Jan 23, 2003

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In Praise of the Romanow Commission

The Romanow commission's recommendations are detailed, specific and answer many of the hopes of we who presented.
By Tom Koch

The criticism of Roy Romanow's report on the future of Canadian health
care began days before the final report itself was published. His conclusions would be expensive, inconclusive, we were told. It would not consider the legitimate role of the private sector in Canadian health care.

After it was published Quebec premier Bernard Laundry was quick to insist the proposed federal supervision of provincial health care spending was intrusive and unnecessary. The proposal for a broad national council including citizen involvement was quickly rejected by officials.

I was a participant in the Romanow commission's public consultation and am today a fan of the resulting recommendations. They are detailed, specific and answer many of the hopes of we who presented. As a secondary benefit there was the process of his commission itself.

Of course the system needs more money. On this everyone is agreed. The additional $7 billion the final report argues the federal government should spend on health care is not new money to be devoted to health care. Even if all the dollars were immediately allocated it would only return federal participation in national health care to a 25 per cent partnership.

That is far less than the federal provincial partnership of the Canada Health Act's early years. In a reasonable world a quarter involvement by the nation in the health care of its citizens would be seen not as excessive but as minimal.

Romanow recommended the money be targeted in specific funding areas. These include, for example, expensive diagnostic equipment and services largely ignored in provinces in the 1990s. According to a 1999 report by B.C. physician and analyst Bill McArthur, Canada's diagnostic infrastructure was among the lowest of OECD nations, somewhere around Turkey's. Comparing B.C. and Washington State services, our health service's diagnostic equipment was found to be wanting.

The failure of federal health participation in the 1990s left provinces relatively free to do what they would in the health arena. More federal monies should require greater national involvement in the re-creation of enforceable national standards. These are clearly needed.

The Canada Health Act includes principles of both portability and comprehensiveness. The former assures people from one province will be able to receive treatment, if needed, in another. Comprehensiveness guarantees a minimum standard for Canadians everywhere.

Both are legitimate goals. They protect us as Canadians and, not coincidentally, protect provinces that meet a national health standard from having to bear the burden of citizens from provinces that do not. At least in theory, it permits a province, that is asked to care for another's patient to be repaid for the services provided.

What gives the Romanow report its legitimacy is the work that went into it. His team prepared an extraordinary review of the healthcare experiences in both North America and Europe. More importantly, however, his commission offered a uniquely Canadian knowledge base, one based upon the coast-to-coast public hearings held last year.

Unlike U.S. senate hearings or the typical parliamentary investigation, Roy Romanow and his minions held hearings in a number of cities and listened to almost everyone who wished to speak to them. The result was not simply extraordinary theatre, but a uniquely Canadian voice.

In the Vancouver hearings, where I spoke, the voices were diverse. A woman whose husband had died of cancer and who had not received sufficient counselling cried for more care for the terminally ill and their families. A woman with relapsing and remitting MS argued for the introduction of holistic medicines that, she believed, had helped her control her disease.

A health economist presented graph after graph to make his point. Health unions argued their case against the changes under way in B.C. Not only did Roy Romanow listen with attention, but he closely questioned each presenter. Romanow had clearly read and considered the submissions each of us had written before the hearing.

Time and again a presenter would say, “I don't expect things to change. I figure the government's mind is made up.” Time and again, Romanow replied, patiently and as it turns out, accurately, “My mind is not made up. I want to hear and promise to consider what you say.”

Here was attention to the vox populi. Participating in the exercise was the rarest of experiences: democracy in action.

My case is not unusual. Romanow interrupted me as soon as I began my prepared speech on the need for federal financing. “Excuse me,” he said. “Weren't you on TV last night talking about disabilities?”

I was stunned. I had indeed been interviewed for a CBC news special on persons with disabilities that had aired the night before. I had not expected Roy Romanow to watch it. “Are you going to talk about that here?” he asked. “This is something I haven't heard about and I want to understand.”

In the question period following my presentation he grilled me for several minutes on issues of disability and the needs of those with disabilities seeking inclusion in the greater community. Afterward we talked, I agreed to send a short, supplemental submission to his commission on the subject.

Similar things happened, I suspect, in city after city. Wherever Romanow went he heard about ideas for reform not commonly discussed and about persons not cared for, constituencies whose health services were insufficient. Time and he again he got excited and asked for more.

The result of the exercise - the sum of our voices - went beyond the typical rhetoric of cost-efficiency, cost-effectiveness, about what we cannot afford. Rather, the Romanow report began with a broadly Canadian sense of what we need to fund and provide to all.

In B.C., at least, we have become accustomed to hearing about what cannot be done. We have been told repeatedly what cannot be afforded. It has made us weary and defeated, ready to accept retrenchment as a necessity.

Roy Romanow's exercise reminds us that we can define what we need, and then insist upon it. His most critical conclusion was that if provinces cannot do the job the federal government must assist, and that assistance will include the legitimate right of the nation-at-large to insist on certain standards and on the methods of their implementation. Government-at-large can and must assure what this or that regional government chooses not to provide in an appropriate and timely manner. That alone is what we academics like to call a fundamental conclusion. It changes the discourse of health from “we cannot” to “we will and must.” In B.C., that's a refreshing change, and a cause for hope.

Tom Koch is an adjunct professor of gerontology at Simon Fraser University and a bioethicist concerned with issues of disability.

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