by Paul Martin
The first discussion of public policy I can remember hearing as a young boy in our household was about health insurance: a program that was the product of tough negotiations between the provinces and the federal government. As federal minister of health and welfare for more than a decade, beginning in 1946, my father was determined to create a national public health-care system in Canada. It is not surprising that, as his son, I have always been an unequivocal supporter of a system that would cover all Canadians and would be publicly financed. Government financing means we pool the risk we all have of falling sick, instead of putting the financial burden on the most vulnerable, the sickest and the poorest among us. This is a deep philosophical commitment for me: it runs in my veins, you might say.
There is, however, a danger with a single-payer system such as ours, as there is with any monopoly: bureaucracies develop inertia and particular interests entrench themselves, to the detriment of those who are sick. That is why it is so important that our public system guarantees timely care. This is what lay behind the Chaoulli decision of the Supreme Court in 2005, which said that when governments put a universal system of health care in place, they must deliver those services in an equitable and timely way. The decision was essentially about wait times and what is reasonable. It will open the door to private health care in Canada if governments can’t get their act together and ensure the timely delivery of medical services.
The issue of whether some of our publicly funded health services could be delivered by private suppliers is a different one, on which I am more agnostic, providing quality care is not imperilled. The fact is most doctors work in private practice, and they represent the single largest expenditure in Canadian health care.
Aside from these large philosophical questions, health care faced other challenges by the time I became prime minister. The provinces had begun cutting hospital funding in the early 1990s and I compounded the problem considerably with the cuts in transfers made in the 1995 budget. As we emerged into the era of balanced budgets and surpluses, it was obviously important to reinvest in the system. It also gave us a chance to make sure results, including medical outcomes, would be evaluated and those responsible would be made accountable.
The health-care system is enormously complex and yet very personal in the way it touches our lives. Few of us go through a year without visiting a friend or a loved one in hospital, or perhaps spending time in one ourselves. Most of us go to the doctor from time to time and, if we are lucky, have a relationship with a physician, which can be an important element in our good health. Because of that intimate contact, each of us evaluates the success of the health-care system much more directly than we do other government programs.
During the 2004 election, I had made a campaign stop in St. John’s, where I spoke to the Canadian Nurses Association national convention, and I did something out of character for me. I spoke in public about the days I spent in the hospital with polio as a child. I told them about my memory of lying in a bed in a ward with other boys who had polio, and how one day the orderlies had brought a huge machine into the room. I asked the fellow in the bed beside me, who was a lot older, what it was. And he said, “That’s an iron lung. You’re going to go out of here in one of those. All of us are going to go out of here in an iron lung.”
I told the nurses how I remember feeling terribly alone, since my parents could only stand at the window at the end of the ward and wave to me. So there I was, eight years old, faced with the possibility of living the rest of my life in this huge machine and nobody to talk to. At one point, a nurse who was working on the ward came by, and realized that I was upset. So she sat down and started to talk. The next night she came by again, and again she sat and talked with me. She did this night after night, usually after she finished her rounds.
Then, one day she wasn’t there for her rounds and I really felt very badly. It was her day off. But a while later, she turned up at my bedside at the usual time. She had come in to the hospital on her day off just to talk to me. I can’t remember much about my experience with polio any more, except that one thing: that a nurse came and talked to a little boy, and I’ll never forget that.
It was a more personal story than I am usually comfortable sharing in public. But I was glad I did. It felt as if I was saying thank you after all those years and I’m glad to recount it here for the same reason.
Of course, everyone knows that it is harder and harder for those in the health professions to give that kind of care because they are stretched to the breaking point. And of course, there is no way of measuring the tenderness I was lucky enough to receive. What you can measure, however, is how long it takes to get care of any kind: wait times, in other words. You can argue that there is much more to the functioning of the health-care system than wait times. But the time it takes to see a general practitioner or a specialist, or to get into the hospital for an operation, or how long you spend waiting in the emergency room are very good indicators of whether you are getting reasonable access. And that’s how most people think about medicare. In a private system, such as in the United States, access to health care is rationed by the ability of a patient to pay; in a public system such as ours, health care ends up getting rationed through waiting lists, and those of us who believe in the future of public health care know they’d better be short.
Shorter wait times should be part of a broader set of reforms that directly relate to people getting better care and more quickly resuming their normal lives, which is why I was determined as prime minister to drive the process: to see the establishment of “benchmarks.” If the public could see that it was taking longer for a hip operation or an MRI than the benchmarks said it should, it would help rally public pressure for increased health-care reform. The deficit had been conquered when I was finance minister because public opinion was mobilized behind what had to be done — an important element of which was laying out specific, achievable targets and then meeting them. I was convinced the same approach would work for health care.
In the 2004 campaign, I promised to give the provinces stable, long-term funding for health care at a higher level, with a special emphasis on reducing wait times. The federal government had been in the habit of settling five-year deals with the provinces on health transfers, but they were constantly being renegotiated before being implemented because they were imposed by Ottawa from on high. The result was that Canada’s “health-care debate” wasn’t really much more than a perpetual federal-provincial squabble about money. Right after the election, I called the promised first ministers conference on health for September in Ottawa.
Before meeting with the premiers, I obviously leaned heavily on Ian Green, the deputy minister of health and Janice Charette, the associate deputy minister. Needless to say, the appointment of the former premier of B.C., Ujjal Dosanjh, as health minister gave us a provincial insight that was invaluable. He was also passionately committed to medicare and had stated that it was an essential component of Canadian citizenship. He was the right person in the right place at the right time. I also sought advice from some of the most knowledgeable people in the country outside the department, including Senator Michael Kirby and Michael Decter, a former public servant with a special expertise in health-care management, whom I consulted many times. I also spoke to Roy Romanow, whose Royal Commission on the Future of Health Care in Canada would play an important role in shaping our policy and influencing the fiscal debate at the premiers meeting. Finally I sought out Monique Begin, who had been the federal minister of health when the Canada Health Act was introduced and who along with Michael Dector had been there whenever I needed their advice.
At the federal level, we had to resolve some issues before negotiations with the provinces began. The first was how much money we were prepared to pony up, and over how long a term. We figured that amount was $42 billion over ten years, including the annual escalators. We were determined to get agreement on the annual increases to the transfers, so that we would not find ours
elves back at the bargaining table every two years, confronted with new demands. But this was going to be a bargaining session, and we did not want to reveal our hand before I met with the premiers. In public we announced that we were prepared to put $15 billion on the table, and an “escalator clause” that would regulate annual increases, but we were deliberately vague about what that was and what it would cover. Although the premiers had announced they wanted us to contribute a flat 25 per cent of the health-care system, we did not agree.
The morning before the day of the conference, I met with the three territorial leaders over breakfast to discuss the unique health-care challenges facing the Northern territories. I committed $150 million targeted at long-term health-care reforms in the North because I knew that national solutions to problems don’t necessarily work North of 60. From much higher costs due to the vast distances between remote communities, to the severe health challenges in our Aboriginal population, delivering health care presents more problems than most of us in the South would realize.
That evening, I had dinner with the premiers at 24 Sussex to get the discussions started in as informal a way as possible. In his inimitable fashion, Ralph Klein left early in order to visit the casino across the Ottawa River in Gatineau. I told him if he won, the federal government would expect royalty payments. He then returned to Alberta to prepare for his coming election campaign, leaving behind his minister of health, Gary Marr, to represent his province.
The next day I convened the meeting at the Government Conference Centre, which was the old downtown Ottawa train station, across the street from the Château Laurier Hotel. During the election I had promised to televise our discussions, which in retrospect was a mistake. In general, I am a great believer in transparency in government, which is why I made the promise. Unfortunately, the presence of the television cameras tempted the premiers to berate the federal government over their grievances, many of them real and a few imagined. I should have known better. At one point, an open microphone picked up a voice saying “Jesus Christ!” in reaction to something a premier had said. The hunt was on for the guilty party. Later, I had to ’fess up, and told the conference about a call I had received from my Aunt Anita and my Aunt Claire, who had recognized my voice and scolded me for my bad language.
While the premiers went after us in public, we knew we had the resources to address most of their real concerns and did not want to back anyone into a corner. We did not want to respond to their jabs, though it probably would have been good politics. I wanted a win for health care, and politics wasn’t going to get that. I understood the premiers needed to vent. I did not want to score points; my goal was to reach an agreement.
Despite the public posturing, the serious negotiations went on behind closed doors. We had a marathon closed-door bargaining session at 24 Sussex, where I was able to take advantage once again of my ability to power-nap while Lucienne Robillard as minister of intergovernmental affairs held the fort downstairs. Unlike the CSL negotiations years before, where I had been forced to resort to sleeping on the library floor, this time I had my own comfortable bed just upstairs, and I was able to retreat unnoticed for twenty minutes to refresh myself and go back at it.
Around eleven o’clock that night, we ordered pizza for the premiers and their staffs inside 24 Sussex — and for the media who were huddled out on the sidewalk. It was only when the TV cameras started to roll on the house manager, Hilary Nicolson, as she arrived with the take-out boxes that it occurred to us that the footage of a health accord catered by a pizza chain might not be the enduring image we wanted for the negotiation. Dalton McGuinty, who, you may have noticed, cuts a slimmer figure than some of us, turned down the pepperoni and bacon special in favour of an apple that Jim Pimblett managed to rustle up from the kitchen.
Eventually, after much back and forth, the provinces, ably led by Premier McGuinty, came up with a counter-offer. McGuinty’s chief of staff, Don Guy, went on a walk around the block with Tim Murphy and they thrashed it out. Then Tim briefed Ujjal Dosanjh, Alex Himelfarb, Lucienne, and me. The provincial counter-offer was $41 billion and was within the limit we had previously set for ourselves. Even before McGuinty, who was acting as spokesman for the premiers, presented what he called their “final offer,” we knew we were closing on a deal.
All that remained was to put in place the agreement concerning evidence-based wait time benchmarks and provincial targets. I believed that if the Canadian Institutes for Health Information were to report publicly on what was happening on wait times province by province, sector by sector, from heart surgery to joint replacement initially, expanding the list over time, public opinion would drive reform. Eventually, thanks to Premier Campbell and a smaller committee of premiers, the provinces came onside. As a result we named Dr. Brian Postl of Manitoba wait times adviser. This was an important appointment, as he played a crucial role in keeping everyone’s feet to the fire.
In the end, we got the deal we wanted for the country, a win for everyone. An extremely important element from the federal perspective was that it allowed for a 6 per cent escalation in costs each year, and had a term of ten years. This made it politically difficult for the provinces to keep trying to reopen the agreement.
From my perspective, something crucial for the future of the federation was that for the first time, unlike previous health-care negotiations, the provinces actually signed the deal, including Quebec. We also signed a side agreement with Quebec, allowing for a separate process of establishing benchmarks. This pleased me because it demonstrated a flexibility that in my view should be considered a normal part of the federal system in this very diverse country. As intergovernmental affairs minister, Lucienne Robillard was instrumental in securing this success, and Jean Charest was so excited with what we were signing that he asked to keep the pen!
Reaching an agreement had taken nearly five gruelling days, but it was worth it. Much of the commentary at the time dwelt on its implications for the survival of our minority government rather than the effect it would have on Canadians’ health care. From my perspective, however, by resolving our differences with the provinces on health funding we had achieved my first objective for the new government before the new Parliament had even met. The issue of funding had been disposed of for a decade. So far this has allowed both levels of government to turn their minds away from squabbles over money to the need for further changes to improve patient care, to address issues such as how to improve health-care management and how to stay abreast of new technology.
The health-care agreement was a major success, but it will require further work to close the loop. As the process of establishing benchmarks widens in scope, and targets are set by the provinces in more areas of health care, the federal government needs to make sure that the public has a clear way of monitoring progress, in order to maintain pressure for further reform. The agreement signed with the provinces was quite clear on this point. That being said, all governments have the responsibility of ensuring this transparency and all governments have the responsibility of ensuring the continued reform of the public health-care system. That in essence is what the 2005 health-care agreement was all about.
In Canada, as in many parts of the world, we have tended to think about our health-care system primarily in terms of treating the sick, thereby neglecting the other elements of health, which include the prevention of disease. We received a sudden and dramatic lesson about what this means in 2003, when Canada lost forty-four people in a very short period to Severe Acute Respiratory Syndrome, more commonly known as SARS. The epidemic had begun in south China but very quickly spread to other countries, including Canada, probably because of the close business and personal relations between people in Canada and Hong Kong. The Canadian epidemic was concentrated in Toronto and Vancouver, but the economic and social effects were much broader geographically than the disease. The Conference Board of Canada estimated that the outbreak cost Toronto $1 billion in lost economic activity. Even in Montreal — a city
without one reported case of SARS — newspapers reported that the Chinese restaurants were empty.
The crisis exposed our lack of infrastructure for dealing with such a public health emergency. I did what I could at a symbolic level to quell people’s fears, which, despite the seriousness of the outbreak, were somewhat exaggerated. I was upset by the images of Canadians walking their own streets wearing protective breathing masks, so I made a public visit to Toronto’s Chinatown during the leadership campaign, popping into shops along Spadina Avenue and meeting with leaders of the Chinese community in a restaurant along with Tony Ianno, the local MP.
When I became prime minister, I was determined that Canada would never again be caught unprepared in a crisis like this. I appointed Dr. Carolyn Bennett, a Canadian physician of wide experience and the MP from St. Paul’s in Toronto, as the first-ever minister of state for public health. In the next two years thanks to her drive we created the Public Health Agency of Canada, headquartered in Winnipeg, where there already was a laboratory for studying the world’s most infectious diseases. To head the agency we appointed Dr. David Butler-Jones as the first chief public health officer of Canada. He proved to be an articulate and outspoken advocate for public health, and with Dr. Bennett’s support helped turn the Public Health Agency into an organization with the capacity and the mandate to prepare for future crises. The truth is that we still have a long way to go in developing techniques of preventing the spread of disease. But I believe the creation of the Public Health Agency will be seen as a major step in Canadian health care, and that it will continue to grow in importance. There are many reasons for this, including the continued failure of the world to understand the need to deal with the health issues that flow from globalization.
