Manitoba Committee Hansard — 3 July 2001 (Management Commission Committee, Sitting 4, 37th Legislature, 2nd Session)

37-2-ma4

Manitoba — Debates (Hansard)

Second Session -Thirty-Seventh Legislature of the Legislative Assembly of Manitoba Standing Committee on Municipal Affairs Chairperson Mr. 1hm Nevakslwnojf Cmrstituency of Interlake Vol. LI No.4- 6:30p.m., Tuesday, July 3, 2001

Member AGLUGUB, Cris ALLAN, Nancy ASHTON, Steve, Hon. ASPER, Linda BARRETT, Becky, Hon. CALDWELL, Drew, Hon. CERILLI, Marianne CHOMIAK, Dave, Hon. CUMMINGS, Glen DACQUA Y, Louise DERKACH, Leonard DEWAR, Gregory DOER, Gary, Hon. DRIEDGER, Myrna DYCK, Peter ENNS, Harry FAURSCHOU, David FRIESEN, Jean, Hon. GERRARD, Jon, Hon. GILLESHAMMER, Harold HEL WER, Edward HICKES, George JENNISSEN, Gerard KORZENIOWSKI, Bonnie LA THLIN, Oscar, Hon. LAURENDEAU, Marcel LEMIEUX, Ron, Hon. LOEWEN, John MACKINTOSH, Gord, Hon. MAGUIRE, Larry MALOWA Y, Jim MARTINDALE, Doug McGIFFORD, Diane, Hon. MIHYCHUK, MaryAnn, Hon.

MITCHELSON, Bonnie MURRAY, Stuart NEVAKSHONOFF, Tom PENNER, Jack PENNER, Jim PITURA, Frank PRAZNIK, Darren REID, Daryl REIMER, Jack ROBINSON, Eric, Hon. ROCAN, Denis RONDEAU, Jim SALE, Tim, Hon. SANTOS, Conrad SCHELLENBERG, Harry SCHULER, Ron SELINGER, Greg, Hon. SMITH, Joy SMITH, Scott, Hon. STEFANSON, Heather STRUTHERS, Stan TWEED, Mervin WOWCHUK, Rosano, Hon. MANITOBA LEGISLATIVE ASSEMBLY Thirty-Seventh Legislature Constituency The Maples St. Vital Thompson Riel Inkster Brandon East Radisson Kildonan Ste.

Rose Seine River Russell Selkirk Concordia Charles wood Pembina Lakeside Portage Ia Prairie Wolseley River Heights Minnedosa Gimli Point Douglas Flin Flon St. James The Pas St. Norbert La Verendrye Fort Whyte St. Johns Arthur-Virden Elmwood Burrows Lord Roberts Minto River East Kirkfield Park Interlake Emerson Steinbach Morris Lac du Bonnet Transcona Southdale Rupertsland Carman Assiniboia Fort Rouge Wellington Rossmere Springfield St. Boniface Fort Garry Brandon West Tuxedo Dauphin-Roblin Turtle Mountain Swan River Political Affiliation N.D.P. N.D.P. N.D.P. N.D.P. N.D.P. N.D.P. N.D.P. N.D.P. P.C. P.C. P.C.

N.D.P. N.D.P. P.C. P.C. PC . P.C. N.D.P. Lib. P.C. P.C. N.D.P. N.O.P. N.D.P. N.D.P. P.C. N.D.P. P.C. N.D.P PC . N D.P N.D.P. N.D.P. N.D.P. P.C. P.C. N.D.P. P.C. P.C. P.C. P.C. N.D.P. P.C. N.D.P. P.C. N.D.P. N.D.P. N.D.P. N.D.P. P.C. N.D.P. P.C. N.D.P. P.C. N.D.P. P.C. N.D.P.

13 7 LEGISLATIVE ASSEMBLY OF MANITOBA THE STANDING COM MITTEE ON MUNICIPAL AFFAIRS Tuesday, July 3, 2001 TIME- 6:30 p.m. LOCATION- Winn ipeg, Manitoba CHAIRPERSON - Mr. Tom NevakshonofT (Interlake) VICE-CHAIR PERSON Schellenberg (Rossmer

e) Mr. Ha rry ATTENDANCE -11 - QUORUM -6 Members of the Committee present: Hon. Ms. Barrett, Hon. Mr. Chomiak, Hon. Ms. Mi hychuk, Hon. Mr. Sale Mr. Derkach, Mrs. Driedger, Messrs. Loewen, Nevakshonoff, Schellenberg, Struthers, Tweed APPEARI NG: Hon. Jon Gerrard, MLA for River Heights Mr. Darren Praznik, MLA for Lac du Bonnet WITNESSES: Bill 25-The Health Services Insurance Amendment and Consequential Amend ments Act Mr. Cory Sui, Private Citiz en Mr. Robert Chemomas, Canadian Centre for Policy Alternatives Mr. Albert Cerilli, President, Manitoba Federation of Union Retirees Ms.

Margot Lavoie, Manitoba Obla te Justice and Peace Committee Mr. Thomas Novak, Manitoba Ob late Justice and Peace Committee Ms. Carolyn DeCoster, Private Citizen Ms. Madeline Boscoe, Women's Health Clinic Ms. Carol Scurfield, Women's Health Clinic Mr. Paul Moist, Canadian Union of Public Employees Ms. Lorraine Sigurdson, Canadian Un ion of Public Employees Bill 50-The Regional Health Authorities Amendment (Accountability) Act Ms. Heather Temple, CEO, Mid dlechurch Home of Winnip eg Mr. Mi chael Doiron, Interfaith Healthcare Association of Manitoba Mr. Raymond Lafond, Catholic Health Association of Manitoba Mr.

Real Cloutier, Winnip eg Regional Health Authority WRITTEN SUBMISSIONS: Bill 25-The Health Services Insurance Amendment and Consequential Amend ments Act Ms. Linda West, Private Citiz en MATTERS UNDER DISCUSSION: Bill 25-The Health Services Insurance Amendment and Consequential Amend ments Act Bill 28-The Labour-Sponsored Investment Funds (Various Acts Amended) Act Bill 50-The Regional Health Authorities Amendment (Accountability) Act *** Mr. Cha irperson : Good evening. Will the Standing Comm ittee on Municipal Affairs please come to order.

This .evening the committee will be considering the following bills: Bill 25, The Health Services Insurance Amendment and Consequential Amendments Act; Bill 28, The Labour-Sponsored Investment Funds (Va rious Acts Amended) Act; and Bill 50, The Regional Health Authorities Amendment (Accountability) Act.

13 8 LEGISLATIVE ASSEMBLY OF MANITOBA July 3, 200 1 We have presenters registered to speak to both bills. Is it the will of the co mmittee to hear public presentations on these bills first? [Agreed] I will then read the names of the persons who have registered to make presentations this evening.

For Bill 25: Cory Sui, private citizen; Robert Chemomas, Canadian Centre for Policy Alternatives; Albert Cerilli, President, Manitoba Federation of Union Retirees; Mi chelle Forrest, private citizen; Paul Moist, President, Canadian Union of Public Employees; Margot Lavoie and Brother Thomas Novak, Mani toba Obla te Justice and Peace Committee; Carolyn DeCoster, private citizen; Madeline Boscoe and Barbara Wiktorowicz, Women's Health Clinic.

On Bill 50, we have Mi chael Doiron, who is going to be speaking for Suzanne Dunwoody, of the Interfaith Healthcare Association of Manitoba; Raymond Lafond, who is going to be speaking instead of Francis Labossiere, of the Catholic Health Association of Manitoba; Andrew Ogaranko of Pitblado, Buchwald & Asper; Heather Temple, CEO, Middlechurch Home of Winn ipeg; and Real Cloutier of the Winnip eg Regional Health Authority. On Bi11 28, we have no presenters. Is there anybody else in the audience who would like to make a presentation and has not yet registered? You may do so with the staff at the back of the room.

For the information of presenters, please be advised that 20 copies of any written versions of presentations would be appreciated. If you require assistance with photocopying, please see our staff at the back of the room. I would like to inform the committee that a written submission on Bill 25 has been received from Linda West, private citizen. Copies of this brief have been prepared and distributed to committee members. Is it the will of the committee for this written submission to appear in the co mmittee transcript for this evening? [Agreed] We have two out-of-town presenters in attendance this evening.

Is it the will of the committee to hear from these presenters first, and in what order does the committee wish to hear the remaining presenters? Mr. Stan Struthers (Daupbin-Roblin): Mr. Chair, I would suggest that we do, in fact, hear the out-of-town presenters first and that we begin with Bill 50. [interjection] Okay, I suggest then we continue on with Bi ll 25, seeing as we already have one presentation put forward on Bill 25, I will get my numbers straight yet, and then move on to presenters on Bill 50, followed by clause-by-clause on all those bills after we have heard from presenters. Mr.

Chai rperson: Is what has been proposed acceptable? Is that the will of the committee? [Agreed] How does the committee propose to deal with presenters who are not in attendance today but have their names called? Shall these names be dropped to the bottom of the list and then dropped from the list after being called twice? [Agreed] Is it the will of the committee to set time limits on presentations? Mr. Struthers: Mr. Chair, I would suggest that we follow standard practice on these com mittees, 15 minutes for presentations, 5 minutes for questions and answers, take it as 20 minutes altogether.

If a presentation exceeds the 15 minutes, then I think it is understood that that time would come out of the 5 minutes of questions and answers, for a grand total of 20 minutes per presentation. Mr. Chair person: Is that the will of the committee? Mr. John Loewen (Fort Whyte): Well, it may be the policy of the members opposite to limit presentations. I would not say that we concur with that, just for the record. I would disagree, if somebody has reached their 15 minutes of presentation time, if it is the will of the committee to let them finish, that should not impact on the question time.

So at 15 minutes, we should either agree that we will allow the presenter to quickly finish or cut the presenter off and accept his written-but we should, in all

July 3, 200 1 LEGISLATIVE ASSEMBLY OF MANITOBA 13 9 circumstances if we want to, have five minutes of questioning. Mr. Struthers: Mr. Chairman, what I did describe has been the practice we have used in this committee for every bill we have looked at this spring and for every bill that I remember from last spring, and going back to days when I sat on that side of the table in opposition. That is standard procedure in this committee. It has worked well. I want to make sure that everyone has a chance to present in a timely fashion and have their say on these bills.

My strong recommendation would be that we go 15 for presentations, 5 minutes for ques tions and answers, and if a presentation does go over that IS-minute mark, that we do afford the leeway of using some of that 5-minute question and answer for the presenter to finish making their presentation. Mr. Chai rperson: Is that the will of the committee? [Agreed] Fin ally, as a courtesy to the individuals on our list waiting to present, are there any suggestions as to how late the committee should sit this evening? Mr.

Struthers: I would suggest that we hear all of the presentations tonight, and then do the clause-by-clause analysis once we hear the presenters and not worry about a time limit just now. Mr. Cha irperson: Is that the will of the committee? [Agreed] Bill 25- The Health Services Insurance Amendment and Consequential Amendme nts Act Mr. Chai rperson : On Bill 25, I now call upon Cory Sui, private citizen. Mr. Sui, do you have a written copy of your brief for distribution to the committee? Mr. Cory Sui (Private Citizen): Yes, I do. Mr. Chai rperson: Please distribute it. The page will take it from you.

Proceed when you are ready. Mr. Sui: Thank you for the time to allow my input regarding Bill 25. At first, I was not sure if I was going to make this presentation. However, reading today's paper convinced me that it was the right thing to do. As you are now aware, my name is Cory Sui, and I am a front-line provider in our health care system. I am a children-oriented dentist who provides care to over 4000 Manitobans from across the province through my private practice in East Kildonan and Concordia Hospi tal. I also am trained for, regulatorily authorized to and do provide pediatric dental surgeries.

For almost four years, I used to provide my services in the northern community of Churchill. However, I stopped going because of the Government's treatment of my patients in the Winnipeg Region. I recognize that, unfortu nately, I may offend some by my presentation today. While God has given me many talents for which I am grateful, he never gave me the ability to pacify egos. I am here today to point to the importance of proper governance and adm inistration of bills. There is more to good government than just passing bills and starting new programs.

This Government loquaciously promotes the Canada Health Act yet, in practice, violates the very principles understood by Manitobans to be contained within. Bold statements without action are unimportant. In the words of Lech Walesa: The supply of words in the world market is plentiful but the demand is falling. Let deeds follow words now. From Mother Teresa: There should be less talk; a prea ching point is not a meeting point. What do you do then? Take a broom and clean someone's house. That says enough.

The purpose of Bill 25, at least according to the Government's press release of May 23, 2001, is to strengthen and preserve universal access to health care and ensure that the principles of the Canada Health Act are upheld. Using the definition: Insured services are services covered under medicare, as supplied in the aforemen tioned government document, today in Manitoba this Government is denying Manitobans due

140 LEGISLATIVE ASSEMBLY OF MANITOBA July 3, 2001 access to medically necessary health care and subverting the principles of the Canada Health Act. Pediatric patients, medically requirin g the Manitoba medicare covered services of an anesthetist during dental treatment, are being denied allotments made under sections 9, 10 and 12 of the Canada Health Act.

While I understand that the provider fee for the anesthetic service is being comprehensively covered, some Mani tobans are having to pay facility fees in relation to the provision of these ensured services, while at the very same site, the minister pays for the fees of other Manitobans. Patients who cannot afford the Government-authorized dental provid er's more expensive fees-which is not an insured service -tenns of payment, or w�o have simply exercised the rights under

section 90 of The Health Services Insurance Act to choose their provider, are being denied their entitlement to receive facility fee funding equivalent to other Manitobans. By forcing these patients to pay for their own facility fees, the Government is denying Manitobans unimpeded access to the medically necessary anesthetic services on uni fonn tenns and conditions. A large number of my patients can afford and are willing to pay the fees hindering their children from receiving the medically necessary services which mandates going to the sites at which facility fees are being charged.

Unfortu nately, many of the children requiring these services come from underprivileged families and are forced to decide between buying things such as food or paying expensive facility fees to prevent their chi ldren from continuing to suffer terribly. Out of compassion, on a number of occasions, I have personally covered the fees for these patients, but this is not my responsibility. • (1 8:40) I recognize that members of the Government may claim that the facility fee being charged to some pediatric dental patients relates primarily to the uninsured dental services.

Given that the facility fees are detennined by the duration of insured anesthetic services, independent of dental services and that the patient's requirement for the anesthetic services is what mandates that they go to that particular facility, I believe that the charges belong to the insured service. Nonetheless, if they believe the charges to be dentally related, I cannot understand how the Government can justify using the money of all Manitobans to subsidiz e the dental care of only some Manit obans.

The ethics by-laws of the Manitoba Dental Association specifically points to the inappropriateness for all dentists to participate in any plan or contract that interferes with the public's right to have dental services perfonned by the dentist of their choice, such as occurs with preferred provider organizations. It would seem to me that the Manitoba government's actions would constitute it being designated a preferred provider organization.

I believe that violating this ethical principle held dearly by the members of the dental communit y, would jeopardize the participation of all Mani toba dentists in all government-adminis tered dental programs, including the Social Allow ances Health Services. As one who never tries to complain without providing possible solutions, perhaps mistakenly taken by others to infer that I think I can do their job better, I hereby suggest that subsection 64. 1 (2) of the proposed bill be amended to read: The minister shall not enter into an agreement under subsection (

I) unless the minister is satisfied that (

a) the surgical facility is accredited by the College of Physicians and Surgeons; (

b) the provision of all Manitoba medicare insured services as contemplated under the proposed agreement will be consistent with the principles of the Canada Health Act, the Human Rights Code, legislatively allotted patient's rights and have been considered free of any potential conflicts of interest; and (

c) the agreement will serve the public's interest and that reasonable opportunity has been provided to allow for public input regardi ng the agreement's impact on the broader community . I stand before you as a single Manitoban in the face of what everyone seems to describe as insunnountable odds. Like many of the bureaucrats I have dealt with, I am sure that some of you cannot figure out why someone would risk what I have to stand up for what is right. The answer lies in understanding who I consider to be heroes, not Neil Ann strong, Bill Gates or even Paul Henderson. My heroes are people such as Abraham Lincoln, King Edward

July 3, 200 1 LEGISLATIVE ASSEMBLY OF MAN ITOBA 141 VIII, Martin Luther King, Elijah Harper, and a Chin ese protester standing in front of the tank. Thank you for your time. Mr. Chair person: Thank you for your pres entation. Mr. Sui. Does the committee have questions? Mrs. Myrna Driedger (Cha rleswood): wonder if you could just give us an example of the conditions of some of the children that you treat. I did have a father phone me who has a little four-year-old autistic son. It is a very poor family, and they cannot afford to access care.

In this case, this little boy, because he was autistic, did not know any differently, and he pulled out two of his own teeth. I am just wondering if these are the kinds of examples that you deal with on an everyday basis and if you could just paint us a picture of what you are dealing with. Mr. Sui: The thing is- Mr. Chai rperson: Mr. Sui, I have to recognize you before you respond, for the purposes of Hansard, so go ahead. Mr. Sui: Thank you. As a front-line provider, on a daily basis, I am faced with the issues of children such as the example you gave.

All of these kids, or most of these kids, are kids that are under the age of six, and it is because of the volume of the work that they require, most of them will have seven or eight teeth that are abscessed, six or seven cavities, very large cavities and with pus and abscess material draining into them. Most of them are having to wait for a long time to get this treatment done. Mrs. Driedger: Can you tell me what kind of daily activities are affected when a child has teeth problems? We are not just talking, I do not think, you know, about having a pain in your mouth.

I think there are probably educational factors involved, sleep factors, eating factors, temperament and all of that. Are you finding you are hearing a lot of those issues? Mr. Sui: There is no question. Most of the time, we get phone calls all the time from desperate parents trying to find ways that they can alleviate some of the discomfort that these children are having. We get calls all night, all hours of the night, from parents that are experiencing these di fficulties. They have diffi culties with eating.

Temperament wise, as you were talking about, a lot of these kids, all they can concentrate on or focus on is the amount of pain that is in their mouths. Hon. Dave Chomiak (Mini ster of Health): am not clear, Mr. Sui, from your presentation, but it seems to me that you are advocating that all the dental services you provide as a dentist should be under medicare. Certainly, that is how it reads. Is that correct? Mr. Sui: No, it is not.

What I am asking for, or what I believe should be done, is that for all patients who are rec eiving insured services, which includes the anaesthetic services for this work, I do not believe that facility fees should be charged for those patients. I do not believe that the dental work itself is something that the Government ought to be responsible for at this time. Mr. Chomiak: Can I just ask you how long you have had this problem, in terms of the waiting lists? Mr. Sui: The problems with the waiting lists precede myself starting practice in Manitoba. I graduated in '95.

I had done some extensive work previous to that while I was going through dental school, travelling to some of the reservations and spending time with some of the children's orientated dentists. I understand that the waiting lists have been an issue for a number of years. I do understand that the Government has taken steps to try and alleviate those lists, and, unfortunately, the lists seem to be growing instead of going down. Mr. Chomiak: Are you aware in the last two years that we have increased the volume and number of surgeries by 30 percent? Mr.

Sui: Yes, I am aware that you have, for selected dentists, increased the number of surgeries that are being covered. It is my opinion that part of the reason why there has been an increase in those lists is because the Government

14 2 LEGISLATIVE ASSEMBLY OF MAN ITOBA July 3, 200 1 has funded only certain dentists. What has happened is that there has been a draining of patients from other dentists who provide simi lar services, and because of that, that is why the waiting lists at hospitals is increasing. Mr. Chomiak: So, if I could understand, the waiting lists precede, the difficulty precedes your going into dentistry in '95 or graduating, but your concern is that the Government, for the services we provide, do not fund some dental surgeons, do not fund others, or do not fund others as much? Mr. Sui: They do not fund others.

For myself and other dentists that are doing simi lar proce dures, the anaesthetic portion is being covered for our patients. However, there is a facility fee that has had to be borne by our patients directly,

whereas for other dental providers, the Govern ment is picking up their complete tab for that. Hon. Jon Gerrard (River Heights): Thank you for your presentation. My question is, I think, germane to the patients that you are looking after. The long-run solution in any of the children is probably better dental care very early on in life. Would it not avoid much of the need for dental surgery if, in fact, there was a much more vigorous approach to good dental care early on? Mr. Sui: Certainly, a lot of the pr oblems are issues that take place before we, as dentists, even see the patients.

I know that education seems to be a term that is bandied around a lot in terms of a possible solution for this, and that has been something that has been tried by the dental community quite extensively. Personally, I feel that perhaps by teaming up better with our friends in the nursing community, in the post natal nursing wards, and by stressing the importance of proper dental care for young children is absolutely critical.

I find it quite appalling that in our country and in this day and age, probably 40 percent of the patients who come to us for the first time, their parents are not aware of proper dental care. Mrs. Driedger: Mr. Sui, are your patients part of the 15 00 that we hear of as a waiting list for these children, or are yours separate from that? Mr. Sui: A number of my former patients, because the Government is now picking up the tab if they see other dental providers, are now part of that 15 00.

In terms of my understanding, for calculation purposes, that 15 00 does not include patients on my waiting list. • (1 8:50) Mr. Chomiak: I just wonder if you have an opinion. In 19 93 the Government of Manitoba cancelled a children's dental program that provided dental service in rural and northern Manitoba. Are you familiar with that? Certainly, it has been my view, that had that program still been in place, we would see a lot less dental damage that we see right now. Do you have any comment on that? Mr.

Sui: I guess since that precedes really myself being in a position to give a proper opinion on that, I think I would like to refrain from giving an answer to that question. I am not aware of exact figures in terms of the duration of time, you know, when these waiting lists first started to balloon and how successf ul those programs were for eliminating some of those problems. Mr. Cha irperson: No further questions? Thank you for your presentation, Mr. Sui. Bill SO- The Regio nal Health Author ities Amendment (Accounta bility) Act Mr. Cha irperson: The next out-of-town presenter is for Bill 50.

We will switch over to Bill 50 for the one presentation. I call Heather Temple, CEO of Mi ddlechurch Home of Winnip eg. Good eveni ng, Ms. Temple. Do you have a written copy of your presentation? Ms. Heather Temple (CEO, Middlechurch Home of Winnipeg): Yes, I do. Mr. Cha irperson: You may proceed when ready. Ms. Temple: This is a short presentation, just to advise you. The copy that you have is there for your reading. I will not be reading it directly, however.

July 3. 200 1 LEGISLATIVE ASSEMBLY OF MANITOBA 14 3 The primary concern IS m relation to the WRHA amendments act specifically in referenc ing

article 29. My concern in relation to

article 29 is the disputes resolution mechanism. I am from a non-profit personal care home facility, and even though we are aware that purchase service agreements may be under review, the only reference to the disputes mechanism under

article 21 is also in relation to the faith-based facilities. Even though we are a non-profit organization, we are not a faith-sponsored organization. My concern is just to ensure that the disputes mechanism, which does not include the arbitration, is addressed for any facility within the- Mr. Chai rperson: Excuse me, ma'am. We are having a little difficulty hearing you. Could you get a little closer to the microphone, please? Ms. Temple: This keeps falling down. Is it better if! hold it? Okay. It is mostly in relation to the disputes mechanism under ar ticle 29.

Very briefly, for those that are the non-profit, non-faith-based facility, there are not a lot of us within the WRHA at this point in time from the personal care home perspective, but I just wanted to bring it to the attention of the committee that within the disputes mechanism, the only reference that I could find under the amendment was in relation to faith-based. I certainly do support their recognition in wishing a disputes mechanism, but I just wanted to bring it to the committee's attention that that is also an issue for us that are non-faith-based or faith-sponsored facilities.

What I would like to recommend is that there be a universal address to that disputes mechanism under

article 29 so that should there be any facility, either within the acute care, I guess, or non-acute long-term care sector that does have a concern with the WRHA who issues a directive that we do have that mechanism in place. The

summary is there. What I did include at the end of it was a simi lar disputes resolution wording which is included in our current purchase service agreements, which I would see very sim ilar to what is under

article 29 in the faith-sponsored ones. I would see that being very simi lar for everybody. Any questions? Mr. Chai rperson: Thank you for your presen tation, ma'am. Are there any questions? Mrs. Myrna Driedger (Cha rleswood): I am assuming that you would be more comfortable if that was entrenched in the bill and not just in the service purchase agreement. Is that correct? Ms. Temple: That is correct. It is already in purchase service agreements for both types of facilities now.

I guess seeing that coming in under the amendment for one type of facility, I would just like to ensure it is there for any type of facility, just to be fair and reasonable for all parties. Mr. Cha irperson: Any further questions? Seeing no further questions, thank you for your presentation, ma'am. Bill 25-The Health Services Insurance Amendment and Conseq uential Amendments Act (Continued) Mr. Cha irperson: We will now return to Bill 25. I call upon Robert Chernomas, Canadian Centre for Policy Alternatives. Mr. Chernomas, do you have written copies of your presentation? Mr.

Robert Chernomas (Canadian Centre for Policy Alternatives): Yes, I do. They are right there. Mr. Chair person: Proceed when ready, sir. Mr. Chernomas: I would like to thank the committee for giving me this opportunity this evening. I am an economist at the U of M. My research area is health economics. A couple of years ago, I published a book comparing the U.S. and Canadian health care systems. The Canadian Centre for Policy Alternatives recently asked me if I would review the most current literature on for-profit health care, which is certainly evolving in the U.S. at a rapid rate.

That is what this paper presentation is about. Bill 25 proposes to close loopholes in existing legislation that could allow for the creation of private hospitals in Manitoba. As such, this legislation will help prevent the erosion of public health care in Manitoba.

144 LEGISLATIVE ASSEMBLY OF MAN ITOBA July 3, 200 1 There is strong evidence from both Canada and the United States that for-profit health care is more expensive, of poorer quality, and less accessible than the public system. It is, therefore, unlikely that introducing for-profit elements to our system will reduce waiting lists for surgery or the number of patients lying in beds in the halls of our hospitals. • (19 :00) Canada's health care system has a number of obvious problems, including long waiting lists for surgery, and a nursing shortage.

In order to determine the cause of these problems and begin to solve them, we must be clear about what the Canadian health care system is set up to do and where the costs have actually increased. Medi care is mandated to control three subsectors of the health care system: Hospitals, physicians and administration. Since 19 71, when the single-payer system was fully implemented, these three subsectors have seen their relative share of the Canadian economy remain virtually unchanged, that is, hospitals, physicians and administrative costs take up no greater share of the economy than they did a quarter century ago.

Yet, over the same period overall, health care costs have grown from approximately 7 to about 9 percent of GD P. Where have they grown, if not for hospitals, physicians and adm inistration? The answer is those parts of our health care system that are privately run. In '93 Canada ranked 16 th among the 24 leadin g industrial nations when public spending was calculated as part of our total health picture. But when the overall health expenditures, which included both private and public, are calculated, Canada placed second, dropping to fifth in 19 95.

Our health costs have grown, not because of the public system, but because of the mostly for profit private system that we do not control. From '87 to '96 the cost of prescription drugs in Canada rose by 93 percent compared to an increase of all consumer prices of 23 percent. Drug costs grew proportionately faster than any other item on the nation's health bill, from 9 percent of total health expenditures in '84 to over 14 percent by 19 96. During this period, spending on hospitals decreased from 42 to 37.3 percent of total health expenditures. Spending on physicians fell from 15 percent to 14 .2.

If you do the math, you will find that hospital expenditur es fell by just about the same amount that drug costs went up. The U.S. health care system, with its increasing reliance on for-profit health care, spends about 14 percent of its GDP on health care, up from 7 percent it spent in '7 1. It is well known that the increasin gly for-profit U.S. health system is less fair than the Canadian system. Approximately 45 million Americans do not have health insurance and approximately an equal number are underinsured. Yet this inequal ity does not result in a cheaper system.

In fact, for less per-capita government spending, the Canadian system covers everyone,

whereas the U.S. covers only the poorest, the oldest, the disabled, and the military. Americans pay more in taxes for health care than we do, and it does not guarantee them care. What can we learn from the U.S. experiment with for-profit health care? There are three essential areas we would need to explore in order to assess the advantages and disadvantages of the emerging U.S. system. We would need to assess the effects of these reforms on costs, quality and access. Starting off with cost: In a 19 99

article in the New England Journal of Medicine, the authors show that no peer review study has found that for-profit hospitals are less expensive than not-for-profit hospitals. On average, they are 3 percent to II percent more expensive than not-for-profit hospitals. It is true that for-profit hospitals spend less on personnel, avoid provid ing charity care and shortened stays, but they spend more on administration, marketing, extra services and executive pay, on top of which they must pay profits to stockholders.

When investor owned hospitals dominate the market, more is paid out by the federal government through its Medi care program, not only for hospital care. but also for home care and care in other facilities. In another 19 99 New England Journal of Medicine study article, the authors looked at hospitals in areas being converted from not-for profit to for-profit and compared their spending with those areas that remained not-for-profit

July 3, 200 1 LEGISLATIVE ASSEMBLY OF MANITOBA 14 5 from '89 to '95. They concluded that spending in the 33 areas converted to for-profit was greater than in the 2860 not converted, not-for-profit areas for hospital services, home health care and services at other facilities, all the categories of service examined. Quality of care: As we move from cost, if for-profit care is less efficient, then the question becomes: Does it provide better care? In a I 999

article in the Journal of the American Medical Association, researchers concluded that, compared with not-for-profit health maintenance organizations, HMOs, investor-owned for-profit plans had lower rates for all I 4 quality-of-care indicators. Investor owned HM Os delivered lower quality of care in the not-for-profit plans when examining the quality of care for everything from heart attacks to diabetes to eye examinations. With HMOs, while total costs in the for-profit and not-for profit are sim ilar, the not-for-profit plans spend more on patient care.

For-profit HMOs provided less preventative care, have higher disenrolment rates, and lose more beneficiary appeals than not-for-profit plans. In a recent study by the Harvard School of Public Health, 82 583 patients in I 82 health plans rated quality of care in the for-profit plans much lower than in the not-for-profit plans. Finally, access: A I 997 editorial in the New England Journal of Medicine expressed concern about the accessibilit y of for-profit hospitals.

They provide fewer money-losing community services, such as care for the poor, 24-hour emergency departments, AIDS clinics, burn and trauma centres and neonatal intensive care units. Private for-profit hospitals will never, the journal argues, provide sufficient care to the poor and uninsured. In a competitive marketplace where cost containment is the rule, if that were true by the way, there is consistent pressure on hospitals to reduce important but unprofitable services and, instead, skim the most lucrative services off the top. Similarly, a parallel for-profit system does not shorten waiting times.

It uses the same health care workers as the public system. So, at a time when there is a shortage of doctors and nurses, splitting them between different systems is counter-productive. The fact is well supported by two studies of cataract surgeries, one by the Manitoba Centre for Health Policy and Evaluation, the other by the Alberta Consumers' Association. Fi nally, prognosis: The evidence shows that for-profit health care is more expensive, of poorer quality and less accessible. It is, therefore, unlikely to reduce waiting lists for surgery or the number of patients lying in beds in the halls.

Spending a dollar on the less efficient for-profit sector means we get less service for the same dollar. Given this evidence, Bill 25 is laudable. The growth of inefficient, inequitable for-profit elements should be stopped in its tracks. In the longer run, rather than moving towards an American-style health care system, Canada should expand its public sector to include drugs, long-term care and better and stronger health care in the community at home. These would be steps on the road to improved efficiency, quality and accessibility. Thank you. Mr. Chair person : Thank you for your presentation, Mr. Chernomas.

Do members of the committee have questions for the presenter? Mrs. Myrna Driedger (Charleswo od): Mr. Chernomas, have you ever had an opportunity to study the Swedish health care system, and do you have any comment on it? Mr. Chernomas: I have certainly studied it in the past and have studied the research literature. I have not done it very recently. There are some articles in the newspaper recently which I have looked at, and I think one of the more interesting things is that they experimented with a for-profit hospital and they decided that it was-it looks like they have stopped experimenting.

They think it is a bad idea because what they discovered in the for-profit hospital is they began to introduce services which were two and three times what was occurring before, and, therefore, they think probably what they are doing is trying to find the places where the most profit is being made, as opposed to where the patients' needs are greatest. So, from what I understand, they have suspended the experiment. Mrs. Driedger: We must be reading very dif ferent articles because I am hearing quite the opposite in terms of what is happening in

14 6 LEGISLATIVE ASSEMBLY OF MAN ITOBA July 3, 200 1 Sweden, and actually, the expansion of programs that is going on down there is a bit contrary to what you have indicated. I am wondering also the-and I do not know if you have run across it. I have been trying to find it. There is an

article that came out in one of the New England journals of medicine, and I heard it was quite a flawed study and that the editor, in fact, of that particular journal was chastised quite severely for publishing it. Have you run across that particular

article or one that you have since heard that might be a particularly flawed

article in terms of the scientific base upon which the research was carried out? Mr. Cbernomas: It is a peer review journal, and I am not familiar with any particular study that there was some question about it. As for other material in Sweden, I would welcome the oppor tunity if you could give me those references. Hon. Jon Gerrard (River Heights): A question for you: We have currently probably about 30 percent of health care in Canada not publicly paid for. It is privately paid for in one fashion or another. So we currently have a mix.

We currently have what are probably dozens of clinics, from Winnip eg Clinic, the Manitoba Clin ic and so on, which are privately owned. Are you advocating that the Government take over all these clinics and operate them? Mr. Cbernomas: One has to make the distinction between for-profit and not-for-profit private health care. There is a di fferent incentive structure in the two systems. In fact, one would argue that our entire health system is privately admin istered, although publicly funded, I do not know what I said, but obviously it had a dramatic effect-so that that is an important distinction.

So there are many countries that have experimented. You know, the British system for example, for a long time was both publicly funded and publicly adminis tered. The Canadian system is a hybrid between publicly funded and privately run. So I think it really matters, the structure, what sort of incentives there are. The for-profit system is different from private. I think the for-profit system, in particular, has been raising the costs, for example, in pharmaceuticals, and this is no time to do that.

But, yes, I would make some serious suggestions about how we might transform how we get our drugs and other parts of our health care, home care as well. • (19:10 ) Mr.

Gerrard: Just with respect to the clinics, what you are suggesting is that it depends very much on the operating structure of private clinics in terms of what the final results are in terms of costs and quality, that it would be quite feasible within a public system to be contracting for services in a way that you could comparatively evaluate the delivery and ensure that the standards, both in terms of cost and quality, are high across the whole system. Mr. Cbernomas: I would see no advantage to that.

I mean, once again, the incentive structure would not matter, whether it is for-profit or not for-profit, but I do not see any advantage in having a private not-for-profit over one that is directly under the state's direction. I do not see the advantage. Hon. Dave Chomiak (Mini ster of Health): Ju st a couple of questions. Firstly, thank you for the presentation. I am a bit perplexed, given all of the evidence and all of the studies that indicate a private system is not as efficient and is less effective. Do you have any speculation as to where this enthusiasm is coming from to go private? Mr.

Chernomas: That is a very large question. I would say that part of it is certainly ideological, and part of it is that there is an important sort of trajectory in the world to turn much of the public sector into a for-profit private sector because it is a source of profit. People with a lot of power are seeking to change the institutions, so there is access to profit. It is true in education. It is true in health care. I would argue that the World Trade Organ i zations, the GAITs. are all about precisely that. Mr.

Chomiak: What I also see is that because there are no statistics, no studies that can be used to justify it, what the people who advocate this do is run up the flagpole one system after

July 3, 200 1 LEGISLATIVE ASSEMBLY OF MAN ITOBA 14 7 another. For a while it was Sweden, and then we found Sweden was freezing its privatization experiment. So that one goes down the flagpole. The next one up the flagpole is France, and they talk about France being so well. What they do not tell you about France is the fact that people have to pay 20 percent of the cost of the health care system. They do not tell you the OECD has said that poorer households and people at the poorer end of the scale do not get access to health care in France.

They do not tell you that there is a 13 % payroll tax on employers as well as payroll deductions on employees to do France. So they run these systems up the flagpole, but there is no comparative and there is no actual data to justify this privatization initiative. Any recommendations on other systems or other ways we should be moving, other than the recommendations you made with respect to expanding to include continuing care and pre scription drugs, et cetera? Is there anywhere else you suggest we might look? Mr. Chernomas: Things like community health centres, possibly.

I realize what this sounds like in this day and age, a public pharmaceutical approach as opposed to the private sector to do this. I mean, there are a whole bunch of things that I could suggest with more time, but I would suggest more public rather than more private along these lines. Health care is different as a commodity, very different. Mr. Gerrard: Just back to your comment that you see no advantage over a private not-for profit or a government-owned not-for-profit.

I mean, if there is not an advantage for a government-owned not-for-profit, is it worth the expense of Government to buy out all the privately owned not-for-profit facilities? Mr. Chernomas: I would have to look at it case by case, but if it is more efficient to have it government-owned, then I would do it. If it is a small part of the over all health sector that-1 do not know. I would have to look at it case by case. By and large, it does not seem to work, the private sector as well as the public sector, but any individual case, I would sort of have to look at it, I guess.

I mean, it is the same resources, right? There is a different incentive structure in different organizations, and one incentive, the single payer system, seems to work better than any other. One of the problems with the Swedes is, I would say for years, when I did look at the literature in the past is that they were too fragmented. They did not have a single-payer system. So what happens is you had a variety of different sectors all raising costs at the local level, as opposed to at the top somebody deciding how many MRis, the equipment and technology that would be produced.

If you have a disorganized system, you are going to wind up with a lot of people making demands for a lot of different technology and also, of course, the costs that go along with that equipment. That was certainly part of the problem in Sweden when I last looked at it, which has not been for a while, and the Swedes have now gone to, at least experimented at least in the short run, with a for-profit system, but as I said, my most recent and, this is not academic but reading the newspaper, it seems they do not like the results that they have had. Mr. Mervin Tweed (Turtle Mountain): Mr.

Chairman, the minister had asked you what you thought might be driving this question about looking at alternatives and options. I guess I would suggest to the minister, it is being driven by the thousands of people that are waiting on waiting lists for a long period of time, and they are looking for alternatives. I am not saying they know what the answer is, but I am saying it is being driven by them, and I just ask you if you might agree with that or to comment on it. Mr. Chernomas: Yes, I think there are ref orms needed in the health care system without question.

Wha t I was suggesting is that into this gap has come with a vengeance a whole lot of for-profit interests that have spent lots of money on research, lots of money on publicity promoting a particular solution to this. I can

14 8 LEGISLATIVE ASSEMBLY OF MAN ITOBA July 3, 200 1 bring you long quotes from stockbroking houses in New York talking about the incredible large market in health care and public-sector health care around the world that ought to be exploited, the same thing about education. What we need to do is we need to get the word out that these are opportunities for us that need to be pursued. These are folks who have more power, I would suggest, in general, than the ordi nary folks in Manitoba who have some reasonable complaints about the fact that there are waiting lists for surgery.

I can suggest to you in the Unit ed States that there are no waiting lists for surgery, but there are lots of people at home in the dark that do not get access to it at all. Mr. Tweed: Would you suggest, then, another factor that may be part of the drive is the fact that by ref erring patients to the United States, they come back with quite good stories about the care and the treatment they received?

Perhaps in their circles of travel and friends that discussion is taking place, and that might also be driving a little bit again, not necessarily to the American model, but the real need for the change and the ability to look at change and not be afraid of it. Mr. Chernomas: Two things about that. One, if you are wealthy in the United States, you have access to some very good health care. The second question is that access to that health care-the question is time limited, of course. One of the interesting things about health care is that there is asymmetry of information.

You go in with a pain and you are sick and you are worried, it is you or your child. There is enor mous pressure to get something done and ultimately you do not really know what the intervention is, whether or not it is appropriate, necessary or not. So you go in and you go to a for-profit first-class American health facility, you will get service and you will get it quickly. The question whether you got what you really needed is a separate question altogether. So, as I suggested earlier, in a lot of these places a lot more heart surgeries are being performed, a whole range of different services being performed.

That would suggest that maybe they are not the services that are necessary. Maybe they are sort of done for profit rather than-so, yes, you go there and if you are wealthy enough you will do quite well, but many Americans would not get access to that in the first place. Mr. Cha irperson: Thank you for your presen tation, sir. I will now call upon Albert Cerilli, President, Manitoba Federation of Union Retirees. Mr . Cerilli, do you have written copies of your brief for the committee? Mr. Albert Cerilli (President, Manit oba Federation of Union Retirees): Yes. Mr.

Cha irperson : Please proceed with your presentation when you are ready, sir. • (1 9:20) Mr. Cerilli: Thank you. Good evening, Mr. Chairperson and members of the committee. The Manitoba Federation of Union Retir ees is an affiliate of the Congress of Union Retirees of Canada and makes up the 500 000 union retirees and their spouses. CURC and MF OUR is a member of the Canadian Health Coalition. The Manitoba Federation of Un ion Retirees wants to commend this Manitoba NDP government and honourable minister, Mr.

Chomiak, for serving notice to the rest of Canada that this provincial government will protect all Manitobans on an equal basis for their health care needs. Bill 25 allows the protection from those that want to profit from one segment of society who fall ill and in need for professional medical treatment. Bill 25 stops those doctors that want to cherry-pick from those that feel threatened and exposed to a sickness in need of treatment. Some will argue that those who can pay should leapfrog those that cannot pay. The Manitoba Federation of Union Retirees does not agree with this principle.

In order to place this issue in some historical perspective, may we take you back to why the Canada Health Act and before medicare. To quote from the collection of indivi duals who wrote in in 19 95 from "The Stories Project" in the book, Life Before Medicare: The Canadian Experience, compiled by Helen Heeney for "The Stories Project," Ontario Coalition of Senior Citiz ens Org anizations,

July 3, 200 1 LEGISLATIVE ASSEMBLY OF MANITOBA 14 9 funded by New Horizon Health Canada. Others involved are with foreword by Dr. Michael Rachlis, edited by Susan Charters, illustrated by Doug Sneyd and designed by Justine Orr. To quote from this recommendation and recommended reading, one reflection by so many that make up this book, I will quote from a Maureen Beardsley from British Columbia who writes: In 19 56, my husband was posted in Germany. Just prior to returning home in December 19 57, I suffered a gall bladder attack which was tended to at a British military hospital in Germany.

When we returned home with our one son who was born in Germany, we purchased Blue Cross to cover me and our son. My husband was covered by the military. In 19 58, I had a bad attac k. This was a major problem as we had not been in B.C. for six months and, therefore, were not covered by the hospital plan, but thought that the Blue Cross would cover the doctor's fees. A week before the operation was scheduled, B.C. changed the residence stay to three months. We were elated. Our second son was born October 21, 19 59.

Several months later, when I was visiting my doctor, I found out I owed him $12 5 for the pregnancy which was not covered, because my husband was not on Blue Cross plan, and that I owed $500 for the gall bladder operation. That operation was not covered after all because it was a prior condition. We were just devastated and did not have funds to pay. I offered to borrow the money, but our doctor was good enough to allow us to pay him $10 per month. It took us five years to pay off the debt. It was quite a financial burden. That debt was more than we paid for the used car.

It was 25 percent of the value of the house we had purchased for $300 down and $25 a month in 19 54. Now you can imagine the dollars in this day and age. If I can pause for a minute, there are a hundred of these stories in the book, and I would recommend that the book be looked at by those who think that privatization is the end to all means of medical care and other means.

The Saskatchewan premier, Douglas, with his then-CCF, now the ND P provincial govern ment, fought all odds to put into place the 19 47 hospital care legislation for the province's citizens regardless of financial status and standing and, in 19 62, put into legislation the Saskatchewan Medicare Act. By 19 67, the federal government promised to share the costs of hospital insurance plans operated by the provinces.

However, the implementation of the recommendations of the report of the Royal Co mmission on Health Services by Chief Justice Emmet Hall were in for a fight to have the medicare act approved by the Parliament of Canada in December 19 66. The provinces had to be forced into developing actual programs to meet the principles of medicare. In preparing this paper, I will quote from the Winnip eg Labour Council files of mid-1 960s. Some of us remember that far back. Some of us were still pretty young. But, in fact, here is what we said at that time. "On December 8, 19 67, a letter was sent to the Honourable Lester B.

Pearson, Prime Minis ter of Canada, and to the Premier of Manitoba, the Honourable Walter Weir." Sometimes I wonder where the attitude of the present Tories come from, but if you read history, you can learn a lot from it because those attitudes then are still in existence today.

"On Tuesday eveni ng, December 5, 19 67, at the regular meeting of the Labour Council of Winnip eg, a resolution was passed unanimously to urge you to press for the implementation of medicare by the federal government on the scheduled dates of July I, 19 68, without any further postponements." The letter continued to the Premier of the province. "Mr . Premie r, we just cannot afford the luxury any further of depriving our under privileged and low-income people of proper medical care on a reasonable basis, no further delays," and so on and so on.

The Manitoba Association of Social Workers on Febr uary 9, 19 68, made a press release, and I quote in part from it, because I think sometimes history tells us a lot from where we came from so we know where we are going and what road to take, because if you come to the fork road and you take the wrong road, then you are in trouble. I tried to stay on the left road,

15 0 LEGISLATIVE ASSEMBLY OF MANITOBA July 3, 200 1 but sometimes you have to look at the other side as well. Here is what it said: In light of the exhaustive inquiry into medicare services conducted by the Hall Royal Commission, the Manitoba Association of Social Workers is most discouraged by the Manitoba government's rejection of the idea of universal medical care insurance and its stated intentions not to imple ment the federal care plan for at least another year. It has been variously estimated that between 15 0 000 to 200 000 Manitobans are without any medical coverage.

These generally are people on marginal or fixed incomes to whom minor illness can result in financial distress and a major one lead to disaster. I guess you could see from the letter from B.C. that the lady was in a disastrous situation, but the good nature of the doctor helped her out in trying to recover.

If I could pause for a minu te, everybody looks to the United States for the make-all, the glory of the buck down there and medical care and privatization, but, in fact, down in the United States, the last figures that we have researched is that 40 million-plus Americans are not covered by any kind of care because it is too expensive. Now, that is the road they have taken. Good luck to them, but keep your hands off our medicare.

The Lutheran Church-oftentimes I quote from the Catholic bishops' papers and so on, and sometimes I quote from the Un ited Church-this time I am going to pick on the Lutheran Church in America. The Canada

section at its convention on June 19 and 20, 19 67, authorized a paper to be released on social concerns titled, A Health Charter for Canada a Concern for the Church. In its forward it stated, and I quote in part: Public debate on the issue of health care services including the implementation of the Medical Care Act of 19 66, medicare, continues. Those doing the debating are mainly the politicians, the professionals and the spokesmen for powerful corporation groups. "What does the consumer have to say?" was a question that was asked in that paper.

"Is this a subject coming within the orbit of Christia n social responsibility?," was the other question that they asked. A universal plan: The Royal Commission of Health Services attempted to deal with the paradox of our age, the enormous gap between our scientif ic knowledge and skills on one hand and our organizational and financial arrangements to apply them to the needs of men on the other.

Hence, its basic recommendation is that Canada take the necessary legislative, organizational decisions to make all the fruits of health science available to all our residents' health services without hindrance of any kind. Thus universal means that adequate health services shall be available to all Canadians wherever they reside, whatever their financial resources may be. End of quote.

Wise words. • (1 9:30) The Royal Commission report by Justice Emmett Hall, and the church, as above quoted, found that in a modern society as in Canada, individu al responsibility by itself is insufficient, for there are those of modest means who also deserve medical care as presently available in Manitoba and who deserve to be protected by Bill 25, to keep privatization out, from those who wish to profit from the misery of others.

The Canadian health services will survive as long as there are governments and social justice activist organizations such as the church, poverty groups, labour organization, retirees groups and the NDP government to ensure that trade agreements, unfriendly governments and opposi tion groups wishing to privatize medicare and Crown corporations are neutralized and kept at bay. Bill 25 does that and requires immediate passage. You know, I just want to pause here for a minute before I close off.

The health coalition does its research and seeks legal advice from a variety of groups, and in 19 66 during the NA FTA debate and during the Free Trade Agreement debate, we felt uncomfortable with the provision of that trade agreement in that it provided for Americanization of our health care. In 19 66, we sought the help of-the coalition did, and on June II, 19 66, we released a legal opinion prepared by Barry Appleton. On March 13 , 19 66, we also released the opinion prepared by Brian Schwartz of the

July 3, 200 1 LE GISLATIVE ASSEMBLY OF MAN ITOBA 151 Un iversity of Manitoba on the impacts of what would happen with internal trade if not covered, and external trade if not covered. I am glad to say that at that time, the present Prime Min ister sought an agreement to make sure that those things were protected, unlike the present situa tion that is on now.

I may say this because I am worried and concerned that the present debate that is going on on free trade agreements with the Americas will open the door up again in regard to what can happen in trade agreements if the public and the provincial governments are not hammering the federal government to make sure that they stay on the straight and narrow line of universal hospitalization for all Canadians. I say that to you, Mr.

Min ister, for the purpose of the fact that we are concerned and the things that are happening now with the debate of a special committee of governments between Mexico, U.S. and Canada, on the fact that- Mr. Chair person: One minute, sir. Mr. Cerilli: -there are open borders and new trade agreements. I think that they have to be told that we will not stand by. MF OUR commends the Mi nister of Health and the NDP government for reinvesting in modem equipment for the health care services and then the people providing this life-giving service. I thank you for your time. Mr.

Chair person: Thank you for your presentation, Mr. Cerilli. Do members of the committee have questions? Mr. Chomiak: Thank you, Mr. Cerilli. I again thank you for your presentation. I just wonder if you might touch on what the implications are from either the Schwartz or the Appleton recommendations of '96 concerning the Free Trade Agreement and its possible impact on medicare. Mr. Cerilli: The pr ovisions of Appleton dealt with the internal trade agreements.

The Schwartz agreement dealt specifically with the NAF T A, and that the provisions in there allowed for investment, if you like, from the Americans to come in here. In some, the concern was so real that this investment would jeopardize our universality and our av ailability of a public system, that we would be really on a slippery side of the slope towards the privatization, American-style, of health care, and that was the concern. He highlighted a number of the passages. I have the paper at home. I will mail it to you.

I think you will be interested in those two documents, and I am sure that they will serve this committee well, if you like, in regard to what should be done and what should be stopped. Bill 25 stops the present situation in Manitoba, but there are provinces like Alberta, for example, who are hell-bent on having a two tier system. It concerns seniors across this country. In November of last year, 13 organizations of seniors met from across this country, representing some two or three million seniors and their spouses.

One of the great concerns was just that, that the trade agreement between the Americas and other things of that nature will open up the door. I think that the Schwartz paper will highlight the concerns he had at the time. Mr. Cha irperson : No further questions? Thank you for your presentation, Mr. Cerilli. Mr. Cerilli: Thank you. Mr. Chairp erson: I now call upon Mi chelle Forrest, private citizen. She is not here. Her name will be dropped to the bottom of the list and called a second time at the end of presentations. I call upon Paul Moist, President, Canadian Union of Public Employees. Mr .

Moist is not present. His name, too, will be dropped to the bottom of the list. I call upon Margot Lavoie and Brother Thomas Novak, Manitoba Obla te Justice and Peace Committee. Does the committee grant leave for both individuals to present jointly? {Agreed] Do you have a written copy of your presentation? You may proceed when ready. Ms. Margot Lavoie (Mani toba Oblate Justice and Peace Comm ittee): Good evening. There are many issues which, at first glance, seem relatively inconsequential and therefore, unde serving of extensive public debate, but some of

15 2 LEGISLATIVE ASSEMBLY OF MANITOBA July 3, 200 1 them, when considered of all their implications, are revealed to touch the very core of who we are as a community, as a society, as a people. The question of overnight stays in private surgical facilities appears to us to be one of these issues. The sanctioning of overnight stays in private, for-profit facilities is, we believe, the thin edge of the wedge in a subtle but inexorable strategy of implementing private, for-profit hospitals.

As members of a faith group which has played a long and important role in the development of medical cart; in the province, we believe that it is the civic duty of some of us to reflect on this critical question. The Obla tes, the Grey Nuns, the Sisters Qf Mis ericorde, the Sisters of St. Joseph, the Salvation Army, the Mennonit e and the Jewish communities have been instrumental in the founding and admin istration of important health facilities in this province. Churches, faith groups and religious communities practically invented organized health care in this province.

Although it might be argued that these faith based hospitals and health clinics were in some ways private, they differed enormously from the kind of medical facility targeted by Bill 25. For many years, members of these faith communities made profound sacrifices to maintain not only the institutions they founded, but the very principle of affordable and accessible health care for all Manitobans, always with a special concern for those most disadvantaged.

There was never any question that these faith-based medical facilities would ever be money-making enterprises for the communities or churches who founded and administered them. Indeed, all of these institutions were founded on principles directly opposed to the principles underlying some of the proposed surgical facilities targeted by the bill. The founders of the faith-based institutions, as the founders of secular public hospitals, were acting out of profound spiritual or humanistic ideals of compassion and human solidarity. These men and women opened hospitals because they felt they could not do otherwise.

People were suffering and believed it was their believers' duty or their human obligation to do something about it. More often than not, they subsidiz ed the institutions they founded with their own finan cial resources or by long hours of labour, often for the slimmest financial remuneration or no remuneration at all. The fruits of their sacrifices were reinforced and advanced by simi larly minded civic leaders who courageously strug gled for many long years to realize a nationwide system of public medical care. • (1 9:40) Mr.

Thomas Novak (Man itoba Oblate Justice and Peace Comm ittee): In an editorial on June 23 of this year, the Winnipeg Free Press advocated the serious consideration of sanction ing private, for-profit facilities, which would be permitted to keep patients for overnight stays. However, and we imagine it was totally unconscious on their part, on precisely the page opposite, they printed an opinion piece which illustrated one of the fundamental arguments against the establishment of such enterprises. The article, written by U.S. federal representative Dick Armey, condemns so-called red light cameras as a cash grab.

The problem with red-light cameras in the states he has studied, it seems, is not the principle itself of red light cameras. No, the problem is the private company that installed and maintains the cameras and that receives a $70 bounty each time a fine for a red light offence is assessed. This company installed its cameras, not in each city's most dangerous intersections, but at those they discovered to have mistimed signals, where the duration of the yellow light was signi ficantly less than appropriate for that intersection. I doubt that many Free Press readers were surprised by this finding.

The primary goal and objective of a private, for-profit company is precisely that, to make profit. This is, of course, not to say that there are not a great many ethical, compassionate and self-sacrificing men and women who have started for-profit businesses. It is only to say that the danger of exploitation is much greater in a private, for-profit system than it is in a public or faith-based system. Indeed, we already know the experience of provinces that presently allow and even encour age for-profit clinics and hospitals. We know

July 3, 200 1 LEG ISLA TJVE ASSEMBLY OF MAN ITOBA 15 3 what services are perfonned in these facilities. They are not necessarily operations that are most critically needed. Rather, they are the relatively simp le procedures that can be perfonned with the greatest possibility of making profit for the facility and its owners. More complex or higher risk cases are left for the public system. It cannot be otherwise. The rules of the market dictate that it must be so. Ms.

Lavoie: But even were for-profit facilities to operate in such a way that they would entirely complement the public system, the question would remain: Do the people of Manitoba want our medical system to be gradually privatized? A few years ago, the previous government proposed privatizing a part of the home care service. After a great deal of heated and extensive public debate, it became clear that the majority of Manitobans did not want this part of their health care system turned over to private enterprise.

To their credit, the government of the day acknowledged the vigorous public opposi tion and withdrew the legislation. Why this vigorous opposition?

It is no doubt due to fears about the consequences of priva tizing any sector of the health care delivery system, lower wages for staff, the temptation to promote unnecessary procedures and services, et cetera; but we believe the opposition also stems from a more fundamental objection, a radical rejection of the commodification of services that have been traditionally provided as a public service out of a disi nterested concern for the public good, out of compassion for those among us who are suffering.

We believe that Manitobans are still fundamentally attached to the philosophy and motivations that underpin the establishment of the original hospital and home care systems in Manitoba. That is, that medical care is essential ly not a business; it is a service, a vocat ion, a sacred calling or duty.

The outpouring of public sympathy for nurses and home care workers whenever they go on strike seems to indicate that we still perceive medical practitioners as neighbours in whose care we commend our loved ones when we lack either the trai ning or physical capacity to meet all their health needs ourselves, as extensions of our families. Manitobans still expect that the pri mary motivation of those who adminis ter our medical system is the public good, not the good of the public company.

We st ill expect that the personal values of those charged with the medical care of our loved ones are more in tune with the values of self-sacrifice and compassion than those of profit and exploitation.

Despite the relentless drive towards globalization of the market economy and the introduction of the profit motive into almost every dimension of human interaction, the people of Manitoba still appear to believe that there are some things that should not be for sale, that there are some things that should be protected from the tyranny of the market, some things that ultimately belong to a totally different universe than the selling of hamburgers or lawnmowers. Mr. Novak: In his poem, "The Rock," T. S.

Eliot, asks: What is the meaning of this city?/ Do you huddle close together because you love each other?/ What will you answer? 'We all dwell together/ To make money from each other'? Like the poet, we believe there are still values that might motivate men and women to provide services for their fellow citizens and neighbours, other than monetary profit.

We also believe that the people of Manitoba have rejected the piecemeal privatization of their health system, because they fear that the consequence of a slowly privatized for-profit health system is the eventual segregation of health care into a high-quality express system for the wealthy and a minimalized system for the rest of us. As people of faith, we believe that underly ing every public policy there is an implicit theology.

We sense that under the movement towards a privatized and segregated health care system, there may lie the following ethical and theological principles: first, that making money and amassing wealth is the fundamental motor driving all productive human activity; and secondly, that it is natural and inevitable that some people have access to a greater share of the resources of the community than others, includ ing those resources such as health care that have their natural origin in human compassion and neighbourly concern.

15 4 LEGISLATIVE ASSEMBLY OF MANITOBA July 3, 200 1 We reject this unspoken theology, and we would encourage our Government to reject it as well. In its place, we would like to promote an alternative theology, one which has attracted considerable interest due to the dawn of the new millennium. Over the last three years, churches across the country have been celebrating the Great Jubilee. The Jubi lee is a concept that comes from the laws and spiritual teachings of ancient Israel.

It is based precisely on the principles of compas sion and neighbourly concern of which we have been speaking throughout this presentation. In the vision of the Jubilee, the resources of the earth belong to all. Given a fair distribution of the land and its resources, there can be eno ugh for all, enough food, enough shelter and enough health care. We believe that it is the duty of a moral and compassionate government to do all that is in its power to ensure that the fruits of the earth and of human compassion be justly and equally accessible to all.

In the case of health care, we believe that this can best be achieved through a system that, through our public representatives, is managed by all the people and for the good of all the people, that is, through a public and non profit health care system. Mr. Cha irperson : I thank you for your presen tation. Do members of the committee have questions? • (19 :50) Mr. Chomiak: I want to thank you for a very eloquent and thoughtful presentation. I under lined certain aspects of your presentation that I was going to repeat, but I ended up underlining so much that I would have to repeat much of your presentation.

What I appreciated was that sometimes in the Legislature-you know, we have great sayings on the top of the Legislature and there are representations of some of the great philosophers and lawgivers of all time. We tend sometimes to forget the underpinnings of what we are supposed to do, and I found that your presentation harkened all of us back to some of the fundamental human goals that we all ought to achieve, so thank you very much. Mr. Chair person: Comment on that? Any fur ther questions? Seeing none, I thank you for your presentation. I now call upon Carolyn DeCoster, private citizen. Ms.

DeCoster, do you have a written copy of your presentation? Please proceed when you are ready. Ms. Carolyn DeCoster (Private Citizen): Mr. Chairman, members of the committee, many of the media reports on this piece of legislation have opposed it. The gist of the arguments that I have read is that if the Government were to allow private hospitals, there would be greater access to care and therefore, waiting times in the public sector would come down. I am here tonight to present some research that disp utes that argument.

I am a senior researcher at the Manitoba Centre for Health Policy and Evaluation at the University of Manitoba. I have been involved in two projects that have assessed waiting times for several types of surgery. One of the procedures that I studied was cataract surgery. Cataract surgery is available in both the public and private sector. Unti l January 19 99, if patients chose to have their cataract surgery at a private clinic, they had to pay a tray or facility fee of approximately a thousand do llars.

Patients who went to a public hospital, and those were Misericordia Health Centre or Brandon Hospital, did not have any out-of-pocket expenses. In both the public and private sector, Manitoba Health paid the surgeons' fees so the extra costs at the private clinics were designed to cover the operating expenses of running a clinic. In the studies that I did, I examined data from fiscal years '92-93 to '96-97, and then subsequently added '97-98 and '98-99, and the patterns that I am going to describe here were the same in both studies.

I brought copies to distribute here of the summarized versions of both studies, and you can download it also from our Web site which is in your notes. I also have here copies of a paper of mine on two-tier health care that was published in a U.S. public health journal. For my study, I define the waiting time as the time between a pre-op visit to the surgeon and the date of surgery. The first chart, which is

July 3, 200 1 LEGISLATIVE ASSEMBLY OF MANITOBA 15 5 on page 2, shows the waiting times for patients who had their surgery in the private sector versus the public sector. I have only shown five years of data here. What this figure shows us is that waiting times were indeed shorter in the private versus the public sector. If patients opted to have their surgery in a private clinic, they waited around four or five weeks. If they went to one of the publicly funded hospitals they waited eleven weeks in '94-95, and that increased to seventeen or eighteen weeks for '96-97 to '98-99.

So far, all I have shown you is that waits are shorter in the private sector, but what about the argument that having a private sector reduces pressure in the publ ic sector, leading to shorter waits? For that, we need to dig a little deeper. What I did next was to divide the surgeons operating in the public sector into two groups. Some surgeons only operate in the public sector; others operate in both the public and private. In the next figure, I have divid ed up the public sector patients according to whether their surgeon operated in the pu blic sector only or in both sectors.

Figure 2 shows the waiting times for three different groups of patients. The left most group of bars shows the waits for patients who chose to go to a private clinic, and it is exactly the same as the first group of bars in figure I. But here, in figure 2, the patients who chose a pu blic hospital are divid ed according to whether their surgeon operated only in the public sector or operated both publicly and privately. If a patient had a surgeon who only operated in the public sector, they waited about seven weeks in '94-95 and '95-96 and ten weeks for '96-97 to '98-99, inclusive.

In other words, the wait was about two to two and a half months. On the other hand, if a patient had a surgeon who operated both in the public hospital and in a private clinic, they could expect to wait quite a bit longer. The wait was between five and six months from '96-97 to '98-99. So having a parallel private sector did not reduce waiting times in the public sector. In fact, surgeons who operated privately had longer waits for their public patients. As a sidebar, I want to add that at the same time as waiting times were increasing, so was the rate of surgery.

In the public sector, the rate increased 19 percent between '94-95 and '98-99, even after adjusting for the aging of the population. The volume increased by over 12 00 procedures, from 52 11 to 6466. So it can be said that an increase in waiting times was due to a cutback in the number of procedures. In fact, my research shows that the relationship between the level of resources and the length of waiting times is difficult to describe.

When coronary bypass surgery rates increased, waiting times decreased, but for some other procedures like cataract, breast tumour surgery and tonsillec tomy, when the rate of surgery increased, the waiting time also increased. The figures that I have shown you here are simi lar to findings in the United Ki ngdom and in the province of Alberta. In the United Kingdom, there has always been a parallel private sector, and the longest wait procedures are those for which there is the most private practice. There are various theories as to why this occurs.

One is that surgeons who have a private practice spend more time there to the detriment of their public sector patients. Another relates to the way surgeons manage their lists. Some surgeons may put patients on their waiting lists at a lower level of dysfunction than others, and therefore their lists and waiting times are longer even though those patients may not need surgery yet. Another theory is that the private sector siphons off other staff such as anesthetists and nursing staff, leaving less for the public sector.

In Alberta, the Consumers' Association has done a lot of work in this area, and I recommend a report by Wendy Armstrong of the Alberta

chapter of the Consumers' Association of Canada titled: The Consumer Experience with Cataract Surgery and Private Clinics in Alberta: Canada's Canary in the Mine Shaft. I do not have copies of that report, but I can get them for you if you want. There was one very interesting finding in that study which may be relevant to this committee. In Calgary, all of the cataract surgery is contracted out by the regional health authority to private clinics. In Edmonton, about 20 percent is in private clinics with the remaining 80 percent in hospital, and in Lethbridge, 10 0 percent is in hospital.

So in this case, all of the cataract surgery is publicly funded, but the providers are different. Table 1 shows that

15 6 LEGISLATIVE ASSEMBLY OF MAN ITOBA July 3, 200 1 Calgary has the most surgeons for its population, and yet the waiting times are by far the longest. Lethbrid ge and Edmonton had waits of one to two months,

whereas the wait in Calgary was four to six months. Many people ask: How does having a privately managed facility threaten the public sector? I think we have to remember that there is a profit motive, and the only way to make a profit is to reduce services or charge for enhancements above the public reimbursement. I read recently about Australia's bad experience with hiring private enterprise to run public hospitals.

It has ended up costing the Australian taxpayers more because several hospitals have had to be bailed out by the government because they were either losing too much money or were cutting services severely to prevent losses. There is plenty of evidence that for-profit health care is more costly and sells more in appropriate services. It seems obvious to me that it is a road we do not want to go down. Mr. Chair person: Thank you for your presen tation. Questions from the committee? * (20:00) Mr.

Gerrard: Carolyn, we appreciate the extent of the research that you have done in a variety of areas and the reports that you have done through the Manitoba Centre for Health Policy and Evaluation. A couple of things. One, this study was based on where there were facility fees, comparing institutions where there were facility fees and where there were not. Where we do not have facility fees currently in the same framework or they are paid publicly, it is not clear whether the same is going to be relevant in the same way. Ms. DeCoster: That is true. I do not have data- Mr. Chai rperson: Ms.

DeCoster, I have to recognize you. I am sorry. Ms. DeCoster: Yes, I forgot. That is true. The data that I looked at did not carry on to when there were no longer facility fees. That is partly why I introduced some of the experience in Alberta where there were no facility fees, and yet the waiting times were longer where services were privately operated. Mr. Gerrard: I think a couple of points. One is it is quite clear from your studies that the waits actually in the private sector were shorter than the public sector. I think there is no argument there.

Second, when you looked at this explanation for why you have surgeons who operate in both having longer waits in the public sector, the surgeons who operated both publicly and privately made maximum use of their public-sector operating time. What that suggests is that the explanation for this is actually much more complex than just the difference between public and private. Ms. DeCoster: I suppose one of the limitations of the research I have done is that we do not have information in the data that I looked at about clinical symptoms.

I put into my presentation that I noticed that some surgeons. and this is basically from research from the United Kingdom, will put patients on the waiting lists sooner than others. What that does is make their waiting list look long er and therefore encourage patients to go to the private sector. Now, I am not saying these patients do not need to have their cataracts operated on. They probably do not need them for some time yet, and maybe, by the time they come to surgery, they will need to have the operation, but having a long waiting list is also a political tool.

It is something that is used in bargaining, so if you put patients on the waiting list early, and therefore they have a longer wait, it encourages them to go to a private clinic. Mr. Gerrard: But part of what you are saying is that there is a lot to do in terms of really standardization of data so that you can make good comparisons and that the reasons for the longer waits in those who operate in both sectors really needs a lot more research before we know precisely why that is occurring. Ms. DeCoster: I think in Manitoba, that is true. We do not know.

There is more that we would need to know to understand all of the ins and outs. There is now a cataract surgery waiting list

July 3, 200 1 LEGISLATIVE ASSEMBLY OF MANITOBA 15 7 registry being maintained at the Mis ericordia Hospital for all patients who have surgery in Winnip eg, and that includes patients at the private clinics as well, or clinic, I think there is only one, and it includes information on prioritization, but I do not have access to those data. I think that would be very interesting to understand if there were differences between surgeons and the level of visual dysfunction when they were put on the waiting list. There was a study that came out of British Columbia recently.

This does not really have to do with private-public medicine, but what it showed was that approximately 30 percent of patients having cataract surgery were having minimal visual dysfunction and I 0 percent of them did not meet the guidelines for cataract surgery, so there is a level of inappropriate care as well. Mrs. Driedger: When you were looking at this, did you take into account a surgeon's popularity and experience as being one of the reasons they might have had so many patients coming to them? Ms. DeCoster: I did not look at individual surgeons' waiting lists.

I was grouping them because we do not look at individual data. I do know that some surgeons are more popular than others, but I think part of that might be because this kind of information is not publicly available, that the referring physicians and patients do not know what the waiting times are for different surgeons.

In speaking with ophthalmologists at Mis ericordia, they say that the procedure itself, the outcomes, are similar whichever surgeon you go to, but I think that because this information is not shared, I mean, certain optometrists probably always refer to the same sur geon when, in fact, they might refer to another one if they actually knew that other surgeons had shorter waiting lists. Mrs. Driedger: Was a surgeon's speciality skills taken into account because, I understand, there are a couple of surgeons, for instance, that only do certain types of procedures?

So when you looked at this, were surgeons' specialities skills taken into account which might explain why some had longer waiting lists than others? Ms. DeCoster: No. I do know that some of the surgeons that operated only in the public sector do have some subspecialty kinds of interests, and some of the really high-volume cataract surgeons pretty much only do cataract surgery, but, again, in the data that I have, I cannot tell that. We do not have that level of detail, so I did not look at those specialty interests by surgeon. Mrs.

Driedger: Were the ages and conditions of patients taken into account when you looked at this study? Ms. DeCoster: I did look to see whether there were differences by age, and I did not find any. I do not have, again, data on the patients' conditions. That is where the cataract surgery waiting list registry would be very helpful, because it has some information on visual dysf unction, and that would be useful to have that information. Mr. Chomiak: Thank you for the presentation, and I know that the Centre for Health Policy and Evaluation is an a1111's-le ngth relationship organ ization from the Government.

Let me just observe something about your report. It is interesting to me that you have provided some credible research data that supports the case that private operating beside public creates more difficulties. You also deal with the Alberta situation, where, again, you have an actual comparison. Then you referenced the Australia experience and you referenced the United Kingdom experience as well. What strikes me as very, very interesting in this whole debate, is the other side of the debate that advocates going privatization can supply no data to justify their position.

Then they pick away at some of the data, but there is no evidence that their position is supported. If there were data like that, clearly, it would be made available, but it is not. I suggest, and you do not have to comment, that both your report and the report from Alberta and the experiences, certainly, counterclaims like we see from people that talk about France and give us eloquent phrases about France but have no data to support their position. Thank you. Mr. Chair person: Comment, Ms. DeCoster?

15 8 LEGISLATIVE ASSEMBLY OF MANITOBA July 3, 200 1 Ms. DeCoster: No, thank you. Mr. Leonard Derkach (Russell): Thank you for your presentation. ·I think all of these things are helpful in terms of trying to deliver a health care system in our province that is not only efficient but meets the needs of Manitobans. I think sometimes, as politicians, we get hung up on ideolo gy and forget about the practical aspects of a system and how we could improve on it, also, perhaps, overlooking or, perhaps, not regarding whether it is private or public but, indeed, how we can deliver the best service.

I would like to ask you a question with regard to the Pan Am Clinic, Ms. DeCoster, specifically because, with the purchase of the Pan Am Clinic, the Government maintains that they will be able to reduce waiting lists and also increase procedures at the clinic. That is their rationale for purchasing the clinic. However, by lifting the cap, I suppose they could have achieved that same agenda. I am wondering whether, based on the research that you have done, you have an opinion on whether or not the efficiency of the Pan Am Clinic and the services to clients will indeed improve by the purchase of the clinic. Ms.

DeCoster: I am not very familiar with the details of the Pan Am Clinic purchase. So I guess all I can speak to is the literature that I have read elsewhere that suggests that a for profit facility is not run as efficiently and so it might be possible for the Government to therefore increase the number of services that are offered at a lower cost more efficiently. I do not know all ofthe details of the Pan Am Clinic. Mr. Derk ach: Well, what do you have to say to Doctor Postl, who actually made statements which are directly contrary to what you have just said? Ms.

DeCoster: Well, without actually knowing what those statements were, I do not think I can address that. Mrs. Driedger: I am wondering if you are aware of the Montreal Economic Institute publishing a research paper, September 2000, where they stated: Canada's prohibition of voluntary, parallel private health insurance and private medical services in hospitals precludes any Canadian-based comparison and control for the current experiment in provincial government health insurance monopolies.

One would almost think they never then looked at perhaps the Alberta study that you were commenting on or even the Manitoba study, because they are certainly indic ating that it is difficult for them to actually compare, when basically in Canada, you know, you do not have two, a public and private system running parallel with each other, that you can effectively make any valid comparisons. It appears that they are saying that it makes it very difficult to actually form any opinions. Are you aware of this particular study? * (20: 10 ) Mr. Cha irperson: Time has expired. Is it the will of the committee to allow Ms.

DeCoster time to answer the question? {Agreed] Ms. DeCoster: It will be a brief answer. I am not aware of that study, so I am afraid that l-it does sound like they did not look at the work coming out of Manitoba and Alberta. Mr. Chai rperson : Thank you for your presentation, Ms. DeCoster. I will call upon Madeline Boscoe and Barbara Wiktorowicz of the Women's Health Clinic. Ms. Madeline Roscoe (Women's Health Clinic): There are two of us. Mr. Chair person : Do you have a written presentation for the committee? Ms. Roscoe: Not written, I am afraid. Mr. Chair person: Okay.

Is it the will of the committee that these two individu als present jointly? {Agreed] Ms. Roscoe: I would like to take an opportunity to introduce my colleague Dr. Carol Scurfield, who will be replacing Barbara Wiktorowicz in our presentation tonight. Mr. Chair person: Okay. Is there leave of the committee for-what was the name again?

July 3, 200 1 LEGISLATIVE ASSEMBLY OF MAN ITOBA 15 9 Ms. Roscoe: Dr. Carol Scurfield. Mr. Chair person: Dr. Scurfield to replace- Ms. Roscoe: Barbara Wiktorowicz. Mr. Chair person: Wiktorowicz. Ms. Roscoe: I will give you the spelling later. Mr. Chai rperson: Okay, proceed when you are ready. Ms. Roscoe: Thank you very much, and thank you for the opportunity to come here tonight. The Women's Health Clinic is delighted to speak in support of this bill. It would help you to know, perhaps, that I am a nurse by training.

I co-ordinate the health promotion and community education team and counselling team at the Women's Health Clinic, where we have been involved in an eight-year working group on women and health reform here within the province. I am on a national research team evaluating health service restructuring from a gender-based perspective.

Rather than repeat and reiterate some of the comments that have been made already this evening, because I am sure we all would like to get out of here as quickly as possi ble, I would like to stress some of the comments that have been made by Bob Chernomas, the Association of Retired Persons, the Obla te and the Canadian Centre for Health Policy and Evaluation. It is clear to us at the clinic and through our practice that for-profit systems, including private hospitals, increase waiting time and decrease access for the general public.

We need to learn from and build on the experiences that have gone on here in Canada and in other parts of the world. We also strongly believe that allowing private hospitals will decrease general access to physicians. There is consistent evidence that a publicly admini stered system is more cost effective and provides higher quality of services than a for-profit system. I would also like to note for the record, that we need to remember that our physicians are a public resource, that public funds primarily pay for the education of physicians.

How they spend their time and how those resources are allocated need to be something that is a debate within the public domain. Too often, I think, we have found in our practice that, as physicians dri ft into private clinics or private hospitals, they are no longer available as early speakers have spoken to. We also think it is really important to address the issue of equity and the principles here. Private hospitals reinforce inequities and strengthen and reinforce class differences. We do not believe that line jumping is a Canadian value or one that we should be reinforcing.

The opportunity to pay out of pocket is a privi lege, but it disturbs the public fabric of our system and is something that, I think, we all need to address. This is why I think this issue was such a hard one right now for the public, because it does get at our fundamental beliefs as a society around how we look after each other and who we decide gets cared for first. That is not to say that our public system is perfect, but that the debate and the discussion and how to improve it should be done within the parameters of a public system. We also want to address the issue of quality assurance.

As an agency that has been actively and passionately involved with quality assurance issues in the health system, both by service providers and by institutions, we are extr emely concerned with an increased privatization of systems where the transparency that is in place and is anticipated in the system will be less accessible. Fin ally, and I am going to hand over the podium to my colleague here, often private for profit systems are held up as a model for innovation in health system renewal.

As staff at a 20-year-old innovative institution within the public system, I think it would be helpful for the committee to hear a little bit about our experiences and our models, because I think we need to differentiate between vision and innovation, and profit. I will pass that over to Carol. Ms. Carol Scurfield (Women's Health Clin ic): Hi. My name is Dr. Carol Scurfield. I am a physician. I was trained as a family physician. I worked in the fee-for-service system. I currently work at Women's Health Clinic, which is a

16 0 LEGISLATIVE ASSEMBLY OF MANITOBA July 3, 200 1 community health clinic. As well, I worked north in Canada in Churchill and further north and in rural areas. So I have had a fairly broad experience of the health care system as some body who provides service within it. I would like to reiterate what Madeline says about physicians being, I think, public servants. It is public money that put me through medical school and gave me the skills that I need to do the work that I do.

So I do believe that I have an obligation to provide that service and that it should not be one that people have to pay for yet again, because they already paid to train me. The issue of innovation, I think, is one that is really important to think about, because it is often touted that a private clinic can give you the most up-to-date facilities, the most high-tech kinds of interventions. I think this is a really short-sighted view of what health is and what health care delivery is. A nice waiting room is not necessarily what is going to give you the best quality of care.

I think true innovation involves looking at your health in a very broad per spective, the ideal being you prevent the need for that intervention, that you have good health education. While there are surgical procedures that are not necessarily something you have to jump to right away, in the for-profit system you tend to jump qui cker than you would in a system where perhaps you can give that person the skills they need to live with this condition until its time ends because there are thi ngs that that happens with.

I think that the Women's Health Clinic is one of the places that has tried to look at health in a very broad sense.

We deliver service, but we also emphasize giving people the tools they need to live with the conditions they have and to prevent those conditions, and as well to teach them how do you use the system, because I think there is a lot of use within the system that is not necessarily something that has to happen at that point in time, and I am afraid that the for-profit system encourages the use of the system. * (20:20) I think there are some other examples of some innovated services that have happened within the public health system.

I was privi leged to be involved in the implementation of midwifery, which I think again is a very innovative system that could have qui te easily been pushed into the private-for-profit system. We fought very hard to have it included in the public system. I think that is very important, and it does show that innovation can happen within a public system if the wi II is there. Quality assurance is another critical issue. Qu alify assurance is something that certainly is something that the public system struggles with.

I have great fears that in a for-profit system, the struggle would be even greater because you have to get past barriers of a profit-making system which has a management system that is simi lar, perhaps, to those that you see in the States, which make it very di fficult for people to function. My clients and patients, and it depends on where you work what you cal l them in this province, want choice in the system. They tell me they want the ability to access the care they need when they need it, and they want a voice in the care they receive, but it does not mean they want to buy it.

What they want is a system that is flexible, that listens to their needs, that is responsive and that offers them choices within the system. That is what they want. For instance, if the public thinks that a community-based surgical centre is what would give them the kinds of services they need, then maybe that needs to be looked at, but it should be within the public system so that there is public accountability and direct input into that system. My colleagues often complain about the system.

You hear lots of the physicians talking about how they want a voice in the care that their patients receive and are frustrated often by the system and say it is cumbersome, inflexible. I think they want a voice, and sometimes that frustration boils out into thinking: I will go into the private system. But most of them say they do not want to do that. They would much prefer to work within a system where they feel they can give the care they want to provide. I do not think that you fix a system by creating a parallel system, and I think that is the risk that we are running here.

I am sure that everybody in this room would agree that the

July 3, 200 1 LEGISLATIVE ASSEMBLY OF MAN ITOBA 161 system is not perfect. There is lots of work to be done, but I have never heard anything being fixed by starting another one and trying to fix the other one while you are working with the other system. I have heard lots of horror stories about the private system in the States, both from patients who had come back and told me about their problems.

I have had to deal with women who have had unnecessary surgical procedures in the States while they were away on holidays and then come back, and I have to deal with the fallout of their complications and the fact that they really did not know what they were getting into. Because they could get that procedure fast, they did it and then they thought about it, which is not a good way to enter into any kind of procedure. I think that a strong publicly funded, universally accessible system is something that is really critical to the quality of life of Manitobans.

I do not think we can take any steps that start to erode this system. I think what we need, though, is for health care providers, for consumers, for RHAs and for the provincial government to work together to fix the system. That is what needs to be encouraged, not to start another one. Thank you. Mr. Chairper son : Thank you for your presen tation. Questions from the committee? Mrs. Driedger: Have you looked at this bill from the point of view of midwifery? I want to give you an example of the definition of private hospital.

A private hospital means a house in which one or more patients are received and lodged for care and treatment for childbirth. To me, that definition is very straightforward: A house where a woman is having a baby is now considered a private hospital. Do you have any concern with that particular definition and all the ramifications from this act that could fall into it? If one were to look at some of the

definitions of this act, including surgical facility, which is very broadly defined, surgical service, which has never been defined before and now, in my view, has a lot of twists and turns to it as far as a definition. You could almost assume that if a midwife was delivering a baby and was monitoring vital signs while she was delivering a baby and perhaps gave some mild sedation and maybe inserted a speculum, in fact, what you have is a surgical service going on during the delivery of this baby by a midwife, and there could be a fine of $30 ,000 then charged against the midwife. It is up to the midwife, then, to prove her own innocence. I have some big concerns in terms of the

interpretation of various

definitions in here and how it actually affects midwiv es. While the minister may be sending out letters assuring everybody that no, no, midwifery is protected in this, what it could end up coming down to at some point is a court case and a judge then looking at these

definitions and making the determination as to what that actually stands for. Certainly, what this bill also seems to do is totally eliminate the possi bility of a hospice or birthing centres. I wonder if you have any concerns about that. Now, I understand, maybe, that the Government is not interested in birthing centres, but do you have any concerns around any of this in the act in terms of what it does to midwifery? Ms. Boscoe: Actually, we have had that conversation, and I think it is real ly important to differentiate in our minds between innovation in a public system and innovation in a for-profit system.

Our concerns are ones, for example, where a birth centre in a private sector would raise the same spectre that we are dealing with right now, which is that user fees would dis criminate against women unequally and create an eddy of injustice that will flow throughout the system. We are passionate about the idea of a birthing centre and more options for women. We are celebrating midwifery even now, a year later.

That being said, though, we are quite committed to working within a system for such things as a birth centre or a hospice, but those innovations can take place, just as the Women's Health Clinic does, within medicare. It is possible to be done. In fact, maybe just to elaborate, we have spent a lot of work iri the last decade on the issue of breast implants and access to information. This is a serv ice that is primarily in the for profit, outpatient clinic facilities in the province,

16 2 LEGISLATIVE ASSEMBLY OF MANITOBA July 3, 200 1 Mr. Chairman, and despite numerous discussions with ministers of Health and professional ac creditation, et cetera, we were unable to get full disclosure of what was going on there or even push for a good client-informed consent, because these things were happening in the private sector without our regular accountability mechanisms. I think that as women, we engage in the system with high standards and with high expectations and with the desir e to use our public, transparent institutions, not to go far afield. Mrs.

Driedger: When I look at the definition of private hospital, it has really nothing to do with whether it is in the public or private system . Basically, the definition, as it stands by itself, is a house where a woman is lodged for the birth of a baby. It does not go into whether that is happening in the public system or in the private system. That is the straight definition of private hospital. So now if one were to look at that, this act does not necessarily always take you down the line as to whether it is within the public or private system.

If you read each clause, clause-by-clause, there are many tentacles to how various pieces of this act are going to impact on other pieces of legislation. The

section on private hospital, if one were to look just at that, would mean that a midwife is delivering a baby in a private hospital when she is delivering a baby in a home. In fact, what this also does is it definitely eliminates, according to this bill, in my view, the develop ment of birthing centres, period. Ms. Boscoe: I must say I did not read it that way, and it certainly is not my in terpretation, for example, of interfering with an indivi dual woman choosing to birth at home, which is what I antici pate is behind that question. I do not read that at all into that clause. • (20:30) Mr.

Chomiak: Before I deal with the inaccurate reflections by the Member for Charleswood (Mr s. Driedger), I just want to comment on your presentation, which I thought was very, very useful. I want to just reiterate a couple of your points: Our physicians are public resources; Do not fix a system by creating a parallel system; For-profit encourages the use of the system; Qualit y assurances require even greater scrutiny in a private system.

I think by virtue of being a nurse, by virtue of being a doctor, by virtue of speaking as practitioners in a communit y clinic, you have brought a perspective to this committee that has not been here. We have heard from consumers, we have heard from organized indivi duals, we have heard from organizations, all valid argu ments, and I think you have added a perspective that is very useful. So I thank you for that. Just, however, though, I have to clear up the inaccuracies I heard earlier. I know this is common. If one is to take any piece of legislation and read a line, one could conclude anything.

That is qui te dangerous because legislation is generally read together as a piece of a whole act. One could take any word or one could take any phrase of a legislation and say whatever they want. With respect to the issue of birthings, where a woman is delivering in a home, she is not received and lodged for care and treatm ent for childbirth. The same could be argued with respect to a delivery that might be for the convenience of the woman giving birth in another person's house. In addition, birthing centres can be allowed under this legislation.

The legislation was designed specifically around all of these concerns, and they were all addressed by legal counsel, people who are experts. I am not an expert at putting together the words of legislation. I took courses in it, but I am not an expert at it. There are experts we have in the Legislature who provide that expertise. So I want to assure you that all of those considerations have been taken into consideration when the drafting of this legislation was put forward.

I just want to close again by thanking you for bringing that perspective, your perspective, to this committee and for some of the issues that you brought forward that had not been brought forward before. Thank you. Mr. Chairper son: Comment, Ms. Boscoe?

July 3, 200 1 LEGIS LATIVE ASSEMBLY OF MANITOBA 16 3 Ms. Roscoe: I would just li ke to add in closing that it might be useful for the commit tee to take a look at iatrogenic statistics. Doctor Scurfield allu ded to the fact that our pell -mell enthusiasm for intervention -sometimes it is a bit of the collusion of the public, consumers, interesting medical shows and practitioners, that there is signi ficant evidence that going in for treatment is a risk in itself. People make mistakes; there are side effects.

Going back to our earlier point around engaging the public in a bit more knowl edge about these realities, being on a waiting li st, you know the jokes about the death rate goes down when there is a strike by physicians, all those kinds of things, are realities. Though we are not experts, it mi ght be useful for the commit tee to educate itself a li ttle bit on that and it may take heart from some of the pressure in the lay media about waiting lists. Sometimes waiting li sts are good things. Mr. Chair person: Time for the presentation has expired.

Would you li ke to seek leave of the comm ittee to pose an extra question, Mrs. Driedger? Mrs. Driedger: Yes, I would. Mr. Chairperson : Does the comm ittee grant leave to Mrs. Driedger to ask an additional question? [Agreed] A brief question, Mrs. Driedger. Mrs. Driedger: I appreciate that from the commit tee. I just want to let you know I have spoken to a lawyer who has ind icated to me that the language in this act is poor. I am glad the min ister also just now made a comment about the value of a nursing perspective being brought to this. I am a nurse too.

I read this act from a nursing background, a health care background, and that is where some of my concerns come about. If a lawyer tells me the language in this act is poor, it is open to

interpretation and misin terpretation, I guess. I just really want to encourage you before we have a midwif e out there sued for $30,000 that you are indeed com fortable with this act. Ms. Scurfield: Well, just to assure you, the Colle ge of Mi dwi ves, which is the governing body for midwif ery, has had their own lawyer look at it and had also met with the lawyer from the Government to seek an

interpretation and is satisfied that it protects what mi dwiv es need to do in this province. Mr. Chair person: Thank you for your presen tation, Doctor Scur field. Bill 50- The Regional Health Auth orities Amendment (Accou ntabil ity) Act (Continued) Mr. Cha irperson : For clarification, we are going to move to Bill 50 now. Two names from Bill 25 were dropped to the bottom of the li st, but that is to the bottom of the li st of all presenters tonight, so if any of them have come back in the interim, I apologize, but you will have to wait.

On that basis, I call Mich ael Doiron of the Interfaith Healthcare Association of Manit oba, who will be speaking in place of Suzanne Dunwoody. Mr. Doiron, do you have a wri tten copy of your brief for the commit tee? Mr. Michael Doiron (Interfaith Healthcar e Association of Manitoba): I do. Mr. Cha irperson : The Clerk will distribute it. Please begin your presentation when you are ready, sir. Mr. Doiron: Mr. Chair man, honourable min is ter, honourable members of the commit tee, thank you for the opportunity to address you.

I represent the Interfaith Healthcare Associ ation of Man itoba, an organization which has nin e denominational sponsor groups and in the neighb ourhood of 35 facil ities in the province. We have an interest in this bill. Faith-based health care, as my coll eagues from the Obl ates have addressed you earlier on a previous bill so wel l and so eloquently, was indeed the first health care avail able in the west, and throughout many uni nterrupted years of faithful service, we have provided to the citiz ens of Manitoba a great deal of service and care.

This Government and many other previous governments have consistently recognized in

16 4 LEGI SLATI VE ASSEMBLY OF MANIT OBA July 3, 200 1 many forms, including faith-based agreements, the outstanding contributions made to health care by various denominational sponsor groups. The Interfaith Healthcare Association of Manitoba is comm itted to the goals of regionali zation in several ways, Mr.

Chairman: by promoting and emphasizing effective leadership and accountabil ities; building co-ordinated networks; establishing standards, benchmarks; promoting common managerial approaches, shared services and programs; maintaining effective accountabil ity with government and the RHAs; working towards a responsibil ity matrix with clearly defined roles and responsibil ities; determ inin g mechanisms for system-wide con sultation and co-ordination of the health system; and partnering with other health providers in meeting the needs of the population it serves.

Having said that, we are aware that in several other parts of the country, regionalization has meant centralization and the eradication of all boards other than the boards of the regional health authorities. We believe that such a view is erroneous and is ulti mately quite destructive to the cause of health care. We believe that the most effective form of regionalization inclu des not a single ownership, but multiple service providers with various perspectives which strengthen and enhance the cult ure and the quality of care available to the citiz ens whom it serves.

It is our bel ief that in five or seven or eight years, when regionalization ceases to be the flavour of the day, the rest of the country may well look at Manitoba and see that we got it right from the start. There is considerable evidence to support this, both nationally and internationally. We therefore would li ke to voice our strong agreement with the aspects of this legislation which acknowl edge and support the principles of faith-based health care as a valu e-added, and we applaud any view that recognizes our contribution as worthy of preserving.

We also support the approach of this legislation which chooses to build upon the carefully laid foundation of agreements that have been erected in this province, including the recently signed operating agreement with the Winnip eg Regional Health Authority and the hospitals in this area, also the various service purchase agreements which lay out the principles of mutual respect, responsibil ities, col laboration and accountabil ity so as to pre serve a spirit of col laboration and co-operation, as together we seek ways to provide the best health care possible for the citiz ens of Manitoba.

It would be our view that it would be foolhardy and reckless for a government to proceed otherwise. • (20:40) While we are commit ted to the view that the best of life is most often expressed in a community, we recognize and we respect the Government's need to provide for further authority to be extended to the regional health authorities. We believe that this legislation is an attempt to responsibly limit and contextualiz e such authority in a manner which is as respectful to the structures of health care in Manitoba as is possible in this present cli mate.

Thus, recog nizing a certain need for the extension of authority to the RHAs, we therefore applaud the attempt of the presently proposed legislation to be consistent with and to be dovetailed with the existing agreements, especially the operating agreement I just ref erred to. The members of the Interfaith Healthcare Association of Manitoba entered into and signed the various agreements with the Government of Manitoba in good faith, and we carry out all of those agreements faithfull y and respectfully.

We therefore accept and support the proposed legislation in its present form, and we express our view that we will find it to be as balanced and respectful a piece of legislation as possible. We would, therefore, consider it to be a great loss if it were to fai l, and we would therefore lik e to thank the Department of Health for proposing it. Thank you. Mr. Chai rperson: Thank you for your presentation, sir. Do members of the commit tee have questions? Mrs. Myrna Driedger (Cha rleswood) : Just to ind icate to you that I have had several

July 3, 200 1 LEGIS LATIVE ASSEMBLY OF MANITOBA 16 5 consultations with the faith-based community, and having worked as a nurse, well, at St. Boniface Hospital for a number of years, I have come to respect very much what the value of faith-based health care means to people in those facil ities. So, just to reassure you, we will be in support of this bill. We feel that it is moving in terms of closing the loophole of accountabil ity. While it does not quit e get there yet, it certainly is an attempt at this time to move in that direction.

As it has been told to me by people in the faith-based organizations, everything has been an evolution. It has been moving forward in that way, and just to reassure you that support for this bill will be forthcoming from us. Mr. Chai rperson: Mr. Doiron, comment? Mr. Doir on : Thank you. Hon. Dave Chomiak (Min ister of Health): Mr. Chai rperson, it is often the case in the Legisla ture that people actually realize there is more often than not unanimity in what we do.

I just want to thank you personally and the interfaith health organization for your assistance in this regard, and your kind words, as wel l as your assistance during the period of time of the drafting of the bill, where we had many discussions and where I learned, as I indi cated to you, many thin gs. I think I am a better educated and a more compet

Document details

Collection	Manitoba — Debates (Hansard)
Citation	37-2-ma4
Type	hansard
Volume / chapter	37th 2nd hansardpdf ma4.pdf
Language	en
Format	pdf
Source	PROVINCIAL
Identifier	cedfd55a3846946b6d6c3bbb4f28eb547933c331

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