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Social Cohesion and Privatization in Canadian Health Care

Published online by Cambridge University Press:  18 July 2014

Hugh Armstrong
Hugh Armstrong
Affiliation:
School of Social Work, Carleton University, Ottawa (Ontario)CanadaKIS 5B6, [email protected]
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Abstract

This paper addresses some of the tensions for social cohesion presented by Canada's medicare system. This system, which constitutes the country's best-loved social program, is broadly governed by the five principles of the Canada Health Act. Independently and together, these principles promote social cohesion. Medicare is however also under threat from various elites, who favour elements of its privatization, and whose principal strategy is here termed privatization by stealth. The argument that privatization is disruptive of social cohesion is advanced in general terms and with specific reference to the case of Ontario's Community Care Access Centres, which broker public funds to non-profit and for-profit home care agencies across the province.

Résumé

Cet article traite de certains aspects du système de santé canadien qui secouent la cohésion sociale. Le plus populaire de tous les programmes sociaux, le système de santé, est régi par cinq principes définis dans la Loi canadienne de la santé. Chacun en soi et comme ensemble, ces principes contribuent à la cohésion sociale. Le système universel est cependant sous attaque de la part de différentes élites qui souhaitent privatiser certains éléments et dont la stratégie principale est appelée ici privatisation à la dérobée. Le texte aborde la rupture de la cohésion sociale par la privatisation de manière générale mais aussi en analysant le cas des centres communautaires ontariens d'accès aux soins qui sous-traitent, à travers la province, des fonds publics à des agences de soins à domicile qu'ils soient à buts lucratifs ou non.

Type
Citizenship, Social Rights and Social Cohesion Citoyenneté, droits sociaux et cohésion sociale
Information
Canadian Journal of Law and Society / La Revue Canadienne Droit et Société , Volume 16 , Issue 2 , August 2001 , pp. 65 - 81
Copyright
Copyright © Canadian Law and Society Association 2001

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References

1 On ‘social cohesion’ see, for example, J. Jenson, “Mapping Social Cohesion: The State of Canadian Research” (Ottawa: Canadian Policy Research Networks, 1998) [hereinafter “Mapping Social Cohesion”] especially at 29–39; P. Bernard, “Social Cohesion: A Critique” (Ottawa: Canadian Policy Research Networks, 1999).

2 Blendon, R. J. and Taylor, H., “Views on Health Care: Public Opinion in Three Nations” (1989) 8:1Health Affairs at Exhibit 4.Google ScholarPubMed

3 Canada Health Monitor, 1995, cited in The Economist Intelligence Unit, “Profile - Canada healthcare struggles with its five principles” (1998; 1st quarter) EIU Healthcare International at Figure 4.

4 See, for example, Gee, M., “Health care is No. 1 concern: poll” The [Toronto] Globe and Mail (7 February 2000) A5Google Scholar, reporting on an Angus Reid poll that listed medicare / healthcare as the top issue for 55%, with education / schools a distant second at 23%, and taxes / tax reform / GST third at 19%. See also “Important issues” Toronto Star (1 July 2000) K2, reporting an Ekos poll listing health care as the most. single issue facing Canadian governments over the next five years, according to 25%, well ahead of level of taxation, unemployment, debt and public finance, and education, each at 7%. An earlier Environics poll had found that “extra money” should go to job creation projects (31%), health care (25%) and reducing taxes (9%), reported Greenspon, E. and Winsor, H., “Spending increase favoured: poll finds” The [Toronto] Globe and Mail (23 January 1997) Al, A8.Google Scholar

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7 “Mapping Social Cohesion” supra note 1.

8 Ibid. at 38.

9 Quoted in “Mapping Social Cohesion” ibid. at 4.

10 Canada Health Act, R.S. 1985, c. C-6.

11 By contrast, the Clinton proposal for universal health care in the United States in the early 1990s took the form of a draft bill covering 1370 pages. It was difficult for all but the most dedicated policy wonk to understand in its entirety, while providing ample grounds for opposition from numerous quarters.

12 See for example Voelker, R., “Activist Young Says ‘Gathering Storm’ Will Propel a Single-Payer Movement” (1997) 280 JAMA 1467.Google Scholar

13 Of late, the majority of Canadians opposed to queue-jumping has actually risen, despite (or perhaps because of) cuts to publicly-funded services. In response to the statement: “Individuals should be allowed to pay extra to get quicker access to health care services,” 55% disagreed while 34% agreed in November 1996. By December 1999, 61% disagreed while 29% agreed. Ekos Research Associates, “Canadian Values in Health Policy,” (Paper presented to the Centre for Health Economics and Policy Analysis (CHEPA) conference, June 2000) [unpublished].

14 Marsh, L., Report on Social Security for Canada (Toronto: University of Toronto Press, 1975)Google Scholar [first published 1943] at 10.

15 Andrews, C., Profit Fever: The Drive to Corporatize Health Care and How to Stop It (Monroe ME: Common Courage Press, 1995) at 90Google Scholar, citing Rolde, N., Your Money or Your Health (New York: Paragon House, 1992) at 7.Google Scholar

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17 Priest, L., “Gloom about health care widespread” The [Toronto] Globe and Mail (3 February 2000) A4.Google Scholar It should be added, however, that according to the Canadian Healthcare practice of PricewaterhouseCoopers, 92% of those who actually used the health care system in late 1999 and early 2000 were satisfied. This semi-annual survey was formerly known as the Canada Health Monitor. PricewaterhouseCoopers, News Release, “Canadians Satisfied with Health Care; Concerned about Home Care and ER Waits” (1 November 2000).

18 Donelan, K.et al., “The Cost of Health System Change: Public Discontent in Five Nations” (1999) 18:3Health Affairs Exhibit 2.Google ScholarPubMed See also Coutts, J., “Canada no longer enjoys image as Shangri-La of medical care” The [Toronto] Globe and Mail (27 October 1998) A12.Google Scholar

19 Ovenden, N., “Canadians gloomy about the future of health-care system” Ottawa Citizen (1 March 1998) A3Google Scholar, reporting on an Angus-Reid poll.

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22 G. Scott, “Post-Summit Communications with the Media: The Text of the Statement by the Summit Moderator, in Access to Quality Health Care supra note 21 at 65–66 [hereinafter “Post-Summit Communications”].

23 “Rationale for a Summit” in Access to Quality Health Care supra note 21 at 7.

24 It is worth noting that the “Summit” was co-sponsored by the CMA, along with Liberty Health, MDS Health Group Limited, and SHL Systemhouse. Among the 50 or so who were invited were the Chairs, CEOs and Presidents of Bell Canada Enterprises, Hewlett-Packard Canada, Trimac, Medisys, Biomara, BC International Power, and Stelco, along with senior Vice-Presidents from Alean, Nestlé Canada, and CP Rail.

25 “Post-Summit Communications”, supra note 22 at 65.

26 Ibid. at 67.

27 I am of course borrowing the term from Ken Battle. See his “The Politics of Stealth: Child Benefits under the Tories” in Phillips, S. D., ed., How Ottawa Spends, 1993–1994 (Ottawa: Carleton University Press, 1993) 417 at note 32Google Scholar, where he points out that making significant public policy changes by technical means without voter knowledge or consent is not new, but that the Mulroney Tories did so extensively and “in a deliberate, calculated manner that definefd] their style”. See also his (writing as Gratton Gray) “Social Policy by Stealth” (1990) 11:2 Policy Options.

28 For an elaboration of the forms sketched here, see Armstrong, H., Armstrong, P. and Connelly, M. P., “The Many Forms of Privatization” (1997) 53 Studies in Political Economy 3.CrossRefGoogle Scholar

29 Canadian Institute for Health Information, (January 2000) CIHI Directions ICIS at 3.

30 This line of argument is nicely made with regard to arts funding in Drainie, B., “We pay the piper, but they call the tune” The [Toronto! Globe and Mail (21 December 2000) A19.Google Scholar

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32 Hon. Jim Wilson, “Notes for Remarks for Community Care Access Centres” Toronto, 25 January 1996. As the then Minister of Health for Ontario, Wilson was announcing the establishment of the community care access centre (CCAC) system.

33 National Forum on Health, supra note 5 at 19.

34 This metaphor is drawn from the influential US book by Osbome, D. and Gaebler, T., Reinventing Government: How the Entrepreneurial Spirit Is Transforming the Public Sector (New York: Penguin, 1993)Google Scholar c. 1. It is reflected in the language of Ontario's (then) Minister of Health, who stated that her Ministry was shifting “in emphasis from being a service provider to becoming a system manager.” Hon. Elizabeth Witmer, “Message from the Minister” Ontario Ministry of Health Business Plan 1998–1999, online: Government of Ontario http://www.gov.on.ca/MBS/english/press/plans98/moh.html (accessed 6 June 1998).

35 This care is not being sent back home, for the acuity levels now being coped with at home were never previously cared for there. Our grandmothers did not work IV equipment or clean shunts. See Armstrong, P., “Closer to Home” in Armstrong, P.et al., Take Care: Warning Signals for Canada's Health System (Toronto: Garamond Press, 1994) 95.Google Scholar

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37 Ontario Ministry of Health, News Release Backgrounder, “Long-Term Care Services in Ontario” (6 September 2000) put the 2000–01 budget for the province's 43 Community Care Access Centres (CCACs) at “over $1.1 billion in annual funding,” an increase of $439 million since 1995. Almost all of this amount goes to home care, as does much of the additional $190 million the province allocates each year to long-term care community agencies such as local cancer societies and meals-on-wheels organizations.

38 It is close to half as much in the broader category of “other health expenditures” reported by the Canadian Institute for Health Information (OHI), a category that includes such items as transportation (ambulances), public health and health research as well as home care. CIHI has announced that it intends to break out home care as separate (public and private) expenditure categories, but has not yet done so. See CIHI, “Preliminary Provincial and Territorial Government Health Expenditure Estimates” (Ottawa: CIHI, 2000).

39 For example, a maximum of 80 hours of homemaking (personal support services) are allowed in the first month, and a maximum of 60 hours in every subsequent month. Ontario Regulation 386/99, made under the Long-Term Care Act, 1994, “Provision of Community Services” (filed 6 July 1999), Section 3(1). Similar caps apply to nursing services.

40 Calculated from Ottawa-Carleton Community Care Access Centre, “2000–01 Budget” (March 2000), Exhibit 9, Community Therapy Services - Divestment.

41 Using a less conservative approach, Ross Sutherland estimates that $247 million is wasted annually by Ontario's CCACs on contracting out and competitive bidding. R. Sutherland, with assistance from S. Marshall, “The Costs of Contracting Out Home Care: A Behind the Scenes Look at Home Care in Ontario” (Ottawa: Canadian Union of Public Employees, 2001) at 19.

42 Braverman, H., Labor and Monopoly Capital: The Degradation of Work in the Twentieth Century (New York: Monthly Review Press, 1974) at 303.Google Scholar

43 If the goal is managed competition among fully integrated services, from home care to tertiary care, an enrolled population of 500,000 to 750,000 is required to make each competing organization viable. This would mean that in Canada competition would be possible only in Toronto, Montréal and Vancouver.

44 Polanyi, K., The Great Transformation (Boston: Beacon Press, 1957)Google Scholar [first published 1944] at 141.

45 Hon. Jim Wilson, Minister of Health, letter of 30 May 1996 to Ontario Home Health Providers, Canadian Red Cross Society (Ontario Division), Victorian Order of Nurses (Ontario), Ontario Community Support Association, and Saint Elizabeth Health Care.

46 Ontario Ministry of Health, “Provincial Requirements for the Request for Proposal Process for the Provision of In-Home Services, Supplies and Equipment” (May 1966) at 1.

47 Bueckert, D., “Victorian Order of Nurses faces bleak future” Toronto Star (28 December 2000) A3.Google Scholar

48 “Olsten says it's facing another billing probe” Financial Post (25 January 2000) C2. See also Handelman, S., “What Alan Rock Isn't Saying” Time (14 February 2000) at 40Google Scholar; YahooFinance website on 27 November 2000.

49 Miller, A., “Nashville, Tenn.-Based Healthcare Firm Agrees to Pay Fine for Government Fraud” Atlanta Journal and Constitution (15 December 2000Google Scholar). HCA agreed to pay SUS95.3 million in fines and penalties and to plead guilty to 14 counts of defrauding government health care programs.

50 Medline, E., “Ontario cancels dialysis clinic deal” Ottawa Citizen (3 May 1996) C1.Google Scholar See also the series of front-page articles on National Medical Care, a for-profit firm controlling over 20% of the entire US market, by K. Eichenwald in The New York Times (4–6 December 1995).

51 The wording of this pre-qualification criterion is that potential contracting agencies must “[h]ave no material legal cases pending or in the recent past”. To satisfy itself on this score, the CCAC asks in its template RFP the following questions: “Within the last five (5) years has the Agency or its Predecessor Organization, or any organization with which it is associated within the meaning of the Income Tax Act, or any of its officers or directors: a) been bankrupt or been subject to any other insolvency proceeding; b) been found guilty of any criminal offence; or c) been the subject of any civil proceeding based upon fraud, misrepresentation, criminal conduct or negligence? Is the Agency (or any of its officers or directors) presently subject to any such insolvency, criminal or civil proceeding?” Ottawa-Carleton Community Care Access Centre, “Request for Proposal for the Provision of Medical Supplies and Equipment” July 2000, at S-3. The same wording appears in the subsequent School Therapy and In-Home Speech Therapy RFP and is to be included in further RFPs.

52 The concept of ‘contract government’ is insightfully addressed, in the context of British universities, by Dominelli, L. & Hoogvelt, A. in “Globalization, Contract Government and the Taylorization of Intellectual Labour in Academia” (1996) 49 Studies in Political Economy 71CrossRefGoogle Scholar, especially at 74–78.

53 Commission d'étude sur les services de santé et les services sociaux (Commission Clair), Solutions émergentes (Québec, 2001); Fyke, K.J., Commissioner, Caring for Medicare: Sustaining a Quality System (Regina: Government of Saskatchewan, 2001)Google Scholar; Commission on the Future of Health Care in Canada (Romanow Commission), appointed 3 April 2001, to report by 30 November 2002; Canada, Standing Senate Committee on Social Affairs, Science and Technology (Kirby Committee), “The Health of Canadians - The Federal Role” 2th Session, 36th Parliament, to report by 30 June 2002.