Debates of April 27th, 1995

Supply

[John Williams, Reform, St. Albert, AB]

Mr. Speaker, I will answer the question of what I mean by competition.

I gave the United Kingdom example, not the United States example, where the cost to the consumer is absolutely free. Yet even the United Kingdom has developed internal markets where hospitals can compete against each other in delivering price, service and quality. These are the three fundamental elements of service one finds when there is competition. If we eliminate competition, we find waste, mismanagement, poor service and declining quality. These are the things we have in our health care system today because of lack of competition.

I said nothing about the American situation except that I did not even consider it to be a competitive market. I used the United Kingdom as an example. It is the cradle of social health care systems in our western world.

The hon. member's first question was on which of the five principles we would abandon. We would abandon the 100 per cent publicly funded principle. We would still ensure that health care was largely funded by the taxpayer, but we are not saying there should be an ironclad guarantee that it has to be 100 per cent. I believe publicly administered elimination of competition is totally detrimental to our system.

[John Harvard, Liberal, Winnipeg—St. James, MB]

Mr. Speaker, I think the member for St. Albert really does not get it especially when he advocates competition among insurers. The evidence is absolutely overwhelming that when there is a single public insurer as we have in this country, that is by far the most efficient and cost effective system. The one way we can control costs is when we have one public single insurer.

I was watching an American doctor on CBC television last night. Perhaps the member also saw him. His name was Dr. Katz. He spoke about the American system with competition among insurers which the hon. member champions. He said that the doctors and insurers cherry pick. They are not interested in you if you do not have money and are not wealthy. Can you imagine a system in this country where there was competition among insurers? Does the gentleman from St. Albert really think if he had a long history of heart trouble, the competitive system would be interested in him? Of course not.

The system with competition among insurers is only interested in the healthy and the young. You talk about privatizing the system. That is what you are talking about.

[The Acting Speaker (Mr. Kilger)]

Order. I would like to remind members to direct their interventions through the Chair.

[John Harvard, Liberal, Winnipeg—St. James, MB]

Mr. Speaker, I want to make one more point. When we privatize the system there is no trouble in taking costs off the public books. We could transfer $1 billion or $2 billion, perhaps even more from the public books, that is medicare, over to the private sector. When those costs show up in the private sector, because of wasteful competition the cost will not then be $1 billion or $2 billion, it will be $3 billion or $4 billion.

The hon. member is dealing in illusion, is that not true? That is my question.

[John Williams, Reform, St. Albert, AB]

Mr. Speaker, if the hon. member for Winnipeg St. James does not understand how competition works, then I would propose that he is the one who is under complete and absolute illusion.

I will refer to the point made earlier by the member for Beaver River in talking about health care and will use the point of the member for Winnipeg St. James who is a government member. Why are members of Parliament entitled to a benefit under the public service health care plan that costs us absolutely nothing yet all other members of the plan, be they civil servants, have to pay $10.35 a month as family members? That is the first of this two-tier system which is creeping in.

Not only that, the member for Ontario has told us that dental services are not covered under health care. Why not? Why would people not want to have dental plans if they want to have their health plans? Because the country cannot afford it. We must realize that there will be abuse of the system unless there is a fee for use, however small.

I will finish on the last point the hon. member made. The member for Winnipeg St. James may think that one single insurer, be it the government, is the most efficient way to run a program. I am sorry but I think he does not understand the first simple fact about economics which realizes that competition gives the best quality and the best service at the lowest price. That is the point.

[Ronald J. Duhamel, Liberal, Parliamentary Secretary to President of the Treasury Board]

Mr. Speaker, it seems to me there is a certain amount of confusion in the member's mind and I do not say that unkindly.

Would the member take the time to rapidly identify the expectations from the federal and provincial governments in the

ideal health care system he described? Many of his expectations in his comments do not belong to the federal government, constitutionally speaking.

Just to give a very quick example about the confusion, in the Canada Health Act there is no prohibition on profit. There is a section where it is not possible to have a health care system that makes a profit. It must be operated on a non-profit basis.

My colleague seems to confuse the two in the Canada Health Act on that particular feature. I get the impression that my colleague is looking for a Pizza Pizza health care system. That is what it sounds like to me. Would he care to comment?

[John Williams, Reform, St. Albert, AB]

Mr. Speaker, my comments were made in all seriousness and had nothing to do with pizza whatsoever. I was merely trying to make a point that competition provides the best service and the best product at the least price.

As I said, in the United Kingdom, not the United States, the cradle of social health care has introduced internal markets where one health care institution competes against another. In that way they are seeing the price come down, the service go up and the quality remain high. At the same time the taxpayer is getting a better deal and a better return on his investment. That is in the United Kingdom. It has nothing to do with the United States. It is still absolutely free to the consumer.

My point is there are many options. The hon. member asked me how I would see the ideal system. The federal government is retreating from funding of health care from 50 per cent down to 23 per cent and falling rapidly. Surely it should recognize that its insignificant contribution it is now making will force the hands of the provinces to go their own way. Therefore because it is a provincial responsibility under the Constitution I feel they should be making up their minds on how it should be done.

[The Acting Speaker (Mr. Kilger)]

It is my duty, pursuant to Standing Order 38, to inform the House that the question to be raised tonight at the time of adjournment is as follows: the hon. member for Notre-Dame-de-Grâce-Access to Information Act.

[Dianne Brushett, Liberal, Cumberland—Colchester, NS]

Mr. Speaker, I will share my time with the hon. member for Winnipeg North.

It is a great pleasure for me to participate in the debate on health care today. There are few issues which we speak of here which touch as many Canadians as health care. It is a central issue to the people of my riding, as it is to all Canadians. They appreciate the security which our health care system gives them and they firmly believe that commitment must be continued.

As we are in a time when there are questions about the commitment, some in the House favour steps which I believe would move us down the road to a two tier system, one for those with money, another for those without. Some in the House favour the balkanization of health care with a withdrawal of federal government from any real role in the health care field. How much support is there really for either of these perspectives? From what I hear from my constituents, not very much. They support the leadership which the federal government has taken on health care issues.

Leadership does not mean rigid centralization. In my remarks today I want to emphasize the flexible nature of federal co-operation in health care. More specifically, I want to talk about the Canada Health Act. This law is not a straight-jacket on the provinces; not now, nor has it been, nor will it be in the future.

The Canada Health Act is a very short piece of legislation. At its heart are five principles grounded in common values which we hold as Canadians, values very close to the hearts of every Canadian. They represent the essential ground rules that most Canadians expect the provincial and territorial governments to respect when it comes to guiding principles of the Canada Health Act. Let me talk about each one of them and the reasons for which every one still matters to the federal government and to every single Canadian.

The first principle is universality. Quite simply, the federal government provides financial support to provincial health insurance plans, plans that cover all citizens. People cannot lose their health insurance because they might be too costly for the system to cover or because they may be unemployed or because their health may be a high risk.

The second principle is accessibility. This means we should not face any financial barriers in receiving necessary health care: no extra billing, no user fees, no facility fees. If the service is medically necessary it will be delivered on the basis of medical considerations, not financial considerations.

The third principle is comprehensiveness. It recognizes Canadians have a range of health care needs and that those needs should be met. The Canada Health Act requires that all medically necessary services be covered.

The fourth principle is portability. This means Canadians should maintain their health coverage when they travel.

The fifth principle is public administration. Our health insurance plans must be operated by a public authority accountable to provincial governments and operated on a non-profit basis.

At various times since the act was passed in 1984 there have been issues that have brought these principles into focus. Between 1984 and 1987 extra billing and user charge penalties were levied against several provinces.

More recently, extra billing has occurred in British Columbia and we have acted by making deductions to the transfer payments. We now see other questions emerging, for example, as the Government of Alberta pushes its agenda of private, for profit health care.

These principles do not extend to dictating how provinces should run their system or what they should cover. Since the beginning of federal support for health care in 1957, decisions regarding what is a medically necessary service have been up to each of the provinces to determine. After all, they manage the system. They have the constitutional authority. They work with the appropriate medical experts and also pay a substantial portion of the cost. It is not for Ottawa to say this procedure or that procedure must or should be covered.

It is better to leave the responsibility of determining medical necessity to the provinces and to physicians who deliver services and are aware of the circumstances under which they are delivered.

The Canada Health Act also leaves much to the discretion of provinces; ensuring the services of health care professionals other than physicians, charging for semi-private or private room accommodations requiring prior consent for elective health services provided out of province, and financing for a variety of methods not including those that require point of service charges.

Remember, the Canada Health Act does not force a province to comply to its requirements. The provinces can accept the cash penalties and allow the non-compliant situation to persist.

These facts alone show that any claims of rigid centralization are simply not founded. That will continue to be the case as we renew the health system.

The federal government and the provinces recognize the health system has to change. Provincial authorities are trying many different ideas in their efforts at renewal. They will continue to experiment but as long as they adhere to the five principles of the Canada Health Act it is unlikely there will be any disputes.

Not one of the principles in the Canada Health Act prevents us from looking at innovative solutions to health care issues. They simply define the limits of the system in a way that Canadians who rely on the system want it to continue. It is not a free for all. Canadians believe some limits are necessary and useful to preserve our accessible and comprehensive health care system which is available to all Canadians.

The federal government is equally committed to finding better ways to achieve our health goals. The most high profile element in that approach is the National Forum on Health. This was a red book commitment and it is a commitment that we have met.

The forum was created to help us adapt our health care system to the new social and economic realities of today. It will create a vision for health in the 21st century. It is made up of 24 Canadians, health care professionals, volunteers and health care consumers from across the country. It is chaired by our Prime Minister, with the Minister of Health acting as vice-chair.

Canadians understand these issues, as does the forum. They want to spark a frank and open dialogue with each citizen about the challenges that will influence the kind of health care we will receive in the future.

There is the impact of technology, the impact of new drugs, of aging and emerging possibilities thanks to research and great technological innovations. Our challenge is to deal with them in a thorough, comprehensive and sensitive way.

We anticipate an open process of consultation that reflects the attachment Canadians feel toward health issues and the commitment to finding real solutions. The government believes the National Forum on Health represents an excellent opportunity to address the future of health of all Canadians in a comprehensive and open way.

The forum is not going back to square one. It is working within the principles of the Canada Health Act quite simply because those are fundamental values that every Canadian has asked the government to respect, to maintain and to deliver on.

I want to end my remarks by saying that despite the ill informed critics, the Canada Health Act is still a valuable piece of legislation, one that enjoys the greatest support of the public. It is probably the greatest factor that binds Canadians together today. It is the underpinning of a system based on universal access to high quality, efficiently run health care. It is not a monument and our task is to find new and efficient ways to achieve better health goals for all Canadians.

As we undertake this process the federal government will continue to be an important source of the funding that keeps the system going. It will continue to be a staunch defender of the Canada Health Act. It will still work with medical practitioners and professionals, but we will protect the system.

The federal government intends to play the national role in health care that Canadians have asked us to do and that Canadians expect we will do. The Canada Health Act will be an important and flexible part in the role of health care in the future.

[Rey D. Pagtakhan, Liberal, Winnipeg North, MB]

Mr. Speaker, I am pleased to address this motion put before us by the hon. leader of the Reform Party:

That this House recognize that since the inception of our national health care system the federal share of funding for health care in Canada has fallen from 50 per cent to 23 per cent and therefore the House urges the government to consult with the provinces and other stakeholders to determine core services to be completely funded by the federal and provincial governments and non-core services where private insurance and the benefactors of the services might play a supplementary role.

I hasten to say that by laying out his party's true agenda for health care in Canada, the leader of the Reform Party has dispelled any doubt that his party stands against medicare as we know it today with its five principles of universality, accessibility, comprehensiveness, portability and public non-profit administration.

So many times in the House we have heard members opposite insist they support medicare. What we have in this motion is the Reform Party's advocacy for a multi-tier health system, one standard for the rich and one standard for the poor.

His motion proposes governments get together with stakeholders to determine core services and non-core services. The member further proposes that only core services be completely funded by governments, while non-core services be left to patients who, in the Reform Party vision, should pay out of pocket for supplementary health insurance.

[The Acting Speaker (Mr. Kilger)]

I wonder if I could draw the attention of the colleagues nearest the member for Winnipeg North. A microphone very close by is also open and we sometimes have some difficulty hearing interventions. I ask for your co-operation.

[Rey D. Pagtakhan, Liberal, Winnipeg North, MB]

This kind of approach by the Reform Party of cost cutting simply will not work.

I call the attention of the member opposite to a recently published book entitled Public Finance in Canada . It states that increased cost sharing in government medicare plans, where the policyholders can afford them, have great potential for reducing health care spending. However, it adds for such plans to be effective governments will have to ban the development of supplementary health insurance that will turn the patient's share of cost into a third party payment.

Simply put, increased cost sharing will have to be made mandatory and applied to all insurance plans, public and private, which would require increased government regulation of the health insurance industry.

I am perplexed that the Reform Party with its penchant for less government involvement is now calling for the very opposite. Is this a deliberate change of policy or a lack of understanding of the dynamics of health care financing in Canada?

The Reform Party is proposing a return to user fees. One very noted Canadian health care economist said that this is like a zombie, not to be resurrected again. User fees deter necessary care just as much as frivolous care. Reformers are showing signs that they have not even read the literature.

I am proud to be a member of the Liberal Party of Canada, which in 1919 conceived the idea for a national medicare plan. It is a party that in government gave birth to its reality. It is a party that when in government again nurtured and restrengthened the national health policy with the passage of the Canada Health Act of 1984. It is the legal centrepiece of our medical system as we know it today and a system that bans user fees and insists on equal access for all citizens regardless of their financial means.

The proposal by the Reform Party might not pose a problem for those with six or seven figure incomes but for me, for my Winnipeg North constituents and for the vast majority of Canadians it is utterly unacceptable. Inevitably we would be left with a system in which only the financially fit would survive. That sort of social Darwinism is anathema to the government.

The government is not looking to make Reform Party style compromises where the health of Canadians is at stake. Yes, this government has acknowledged the need to contain health care costs, which in 1991 were roughly equal to 10 per cent of the gross domestic product.

The difference between the government approach and the policies embraced by the party opposite is that the government is not prepared to surrender the principles of medicare to fiscal constraints but instead is working to balance fiscal responsibility and the preservation of medicare.

The solution is not easy. The government believes in a more imaginative approach than simply wielding a broad scalpel and cutting away indiscriminately at medicare as the Reform Party proposal would do.

Utilizing alternative modalities to achieve desired health outcomes and substituting equally effective lower cost treatment approaches for the traditional are parts of a strategic approach to meaningful reform of the health care system.

For example, more patients could be managed at home on an outpatient basis rather than in hospital. Patients could be encouraged to see their family physicians before consulting specialists. Medications could be used instead of surgery where possible. Other health care professionals could substitute for medical doctors in defined areas of treatment. Some of these approaches may require legislation to ensure that health care professional substitution does not compromise standards.

Another means of controlling expenditures without compromising quality of care involves eliminating costly waste in our system. Just as certain established medical routines, such as annual physicals and routine chest radiographs of tuberculosis patients on follow up have been discredited as effective and efficient health policies, other diagnostic and therapeutic routines should be scrutinized. There could be a greater reliance on physiotherapy and less on orthopaedic surgery.

Physicians should not hesitate to debate the issue of human resources supply in relation to the per capita needs of the community nor the issue of arranging funding so that moneys will be allocated according to patient needs and not the provider's level of activity.

All of these elements and many more constitute an effective health care reform strategy which would ultimately yield greater dividends for all Canadians in contrast to the quick fix, multi-tiered system the Reform Party proposes.

The government has positioned itself as a staunch defender of medicare as we know it but that does not mean it is committed to the status quo. It means that the government will continue to explore creative and cost effective options for maintaining health care for all Canadians in accordance with the five principles of medicare.

That is why the government has launched the National Forum on Health chaired by the Prime Minister. That is why the Canada health and social transfer program is now being negotiated between the provinces and the federal government, giving provinces the flexibility to deliver the health care system but, at the same time, maintaining the five principles of medicare. Then and only then can we ensure the crown jewel of our social programs survives and is strengthened. We can also ensure the quality of health care for all Canadians, rich or poor.

In conclusion, I appeal to the Reform Party to withdraw its motion rather than face the certain defeat it merits from the majority of the House, who have been sent here by the vast majority of Canadians to be their voice and their guardians and to defend, preserve and strengthen medicare.

[John Williams, Reform, St. Albert, AB]

Mr. Speaker, I was quite eager to note the emphasis the member for Winnipeg South put on one of the principles of their pillars of health care, accessibility. If I may read again from the letter from the director of home care at the Sturgeon Health Unit, Carol Simms: "There is decreasing access to acute hospital care".

I would like to ask the member for Winnipeg South if this is the type of access he wishes to guarantee where people who have need of access to an acute care hospital cannot get it under this system? Is that the type of access he wishes to guarantee for Canadians?

[Rey D. Pagtakhan, Liberal, Winnipeg North, MB]

Mr. Speaker, of course that is not the access I would like to see happen. We recognize the problem and it must be solved. But their treatment for the problem is wrong. That is the difference between the Reform Party and the Liberal Party.

We must explore the means to solve the problem, not propose a solution that will create another problem where the ultimate result is even an greater lack of accessibility to the health care system.

[Alex Shepherd, Liberal, Durham, ON]

Mr. Speaker, I was interested in the comments from the last exchange. The hon. member for St. Albert mentioned his concern about home care in his riding.

I read an interesting article the other day. It said that the evolution of the medical practice involves more home care. Patients are better taken care of in their home environments and to some extent actually display better recovery rates. I wonder if what he is looking at is not a problem but a possible positive solution to some of the problems in health care.

[Rey D. Pagtakhan, Liberal, Winnipeg North, MB]

Mr. Speaker, I thank the hon. member for his comment and question. Before I entered Parliament in 1988, I presented a paper in Australia at the International Congress on Cystic Fibrosis. My paper was about home care treatment of patients with cystic fibrosis, giving them intravenous antibiotics at home. It can be done. We were able to decrease the health care cost sixfold. At the same time, even more important, we were able to enhance the quality of care for these patients.

I congratulate the hon. member on his insight as to the importance of home care. We must provide the resources for home care and not misplace our focus on a wrong approach as the Reform Party is trying to propose.

[Herb Grubel, Reform, Capilano—Howe Sound, BC]

Mr. Speaker, as a professional economist before coming to Ottawa I had taken some interest in the economics of health care. In 1992, I published two editorials on the subject in the Medical Post .

Today I would like to share the most important insights about the problem of health care I have gained from these studies and suggest some policy initiatives based on them. These ideas are my own and not necessarily those of the Reform Party.

I believe the public provision of health care through the present Canadian system is bedevilled by a fundamental problem which is due to the absence of a deductible and of co-insurance. This problem is amenable to relatively easy solutions once political and ideological rhetoric is put aside.

Of course, the system has other problems. There are no patent solutions. Some of these problems involve fundamental issues of technology, incentives, values, ethics and morality. I will not discuss these today.

I would like to remind everyone that the Canada Health Act has created a gigantic system of insurance. Every Canadian contributes premiums through general taxes. Benefits are provided to anyone without the need to pay financial deductibles and co-insurance. As everyone knows, our system has produced a wonderful world in which every taxpaying Canadian is eligible to receive free of any charge general medical care, specialized services and hospitalization. Congratulations Canada.

In my view, one of the most important reasons for the financial problems which undoubtedly now are haunting our system stem from the absence of deductibles and co-insurance. I have reached this conclusion because the absence of restraint on demand stemming from this completely costless service has resulted in very large increases in demand. This is not a universally accepted proposition. Therefore, I would like to illustrate its validity by making reference to two historic experiments of public insurance systems that failed because of the absence of deductibles and co-insurance.

The first involves the government automobile insurance monopoly introduced by the NDP government in British Columbia in 1972. It started with great fanfare, having no deductibles at all on any repairs on cars, on the grounds that even small scratches and dents on cars ultimately lead to more serious problems. Therefore, it was argued it was wise to encourage repairs of such damage at no cost since some shortsighted owners might be discouraged from having the work done by a deductible of $50 or $100 or whatever it might be. The rest is history. The policy was cancelled by that same caring, foresighted NDP government because it was simply too costly.

The second experiment involved the British government, which in the early days of the public health scheme argued that no one in Britain should suffer because he or she did not have the money to pay for medication. I have heard the same arguments here about access to health care. I wonder why the rhetoric from members of the Liberal Party has not also extended to medication. After all, some people are suffering because they do not get all the medication they want just like that. They may have to spend some money.

The universally free dispensing of medication was ended after only a short time. Costs had become much higher than had been anticipated by a study of demand, a study which had been conducted under conditions when people paid for their medication. Studies have shown that if the cost is free it is easier to go back to the pharmacy to get medication rather than look for it in the medicine cabinet. People ended up with huge stocks of medication which were finally flushed down the toilet at an extremely high cost to society.

These two examples are instructive for Canadian medicare. The policy of having no deductibles or co-insurance in Canadian health care was motivated by the noblest of intentions, just like they were in the case of automobile insurance and free medication in England.

We need to take care of the needs of the most poor in society and we must prevent serious problems which might develop if small ones are neglected. The two experiments were terminated because of the universal law of demand. The price was too low and demand became too high. I believe that what we are seeing after 20 years of operation in Canada is exactly the same situation. That is one of the main reasons why the Canadian health care system is in such financial trouble.

There is a fairly straightforward solution: introduce user fees. However, there is a strong resistance in Canada to the use of this instrument.

We heard them just a few minutes ago. The arguments are the traditional ones: care about access for those who cannot afford it, and those who, even if they can afford it, are stupid enough to let illnesses go and the consequences will be more costly than if they had taken care quickly of the illness symptoms at the beginning.

Some even argue, somewhat more sophisticatedly, that the inconvenience of visits to physicians and the risk associated with all medical procedures represent a strong deductible and co-insurance. Others argue that the deterrent effect of such measures is small and not very cost effective. This is the position taken by my colleague at the university of British Columbia, Bob Evans, a professor of health economics, one of the most highly respected and best known economists in Canada. I disagree with him.

The arguments against deductibles and co-insurance involve empirical judgment on the way in which these incentives are introduced. I would now like to propose and outline briefly a scheme for the introduction of co-insurance and deductibles, which I have published in the Medical Post . It can be summarized quickly as follows.

Every doctor visit or treatment by a Canadian elicits a government notification of the cost involved. One gets a little postcard saying that your visit on such and such a day cost society and you $30. At the end of every tax year, the value of the medical services consumed is added as income when we file our income tax.

Think about what this would do. The poor would have access. Universality of access would be preserved. In the end, the poor would not pay anything. One of the most cherished, basic,

fundamental characteristics of our system would be preserved, one I think is worth preserving. Of course, the better off who have income tax to pay would as a result pay a share of the cost they have incurred on society.

Now I must state something that immediately comes up whenever I discuss this in a public forum. Of course there would have to be a ceiling to the amount of money that individuals would have to add to their income tax as income and on which they pay taxes. I do not even want to venture what it is, but maybe nobody would have to pay more than 5 per cent or 10 per cent of their income.

One of the most important things that every health care system must present is protection against the catastrophic consequences of serious illnesses. That could be preserved and will be preserved by the proposal I have just outlined.

One of the biggest problems I have is with the idea that these incentives of people paying their own money, in a way, having a deductible and co-insurance, would not work. Just recently I received some information about experimentations that are going on in the rest of the world. I would like to share these ideas with members.

I found the following. Most health economists agree that the primary reason why health care costs are rising is that the money we are spending in the medical marketplace is usually someone else's. More than a decade ago, the Rand corporation discovered that when people are spending their own money on health care, they spend 30 per cent less, with no adverse effect on their health.

Now it turns out that in the United States some employers are experimenting in putting this principle to work. Please do not be turned off by the idea that I have just mentioned that this is taking place in the United States.

Let me set the stage. Here are companies whose names I will read off that have for their employees systems of health care that are superior to that available to every Canadian. They have health insurance from the first dollar. They have catastrophe insurance. They are employed. They are very well taken care of.

Here is the experiment: Forbes magazine pays each employee $2 for every $1 medical claim they do not incur up to a maximum of $1,000 a year. For every time they look at what it costs to go to the doctor and they decide not to go during the year, they can earn as much as $1,000 extra income. Forbes' health costs fell 17 per cent in 1992 and 12 per cent in 1993.

Another example: Dominion Resources, a utility holding company, deposits $1,620 a year into a bank account for the 80 per cent of employees who choose a $3,000 deductible rather than a lower one. The result is the company has experienced no premium increase since 1989, while employers face annual increases of 13 per cent.

Another example: Golden Rule Insurance Company deposits $2,000 a year into a medical savings account for employees who choose a $3,000 family deductible fee. The result is in 1993, the first year of the plan, health costs were 40 per cent lower than they would otherwise have been.

Take the United Mine Workers, a union that is very concerned about the welfare of its members. Last year they had a health plan with first dollar coverage for most medical services. This year they accepted a plan with a $1,000 deductible. In return, each employee receives a $1,000 bonus at the beginning of the year and employees get to keep whatever they do not spend. As a result, the mine workers still have first dollar coverage plus all the catastrophe insurance coverage and all that, but now the first $1,000 they spend will be their own money rather than their employer's money.

These plans are popular with employees. They can save money in an amount directly related to their own effort. They are not deterred from seeking medical care by the traditional out of pocket deductible. They can usually use their medical savings to buy services not covered by traditional services, and they are usually not restricted to certain doctors, as they would be under a managed care plan.

We have here very strong evidence that deductible co-insurance works. It works in ways that satisfy the people who are involved.

Let me try in my own words to explain what are the fundamental benefits. These experiments have permitted individual employees to feel clearly and voluntarily that under a wide range of conditions they would have gone to the doctor if it cost them nothing, but when faced with the true cost of the doctor visit they preferred having the money instead.

It is important to note that under these medisave schemes that I have just described individuals retain the benefit of full protection against the consequences of serious illness. They are making these choices with their own money. We have just deleted the distortion the zero deductible and co-insurance system has introduced into the incentives of the individual. They are being misled by the system into believing that for them and society the cost of going to the doctor is zero. It is not.

As we can see, individuals like it if they are given the choice, the freedom to do so. They prefer it. And the system itself saves money. It is an opportunity that I believe we in Canada can also take advantage of. Of course there have to be modifications, because we want to preserve the current system of universality of access and all the other aspects we have just discussed.

Let me conclude by suggesting that these well documented experiences provide strong support for the effectiveness of introducing deductibles and co-insurance into the Canadian health care system through the tax system I just sketched. It could be modified and create more positive incentives by giving every Canadian a $1,000 tax offset against which the cost of medical services would be deducted. I think that very quickly after such a system is introduced people would know about it and they would pay attention to these things.

However, I believe these are details. I want to add to the current debate over the possible reform of the health care system the idea of using deductibles and co-insurance for routine medical services, administered through the tax system, while the system continues to provide universality of access and protection against catastrophic health costs.

Let me repeat: It is possible that this scheme-which not only I have proposed in the Medical Post editorial, but which has been proposed by the Fraser Institute competition for the reduction of the cost of government and has been proposed by other doctors who wrote to me after my publication-may very well be a way in which Canada can have all the wonderful qualities of our system we now have and create incentives for greater efficiency and prevent the demise of the system, which otherwise might collapse under the threat of excessive financial costs.

[The Acting Speaker (Mr. Kilger)]

Questions or comments. I just want to remind the House that at 5.46 p.m. I will suspend the debate to move on to private members' hour.

[Dan McTeague, Liberal, Ontario, ON]

Mr. Speaker, I will ask two very direct questions to the hon. member, given that time is limited.

The system he is proposing is a claims bonus system. In my view, it contradicts the public health preventative care policy we are concerned with in this country. Someone who might, for instance, suffer a headache and does not go to a doctor or a health care facility might otherwise wind up with an aneurism, which of course will be more expensive to the health care system. That is only an observation, but it connects with my previous question.

A more important point is the one the hon. member made concerning deductibles. I am wondering if the hon. member has discussed this with his colleagues, including his leader, who during the 1993 campaign cited: "I want to make it absolutely clear that the Reform Party is not promoting private health care, deductibles or user fees". I think the hon. member has to check his facts and perhaps check with his leader. Could he please respond to that?

[Herb Grubel, Reform, Capilano—Howe Sound, BC]

Mr. Speaker, I thank the hon. member for this silly remark.

We are talking about something that has potential, regardless of what my leader said a year ago. I do not care. I present this as my personal opinion. Every time I go on a radio program or any time I present it to a general audience, they ask why we are not doing this. It is because of silly remarks of the sort I just heard.

[Dan McTeague, Liberal, Ontario, ON]

Your leader said it.

[Herb Grubel, Reform, Capilano—Howe Sound, BC]

My leader had not had the opportunity to hear what I had to say when he made this remark. It takes time for these ideas to spread.

I think it would be very much in the interest of Canada if members from the other side opened their minds just a little bit. There might be ideas out there that they have not thought of that would do exactly the same thing they want to do, except it would save the system at the same time.

Let me read something. Some critics claim that these medical service accounts that have been experimented with in the United States will encourage people to avoid preventive care. Yet experience shows that the reverse is true.

I wonder if the member would please listen.

Medical service accounts make money available immediately when the medical need exists. This allows people to make purchases they might not make if they had a traditional deductible requiring an immediate out of pocket payment. Therefore his objection to this scheme is simply incorrect. We would preserve exactly what we have now. It is not a traditional deductible system.

On the other hand, it is quite clear that I am prepared to continue to support a system which has no co-insurance and no deductibles if ways can be found to finance it.

[The Acting Speaker (Mr. Kilger)]

It being 5.46 p.m., it is my duty to inform the House that pursuant to Standing Order 81, proceedings on the motion have expired.

I have a statement concerning private members' hour for tomorrow, Friday, April 28, 1995. I have received written notice from the hon. member for Winnipeg Transcona that he will be unable to move his motion during private members' hour tomorrow.

As it has not been possible to arrange an exchange of positions on the order of precedence, pursuant to Standing Order 94(2)( a ), I ask the clerk to drop this item to the bottom of the order of precedence.

Pursuant to Standing Order 94, private members' hour will be suspended for tomorrow, and the House will continue with consideration of business before it at that time.

The House will now proceed to the consideration of Private Members' Business as listed on today's Order Paper.

Peacekeeping Act

[Chuck Strahl, Reform, Fraser Valley East, BC]

moved that Bill C-295, an act to provide for the control of Canadian peacekeeping activities by Parliament and to amend the National Defence Act in consequence thereof, be read the second time and referred to a committee.

Mr. Speaker, I am very pleased today to have the opportunity to speak to Bill C-295, which I will refer to as the peacekeeping bill. It offers a golden opportunity for all members to rationalize and focus Canada's peacekeeping efforts. I am especially pleased that the House leader for the government affirmed his intention on April 6 to treat all private members' bills as free votes. This means that all members will be able to make up their minds purely on the merits of this legislative suggestion.

This is a breath of fresh air in the House. I sincerely hope members speaking to the bill today and those voting on it later will have taken the time to study it thoroughly. Free votes may mean a little extra work for individual members of Parliament but as an exercise in democracy free votes help to establish the credibility of the House.

Bill C-295 is a good idea, worthy of all party support because it would not cut off or even reduce Canada's peacekeeping role in the world. Rather, it would affirm and institutionalize the role of peacekeeping in Canada's foreign policy and strengthen Canada's place as a leader among the United Nations.

Neither would it reduce the power of the government to make decisions about the deployment of Canadian troops. The bill deals strictly with peacekeeping and allows cabinet full authority to act on a temporary basis. However, it also places the responsibility for our long term commitments squarely where it belongs, in the capable hands of the Canadian people through their members in the House of Commons.

At the moment there is no legislation governing Canada's peacekeeping effort. Legally peacekeeping is still regarded as sort of a side show, an informal duty that Canada undertakes almost as an afterthought. However, in reality peacekeeping has become one of the most visible aspects of the Canadian forces. Certainly Canada's international reputation hinges to a large and increasing degree on its peacekeepers.

However, the only legislation that acknowledges this reality is the National Defence Act which allows cabinet to place Canadian soldiers on active service and pay our soldiers as if they were at war. This is purely an administrative necessity and it does not even address the modern questions about peacekeeping that demand attention.

I quote from the defence policy review tabled last fall:

Defence policy cannot be made in private and the results simply announced-Canadians will not accept that, nor should they. Nor should the government commit our forces to service abroad without a full parliamentary debate and accounting for that decision. It is our expectation that, except in extraordinary circumstances, such a debate would always take place prior to any such deployment.

I agree wholeheartedly with this recommendation which was made by an all party committee of the House. I assume it should become parliamentary policy and I note the government allotted three hours on March 29 to debate the renewal of Canada's commitment in the former Yugoslavia. The government has thereby acknowledged that Parliament does have a role to play in making these important decisions.

Unfortunately the effectiveness of that role is questionable because the matter was not put to a vote on March 29. Although 20 members of the is House spoke to the issue that day, the input from those MPs was not as effective as it could have been because it was just a take note debate. The motion put before the House was non-votable. We have no idea of the consensus of the Canadian people. The debate was not brought to its logical conclusion. Some people have speculated the decision was finalized before the debate had begun.

Would it not have been better if at the end of that debate, where the pros and cons of the peacekeeping proposal had been discussed in this most public of forums, we had considered this issue important enough to stand up and be counted? Canadians deserve to know our position on this important subject. We are ready to move past the old ways of doing things where this House rubber stamps decisions which have been made in the bureaucracy. Canadians want and need assurance that it is their members of Parliament who actually make the decisions in Ottawa.

Failure to bring a debate to its proper conclusion on such an important topic as this results in a patchwork policy which does not seem to make sense. Bosnia is an example. The UN has 44,300 people on the ground from 38 nations. It is the largest UN mission ever. The operation began over three years ago and has continued at great expense and high risk to Canadians in a situation where neither side seems to appreciate the value of Canadian peacekeepers.

Last July I attended the funeral of Corporal Mark Isfeld, one of the Canadian soldiers killed by a land mine while performing his peacekeeping duties in the former Yugoslavia. His family and friends and all Canadians knew peacekeeping frequently means lives are put at risk. Mark was one of nine people who

have made the ultimate sacrifice in service to their country in that war torn zone.

Our peacekeepers are honoured to represent Canada on missions overseas and I am honoured to be represented by them. However, it needs to be said that the mission in Bosnia has no foreseeable end and it seems to have a diminishing hope of success.

I refer now to a different situation. A few weeks ago a Canadian, former Major General Lewis MacKenzie, investigated Canada's oldest peacekeeping effort. Canada has been in Cyprus for 30 years, since 1965. The original UN mandate was just three months. Three full decades later the UN is finally thinking of withdrawing, only because other nations are starting to mutiny. Canada, of course, soldiers on.

Both of these situations tax the very idea of reasonability. They also tax our resources and denigrate the reputation of the United Nations. At the same time we look at a nation like Rwanda where genocide was attempted last year, or Burundi where unrest is threatening to boil over again into mass slaughter, perhaps another attempt at genocide. However, the UN sits on its hands and Canada's hands are also bound in part because so many of its resources are committed in so many other places in the world.

The obvious disparities between these operations show that Canada's approach to our peacekeeping function is not rational. We lack an orderly process by which we can sit down together and weigh the increasing numbers of peacekeeping requests we are receiving. We need a way of ordering our priorities to make sound decisions about where to become involved, what to do when we get there, how much to spend and, most important, when to call it quits.

Major General MacKenzie made a good suggestion:

Perhaps what is required is a deadline. What if the UN were to say we will give you a set period of time, say three years. You sort your problem out during that period or we are out of here.

This is a celebrated peacekeeper saying we need a new mechanism for dealing with Canada's peacekeeping decisions. It certainly would have helped in the case of Cyprus. We need guidelines and mechanisms so that all Canadians whether they are taxpayers, men and women of the armed forces or members of Parliament will know what we are committing ourselves to when we go overseas.

The peacekeeping bill provides the mechanism we need. Let me describe the basic elements. It is a very simple bill, worthy of the support of all members of the House.

In summary it says that when Canada is approached by the United Nations to participate in a multinational effort the government should develop a peacekeeping plan and present it to the House by way of a motion.

The elements of that plan are very simple: estimate the cost of the mission, its location, its duration and its role. That is it. The House would debate it for less than five hours. It would pass the resolution and the mission would be in full force.

If the government had to act immediately it could do so by joining the mission without any debate and sending as large a contingent of troops and materiel as it needed to. A peacekeeping mission is carefully defined in this bill as more than 100 soldiers sent under a UN mandate for more than one month.

This means soldiers deployed with a UN mandate would not require legislation approval. The cabinet needs that authority and ability. It means that fewer than 100 Canadian forces personnel acting for more than a year would not constitute a mission. They as well could be sent by the cabinet.

A thousand soldiers on a mission lasting less than a month, something that we had to do quickly, would not require parliamentary approval.

When we get into major commitments for long periods of time Bill C-295 would come into play. Once Parliament has approved a peacekeeping plan that plan would become the mission's mandate. If the mandate expired the mission would automatically be over and the troops withdrawn. If a situation called for the mission to be extended that process is also contained in the bill. The government would simply come back to the House with amendments to the plan and pass a new resolution.

This simple process in many ways mirrors a letter I received last May from the Minister of National Defence which detailed the criteria for Canada's peacekeeping commitments. He said there must be an achievable mandate. The principal antagonists must agree to UN involvement. Are the lines of authority clear? Is the mission adequately funded? What is the risk for peacekeepers and the rules of engagement?

Laws are simply a codification of what is necessary and reasonable. The things the minister mentioned are both reasonable and necessary considerations. Now it is time we codified these requirements into a law that allows Parliament to have significant and effective input.

I can think of important benefits to this idea. The first is participation. Through the political process Canadians would decide Canada's priorities, where Canada should be involved around the world. There would be a special benefit for the government of the day in that it could lay before Parliament a peacekeeping plan from which it could gauge support for a mission before we actually made the commitment in the international arena.

Also, the debate would allow all political parties to endorse a proposal in an official way through a vote. Having endorsed a mission a party would be reluctant later to criticize a plan it had helped finalize.

The second benefit is preparedness and co-ordination. The government as well as our international partners would know beforehand exactly what Canada is prepared to do in each situation and other nations could prepare accordingly. Our national defence people could better prepare for a mission if they knew its parameters in advance.

The third benefit is budgetary. By putting a cost ceiling on all our missions we would know how much the country will allot for peacekeeping and in these days of tightening budgets the ability to fix our costs as much as possible ahead of time is vital.

If governments had to return to the House for more money the political hurdle this would pose in some cases would cause the government to be more careful about the money it spent and committed to in the first place.

Governments need to be held accountable for the money they spend and certainly the current government needs to recognize that the budget for peacekeeping is like other departmental spending plans for which they present estimates to the House. We simply must be able to keep to the budget allocated by Parliament.

Some people will argue political situations change so rapidly that Canada cannot make firm commitments ahead of time. I would answer that firm commitments ahead of time could in themselves positively affect the political and military decisions others will make.

Firm decisions will allow us to direct our circumstances and set our own course rather than have external events lead us around by the nose. As General MacKenzie implied, by giving generous but firm guidelines ahead of time, we may even influence warring factions to resolve their differences in a timely fashion.

In any case, the bill is flexible. It allows for the government to make corrections in midstream, to extend, for example, a peacekeeping mandate. Having said that, all of us elected to this House know our first duty is not to satisfy the wishes of other nations. The government's first duty is to satisfy the Canadian people that our foreign involvements are necessary and fiscally prudent before running around the world putting out other people's fires. For Canada's peacekeeping function to continue to be legitimate in the eyes of Canadians, it must pass the test of continuing public approval.

We also need a bill that touches on other areas of Canada's peacekeeping function. This bill does that. It refers to the command structure of Canadian forces and requires that our troops be placed under the command of other Canadians. As we know, a major complaint about the UN is the notoriously low quality of its commanders. We feel that Canadians, especially Canadian soldiers, will feel more secure with Canadian commanders.

Even here we have constructed this bill to allow some flexibility. Clause 6 states that cabinet may delegate that command structure if it wishes to another body for periods of six months at a time. At least cabinet would have to make a conscious decision to place our troops under someone else's care.

We also talk about the neutrality of our armed forces. Neutrality is a precious commodity in this world. Once we give our reputation away for neutrality it is very difficult to restore. Canada is known and welcomed around the world for its fairness, impartiality and even-handedness. We should not be seen to be installing and deposing governments, even non-democratic governments, at the behest of the UN. It is not our role to take political sides in political disputes.

Our peacekeeping task, our role, our function is to enforce ceasefire agreements and to deliver humanitarian aid, thereby earning the respect over the long term of all sides in the dispute rather than breaking the bounds of neutrality in a short-sighted way and turn half of a population against us. This is a delicate task. It can only be accomplished if our armed forces continue our traditional neutrality in peacekeeping roles.

There has been some question about the use of deadly force in peacekeeping situations, situations in which our peacekeepers have felt ashamed of themselves and deeply frustrated by their inability to protect themselves and others. My bill helps to resolve this problem by allowing our peacekeepers to use deadly force in self-defence, in defence of innocent civilians or to stop serious abuses of human rights where deadly force seems to be the only way to do it.

What is an army for? An army exists to pit force against force. That is its only purpose. Even peacekeepers are an army that moves physically into a dangerous area to provide a physical check on another armed force. But we fight a different battle than either of the antagonists. We are warriors stepping between other warriors in a battle for peace, risking everything in our striving to end war and deliver hope where little exists.

We cannot ask our soldiers to go into these types of situations completely unprotected. Although we must minimize our own use of deadly force, I feel it is justified in the situations I have just outlined where it will clearly forestall an immediate situation that is obviously worse. However, I acknowledge this is a difficult area.

Let me sum up by talking about Canada's identity. Canada is a young country. As such, its personality, if we want to call it that, is still developing. Different nations seem to be known for different things. When we think of Switzerland we naturally

think of neutrality. Germany is an industrial giant and Sweden is perhaps a classic welfare state.

What do people think of when they think of Canada? I would say that other nations long ago recognized Canada's peaceable nature, her natural co-operativeness and her concern for stability in the world. We offered a novel idea, that there is a third option between defeat and victory.

The UN requested our assistance as peacekeepers. Canada did well and the public supported it. We have continued to respond proudly and generously for 40 years. In doing so, we have defined our own nature, shaped our identity and become comfortable with our role in the international community.

We are peacekeepers. It is a role that receives applause around the world. A peacekeeping bill would formalize this positive definition of Canada. It would cement it in the minds and hearts of Canadians. I can think of no more noble role than being a peacekeeper, no higher legislative aim than to entrench this function as a formal element of Canada's identity.

It is said that we reap what we sow. If that is true, and I think it is, what kind of harvest do we reap, what kind of fruit grows when peace is sown? Peaceable people co-operate more. The food of peace is better health, prosperity, long life, happy relations, improved working conditions. To strive for peace is to strive for all that is necessary for humanity to thrive on this planet.

Finally, in addition to those tangible benefits of peace, the fruit of peace is also hope. That precious seed of hope is sown in peace by those who make peace. I trust that all members of the House would see fit to formalize Canada's peacekeeping identity by voting to submit the peacekeeping bill to committee for consideration.

[Fred Mifflin, Liberal, Parliamentary Secretary to Minister of National Defence and Minister of Veterans Affairs]

Mr. Speaker, I am pleased to speak on Bill C-295, an act to provide for the control of Canadian peacekeeping activities by Parliament and to amend the National Defence Act in consequence thereof.

I have no doubt that the bill was motivated by the concern of all members for the well-being of the Canadian forces personnel and for a wise and sound decision making process on the part of the government.

Unfortunately I have to say that after close study of the bill, in my opinion it might on serious consideration make the process a little worse than the situation that we now have in place. For that reason I oppose it.

Before describing the details of my opposition, I have a general observation to make that applies to much of the thinking that emanates from our hon. colleagues on the Reform benches. It is a tendency that I see reflected in this bill to look for American models in matters of public policy in Canada.

This tendency skews the vision and certainly on our part. I do not believe we can make policy on the basis of the trends and obsessions of our American neighbours, as much as we respect and admire them. We are not them and their examples are foreign to our needs and purposes.

The government has gone to great lengths to ensure a made in Canada defence policy. In fact, members of all parties were members of the special joint committee that put together an outstanding report. I say this not in any sense of gloating but in modesty. Ninety-five per cent of it is reflected in the white paper. It is a Canadian defence policy and one that reflects Canada's needs and aspirations. I for one-I am sure I am joined by many others-would want to keep it that way.

Bill C-295 would restrict the prerogative, the speed and the discretion of the crown to determine Canada's contribution to the United Nations for reasonable peace operations. Like other military operations, peacekeeping is carried out under the authority of the Minister of National Defence under the National Defence Act. It provides that the minister has the management and direction of the Canadian forces and of all matters pertaining to national defence. The bill would remove the responsibility and the discretion not only of the minister but also of the government respecting military operations.

As a result, the bill would adversely affect the speed with which the government can respond to UN requests for assistance in peace operations as well as the timeliness with which it can respond to changes in the peacekeeping mandate.

One of the major problems cited by many former Canadian UN commanders is that it takes too long for the international community to become involved in times of crisis. Most recently Major-General Romeo Dallaires has been an eloquent and passionate advocate of the need for speed in emergencies, claiming that he could have saved tens of thousands of lives had he received the troops he needed when he requested them.

Bill C-295, which would add another layer in the decision making process, would ensure that it would take still longer for Canada to become involved and to provide help. In an emergency we should treat it like one and act urgently. The bill would also create an unworkable structure for the management of international Canadian forces operations. All potential operations are evaluated against a series of guidelines that include the broad political and foreign policy context, the overall mission requirements and, of course, our own military capability.

The 1994 defence white paper outlines certain key principles intended to help the government assess the various factors to be considered before deciding whether Canada should participate in a mission. These guidelines are based on the peacekeeping experience we have acquired over the last 40 years. They also illustrate in a careful but pragmatic way the new international world order that has followed the end of the cold war.

The white paper highlights the key principles that must guide the design of all peacekeeping missions. These principles are as follows: first, there must be a clear and enforceable mandate; second, there must be an identifiable and commonly accepted reporting authority; third, the national composition of the force must be appropriate to the mission, and there must be an effective process of consultation among mission partners; fourth, in missions that involve both military and civilian resources, there must be a recognized focus of authority, a clear and efficient division of responsibilities, and agreed operating procedures; finally, with the exception of enforcement actions and operations to defend NATO member states, Canada's participation must be accepted by all parties to the conflict.

Canada's experience also suggests that successful missions are those that respect certain essential operation considerations. Some were touched on by the hon. member. The size, training and equipment of the force should be appropriate to the purpose at hand and remain so over the life of the mission. There should be a defined concept of operations, an effective command and control structure and clear rules of engagement.

To look at another aspect, I believe Bill C-295 would give up Canadian sovereign command of Canadian forces elements and would create in its place an unworkable command and control relationship. In this area, in particular, I have problems with the intent of the bill.

Canadian forces personnel now serving on peace operations are always commanded by a Canadian. Command of Canadian forces personnel is no longer given up to allied or UN command, as it was during the first and second world wars. Canadian units and personnel can only be placed under the operational control, not the operational command, of the UN or other multinational commanders for specific tasks.

The practical difference between the two is that when Canadian forces are deployed under operational control, changes to the task assigned or significant changes to the area of operation cannot be implemented. For example, the UN would have to seek Canadian approval to deploy Canadian forces UNPROFOR personnel to the former Yugoslav republic of Macedonia from Croatia, should the need arise. Such approval would not be required under operational command.

On the other hand, a non-Canadian commander who only has operational control cannot assign separate deployment of components of a unit. For example, the force commander of UNPROFOR who has operational control of Canadian forces personnel cannot unilaterally assign, for example, B company of 2-PPCLI to the British battalion. Such a deployment would require Canadian national approval. If the commander had operational command, there would be no requirement for such Canadian approval.

Currently, commanders of Canadian contingents are directly responsible to the chief of defence staff for the Canadian contribution to the overall mission and tasks of any given operation abroad. The subclause of Bill C-295 which calls for the Canadian commanding officer to be placed under UN or other international command would be contrary to current practice and would mean less, not more national control, something my instincts tell me is far from being the intent of the bill.

Bill C-295 would restrict Canada's capability to contribute to the strength of a fast reaction force on standby. As the hon. members probably know, the Minister of Foreign Affairs and myself have launched an initiative to assess the short, medium and long term implications of a United Nations fast reaction force and a possible Canadian contribution to this effort in the future.

Let us come back to Major-General Dallaire's plea for rapid deployment to Rwanda and in response to other international crises. Whether or not Canada participates in a given mission, when the decision is made to participate, timeliness is often crucial. This bill, if passed, would slow the decision-making process down almost every time there is a crisis.

In summation, I regret I do not support Bill C-295. I know the hon. member has put a lot of work into it and I appreciate the comments he has made. However, under the guise of providing greater control by the Parliament of Canada of international peacekeeping operations, I believe it tends to confuse certain key concepts, some of which I have alluded to. It reduces national authority over our peacekeeping troops abroad. It significantly restricts one of the government's prime assets, the flexibility and ability to manoeuvre and shape our resources to suit rapidly changing requirements in dangerous times.