HEALTH CARE * LES SOINS
Separation will hurt Quebec health care system, Ottawa physician warns Peter P. Morgan, MD, DPH Lynne Cohen
If Quebec leaves Canada, its 6 million residents will face a huge increase in the cost of any medical care they get outside La Belle Province, an Ottawa doctor warns. "If Quebec becomes independent, its citizens will likely be treated no [differently] than foreigners who now obtain health care in Canadian hospitals," says Dr. Charles Shaver, a general internist. Canadian hospitals' charges to non-Canadians are not restricted by any federal or provincial law, he pointed out, and will likely rise as provincial hospital costs mount in the face of reduced federal transfer payments. Canadian hospitals already charge foreign patients what the market will bear, one hospital administrator told Shaver. He was explaining why a visitor from the Caribbean had been charged $105 for an electrocardiogram that earns only $20 via the medicare route. Another Canadian hospital official told Shaver that hospitals routinely double the per diem rate for Americans and other visitors, and often require a credit card payment in the emergency department. The patient is usually billed directly, and if payment isn't made promptly the hospital hires
a collection agency. In other words, Canada's kinder, gentler health care system is strictly for Canadians. Shaver's practice has convinced him that the health care system in Quebec, particularly its border areas, cannot satisfy all the province s medical care needs. "West Quebec patients will always have need of specialized medical services in Ottawa, and [other] Quebecers will, on occasion, find themselves unexpectedly ill when travelling in other parts of Canada. Despite improved economic ties with the United States, I doubt whether most Quebecers would really wish to fully embrace the American style of care." Conceivably, if separation occurs, some kind of Canada-Quebec arrangement would enable Quebec residents to use their government insurance plans for physician and hospital services outside Quebec. However, because those rates of payment are low, travel insurance would be needed, and it is most expensive for those needing it the most. Shaver noted that it is often unavailable for people with pre-existing illness such as diabetes, heart disease, malignancy, chronic renal disease or AIDS. Premier Robert Bourassa has used the European Economic Community as a model for what Peter Morgan is a CMAJ consulting editor. relations between an independent an Ottawa-based is Cohen freelance Lynne Quebec and the rest of Canada writer.
could be like, but Shaver is decidedly sceptical. "Within the community, the availability of free medical care varies widely," Shaver wrote recently. "For example, a person from the United Kingdom must pay in advance for hospital and physician services in Belgium and France, and obtain partial reimbursement later." National unity is but the latest focus in Shaver's 4-year battle to force Quebec to obey the Canada Health Act (CHA). He is furious over Quebec's refusal to pay host-province rates to most doctors who treat Quebecers outside their province - in direct violation of the CHA - and over the federal government's failure to punish Quebec for its intransigence by reducing its share of transfer payments. This is a particularly hot issue in Ottawa because of the number of Quebecers who seek treatment in Ontario. In running his own vocal, one-man lobby in an attempt to get governments to act in accordance with the CHA, Shaver has met with some success. The Quebec government recently agreed to pay Ottawa-area physicians, at least in some cases, at Ontario rates. Shaver, who can claim at least tacit support from medical organizations and a fair amount of editorial support from some major newspapers, told CMAJ: "My goal is to increase fairness to doctors and to patients. I want
NOVEMBER 15,1l991
CAN MED ASSOC J 1991; 145 (10)
1343
"If Quebec becomes independent, its citizens will likely be treated no [differently] than foreigners who now obtain health care in Canadian hospitals." Dr. Charles Shaver
Quebecers to feel like first-class Canadians when they travel coast to coast." They can only feel this way, of course, if Quebec remains in Canada, and Shaver believes they should be informed of some of the ramifications of separation. For instance, he believes they should be frightened by the prospect of losing medicare, one of Canada's truly national devotions. But his battle is getting tougher because the Quebec government is steadily rewriting its theory and practice of health care and the federal grip on medical care is loosening. Even if Quebec chooses to stay part of Canada, its health care system may spin further away from the principles of the Medical Care Act (1966) and the CHA. When they announced sweeping changes to their own $1 2-billion-per-year health care system by introducing Bill 120 late last year, Quebec politicians and health care officials were far more concerned about streamlining, decentralizing and making more community-based their own internal health care delivery than they were about adhering to CHA principles. "What we are doing is a revolution, I can tell you," says Bruno Lortie, political assistant to MarcYvan Cote, the province's minis1344
CAN MED ASSOC J 1991; 145 (10)
its power. It eliminated $1.1 billion in health-related transfer payments to the provinces in the last budget, thus weakening its own chances of enforcing the CHA by denying delinquent provinces money. It remains to be seen if former Finance Minister Michael Wilson's promise to introduce legislation giving the federal government other enforcement mechanisms will give the CHA its bite back. For now, federal officials are noncommittal about CHA violations. "There are a number of issues around the CHA, the details of which must be examined in order to determine whether provinces are in total compliance," Guy Bujold, director of health policy in the Policy, Planning and Information Branch at the Department of National Health and Welfare, told CMAJ. "As of now, we have nothing to indicate [that there has been any] violation." Many analysts believe federal transfer payments will start disappearing completely within 5 years. "I don't think 5 years is accurate," Bujold responded, "except perhaps for Quebec, which receives a greater portion of its entitlement in the form of tax transfers. But I don't believe healthtransfer payments will ever be zero, [although] no one can predict the shape of financial arrangements that will exist between the federal government and the provinces in the next few years." Shaver is not convinced. He still insists Quebecers are threatened and risk losing their precious medicare benefits if the province leaves Canada. "Quebecers will be very vulnerable if the province becomes independent. I contend that residents of Quebec, once given full portability of medical benefits, might well be reluctant to throw it all away [in exchange for] sove-
ter of health. He explained that Bill 120, which finally became law in August, contained 222 measures designed to greatly increase the decision-making power of patients and communities when it comes to health care priorities. [Because the province's doctors put up stiff resistance to Bill 120, some aspects have been watered down and physicians have been given a greater say in running the health care system - Ed.] The bill was also designed to integrate health care with other social services, said Lortie, and "to allow us to do more with the same amount of money." The new legislation tends to further undermine CHA principles. "It is wrong [to say] that portability is a recognized right of every Canadian citizen," Cote wrote in a letter to Shaver. He admitted some 6 months ago that the price of endorsing the Reciprocal Medical Billing Agreement - the 1988 agreement among the rest of the provinces and territories that makes the portability guarantee a reality - would be small, only $6 million a year. Flippantly, he added: "With $6 million I can buy a lot of equipment for hospitals here in Quebec." The federal government itself seems to be depriving the CHA of reignty-association."
LE 15 NOVEMBRE 1991
Separation will hurt Quebec health care system, Ottawa physician warns Peter P. Morgan, MD, DPH Lynne Cohen
If Quebec leaves Canada, its 6 million residents will face a huge increase in the cost of any medical care they get outside La Belle Province, an Ottawa doctor warns. "If Quebec becomes independent, its citizens will likely be treated no [differently] than foreigners who now obtain health care in Canadian hospitals," says Dr. Charles Shaver, a general internist. Canadian hospitals' charges to non-Canadians are not restricted by any federal or provincial law, he pointed out, and will likely rise as provincial hospital costs mount in the face of reduced federal transfer payments. Canadian hospitals already charge foreign patients what the market will bear, one hospital administrator told Shaver. He was explaining why a visitor from the Caribbean had been charged $105 for an electrocardiogram that earns only $20 via the medicare route. Another Canadian hospital official told Shaver that hospitals routinely double the per diem rate for Americans and other visitors, and often require a credit card payment in the emergency department. The patient is usually billed directly, and if payment isn't made promptly the hospital hires
a collection agency. In other words, Canada's kinder, gentler health care system is strictly for Canadians. Shaver's practice has convinced him that the health care system in Quebec, particularly its border areas, cannot satisfy all the province s medical care needs. "West Quebec patients will always have need of specialized medical services in Ottawa, and [other] Quebecers will, on occasion, find themselves unexpectedly ill when travelling in other parts of Canada. Despite improved economic ties with the United States, I doubt whether most Quebecers would really wish to fully embrace the American style of care." Conceivably, if separation occurs, some kind of Canada-Quebec arrangement would enable Quebec residents to use their government insurance plans for physician and hospital services outside Quebec. However, because those rates of payment are low, travel insurance would be needed, and it is most expensive for those needing it the most. Shaver noted that it is often unavailable for people with pre-existing illness such as diabetes, heart disease, malignancy, chronic renal disease or AIDS. Premier Robert Bourassa has used the European Economic Community as a model for what Peter Morgan is a CMAJ consulting editor. relations between an independent an Ottawa-based is Cohen freelance Lynne Quebec and the rest of Canada writer.
could be like, but Shaver is decidedly sceptical. "Within the community, the availability of free medical care varies widely," Shaver wrote recently. "For example, a person from the United Kingdom must pay in advance for hospital and physician services in Belgium and France, and obtain partial reimbursement later." National unity is but the latest focus in Shaver's 4-year battle to force Quebec to obey the Canada Health Act (CHA). He is furious over Quebec's refusal to pay host-province rates to most doctors who treat Quebecers outside their province - in direct violation of the CHA - and over the federal government's failure to punish Quebec for its intransigence by reducing its share of transfer payments. This is a particularly hot issue in Ottawa because of the number of Quebecers who seek treatment in Ontario. In running his own vocal, one-man lobby in an attempt to get governments to act in accordance with the CHA, Shaver has met with some success. The Quebec government recently agreed to pay Ottawa-area physicians, at least in some cases, at Ontario rates. Shaver, who can claim at least tacit support from medical organizations and a fair amount of editorial support from some major newspapers, told CMAJ: "My goal is to increase fairness to doctors and to patients. I want
NOVEMBER 15,1l991
CAN MED ASSOC J 1991; 145 (10)
1343
"If Quebec becomes independent, its citizens will likely be treated no [differently] than foreigners who now obtain health care in Canadian hospitals." Dr. Charles Shaver
Quebecers to feel like first-class Canadians when they travel coast to coast." They can only feel this way, of course, if Quebec remains in Canada, and Shaver believes they should be informed of some of the ramifications of separation. For instance, he believes they should be frightened by the prospect of losing medicare, one of Canada's truly national devotions. But his battle is getting tougher because the Quebec government is steadily rewriting its theory and practice of health care and the federal grip on medical care is loosening. Even if Quebec chooses to stay part of Canada, its health care system may spin further away from the principles of the Medical Care Act (1966) and the CHA. When they announced sweeping changes to their own $1 2-billion-per-year health care system by introducing Bill 120 late last year, Quebec politicians and health care officials were far more concerned about streamlining, decentralizing and making more community-based their own internal health care delivery than they were about adhering to CHA principles. "What we are doing is a revolution, I can tell you," says Bruno Lortie, political assistant to MarcYvan Cote, the province's minis1344
CAN MED ASSOC J 1991; 145 (10)
its power. It eliminated $1.1 billion in health-related transfer payments to the provinces in the last budget, thus weakening its own chances of enforcing the CHA by denying delinquent provinces money. It remains to be seen if former Finance Minister Michael Wilson's promise to introduce legislation giving the federal government other enforcement mechanisms will give the CHA its bite back. For now, federal officials are noncommittal about CHA violations. "There are a number of issues around the CHA, the details of which must be examined in order to determine whether provinces are in total compliance," Guy Bujold, director of health policy in the Policy, Planning and Information Branch at the Department of National Health and Welfare, told CMAJ. "As of now, we have nothing to indicate [that there has been any] violation." Many analysts believe federal transfer payments will start disappearing completely within 5 years. "I don't think 5 years is accurate," Bujold responded, "except perhaps for Quebec, which receives a greater portion of its entitlement in the form of tax transfers. But I don't believe healthtransfer payments will ever be zero, [although] no one can predict the shape of financial arrangements that will exist between the federal government and the provinces in the next few years." Shaver is not convinced. He still insists Quebecers are threatened and risk losing their precious medicare benefits if the province leaves Canada. "Quebecers will be very vulnerable if the province becomes independent. I contend that residents of Quebec, once given full portability of medical benefits, might well be reluctant to throw it all away [in exchange for] sove-
ter of health. He explained that Bill 120, which finally became law in August, contained 222 measures designed to greatly increase the decision-making power of patients and communities when it comes to health care priorities. [Because the province's doctors put up stiff resistance to Bill 120, some aspects have been watered down and physicians have been given a greater say in running the health care system - Ed.] The bill was also designed to integrate health care with other social services, said Lortie, and "to allow us to do more with the same amount of money." The new legislation tends to further undermine CHA principles. "It is wrong [to say] that portability is a recognized right of every Canadian citizen," Cote wrote in a letter to Shaver. He admitted some 6 months ago that the price of endorsing the Reciprocal Medical Billing Agreement - the 1988 agreement among the rest of the provinces and territories that makes the portability guarantee a reality - would be small, only $6 million a year. Flippantly, he added: "With $6 million I can buy a lot of equipment for hospitals here in Quebec." The federal government itself seems to be depriving the CHA of reignty-association."
LE 15 NOVEMBRE 1991
