Fourth Session -Thirty-Second Legislature of the Legislative Assembly of Manitoba STANDING COMMITTEE on LAW AMENDMENTS 34 Elizabeth 11 Chairman Mr. Phi/ Eyler Constituency of River East VOL. XXXIII No. 1 - 10:00 a.m. , TUESDAY, 28 MAY, 1985. Printed by the Office of the Queens Printer. Province of Manitoba ISSN 0713-9586

MANITOBA LEGISLATIVE ASSEMBLY Thirty-Second Legislature Members, Constituencies and Political Affiliation Name ADAM, A.R. (Pete) ANSTET� Hon. Andy ASHTON, Sieve BANMAN, Robert (Bob) BIR� Charles T. BLAKE, David R. (Dave) BROWN, Arnold BUCKLASCHUK, Hon. John M. CARROLL, Q.C., Henry N. CORRIN, Q.C., Brian COWAN, Hon. Jay DESJARDINS, Hon. Laurent DODICK, Doreen DOERN, Russell DOWNEY, James E. DRIEDGER, Albert ENNS, Harry EVANS, Hon. Leonard S. EYLER, Phil FILMON, Gary FOX, Peter GOURLA Y, D.M. (Doug) GRAHAM, Harry HAMMOND, Gerrie HARAPIAK, Hon. Harry M. HARPER, Elijah HEMPH ILL, Hon.

Maureen HYDE, Lloyd JOHN STON, J. Frank KOSTYRA, Hon. Eugene KOV NATS, Abe LECUYER, Hon. Gerard LYON, Q.C., Hon. Sterling MACKLING , Q.C., Hon. AI MALINOWSKI, Donald M. MANNESS, Clayton McKENZIE, J. Wally MERCIER, Q.C., G.W.J. (Gerry) NORDMAN, Rurik (Ric) OLESON, Charlotte ORCHARD, Donald PAWLEY, Q.C., Hon. Howard R. PARASIUK, Hon. Wilson PENNER, Q.C., Hon. Roland PHILLIP S, Myrna A. PLOHMAN, Hon. John RANSOM, A. Brian SANTOS, Conrad SCHROEDER, Hon. Vie SCOTT, Don SMITH, Hon. Muriel STEEN, Warren STORIE, Hon. Jerry T. URUSKI , Hon. Bill USKIW, Hon. Samuel WALDING, Hon. D. James Constituency Ste.

Rose Springfield Thompson La Verendrye Fort Garry Minnedosa Rhineland Gimli Brandon West Ellice Churchill St. Boniface Riel Elmwood Kildonan Arthur Emerson Lakeside Brandon East River East Tuxedo Con cordia Swan River Virden Kirkfield Park The Pas Rupertsland Logan Portage la Prairie Sturgeon Creek Seven Oaks Niakwa Radisson Charleswood St. James St. Johns Morris Roblin-Russell St. Norbert Assiniboia Gladstone Pembina Selkirk Transcona Fort Rouge Wolseley Dauphin Turtle Mountain Bu rrows Rossmere lnkster Os borne River Heights Flin Flon lnterlake Lac du Bonnet St.

Vital Party NDP NDP NDP PC PC PC PC NDP IND NDP NDP NDP NDP IND PC PC PC NDP NDP PC NDP PC PC PC NDP NDP NDP PC PC NDP PC NDP PC NDP NDP PC PC PC PC PC PC NDP NDP NDP NDP NDP PC NDP NDP NDP NDP PC NDP NDP NDP NDP

LEGISL ATIVE ASSE MBLY OF MANITOBA THE STANDING CO MMITTEE ON LAW AMEND MENTS Tuesday, 28 May, 1985 TIME - 10:00 a.m. LOCATION - Winnipeg, Manitoba CHAIRMAN - Mr. P. Eyler (River East) ATTENDANCE - QUORUM - 10 Members of the Committee present: Hon. Messrs. Cowan, Desjardins, Lecuyer, Plohman, Hon. Mrs. Smith, Hon. Mr. Uruski Messrs. Enns, Evans, Eyler, Filmon, Fox, Harper, Hyde, Malinowski, Manness, Nordman; Mrs. Oleson; Mr. Orchard ; Ms. Phillips; Messrs. Santos, Scott, Steen WITNESSES: Presentations on Bill 2 (oral) Dr. Br uce Tefft, Canad ian Mental Health Association and Community Coalition of Mental Health.

Mr. Sidney Green, Q.C., Manitoba Progessive Party Mr. Gr eg Dunn, Presi dent, Ma nitoba Chiropractors' Association Dr. Rivian We inerman, Asso ciation of Independent Physicians Dr. Pia Longstaffe, Private Citizen Dr. Wayne Longstaffe, Private Citizen MATTERS UNDER DISCUSSION: Bill No. 2 -

An Act to Amend The Health Services Insurance Act. MR. CHAIRMAN: Committee come to order. We are considering several bills today; Bills 2, 17 , 32 and 33. I understand we have a list of 12 people who would like to make presentations on Bill 2. What is the will of the Committee on how to proceed beginning with Bill 2 and hearing the presentations first? Is that agreed? Ok ay, the first person on my list of people wishing to make a presentation is Dr. Bruc e Tefft. Is Dr. Bruce Tefft present? DR. B. TEFF T: Yes I am. I'm here in a dual role.

I'm here as the President of the Canadian Mental Health Association, Manitoba Division, and I'm also here as the Chairman of the Community Coalition on Mental Health. 1 CMHA, as you probably know, is a province-wide body. it's a voluntary secular body. Our members are individuals from all walks of life. We are strongly in favour of comprehensive community-based care. CMHA has endorsed the report of the Mental Health Working Group, which has become government policy. We view that as a very prog ressiv e ste p. CMHA also has branches and regions throughout the province.

The Coalition is also a province-wide voluntary sector body. Our mem bers there are approxima tely 30 organizations, social service groups, self-help groups, advocacy groups of all kinds. Rather than read you the list of names, I'll leave a list with you to save time. We also support comprehensive community-based care and we have endorsed the report of the working group and the government's actions with regard to that. Each of our member's boards or other governing body has endorsed the principles and policies therein. Both groups support Bill 2 and that's why I'm here today to speak to that.

Our reasons are very simple really. We understand that nearly all psychiatrists in the province extra bill patients, in some cases, by as much as $75 per hour or more. We feel that that constitutes a serious .financial barrier to care and restricts access to care. In this sense or on those grounds, we feel that extra billing is inconsistent with modern principles of human service systems. We feel the government's actions with regard to Bill 2 are consistent with those principles. We feel that Bill 2 is consistent with government-stated views concerning mental health, which is our specific concern.

Therefore again, I would like to say on behalf of both the Canadian Mental Health group and the Community Coalition, that we support Bill 2 and, at this time, I'd like to just thank you for an opportunity to speak to you, and I'd be happy to answer any qu estions you might have. MR.

CHAIRMAN: Before starting qu estions, I wo uld like to explain to the peo ple who wish to make presentations today that qu estions are asked by the committee on matters of clarification of the presentation and the people who appear here are not asking the committee qu estions; so the qu estions are one way, just for information and clarification of the presentation. Are there any qu estions for Dr. Tefft? Seeing none, I would like to thank you on behalf of the committee, Dr. Tefft, for ap pearing here today. The second person on my list is Mr. Sidney Green. MR. S.

GREEN: I'm here representing the Manitoba Progressive Party and I'm here to deal with this piece of legislation, which I'm advised was unanimously passed in the Legislative Assembly of the Province of Manitoba. I was qu ite concerned, Mr. Chairman, with the contents of the bill and far more conc erned now with the atmosphere in the Province of Manitoba which would perm it a measure of this kind to pass unanimously.

Tuesday, 28 May, 1985 I think I indicated, Mr. Chairman, several years ago that eternal viligence is the price of liberty and that one cannot ensure liberty by the enactment of the Charter of Rights. Indeed, the enactment of a Charter of Rights probably does something to put people off their guard and permit the erosion of liberties, because the citizens feel that they are protected by a statute. As a matter of fact, that's the most nefarious result of a constitutionally-entrenched Charter of Rights. I am here on this bill more than on a political basis.

I'm here for this bill on a personal basis, because in 19 62 in the Province of Saskatchewan and in 19 66 in the Province of Manitoba there was a promise . put forward by the people who were announcing a program to see to it that medical fees would be the responsibility of all of the citizens and not jus t the person who was sick. We put forward that proposition, .because we said that it was in the interests of all of the citizens that a sick person be treated, and not the interests of the · sick person or not simply the interests of the sick person or that sick person's family.

I now have a bill before me, which should be properly entitled "An Act Proclaiming the Failure of the Medical Care Plan in the Province of Manitoba," because this is what this act does; and those people who were active in proposing the plan will recall, Mr. Chairman, without any equiv ocation whats oever , that Mr.

Doug las in Saskatchewan and Prime Minister Pearson, federally, said that the plan would ensure that there would be maintained and would not interfere with the private relationship of the patient and the doctor in any province that adopted the plan, and the plan would not, in any way, result in a conscription of the medical profession.

The plan would be based on the voluntary and active participation of the medical profession, and if somebody would have suggested, in 19 62 or in 19 66, that in order for this plan to be effective there would have to be a law that said that a doctor and a citizen were prohibited from making an arrangement with regard to the payment of their medical fees, apart from the statute; and that if such an arrangement was made, the doctor would be fined $1 ,000 for every time he made that arrangement, and that if he didn't pay the fine, he would go to jail. There would be no Medicare in Canada today.

Is there a doubt about it? Mr. Dougla s was absolutely eloquent in his assertions that the medical profession was protected. Mr. Lloyd -and as a matter of fact, the Saskatchewan bill never had a provision which required a doctor to opt in or out. He could opt in or out on any patient. In Manitoba, we took the position that if a doctor wanted to work within the plan, he would have to accept the fees of the plan, and we would not permit those fees to be assigned. If he wanted to work outside of the plan, he was completely free to do so.

In that case his patient would receive what every other citizen in the Province of Manitoba would receive with regard to medical fees, and the deal between the patient and him or her was as free as any other deal that's made between two citizens selling and buying services in the Province of Manitoba.

This piece of legislation says that if I wanted to go to a doctor and I wanted to say to that doctor, ignore Manitoba Health Insurance, you and I will make an arrangement and I will pay you $1 ,000 for the medical services that· you supply me, regard less of what the 2 plan says, even if I said I won't collect it from the Manitoba Health Services, I won't apply; that deal would be illegal.

And the Act says that we will then go before a judge and I will say to the ju dge, I wanted to pay him $1 ,000 and the Attorney-General's Office would say that doesn't matter, we're prosecuting you, we're prosecuting the doctor, not the patient. The fee is only $300; $700 is excessive and we are insisting that the $700 to pay into court the amount of the fee and the court shall, on receipt, refund that amount to the insured person.

So you're going go to the judge and you're going to say, refund tha t amount to Green, the $700, and give it to him; if he doesn't want it, he may give it back to the doctor and then there will be a .la w that you can't give it back to the doctor or you 'll go to jail, because how do you enforce such regu lations? How do you expect to pass a law that water will flow uphill? Mind you this government has done it on numerous occasions and then it had to undo it. -(Interjection) - That's right, Mr. Chairman.

A member from the NDP caucus says that that is their philosophy, it works -that they will pass laws to make water go uphill. lt works. lt works. Now, Mr. Chairman, when we passed Medicare -and the reason that we are at this stage is that those people who pursued this program are admitting fa ilur e. Between 19 66 and 19 84, the medical profession in the Province of Manitoba has shown itself, by and large, and in great numbers, to be willing participants in the Medicare plan. I think that 90 percent to 95 percent of them work within the plan, which requires them to accept the fee that's paid by the plan.

They can't bill more and they know it. Five percent of the doctors - and let's say that it is growing to .10 percent -say that they don't wish to work for government insurance, that they don't object to the patient getting that insurance and paying it to the doctor, but they choose to make whatever arrangement with regard to fees that they want to make.

But what has happened is that there has developed a hysteria throughout the country that more and more doctors are going to opt out of the plan, that eventually everybody will be out of the plan and that we won't then have Medicare, we'll have "doctorcare." That is a legitimate fear, Mr. Chairman, that the doctor will work for a basic fee, which will be paid for him by the gov ernment and everybody will have to pay an additional fee. That's a legitimate fear. Every single proponent of Medicare recognized that problem and they said, Mr. Chairman, and I can quote you

chapter and· verse -and I don't have to quote others; I know because I was in the position of the Minister of Health at the time-they said, if we continue solely with entrepreneurial medicine, Medicare will fail. We never anticipated that we would conscript doctors. We said it would be a failure. The notion that one would conscript doctors to make it a success didn't enter anybody's mind. We said, if we have to stick with entrepreneurial medicine with a doctor and a patient and a fee, eventually and if that was the only form of medicine, the danger of opting out and extra billing would take place.

So we said, we have to establish more public medicine; we have to establish an alternative form of medicine where the public community clinics would have

TUesday, 28 May, 1985 doctors under their employ. The doctors under their employ would be based on salaries, which are prevalent throughout many many areas of the civilized world, and the Medicare of those patients who were attached to the clinic would be paid to the clinic and the y would be gua ranteed a service, and tha t service would be the check on the price of entrepreneurial medicine.

Now the governments were, frankly, lazy and unwilling to fulfill their obligations under the Medicare Plan, and as a result of that fact, in 19 85 we are limited to entrepreneurial medicine in the Province of Manitoba; and since entrepreneurial medicine cannot gu arantee the integrity of the Medicare Plan, we have decided to try to do what the Member for Bur rows said, pass a law that water will flow uphill, and we think it will work. Mr. Chairman, first of all, it is an abdication and an admission of failure -not the Mem ber for Burrows, I'm sorry, it was the Member for St. Johns, excuse me.

We are now adopting the position that we can pass the law and it's as simple as this, Mr.

Chairman. lt says, "Whether a doctor is in the plan or not, whether he makes an election or not, any medical practitioner who renders medical service and any person rendering other health services shall not charge to or collect from an insured person," and all of the people of the Province of Manitoba are insured, "in respect of those medical services or other health services, a fee in excess of the benefits payable and respect thereof under this act." So there is a regulation which sets out the benefits and whether I have opted to work in the plan or outside of the plan if I'm a doctor, and I charge more than that fee, I am liable to a fine of $1 ,000 for each contravention; and the fact is that failure to pay a fine, under our law, means that you go to jail.

So ultimately, and the Minister will say, well, the doctor won't go to jail, but we are req uiring medical practitioners to work for a specified State-set fee under threat of fine or imprisonment or both. That's what we are doing. If that had been what was shown to the Canadian public as being the Medicare Plan in 19 62 or 19 66, we would not have Medicare in this country. As a matter of fact, this is worse than what we had when we had private medicine. I say this, Mr.

Chairman, you know in 19 66 and up to 19 69, and I reminded one of my colleagues of this, I made several speeches relating to labour laws in the Province of Manitoba, and I tried to convince my Conservative colleagues that I was not speaking for unions.

I was speaking for human beings, that the same laws that I wanted for the steelworker, I wanted for the doctor and the lawyer; that I was much more interested in myself than I was in the plumber; and since I would not want to be subjected to a law, that I must work at the fee established by the State, that I did not have a right to negotiate that fee, that if I did not work for that fee I would be put in jail or fined or imprisoned. Since I didn't want that for me, I didn't want it for the plumber.

I tried, and I'm sure that the Member for Lakeside, who is not here, will remember that I said, you think that I'm saying this because I work for the Manitoba Federation of Labour; you're wrong. I'm saying this because I believe in it and I am much more concerned as to how it affects everybody else's rights in society, as I am for a particular worker. But let's look at this bill and change the wording a little bit.

Section 11 9 -it's a short bill. "A steelworker, 3 whether or not he is a member of a union, who renders his labour to any person shall not charge or col lect from such person a fee in excess of the benefits set by regulation." Is that fascism, when you say it of a steelworker? Is it fascism when you say it of a plumber? Well, it's fascism if you say it of a doctor, and I have no brief for the medical profession. When I was in the Legislature, I said if the doctors don't want to work under the plan, let them set up their own hospital, let them not take advantage of public hospitals.

Let them say that they will set up their own medical school, but don't say to them that the state will control the amount of fee that you can arrange with a free individual in a free society -or is it, "was" a free society? The most disturbing feature of this bill is that there was unanimous affirmative votes for it in the Legislative Assem bly of the Pro vince of Ma nitoba. What's happened to this world? Isn't there one MLA who would say this is not right? Not one of 57. That's the most serious feature ot'this bill. Mr. Chairman, I don't have to prove that from time­ to-time there should be at least one.

I mean when you voted that you're going to take my blood without my consent and give it to a policeman, there were at least two who said this is wrong. Mr. Minaker said it was wrong and I said it was wrong, and you know the courts are saying it's wrong too, but every body in the Leg islature said, it's fine. The guy's lying there; he's unconscious, take his blood and give it to a policeman.

That's okay, and now you're saying it's qu ite okay, pass a law saying that a medical practitioner will not be able to make a private arrangement with a patient who wants to make the arrangement to pay him more money, he's not in the plan, they say they won't even collect from the plan, although I don't see why they shouldn't collect from the plan. I don't see why a citizen who chooses to go to a doctor who wants to ch arge more money, and they choose to do it, why they should not collect from the plan as long as he's a doctor.

You know we permit them to go to a naturopath, who we don't have in the plan, and pay them whatever they want. They can go to a naturopath because that is not an insured service, and they can pay him whatever they want and a naturopath can charge whatever he wants. But if he goes to a doctor, he shall not charge more than a rate specified by the state, and if he does, he is subject to fine and/or i mprisonment. This, Mr. Chairman, is

an act proclaiming the failure of Medicare in the Province of Manitoba and when I see Medicare failing -and it's something which I fought for very hard, and most of the current mem bers did not, but it's something that I fought for - I don't like to see it fail. I don't like to see it being destroyed by people who had nothing to do with setting it up and that's what's happening.

And the strongest exponents of the voluntary performance of services and the non­ interference of the relationship between the medical practitioner and the patient, or the people who pursued Med icare, and none of them said they would restrict medicine. Mr. Chairman, this bill, I submit to you, says what I say it says. I know that that's not what the Minister would like to see happen. He would like to see every doctor charged a fee and willingly accept a fee from the patient, but the doctors have a problem with respect

Tuesday, 28 May, 1985 to that. They know that governments get tight and money becomes scarce and more and more they start looking at their budget and say they have to restrain.

And if they had to restrain adver tising in the newspapers that we are a wonderful government and that we are a wonderful province and that we are creating wonderful jobs and that we are going to have a great power sale to the United States in which, for the first time, we are going to export jobs by selling firm power, something we have been against all of the years of our lives and we're going to spend $7 million for that -or allow another dollar of service on Medicare, which has got to go? Of course, the dollar of service for Medicare has got to go, because the ads can't go.

Our very livelihood depends on the ads. I think Mr. Banman repeated a speech that I made to him in 19 67-68, when I told him that when th ose party hacks come and tell you that you're doing fine but the public is not getting it and you've got to spend money on advertising-they're digg ing your grave. And you know, I'm not really displeased with that but I'm merely telling you because I know you won't do anything else. I know you won't change, even though you know.

But the y are digging your grave, and the faster the better. - (Interjection) - Yes, it is wishful, absolutely wishful - I mean wishful, prayerful -with all my heart I wish it. That's right. - (Interjec tion) - Mr. Chairman, that will remain to be seen. The fact is, we're dealing with this bill ... MR. CHAIRMAN: I would like to ask the members of the committee not to interrupt the speech of the witnesses appearing here. MR. S. GREEN: Mr. Chairman, I welcome it. Other than your admonition, I think it's fine.

The fact is that the Attorney-General sends a req uest to his constitutional advisor to find out which of our previous statutes interferes with the Charter of Rights. I want him to find out whether it is an interference with the Charter of Rights that a medical practitioner in the Province of Manitoba and a free citizen cannot get together and agree on a fee. He didn't send this one; he's bringing this one in. Actually, that's a waste of money -what he did. If it interferes with the Charter of Rights somebody will complain and the courts will declare it to interfere.

Whether or not your lawye says it interferes doesn't mean anything. But this one interferes, and I suspect that if it passes, there will be a Supreme Court case on it. There has been one dealing with extra billing, but none in this context. In this context, I sugge st to you that it would go wr ong. Now the Minister says he has a problem; he says Ottawa is forcing him to do this or he will lose money. Why not challenge the Ottawa bill? That's not a problem, in any event. If it costs a million dollars to maintain freedom in the Province of Manitoba, is that worth it?

We were prepared to sacrifice many young people's lives to do it. We are prepared -and we proudly boast of it -to have a reduced credit rating, costing us $7 million, not to give in to the New York financiers. Why will we not cost ourselves a million dollars not to give in to the Federal Government, and maintain freedom in the Province of Manitoba? Is it worth it? 4 Mr. Chairman, it doesn't stop there. Regulations beget regulations. If this is supposed to enforce the provision of doctors' services in the Province of Manitoba, it won't.

And you know, the doctors believe that the bill provides them with compulsory arbitration. There's nothing in the bill about compulsory arbitration. Many of the doctors were of the understanding that this is a quid pro quo. Of course, Mr. Desjardins didn't say that; they have said that. They believe that this is a quid pro quo, but it's not a quid pro quo. So then you will have, ostensibly, the free right of doctors to withdraw their services. Now you can't have that, so you have to pass a law that doctors must deliver services at this specified fee or again you will have a failure.

Then after you pass that law - and this, Mr. Chairman, was told to me by a labour lawyer in Cincinnati who understood this subject better than anybody around this table including myself. The court ordered a group of people to go to work. The people didn't go to work and then the court granted an injunction. I told the Cincinnati lawyer, whose name wa.s Wilson, about this injunction and he says that's an impossible injunction. I asked why. He says, if a cour t orders a person to go to work, they will then have to have an injunction ordering him to work harder.

They will then have to have an injunction requiring a sheriff to stand beside that man with a whip to see to it that he works harder. Tha t's the inevitable co nseq uenc e of any state thinking that it can require people to perform personal services. Mr. Chairman, you were there - I didn't say this about doctors in 19 66 to '69; I said it about bricklayers and plumbers and steelworkers and I said that it included everybody.

But that will have to be the one law, that first of all there will be a prohibition of the medical people from withdrawing their services; then there will be an injunction requiring them to perform operations; then there will be an injunction requiring them to cut straighter and more carefully. And it won 't stop there. Ther e will then be a prohibition of doctors leaving the country and then there will be laws which say that you can only leave the country if you pay all the medical expenses that we paid on your behalf during the years that you went to medical school . lt sounds far-fetched, Mr.

Chairman? lt's happening. Those laws exist. They exist in ju risdictions which think that you can do this type of thing, and the worst feature of it is that we will all become lesser human beings, because there is nothing more precious to the integrity .. of the human being than his freedom. When you take it away from one, you reduce everybody. You may have doctors performing services under threat that they will go to jail, but you will produce very bad medicine because medical services, like any other services, depend on a hu man being's desir e to achie ve excellence.

When his desire to achieve excellence has been destroyed by the enactment of this type of legislation, you demean the entire citizenry and in particular, you demean the performance of medical services. Mr. Chairman, I regret this bill. I regret more the fact that it passes a dem ocrat ically-elected Leg islative Assem bly unanim ously . I consider that to be an incred ible retrograde step in this hitherto free democratic province.

Tuesday, 28 May, 1985 MR. CHA IRMAN: Are there any qu estions for Mr. Green? Mr. Orchard. MR. D. ORCHARD: Thank you, Mr. Chairman. Mr. Green, I may have misunderstood one portion of your presentation this morning, so I'm seek ing clarification. This bill prevents, on the surface, a process known as extra billing in that a physician will charge more than the prescribed allowable fee

schedule under Medicare. I seem to glean from your presentation this morning that you may believe this bill would prevent a further patient-physician relationship. I'll explain it to you that if I go to my physician and I say that I want to have a given medical service provided, which is covered under Medicare by the Medicare set fee schedule, but I want to pay for it entirely on my own MR. S. GREEN: Can't do it. MR. D. ORCHARD: . . . your impression is that this bill prevents for instance . . . MR. S. GREEN: lt says you can't do it. I'll jus t read it to you.

". . . shall not charge to or collect from an insured person" -that's you -"in respect of those medical services or other health services a fee in excess of the benefits payable." Those are set by the Act. I could hardly believe it, but I checked it with the lawyers here and that's the impression.

Then it says, "A judge who convicts a medical practitioner or other person of collecting an excessive fee from an insured person shall order the medical practitioner to pay into court, in addition to any fine the judge may impose, an amount equivalent to that part of the fee that is excessive, and the cour t shall upon the receipt thereof refund the amount to the insured person." Let's say they give it to you back and then you go back to your doctor and say, I'm sorry you were fined and I did want to pay you the money and I don't like the court telling me to, here is your fee.

The next thing they'll do is make that illegal, because how does it work? The Federal Government passed a law that if you find out that any patients are giving back to doctors their fees, you won't get the $1 ,000 back, you won't get the fine back, but you can't make that arrangement with him under this bill. That's what it says. lt says he can't do that even if he is elected to not practice under the plan. Under

Section 11 5, you can elect not to practice, and there were doctors who elected not to practice under the plan. Some of them charged the same fee, they were out on principle and I respect that. One thing I told the medical profession when I was Minister of Health that whatever I do as Minister of Health, I would never require any doctor to work at a state-imposed fee if he didn't want to, that he could make whatever private arrangement he wanted with his patients and if that resulted in the failure of Medicare, it won't be his fault, it'll be my fault. MR. D. ORC HARD: Mr. Chairman, I'm not a lawyer, but this

section that you quo ted, Mr. Green, prevents 5 my relationship with my physician being private and outside the plan if he ch arges me in excess of the fee schedule. MR. S. GREEN: lt doesn't say you can't pay him. lt says he shall not charge or receive from an insured person, and you are an insured person; you are a citizen of the Province of Manitoba. Check it with the Minister. I'd like to know that I'm wrong. MR. D. ORCHA RD: Well, I will as soon as I finish with you, Mr. Green. MR. S. GREEN: I pray to be told that's not what the act is, but that's what it says. MR. D. ORCHA RD: I want to clarify . MR.

CHA IRMAN: Order please, order please. I'd like to clarify some of the arrangements for committee. I'm sure that Mr. Green is well aware that the Hansard recorder needs an identification of the speakers in order to keep the dialogue straight. I would ask the ... MR. S. GREEN: I was well aware of it then, and I did it then too. MR. CHA IRMAN: Order please. I'd like to ask the members of the Committee, as well as the people making presentations to wait to be recog nized by the Chair before speaking. MR. S. GREEN: How are you going to change my ways after 16 years? Okay, I'll try. MR. CH AIRMAN: Mr. Orchard. MR. D.

ORCHA RD: Thank you, Mr. Chairman. To me,

Section 11 9(1) reads that they shall not charge or collect from an insured person, myself, a fee in excess of the benefits payable. Now, what happens if I go to my physician, and I'm in a position of some public exposure and my physician happens to be a psychiatrist and if I was seeing him for some problem that I don't want my employer, because of my public position to know, and I say ... MR. S. GREEN: This is true confessions? MR. D. ORCHARD: Yes, this is true confessions. And I say to my psychiatrist that I don't want any record of this to show up any place in Medicare, I'm going to pay you only the prescribed fee

schedule because that's all that's allowed now under Manitoba's Health Services Commission now that this act is law presumably -I'm talking after this has passed -I'm only going to pay you the prescribed fee schedule, but I'm going to pay you out of my pocket and I'm not going to collect reimbursement so there's no record of our dealings any place so that someone might be able to make that information public on me. Is that allowable?

Tuesday, 28 May, 1985 MR. S. GREEN: Wha t you say would be legal whether there was a record of it or not. There is no requirement on the part of a citizen to claim his insured benefits from the medical health plan. Let's say that you're entitled to $10 0 for that service and you pay the $10 0, that's not illegal because there has been no charge in excess of the fee for the benefits payable.

If he charges you $12 0 and you don't collect $10 0 from the medical health plan, and I don't know why you wo uldn't, but nevertheless most people do, the $20 is illegal and they can go to cour t and there can be a fine of $1 ,000 and repayment of the $20.00. MR. D. ORC HARD: That's fine. I understand that to apply to the act in terms of fees in excess of the schedule, but we've got within the Health Services Commission now what they call a PH IN number, which is, I believe, a nine-digit identification number.

Every person in Manitoba is assigned one of those numbers and at the punch of those nine numbers into the computer, his complete medical record can come up. I'm talking about a circumstance where a person wants none of those things to appear for whatever reason and he wants to deal completely on his own with his physician. That is allowed providing it's within the fee

schedule only. MR. S. GREEN: Right. The only way they will know you is that the doctor has to report his income to the Department of National Revenue. If he does that, they've got a number and you're numbered here or you're numbered there. He doesn't have to disclose who paid him his fees unless they ask, but eventually they could find out, provided he discloses his income. MR. D. ORCHARD: Then, under this act, we could have an independent medical service without any reporting. MR. S. GREEN: Yes.

In the remote case of a person wishing to pay the prescribed fee and not claiming it from Medicare, there is no req uirement that a citizen claim his entitlement from Medicare. I've speculated on a lot of possible regulations that could be made under this act.

I can't speculate as to how anybody would want to pass that. lt would merely reduce the Medicare fund and not give ... unless they could use those monies to advertise, then they would want a requirement that you say that you didn't collect money so they wou ld know there's that much money available which could have been paid out and they could use it for something else. MR. D.

ORCHARD: But the moment I make that private arrangement with my physician, with no intention on my part as the recipient, as the insured person, of ever claiming back to the Health Services Commission the prescribed fee schedule, if the fee set between myself and my physician is above that fee schedule, even though I'm not claiming it back from Medicare, that would be illegal. MR. S. GREEN: That is right, even though you don't claim it, the excess is illegal, excess over the fee is illegal.

That's what it says, ". . . shall not charge or 6 collect from an insured person, in respect of those medical services, a fee in excess of the benefits payable." Not paid, but payable. What it is, the medical services provides a

schedule of fees and these

schedule of fees become the only legal fee that a medical practitioner can charge above that. He can charge below it. He can't charge above it. He can charge below it and the cit izen can claim above it because the insurance pays him and he can pay the doctor. The doctor may charge him nothing; it may be a friend. He's still entitled to get payment of that service -at least, I believe so. There's no reason why he shou ldn't. The doctor is giving him a gift, not the government.

I am not aware -there may be -but I am not aware of other citizens in the Province of Manitoba who have a prescribed fee which they can't make a separate arrangement for. There are lawyers in the Province of Manitoba. We have to work according to a tariff, but we can say to a prospective client, we are going to make a deal with you and our deal is that you will pay us X dollars and, provided you are mature and over 21 and know what you're doing, the law won't upset that and that could be three times the tariff; and there are some people who will pay that for getting what they consider to be the right la1ivyer.

There are some people who will pay excess fees to get what they consider the right doctor. There are people doing that today. There are people, let's say, going out of town, paying more money, even though they could get the service in town and it would be entirely paid for. There are people who go to naturopaths because they won't go near a doctor and the y'll pay the naturopath and the government won't pay and that's their way. Nobody can stop them, but this says that the fee will be prescribed by regulation. MR. D. ORC HARD: Mr. Chairman, might I ask the Minister if the

interpretation of the second set of circu mstances, where I make a private arrangment with my physician and he ch ooses to ch arge me some percent above the prescribed fee and even though I, as the insured person, do not claim any benefits from MHSC for that service, from the Medicare Plan, will that private arrangement be illegal under this bill? MR. CHA IRMAN: Mr. Minister. HON. L. DESJARDINS: Mr. Chairman, I think this is rather an unusual procedure. I think that we should deal with the presentation first and then we'll discuss and entertain any comments. MR. CHA IRMAN: Mr. Orchard. MR. D.

ORCHARD: We'll bank that qu estion, as they say in the vernacular of the House then, Mr. Chairman. The second topic, Mr. Green. lt has been said by various groups, various individuals, that allowing the process of extra billing by physicians creates a two­ tier medical system which den ies access to the excellence of that system, if you will, by people who cannot afford to pay an additional premium; and that appears to be one of the major motivations in passing

Tuesday, 28 May, 1985 this ban on extra billing, both at the federal level back two years ago, I believe, and currently in Manitoba with this complying legislation. MR. S. GREEN: Mr. Chairman, there is no doubt that danger exists and I have acknowledged that earlier and when we went into Medicare we said that if -and the radiologists were the first group -the radiologists, almost as a block, said that they won't work under Medicare and they charged whatever fee they wanted and some people couldn't afford it; and yet, somehow, medical services went through to all of the people.

There are some doctors who say you can't buy my services, you can go to somebody else; and what we said at the time was that unless the state is able to so structure the medical delivery system, that there will be doctors available at affordable rates, there will be a problem with Medicare, and the suggested solution was that there would be not simply entrepreneurial medicine in the Province of Manitoba. There is a feature of Medicare where the person is not able to obtain equal treatment. There is a feature in the educ ational system where a person is not able to obtain equal treatment.

There is a feature of almost everything we do in society where people are not able to get equal treatment, but we've gone a long way toward producing that with the medical health system; and the medical health system resulted in 90 percent to 95 percent of doctors opting in and the government sitting on its hands and doing nothing to see to it that those areas of danger would be covered. If we knew that radiologists were going to opt out as a block , it was our job to set up radiology clinics, and I say that, some doctors would be violently annoyed to hear me say that but I have no problem with it.

You look at the sensitive areas and you do. Doing is much more productive than taking. There are governments who think that they can get by saying, others will make and we will take. This government hasn't done a damn thing. They say others will do it and we'll take it from them. In this case, you want to provide a radiology system and radiologists are not working under the plan. You tell the radiologists, you don't want to work under our plan, fine. You are taking certain things from us; you are taking equipment from us; you are taking training from us.

We're going to set up a system to see to it that the people who take that training and take that equi pment and take that education are available to perform radiology services, at least as an alternative. But this government's alternative is that if a man won't do what we want him to do, we'll pass a law saying he will do it and if he doesn't do it we'll put him in jail. The ultimate power of· the State to conscript is to deprive the citizen of his liberty. That is the ultimate threat, and that doesn't work.

When they do that, people start to leave the country so they have to start up setting up walls and we know what I'm talking about is not hypothetical. lt happens and it can happen anywhere and it's happening here. This is simply the first step. MR. D. ORCHARD: Then, Mr. Green, to . . . MR. S. GREEN: Mr. Chairman, I can tell you, I won't work for a state imposed fee. You try it. 7 MR. CH AIRMAN: Order please, order please. Mr. Orchard . MR. D. ORCHARD: Thank you, Mr. Chairman. lt would seem as if Mr.

Green is suggesting that rather than this legislation which is restrictive on all medical practitioner s and has some potential future consequenc es which we may well see sooner than later, that the solution to universal access, if you will, to a qu ality Medicare system is not the forcing of compliance of all people who practise medicine, but rather to possibly -if you want to use an American medical example -to set up a DRG, Diagnostic Related Group, where a group of physicians are retained under salary for a performance of service which will be provided to all those and retained with it, as well as the DRG, if that's a proper analogy. lt may not be fitting to this government's philosophy, but that kind of a system where you have a group of medical practitioners of all disciplines in a group paid a salary to perform services, and if that is not a suitable group for you and I as individuals to use, we'll go to the physician of our choice and if we have to pay him more, that is our personal choice, but anyone who can't afford to pay more can avail themselves of the services of a DRG.

MR. S. GREEN: Let me say to Mr. Orchard that it's my view that the best service should be the public service, that the people who want the alternate get an inferior service, that you want the best service. That was my whole argument on the school qu estion. Once you permit the private schools, you are in the position of saying, if you can't afford a private school, you will go to the public school. I say the best system has to be the public school system, and then those who don't want it can go to the other system.

We have to, as a public, set up so that the people in our society, who are the general population, have the best service avai lable. I would want to see to it - you know you can't do it immediately -but I would want to see to it that there is available service. Now we had tremendous success with Medicare. Why are we proclaiming its failure? Ninety-five percent of the medical practitioners in the Province of Manitoba deliver services, still deliver services to their patients at the fee that is set by· the Medical Health Services Commission.

Why are we going to do this? lt's fear, not about what others would do, but fear about what we are able or capable of doing and not doing. When we say we are incapable of providing alternate services, we have to lock in the other services. Look what happens. I gave you a scenario that may have sounded a little way out, but it happened in the Province of Manitoba. Some psychiatrist told a patient that he may leave the Province of Manitoba. I don't see anything unusual about that. I am sorry about it, but a psychiatrist has a right to determine that he wants to leave.

The Minister of Health made a statement, publis hed in the newspapers, and I believe it, that the psychiatrist who told him that he's going to leave the Province of Manitoba, if he is not permitted to practise freely, was unethical in telling his patient that. So now it becomes unethical to say that you don't like what's going to happen and that you're going to

Tuesday, 28 May, 1985 leave. There will be a regulation in the Province of Manitoba that no doctor can say that he doesn't like it here. But, Mr. Chairman, that's not good enoug h, because if they sit silent, they might have sneers on their faces, they might show displeasure other than by words, so there will be another regulation, that every doctor must say he loves it in the Province of Manitoba. You cannot stop with these things if your objective is that by legislation you will see to it that patients are served at a particular fee.

Tell the Minister this, I won't work at a state-set fee, even if it's a fee higher than the one I'm getting now. I won't do it. You may have to put me in jail, but I won't do it. And then you will see the conseq uences of the action. This is the road to serfdom and I want to stop it, if I can; and not a single member of the Legislative Assembly spoke up -or maybe they spoke apparently -but they didn't vote against it. MR. CHAI RMAN: Mr. Santos. MR. C. SANTOS: Yes, Mr. Chairman, as I understand democratic society, there is no such thing as absolute liberty.

Any liberty we know is liberty under the legal system or under the law. I'd like to ask Mr. Green, does he think that the doctors have absolute liberty to set any fee they like, even if it is unconscionable? HON. L. DESJARDINS: Mr. Chairman, on a point of order. MR. CH AI RMAN: Order please, order please. The Minister of Health on a point of order. HON. L. DESJARDINS: Mr. Chairman, this is getting to be a ... MR. S. GREEN: I'd like to answer the qu estion, please. HON. L. DESJARDINS: That's not the point here. Mr. Chairman, Mr.

Green knows -of course he'd like to answer, so would I, but the point is that that is not permitted under our system. The presentation was made. I think you've been very lenient and the questions are for clarification. Inviting comments such as that is certainly out of order and this is providing a debate. MR. CH AI RMAN: The purpose of the committee is to hear representations on the bill. The purposes of the que stions are to clarify the details of the presentation. lt is not a forum for debate between members. Mr. Orchard . MR. D. ORCHA RD: Mr. Chairman, Mr.

Green, in the course of his presentation, indicated that he did not believe that limiting a physician's ability to charge for what he believes his services are valued at should be done. Mr. Santos has asked a qu estion as to whether there's any limit to that extra billing, and I think it does follow on the subject matter of Mr. Green's presentation, and is very relevant to Mr. Green's presentation this afternoon. lt isn't entering into a debate. it's clarifying whether Mr. Green believes there's an upper limit to what a physician should be able to charge. MR. CHA IRMAN: Order please.

The qu es tion is argumen tative which leads to debate; it is not a matter of clarification for the details of the bill. 8 MR. D. ORCHARD: Mr. Chairman, on the same point, the forum is to elicit from the public of Manitoba their feelings on legislation that we're passing, and even though the Minister may not agree with some of the things that this presenter has indicated to the committee what he feels is right and wrong with this legislation; that should not affect the ability for other members of this committee to clarify where Mr. Green sees a limit to the proposals he has made in his presentation.

Even though you don't like the answer, you should not have the ability to prevent the qu estion from being posed. That's stifling the flow of information that we 're here to gather from individuals. MR. CHA IRMAN: The Minister of Health. HON. L. DESJARDINS: On the same point of order, Mr. Chairman, I certainly would have no hesitation in agreeing with the statement that it's not if you like the statement or not, the position of any people that are making presentations. In fact, the honourable member might be surprised how much I do agree with the speaker.

The situation is that we have a system here and if we're going to change that, this is not the time to do it. it's during the proper committee to do that. lt is very clear that we have an orderly fashion. I think that we've been very lax, it's been going qu ite well, but the situation is not to invite more statement or observation; it is for clarification of what has been done. There is no limit in the time that the speaker, so far, unless the committee decides, and this is only for clarification, and that is not a qu estion of starting a de bate.

Un less this is change d , this is what the committee has approved. These are the rules of the committee and they've been around for a long time. The speaker, first of all, made a statement and then he said, what do you think, and invited a rebuttal from the delegation and that certainly is wrong. You are not trying to lead the speaker into making another speech, you are trying to get clarification from what he originally said. My honourable friend knows that this is it. it's not a ques tion of liking the answers or not. MR. CHAI RMAN: The Member for Lakeside. MR. H. ENNS: Well, Mr.

Chairman, I just want to support what the Minister jus t finished saying. We have a long­ established system in this committee. My understanding is the Member for Burrows asked a question of the person making presentation before, he's prepared to answer it. it's just that simple. The qu estion was to what extent, what limit. That's a very straightforward qu estion and I'm sure the Minister acknowledges it's not a qu estion of being argumen tative or not.

If the qu estion is framed in such a way that it asks for a longer answer, we have the informality of this committee to do precisely that. lt seems to me a qu estion was asked - (Interjection) - surely the Minister is not -or the Chairman is not sugge sting that this Committee should not hear the answer. MR. CHA IRMAN: The Member for Bur rows. MR. C. SANTOS: . . . formulate my question, Mr. Chairman?

Tuesday, 28 May, 1985 MR. CHAIRMAN: If there is a qu estion - (Interjec tion) - on the presentation made. MR. C. SANTOS: My qu estion is whether Mr. Green is trying to say to this Committee that in a free democratic society such as ours the doctor can have no limit at all in whatever he can charge on the basis of free collective bargaining rights? MR. S. GREEN: Mr. Chairman, I'd like to answer the qu estion. I believe the difference between a free society and a slave society is when the state imposes limits and requires people to work at those limits. lt might a surprise to Mr.

Santos that the plumber can charge whatever he likes, he may have trouble getting it. The lawyer can charge whatever he likes, he may have trouble getting it. I believe that a group of people, a doctor, has a right to make an arrangement with another free citizen as to what his fees will be. When you ask for a limit, it may be a surprise to my friend to know that there are limits other than law. They think that the only limits to human responsibility is to pass a statute saying you can't do it, but for 10 0 years this society has existed free with people being able to get medical fees paid for.

Sure there are complaints from time to time; there are complaints about steel worke rs' fees; there are compla ints about civil servants fees; there are complaints about MLA's fees; there's no legal limit to what they can charge; there are no legal limits. You can pass a law taking the whole $3.6 billion and you may do it before you don't have a chance to do it anymore, but there are limits, Mr. Chairman. The limit is based on responsibility and the limit is based on the fact that if you try to do that type of thing you won't get it.

If you did that type of thing, jus t as I said to the member earlier, then the state would have to organ ize the system so that there is an alternative system and that keeps down the fees, not laws. MR. C. SANTOS: A supplementary, Mr. Chairman. If Mr.

Green realizes that are some limits to liberties of people in organ ized society, does he not also recognize that it is the responsibility of the state through their elected representatives to intervene when there is a situ ation whereby the potential parties to a bargaining agreement are in a very unequal bargaining position as is in the case of a doctor who has been perceived in our commun ity as very influential, who earn an income of $1 00,000 or more, whose words are sometimes taken by patients as law, and it's against the patient who seek and who rely on the knowledge and expert ise of their physician who is mentally disposed to do whatever the doctor would sugge st, does he not recog nize that there is an equal bargaining position between the two?

MR. S. GREEN: Mr. Chairman, may I say to the honourable member that my ideas of liberty are distinct from his, that I do not believe that it is necessary for the state to intervene to impose that in order to provide a useful system.

I believe, as did Tommy Douglas, as did David Lewis, as did the New Democratic Party when 9 they formulated Medicare that it is possible to provide a universal health system available on a basis of free interrelationship between the doctor and the patient without conscripting doctors, that at the point that the only way that this system can be provided is by conscription of doctors, that is the failure of the system. That's why I proclaim this act to be

an act proclaiming the failure of Medicare in Canada and in the Province of Manitoba. When my friend says are there limits, I undertook with myself and with the people who elected me in 19 69 that I would never pass a law ordering workers to work. Between 19 69 and 19 78, and it's carried over to this day, Manitoba has been one of the only provinces that did not pass a law ordering people to work. If my friend, Mr.

Santos, says do I not recognize that there are limits and that the Hydro workers have the power of holding up the province to blackmail and that they are entitled to collect whatever they want by saying that they're going to turn out the lights and don't I recog nize that there is a limit on that type of liberty and that we have to impose a legislative law prohibiting that, I say no, that is not my idea of liberty. MR. CHAIRMAN: Are there any further qu estions for Mr. Santos. MR. C. SANTOS: A final ques tion, Mr. Chairman.

In a democratic society such as ours where both the majority party and the opposition party have come to an agreement of what is socially desirable, can Mr. Green say that all these representatives of the people freely and democratically elected are wrong and that he is right? MR. S. GREEN: Yes, absolutely. That is one of the most reg rettable things that I have seen is that this thing was passed unanimously, but I can tell the member that I was right and the rest were wrong when I said that the doctors should not be able to take your blood while you are unconscious and give it to a policeman.

Everybody voted one way, I voted the other way. They were all out of step. MR. C. SANTOS: Thank you, Mr. Chairman. MR. CHA IRMAN: Mr. Orchard . MR. D. ORCHARD: In answer to a qu estion about the avoidance of the two-tier system, in other words, providing a government-provided service which would be superior -Mr. Green hopes -to what would be available outside on an extra-billing basis presumably, would Mr.

Green not detect a problem with that in that to provide the superior service, theoretically, by having physicians on salary that the government could not afford to pay the kind of salaries to make sure that the government system was the best? MR. S. GREEN: You'd be very surprised, Mr. Orchard, to find out when people are working together and when they have a society which means something to them and which they see good things coming out of, how much people are prepared to work as part of a unit

Tuesday, 28 May, 1985 society be well rec ompens ed and not to be overcharging. I know that some of the people who work the hardest in our society are people who get nothing for it at all because they have satisfaction in doing what they're doing. When you asked me do I see problems -sure I see problems. When I say that I'd like the public system to be the best service, I recognize that can't happen from Day One, but my aim would be to see to it and to work at seeing to it that that service which is available to everybody is the best service and if you go elsewhere you're getting a less good service.

That has been badly hurt with the public school system over the last seven or eight years. What has happened is many people have said I can send my child to a private school, pay less money than I used to have to pay and now I can ignore what happens in the public school system, let that be a gar bage can for people who can't afford better. That's the biggest danger to the public school system and that's being facilitated by this gover nment. MR. CHAIRMAN: Are there any further qu estions for Mr. Green? Seeing none then, on behalf of the committee, Mr. Green, I would like to thank you for coming today.

The next speaker on my list is Dr. Greg Dunn. DR. G. DUNN: Good morning, Mr. Chairman, Mr. Minister, members of the Committee. I'd like to thank you for the opportunity of allowing me to come here today to address some of the issues that face chiropractic in the Province of Manitoba, and also more specifically, those issues that pertain to Bill No. 2. By way of backg round, the Ma nitoba Chiropractors' Association has approximately 10 0 members. Ninety of those are currently practising. We provide a valuable service to the people of Manitoba and we respond with dedication to the need for chir opractic care.

In 19 70 in this province, chiropractors treated about about 56,000 different Manitobans. In 19 84, chiropractors in Manitoba treated about 13 9,000 Manitobans. This reflects about 14 percent of our population here in Manitoba. This is the highest in Canada. Not only that, this is the highest utilization by a population of anywhere in the world, according to our current statistics. We also estimate that since 19 70 over a million Man itobans have made thems elv es avai labl e to chiropractic care. We estimate that would affect at least one in every two Manitobans.

We're proud of these statistics; we're proud of the fact that Manitobans are increasingly finding satisfaction in chiropractic health care and in the chiropractic profession in Manitoba. We have a growing place within health care in Manitoba and with the healing arts community and, as most members know, our patients are a dedicated and loyal group. Turning to Bill No. 2 itself, when the Minister introduced the bill into the Leg islature on March 20th for second reading, he made reference to The Canada Health Act.

The effect of that federal statute is to penalize provinces on a dollar-for-dollar basis for money that is permitted to be charged to patients in the form of user fees and extra billing. The Minister indicated 10 that as a resu lt of The Canada Health Act and Manitoba's allowing physicians to extra bill, our province was being penalized approximately $1. 4 million annually. From a practical standpoint, the prospect of losing these kind of dollars annually is a compelling reason for outlawing extra billing.

Particularly, in the financial circumstances of this province at the present time, we can ill afford to be losing this amount of transfer of funds from the Federal Government. Chiropractors understand the realities. However, this money rationale does not apply to the situation of the chiropractors. Chiropractors are not within the scope of The Canada Health Act and therefore the province would not suffer any financial penalty if it were to permit chiropractors to extra bill; but our right to extra bill is nonetheless being taken away.

Therefore, the most compelling pragmatic or practical reason for eliminating extra billing for physicians simply does not apply to the case of the chiropractors. Therefore, we must ask, why are chiropractors within the scope of Bill No. 2? We must look to other rationale to find a reason why the Manitoba Government and the Minister feel it's necessary to include chi ropractors within the scope of this bill. The Minister has said, and I think accurately, that there is unanimous concern with respect to maintaining an excellent health care system in the Province of Manitoba and in Canada.

We all agree, the government must take whatever steps are necessary to ensure that the principles of universality are not threatened by such things as user fees and extra billing. As chiropractors, as Manitobans, we accept it. lt's a !aud ible goal, but the fact of the matter is that chiropractic care is not now and never has been universally available to Manitobans. The Minister of Health can confirm that there are limits to care available to chiropractic patients.

After the limit of visits is exhausted by a chiropractic patient in any given year, there is no coverage at all by the Manitoba Health Services Commission. A patient is completely on their own. Our association and the Minister agree that a long-term goal should be full coverage for chiropractic care and service but we appreciate that the present financial constraints on this government do not permit full coverage at this time.

But we have a gov ernment that on one hand eliminates the right of doctors to extra bill in the name of maintaining universal ity, and at the same time requires patients to be extra billed completely, once their services are exhau sted . This is cert ainly inconsistent. In a sense, it's hypoc ritical. The government cannot use the universality argument as a rationale for including chiropractic services within the scope of Bill 2, when it requires the patient to be extra billed at a certain point. This, of course, raises the issue of the limit of benefits available to Manitobans.

In February of this year, the Manitoba Government retroactively to January 1st, eliminated the family benefit portion of the benefit schedule. The Health Minister claims that this is in the interest of equal ity, in that no longer will an individual member of a family be able to take advantage of the entire family benefit, but everyone, regardless of family status, will be limited to the value of 11 visits of chiropractic treatment.

Tuesday, 28 May, 1985 That change in the benefit

schedule resulted in the government appreciating a $600,000 saving acq uired on the "backs" of chiropractic patients. Later, and as a result of the pressure that chiropractic patients brought to bear on this government, the Health Minister announced without any prior notice that it would be reinvesting half of what it had previously taken out and raised the number of visits from 11 to 16 .

There is still $300,000 worth of benefits that this government has cut back from Manitobans and I sugge st that this is cont rary to the principles which Premier Pawley espoused when he spoke to the media following the Throne Speech and said, and I qu ote, ". . . but we are going to preserve what we have; we are not going to tear down; we are not going to use a meat cleaver as is taking place elsewhere in this country, and where possible, not in an expensive way, will enhance the hu man conditions in important health and social programs." I ask the Health Minister to tell us how the reduction of chir opractic benefits to Man itoba chiropract ic patients is an enhancement of the human condition.

If we look closely at the words tha t were used by the Minister in introducing Bill 2 on Wednesday, March 20th, 19 85, we find the reason why chiropractors are includ ed . He said that his go ver nment fel t, "for ad ministrative purposes, " care provided by chiropractors and other partially covered specialties would be included in the scope of Bill 2. Our profession and others were simply slipped in for administrative ease.

The government ignores the pleas for fair treatment from our association while running roughshod over the rights of chiropractors, all in the name of expediency, in the name of government bureauc racy, in the name of convenience. By saying our profession is included for administrative purposes, the Minister adm ists that there is no luna mental un derlying principle, outside of administrative ease, to include the services that we provide to Manitobans in this legislation.

With all due respect, we sugge st to the Minister that to treat a significant portion of the healing arts community in this province with tha t type of attitude is un fair, is unreasonable and is unacceptable. We don't want to be unfair to the government. Indeed, the Manitoba Chiropractors' Association has always been open, ready, willing and able to consult and negotiate and discuss health care in this province. The Minister of Health is the one who has turned his back and the back of his government and his party on the healing arts community.

In appearing before the committee today, it is no t our desire as an association to sugge st to government that we demand the right to extra bill. This is not the reason why we want to be excluded from this legislation. Statistically, chiropractors extra bill to the extent of 6 percent of the practicing profession with respect to insured services in Manitoba, a very moderate and reasonable percentage. On that point, extra billing has some place in the scheme of health care. it is used as an indicator to determine the degree of appropriateness of the existing MHSC benefit schedule. Bill No. 2 will take that away.

Our association may be prepared to accept the sacrifice of the right to extra bill, but not without compensation, not without fair treatment. 11 The government, in negotiating with the Manitoba Medical Association and medical doctors, decided that if the doctors sacrificed the right to extra bill, the government would enter into a three-year trial period permitting binding arbitration. The MM A was permitted to negotia te with the government, to consult with the government, to even hold a referen dum throughout its profes sion to determine the advisability of proceeding with such an ag reem ent.

The go ve rnment extended all tho se courtesies to the medical profession and we submit qu ite rightly so. it's a question that touches upon the very fu ndamental elements of health care in this province and the government is only acting prudently and reasonably in embarking on such negotiations and consultations. We submit that when decisions are made regarding chiropractic health care, one ought to consult with the experts in that field, and to my knowledge we're the only experts in that field. This has not been done.

Regrettably, the government has not seen fit to deal with chiropractors in the same fashion as they have with the medical doctors. The He alth Minister has refused to permit the Manitoba Health Services Commission to negotiate the issue of binding arbitration with us. The Minister wants our association's fee structure to be at his whim. If Bill 2 is passed in its present form, the Minister will have succeeded in expropriating or confiscating the only right we have as an association to negotiate fairly with the government with respect to our fee schedule.

And remember when we negotiate, we negotiate for all Manitobans, something that might be forgotten here. We are rightly or wrongly in charge of negotiating the benefit

schedule for the people of Manitoba, not only our fee

schedule when we go to Manitoba Health Services, we are the watchdogs on the benefit schedule. That is why we had to take a stand when the benefit

schedule for our patients was changed . That is why it's so critically important at this time, that until a scheme can be worked out that is fair to us, that we be at least temporarily excluded from Bill 2. The government would not treat any other professional association or labour organization in such a disrespectful fashion. The Health Minister said, when intr oducing Bill 2, that the agreement to enter into binding arbitration with the MMA and the removal of the right to extra bill are issues that are unrelated in his mind. We submit that this is the only place that they are unrelated.

The MMA certainly considered the issues to be a package deal. Doctors understand that in exchange for one method of determ ining a fair and reaso nable fee structure, they are receiving another; that being binding arbitration. In short, there is simply no compelling argu ment to sug gest that the issues can, in any way, be separated because factually they're a package and to sugge st otherwise is a deception. Therefore, we arrive at our position that we advance to this committee today. We are asking the committee to remove from Bill 2, its applicability to the chiropractic profession.

That is not to say we demand the right to extra bill. That is to say that we wish an opportunity to sit down with the Manitoba Government or with the Minister of Health and the Manitoba Health Services Commission and discuss, negotiate and consult in a meaningful and substantive way, the issues as they

Tuesday, 28 May, 1985 relate to chiropractic care of Manitobans. We wish to receive the same type of treatment the government has accorded to medical practitioners and the type of treatment that they would offer to any labour or professional organization, no more, no less. We feel that we have the right not to be treated as second­ class citizens, not to be ignored and certainly not to be run roughshod over. I wou ld like to thank you for listening to my submission.

I have a draft of a proposed amendment to Bill 2 that I would like to make available to you, and I would certainly be willing to ans wer any qu estions that anybody would have of me. MR. CHA IRMAN: Mr. Orchard . MR. D. ORCHARD: Mr. Chairman, thank you. Dr. Dunn, in your brief you mentioned that -I'm trying to find it in the brief -but I believe you indicate that presently some 6 percent of the members of your association are currently extra billing on their fee schedules. DR. G. DUNN: Yes. MR. D. ORCHARD: Now, Dr. Dunn, has that been a relatively steady percentage or has it been declining or growing? DR. G.

DUNN: Of course now it's declining. I suppose with some of our members imminently seeing the writing on the wall with Bill 2 have opted back in, in the last month or two. Up till then, it was a fairly stable figure for, I would say, the past two to three years. Prior to that it was a very low figure. I think what it does reflect and the fact that it increased several years ago -I'm vague about the time because I can't ramember specifically -but it would be two to three years ago that the number of opted outs incr eased , and that of cou rse reflects the unacceptability of the fee schedule.

I might add that when we entered the plan in 19 69, to this date we're 10 9 percent be hind inflation. Wha t other group would stand for that? Wha t other group could tolerate that kind of treatment in the system? That's why it's so dangerous to not give us any right, or to include us in Bill 2, until we have some form of stable and safe means of ensuring that we're going to get fair treatment. We haven't had that. We're not only 10 9 percent behind inflation, we haven't even been treated as fairly as the other primary health care providers in the plan.

We're 30 percent behind them, and who knows how far we'll fall behind in the future? We need the protection of the government. We need the protection of this committee, and until we're satisfied that we have a safe means of protecting us, protecting our patients, Bill 2 is unacceptable. MR. D. ORCHARD: Dr. Dunn, you made mention in your brief that there was no consultation with your association. Is it fair to assume then that you were made aware of your association's inclusion in Bill No. 2 when the legislation was tabled? DR. G. DUNN: That was partially it. Actually we had a little bit of lead time.

We had heard about it in the 12 press prior to it actually coming out in the Legislature. There is a matter of contention about that. Health Services maintains that they informed us of that back in June of 19 84. We had four people there, including our negotiator who's a lawyer, and nobody found any record of that in our side. lt could be an administrative gap on our side or their side, but we have no record of that notification and certainly I have no memory of that notification.

So I guess, in a roundabout way, what I'm saying is my first impression that we were going to be included in Bill 2 perhaps goes to the press, perhaps goes back into about early January when, on occasion, I did ask outright of one of the members of the Health Services Commission whether there was intent to include us. That individual felt there was intent, but since it was a government bill that we would have to clarify it with the government, which we then attempted to do. MR. D.

ORC HARD: So the controversy then, as to notification stemming back to June 19 84, to your knowledge, your association has nothing in record or on file ... DR. G. DUNN: No sir, we don't. MR. D. ORCHARD: ... or anything from MHSC that that would be the case? DR. G. DUNN: No, sir. MR. D. ORCHARD: Mr.

Chairman, then the point you're making is that because The Canada Health Act in no way penalizes the province on a dollar-for-dollar for any extra billing by some 6 percent of your association, who are currently extra billing, that it has no financial impact on the Provincial Government and the financial impact is one of the motivational factors to speed passage of Bill No. 2, you rest, at least in part, your position to be excluded from Bill No. 2 on that basis. DR. G. DUNN: Ab sol ute ly.

There is cert ainly no compelling reason for the government to move in any hurried way at least to include chiropractic in Bill 2. There is certainly no impetus because of The Canada Health Act for them to do so. As I under stand it, in the news rel ease that accompanied the passage of Bill No. 2 through second reading, the primary reason given that it went through unani mously was becaus e of the loss of transfer payments, and that is a compelling reason. However I want to make -certainly you, Mr. Orchard and the opposition party aware that that's not a case as far as chiropractic care is concerned.

We have a letter on record from Monique Begin, the Federal Health Minister, who orchestrated The Canada Health Act, assu ring us, and we've had further assurances from the Honourable Jake Epp, who is now Federal Health Minister, that chiropractors are not included. There are no transfer payments that will be lost or in jeopardy because of extra billing by the chiropractic profession. MR. D. ORCHA RD: Now, Mr. Chairman, Dr. Dunn has indicated that his association, on Page 7 under the

Tuesday, 28 May, 1985 topic of "Binding Arbitration" -"Our association may be prepared to accept the sacrifice of the right to extra bill, but not without compensation and fair treatment." On Page 8, second paragraph, you indicate that the Minister of Health has refused to permit the Manitoba Health Services Commission to negotiate the issue of binding arbitration. lt was my understanding in the controversy that you outlined in your brief regarding the government decision to change your office visit compensation schedule, that the agreement that existed between yourselves and the Health Services Commission set up the framework for a formal committee to negotiate fee schedules, etc. etc.

DR. G. DUNN: Yes. MR. D. ORCHARD: Now, your statement on Page 8 indicates that that committee certainly is not at present working. There's no meeting of that committee with yourselves as an association, and the Health Services Commission. DR. G. DUNN: Not at the present time. There isn't anything scheduled. We did have a meeting scheduled back, I bel ieve in early April -that mee ting was postponed pending some discussion with the Minister that didn't turn out to be productive and didn't result in a meeting with the Minister at that time.

Since then, commun ications and so on have been going at higher levels than MHSC and we haven't got back to MHSC to negotiate. They have, I want to say for the record, accepted a willingness to discuss matters with us. Our problem with going to MHSC is that we're very unclear on what their mandate is at the present time. These issues are delicate; these issues are, as you can tell from my presentation, very pressing on us. We want to be sure when we're discussing the issues, we're discussing them with the people that have the authority to deal with them. MR. D. ORCHARD: Dr. Dunn, I agree.

The presentation you've made is, I think it's fair to say, qu ite a strong presentation. You've made some very strong points in here as to your relationship with this gover nment and with the Health Services Commission.

But it's my understanding, and correct me if I'm wrong, that within the agreement -mind you, that agreement expired, theoretically, March 31 of this year -but explicit in that agreement, to my recollection, was the req uirement, if you will, that yourselves as an association and the Health Services Commission set up a comm ittee to discuss future fee negot iations and other matters related to your . . . DR. G. DUNN: That has not been done. MR. D. ORCHARD: Agreed, Mr. Chairman. Dr. Dunn indicates that that has not been done.

The statement that the Health Minister has refused to permit the Health Services Commission to negotiate the issue of binding arbitration is even stronger. Given, on the previous page, that you indicate a willingness to accept the sacrifice but not without compensation, I presume would mean 13 that if your association was to accept inclusion under Bill 2, it would be done only on the basis that you reach some mutually agreeable terms as did the MMA in terms of binding arbitration. DR. G. DUNN: Absolutely. That's our bottom line.

Once Bill 2 goes through, you must remember that there is absolutely no protection in the negotiating process for the chiropractic profession in Manitoba-nor its patients, I might add, because as I stated earlier, rightly or wrongly so, we also negotiate the benefits level for our patients. Nobody else watches over that except us. Once Bill 2 goes through, we're naked -if you like - in the baraining process. We're at the discretion of the government, if you will. If the government decided that chiropractors were to get a 1 percent increase, that would be it.

They would phone Health Services and tell them, this is what we've decided; phone the chiropractors and tell them that's what they're getting and there's no use coming down to negotiate because there's nothing to negotiate. Wha t type of organization, what professional body, what group of people -the government employees, the people who actually work at Health Services, would they accept that? That's not acceptable. That's not acceptable to civil servants; it's not acceptable to chiropractors; it's not acceptable to labour unions. it's not acceptable, period. MR. D. ORC HARD: Mr. Chairman, I believe that Dr.

Dunn on behalf of his association, has made probably one of the more persuasive arguments for exclusion from Bill 2 as it is presently written in the fact that we understand there is no penalty imposed by the Federal Government under the Canada Health Act. Secondly, the points you make about the interrelation of the issue of extra billing and binding arbitration are tied in the minds of the Manitoba Medical Association, even though the Minister has maintained they are two separate issues. One gives birth to the other, if you will.

Your association is today seeking exclusion from Bill 2 pending a negotiating process with either the Health Services Commission or the Minister of Health, whoever can make the decision. If you can come up with an arrangement -and if I can be so bold as to sugge st an agreement similar to what the MMA had reached regarding binding arbitration . . . DR. G. DUNN: That agreement has changed and I'm not familiar with its current parameters, so I wouldn't want to tie myself to that, I'm sorry. MR. D. ORCHARD: Right, and I agree. I'm not intending to tie you to that.

But basically, what you're looking for today is a commitment that you be excluded from the provisions of Bill 2 until such time that you can negotiate on behalf of your organization representing the chiropractors, but more importantly, representing those 15 0,000 patients that visit your association members yearly. Until you get an agreement on your behalf and on behalf of those patients as tb a method of future fee negotiation settlement, that inclusion under Bill 2 makes you a pawn of the state, if you will. DR. G. DUNN: Absolutely.

Tuesday, 28 May, 1985 MR. D. ORCHARD: That's all the qu estions I think I have at the moment, Mr. Chairman. MR. CHA IRMAN: Are there any further qu estions for Dr. Dunn? Seeing none, on behalf of the committee, Dr. Dunn, I would like to thank you for coming today. Mr. Orchard on a point of order. MR. D. ORCHARD: Mr. Chairman, Dr. Dunn did not, I bel ieve, read into the record the proposed amendments, but they are tabled. Do those become part of the record of the committee? MR. CHA IRMAN: No, they would not. The record is only the spoken word . . . MR. D. ORCHARD: Mr. Chairman, could we give Dr.

Dunn the opportunity to go over his proposed amend ments? Obviously he's here making these amendments as part of his presentation. MR. CHA IRMA N: Dr. Du nn, could you read your proposed amendment into the record? DR. G. DUNN: Proposed amendment to Bill 2,

An Act to amend the Health Services Insurance Act. 1. By deleting the words "and any person rendering other health services to which this act applies by reason of an order made under

Section 97" from

Section 11 9(1) ; 2. By deleting the words "or other person who contravenes subsection (1) " from

Section 11 9(2); 3. By deleting the words "or other person" from

Section 11 9(3). MR. CHA IRMAN: Thank you, Dr. Dunn. ' Mr. Orchard . MR. D. ORCHARD: Ju st some qu estions to clarify. Basically, Dr. Dunn, in your opinion, and I'm asking you a legal opinion which you may not be at comfort to respond to, but is my understanding correct that those three proposed amendments only change the intent of Bill No. 2 in that they remove from the ban on extra billing those groups who are not affected by The Canada Health Act? DR. G.

DUNN: Yes, that's my understanding of this, and I'm sure the legal counsel for the government would obviously have to check into that, but this is the intent of this document. MR. D. ORCHARD: Thank you, Dr. Dunn. MR. CH AIRMAN: Thank you, Dr. Dunn. The next person on my list is Dr. George Habib. DR. R. WEINERMAN: I'm not not Dr. George Habib. He's not present here and I was wonde ring, Mr. Chairman, and the committee if I would be allowed to speak in his place as I have other commitments. I'm Dr. Wei nerman. MR. CH AIRMAN: Is that agreed? Could you give your name to the Clerk as well? 14 DR. R.

WEINERMAN: Yes, Dr. Rivian Weinerman. MR. CH AIRMAN: Excuse me, are you speaking for Dr. Weinerman , did you say? DR. R. WEINERMAN: I'm Dr. Weinerman. MR. CH AIRMAN: You're Dr. Weinerman. Okay. Pardon me, you would be speaking jus t once for Dr. Habib, as well as yourself? DR. R. WEINERMAN: I'm jus t speaking for myself. MR. CHA IRMAN: In place of Dr. Habib? DR. R. WEINERMAN: Yes. MR. CHA IRMAN: Is it your intention to speak again? DR. R. WEINERMAN: No. MR. CH AI RMAN: Okay. Mr. Orchard. MR. D. ORCHARD: In case there's any confusion, are you, Mr. Chairman, then saying that if Dr.

George Habib shows up later in this hearing that he would not be allowed to speak? You're not saying that? MR. CHA IRMAN: No, he would come at the end of the list. Mr. Steen. MR. W. STEEN: In all fairness, though, there are other names on your list that are in between. Should this doctor appear before the other names? DR. R. WEINERMAN: I have discu ssed with Dr. Shucke tt - the names above myself have agreed to allow me to speak in that order and they'd be moved down one. MR. CH AIRMAN: Okay, proceed. DR. R. WEINERMAN: Thank you very much. Mr.

Chairman, and members of the Committee, thank you for allowing me the opportunity to speak here. I'm a psychiatrist, and I'm here mainly as President of the Manitoba Psychiatric Association, a

section of the Manitoba Medical Association, and as a member of the Association of Independent Physicians. I would like to have you understand why my practice and many others will be permanently altered detrimentally by the passage of this bill. I would like you to try to imagine what I do when I practice psychoanalytically-oriented psychotherapy. A patient calls me up and says they would like to see me. I ask them if they know the type of psychotherapy I do and if they don't, I explain it to them and they decide if this is what they want.

If it is, I arrange a consultation with them explaining that my fee is more than what Medicare insures them for and that they must tell me what they can pay, but that I insist it must be something, because I believe in the principle of the

Tuesday, 28 May, 1985 patient assuming some financial responsibility for their therapy even if it is a few cents. This principle is very important in the work I do, because I work with people who have difficulty dealing with the realities of life and taking responsibility for their thoughts, feelings and actions. Thus, finances becomes an important, immediate, concrete issue for them to deal with. I work, for instance, with many older adolescents as well as adults.

Take, for instance, the theoretical case of older adolescents who are frightened of growing up, taking responsibility for themselves, determining what they want in their life as far as their studies are concerned, their relationships are concerned , their life separate from their parents are concerned . They fight at home and yet are terrified of being on their own. When they call me for help, they have to decide whether they want their parents to pay for their therapy or whether they will pay; a much less amount but it will be theirs, it will belong to them.

Most often what happens is they grab the chance of paying themselves, will determine often to enter the real world of work so that they can even try to meet my full fee. I would like to try to get it across to you the feeling of self-worth of a person who has had difficu lty being on their own has when they make the first moves of taking responsibility for themselves. Contrast this with their coming and their therapy being paid for by government.

This is also the situation, for instance, of many wives who are in seriously disturbed marriages and are terrified to leave and be on their own, who use their therapy as a first example to themselves of their ability to stand on their own. The situation is different, but just as important with people who really do not come because they want to, but because their husba nd, wife, teacher , parent, etc. want them to. Making a comm itment in financial terms helps them to decide whether they really want help or not.

Here they decide that even if someone else wanted them to come, they are the ones who will do it or not. In this situation, many people decide no and don't waste their time, gover nment money, and do not fool the mselves and others about what they are doing. Contrast this with not having to pay and going along for some time not intending to change at all, but ju st appeasing whoever wanted them to come. If you ban private billing, you are rea lly interfering in the type of medicine I practice. You are seriously intruding into what I believe to be a very important therapeutic tool.

The patient also knows the cost of his treatment because he receives my bill, receives the cheque s from the government and pays me directly, very different from invisible payments of which he is unawares. With the therapy I do and others like me, you are not going to get any abuse of government monies. You ma y get more emp loyment, mo re people taking responsibility for themselves and taking productive roles in our society. I am going to lose about 25 percent of my income. I cannot increase the numbers of patients I see per hour, because psychoanalytically-oriented psychotherapy involves one patient per hour.

Yet, I would prefer to take a drop in government reimbursement and not lose the right to private bill than to lose this important tool and receive a raise in government pay. My husband has opted in and salaried. He is chief oncologist at St. Boniface Hospital. He supports the 15 right to private bill for the type of therapy I do and for other very important reasons. He is very concerned about the lack of government money available for the advances in therapy and technology coming in cancer therapy.

He, like myself, does not yet know the answer, but knows clearly that closing Medicare to any new monies means spending the same amount of money in spite of advances. lt means that people in this province won't be able to get the advances. lt means equal, mediocre care, not the excellent care Manitobans have been used to. I believe that private billing should be allowed and I am not at all against some enforcement that states that no patient can be turned away because of money. lt is my experience that payment of any amount even for the weal thy is fra ught with decisions as to commitment and priority. Thank you.

MR. CHA IRMAN: Are there any qu estions for Dr. Weinerman? Mr. Orchard. MR. D. ORCHARD: Dr.

Weinerman, you've raised a rather -I'm looking for the right kind of word -unique side to extra billing as it applies to some of your more youthful patients; patients who, if I understood your presentation, are wrestling with the outside world and the entry into the outside world and the first coming to grips with reality of being on their own and independent citizens is coming up with a fee, whatever it may be, to pay yourself in addition to the Medicare prescribed fee and the loss of that -if I could be so bold as to paraphrase it -probably coins the adage that when a service is for free, you don't value the service.

That's a very unique proposition you've put to the committee this morning as to the value of extra billing in making the patient appreciate the worth and make a conscientious decision that it is worth that to him or her to undertake and makes them come to grips more qu ickly with the realities of the real world. DR. R. WEINERMAN: Yes. MR. D. ORCHARD: Now, Mr. Chairman, are you saying that loss of that will make your ability to assist, particularly those youthful patients, will it make your ability to help them less, in your professional opinion? DR. R.

WEINERMAN: Yes, I believe that it will really interfere with a tool that I use that is extremely potent, not only with my young patients, but with patients all the way - I have patients in their late fifties, who I treat with this type of therapy, and in those cases the theme is the same.

For instance, people who may have lost a job and are helpless and hopeless and give in to drink or to withdrawal from taking responsibilities in society and when they do decide to come for help and then they do also have to deal with this primary -important in our society -responsibility, then those people, also they're in their late fifties, but they determine whether or not they're going to pay money for their alcohol or get into the employment scene again or do what they have to in order to take responsibility for their therapy,

Tuesday, 28 May, 1985 to have their therapy. So it's a very important tool for all the way across all the age ranges. MR. D. ORCHARD: Mr. Chairman, making the assumption that Bill No. 2 passes and you won't be able to use that extra billing as the initial therapy, if you will, what are you going to replace that with in a professional way to assist your patients in the same method that obviously you're assisting them now? DR. R. WEINERMAN: I don't know. This is an extreme dilemma for me.

I have options of saying, well, I cannot do the type of therapy that I do in this way, in this province; or ther e is the option of opting out of the system totally and being able to charge my patients directly and deal directly with them. I have thought of things like -right now I can treat a broad spectrum of patients. I have a patient pay me 85 cents per session. I can treat all kinds of patients from all strata of society.

If I decide to get out of the system because I can't do what I do with those kinds of limitations, then I have decided with the patients I have, I will continue to charge them just what I private bill them for right now until their therapy with me is terminated. So I'll have to go through a kind of lax period as far as my income is concerned - I have the luxury of not being the only income earner in my family -but I'll have to go through that period until I build up a practice of patients who can afford my full fee and that, to me, is creating a two-tier system.

Right now because I extra bill, I can treat all range of people with my wealthier patients subsidizing my poorer patients. MR. D. ORCHARD: Dr. We inerman, un der the provisions of this act, the method of practice that you've jus t described would only be possible providing you did not exceed the fee

schedule as prescribed. DR. R. WEINERMAN: Okay, if I decide to stay in Manitoba and that's that law, I'll have to do that, but at least I will be able to practise the type of therapy that I practise and tha t I think is worthwhile. MR. D. ORCHARD: Then just one more qu estion. You might envision -and I ju st want to make sure I get it correctly - a new practice wherein you will be an opted­ out psychiatrist, only charg ing the prescri bed fee

schedule and it's up to your patient whether they wish to bill MHSC for the services or otherwise. DR. R. WEINERMAN: They wouldn't have the option to do that, I don't think. MR. D. ORCHARD: Yes, I believe they would. DR. R. WEINERMAN: That I could opt out? MR. D. ORCHARD: And the way I understand it you could opt out . . . DR. R. WEINERMAN: Yes, but . . . MR. D. ORCHARD: . . . charge the fee

schedule that is prescribed and your patient would have the option of reimbursement from MHSC or not. 16 DR. R. WEINERMAN: No that's not - I can't see that option for myself, where I would opt out and the patient would get paid by the government the full amount, and not have to be responsible financially themselves at all. What I mean is -and maybe I'm misunderstanding, maybe I won't be able to do this under the act -is getting out of Medicare, practice privately, and say I won't charge more than what the govern ment is saying, but at least it's between me and my patient and that tool is maintained for me.

If I can't do that, I have no options. MR. CHA IRMAN: Are there any further questions? Mr. Orchard. MR. D. ORCHARD: Mr. Chairman, now I believe from the circu mstance you described, your intention is that you would charge your patient, a new patient, say, after the proclamation of Bill No. 2, you would opt out of Medicare as a physician? DR. R. WEINERMAN: Yes. MR. D. ORCHARD: And you would charge your patient -you would only be able to charge them the prescribed fee schedule, because anything in excess, you would be subject to ... DR. R. WEINERMAN: Yes, a fine or jail. MR. D. ORCHA RD: ... jail or $1 ,000 or a

summary conviction on either one of them, which is a very convenient method of conviction -that's not the issue we're at right now -but I believe that your patient would still have the ability to bill the Manitoba Health Services Commission for the prescribed fee

schedule for the services you perform. DR. R. WEINERMAN: Okay, then part of my agreement with my patient would be that they would not do that. MR. D. ORCHARD: Well, then I think, Mr. Chairman, we might be back to Mr. Green's regulation of another regulation to prevent you from doing that. DR. R. WEINERMAN: I understand that. MR. D. ORCHARD: Mr. Chairman, this is an area that I have no kno wledge of, psy choth erapy and psychoanalysis, but obviously the doctor considers her method of billing to be as valuable as almost anything you can do for your patient. Is that correct? DR. R.

WEINERMAN: I have seen people come in totally disorganized in their thinking, in their way of relating, having to organize their thoughts and their dealings with reality in order to meet the few cents or whatever, to be able to pay for the therapy that they own, and as I say, I have a patient that pays me 85 cents. MR. D. ORC HARD: So then it's fair to say, and I believe I'm correct in what I've described to you, in terms of how your practice would operate, I think this legislation disallows you completely from doing that.

Tuesday, 28 May, 1985 DR. A. WEINERMAN: You are really interfering in a way that I have no options to be able to practise the type of practice that I practise here. MR. D. ORC HA RD: And just a final que stion and comment, that it is that method of practice, from your professional experience, that has been probably the single most beneficial thing you could do for your patients. DR. A. WEINERMAN: For Manitoba, yes. This is what I am good at. This is what I offer and this is what my patients benefit from. MR. D. ORCHARD: Then, Mr.

Chairman, that is what has been success ful in your ability to help Manitobans and that's being denied by this legislation. DR. R. WEINERMAN: Yes. MR. D. ORCHARD: Thank you, Mr. Chairman. MR. CH AIRMAN: Are there any further qu estions? Mr. Scott. MR. D. SCOTT: Thank you, Mr. Chairman. Dr.

Weinerman, is it my understanding, and I've only got the dialogue that we 've had here in the last few minutes, that the focus of your practice in psychotherapy with your patients is that you feel the most important part of that practice is for those individuals to be able to decide that they are going to pay you a certain amount of fee for your services. DR. R.

WEINERMAN: No, the focus of the type of therapy I do is for a patient to take responsibility for their thoughts and their feelings and their actions; and money, in our society, in the civilized world, is a very concrete tool that one cannot avoid and can use as it's the first thing that comes up and it is extremely a strong tool to begin that work.

So immediately, from the first outset, the patient is dealing with taking responsibility for what they want, for what they do, even if it's telling me -and this is not something that I que stion them on -their word is taken, I can afford to pay you $5, a dollar, whatever it is, and I say, fine. MR. D. SCOTT: Dr. Weinerman, you say that money is, I guess in other words, a focus of your practice in deciding what the fee is and one of the initial discussions of what they shall participate with you in the decision of what the fee making is, with the primary responsibility given to your patient.

Are you telling us that other forms of expenditures, through their life, if you want to use a monetary-based, I gue ss, therapy, that it has to be focu sed around a fee paid to yourself versus payments that they may make in actually working with you in your office, of financial decisions that they have to make themselves, be it perhaps the, it could even be the paying of certain bills, it could be the making out of family budgets or a portion or a small fraction of perhaps a family budget of what they're going to spend this week on such and such goods. 1 can see using that sort of therapy on an awful lot of items of daily necessity that are very much in the 17 phraseology that's been used here today in the so­ called real world; and I don't see why your practice of medicine, or at least I don't understand that your practice of medicine would be severely hampered if the decision-making was on financial matters other than the fee being paid to you, because they also have to make other decisions of whether or not they're going to enter into agreements or enter into purchase new items or pay bills, whatever.

DR. R. WEINERMAN: I do psychoanalytically-oriented psychotherapy. This is the type of therapy that aims to help a person in their understanding of why they think the way they think, why they feel the way they feel, why they do what they do that has got them into trouble; otherwise, they wouldn't have come to me in the first place. They have problems functioning ih these areas, so my therapy has not got to do with any kind of counsel ling as far as how they should work their budgets or any of the other things you're talking about.

My therapy has got to do with dealing with them in depth around these issues, taking responsibility for their thoughts, feelings and actions and understanding why they behave and think and feel the way they do.

Mone y, the fee , is some thing they can -that's happening between me and them right there, and they can take that experience and that understanding of how they're dealing with me in that interaction, as well as in any other interaction; and the idea that they would then be able to take that and generalize it to all their other financial resp onsi bilities, because that's immediate, that I know, that I can see, that I can deal with directly, that I don't have to guess about, that I don't have to do anything. lt's right there for me to see and to understand and to help us both look at what's going on and then they can take that. lt works that way in therapy and take that out there and deal with the rest of their lives, generalizing from what's going on here. lt's extremely powerful, because it cannot be denied. lt's happening right there.

MR. D. SC OTT: Then you'r e saying you cannot su bstitute that for something other than a fee, that the whole basis of your psychoanalytic practice is based upon your fee, as the focal point started off. I just, I gue ss, find it difficult. · DR. A. WEINERMAN: Maybe I can make it clear this way. MR. D. SCOTT: I think you're making it clear. DR. R. WEINERMAN: No, I think there's an aspect, if I can be allowed, that I'd like to address.

My practice is not based all around my fee. lt's the first thing that goes on, so right there, also people who really don't want interest and unde rstanding themselves, who really do not really examine with themselves whether or not they want to do this, can also use that as a way of testing themselves and saying, no, this is not what I'm interested in, this is not what I want to make a commitment to, I have other things that I want to make priorities and commitments and I don't want to do this. So it is not just that that is taken and everything is ·centred all around that for the

Tuesday, 28 May, 1985 rest of their therapy. it's an immediate concrete way of patients deter mining whether or not they are responsible, whether or not they want to take ownership of this type of therapy and whether or not they want to go for it and make this kind of commitment and so on. MR. D. SCOTT: Thank you. MR. CHAIRMAN: Are there any further qu estions? Mrs. Oleson. MRS. C. OLESON: Dr. Weinerman, do you have any idea how many other physicians would be in the same position as you are? DR. R. WEINERMAN: There are 24 of the 85 psychiatrists, 83 or 85 psychiatrists in this province are opted out.

Most of those are the psychoanalytically­ oriented psychotherapists like myself. So, these are the people mostly that are in this kind of position. MR. CHAIRMAN: Mr. Enns. MR. H. ENNS: Thank you, Mr. Chairman. I really wish to ask a qu estion of the Minister and his staff in the presence of this expert witness. MR. CHAIRMAN: Order please. This is not the time to be debating among the committee the merits of specific arguments that will come later. The qu estion period is used for qu estions from the members of the committee to the witness. MR. H. ENNS: Mr.

Chairman, I'll direct my que stion to the witness. lt bothers me a little bit, Mr. Chairman, that you're applying such rigidity to the informality of this committee. Having listened to Dr.

Weinerman, and I have no cause to take issue with how she practices her profession, but she has made it plain to all of us with perhaps the exception of the Member for lnkster that she regards this physical act of making a contribution on the part of her patient as being, not all-important, but an important step of her psychotherapy. lt's obvious to us that you feel very strongly about that. it's my understanding of the act that if you still wish to proceed and practise in that way but woula instruct the patient to pay the $5, the $1 or the $20 to the United Way or to the Red Cross, would that still do what you're trying to do in terms of bringing reality to those patients?

Except I believe this legislation would prevent you from doing it -this is why I wanted to ask the ques tion of the Minister and while his staff is here. What I'm trying to get at is to accommoda te your method of practice which calls for some contribution on the part of your patient; the act is preventing you from receiving it, but you're telling us as a professional person that it's important in the manner and way in which you carry out your work that a contribution be made. I'm suggesting that contribution could not even be made some charitable organ ization such as the Red Cross or Un ited Way . . . DR. R.

WEINERMAN: Yes, I hadn't thought of it. 18 MR. H. ENNS: . . . which may help you in carrying out your practice but this act, as I understand it, would not allow that to happen. Is that right, Mr. Minister? Are you opposed to the Red Cross, United Way? MR. CH AIR MAN: Order please, order please. DR. R. WEINERMAN: As I understand it, that's a fact. MR. H. ENNS: Thank you. MR. CHAIRMAN: Mr. Orchard . MR. D. ORCHA RD: Mr. Chairman, just one more qu estion. Dr. Weinerman, are you at liberty to indicate how many of your patients would be affected by the passage of this legislation and the restriction on your ability?

If you're not at liberty to share that with the committee, then by all means . . .. Is that a substantive number? DR. R. WEINERM AN: All my patients. I work approximately 40 hours and that involves 40 patients per week. MR. CHA IR MAN: Are there any further qu estions for Dr. Weinerman? DR. R. WEINERMAN: I see 40 patients per week but it's ongoing therapy, so it's 40 patients until I terminate with those patients and those patients always are replaced by others. MR. CH AIRMAN: Mr. Harper. MR. E.

HARPER: Yes, I just wanted to express my appreciation for your comments in regards to the therapy in one-to-one personal contact with the person. I'd jus t like to make that known that I've heard what you said. I ju st wish that you could do psychoanalysis with the Federal Government and make them aware of the realities. DR. R. WEINERMAN: Thank you. MR. CHAIRMAN: The Minister of Health. HON. L. DESJARDINS: I just want clarification, if I may, from the doctor. The doctor is saying that she sees approximately 40 patients per week.

Would that be the same patients every week or approximately the same patients every week or what? DR. R. WEINERMAN: No. Those are ongoing therapies. HON. L. DESJARDINS: What's the average a month that you would see your pa tients? DR. R. WEINERMAN: I do psychoanalytically-oriented psychotherapy so I deal mostly with patients who have personality disorders. They're maladaptive functioning in terms of the way they perceive and interact with their environment, so these are long-term difficulties in coming and the therapy is long-term, so I work with them over a long period of time.

Tuesday, 28 May, 1985 HON. L. DESJARDINS: That's my que stion. How many times approximately? DR. R. WEINERMAN: That's what I tried to clarify. HON. L. DES JARDINS: How many times then approximately a month or a year are the patients seen? The average, jus t the average. DR. R. WEINERMAN: Oh, I see my patients twice a week. HON. L. DESJARDINS: The same patient twice a week? DR. R. WEINERMAN: Twice a week. HON. L. DESJARDINS: Twice a week every way. DR. R. WEINERMAN: Yes. MR. CHAIRMAN: Are there any further qu estions? Seeing none, on behalf of the commit tee, Dr.

Weinerman, I would like to thank you for coming today. The next person on my list is Dr. Paul Shucke tt. I would note, Dr. Shuc kett, that the usual time for adjourning the committee is 12 :30. I don't know if that will mean anything to your presentation, but . . . DR. P. SHUCK ETT: Well, we may run over. Shall I stop now and start some other time? MR. CHAIRMAN: Pardon, I couldn't hear you. DR. P. SHUCK ETT: Do you wish to meet some other time? MR. CH AIRMAN: Tha t would be the will of the committee. MR. D. ORCHARD: Mr. Chairman. MR. CHAIRMAN: Mr. Orchard . MR. D. ORCHARD: If Dr.

Shuckett's presentation would take more than the nine minutes that are available to us and he was able to come back at the next scheduling of this hearing, it probably would be better for his presenta tion, but if he's only available toda y - (Interjection) - DR. R. SHUCK ETT: When would the next session be? MR. CHAIRMAN: The next session would be -it's not scheduled at the moment. lt would be at the call of the Chair. MR. D. ORCHARD: There are other committees though on Thursday. DR. R. SHUCK ETT: lt would seem to me if I spoke now and qu estioned later, the train of thought would be lost. MR.

CHAIRMAN: Are there any people here today who would be able to make their presentation in 10 minutes? I see one. 19 Could you identify yourself please? DR. P. LONGSTAFFE: I'm Dr. Pia Longstaffe, I'm the last on the list. Good morning, Mr. Chairman, Mr. Minister, and members of the committee. I'm speaking to you today not as a representative of any group but as a member of the Ma nitoba Chiropract ors' Associa tion. I'm speaking as an opted-out chiropractor, one of the seven chiropractors that this Bill 2 will directly affect.

Now, you might rightfully say, so what if seven chiropractors have to go through some economical changes in the near future? I'll have to agree that it's no big deal for the total picture of health care in Manitoba, but there's a much greater concern that I have as a chiropractor, that of the future of the chiropractic profession. The passing of Bill 2 will remove any safety valve tha t the profession has in its deal ings with the government. What I mean by this is two-fold. First of all, the options of opting out and extra billing can be used as a negotiation tool.

Any negotiation always is a power play and if Bill 2 gets passed, the Chiropractic Association will be rendered powerless and all the power will be in the hands of the government, since they haven 't even offered any binding arbitra tion. Our negotiations are not only for ourselves, but also for the patients that we have since they are not fully covered, and any future coverage for them will be dependent on our efficiency to negotiate. We have greatly fallen behind as far as inflation is concerned .

Since 19 69 inflation has been 207 percent and the fee of chiropractors have increased only about half of the inflation, to that of 10 4. Now this is with the so-called safety valve in place. If this trend continues, the profession cannot possibly survive. The hardest hit will be the new chiropractors, the future growth of the profession, since they have to pay student loans in addition to setup cost in covering their daily overhead. Secondly, the act of opting out in extra billing is a safety valve when the gap between fee increases and inflation becomes too severe.

The profes sion has survived this far by becoming busier, seeing more patients and working longer hours, but this is self­ evident that this is not a lon g-term sol ution to inadequa te fees. Having said this I would like to suggest for the future protection of the chiropractic profession that Bill 2 be amended to exclude the chiropractic profession. Now when I was listening to some of the qu estions, there were a few interesting points that came up, I thought. I have, as I said, been opted out, but I can say that if patients have not been able to afford my services, I have never turned anybody away.

I have always been more than happy to give a reduced rate and 25 cents is jus t fine, if that's what they can afford. But I will also have to agree that there is a merit if people are paying. lt makes them much more willing to comply with what you recommend for them to do. The chiropractic treatment is not jus t the adjus tment in the office. There is also certain things that the patient can do themselves that will facilitate the healing, and because there's a monetary exchange involved, they seem much more willing to listen to the recommendation that you are giving them.

TUesday, 28 May, 1985 Thank you. MR. CHAIRMAN: Are there any qu estions for Dr. Lon gst affe? Seeing none, then on behalf of the committee, Dr. Longstaffe, thank you for coming today. DR. P. LONGSTAFFE: Thank you. MR. CHA IRMAN: Are there any further brief presentations? Yes. DR. W. LONGSTAFFE: I'm Dr. Wayne Longstaffe. MR. CHAIRMAN: Okay. DR. W. LONGSTAFFE: Good morning, Mr. Chairman, Mr. Minister, and members of the committee. I am a chiropractor presently practising in Steinbach with my wife, who we jus t heard.

I am proud to be a member of this profession and like other chiropractors and health-care professionals, I am dedicated to maintaining an increasing wellness. I'd like to give a bit of background here about the profession. The chiropractic profession has fought long and hard for the gains we have made for our patients and ourselves and the position we now hold as primary chiropractitioners. The profession is growing at a rapid rate, as the needs of the patients we serve increase.

The four-year, 5,000 hour course is begun after a minimum of two years university, with most students entering with Bachelors and Ph.D degrees. In order to meet the growth of public need, colleges now exist in Toronto; there's 16 in the U.S.A.; two in Japan; two in Australia; one in Great Britain; and most recently in France. There are prese ntly mor e than 60,000 chiropractors and chiropractic students world-wide.

Chiropractic, because of a success in a variety of health problems and maintenan ce, has received significant public acceptance and enjoys the distinction of being the second largest general health profession, after allopathic medicine in the world. In Manitoba, there is an increase of approximately 6,000 to 10 ,000 users per year and 14 percent of the population sought chiropractic care in 19 84. Having given this backg round, I find it even more difficult to comprehend why this profession is being so severely penalized by being included in Bill No. 2.

As my submission continues, we will look at the reasons given. I am here today to defend my rights as an individual, and as a chiropractor, to have some say before you pass sentence on my profession and myself. I say pass sentence, because through Bill No. 2, in its present form, you are truly passing a sentence that denies this profession its inalienable rights to a fair negotiating process. In essence, we have been expropri ated by the government with no compensation.

The right to opt out and bill for the worth of the service, or in simpler terms, the right to disagree with MHSC, will effectively evaporate, and the little bargaining power that we possess and any protection from abuse is gone. The present confines of Bill No. 2 will also serve to effectively reduce the number of new chiropractors 20 needed in this province to meet the demand for services.

Wha t safeguards of adeq uate fee increases through negotiation are in place for a new graduate with a debt of over $1 00,000 by the time he opens his office door? lt was difficult in the past to negotiate with MHSC over patient limits, X-ray coverage, fees and the like. Under Bill 2, it will soon be impossible. There is no need for MHSC to negotiate in earnest if the chiropractors are included in Bill No. 2. There will be no checks and balances. All the power will be on one side, a dictatorship. Why? What are the reasons for inclusion? As Dr.

Dunn stated earlier, on behalf of the Manitoba Chiropractors' Association, it is not because of a loss of federal funds, because chiropractic is not included in The Cana d a He alth Act. Is it because of the universality motive? No, because chiropractic care has limited coverage anyway and the patient must pay entirely after these limits are exhausted. Is it because the Minister wishes all things equal? That is, no profession to have extra billing privileges.

If this is so, then in all due respect to the Minister, he has closed his eyes and does not see or does not wish to see the greater inequity that will exist, because the medical profession has not lost a method of achieving reasonable negotiated demands in this case through binding arbitration, which itself was negotiated with the present government. The last reason is, as cited by the Minister on introducing Bill No. 2 on March 20, 19 85. That was also mentioned by Dr. Dunn, and that is for administration purposes.

Let me say that if this is true, then it is a sad day to have an entire profession effectively neutered in order to facilitate administrative ease. I also would like to add a few more points to what my wife was saying earlier to as well before I conclude. We are both opted out of the plan. We opted out in 19 82. We have worked under the plan, as well as worked out of the plan. There are different techniques and different ideas in chiropractic as there are in other medical specialities.

Some of them take longer than others, some demand more time, as I said, and there is a limited number of patients you can see over a certain period of time. There is more than just an adjustment in the office as was also mentioned. There is intensive care with nutritional counselling; there's exercise programs, and other things to get the patient back on their feet. There's also with back problems, as anyone here who has had a back problem, psychological overtones that can also increase the patient's pain and dependability. These are all cared for in our practises.

We have a limited number of patients a day, as I say, and to continue to within the fee schedules, as it is presently written and practised the way we wished to, was ve ritably impossible, so we decided to opt out of the plan. We've also found, working in the plan and out of the plan, that there is better control of the patient, and I hate to say this, but sometimes getting better is not adequa te enough compensation for a patient to follow advice.

Sometimes if they realize that this is going to cost them a certain amount of money, they tend to pay more attention to what you're saying, and how you're trying to run their particular health regimen, and this has been proven to me over and over again in a number

Tuesday, 28 May, 1985 of cases. If it's for free. there's an invisible hand coming out and th