Two women died in Nova Scotia recently despite having presented themselves at hospital emergency rooms for treatment. One woman – only 37 years old – waited six hours for treatment at a hospital in Amherst Nova Scotia. She was in such extreme pain that she was unable to sit in a wheelchair and wound up lying on the floor and crying out from her pain. By the time the emergency room staff finally got around to treating her it was too late, and she died. Cause of death was internal bleeding. She had been suffering pain ever since a fall off a horse some three months previously. Image

The other woman was suffering from pain in her jaw and “flu-like symptoms”. She waited for some seven or eight hours in a Sydney emergency room and then returned home when she was told that she wouldn’t likely be seen until the next morning. She died within an hour of returning home with fluid build-up around her heart. 

The first incident, the Amherst fatality, prompted calls for a public enquiry, and/or an emergency debate in the Nova Scotia Legislature. By far the most common reaction from politicians, and from news networks has been “the system is broken”. I think that’s true. But quite honestly someone at the pointy end of the stick in this system, broken or not, failed. My understanding is that emergency rooms operate on a triage system, not on a first come, first served basis. The victim in Ahmerst was lying on the floor because her pain was so intense she couldn’t sit up. The very first step in the process – the recognition by the triage team that she was in serious difficulty – failed her. Similarly, in Sydney, the woman was presenting with symptoms that pop right up on my screen when I google heart attack symptoms, but she was allowed to leave the hospital and die at home. Have our Health Care workers gotten to the point of saying “don’t bother me now. I just can’t deal with any more people. You’ll just have to wait.”? 

If that’s what happened, I suppose it’s a system failure. On the other hand if a professional in the system performed a triage evaluation and decided she could wait, then there’s a problem with that individual’s triage skills on top of the larger systemic failures.

That unfortunate digression into ill-informed finger-pointing and blame-throwing was really unnecessary. I accept totally that health care  systems across the country are broken and need to be fixed. Whether some unfortunate health care professional needs a remedial training course or not doesn’t really affect the bigger picture.

I saw Nova Scotia Premier Tim Houston interviewed on Power and Politics (CBC). He campaigned on a promise to do something to fix the health care system in his province, and in the interview, he went on to say that he had not only thought that the system would get worse before it got better, he’d gone on the record to say so. I have some advice for Premier Houston, and for all the other Premiers. The advice is simple. Fix it.

I have observed, with some sympathy, the provincial Premiers and their Health Ministers trying to gang up on the Prime Minister and the Federal Minister of Health to restore federal funding so that they can fix the broken systems. But, do you know who’s accountable to deliver health care within the province? It’s the responsibility of the provincial government. “But we cannot do it”, the provinces say. “Mean old Trudeau won’t give us the money we need to get it done.”

Here’s the kicker. The provinces don’t need to get the money from Trudeau. The provinces have taxation powers to raise the money they need from their own populaces. There is no constitutional impediment. The Provinces could simply decide that the medical system is broken, and people are dying in hospital waiting rooms, and it will take X Billion $ to rectify the problem and so our provincial income tax is going up, and so is our HST tax rate. 

There is not even, in my opinion, a huge political cost from making that decision. A provincial government that took that step could campaign on the basis that we got it done, that we cared about people’s health and that in the absence of support from the Federal Government (F’ing bully!) we took decisive action to remedy the problem (My Hero!). And if they all chose to do that together, wouldn’t it leave Messieurs Trudeau and Duclos in an awkward position?

It doesn’t much matter which government raises the money. Do I care whether it’s Trudeau or Ford who’s taking new money from my pocket to fix the Health Care system? No, not a goddamn bit. In either event, fixing the system will cost money and it’s going to be extracted from my pocket. I don’t care who grabs it as long as quality health care is restored.

Prime Minister Trudeau is on record saying that the provinces need to agree to “reform and improve their health care systems”. He’s saying “you’re not getting money until you fix the system” and the provinces are saying “we can’t fix the system without more money”. And while they try to make whatever political hay they can out of those positions, people are dying needlessly in hospital waiting rooms. It’s pretty sad.

I began looking for articles on the Canada Health Act to see what it actually requires of the provinces and of the federal government. Let me give you a little bit of dry summary of the act, and I’ll then get into some juicier observations on how it’s being implemented and what that means for Canadians.

There are five key principles of the Canada Health Act as follows:

1. Administration – The Health Care system in each province or territory must be administered on a non-profit basis by a public authority.
2. Comprehensiveness – The wording of the Act is “In order to satisfy the criterion respecting comprehensiveness, the health care insurance plan of a province must insure all insured health services provided by hospitals, medical practitioners or dentists, and where the law of the province so permits, similar or additional services rendered by other health care practitioners.” That’s a terribly badly worded criterion, but what I think it means is that if doctors are doing heart transplants and tonsillectomies, you cannot choose to fund the heart transplants and ignore the tonsillectomies.
3. Universality – the health insurance coverage applies to all legal residents of a province or territory.
4. Portability – You become a member of a provincial plan within three months of moving there, and you are covered by your plan for emergent medical needs while temporarily absent from the province.
5. Accessibility – The intent of the accessibility criterion is to ensure that insured persons in a province or territory have reasonable access to insured hospital, medical and surgical-dental services on uniform terms and conditions.

In addition to the principles of health care, the legislation sets out two “conditions” and two “provisions” for continued federal support for their health care programs. The first condition is that the province must provide information to the feds as required by regulations pursuant to the act. And the second condition is that you “are required to recognize the federal financial contributions toward both insured and extended health care services.” So, we actually have written into the legislation that provincial government must kiss federal ass every time they make a payment. Now there’s a truly functional requirement that makes health care systems work better – not! 

There are also the two provisions, and those are that the provincial health plan must not permit extra billing or user fees, because these charges constitute a barrier to access and violate the principle that all persons must have access to government provided health care.

I expect that I will return to the subject of extra billing and user charges and private facilities in some future article when I think about, and do some research on, what a medical care system ought to look like. But in the meantime, let us examine the current situation.

The Federal Ministry of Health produces an annual report. While seeking something else, I found myself in the 2014/2015 report. I found the following little tidbit in the section where the government is patting its own back about what a great job they are doing enforcing compliance to the act: “Charges for preferred accommodation are permissible under the CHA only where such accommodation is not medically required, and is provided at the patient’s request. If ward level accommodation is not available or cannot be offered, patients must be provided private or semi-private accommodation at no charge. In January 2014, Health Canada learned that two hospitals are being built in Quebec that will have only semi-private and private rooms, and that the Quebec health ministry considered permitting these hospitals to charge fees for all stays. Health Canada reviewed the applicable provincial and territorial legislation and policies and found similar practices in Ontario and British Columbia. In July 2014, Health Canada informed the health ministries of British Columbia, Ontario and Quebec that such charges are contrary to the CHA. British Columbia has since corrected the problem, while Ontario and Quebec are still examining the issue.”

My reaction to that? What a crock. First of all, the Ministry says that if you don’t have ward level accommodation, you have to be prepared to offer semi-private or private accommodation as an insured service. So, three provinces say, “Sure, we’ll do that. We think a modern hospital will work better that way”, and the Federal Government says “No, you have to design hospitals to our expectation”. Overbearing, paternalistic bastards.

Also in that report, was this paragraph: “In November 2014, Health Canada provided an advance assessment under the CHA to Nova Scotia on a proposal by some ophthalmologists to charge patients for certain tests when they are performed in the physician’s office instead of a hospital, in respect of the cost of the technology used. Health Canada confirmed that no additional fees can be charged in conjunction with a medically necessary physician service.” I guarantee that what that brilliant decision did was to limit the availability of ophthalmology testing in Nova Scotia. The physicians aren’t about to buy that expensive equipment with no means to be reimbursed for the cost, so they’ll write requisitions for testing at the hospital. The patient, denied the opportunity to pay $20 for an immediate service, will join the queue at the hospital and make the line-ups there even longer. Good call fellows!

The 2020/2021 annual report lists the recent history of deductions made from Health care transfers to the provinces as punishment for the failure to completely suppress extra-billing and/or user charges in the provinces. It says “Since the passage of the Act, from April 1984 to March 2021, deductions totaling $101,610,131 have been taken from transfer payments in respect of the extra-billing and user charges provisions of the Act. This amount excludes deductions totaling $244,732,000 that were made between 1984 and 1987, and subsequently refunded to the provinces when extra- billing and user charges were eliminated.” Per that paragraph, approximately $350 M has been withheld from the provinces as punishment. Of that amount, a quarter of a billion dollars has been reimbursed when the provinces danced to the Feds’ tune, leaving the provinces short by a hundred million dollars. 

Why are those things happening? It doesn’t matter, and the Federal government really doesn’t care. The legislation says punish those bastards, and they happily oblige.

Look, I understand that user fees and extra-billing are complex and potentially divisive issues. But the system is failing to deliver adequate health care all across Canada. Is the Federal Governments best answer really to take away the tools needed to do the job? 

The Provincial governments are demanding that the Federal Government provide additional funding. They claim that after promulgation of the Canada Health Act, the Federal share of health care was 50%, and that it has now dwindled to 22%. It’s not surprising that they claim they need more money.

Trudeau’s response is that it’s really 33% when you do some fancy accounting tricks. And both Trudeau and his Health Minister, Jean-Yves Duclos are insisting that any increase in funding must be tied to approval and acceptance of a national human resources and data collection programs. M. Duclos was quoted in a Globe and Mail article saying “All that premiers keep saying is that they want an unconditional increase in the Canada Health Transfer sent to their health ministers. That is not a plan; that is the old way of doing things. If there was anyone still doubting it, the current crisis is the undeniable proof that the old way doesn’t work. We need to do things differently.”

Really? Really? If only we had a better human resources database, all our medical system problems would disappear? Please understand that this solution has been brought to you by the people who brought you the Phoenix pay system for Federal employees. 

Just to keep this bipartisan, let us acknowledge that the pay systems mess started way back in the Brian Mulroney days. They issued a $45M contract to Accenture. Mulroney lost the next election, so Jean Chretien and company terminated the Accenture contract and settled the resultant lawsuit for an undisclosed amount. In 2011, the Harper government issued a contract to IBM. In 2016, the Trudeau government rolled it out, despite a Treasury Board report that said it wasn’t ready. It was a disaster.

The University of Regina used the who thing as a case study. The case study noted that “In 2019, Parliamentary Budget Officer Yves Giroux said the final cost to taxpayers could top $2.6 billion, almost 10-fold the initial budget of $300 million.”

So no, it doesn’t feel to me like now is the time to divert money and attention and energy from real health care issues and turn to human resources database issues.

I think the Federal government needs to stop focusing on peripheral issues, stop playing for political advantage, and start addressing the delivery of health care. And to that end, they should start aggressively funding health care. The money entrusted to their care has not been given to them for the care and political advancement of the Liberal Party of Canada. It has been given to them to buy things that Canadians need, and right now they need health care.

As for the Provincial government, I sympathize with them for the position they’re in. However, it’s time for them to stop using the federal government’s inaction as an excuse. You cannot blame the federal government for inaction and remain inactive yourself. Provision of health care is a provincial accountability. Accept, if necessary, that Trudeau isn’t going to fix this. Bite the bullet and move ahead immediately, leaving an embarrassed Prime Minister to explain why he isn’t participating in the resolution of a national health care crisis, and why he has forced Provincial governments to significantly increase the tax burden on Canadians in the middle of this inflationary crunch.