Submission: Commission on the Future of Health Care in Canada

October 2001

Introduction

SEIU Canada welcomes the opportunity to participate in the Commission on the Future of Health Care. SEIU Canada represents more than 80,000 women and men working in health care services sector. The majority of our health care members work across a range of services in both public and private health facilities. SEIU members include registered and licensed practical nurses, dietary aides, health care aides, home care workers, cleaning, maintenance and housekeeping staff, therapists and occupational aide workers, diagnostic and administrative support workers. Our members, the majority of whom are women, stand at the front lines of health care, and are committed to preserving and improving the design and delivery of health care services within the context of Medicare and the Canada Health Act.

The Romanow Commission was appointed by the federal government to address the following three themes:

1. The sustainability of the public system
2. Managing change
3. Co-operative relations

We have identified the following as key issues to be addressed: stable federal funding; privatization; out-of-control increases in health costs, in particular pharmaceuticals; increased private spending by individuals; diminished government capacity in the face of multi-lateral trade agreements; recruitment and retention of skilled health care workers.

Recommendations

SEIU Canada supports the goals of the Canada Health Act. In this context, our recommendations include the following:

1. Ensure that Medicare and the CHA remain the primary mechanism for health finance and the delivery of health care services in Canada.
2. Amend the Canada Health Act to include a National Home Care program.
3. Amend the Canada Health Act to include a National Pharmacare program.
4. Restore federal health transfers under the CHST to a minimum stable base level.
5. Reform delivery of comprehensive primary health care services based on community need 24 hours a day, seven days a week under the auspices of the Canada Health Act. Primary care services should be provided through public administration and delivery by multi-disciplinary teams of health care providers.
6. Promote the introduction of multi-disciplinary teams for community care, with a comprehensive program geared to a modernized human resource strategy that makes recruitment and retention a top priority. Provide full scope of practice to non-physician health care workers with full wage parity/pay equity across all points of the system.
7. Provide funding for comprehensive pay equity adjustments to all health workers within the health care system, both public and private facilities operating in the context of publicly provided health services.
8. Ensure greater accountability in health spending and policy to include national standards and accountability measures in all federal transfers. Enforce full disclosure on all spending not related to patient care. Provide for "whistle blower" protections to those who would report managerial and related malpractice.
9. Protect public governance and policy development by demanding full accountability and disclosure in the negotiation of multi-lateral trade agreements and in all contracts tendered to private sector providers engaged in the appropriation of public funds and/or delivery of health services to the public.

Is there a crisis in Medicare?

The Commission comes in the midst of a brewing crisis in public confidence in our health care system. Canadians in every province and territory continue to express strong support for universally accessible public health care. But we also know that corporate interests and private sector lobbyists – and some governments – do not necessarily share these democratic views.

Confidence in Medicare is slowly being chipped away. Canadians are faced with a barrage of media stories detailing the erosion of both the quality and the level of health care services. We read about waiting lists for vital cancer care services. We hear about needless pain and suffering – even death – caused by emergency department overcrowding, shortage of hospital beds, and errors in diagnosis and treatment by overworked medical practitioners. In a 1988 Angus Reid poll, health care did not figure as a priority when respondents were asked to describe what they thought was the number one national issue. By 2001, a sea change has occurred in public opinion. Now one out of every two Canadians say health care should be the highest national priority.

So what has happened since 1988?

For one thing, virtually every province has joined the federal government in commissioning a major review of health care. During the 1990s, provinces across the country engaged in massive cost-cutting exercises as part of a deficit-cutting frenzy that seized the political agenda of leaders of every political stripe. In fact, job destruction was highest in the public sector during this period. By the end of the 1990s, 40% of all jobs lost across Canada were in health, education and other public services.[1]

Since 1988, we have seen far too many inquests conducted into "death by misadventure" due to ill-advised medical procedures, failure of emergency medical systems, failed hospital reporting and treatment systems, faulty prescription drug therapies and follow-up, under-staffing and physician malpractice.

Since 1988, nearly every community has been hit with hospital closures. Thousands of jobs have been lost from the health sector. Drugs and services have been de-listed and de-insured, while private sector health expenditures have risen from $452.43 per capita to $869.47 in New Brunswick, $540.63 to $1,012.08 in Ontario, and $195.93 to $797.91 in the Yukon Territories.[2]

Community forums conducted across Ontario in the past year revealed the legacy of shortsighted deficit-driven cuts to institutional care with no compensating increased investment in community-based care to balance the effects. A report issued by the Ontario Federation of Labour and the Ontario Health Coalition, People of Ontario Take Back Health Care, identified the following concerns:

• Lengthy waiting lists for cancer treatment;
• Patients discharged "quicker and sicker";
• Emergency departments in chaos and ambulance workers searching for a hospital to which to take patients in crisis;
• Seniors, young people and others on limited incomes unable to afford their prescription drugs;
• Serious staffing shortages in all health occupations;
• Severe lack of services and supports for psychiatric survivors;
• Inadequate home care and long-term care services.

Back to the basics: Assessing the federal role

The Canada Health Act is intended "to protect, promote and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health services without financial or other barriers."

Under the terms of the Canada Health Act, the federal role is to support the provision of universally accessible, publicly ensured health services provided by physicians and through hospitals by contributing to provincially-run health insurance systems. Five key principles govern the provision of public health care, outlined in the Canada Health Act: universality, comprehensiveness, accessibility, portability and public administration.

	The Canada Health Act is the only set of rules people in Canada have in order to know their entitlements to health care. These rules are now blurred and citizens no longer understand what they will or should receive for the heavy taxes they pay. They either accept ideological arguments about "being able to pay," or worry about what is going to happen in the future. And they purchase more health insurance, forgetting in the process that they have already paid high taxes for a "free," universal, and comprehensive health care system. - Monique Begin, former federal Minister of Health

Canadians are deeply concerned that little can be done to prevent the gradual erosion of health services. Some provincial premiers and federal leaders are abdicating their leadership responsibility and are thereby encouraging the growing anxiety Canadians feel about the future of Medicare.

We believe that the fundamentals of Medicare are sound. There is no question that well-advised and thoughtful reform can improve the health system. However, the rhetoric of crisis has less to do with the sustainability of public health insurance and more to do with those who oppose the principles of Medicare and any continuing federal role in health care as outlined under the CHA.

Health care workers welcome change that is designed to improve the conditions under which our services are provided, but not at any cost. For example, as budget-cutting exercises of the past decade show, all too often the shift from institution to the community has been motivated largely by the drive to reduce costs, and labour costs in particular.

Working Conditions & Declining Quality of Care

Health care workers have been hard hit by cuts in health spending. Budgets have been slashed. Spending in vital areas has been frozen. Managerial groups have opted for cutting back the work force to find short-term savings, with insufficient attention to the long-term ramifications of these cuts. Contracting out of core functions such as laundry, dietary and cleaning, has translated into unhygienic conditions in most hospitals, low quality food, and an increase in casual, temporary and part time workers employed at below standard wages.

Wages and working conditions are strong indicators of the health of our system. Quality of life cannot be considered apart from the quality of the work environment. For health workers, working conditions have steadily deteriorated under the combined effects of inadequate staffing levels, widening wage-gaps, overwork, the intensification of work, inconsistent and counterproductive managerial strategies, and the undervaluing and underutilization of skills, knowledge, training and experience. These factors have all made recruitment and retention of health workers one of the lead issues confronting health care organizations – both public and private.

Hospital organizations in particular have been slow to meet and address the deepening crisis in working conditions. But private sector health organizations are even less inclined to face up to the challenge. In the absence of accountability guidelines written into funding contracts, it is clear that community and union pressure remain the best and most democratic means for ensuring a decent quality of working life and of quality patient care.

The downward spiral of federal health spending

Medicare began as a federal-provincial partnership, a partnership that saw the federal government cost-sharing 50% of the costs with the provinces. Both levels of government agreed to the principle of providing universal, publicly insured medical services to Canadians. Of course, health services are a major expenditure and, since the inception of Medicare, public and private spending has risen considerably. But few can question the benefits of reliable, high quality health care in an advanced industrial democracy like Canada. Few would openly oppose the principle of equalization among the provinces and territories to ensure that residents of Prince Rupert, B.C. enjoy the same standard of health as those of a wealthier province, such as Alberta.

Public federal financing has declined steadily over the past decade. Since 1986, federal transfers to the provinces have dropped by a staggering $36 billion. The biggest hit came in the 1995 budget when the Chretien government cut provincial transfers by 33%, from $18 billion down to $12 billion. This low level of federal transfers has been maintained ever since as part of the CHST. The carrot in that deal was that provinces were free to 'spend" their share of the health transfer however they chose, opening the door to accelerated privatization in provinces such as Ontario and Alberta.

Privatization

Some point out that our system has always combined public and private delivery, and that is true. Medicare is an insurance scheme that is publicly funded but privately delivered by doctors and other health practitioners, in private non-profit hospitals and related facilities. What is new in more recent proposals, however, is the permanent entrenchment of the profit motive as a key determinant in the design, development and delivery of health care – privileging the pursuit of profit over the right of Canadian residents to universal public health care services. Core services have been contracted out to for-profit corporations – a move that institutionalizes higher costs.

The primary threat to Medicare comes in the form of a manufactured crisis brought on by chronic under-funding. It is this crisis that permits governments like Alberta and Ontario to open the door to the private sector to make up the funding shortfall.

Mixing public and private financing in the same system creates a two-tiered system where the top tier provides allegedly superior service, preferential treatment and queue-jumping privileges for those who can afford them. Mixing public and private funding also provides a direct subsidy to private health corporations. For example, the Ontario government allows private facilities to receive public financing through the tax system and charge user fees at the same time. This is just one of the many ways that corporations like Medical Data Services get a guaranteed share of the lucrative market.

	Private Labs: the equity-efficiency trade off? The large private medical laboratories opening in Ontario – in particular Gamma-Dynacare Medical Laboratories Inc. and Medical Data Sciences (MDS) Inc. – are guaranteed an estimated $275 million in public funds every year, no matter how well or poorly they operate. How did this happen? Prior to 1998, the Ontario government divided the $145 million it allotted for medical testing among the two dozen labs, which got work based on their quality and service. But the big labs were starting to lose business to smaller labs, so the big ones lobbied the Harris government to pass O.Reg.2/98, which divides the money based on the market share each laboratory had in 1995. For Gamma-Dynacare and MDS, this ensured that they receive 60% of the $415 million (now risen to $458 million), while sharply reducing the shares of the subsidies going to the smaller labs. Incredibly, because the regulation was made retroactive to 1995, the smaller labs were forced to pay back to the larger ones all the revenues they had earned above their 1995 market shares. Says Dr. Joseph Kurian, owner of the small Alpha Laboratories Inc. based in Don Mills, "The main purpose of this regulation is to eliminate the small labs so there will be an oligopoly. That was its sole purpose." Eye newspaper, Toronto

MRI Clinics in Ontario

The Paperny family operate private MRI clinics in Alberta, Ontario and Quebec. These for-profit clinics provide an MRI scan within 48 hours for a nominal fee of $775. The Paperny family is no stranger to the federal liberals. According to a recent report in the Brantford Expositor, Mr. Paperny was Jean Chretien's campaign director in BC in 1993. Alan Rock appointed Marina Paperny as a judge in 1996. The Paperny group also donated $35,000 to the federal Liberal party.[3]

Multilateral Trade Agreements are Putting Our Health System at Risk

A pan-Canadian approach to health care must respect and maintain our public health care system. Trade agreements that include the health sector are clearly an attack on democratic governance and a serious threat to the policy-making capacity and policy development process of democratically elected governments at all levels.

The federal government has repeatedly denied that the General Agreement on Trade in Services (GATS) includes health care services. Recent research reports suggest otherwise. There is no question that the GATS is intended to facilitate transnational corporate access to national markets. Further, GATS makes provision for securing and maintaining market access, delimiting the ability/powers of governments to restrict any such access, and providing compensation for profits denied where governments do seek to deny market access. When it comes to public services and programs, there can be do dispute that governments would, and many fear will, be restricted from introducing new or expanding existing public programs and services.

To date, both the federal Minister of International Trade and federal officials have wavered and equivocated when the question has been put directly. In fact, a recent study conducted for the Canadian Centre for Policy Alternatives makes it clear that health care is on the table for negotiations. If health services are included in the final deal, the government will have placed all publicly provided health care services under the commercial rules of GATS, effectively limiting the democratic rights of Canadians to decide what we want our health care system to look like. As a recent report puts it: "any extension of public health insurance to cover pharmaceuticals or home care would almost certainly be challenged by the multinational drug giants and US for-profit home care companies. They would be able to demand stiff compensation, and the added cost would be a huge deterrent to implementing such policies."

The federal government must take a leadership role in protecting health care in future rounds of GATS negotiations, by introducing:

• A self-defining general exception for health care to be applied to all WTO members
• Negotiate explicit exceptions and limitations to all GATS commitments which may affect healthcare services
• Exclude healthcare from the scope of the agreement
• Invoke GATS Article XXI to modify Canada's schedule of commitments in health insurance, and enter a limitation which shields public health insurance and ensures that Medicare can be expanded in the future[4]

Is Health Care Spending Out of Control?

Canadians are spending more to meet health care needs

Between 1992 and 1997, average household spending on health care grew by 30%. By 1997, Canadian households were spending an average of $1,179 on health-related items including dental care and health insurance premiums, drugs and de-listed services.

Annual growth in services not covered by the Canada Health Act (non-CHA services) is much greater than the growth of CHA services: 9.3% per year vs. 7.2% between 1975-1999. Private spending on health care generally today accounts for 30.4% total health care spending.

Many Canadians are paying more for non-insured Home Care services and for prescription drugs. According a recent private sector survey, 25% of Home Care clients reported out-of-pocket expenses on average of $407 per month on Home Care and $138 for prescription drugs.[5]

And the public share of health spending is dropping

The overall trend is toward higher co-payments and private coverage, both of which increase out-of-pocket expenditures by individuals. The public share of health spending has dropped from 75% twenty years ago, down to 70% and less in some provinces. Quebec, which committed 81.5% to total health spending in 1980, had dropped to 69.1% by 1998. Ontario similarly reduced the public share from 72.9% in 1990 to 66.9% in 1998.[6] Compare these rates to the prairie provinces, where creeping privatization is occurring in sectors like home care, but where the political will to maintain the public system remains strong. In Manitoba, 74.5% of health costs are publicly funded and in Saskatchewan the public share is 74.8%.

Private expenditures on drugs are also rising at a rapid rate. The costs of pharmaceutical products continue to escalate as more drugs are de-listed and costs absorbed by individual households. Again, for the same five-year period between 1992 and 1997, household spending on pharmaceutical products rose by a staggering 51%. Even in provinces that do provide some coverage for pharmaceuticals, the deductible is becoming prohibitive. For example, Saskatchewan provides nominal coverage under a provincial drug plan. But here, people must first pass through the hoop of a family deductible of $850 every 6 months before they are eligible for any public coverage. In 1998, BC raised the annual deductible for its Pharmacare program from $600 to $800.

Seniors on low incomes are among the hardest hit. While the National Population Health Survey (1998/99) suggested that 74% of people aged 12 and older were covered under some form of drug insurance, the 1996/97 survey reported that only 51% of people aged 65 and older were covered under an insurance plan. For low-income seniors receiving the federal Guaranteed Income Supplement, seniors in Saskatchewan face a $450 deductible, compared to $40 in Ontario.[7]

Social assistance recipients and other low-income groups in Quebec have, since 1996, been hit with significant increases in drug user fees, the technique used to finance the extension of public drug coverage to these groups. As a recent study found, requiring co-payments resulted directly in a 194% increase in the rate of hospitalization and institutionalization; a 22% increase in physician visits and a 106% increase in emergency room visits.

There are, in other words, severe disparities among age and income groups, and deep inequalities among provinces and regions. Imposing fees on those who cannot afford them does nothing more than deprive individuals and their families of treatment, and shift the ultimate costs of deprivation further downstream and/or to other parts of the system. The end result is generally greater illness and needless suffering.

Getting the costs of drugs under control: A National Pharmacare program

Health costs are increasing to be sure. Why? A closer look at the books points directly to the inordinately high costs of pharmaceuticals, of prescription drugs people need, doctors prescribe and transnational drug companies actively promote. While hospital care continues to top the list as the highest category of health spending, drugs have now overtaken physician costs as the second highest category and are expected to keep growing. According to Canadian Institute for Health Information figures, drug costs increased 9.6% between 1996 and 1997, reaching $11.3 billion, or 14.5% of the share of total health spending, compared to the physician share of $11.1 billion for the same period.[8]

Pharmaceuticals constitute the highest and fastest growing component of spending under both private and public insurance sectors. A recent Halifax study noted that there is a marked tendency toward prescribing newer and more expensive drug therapies, even though older and still recommended therapies continue to be just as effective. The net result, according to this study, was that the average daily cost of therapy increased by 77%.[9]

Efforts to contain pharmaceuticals costs have been short-lived in Canada. Compulsory licensing was introduced in 1969, increasing the availability of less expensive generic drugs. That policy was abandoned in the late 1980s under pressure from US lobbyists representing American pharmaceutical giants that were rewarded with a market monopoly for brand name drugs. Between 1994 and 1998, only 24 of the 408 pharmaceutical patents granted in Canada were "breakthrough" drugs. The rest were either reformulations of existing products or "me too" new drugs/dosages of an existing product with little if any improvement over medicines already on the market.

A recent study by Dr. Joel Lexchin, whose research findings are also reflected in a broader study conducted for the World Health Organization, supports what Canadians have said for years. A national Pharmacare program would decrease costs to individuals by 10%, or $650 million. Drug prices under a publicly insured formulary would decline by approximately 15%, and administrative costs would similarly drop.[10] Australia's national drug plan saw drug costs averaging 30% lower than the average of all OECD countries, while Canada's were nearly 30% higher than the OECD average.

A national drug insurance program is the best means for bringing pharmaceutical costs under control, monitoring prescription drug therapies and reducing the social and economic costs associated with over-prescription and faulty prescription practices that all to frequently result in hospitalization, particularly among seniors.

A National Home Care Program

Home Care is at the leading edge of health care in Canada. Home Care expenditures are likely to grow by 80% by 2026, bringing the Home Care share of total health expenditures – public and private – to more than 10% of total health care spending.

Between 1975 and 1997, the average annual growth of Home Care spending was 17.4%. In fact, total annual Home Care spending increased from $62 million in 1975 to $2,096 million in 1997. Between 1975 and 1992, the annual growth rate of Home Care spending was almost double that of health spending generally: 19.9% vs. 10.8%. And in the five years from 1992-1997, the growth rate was nearly 4 times all other spending: 9% vs. 2.2%.

Major health corporations have targeted this sector as a lucrative market with significant potential for future growth. Home Care represents the fastest growing sector in health care. Provincial governments are restructuring health care delivery, moving from institutional to community-based care, as the quickest way to reduce public sector spending. When people are discharged "quicker and sicker," much of the burden of health care falls to women in the family and at the community level. That is just one of the reasons why home care has grown so quickly. It's also why Canadians are paying more every year for non-insured Home Care services.

At the same time, provincial governments like Ontario are dismantling the public and non-profit community agency network for Home Care delivery. Non-profit agencies such as the Red Cross and the Victorian Order of Nurses compete directly with private for-profit companies for contracts. Corporations like Extendicare want to capture this fast-growing market. Competitive bidding like this is based on the low wage strategy. It's a race to the bottom that results in deteriorating standards of employment, of working conditions, and of health care services.

This is one of the reasons why standards and working conditions vary drastically from one province to the next. For example, public sector workers deliver 90% of Home Care services in Saskatchewan. The majority of them are SEIU members. In fact, Saskatchewan come closest to a model of care based on wellness and continuity of care.

In Ontario, on the other hand, creeping privatization means reduced standards of care and no accountability for how public dollars are spent.

Home Care covers a range of occupations. The majority of Home Care workers are women who bring an incredible array of skills, knowledge and experience to this work. We demand recognition for the work that we do. We demand safe working conditions and the supports we need to face an increasingly complex array of health needs. As the work intensifies so do the risks to health and safety. Increasing workloads, shorter visiting times and increased acuity of care all result in a rising level and complexity of workplace injuries and stress-related illness. We demand decent wages and wage parity with our counterparts in the rest of healthcare. Home care workers should earn the same wages for the same work.

Equity vs. Efficiency in Health Care

Public musings about the privatization of health care contribute to the growing sense that there is something wrong with the health care system. Conclusive evidence is sorely lacking in this discussion. We have yet to see a comprehensive, credible and conclusive study that proves what private sector advocates want us to believe: that the so-called "free market" is more capable of delivering health care services more efficiently than the public sector. Would private health facilities prove more flexible, more effective, more responsive to change than public facilities?

Health is not a commodity just like any other. In health facilities across the country, management groups are importing strategies and techniques developed for private sector production wholesale into the operation of health facilities, both public and private. TQM, supply-chain management, re-engineering and related accounting-driven techniques may work well in the auto sector, but people cannot be reduced to body parts and organ systems.

Private sector promoters like to point out that the free market is a more efficient and rational way to deliver services and products. Think-tanks like the Fraser Institute resort to asserting what has yet to be proven: that private sector delivery is the answer to long waiting lists and crowded emergency departments. Recent major reviews of health care, both provincial and federal, of health care all point to the need to revisit the two principles that have informed the design and delivery of services over the past 30 years: individual physicians and hospitals as the primary points of intervention. The Saskatchewan Fyke Commission and the National Forum on Health Care both highlighted the need to investigate multi-disciplinary teams and the greater use of community-based facilities. These studies and others have presented a range of options and alternatives that would restore integrity and purpose to Medicare within the framework of the CHA: regional health authorities, stepped-up preventive care strategies, a national drug program and a national home care program.

We, like our community allies, agree that costs can be contained. That is why our proposals include a review of the near-absolute control of physicians in determining both health procedures and health costs with little if any accountability for how these public funds are spent.

Cost cutting from the federal level downward has strained community-level facilities, including hospitals, to the breaking point. The shift from institution to community-based care has not been met with increased investment at the community level. Alternative models of care must be accompanied by increased stable funding from the federal level downward. Any shift of services to the community level must also include a complete review of the roles and division of labour among health care providers. A community-based model for primary care would include an expended scope of practice for non-physician health providers.

Some argue that expanding the private sector option will relieve pressure on the public. Again, there is little evidence to support this claim. In fact, the evidence is all on the other side. On the contrary, private clinics, operating as they do with an eye to the bottom line and a direct channel of accountability back to their shareholders, will skim the most profitable services from the system, leaving behind the more costly/less profitable procedures and services, along with those who cannot afford to pay. As a 1998 study by Health Canada points out, "There is no evidence to suggest that offering a private sector option will result in shorter waiting times in the public sector. Greater access to private care appears to be generally associated with longer public sector queues."[11] In fact, Health Canada understated what has been conclusively demonstrated in other comparative studies of Canada and the US. Privately administered, for-profit health care facilities consistently record higher administrative and operational costs than do public not-for-profit facilities and services. As a 1999 SEIU study found, US for-profit hospitals cost far more to operate because of higher administrative costs, costly duplication of equipment and facilities, together with built-in profit margin requirements. As a study published in the New England Journal of Medicine argued, no peer-reviewed study to date has demonstrated that profit-based facilities comprise a less expensive, more efficient delivery model.[12]

No Justice No Peace: Federal leadership in public health, child care & social housing

A healthy and democratic society depends on a healthy and developed people. There can be no social health without economic justice.

While it is true that the right to health and universal health care is not covered under the Canadian Charter of Rights, the right to medical care is part of the United Nations Universal Declaration of Human Rights. Article 25 of the Declaration reads, in part, "everyone has the right to ... medical care and necessary social services."

Health care represents the largest spending envelope of every provincial and territorial government in Canada. At the same time, major health care studies commissioned by the federal and provincial governments identify the need to increase research into the determinants of health. The most recent review of the Saskatchewan health care system echoed the findings of the National Forum of Health Care in calling for a major commitment to the use of evidence-based research as a key instrument for future health policy development.

Canadians know that poor health diminishes our quality of life. Unemployment, underemployment and poverty are among the major determinants of ill health. There is no need to repeat here the findings of studies that demonstrate the link between employment, income level and quality of life. What does need to be repeated here is the role policy changes introduced by the federal government have played in contributing to the economic insecurity of Canadians.

- Since 1993, eligibility to Employment [formerly Unemployment] Insurance has dropped from more than 85% of the labour force to less than 36% nationally.

- 56% of women heading single parent families have incomes below the poverty line. Sole support mothers average $9,000 below the low-income cut-off and older women average $3,000 below the low-come cut-off.

- 40% of working women are employed in non-standard jobs such as part-time, temporary or contract work, with no benefits, no pension and limited supports.

- The economic situation of women in Canada has not improved overall in the past 30 years. Almost half of all women aged 65 or older live on low incomes – the same proportion reported by the Royal Commission on the Status of Women in 1967.

- Child poverty rates in Canada are among the highest for all of the OECD countries, the leading industrialized nations.

- A minimum wage worker in BC, working full-year at 40 hours per week will earn less than $15,000 per year.

So-called non-medical determinants of health such as these are the direct result of the economic and social conditions working people and their families face. They are not the product of individual choice.

Getting a healthy start

Economic productivity and growth depend largely on the development of people. People are the greatest national asset of an information-based, technology-intensive economy like Canada's. If we accept this, and the federal government has indicated that it does, then it also follows that early childhood development receive the full attention and the full resources of the federal government.

The federal government's promise for a national childcare program is long overdue. A full proposal, one based on a commitment to healthy childhood development – both physical and intellectual – would encompass a national network of child care centres capable of providing a range of health care, caring and developmental services and programs for children at the community level.

Further, communities across Canada require firm commitment and investment in a variety of child and youth services including school lunch programs, eye and dental treatments, crisis housing, parental counselling, pre- and post-natal clinics.

Child poverty is the result of unemployed or underemployed adults. Over the past decade, the wage gap in Canada has widened: between rich and poor, between men and women, and between regions.

Socio-economic, gender, and racial equality are fundamental to the health and well being of women and men in Canada, to the capacity of our families and communities to sustain a healthy quality of life and social development.

Successive cuts to social assistance by provincial and territorial governments have meant that thousands of women, men and children are deprived of necessary health services. Once cut from welfare, social assistance recipients are immediately denied coverage for drugs and related health services.

In major cities across Canada, winter is setting in and so is the crisis in homelessness in particular among seniors, young people, and psychiatric survivors. Federal support for social housing has reached its lowest level in decades, contributing directly to the housing crisis. Provincial governments, Ontario in particular, have worsened the housing crisis by introducing punitive legislation on the one hand, and further cuts in income support and stabilization programs on the other.

Co-operative Relations

Public participation in health reform is a two-way street. Open consultation must be just that: open and meaningful. Over the past decade, health workers unions have participated in various discussions about change and reform. We broadened our concerns from basic job security to a more all-encompassing framework of employment security. In doing so, we have put forward proposals that would see an improvement in the effectiveness and efficiency of health cares services, one that would allow health care workers to participate in a full and meaningful way in the design and delivery of health care services.

SEIU Canada calls on the Romanow Commission to endorse a program of strong federal leadership. We need open and democratic consultation with the public and with all stakeholders in the health care system. To date, physician organizations, corporate lobby groups and managerial groupings including the provincial hospital associations dominate these discussions. Non-physician health providers represent a vital resource that goes unrecognized and under-utilized. Unionized health care workers are interested in ensuring that the health sector develops a comprehensive human resources program emphasising as its main objective the recruitment and retention of skilled and knowledgeable workers.

Many of the changes in design and delivery services are taking place in arenas that are closed to democratic debate. This is what one policy analyst has termed "public policy by stealth." Private sector lobbyists are closing in on the only means Canadians have to define and defend the social and political choices that ultimately shape the health and security of our families and our communities.

Corporate think tanks and paid lobbyists have set their sights on the lucrative health care service and product market in Canada. Trade agreements such as GATS are designed specifically to limit the capacity of democratically elected governments to do what voters elect and expect them to do: govern in the public interest. Protect what Canadians have clearly identified as public social goods and services.

Restoring the Federal Role

	Health Canada needs to remember they are here to look after the health of the country, and industry will look after industry. This isn't about money. It's about whether a government decides to organize its resources for the benefit of all the people of this country and not just the privileged few. Shirley Douglas, health care activist.

Federal contributions to health costs have declined substantially under the terms of the Canada Health and Social Transfer. Certainly, federal policy advisors and some members of the cabinet may oppose cost-sharing arrangements with provincial counterparts on the argument that the federal contribution – and the political credit that goes with it – is usually lost. Federal officials have stated that voters tend to see only the provincial government's role. At the same time, federal powers of enforcement may also be limited. However, the federal government cannot have it both ways. Withdrawing, scaling-back and/or downloading federal cash and tax-point transfers to the provinces and territories is starving the system of needed funds and depriving provincial systems of the secure and stable funding needed to support long-term planning.

The federal spending power remains the major means for enforcing the five principles of the Canada Health Act. When physician lobby groups tried to push their demand for extra-billing, the federal government did not hesitate to use the federal spending power to enforce the terms of the CHA.

Between 1995 and 1998, the Chretien government cut another $25 billion from the CHST. What was the result? Ontario is a good case in point. During this period, the Conservative government cut hospital budgets by $800 million. By 1998, 64 hospitals across the province were shut down or merged, the decision of an independent and wholly unaccountable independent commission appointed by the government. The result was an entirely predictable 33% drop in the number of acute care beds.

The principle of 50-50 cost sharing has been considerably revised over the years. In allowing the federal-provincial transfer to drop to below 25%, the Chretien government is adding to the manufactured Medicare crisis and directly weakening federal enforcement powers. Medicare can only survive as a partnership if shared costs support the shared principle. To paraphrase: "less cash, less clout."

References cited: