House leaders and to discuss this issue and to attempt to come to a better process resolution to dealing with this very important bill and the major public concern that is out there.

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Mr Clement: I do not support the motion, Mr Chairman, for the same reasons for the previous six motions Mrs Lankin has put forward with very similar wording, or whatever the number. Maybe it was four or five, but it sounded like six. I'm sorry if I sound facetious; I don't intend to, Mrs Lankin, but just as Mrs McLeod is frustrated with our interpretation of the bill, I get frustrated by the myth-making that is occurring by the opposition respecting the lack of hearings. For instance, Mr Bisson and Mrs Lankin, I believe, earlier indicated to the public that the government side was not in favour of hearings on the bill and it had to be forced through the opposition. That is absolutely incorrect.

Interjections.

The Chair: Excuse me. Mr Clement has the floor. He did not interrupt Ms Lankin, so I appreciate the same consideration for him.

Mr Clement: As my honourable colleagues well know, in fact the government House leader, Mr Eves, suggested to the other House leaders that we have 360 hours of hearing time. As it stands, Mr Chairman, we on both sides of the committee, both the health and the non-health side, will have heard at the end of this process by my calculations 750 separate presentations. There is also an opportunity for written presentations, which we have been receiving and have been reading. We are visiting 11 cities in 10 days to hear from other persons in Ontario who wish that their views be recorded, and in fact this is what this process is all about.

If I'm evidencing frustration, Mr Chairman, I do not wish to project that to my friends and colleagues on the other side, but it is simply that we are going through a process which is legitimate, which will allow for differing points of view to be heard, and we've heard some today, and that's what this process is all about, quite frankly. At some point, as the House leaders have agreed, government has to come together with the opposition parties in the Legislature, the duly constituted democratic body in this province, and decide on legislation. That date has been scheduled for January 29. That was agreed to by the opposition House leaders, and we intend to stick to the agreement that was sanctified by the Legislature.

Mr Miclash: I think as we travel throughout the north the government members will find out that there is a fair amount of uniqueness in the north and at this time I would just like to welcome you to the north. I haven't had a chance to do that yet, but it only shows you that out of 35 requests in Thunder Bay alone we're going to listen to 10 only. Had we not travelled to the north, we probably wouldn't have even seen any of those 10. So I really have a concern for that. I would just like to say that I've heard there have been up to 1,200 groups out there that have requested time at the hearings. As Ms Lankin has indicated in her motion, there have only been 274 spaces allotted to some 1,200 groups.

As we continue into the hearings, we understand there is more and more interest in this bill, one which is flawed to a great amount, noting just the announced amendments that the minister is talking about presently and the ones that we're looking for. When you take a look at just some of the responses of the ministers in the House over the last week of the Legislature, you have to realize the need to listen to this great number of groups, because one minister in particular didn't know what the bill contained. That even shows us the need to ensure that all of these groups have a chance to say something to the bill. So I would just like to say at this time that we certainly would like to see more than just one fifth of those who have requested to present on the bill to be able to present to this committee. We fully support this resolution.

The Chair: Thank you, Mr Miclash. Okay, the --

Ms Lankin: Just the wrapup.

The Chair: We said one speaker, a maximum of five minutes. What's what we agreed to.

Mr Clement: No, but she wanted to have the beginning half.

The Chair: Yes, Ms Lankin.

Ms Lankin: Just very quickly, in response to Mr Clement's comments, number one, I'd like to raise a point of privilege in terms of violation of rights of the member. He indicated that the committee has received written submissions from people and that he has been reading those. I have not received one copy of a written submission, and if the government members have been receiving them and the other parties have not had them circulated to them, then there is a problem. I have not received any that have been sent through, so I don't know what that's about but we can deal with that separately as a matter of privilege.

With respect to his comments that the government had offered more hours of hearings, again I want to point out the myth-making here. In the week leading up to December 14, when no one had copies of the bill, when no one had done the analysis, when the public didn't even know what was in it yet, when people had had only knowledge that had been introduced a week before that, I just think it's really inappropriate to continue to put that myth out.

Lastly, you say that the agreement was reached. Let me tell you, it was forced through the action of the opposition parties, and the final agreement was one that we barely could reach between the three parties for January 29. Since that time, we have found out what the response of the public was. We didn't know there would be that many people who wanted to come forward. That is reason enough for any reasonable people, particularly those accountable to the public, to rethink the agreement. That's all I'm asking, that they meet and they rethink it.

The Chair: The motion has been put.

Ms Lankin: A recorded vote, please.

The Chair: All those in favour of the motion?

Ayes

Lankin, Miclash.

The Chair: Opposed?

Nays

Clement, Ecker, Johns.

The Chair: The motion is defeated. We recess until 1 o'clock.

The committee recessed from 1206 to 1309.

ONTARIO PUBLIC SERVICE EMPLOYEES UNION NORTHEAST AREA COUNCIL

The Chair: The first presenter for this afternoon is the Ontario Public Service Employees Union, Northeast Area Council. Helen Riehl is the chair. We had made a decision that we would begin on time, regardless of who was here to listen. I've given them an extra 10 minutes, and we're still a little short, but they will be coming in as your presentation is going on. So I think in the interests of time we'll let you get started. You have a half-hour to use as you see fit. Any questioning time at the end would start with the Liberals. So the floor is yours.

Ms Helen Riehl: Okay, great. I'd like to start by thanking you for giving me the opportunity to make this presentation. I'd also like to let you know that I am a front-line worker. I work in the community of Timmins with the developmentally handicapped, and I've been working there for approximately 15 years.

The Northeast Area Council represents about 1,000 people in the city of Timmins and an additional 1,000 people in the areas of New Liskeard, Kirkland Lake, Haileybury, Kapuskasing, Chapleau, Foleyet, Moosonee and surrounding area. We are members of the Ontario Public Service Employees Union and work either directly for the Ontario government or in the broader public sector.

We are very concerned over Bill 26 and its consequences, not as only as workers but also as taxpayers and users of the service. This bill is clearly about the privatization of services. In regard to health care, the power that is taken away from the people and given to the Minister of Health is alarming. The minister will have the power, at his discretion, to administer grants, loans or financial assistance, with the added power of reducing, suspending, withholding and terminating assistance. As well, the minister will have the power to impose terms and conditions and set requirements for the repayment of loans.

The minister will have the power to dictate what services may or may not be offered, to close or merge hospitals, and to order that a hospital cease operating as a public hospital. All of these powers are given without the need to consult or to have public hearings. The closure of one hospital in the north would have a large impact on the citizens, and it is unthinkable that a decision such as this could be made without hearing the concerns of the people.

Prior to Bill 26, an investigator could be appointed by the government to report on the quality of care, management and administration of a hospital. Based on the report of the investigator, a supervisor might be assigned to act as an adviser to the hospital board and administration for the purposes of improving the management and care of the facility.

This bill would allow a supervisor to be assigned at the discretion of the Lieutenant Governor, with no connection to an investigator. The supervisor reports to and follows the direction of the Minister of Health.

Bill 26 virtually gives the minister the power to make any changes to the hospital that he feels is in the public interest, and I emphasize "he." This is from a government that says it wants to get out of the business of running business.

Prior to this bill, these powers were not left to an individual. How can one person decide what is in the public interest for the people of this province? That is an attack on the democratic rights of the people.

The powers given to this minister will result in groups having to do extensive lobbying for the hospitals in their areas. It's very difficult to lobby effectively in a province the size of Ontario. You need a lot of money, a lot of time and a lot of people. You need to be close to those you are lobbying. How are the people in northern Ontario able to effectively lobby the minister in Queen's Park?

Another very disturbing fact is that the minister and cabinet are protected from any liabilities as a result of their decisions. I thought the government was supposed to be accountable for its decisions.

The minister will also have the power to revoke a private hospital licence or reduce the level of government financial assistance. This will open the door to private, for-profit hospitals. When agencies are run for profit, the ability to provide quality care is diminished by dollar signs. With the added proposal to remove the preference given to Canadian-owned, non-profit facilities, it is clear that the hospitals will be run by out-of-country agencies. This will only take money out of the province and lower the tax base.

These corporations are only here for profit. They will not want to run routine tests due to the cost and time that it takes to do so. If we allow this to happen, we would be setting ourselves up for outbreaks of epidemics such as diphtheria, which is presently a routine test done by the provincial health labs. If we look at past experience, we can see that private, for-profit services cost approximately 34% more than publicly run services.

The need for continued profits creates an unduly stressful environment in which to work. I heard a story that I'd like to share with you from a co-worker who worked in a hospital in the United States. This hospital would frequently receive patients from nursing homes in the area. They had large bed sores and it was obvious that they hadn't been bathed in days. This person was concerned about that. When she brought it up to her supervisor and asked about filing a report, she was told to keep her mouth shut because if there was a report filed, the nursing home would no longer send people to that hospital and that hospital would lose profits.

I don't think that's what we want to see in Ontario, but I think that's what will happen if this bill proceeds. I'm amazed that we would be looking towards an American-type system when they are looking to us for ways they can improve their system.

Another issue that appears not to have been given much thought is one surrounding the terms of the North American free trade agreement. It's my understanding that under NAFTA, once a service is privatized it cannot revert back to a publicly run service. What is this government going to do when it realizes that privatized services cost more money? By that time it will be too late.

Schedule G of Bill 26 is another area of concern. This directly affects the people I work with. These people need medication to sustain a quality of life. Some of them are on as many as 12 prescriptions a month and they receive a personal needs allowance of just over $100 a month. They cannot afford to pay extra money for prescriptions. This part of the bill will place some people in the situation of having to decide whether to buy food or fill a prescription. Some people need medication to prevent them from injuring themselves or others; without it many will end up in jail, in the hospital or on the street. Not filling prescriptions due to the deterrent of cost will increase the need for crisis intervention, hospitalization and long-term treatment.

The deregulation of drug prices will result in the overpricing of medication and, again, people on fixed incomes will have to decide if they should fill a prescription or if they should buy food for the table. People who have benefit plans will face higher premiums. Why does Ontario have to be the only province that does not have regulated drug prices?

Schedules H and I will present changes to the definition of "medically necessary." This was previously negotiated with the Ontario Medical Association and defined by regulation. Once again the minister will have the authority to determine what is insured. This will create a two-tiered system, with minimum care for the majority and extensive care to those who can afford to pay for it. I can't imagine being seriously ill and having to decide if I can afford to purchase the care that could save my life. The changes to this bill have very serious repercussions for the citizens of Ontario. The changes are being made far too fast and with little thought to how the majority of the people will be affected.

During the election campaign, Ontarians heard promises that were made and printed in the Common Sense Revolution and distributed by the hundreds of thousands. The promises voters heard were clear: "We will not cut health care spending; health care spending will be guaranteed; health care funding won't be touched; aid for seniors and the disabled will not be cut; how the savings will be achieved will be discussed in partnership with all Ontarians; our four-year plan will be based on analysis and consultation with workers and ordinary Ontarians through extensive public hearings; there will be no new user fees and we will work with OPSEU members, listening to their ideas and eliciting their help in taking action." This bill breaks every single one of those promises. We urge the government to meet its promises and repeal this bill.

The Chair: Thank you for your presentation. We've got about five or six minutes per party left for questions, beginning with the Liberals.

Mrs McLeod: I appreciate your presentation and the time you've put into it. One of the things that strikes me is your concern about increasing privatization of health care. That's one of the things we worry about as something that can happen down the road with this bill. There's so much that concerns us that will happen immediately that sometimes it's hard to look down the road and say, "What's the long-term impact of this?" I personally think you're right to be concerned that what we could see here is an increasing privatization of health care and that it would more and more become one system for those who could afford the best and another system for those who can't afford to get something more than the public system can provide.

It all comes at a time when there is real funding pressure on the public health care system. You're right to quote some of the promises the government made before they were government, because not a penny was supposed to come out of health care, and we're looking now at a budget that takes $1.5 billion out before we see any real evidence of those dollars being replaced. Our concern -- and I think you've reflected on that -- is that if you're really squeezing the public system, the pressure to let the private system in becomes almost overwhelming.

I also appreciated that you picked up on the fact -- you obviously work in a long-term-care setting; at least, I gather that from your presentation -- that the copayment for drugs becomes really punitive for those who are on a relatively small comfort allowance. I appreciate your picking up on that.

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Knowing that the health care system is under financial pressure -- even if the government weren't trying to take $1.5 billion out of it, there'd still be some real financial challenges to meet the need that's there -- do you as a front-line worker see changes, ways dollars can be saved, ways we can meet the needs without new dollars in the system? Do you see an opportunity for people in a community like this one to work to find those kinds of changes without the government having to step in and do it in a heavy-handed way?

Ms Riehl: Definitely the front-line workers have ideas of how savings can be achieved, and I think it's only through talking with them that you'll find the best way to do it, because they know how to achieve the savings without affecting the service.

Mrs McLeod: Is that kind of consultation happening? I suspect it hasn't happened on this bill.

Ms Riehl: No, I don't see it at all. I saw it prior to June, but I don't see it now.

Mr Michael A. Brown (Algoma-Manitoulin): I'm interested in the process here. One of the most interesting things about this process is that this is obviously a major bill dealing with not only health care but myriad other subjects.

I'm the Natural Resources critic for the Liberal Party, and I was in the last Parliament also, and we went through a rather major forestry bill, Bill 171, which a lot of people here in Timmins would know about. During that process, we did three weeks of public hearings on that bill, and the opposition, led by Mr Hodgson, the present Minister of Natural Resources -- both Mr Hodgson and I said, "We won't start unless we get the manuals, the regulations; you've got to show us what they are before we're willing to start," because it gave the minister huge discretionary power, much like this bill does. Well, we got the 1,000 pages of manuals and regulations, and I assume this bill will generate more than a thousand pages of manuals and regulations.

My question follows from Mrs McLeod's question. Has your organization, you personally, the community, had any kind of input into the development of these regulations? Have you seen any regulations that this bill might be implementing and how that really affects it? Even if we believe our good friends across the floor here that everything's going to be fine and swell and wonderful, do you know what? They're not going to be there forever, this minister isn't going to be there forever, and whichever minister inherits this bill then gets to do whatever he or she wants. Even if we believe what they're saying, the powers given to a minister under this bill are absolutely incredible -- most would say outrageous. Have you had any dialogue about what they intend to do at this juncture?

Ms Riehl: No, I haven't. I agree with you that the bill is far too large and the regulations will be far too detailed. It's really being rushed through. To want to vote on it at the end of this month and rush through these types of meetings -- you need to listen to far more citizens of Ontario to get a full picture of what the citizens of Ontario feel and how they feel this will affect them.

Ms Lankin: We certainly appreciate your presentation. Helen, where do you work? You mentioned the clients you work with.

Ms Riehl: I work for the Cochrane-Timiskaming Resource Centre. It's a schedule 2 facility for the developmentally handicapped.

Ms Lankin: In that community and in the broader community that deals with people who have mental health problems -- that's a little different from the developmentally handicapped area, but I'm interested in the concerns you raised about the copayment. I think I heard you touch on two issues. One was that for those who were in some kind of collective living situation, and that would be the same for seniors in nursing homes, for example, who are without financial resources and are living on a comfort allowance in terms of any additional purchases they need to take, the copay would come out of that money.

From your experience I'd like you to elaborate what it would mean for those people. What sorts of things do they do with that comfort allowance now that they won't be able to do when they pay that $2 per prescription? You said some of them are up to as many as 11 or 12 prescriptions a month.

The second thing I thought I heard you touch on I've heard some people working with clients in the mental field raise, and that's the issue of drug compliance. As we try to move away from such reliance on institutions and to support more people in our community, in the mental health field in particular, one of the things we know is really important is support in working with them for medication compliance. The concern has been raised that the $2 copayment will be a tremendous deterrent for some of these people who are very marginalized in terms of their economic power, that it could lead to a lack of compliance which then becomes the revolving-door problem of people becoming reinstitutionalized.

Could you just elaborate on those two areas for me?

Ms Riehl: The comfort allowance is used to purchase personal hygiene products, to have haircuts, to go to the movies, go out for supper, anything other than what's necessary, like food and shelter and medication.

The compliance with medications -- we have a lot of people who are epileptic and who have behaviour outbursts, and that's controlled somewhat by medication. If they didn't have that, they'd be at risk of becoming aggressive, hurting themselves, hurting others, as well as the staff who work there. For people who are epileptic, even with the medication they're on their epilepsy is not completely controlled, and they can have maybe a dozen or so seizures a month. It would substantially affect their quality of life if they were unable to purchase the medications.

With the push to have more and more independent living, some of those choices are left up to the individuals themselves, and if it means, "I can buy a chocolate bar and a pop or I can get my prescription," they're going to buy a chocolate bar and a pop.

Ms Lankin: You're talking about someone in an independent living situation out in the community.

You just raised a question that we haven't talked to anybody about during these hearings. For someone who is living in a home, an institutionalized setting, currently staff are involved with them in terms of medication compliance, I'm sure to try to help control the kind of --

Ms Riehl: In most agencies, yes.

Ms Lankin: Do you have a mechanism? How do you get someone to take the drug if they don't want to? At least right now you've got the drug there. Will there by any mechanism for you to force them to spend their comfort allowance to pay the copayment to get the drug in the first place? What if they don't even have the drug? Do you know how that plays itself out?

Ms Riehl: I think it would depend on how the agency is run. In some agencies those decisions would be left up to the individuals alone, and in other agencies it would be up to the staff; the staff pick up the medications and deliver them to the homes. In some agencies it would be easier to ensure compliance than in others.

Mrs Johns: Thank you for your presentation this afternoon. Obviously there are some things we agree with and some things we disagree with. I thank you for bringing up about the medication. We've heard that a number of times, and the $2.

I think one of your fundamental premises today was how fast we're moving and why we need to move so quickly. I'd like to address that for a moment, if I may. The province spends $1 million more an hour than it receives in revenue at this point, and at this point, we worry in the long run that if we don't make some tough choices today, there will be no health care in the future, there will be no education in the future. As a younger person, especially in my case where I have young children, I really worry about where the health care will be tomorrow if we don't make some decisions today, decisions that are hard, admittedly, but that will put Ontario in the position where it will be able to compete and we'll be able to have health care in the 21st century.

We worry that there will be a two-tier health system, obviously. We worry about it as the ability of people to have health care, that people can't as a result of not having doctors. I come from rural Ontario, and as you come from northern Ontario, I know you understand the problems with having physicians in our areas to take care of us.

You talked a little about emergency in the hospitals, and I want to touch on this. First of all, I'd like to say that we are trying very hard as a government to get emergency rooms open. We have made the first stand in paying the doctors $70 an hour to man emergency rooms after hours and on weekends. We are making some stance; that's a reallocation we're making back into the health care system.

We've closed beds previously in previous governments, we've tried to make some changes. Nothing has happened or not enough has happened. We haven't been able to close those hospitals. You say you have some suggestions, and I know the people who work in health care institutions do have suggestions, but nothing's happened in the last 10 years. Why should we give it a little more time before we start to close the hospitals? What do you think will happen that hasn't happened up to this point?

Ms Riehl: I think all that's going to happen with this bill is that all the hospitals in the province are going to be privatized and for-profit and they're going to be American-owned and American-run. That's going to make a worse health care system than we've ever had in the province of Ontario. If you don't consult with the workers and the people on the front line, who know how to save the money and keep the service, it's not going to change. And it was coming, it was changing.

Mrs Johns: We obviously don't believe the system is going to become an Americanized system.

Ms Riehl: Could you guarantee that in writing to the citizens of Ontario?

Mrs Ecker: I didn't run as an MPP in this province to turn the Ontario health care system into an Americanized health care system. That's one of the reasons I'm here, to make sure that the changes we can make will save that system so it won't become Americanized.

The Chair: Thank you very much. We appreciate your interest in our process and your presentation.

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ONTARIO PUBLIC SERVICE EMPLOYEES UNION, LOCAL 645

The Chair: The next group is the Ontario Public Service Employees Union, Local 645, represented by Doug Heath, who is a music therapist in the psychology department of the Timmins and District Hospital. Welcome to our committee. You have a half-hour to use as you see fit. Any time you leave for questions will begin with the New Democrats. The floor is yours, sir.

Mr Douglas Heath: Mr Chairman, honourable members of the standing committee, I would like to thank you for allowing me the opportunity to express the feelings of my fellow employees at the Timmins and District Hospital. I understand there was some doubt that these public hearings would take place, as occurred with Bill 7, and thank the members whose lobbying made this possible.

Bill 26, a rather massive bill, repeals two acts, creates three new ones and amends 44 pieces of legislation. Included in this bill are articles that give the government autocratic powers that bring about fundamental changes to our health care system. Bill 26 gives complete power to the Minister of Health to make changes to hospitals, physicians' conditions of work. It even allows access to patients' confidential records.

This bill will eliminate provisions that give preference to Canadian-owned, not-for-profit health care. By deregulating drug prices and allowing drug companies to determine the price for drugs, they will surely go up. Competition will not keep drug prices down because of the patent protection of Bill C-91.

Schedule F: Under section 8, the Ontario Council on Health is replaced by the Health Services Restructuring Commission. The Ontario Council on Health's role was to advise the minister on health matters and the needs of the people of Ontario. The commission will perform "duties assigned to it" with immunity from liability. We feel this is truly the function of our district health council. Mr Wilson stated that the commission will facilitate restructuring of the health care system by working with local communities to implement their restructuring reports. Mr Wilson has also recently instructed local planning bodies to submit their restructuring plans now, with or without consulting the stakeholders.

Timmins and District Hospital has worked hard at reducing its deficit and now has achieved a balanced budget by working together with all stakeholders. This bill will enable the government to make decisions that adversely affect health care in this community and district.

Bill 26 says the Minister of Health can make "any direction related to a hospital" that he wants, as long as he considers it to be in the public interest to do so. According to this bill, the public interest is defined as what is of interest to the Minister of Health 500 miles away, not what is of interest to the stakeholders who reside in the community. What is an appropriate solution to a situation in Toronto usually does not work in northern Ontario.

Changes to the Private Hospitals Act in sections 5 and 6 repeal the language that directs the minister to give preference to Canadian-owned non-profit facilities. With these changes, the Minister of Health will be able to selectively request proposals from foreign firms which are just waiting to acquire the lucrative Canadian health care business.

For example, look at the issue of funding and ownership of private laboratories in Ontario. Hospitals are funded for laboratory work out of their global budget. They are not permitted to bill OHIP on a fee-for-service basis as private labs do. It has been shown that private sector medical labs are 34% more costly than their hospital counterparts. In fact, recent research proves that if hospital laboratories were allowed to compete fairly with private labs -- in other words, bring the services back into the outpatient clinics of our hospitals -- the government would save $106 million annually and our hospitals would get $318 million in new funding. Over the last 20 years, the private labs have expanded their business in Ontario to the point where they were billing the Ontario government close to half a billion dollars a year in 1993.

The laboratory outpatient pilot project of 1980 included Laurentian Hospital. They set up a collection depot in downtown Sudbury. They started the project one month late but still made $304,968 in outpatient billing from February 1 until August 31, 1981. The profit of $206,968 was divided 50-50 between the Ministry of Health and Laurentian Hospital. According to Dr Raymond Bonin of Laurentian Hospital, most of this work came from only nine physicians.

In 1990, the Ontario Hospital Association moved and passed the following resolution:

"Therefore, be it resolved that the OHA make representation to the Ministry of Health, to permit hospitals to bill OHIP for outpatient lab services on a basis similar to that extended to private laboratories, and in a manner similar to the way in which hospitals handle the billing for radiology procedures."

At Timmins and District Hospital, we strive to provide our patients with the best quality of care, which includes convenience. When patients are going to be admitted to hospital on a non-emergency basis, they attend a pre-admission clinic where X-rays and all workup are done, except lab work, prior to being admitted. Then they have to go to another part of town for their lab workup at a private laboratory. This is not convenient and does not meet the one-stop-shopping concept we have. Parking is a problem in this area, as is the extremely cold weather, often -40 degrees Celsius. This does not make for a pleasant experience. As a point of interest, we in northern Ontario usually experience temperatures 20 degrees or more lower than in Toronto.

We also have had situations where lab work completed at a private lab in the day had to be repeated in the evening when patients have been admitted on an emergency basis, as these reports have not been available, resulting in added costs to our health care system. Other costs that must also be assumed by hospital laboratories include over 400 tests that are done by hospital labs but are not performed by private labs. Private labs tend to perform the most common, standard tests that can be done easily in volume and can be automated. These tests are done with no additional funding, at a mean substantial cost to hospitals that the private laboratories do not incur.

Dr Mazzunchin, a member of the steering committee on hospital laboratory financial reform, in his report released on December 12, 1995, using data obtained from the 1994 laboratory services review, proves that hospital laboratories have lower costs per test than private sector labs. The data show:

(1) The hospital sector performs 1.6 times more work than the private sector.

(2) The hospital sector employs twice the number of professionals than the private sector.

(3) Even though the hospital sector employs more professionals and technologists, its cost per test is still $1.40 per test, or 20.6%, less than the private sector.

The opportunity to have public lab dollars put back into the operating budget of a hospital is a much better way of utilizing tax dollars than going to private industry, some of which is not even Canadian, as is the case of Dynacare, an American company which is operating Toronto Hospital's labs. All of these regulations seriously impact on the universality and accessibility of health care services, of medically necessary treatment and medication, for people who need support.

Schedules H and I amend the Health Insurance Act and the Health Care Accessibility Act, and create the new Physician Services Delivery Management Act. These changes will allow the minister to determine that certain services will not be insured unless provided in or by designated facilities. This constitutes a serious threat to our hospital and the people of our district in that excessive travel will limit access to treatment within our area. Schedule I gives the government enormous powers over health care delivery which will affect the availability and accessibility of health care services.

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The government, in its Common Sense Revolution, has made promises that it would not cut health care spending, that health care spending will be guaranteed, that health care funding won't be touched, that aid for services and the disabled would not be cut, that we would discuss how savings would be achieved, that there will be no user fees. We feel that this bill breaks all these promises.

Thank you again for allowing me to express my concerns regarding the future of health care.

The Chair: Thank you. We've got six minutes per party for questions, beginning with the New Democrats.

Mr Bisson: There was a comment, I think made by Mrs Johns -- and I know I've heard Mr Clement make the same comment out of Toronto when I was watching it over the parliamentary channel -- that without this bill, reform can't happen in the health care sector, because which hospital on its own would do this stuff unless forced to go through it.

I guess it angers me because I know the work that the Timmins and District Hospital has gone through over the past number of years, first of all amalgamating a number of hospitals together, then going through the restructuring that you did over the last three years, and on top of that the closure of the chronic care unit in South Porcupine, all decisions made by a local board in light of the financial situation that it finds itself in.

What do you say to somebody who doesn't recognize the work and the value that you have done within the health care sector as hospital workers and as administrators in regard to trying to find efficiencies on your own, without having them dictated from Toronto?

Mr Heath: I feel the work the Timmins and District Hospital has done as far as balancing its budget and making changes to help the patients in the service area that we provide service in has been phenomenal. We don't need individuals from southern Ontario who are appointed as "supervisors," I believe the term was in the bill, if I can refer to it, coming in and telling us what is best for the needs of northern Ontario.

We have acted very responsibly in the administration of our hospital. The unions, the stakeholders, the people who are receiving treatment have all consulted together, have developed means of trying to save money and have achieved a balanced budget, something that we did not believe was possible a number of years ago. We're very proud of that and at this point in time we don't need regulators coming from Toronto telling us what we need to do with our health care system. Our mechanisms that we have in place now, including the health council, I feel are doing an excellent job.

Mr Bisson: Has it been easy, just maybe to put it in perspective? Because you're right. I remember being first elected and having to deal with this when my colleague was the Minister of Health. You were one of the people who was opposed to the change and worked eventually within it to make the changes that have come.

The comment I would make is that I find it highly insulting, knowing the work the hospital has done here, the unions have done here, the patients have done, the doctors have done, to be told that we need to be dictated to from Toronto, rather than trying to find local solutions within our community. It's highly offensive to the work that you have done as unions, to the work that the administration has done and the hospital board has done in being able to balance their budget. I just wanted you to keep in mind that the city of Timmins is actually very responsible and doesn't need to be dictated to by the city of Toronto on how we should be running our hospitals. We can live within the confines that the government puts in, but allow us to make our own decisions locally. I just would want to say that.

Mr Len Wood: I was there during the election campaign when Mike Harris was travelling through the north, saying that health care would be protected. The cuts they're doing now, he never talked about during the campaign, and yet we find out six months later the cuts that there are to health care, the cuts that there are to hospitals, the cuts there are to services.

As a matter of fact, even the snowplowing on the roads is being reduced, making it unsafe for people to travel on the roads. The airline is being shut down so that people are going to be isolated in their communities. NorOntair is not going to be travelling any more in the next little while.

Everything that he said he was not going to do as far as cuts is being done now, six months later. I know the frustration that we've had from everybody making presentations.

I want to ask the question that was asked earlier of another group: Was there consultation with anybody in your group on the cuts and slashing and the firing of people that is going to take place? I understand up to 26,000 people could be fired within the hospital system with Bill 26. Has there been any consultation up to the introduction of the bill?

Mr Heath: No, there has not been any consultation. We were very hopeful at one point in time with the announcement that there would be a central pool that hospital workers could be placed into, where first job allocations would be available to them in other sectors of our province. Unfortunately, with the HSTAP program no legislation was ever put in place to legislate that this central pool be utilized. From the last things that I've heard with regard to it, it's basically on hold and nothing is happening with regard to allowing hospital workers who are highly skilled and highly trained with tax dollars to be utilized in the province.

Mr Clement: Thank you very much for your presentation. I share some of your concerns, although your conclusions as to how to rectify that differ sometimes from the avenue I personally would like to pursue.

Let me just give you some assurance that public hearings would have taken place prior to the deal that was arrived at with the three House leaders in the government, that we had every intention of having public hearings at every stage of the process. I wanted to correct the record --

Mr Len Wood: You wanted to ram it through like you did Bill 7.

Mr Clement: I guess I'm eliciting some response from the partisan side opposite, which is fine; that's democracy. But I did want to correct the record on that.

Mr Len Wood: You were going to dictate it as you did with Bill 7, no consultation at all.

Mr Clement: Obviously I've struck a very delicate nerve on the other side there, but I did want to plow forward with a question or two.

You evince great concern over the sections of the bill dealing with the independent health facilities and whether there would be preference for Canadian owned versus not Canadian owned. I'm just trying to think this through myself as well as to what the potential scenarios are. What if there's a patent on a piece of equipment that is owned by a company based in Milan, Italy, let's say, and this piece of equipment can really deliver much better health care service for less? They don't particularly want to deal, for whatever reason, with Canadian-owned operations; they want to deal with Italian-owned operations. Aside from the potential loss of union jobs if they want to go with non-unionized, let's say -- and I can understand your personal concern about that -- what harm is there in having that entrant into the health care system so that we can get better health care for less for patients?

Mr Heath: I think one of the things we have to look at is maybe the case of MDS Laboratories with their MDS multilab now, the major centre they have. I believe over $10 million was invested by the Ontario government in research for automation, for robotics, for MDS Laboratories. At one point in time, Sunnybrook Hospital had a private laboratory. It has now been taken over by MDS, and unfortunately this multilab, this huge multilab that is now roboticized, and at the expense of the Ontario taxpayers, is taking money that could have gone into a hospital global budget to help run that hospital and putting it into private sector pockets. This private sector profit I believe should be used to help the people of Ontario within their hospitals, not going into multicapital corporations.

Mr Clement: I know this sounds hard to believe, but sometimes the private sector can do a job better than the government can, and if that saves us taxpayers' money, I'm all in favour of that. In fact, I wanted to talk to you about that.

I noticed the report of Dr Mazzunchin. I guess I haven't read this yet; it was released December 12, 1995. Dynacare happens to have a plant in my riding of Brampton South where they hire dozens and dozens of Bramptonians. They're not Americans as far as I can tell; they're full-fledged Canadians, many of them new to this country, and they work at the Dynacare lab there. The data they shared with me indicated that they in fact can do better for less. So I'm quite anxious to see this report and its definitive-seeming conclusions. Do you know the extent of the research that was done on this?

Mr Heath: Yes, I do. "Test Case: Private versus Public Laboratories." This is a large document, as you can see, where they've gone through, listed the expenses, listed the profits that they have made with regard to private versus public laboratories. I'm sorry you haven't had a chance to look at it yet, but I assure you that if you did, you would find some of the tables from it in the back of the presentation that I've made that will show you the percentage of hospital lab tests in millions to private labs, the total laboratory costs and the average cost per test.

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You'll notice that the average cost per test in table 3 at the back is always less in the hospital than it is in the private lab. Again, I can point out that the 400 tests that the hospitals have to incur to provide good health care are not being performed by private labs because they're too costly. We're talking about things such as the dexamethasone suppression test, which is an expensive test that a public lab would not even look at.

Mr Clement: That's a fair point. I guess it depends what you include as costs. It doesn't happen all the time, but sometimes when you exclude certain items as part of your operational costs, you can really look like you're doing something quite efficiently. Sometimes you're excluding costs which are part of your overhead, but you're shifting them to other things. I'm not saying that's what hospitals are doing. All I'm saying is I'd really like to see what his basis was for making that conclusion in terms of the overhead costs and who pays for those.

Maybe it's not opportune for us to discuss it, because I haven't read the report, and I acknowledge that, but I am quite looking forward to reading it.

Mr Heath: I would advise you as well that the Dynacare Canadian operation is a very, very small percentage of Dynacare's overall worldwide holdings. They are a multiconglomerate. They are based in the United States, and profits from Canada, even though they may be employing a few people in your riding, have unemployed a number of people across Ontario. This money is going to the United States.

Mr Clement: I'm sure you didn't mean that as being offensive, but thank you for your comments.

Mrs McLeod: I will take just a moment to once again set the record straight as Mr Clement attempts to revise history in the course of explaining how we happen to be in Timmins today. I think even Mr Clement would have to admit that even if the government had been able to persuade us to accept the rather sham hearings of a week before Christmas, those hearings would have been held entirely in Toronto and we would not have had an opportunity to be here today in Timmins in order to hear your presentation.

I was interested in the fact that Mr Clement himself, a little bit earlier in the day, before lunch, said that they weren't prepared to table government amendments until they had heard from people across northern Ontario because they were so anxious to hear from people in the north. So I think he should surely share our pleasure that the government's original proposal for hearings was not accepted.

I would like to pick up on a couple of parts of your brief which I appreciate. I don't have a page number, but you've said the concern about essentially the minister determining what health care is going to be provided and where it's going to be provided and the unilateral power he will have to do that -- you say, "This constitutes a serious threat to our hospital and the people of our district in that excessive travel will limit access to treatment within our area."

I put that together with an earlier statement you made about the Minister of Health having already "recently instructed local planning bodies to submit their restructuring plans now, with or without consulting the stakeholders."

I guess I'd like to ask you what some of your concerns are when you make that statement that there's a real threat here to northerners and their ability to access health care because of the distances. Are you concerned about greater centralization, that closure decisions in the name of funding dollars are going to lead to centralized health care in a community like Timmins or Sudbury, where we potentially can offer different levels of health care, but that there could be nothing left, even emergency care, in smaller communities?

Mr Heath: Yes. We have had that happen already. I can quote a specific situation where a young individual broke his leg in two different places last winter. He was brought to the Timmins and District Hospital emergency room. No orthopaedic surgeons were available; both of them were on holidays. He was to be shipped by air ambulance to Sudbury. Unfortunately, we were snowed in. This individual waited for four days in Timmins before he was able to get treatment. That's one aspect.

Another aspect that concerns me is the fact that specialists can be legislated to certain hospitals. Certain procedures can be specific to certain hospitals. With the powers this bill gives the minister, he can come to a hospital and say: "You no longer are going to be able to do an obstetric procedure. It is going to be done at this central hospital located in Sudbury." We may have been doing it for years and all of a sudden we can't do it. Our patients now have to get to Sudbury in a snowstorm or be denied that treatment?

I think the powers that are being given to the minister are so broad in this bill that it actually sets the way for a total dismantling of our health care system.

There were comments previously of a two-tiered health system. I can see that happening right now. The first thing I think of is the sale of Blue Cross to Liberty Life, an American-based corporation. I can see them trying to buy the WCB here in Ontario. It is paving the way for privatization, and I really feel that health care is one of the sacred things that we have. We have the best system in the world, and to change it this dramatically is going to be a detriment to us.

Mrs McLeod: I want to keep even a little more focused on closure decisions and the rationalizing of health care. I think everybody around this table, and I'm sure everybody in this room, would agree that we have to look at the most cost-effective way of providing health care services. Government members will say nothing has happened in however many years they like to use -- it tends to be 10 -- and therefore they've got to step in and make the decisions for northern communities and for other communities.

I'm concerned about your statement here that the Minister of Health is already saying, "Submit your plans without further consultation with stakeholders." We've got a lot of northerners here and our experience has always been that Queen's Park, with due respect to the Ministry of Health working out of Queen's Park, does not always have a good sense of northern reality, so the decisions they make on our behalf aren't always what's in the best interests of our communities.

I'm asking you a leading question, so I'll acknowledge it. Do you not think that in smaller communities we can come together and we can determine what is the best for people in our communities and still do that in a cost-effective way?

Mr Heath: I certainly do. One of the items I can think of that has been in the news recently is when the Minister of Transportation was asked to come to northern Ontario to view the roads, to see the conditions that existed in northern Ontario, and said, "I don't need to go up there and look at it." I think that type of attitude is what happens.

By the way, the first snowstorm of this season, my wife's cousin was killed in a car accident because there were two plows sitting in a yard with no drivers.

Mr Len Wood: Just pick up a cell phone; everything will be all right.

Mr Heath: Mr Wood knows this person because they were from his riding.

The Chair: Thank you, sir, for your presentation. We appreciate your interest in our process.

CANADIAN UNION OF PUBLIC EMPLOYEES LOCAL 1214

The Chair: The next group is the Canadian Union of Public Employees, Local 1214. Good afternoon and welcome to our committee. You have a half-hour to use as you see fit. Any time you leave for questions will begin with the government. The floor is yours.

Ms Nichole Daggett: Good afternoon. My name is Nichole Daggett and I have been working in the health field for the past 20 years.

This morning you heard Sister Brenda Cooper from a sister local speak on certain sections of Bill 26. I will now speak on other sections of Bill 26 which I feel will cause massive deterioration of the public services which took generations to build.

Changes to the Independent Health Facilities Act essentially eliminate tendering processes by giving the minister the authority to request proposals from specific individuals for the establishment of a private health facility. As a criterion for selecting the provider, he can examine the availability of public funding to pay for the establishment and operation of such a facility. The new legislation will expand the power of the minister to bring new types of health services or facilities under the act and will also eliminate the requirement that preference in the tendering process be given to non-profit Canadian operators.

These changes will allow the Minister of Health to handpick corporations or individuals to open up shop, even open franchises of health care clinics that charge people money. In tandem with the massive cuts being proposed to hospital services, it seems clear that this new legislation will allow health care gaps to be filled by more private clinics or organizations intent on making profits off public funds.

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To date, the Health Insurance Act has required that OHIP cover all medically necessary services provided by physicians. The bill removes any references to medically necessary services and instead authorizes the cabinet to decide which services will be insured and under whatever limitations or conditions. Cabinet is also given the power to determine that certain services will not be insured unless they are provided in or by designated hospitals or facilities. The only restriction is that no regulation may contradict the Canada Health Act.

These provisions will, it seems likely, be used to limit access to services which are now provided under the Health Insurance Act. The government can decide, at will, what types of care are medically necessary and what are not. The potential for abuse is enormous and certain services which are currently covered under OHIP could be delisted simply because the government decides that they are too expensive.

While hospitals are presently permitted to charge patients for a limited range of insured services, the bill will provide explicit authority for cabinet to make regulations which could permit hospitals to charge patients user fees for any hospital-based insured services, including those already covered by OHIP.

As an example of this, the government has already announced that hospitals will be able to charge daily user fees to those patients in acute care beds who are waiting placement in chronic care facilities or nursing homes. Patients will essentially be penalized because they have been placed on a waiting list for services that are already critically underfunded.

With this new legislation, the Tories are encouraging hospitals to offset their budget reductions by charging user fees and even allowing them to make a profit at the expense of patients. Again, decisions regarding the delivery of health care are not based on access and quality of services but on financial considerations and on the desire to privatize Ontario's medicare system.

The Ontario drug benefit plan provides payment for prescription drugs to seniors and those on welfare. Should schedule G be enacted, the legislation will have dramatic impacts on low-income persons and seniors. Bill 26 brings in a $2 copayment for all prescriptions under the Ontario drug benefit plan. This is especially hard on the many mother-led families of disabled children, who already have had their social assistance benefits cut by almost 22%.

In addition to the already deep cuts in income to the poor, the government is proposing increases to the cost of their medical care. The ability to pay for prescription drugs for sick children and seniors should not be an issue for residents of Ontario. The bill would put a two-tier health system in place. If the bill passes, a user fee for prescription drugs could be introduced. This, along with the proposed $100 deductible, for the poor will mean large numbers of the sick will be unable to afford treatment.

As with other sections of the bill, the minister and the cabinet will have full power to establish and set, behind closed doors, the level of user fees or copayments under the Ontario Drug Benefit Act.

In addition, the current law requires that individuals be reimbursed for the full cost of their drugs when their doctor has specified that no substitutions to the prescription be allowed. The proposed bill, however, requires the individual to pay the difference between the generic and the specific drug. Typically, for example, the doctor specifies no substitution for medical reasons when the generic would interfere with other medication or allergies.

Negotiations will be replaced by cabinet decree. The government intends to terminate the negotiation process with the pharmacists whereby the professional fee for dispensing drugs is typically negotiated between the government and the pharmacists' association.

Cabinet will then act as pharmacists. The bill will give cabinet decision-making authority over which drugs are eligible to receive reimbursement under the plan, again with no need for public process or rationale. The schedule suggests that cabinet will be authorized to consider any matter it considers advisable in the public interest, including the cost of the drug, in determining whether or not to list a drug. The interference in the medical process by government is astounding. Medical necessity or other health criteria do not necessarily have to be considered. Cost will be the criterion.

Interestingly, however, the schedule would allow the cabinet to establish clinical criteria for the purpose of determining what drugs the benefit plan will cover.

The bill will repeal the power of the minister to regulate the price of drugs charged to anyone not covered under the Ontario drug benefit plan. Manufacturers are thus freed to independently determine the price for their drugs other than those provided under the drug benefit plan. We can speculate that the price of drugs will increase, particularly in small communities where little or no competition exists. Without regulation, we can expect that the cost of drugs will increase substantially.

Increased drug costs will severely impact upon CUPE members' group benefit packages. We are already feeling the crunch at the bargaining table because of the increased costs for extended health care due to the increase in the price of drugs. The bill will exacerbate this problem.

Clearly, the government is putting itself above the law. The bill will reverse and nullify certain court decisions which found that the Minister of Health acted without jurisdiction in limiting the price for certain listed drugs.

Not only does the legislation remove any public process for setting prices of drugs and determining issues under the Ontario drug benefit plan, but it is reversing court decisions that went against past government decisions. Why should Ontario be the only province in Canada that does not have a ceiling on drug prices?

Schedule G will hurt seniors and low-income citizens in the province. Drugs prescribed by licensed doctors and dispensed by licensed pharmacists must be covered by the Ontario drug plan. Not only must they be covered; they must be affordable to low-wage workers. Otherwise, we are placing the health of low-wage workers even more seriously at risk. That means people will be forced to shop around for the best price on their prescriptions.

Even though this sounds simple enough for us to do, many low-income families do not have the luxury of having their own transportation and must depend on public transit systems. But this government has taken care of that too. By cutting transfer payments, we are seeing our transit routes being reduced. So shopping around for lower drug prices could cause these low-wage workers or welfare recipients further hardship.

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As workers in the health care field, most of us fall under "essential services" and are denied the right to strike by government, yet this same government is now saying these "essential services" are not that important and can be downgraded to the point that people under our care are being seriously affected.

As an employee of the health care system, I have witnessed first hand the cuts to health care which have already taken place. For example, in order to cut costs at my health care institution, the residents are now being given one bath per week. Would you consider this to be quality care for seniors? Would any of you be willing to take one bath per week? How healthy could this be? I am ashamed to call myself a caregiver when I am forced to carry out such directives for the sake of cutting costs. The fact that this government would consider further cuts to health care at the expense of the sick is totally appalling and unacceptable.

I am a member of the Canadian Union of Public Employees, and like all my brothers and sisters in the labour movement, I say scrap this omnibus bill which will destroy local democratic institutions, devastate public services and impose hardship on Ontarians, especially those who are most disadvantaged.

The Chair: Thank you. We've left about 15 minutes for questions, to begin with the government. Mrs Ecker.

Mrs Ecker: Thank you very much, Ms Daggett, for taking the time this afternoon to bring forward your views and concerns about the legislation. One point you do make about the no-substitution rule -- I share that concern. I think that's something I certainly would like to suggest to the Minister of Health, that we may want to take a look at that and see if there's another way to do that, because I quite understand that there are times when there are differences in the drugs that are very, very important, and I think that's a very good point.

You mentioned that the legislation removes any public process for setting the prices of drugs. What's the public process for setting the price of drugs now?

Ms Daggett: For setting the price of drugs, yes, it's regulated.

Mrs Ecker: I wasn't aware there was a public process for setting the price of drugs. That's why I just wanted to clarify that, because I wanted to make sure I didn't miss anything here, since you had said that the legislation removed it.

The second thing, you talked about "Drugs prescribed by licensed doctors and dispensed by licensed pharmacists must be covered by the Ontario drug plan." Are you saying that we should be expanding the drug plan, we should be spending more money on it?

Ms Daggett: What I'm saying is not expanding it, but whatever the situation is now, I'm seeing that some of the senior people won't be able to afford some of these drugs.

Mrs Ecker: Well, they don't have to pay for the cost of the drug. One of the things we've tried to do with the changes is to also extend drug benefits for 140,000 low-income people, because I agree that there are many working people who do not have the benefit of an employer drug plan and need the support. So that's one thing we have been able to do.

One of the other things, you were concerned about the power that the minister and the government are giving themselves in this. You quite rightly point out, and our colleagues across the way quite frequently point out, that the north has unique health needs, which I certainly understand all too well. How do you suggest that the government should try and reallocate the health care resource, for example, go to communities, say, in the southern part that may have excess health care resources and convince them to give them up so that the minister can reinvest them here for very good purposes up here? How does the minister do that without some legislative power in order to do that?

Ms Daggett: I think some of the ministers should maybe come and talk to the workers and listen to the workers, listen to the people; they know what's best for our region or our small communities. Listen to them.

Mrs Ecker: I know you're quite right that there are unique needs in the north. We've had many people talk about the problems that have existed to date in northern health care, and we all agree that we have to do more to improve that. How does the Minister of Health go to the communities in other areas of the province, the other workers, and say, "I want to take that money away from you to give to the north, because we know we haven't got new money in the system"? How does the minister do that, answer the concerns that you've pointed out here in the north, without some power to be able to do that?

Ms Daggett: Well, I'm not quite sure how the minister would do that, but I think it should be done more democratically, have a voice. Everybody should have a voice in how you're going to be doing it, not just say, "Well, this is how we're going to be doing it."

Mrs Ecker: One of the things that I think the minister has been very clear about is that the local planning process, the district health council planning process, which many areas started under the previous government, many areas are now just starting, will be the recommendations that we will be basing restructuring on, because it's the local communities that will have those recommendations and that expertise for the restructuring commission. The difficulty, of course, has been that when the district health councils have made and are making the recommendations we've had no mechanism to start making that change happen. So that's one of the reasons why we needed the changes.

Mrs McLeod: Mr Chairman, I actually feel a moment of hope that we're making some progress when I hear Mrs Ecker say that the government -- at least she, as a government member -- would like to encourage the minister to look at the no-substitution rule. Since before Christmas we were being assured that there was no problem with the no-substitution issue, I feel as though maybe we are making some progress, and that is encouraging.

I did think that your presentation on the whole question of the affordability of drugs was very clear and that you were raising two very separate issues; one was the copayment cost and what that would mean for welfare recipients and seniors who are on the drug benefit plan and will now have to pick up that copayment. The other point I thought you were raising very fairly was for those who aren't on the drug benefit plan but are still low-income people, and there are lots of those out in our communities, that they're going to have to, as the minister said, barter for the best drug price. I was raising the point earlier that in a small northern community there isn't likely to be an opportunity to even barter, because there won't be more than one outlet. So I thought your point was made very clearly.

The other point, among others, that I was struck with in your presentation was the statement that the only restriction on the government's ability to decide what will be considered medically necessary is the Canada Health Act. I should tell you that there is a very large question about this entire portion of the bill, as to whether or not the whole thing contravenes the Canada Health Act. I find it a little bit alarming that any government would propose such sweeping changes in government decision-making powers on health care without having determined whether in fact it can do any of this without being in violation of the Canada Health Act. I hope we get a clarification on that very quickly, before this province faces a very severe concern with the way in which we get funded for health care.

I have a couple of things that I wanted to ask you. It follows up on the previous questions. I guess one of the points where I get a little bit alarmed, because I'm a very strong believer in regional planning, is when I hear the government say that the district health councils' existing consultations will be the basis of them stepping in and deciding to take immediate action, and other presenters have said that.

I'm not sure that in every community the district health council consultations have been seen to be very satisfactory. There are a lot of stakeholders who feel as though they weren't involved. I can't judge in this particular district, but I've heard that in other districts. In fact, I've heard the current Minister of Health when he was the Health critic be very critical of some of the district health councils and the work that they had done. So I'm a bit surprised that he is now going to take all of those existing studies and use those as a basis to just say, "We want this done, and we want it done tomorrow."

Do you think that as front-line health care workers you can be involved in a real consultation that will lead to savings and more cost-efficiencies in the way health care is delivered in this area?

Ms Daggett: I think we should be more involved; I don't think we are right now. Everything is being decided and nobody is asking for our input. I don't know. I'd like to have more input to try and work together instead of having just one or two people deciding how it's going to affect everybody in our area.

Mrs McLeod: You're in a long-term care facility, I would suspect?

Ms Daggett: Yes.

Mrs McLeod: I was alarmed by the statement you made about residents only getting one bath per week, which is obviously a very great concern. But have people in the long-term care facilities been involved in any of the consultations about the future of health care in the region?

Ms Daggett: No, not in my facility. I couldn't say about others, but in my facility we weren't approached.

Mrs McLeod: That's fine.

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Mr Len Wood: Thank you very much, Nichole, for bringing forth an excellent presentation. I found interesting the question that was put to you by Janet Ecker.

Our concern is the reverse. She's talking about bringing southern Ontario health care dollars up to the north, and in effect what is happening is the Tories are taking health care dollars out of the north to supplement southern Ontario, and I think it's very unfair. We have the harsh climate, we have the long distances between communities and yet right now, as we're sitting here, when she's saying that they want to bring health care dollars from southern Ontario to the north, they're actually taking health care dollars out of Cochrane North so that they can move them into Stoney Creek. They're also trying to shut down a long-term care facility in Hearst. Cochrane and Hearst are both being attacked so that they can spend those extra dollars in southern Ontario.

I think it's very nasty on their part and uncalled for and they should be apologizing to the people in northern Ontario. We're being attacked, as far as the condition of the roads is concerned, for winter snowplowing. They're shutting down the airline service. They're taking health care dollars out. Every time you turn around they're being attacked on it.

I find it interesting, on page 7, where you're saying that the seniors and the poor and the people living on fixed incomes are not going to be able to afford the money for prescription drugs, whether it's a prescription dispensing fee of $6.11 or the $2 per prescription that they have to pay the druggist. In the event that they are not able to buy this, I would presume that they're going to end up in the hospital, and health care costs are going to increase.

Ms Daggett: Yes.

Mr Bisson: I sit here like Mrs McLeod, a little bit in amazement as I'm listening to the government members. I think they are having a change of heart. I think they may be starting to listen, and I hope that's what they're doing, to some of the submissions here because they're starting to recognize just how flawed this legislation is. What particularly amazed me was the comment made by the government member that she wasn't aware of what was happening in the act in regard to drug prices. I just want to quote directly from the act here.

There are two important things that are happening in regard to medication that is dispensed in the province of Ontario.

The first is that the scheme for determining the price the minister pays for drug product is changed. The concept of best available price is eliminated. Instead, the price will be agreed to by the manufacturers.

What that means to say is that we, as purchasers through the Ontario Trillium drug program or through the Ontario drug benefit program, are not going to go by the best possible price; we'll go by whatever the market can get out of us, which means to say that we, the consumers paying those tax dollars to help to pay for the medication of people in institutions and people on benefits, over the long run are going to end up paying more. So it's quite contrary to what you're trying to do.

The second thing that it does, and again I quote directly from the act, is that the restrictions on the markup the minister pays on the drug prices are removed. Presently in Canada, every province regulates the amount of money that we pay for medication as we buy it from the pharmacist down the street. In other words, the pharmacist and the person who manufactures the drug can't raise drug prices more than a certain level, as prescribed under legislation. What this act does is to open that right up and it says basically that the manufacturers and the pharmacists can charge what they want. I don't know, but I think we're going to be put in a little bit of danger.

I guess it comes back to a question that was asked earlier. I got a call from the executive director of one of the long-term care facilities here in Timmins who was really concerned, followed by phone calls by residents who were making exactly that point, that the comfort allowance people are getting in institutions is barely enough as it is now. I know I was lobbied, when I was government, to have them increased to be able to deal with basic necessities, and what they're really worried about and what senior residents are worried about in these facilities is, "If it's a choice between getting my hair done, of being able to buy my toothpaste or being able to buy whatever type of sanitary product I need or being able to purchase drugs" -- in some cases they're not going to purchase the drugs. I think we're putting seniors at risk in those institutions. I certainly hope the government is hearing that message and is prepared to make amendments along that line.

The question I have for you is, and it was touched on in your presentation and the one before -- there is a recurring theme inside this act. What it basically does is it changes a number of acts in order to give the minister the power to reduce the amount of funding to public facilities, and therefore the public facilities don't have the bucks to make them operate and they will offer substandard services in order to cope with the budget reductions. At the same time, they're giving the private sector the ability to move in and set up facilities in competition with the public sector.

Do you see that, in the long term, as being something that will set up a two-tiered health care system in Ontario and what it means to people of the north?

Ms Daggett: Yes, I see that. Will it be quality care that these people are going to be getting, these seniors?

Mr Len Wood: Only if you can make a profit.

The Chair: Thank you for your presentation. We appreciate your interest in our committee process.

PATIENT ACTION

The Chair: Next is Patient Action, represented by Ginette Lafond, the founder and executive director. Good afternoon and welcome to our committee. You have a half-hour to use as you see fit. Questions will begin with the Liberals, should you allow any time for them. The floor is yours.

M^me Ginette Lafond : Bonjour. Bienvenue à Timmins. Bonne année. Je suis ici aujourd'hui pour exprimer mes commentaires au sujet du projet de loi 26.

The Chair: Excuse me for a second. Would give us few minutes to put the translators on?

Ms Lafond: If I'm going rely on a translator, I might as well do my own in English.

The Chair: It's your choice.

Ms Lafond: I'll do it in English to get the message across. I feel I'm the best person to do it.

The Chair: Okay. Proceed.

Ms Lafond: I've got everything in French, so I have to translate real quick.

First of all, I have important questions for the committee before I give my presentation. I'd like to know what the committee's mandate is, Mr Chair.

The Chair: The committee's mandate is to have public input on Bill 26.

Ms Lafond: What are your powers?

The Chair: Our powers are to listen to the public input, to go through the bill clause-by-clause the week of January 22, to entertain any amendments and to report the bill back to the Legislature on January 29.

Ms Lafond: Will you be submitting recommendations?

The Chair: It's too early to tell yet. We haven't heard all the input yet.

Ms Lafond: The reason why I'm asking this is, I'm wondering, are all the presenters here today wasting their time or will their suggestions be taken into consideration?

The Chair: Every submission that the committee receives, be it a verbal presentation like yours or a written submission by people who haven't had an opportunity to present verbally, will be considered by all the people who are part of the committee and will be discussed during the clause-by-clause part of the bill, which is the week of January 22. So in my opinion you're not wasting your time.

Ms Lafond: Okay, in that case I will proceed.

This morning I picked up a copy of the 1995 Fiscal and Economic Statement by Ernie Eves, and in the introduction it states, "We have listened -- and will continue to listen." Why, then, has the government decided to send the committee after the execution of cutbacks and not prior to?

If the government really listened to Ontarians, sessions such as these would be extended over a period of time much more extensive than what it is now. Six hours in the region of Timmins to discuss vital services which represent a very large geographic area -- as a matter of fact, according to the road atlas, the Timmins area is more extended than any other areas in North America. So six hours to make a decision on what will happen to the north is very hard for me to digest today.

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I will, however, represent vulnerable northern Ontario patients today. I will present cases. The reason why I decided to present cases is because I wish to let the government know that in northern Ontario we have real people and we are also human beings. We all have a face, a body, we live our emotions, we have no money, and the government wishes to remove the only things that keep us together right now: our dignity and our humour. Where will they go? What will you do for them?

Case number one: An invalid, 75 years old, must take a variety of medications for a variety of medical problems. He also has to travel to obtain vital services for his survival. He lives in a very small town. He must go to North Bay, Timmins or Sudbury to obtain specialized treatments. His pharmacy, his family doctor and hospital are a 20-minute drive from his house. He has no family. He has no car. The only mode of transportation for him is Ontario Northland which, for now at least, passes once in the morning, and he must return at night. So for any business he has to do for medical reasons he must go out of his community, 20 minutes away by car, and he must stay there all day, including eating his meals.

The Harris government wants to deregulate pharmaceutical services and medication. It states in here that the patients will have to pay $100 a year plus the cost of dispensing for every medication. Imagine this gentleman who has to travel to seek medical help; or even if he needs to replenish his medication, he either has to go or have a taxi pick up his medication. That means this widower must pay dearly, sometimes double and more, more so than the patients in metropolitan areas.

The travel grants have also been cut, and he realizes that the so-called specialists the government is trying to push on our area will definitely never go into his little community; they will go to places like Timmins, Sudbury and North Bay, the same as they do now. They will definitely not go in an area where there are no hospitals, so he'll still need to travel his 20-minute drive. He is poor. He is alone. What will the government do for him?

Case number two: A young patient has been sexually assaulted by a so-called health professional. After many years of counselling, the patient feels courageous enough to start legal proceedings. The defence lawyer wishes to see her mental health file. Nowadays, at least for now, the Supreme Court of Canada has judgements against the delivery of such services.

Bill 26 gives a blank cheque to the commission to obtain any medical file and also to do whatever it chooses to do. Also, no one will have the choice, no one will be able to sue the government, because according to subsection 8(9) there is complete immunity. I can read this. It says, "No proceeding for damages or otherwise shall be commenced against the commission or against a member, officer, employee or agent of the commission for any act done in good faith" -- by whose standards I'm not sure -- "in the execution or intended execution of any its or their powers or duties or for any alleged neglect or default in the execution in good faith of any of its or their powers or duties."

Now, that scares me. That means the government now will be able to walk in, obtain medical files not only describing the physical condition, the mental condition, but they now are also taking the patient's soul. Where is the justice? Who will be responsible for the suicide that will follow?

Case number three is a young quadriplegic. She worked, then she went for a treatment and something happened during that treatment. She is now a quadriplegic. She needs 24-hour service. The nurses are with her at all times. However, because of cutbacks in the small areas -- again we're dealing with a very small area -- registered nurses are now leaving the area because they've been laid off. Because her situation is too complicated for nursing services, consequently, on December 26 of last year she was sent forward to Sudbury and she is now in an intensive care area in Sudbury area.

This patient is not sick. She is a quadriplegic, she's on respirators, tracheotomy, the whole ball of wax, but she's not sick. The local area hospitals could not accommodate her, again because of budget cuts not being able to expand the service for her. Here she is, stuck in an area of intensive care. I know; I saw her last weekend. Here she is stuck in an area of intensive care, not in the same area as the others because she's not sick and she also does not wish to see what goes on in the rest of the ICU. If any of you have been to an ICU area, you will know what I mean. It's an open complex.

Her only social life right now is a TV. Then the medical staff wonder: "How come she's depressed? We don't understand it." What will the government do about her?

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Case number four: A northern Ontario baby had a heart transplant at the age of seven months. Getting a heart transplant is not the end. That patient must stay in Toronto for months. Once in a while she's allowed to come home in her remote area. The government, as of November 30, has cancelled the multipatient transport unit. There are no more.

How is this patient going to be transported? I suppose she could rely on norOntair for this week, and they're shutting it down. So now, in order to transfer this little girl, they will have to admit this little girl into the hospital overnight in order to get a dedicated aircraft, because the multipatient transport unit is no longer around. What will the mother and the child do? Does the Harris government have solutions for that one?

Case number five: A young man from the Sudbury area has a heart condition. You say, "But there is a heart hospital in Sudbury." Wrong. The heart hospital in Sudbury cannot accommodate him. He must be transported to the research centre at Mount Sinai because of the condition of his heart. He is not allowed to drive. We tried to transport him in a private car. We also tried to transport him by bus. Upon arrival, he suffered heart attacks because of exhaustion from the trip. And that's only from Sudbury; he's not even in Timmins yet. He's not allowed to take a commercial aircraft, again because of his heart condition. Will the Harris government send a private jet for this gentleman?

I could go on all day giving you case after case. I could spend the whole afternoon, but we only have six hours today and I'm not the only presenter. I'm just hoping the Harris government will listen to the dilemmas and realize that there are true human beings up north. Thank you.

The Chair: Thank you. We've got about four minutes per party for questions, beginning with the Liberals. Mr Brown, I guess you're carrying the flag here.

Mr Michael Brown: Thank you for presenting. I think you brought to us a very important perspective that, up to this point today anyway, we have not heard from. Health care is about people and it's about patients, and the examples you've given us today illustrate the difficulty we have in northern Ontario. I represent the riding of Algoma-Manitoulin, where a large section of the riding is what you would call very rural and very northern.

One of the things our friends from southern Ontario don't quite understand is that although we're maybe 8% or 9% of the population of this province, 75% of us live in one of the five major centres. So we've got about 2% of the people in this province spread out across 90% of the land mass. That is critical to us in terms of providing health care. It makes it enormously difficult, I think, for providers, but it has to be done because there are real people out here.

I think the examples you're giving drive that home. Losing our air service to the communities that now have it will have a definite effect on the people I represent and certainly the people in this area; losing the ability for certain things -- to be able to go to a nearby hospital, even if it is Timmins, if you happen to live 50 miles from here, or North Bay, if you're 25 minutes from there -- if we lose some of those services, which this bill quite clearly, at least in my mind, is going to facilitate from the government's point of view.

When I sit here and I listen to what the government's saying over there, I think we all should think of it from the patient's perspective. Are we going to get more health care or better health care, improved health care, or are we going to get less health care and quality care deteriorating in this province?

I sit here and I understand that we're going to pay more for health care. We are. There are user fees. I think we've only scratched the surface on what user fees are about to appear. We know people on low incomes on the Ontario drug benefit plan are going to be paying increased amounts of money. The government is clearly taxing health care, taxing the sick, taxing those who are least able to access the system as it is, yet they're going to provide us with less services. I don't see how you can come to any other conclusion.

Is that what you're telling me here today? Because I think those problems you've related to me in terms of patients are similar to problems that I've dealt with in my constituency office.

Ms Lafond: Absolutely. My office has only been in operation since September 1995 and I am overwhelmed. We were seriously considering hiring, because I must spend so much time with the patient service that I don't have time for the administration. It's unbelievable, and this I did for three years on my own.

Ms Lankin: The concerns you've raised are concerns that we've heard from a number of presenters today about how this bill centralizes decision-making power in the hands of a few, perhaps senior, bureaucrats and the minister down at Queen's Park and that decisions made in Toronto aren't going to be in the best interests of the north. The lack of understanding and the history that people have had -- I mean, you just know that and you've driven that home in a very, very powerful way, and I thank you so much for your presentation.

Some of the things you touched on, the government keeps saying: "Not to worry. It's not a problem." Like the concern about privacy of health records. They say nothing's really changed here. You've raised concerns. I say, if nothing's changed, then why are they amending the act in that provision?

They say the appointment of supervisors to a hospital is so rarely used, even though they're giving themselves more power to do that now unilaterally, and the Health minister told us he probably would never use it. Why are they changing the legislation then?

The section that allows them to say certain OHIP-insured services would be prescribed for only people of certain ages and not other ages, they say that was there before and it's just moved and nothing's different. Why are they tampering with it then and why are they moving it? We haven't had any answers to this.

They say they don't want to Americanize the health care system, but they're removing the Canadian not-for-profit preference in independent health facilities. Why are they removing it, if not to open the door for Americans or others to come in?

They say that they're not going to move to a two-tier health system, yet they're removing protections of the Canada Health Act language that's in certain parts of the bill governing certain things that they're moving out from underneath that protection.

I've got a letter a doctor sent to his MPP, who happens to be the Honourable Bill Saunderson, the Minister of Economic Development and Trade. He references the fact that Mr Saunderson is a member of the policy and priorities board of cabinet, the inner cabinet. This scares me, and I just want to leave you with this to think about, because I think it will upset you too. He relates what the doctor and this powerful cabinet minister talked about.

"You indicated that deductibles for drugs were being discussed and that might be extended also to apply to physicians' services in some form of deductible or user fee." This is the writer saying Mr Saunderson indicated that. "We've discussed that the idea of a two-tier system was abhorrent to certain left-leaning sectors of society and the media, but we did agree that it already exists de facto."

He goes on to talk about: "You indicated that relief was around the corner in the form of decreased personal taxes. But we then talked about the abolition of the employer health tax and perhaps the reinstatement of OHIP premiums. We also discussed the development of a list of core services that are fully funded by government, others not being fully" -- in other words, delisting.

"We briefly touched on the role of the federal government decreasing transfers but their wish to maintain control. This will have to be addressed, and legislative barriers to private insurance as an alternative form of health care funding must be examined." These are the things that a member of the inner cabinet of the Harris government is talking about with this particular physician, who documents it all in a letter back to him.

I worry about paving the way for a two-tier system, and I think I heard you talk about that as well.

Ms Lafond: There's not only the two-tier system, but all these private insurers will also have access to our medical file, because they can do whatever they want with it.

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Mrs Johns: I just have a few comments. I'd like to thank you for your presentation. It's always interesting and teaches us a lot when we hear about specific individuals, and I appreciate that. I just want to comment about what will happen for some of those people.

But I want to say first that we believe we are listening. We believe we're taking documentation back to Toronto, and we will be looking at all the transcripts from every day and searching through them to see what's good and what's bad about the bill. We believe we will be making changes that people ask for. We believe this is a listening process, and I just wanted to verify that with you.

We talked about personal records a number of times today. It was our intent at the time we put the personal record information in that we would be able to use that to track the misuse of billings and inappropriate billings. So if someone billed inappropriately, we would be able to go back and see if the person actually had that service and we could trace that.

We understand, after going through these meetings, that people see more far-reaching issues with it, and we will be making some amendments to hopefully satisfy people. It was never our intent that my health records would become part of your knowledge throughout Ontario. So that's what we're trying to. Do you want to comment on that?

Ms Lafond: Yes, I want to comment on that. First of all, if more of the public would know that everybody has a boss and if you're not satisfied with the service you're getting, there are regulated colleges and regulated professional bodies -- however, unfortunately, many of the public do not know this. Now, with the Regulated Health Professions Act, we are getting the word out to the public. There's one way of discovering -- uncovering, I should say; not discovering -- much of the OHIP fraud.

Another way -- I know because it happened in my very own family -- some insurance companies are now contacting the insured or the people who have had insured benefits and asking them, "On such-and-such a date, did you see Dr So-and-so and what did he do?" That's happening right now. There are more ways of uncovering professional scams.

Unfortunately, no, we will not be able to get them all. For every three we take, there are another three that are uncovered, because more and more people are getting wiser and the ethics are now going down. But with the public awareness that has started already, we have to give it a chance. The patient relations committees, the quality assurance committees, are just in the works now. I know. I'm a public appointee and I'm sitting on a quality assurance committee, and that's exactly what we're doing. We're just putting things together, but you have to give us a chance.

Mrs Johns: We agree with that too. There are a number of areas of quality assurance that are in the works and we wanted to make sure that there was enough to take care of consumers' needs. I'm not in any way implying that the doctor is the bad guy in this. I'm not saying that at all. When we look at the total percentage, it's very small in comparison.

We're also doing things for people with spinal injuries. We've brought a lot of them back from the US, as you know, and we will continue to look for new facilities to put those people in. I have heard on all of my long-term- care meetings that people with spinal injuries are not sick; what they are is not able to take care of themselves in a number of ways and they need special treatment, and we will be working towards that.

I just wanted to say from our side that I'd like to thank everybody who presented here today. We certainly learned a lot and we will be taking a lot of information back. We appreciate everybody's commitment to the process, and I'd like to thank you all very much for helping us out today.

The Chair: Thank you for your presentation. We appreciate your interest in our committee process. Let me add my thanks to the people of the city of Timmins. We've enjoyed being here and hopefully we'll all get a chance to come back some day.

The meeting is adjourned until tomorrow morning at 9 o'clock in Sudbury.

The committee adjourned at 1456.