Debates of April 27th, 1995

Supply

[An hon. member]

That is the truth.

[Pauline Picard, Bloc, Drummond, QC]

In terms of health care transfers since 1982-83, Quebec will yet again be shortchanged by Ottawa, by $2.4 billion between now and 1997-98. Then, with the increase in health care costs and the cost of new technology, it is supposed to do more with less? How can health ministers ensure that the five main principles are applied if transfer payments and social programs are cut. I do not understand how your constituents are not fighting this. You have just cut social programs.

[Grant Hill, Reform, Macleod, AB]

Madam Speaker, health care is too important to be left to politicians.

I would like to quote the Prime Minister, as I did in the question and comment portion of the debate. The Prime Minister has said to all Canadians, in a public forum, that we must go back to basics. I would also like to quote the health minister when she said, in reference to the Canada Health Act, that we will enforce the provisions of the Canada Health Act but we will be very, very flexible.

On those two comments and those two reflections on health care I am in wholehearted agreement. That statement will come back to haunt me. I know I will be quoted as saying that I wholeheartedly agree with the Prime Minister and the health minister on all issues of health care. I agree with those statements in particular.

When I say that health care is too important to be left to politicians, how would I determine where health care should go? I would line up in these halls 100 high school students and I would make a speech in this Chamber, much as I am doing today. I would ask the health minister to do the same, and I would ask for the old-fashioned thumbs up or thumbs down on the proposals of the health minister and my proposals. I would determine whether or not I was on base with health care reform or whether the health minister had it right. It is the old Roman up or down. Maybe the pages could do it for me today.

If the Prime Minister and the health minister and I are so close on the issue of health care reform-those were basic statements, brand new statements, statements that have not been made in our country for some years-where do we differ? Frankly, we differ on the cause of the need for health care reform.

I will now go to a brand new survey from Statistics Canada on government spending. The figures I am quoting do not come from the Reform Party, they do not come from a strange source, they come directly from StatsCan.

In 1994-95 the federal government will spend $1,522 per person on servicing the debt. What will the federal government spend on health care per person that same year? Two hundred and sixty-eight dollars. That is the reason we stand in the House today debating the future of the health care system. Anyone who stands up and says that is not the reason is an ostrich, hiding his or her head in the sand, ready to be plucked.

Teenagers in Canada will not listen to that kind of nonsense any longer. Fifteen hundred and twenty-two dollars per person on debt servicing is squeezing the heart out of the $268 left for health care.

Reformers are looking for specific, positive solutions. To do what? To rip the heart out of health care? Not a chance. To preserve and save this most valuable of our social programs. Therein lies the problem. Therein lies the anchor. Therein lies the noose for health care.

My focus with these words will be the Canada Health Act itself. The health minister said: "I want Canadians to know that the Canada Health Act is alive and well and able to take on the challenges of the future".

I have another quote from Dr. Steven Stern of Ajax, Ontario: "We must recognize the financial crisis in most provinces that has rendered the Canada Health Act hopelessly obsolete and the fantasy of supplying all medical services to all of the people all of the time from ever escalating middle class taxation is a futile hallucination".

I believe the Canada Health Act is in trouble. I believe the Canada Health Act needs help. I believe Canadians will no longer allow rhetoric to judge whether the Canada Health Act will survive.

What has broken down in the act? I will talk specifically about provisions in the act that are failing. First, on portability, the act guarantees services provided to Canadians outside the country will be paid for at the same rate as if a person got sick in Canada. That is broken. Snowbirds who travel to Florida and come back to Ontario are paid $100 per day per hospital visit. There is not a hospital in Canada that can provide $100 per day service. Portability is broken.

In "la belle province", Quebec, there is a provision to the effect that each doctor is entitled to a certain portion. Here in Ontario, the portion is not the same.

Portability is broken and the minister knows it. The minister knows the Canada Health Act is falling down in portability.

On accessibility and reasonable access, where are we with reasonable access guaranteed in the Canada Health Act? One specific breakdown is that Manitobans are waiting 60 weeks for hip replacements when the norm is 12 weeks. Reasonable access is toast under the Canada Health Act.

Comprehensiveness is another plank of the Canada Health Act. How about the issue of what is medically necessary? Here we have provinces unilaterally deciding to take test tube babies off the medically necessary list and put on sex change. Those two things might be discussible under the provision of medically necessary. This is arbitrary and fragments health care across Canada.

What about the bill's provision-this is not one of the planks of health care but one of the very basic provisions of the Canada Health Act-that there will be a prevention of user fees?

In the House I have mentioned to the Minister of Health-this is not a unique thing to the province I will mention-that there is a hospital in Wolfville, Nova Scotia whose facilities were being shut down. It stated its facility was too important to be shut down. The province stated it could not afford the facility any longer but the staff was to keep it running. How were they to keep it running? By volunteer nurses, by a fee for the syringe, the local anaesthetic and the suture so that each patient who comes in with a laceration now pays for those basic facilities. Is it a user fee? Yes. Is it medically necessary? Yes. Is it the choice of the people in Wolfville, Nova Scotia? Yes. Should they be allowed to have that choice? Yes. It is their health; we should not be leaving this issue to the politicians.

The act guarantees, and this is not commonly known, reasonable compensation to practitioners who provide the services. I know of three provinces which have broken agreements with their medical practitioners unilaterally, agreements signed, sealed and delivered. Is reasonable compensation being given? The act is broken and there are no repercussions for that.

If the act is broken and I ask the minister to stand up and tell Canadians that what I have said is inaccurate or untrue, should the minister be protecting this most valuable act? I think she should. Her reaction is to reinterpret sections of the act. She has gone on to define the hospital to include private clinics. She has decided semi-private clinics do not deserve the funds they have been getting. That issue is one that we may argue a lot but this does not sound like going after the basic principles of the act to me at all.

We have been over funding provisions. I hear members of the Bloc say the federal government should not be withdrawing funding. There is no question in my mind the federal government has no choice. I do not think there is any point in going back and deciding the reasons for these choices. The federal government has no choice.

I listened to more rhetoric not so long ago in my province of Alberta. The Prime Minister says the Canada Health Act does not allow private health care. I shook my head when I heard that,

recognizing that almost 30 per cent of what is provided in Canadian health care is private.

I asked the Prime Minister about the Shouldice Hospital in Ontario for hernias, about totally private laser eye surgery, about physiosports medicine clinics, about chiropractic, about cosmetic surgery that has been taken out of the fee schedule, about laser treatment for snoring, sleep apnea and bad breath. All these things are available so close to the House of Commons privately and there is no room under the Canada Health Act for private health?

We have two tier health in Canada now. We will end up if we ignore the Canada Health Act, if we do not improve the Canada Health Act, with universal access to nothing. The $1,522 of debt servicing will choke that $268 and we will kiss it goodbye, and that will be wrong.

This is not an answer that comes from me but I am now elucidating the answer from my colleagues. My answer is to give sensible Canadians choice over their most important resource, their own health. That is why I would line up the 100 high school students.

A journalist phoned me the other day. He said: "I will ask you what you mean by your core essential services because I have asked a whole host of other individuals in Canada and none of them will tell me what they would take out of the core essentials. I know you will do it because you Reformers are not filled with political rhetoric yet". I had the opportunity to tell him some of the things I would take out.

For members opposite I will give a specific example of one thing I would take out of our broad health care coverage and put beyond the core essentials. This is actually being done in Quebec. The members of the Bloc will not be interested in this. Quebec has decided that psychoanalysis is no longer coverable under health care. Psychoanalysis is the treatment where one lies on the bed, the psychiatrist sits there and one comes in week after week for years on end to figure out what was the matter with one's psyche.

Quebecers in their wisdom, I give them credit, have said psychoanalysis is not something that should be covered under our core essential health care budget. They pay for psychotherapy which is much tighter, better controlled, involves looking after something like anxiety or suicide, possibly giving medication and a fairly rapid return to the workplace.

Outpatient psychotherapy is covered and with outpatient psychoanalysis you are on your own. You can either get insurance coverage or pay for it out of your own pocket. In their wisdom they are doing what Reformers are suggesting.

Will this be a big bureaucratic process? Not on your life. This is a process that will also be flexible. This is surely a process that our national forum on health should have and could have addressed.

I listened last night to the minister make a very good speech. It was tight and controlled. I really credit her for this. She said, using different words and phrases, virtually the same thing I am saying. There are things we are doing today in health care that are ineffective.

She said we must look at those things. That is what we are talking about. Define the essential core. Look at the things that are ineffective and set them aside. They are discretionary. They may well be covered by private sources, insurance or other sources.

We are not so far off. The rhetoric may put us a long way apart but we are not so far off. Evidence based issues, let us call them what I call them or call them what the minister calls them, core essential, evidence based; not so far off.

The national forum on health, which has people with vast experience from all over the country, should and could be doing this very thing today.

My time is rapidly drawing to a close. I hear delight from across the way. It is a shame because this debate in the House is so important and has not been done for so long. I will be disappointed if there is not a frank and open interchange on this.

There are other problems with health care beyond the federal portion. There are problems with accountability. There are problems with abuse. There are problems with our medical legal system and there are big problems with our drug costs.

Each one of those deserves a good, frank expose as well. I have colleagues who will talk about other innovations we think might have some benefit for health care, funding changes that might well be present. I ask each member to consider what will happen if we ignore the $1,522 for debt servicing versus the $268 being spent on our health.

[Diane Marleau, Liberal, Minister of Health]

Madam Speaker, I thank the hon. member for Macleod. As I listened to his speech I realized that we are a lot closer than perhaps is apparent in many cases.

I listened to some of the interventions the hon. member made and I will make a few statements to perhaps rectify some of the misconceptions out there.

I have not ever said there have not been problems and that there do not continue to be serious problems with other sections of the Canada Health Act. Portability and out of country portability is one of the areas we are working on. We are trying to reach a solution with provincial governments. We believe in working co-operatively with them.

When it comes to Quebec and the portability issue there has been considerable movement on the part of Quebec to address some of the problems of people from Quebec travelling to Ontario and not getting the coverage they should have.

There is an agreement of sorts in place to cover any treatment here in the Ottawa Valley or in the Abitibi section up north. I am hopeful, because I know that the Government of Quebec is extremely interested in serving the people of Quebec, wherever they travel. I would hope we can get some kind of an agreement on that in the near future.

When it comes to accessibility and reasonable access, there will continue to be waiting lists. Some provinces have done a lot of work to address that. Not to be discounted, some provinces have a central registry of where there are rooms available so that hip replacements can be done. As you well know, there are waiting lists, but often when the need is very great those people jump to the front. When they get access to hip replacement it is generally because their need is much greater. Although access is not always perfect, everyone works to address the problem.

The member has talked about a place in Nova Scotia, Wolfville. I do not have the particulars of Wolfville, but user fees and facility fees have been and will be outlawed. Just go back to my letter of interpretation in January. I would expect that Wolfville would be addressed by that letter of interpretation. If the member has any other information, please let us know.

There are a number of other points the member made, including Quebec's psychotherapists and what is happening in the province of Quebec. They are working with medical professionals to determine the medical necessity and what they will cover. That is the beauty of what is happening with the Canada Health Act. We encourage that.

These are the kinds of things that are happening across the country. When one province gets one thing right, others often follow suit.

The member spoke about the Shouldice clinic. Yes, it is a private clinic, but it is covered by the Private Hospitals Act in Ontario. There is an act in Ontario that governs that. Therefore, people do not have to pay additionally. They get access.

We have to understand that while we have a good system, it is not perfect. Any other suggestions the member may have would help us. One of the things he seems to be proposing, at least as I understand, is a system of user fees for certain procedures or items, which would be based not on need but more on the ability to pay. This is where we fundamentally disagree.

When a facility charges a facility fee and general taxpayers are paying the physician fee, they are in essence subsidizing queue jumping for those who have the money. That goes against our principles. I would hope it goes against yours, although it does not appear to do so. That is a tax on illness. That is not a fair tax, at least in my book. Perhaps the hon. member can tell us how he thinks a facility fee is fair.

[Grant Hill, Reform, Macleod, AB]

Madam Speaker, what has been missed in all of this discussion is unless we define the core essential we cannot decide whether or not a user fee has any place in our system. For discretionary, elective things, surely the minister would not deny those things to be done. That is why we need the definition. That is why there cannot be this airy-fairy situation where one thing is medically necessary in one part of the country and one thing is medically necessary in another.

On the issue of facility fees, the semi-private clinic, there is a philosophical argument on that specific issue. If the procedure is medically necessary, it must be paid for by public funds in Canada today. If the procedure is medically necessary and it is done outside a hospital and the costs generated to do that outside the hospital are not borne publicly, where should they be borne? I believe they should make no impediment whatever to the public system.

I ask the minister, although this is not interchange time, to find me a country-without using the U.S. example, which is commonly used and where that is not done-where that produces a problem.

[Harold Culbert, Liberal, Carleton—Charlotte, NB]

Madam Speaker, I listened with great interest to my colleague for Macleod. We had the opportunity of serving together on the Standing Committee on Health.

I would ask the hon. member what his definition of core is. He would know that there are criteria established presently from one province to another about what is included and what is considered outside those parameters.

Generally speaking, Canadians look on our medicare program as one that is accessible to all Canadians for good health care, regardless of their status in life. Surely my colleague is not suggesting that we should revert to a system that is dependent on how wealthy one happens to be, or a system such as the United States currently has, where we know there are literally thousands of people who are left outside the system.

I want to refer to one particular incident that I am well aware of regarding efficiencies. Of course we must change from time to time in order to be much more efficient. There is no question. That is why health care has to be upgraded continually from that perspective. That is exactly why the Prime Minister appointed the National Forum on Health to study that whole scenario.

Surely my colleague for Macleod is not suggesting that we open up to some other system, for example the system that is in the United States, which does not work. The medicare program is so important for all Canadians, and treats everyone from coast to coast on an equal basis.

[Grant Hill, Reform, Macleod, AB]

Madam Speaker, I appreciate the opportunity to respond.

Let me give the member another example of something I would take out of the core. It seems to be lost on the member that the core must be defined. The core has the essential things.

Although I have some expertise in this area, I do not pretend to be able to define the core perfectly. When health care started, there was no such thing as joint replacement. The first joint replacement literally came with health care.

The hip joint prosthesis ranges from $1,000 to $7,000. I would decide which of the prostheses is cost effective for Canadians and say that if you want a $7,000 prosthesis, pay for it yourself: we in the public system will give the Chevrolet prosthesis; if you want a Rolls Royce, you pay for it.

[Hedy Fry, Liberal, Parliamentary Secretary to Minister of Health]

Madam Speaker, I rise to speak with a mixture of emotions. There is some confusion, some humour, and some sadness.

I am confused that members of the third party would bring forth this kind of motion when it so clearly contraindicates everything they have ever said in the past during their campaign and even during their proposed budget earlier this year.

There is some pleasure because I am proud to be able to speak for the system of health care we are espousing in this country and in which we so firmly believe. And there is a little sadness because one of the movers of this motion is a physician and has shown such a lack of understanding of the system, the words, the terminology and the principles that medicare is all about. It saddens me that he should rise to speak to this motion when he so obviously does not understand the system. I would like to know why he does not understand it.

What we have heard is simplistic rhetoric. It is the kind of thing we have come to expect from the third party: there is always a simple answer; let us not confuse the complexity of the question, let us just throw a simple answer at it.

What is so simplistic about it and what is so rhetorical about it is in terms of the statement of the problem, which is not factual. The statement of the problem is not based on fact at all. As the Minister of Health said when she spoke earlier, the figures quoted, which indicate a decrease in the percentage of payments to the provinces from the federal government, are absolutely untrue. The statement talks about total health care cost. It does not show any understanding of what the cost the federal government contributes to, as written in the established programs financing, is all about. That cost is purely for hospital and physician services. It is not for the whole bailiwick of health care services, which each province has expanded or constricted as it feels it wants. That is not what the federal government sends the transfer payments for; it is purely for physician and hospital service. That is the first bit of disinformation that came about in this.

The second thing that is simplistic and rhetorical about the whole thing is the solution, the constructive alternatives we were given. They have absolutely nothing to do with ensuring efficient, universal, affordable, quality health care in this country. Universal quality health care is far more complicated than giving a cute, uninformed speech. It is a complex issue.

Let us look at the preamble of the speech made by the hon. member for Calgary Southwest. He talked about the fact that we already have a multi-tier system. That alone shows a lack of understanding of what is meant by the term comprehensive, which is one of the five principles of medicare. It shows a lack of understanding of what medically required services means. It shows a lack of understanding of what the terms universality and accessibility actually mean under the Canada Health Act. The hon. member did not even read the Canada Health Act. He does not even understand the definition of the terms.

The whole idea of having a multi-tier system is one of the usual red herrings that are thrown at us. Of course we have systems where there are always and have always been non-medically required services that patients pay for. They have always paid for them. If anyone wishes to have a face lift, they can always pay for one. There are many instances where people think they want something that is not medically required and they go out and buy it. That does not constitute a multi-tier system; that constitutes a system that operates outside of what the Canada Health Act defines as the five principles of medicare. The hon. member should go back and read the Canada Health Act.

The other thing the hon. member said in his preamble was that users should define full services. Users define full services? I do not know that many patients would want to define what an essential service is and what a medically required service is, because they are not physicians. They may want to participate in the decision making of what is appropriate in the treatment, but they would not want to define what is clinically necessary and clinically required for them. That is why they go to a physician or a health care provider. That alone seems to me to be a rather simplistic and very impractical solution.

What else do we have if we have started off with the first part of the motion being based on a false premise? The whole scaffold on which the argument is based is nothing more than

smoke and mirrors. It is a weak scaffold because it is based on lack of fact, lack of information, and lack of knowledge.

The hon. member said that we talked earlier on about the 50 per cent the federal government is supposed to transfer to the provinces.

As the minister and I said earlier, we were never supposed to transfer 50 per cent. In 1975-76 we transferred 39 per cent of total health care. That 39 per cent constituted a greater percentage toward hospital and physician services only which is where it was supposed to go. Therefore, the rest of it is nonsense.

That has not gone down a great deal when we look at the fact that in 1992-93 the total percentage of transfer has gone down to 32 per cent and the provinces have expanded their total pot. That again is a false presumption of what the percentages should mean.

There again I think the mathematics and the understandings were not done. If the figures were wrong and the assumptions were wrong, is the whole concept we are debating today wrong? It must be because it is based on a false assumption and a false concept.

Everyone is saying that we need more money for health care. The concept of more money does not seem to sit well with the third party. The leader of the third party said in his budget speech and in fact said in Saskatchewan that he would transfer more tax points to the provinces. He would give them more money.

Simple mathematics, and I am not a mathematician, tells me that in taking away from one side of an equation there is surely a corresponding addition to the other side. Therefore, if we take money away from our big pot to give more tax points to the provinces, what the hon. member did not factor in in his budget speech is that he is going to be $10 billion deeper in the hole in the deficit. How does that make sense with fiscal responsibility and cutting the deficit to zero in one year that we were talking about? It does not make sense. None of it makes sense.

It is widely recognized as a fact that anyone who understands health care economics knows that throwing more money at health care is not the answer. In fact the quality, the outcome, the efficiency and the effectiveness of a health care system does not depend on money. If it did, the United States which spends the most amount of money not only per capita but as a percentage of GDP on health care would have the best health care system in the world. However, it does not.

At the moment the country that ranks the highest for having the best health care system in the world is Japan. It spends a lot less money than Canada spends as a percentage of GDP. Money and a good system do not equate. Money in a health care system does not equal outcome.

We know that many other things determine whether people are healthy or not. They have to do with socioeconomic factors, environmental factors, lifestyle factors and quality of life factors. None of those things are part of giving people more medical care. We can give people more medical care and we will not decrease those outcomes one whit. Throwing money at the health care system is not the answer.

The challenge is how wisely we spend the money we put into the health care system so we can use the money for the socioeconomic and other issues that determine health. It is one of the big challenges we have to look at when we talk about health care.

Let us look again at the third party using money as a criteria for effective and efficient health care services. If we talk about that then we are talking clearly about the fact that if one cannot afford the health care system and more money has to be thrown at it then people must pay for the health care system. Therefore, we are back to this hidden or not so hidden agenda the third party is talking about which is in fact finding a way to get the user, the person who is sick, to pay for their health care.

It is a not so clever plot to say the system needs more money, the system needs more money, the system needs more money. Then we are going to have to say that if we are going to balance our budgets, and we cannot find the money from government, let us charge the people, the ill. Let us tax them. That is what is so underhanded and so disturbing about this motion, the whole concept that is underlying what we are talking about here today.

It is a typical mentality that comes from people who espouse a south of the border policy on health care. We look at the United States and the kind of health care it gives. Yes, there is a two tier system there and yes of course people are allowed to buy health care but it is based on one criteria, the pocketbook. Those who can afford it can have unlimited access to health care. Those who cannot afford it, we see what the outcome is.

At the moment the United States is sixth among the developing countries in its health care outcomes. It does not have the health care outcomes of a developed country because those who cannot afford it, with poverty being the major determinant of health, those people are sicker.

That is the way the Reform Party would have us go and it concerns me. In fact, if we give the rich unlimited access to health care what we see is that the number of interventions and the amount of laboratory tests are greater as a percentage of users in the United States than it is in Canada. The people who are using them more are based purely on the people who are in a

high socioeconomic bracket. In other words there are people who are having care and interventions.

Open heart surgery is one example. The rich are getting more open heart surgery. It does not fulfil the criteria of whether they need it or not. The fact is they want it, they want to buy it and they are getting it. I do not consider that to be good medicine and I do not consider it to be good health care. I do not think we want that situation in this country.

Let us look then at the solutions the third party recommended. The solutions it talks about are core services. We all know on reading the Canada Health Act and if we understand the principles of medicare, that the definition of medically required services is a provincial jurisdiction. The provinces have to define medically required services. This is a good thing. The provinces are where the regional disparities lie. Different provinces have different health care problems. Different provinces have different needs.

We talk about bottom up care. It is appropriate to have the provinces deciding. That is what we have tried to do when we have discussed how we give the provinces more decision making in health care. It is to allow them to provide appropriate services for people where they need it, when they need it and how they need it. They know that better than the central government.

We believe our role to play as the central government is to bring about and co-ordinate what it is we see within the principle that those medically required services are based on clear clinical guidelines. This is why the health forum was set up. The health forum is dealing right now with how we define, how we look at outcomes. It is dealing with how we look at what is the care and the criteria necessary to provide those outcomes so that we are not guessing as the hon. member for Macleod would have us do and set all sorts of criteria for who should get it and what a core service is.

The hon. member for Macleod has decided that a core service should be something that is on a list of items. A core service is not an item. If we take for example the item of ultrasound for pregnant women and say that only one ultrasound will be done on a pregnant woman, that does not make any sense. Some pregnant women clinically require more than one while others only require one.

We need to look at clinical guidelines when we talk about core services, not whether the item is a good idea or not, not to generically define items. That will not give us good care.

Nor should it be like the hon. member for Macleod said to the Calgary Herald when he defined who should get health care and who should not and that if a woman in her past history had been promiscuous and had her tubes blocked she should not have a tubal ligation paid for by the government. What sort of subjective, moral, paternalistic health care system are we talking about here when we want to define core services that way? That concerns me a great deal.

We also hear terms like private insurance. We all know from the United States and Robert Evans of UBC has shown us very clearly that multiple insurance systems and multiple payer systems are more expensive. They are more inefficient and in fact do not create the right kind of outcomes.

The United States has multiple payer systems. The administrative costs are 25 per cent of the health care costs. Recent studies have shown in the United States that if that 25 per cent on administration could be rolled into a single payer system, there would be enough money to give health care services to the 37 million Americans who do not have it right now. If the money spent on Massachusetts Blue Cross alone could be decreased in administration there would be universal health care in the United States.

When we talk about health care and about multiple systems, we are talking about greater costs. We are talking about defining who can no longer be insured because they are now chronically ill.

In the United States someone who is chronically ill becomes uninsurable. Even if that person has millions of dollars to buy insurance, he cannot buy it. That person has to pay out of his pocket. That is okay if he has millions of dollars but someone who is a middle income worker cannot.

The other term "benefactors to pay" as I see it is a nice term for user fees. We are hearing all these little words that have been put in so that it sounds wonderful. We are talking about a two-tier system that in this country does not define what we see as health care.

When we talk about health care we are talking about looking at how we can save money on health care costs. Recent studies at the University of Ottawa and Judith Maxwell have told us that we can save $7 billion a year in health care costs if we do some real things. For example we could shift from hospital based care to community based care. We could look at how we set clinical guidelines for care. We could look at how we help the determinants of health so that the socioeconomic factors that create illness in people are decreased.

There are many things we can do to decrease health care costs without changing the five principles of medicare, without having to make people who are sick pay. The only way the third party can see for solving the problems is to define core services with the kind of hidden agenda it is defining. Reformers are talking about user fees and multiple insurance systems.

What is wrong with that solution is that every system of health care in the world is based on some sort of rationale. The rationale in this country has to do with clinical need and that is the way we want to keep it. I do not ever want us to see where the rationale for our health care system is the pocketbook. There-

fore I strongly speak against first and foremost the problem which is not factual and also the solutions put forward this morning by members of the third party.

[Pierre De Savoye, Bloc, Portneuf, QC]

Madam Speaker, I listened with great interest to the comments made by my hon. colleague. I know that she is very knowledgeable about health issues and that she really wants to ensure that the Canadian health care system is in the best of shape.

I would, however, like to remind her and this House that medicare was invented by Quebec a few decades ago through the good services of Mr. Castonguay. That is why we as Quebecers care about maintaining the essential characteristics of a good health care system.

Of course, such a system needs predictable financing. The Canadian provinces and Quebec have had to deal with the cuts in established programs financing that have been carried out for over a decade, in violation of the 1977 agreement promising reliable funding to the provinces; they had to make do and, in some cases, even improvise in health care matters. That is where the shoe pinches.

By redefining the transfer of taxpayers' money to the provinces, the federal government has gradually destabilized the Canadian health care system. In fact, the federal government has, unintentionally, I admit, contributed to this decline of the Canadian health care system, which is already leading to a two-tier system.

Basically, we have a right to ask the following question: Why does the federal government not transfer to the provinces and Quebec all the tax points linked to health care financing so that the provinces and Quebec can determine themselves the best way to provide services in compliance with the five fundamental principles of health care?

I would like my colleague to give me her opinion on this.

[Hedy Fry, Liberal, Vancouver Centre, BC]

Madam Speaker, I thank the hon. member for rewriting the history of medicare a bit. Some people would argue that it was Saskatchewan and others would say it was Quebec, but that is a moot point.

The hon. member mentioned money. We keep hearing about money being a factor in providing effective health care. There is an English saying that necessity is the mother of invention. Because of necessity and because there has been very little money, provinces have begun to be inventive. It is not an invention that has decreased the quality of health care.

Something that has been necessary for many years which neither the provinces nor the federal government faced up to was that we needed to change our health care system to make it more appropriate to the needs of people and to make it more effectively and efficiently managed. As a result of the necessity, people are beginning to manage the system.

The amount of money put into a health care system by any study of any country does not equate to quality of care. Otherwise, as I said, the United States would have the most wonderful health care system in the world because it spends the most money. Yet Japan, which spends the least, has the best. There are more things that determine the health status of a country and the health of individuals than money spent on intervention and on medical care.

I spoke as well about the ways in which we could decrease the cost of the system, improve accessibility and improve the ability of patients to make decisions within their own health care system. That is by shifting from acute care to community care, by shifting and creating guidelines for care, by looking at outcome analysis and by setting up technology assessment, by doing all the things we are learning to do that some provinces have already begun to do.

Judith Maxwell of the University of Ottawa is predicting in her report that if we continue to do such things we will need to put less money, almost $7 billion less, into health care. It is very important to understand that and not fall prey to the rhetoric that continues to say that we should keep throwing money at health care in the hope that it will stick somewhere. It never has and it never will.

All the studies on mortality, morbidity and quality of life are telling us that is not what will create the outcome we are looking for.

[Keith Martin, Reform, Esquimalt—Juan de Fuca, BC]

Madam Speaker, what does hon. member think about the recent comments of the British Columbia Health Association about being significantly concerned about access to essential health care services in British Columbia? This is not something occurring solely in British Columbia. As the member well knows, it is occurring across the country.

My party has proposed an alternative form of the Canada Health Act. We would allow the provinces to have such structures as private medical clinics. Not a dollar from Canadian taxpayers would go toward paying for it. Members of the public would have the choice to pay for the services, whatever they happen to be, in private clinics. We must bear in mind that the services would be offered to anybody in a public hospital or a clinic.

What is so wrong? How will private structures involving the exchange of private moneys impede the ability of the public sector to provide services? Also, why does the government have such an aversion to choice when we have choice in almost everything else in our lives?

[Hedy Fry, Liberal, Vancouver Centre, BC]

Madam Speaker, I thank the hon. member for his question.

What is wrong with setting up private clinics so that people who want to pay can pay? We only have to look at the United States where people who want to pay can pay and buy as much as they want whether or not they need it and people who cannot afford it have inadequate and inappropriate access to health care.

A major determinant of health is socioeconomic status. Poverty is the greatest determinant of health. Poor people need more services. We are basically saying that we have some false savings here. We will not save any money. The people who need the services more will be the people who cannot afford them. They will still be going to the public sector. That is the first point.

Second, if we look at the United States model, private clinics have tended to create massive costs and inefficiencies in the system. They have taken away clinical autonomy from physicians who no longer have the ability to choose what they do for their patients but have to ask a non-medical person, some insurance adjuster, what they should and should not or can and cannot do. That is not what I consider to be choice.

We have choice in this country. In the United States they are not free to choose a physician. They are only free to go to a physician who is under a particular insurance plan and works for a particular insurance company. In Canada we are free to choose a physician anywhere and everywhere we like.

We have what is known as access to anyone we want to see. That is choice. In this country we are free to go to any hospital we choose. We are free to have a bed in the hospital next to anyone we choose to be with. We do not have to go to one for the poor if we are poor. We can sleep under a bridge or lie next to some multimillionaire in a Canadian hospital.

What the member is considering is wrong. If he does not believe me, let him think about what happened in the United Kingdom. I did my medical training in the United Kingdom. Its wonderful easy answer was that it would take care of the poor and those who could pay would pay. We have seen a two-tier system in which the poor have been relegated to second rate medicine. Physicians do not want to work in the areas where there are large poor populations. The United Kingdom is sending for physicians from developing countries to go there to provide care. That does not create equality of care. That is what is wrong.

[Keith Martin, Reform, Esquimalt—Juan de Fuca, BC]

Madam Speaker, my colleagues will be dividing their time from now on.

It is with great sadness that I am here today to speak on the motion. It is with great sadness and anger that I listened to the response of the government to the most important thing in people's lives, their health.

The government continues to put forth the fantasy that medicare can continue in its current form. This is criminal, reprehensible and an outright lie. The reality is that medicare is like a ship with holes in it that is sinking with its captain, the government, saying all is well. Unfortunately when we look inside where the people are, the patients, we find that they are dying, suffering and in pain. That is exactly what is happening in health care in Canada today. It is a profound tragedy and should not occur in a country such as ours.

The provinces have found that demand is increasing. Costs are escalating with an aging population and more expensive technology. Also revenues are going down as was demonstrated in the last budget with an $8 billion decrease in transfer funding from the federal government.

Who is caught between a rock and a hard place? In reality it is the patients who are sick, who are unwell. When they go to hospital they discover that essential health care services cannot be provided in a reasonable amount of time.

The provinces are hamstrung by the current Canada Health Act. They are forced to engage in rationing. I will give some real life examples from across the country. In Victoria, B.C., where I live, 40 per cent of hip replacements for elderly people who are in severe pain take 13 months. The British Columbia Health Association is very concerned about the critical lack of access to essential services.

In Prince George a very interesting and sad thing happened. People going for surgery were given the option of receiving autologous blood transfusions, which allow people to have their own blood taken and purified for use in their next surgery. The cost charged to each patient was $150. The reason for that was the Red Cross and medicare system could not pay for it. They gave the patient the option of using their own blood in a safe fashion that would not subject them to HIV, hepatitis and a number of other diseases.

Two months after this came out the Ministry of Health said that it could not be done, that patients could not be charged for it. It prevented the Prince George Regional Hospital from doing so. Now patients have to get packed cells for blood transfusions at $500 a unit.

In Alberta it takes three weeks for emergent and urgent open heart surgery. The surgeons there say it is a miracle so far that nobody has died, but it is going to happen.

The Prince George hospital, because of the funding cutbacks that have been foisted upon the provincial government, is forced to cut back its operating room days by 12 days a year, knowing full well that it has hundreds of people waiting for urgent surgery.

The minister said that doctors were returning to Canada. I had a conversation with one of her close advisers the other day who said that it was the bad doctors who were leaving the country. He asked: "Isn't that so?" Half our neurosurgeons leave the country. Eighty per cent of orthopedic surgeons in some cities have left as well as 50 per cent of obstetricians and gynecologists.

Dr. Joel Cooper of the University of Toronto, a world famous cardio-thoracic surgeon, left. Dr. Munro from the Hospital for Sick Children left. These world famous individuals left the country not because they wanted more money but because, in their words, they could not practise the way they were supposed to and were sick and tired of having their patients suffer. That is not adequate health care.

The reality is that the population is increasing and costs are rising. The minister said that we do not have a two-tier system. What nonsense. A billion dollars every year goes to the United States. Why? It is because Canadians cannot obtain essential health care services in a timely fashion so they go to the states. Why do we not keep that money in Canada?

The minister said that private expenditures were increasing. Of course they are increasing. Why? It is because people will not wait for the current public system to provide their health care services. They do not want to be in pain and they do not want to die. The government is forbidding them from doing that and is not accepting the fact that it cannot provide essential services in a timely fashion. That is a travesty. It is also extremely arrogant for the government to tell the public that it is forbidden to do that. In effect the government is sacrificing people's health on the altar of a dead socialist ideology.

We must recognize the financial crisis of today and the decrease in funding. We must recognize that people cannot be taxed more and that demand is going up. We must recognize that the Canada Health Act is hopelessly obsolete and unable to provide the same health care services to all people all the time, especially essential health care services. Sick people are in effect dying.

We must move to a new era. We will present constructive alternatives. Let us make a new made in Canada health act. It should not be one from the United States or one from England but one from Canada. We do not want an American style system. There is no resemblance whatsoever in what we propose to the system south of the border.

First, we must get the federal government, the provinces and the people together to define essential health care services for which all people across the country will be covered regardless of income. We may want to look at the Oregon model to begin with.

Second, let us allow the provinces to experiment with alternative funding models, such as private clinics, private insurance and the like. Why? It is because the system needs more money to provide health care. It is true that it needs to be revamped, but it also needs more money to reflect our current fiscal crisis and fiscal crunch in health care.

This is not a threat to medicare, rather it will make it better. What is so wrong with enabling private clinics to provide private services in the private sector where only private dollars will be exchanged? It will not in any way affect the public system.

In fact the demand on the public system will go down so that those people who are in this system will be able to get essential health care services in a more timely fashion. Is it a two-tier system? Yes, but we have one now. Is it unequal? Yes, but it provides for better access for all people regardless of their income. It ensures quicker access to those essential services that Canadians are not receiving now.

It is time to move forward. It is time to move with courage. It is not the time to delve into a morass of ideology but open our eyes and work together. My colleagues and I are more than happy to work with the Minister of Health in the interests of the Canadian public and the health of Canadians, to develop a fair and equitable solution and to provide better health care for all now and in the future.

We are not the enemy. We are merely trying to ensure that we have an improved system from coast to coast. Let us set up those national standards. As individuals we are not going to do that here, nor should we. We cannot nor should we play God. This must come from members of the public. It must come from the provinces. It must come from health care professionals. It must come from the federal government.

Let us ensure that we have portability for these national standards, that we have comprehensive coverage for essential health care services for all people, that we have good public administration of essential health care services, that we have universal coverage for essential health care services for all Canadians.

Last, let us ensure that we have essential health care services provided in a timely fashion. The Canadian people are not receiving their essential services in a timely fashion. One only needs to go into the field, go into the hospitals, to see the people who are not receiving them. Morale is the lowest it has ever

been, as is the pain and suffering on people's faces when told they have to wait 13 months potentially for their hip replacement or three months for their urgent heart surgery. That is not good medicine. That is bad medicine.

[Hedy Fry, Liberal, Parliamentary Secretary to Minister of Health]

Mr. Speaker, typical of the third party is the sentimentality, the rhetoric, the lack of any real fact but let us spew it anyway. Let us do the emotional dance on people.

I would like to ask the hon. member if he could give me clear statistical data which shows that the outcome in acute care is not one of the highest and best in the world, that people who clinically need care are not getting it.

We have to be very careful to clear the wood between need and want. Health care is not a marketplace commodity. The difference between what a patient needs for appropriate care and what a patient thinks he or she wants is very different.

We provide the best health care in the world that patients need. When we talk about people needing urgent care and not getting it I would like to ask the hon. member if he can give me clear examples of people who have increased mortality because they need acute care and do not get it. That, Mr. Speaker, is not true.

[Keith Martin, Reform, Esquimalt—Juan de Fuca, BC]

Mr. Speaker, I cannot believe the hon. member is saying what she is saying. I will repeat again, this is not rhetoric.

I just spent half of my speech giving the government constructive solutions on what to do. My colleagues, Dr. Hill and Mr. Manning have spent the last hour giving constructive solutions to the government.

[The Acting Speaker (Mr. O'Reilly)]

I have to interrupt the member. Although he is complimenting them on doing a good job, it is not the custom of the House to name members but to use their ridings.

[Keith Martin, Reform, Esquimalt—Juan de Fuca, BC]

Mr. Speaker, we have been giving constructive solutions. At the end of my speech I stated that members of the Reform Party would be more than willing to help get the Canadian health care system back on its feet and to ensure that medicare is provided in a fiscally sustainable fashion in the future. Obviously somebody is not listening.

We talk about essential health care services and who is not getting them. I can give the House cases. I have just mentioned the three-week waiting list for urgent heart surgery in Alberta. If that is not an essential health care service and irresponsibility I do not know what it is. The physicians who are dealing with these patients-the member knows because she is a physician-would be more than happy to inform her that this is completely inadequate. This is not something happening only in Alberta but it is going on across the country. In Ottawa it is a five-month wait for open heart surgery and in B.C. it is a thirteen-month wait for people who are in severe pain.

What the member and the government have been saying is that the government will decide what the patient needs. The government will decide what the public can and cannot do with their health care system and for their health. How arrogant to do this when health care is that which is most important to all of our hearts. That is irresponsible.

I would be more than happy to provide a long list to the hon. member of situations that demonstrate the fact that our current medicare system is not working.

[Sharon Hayes, Reform, Port Moody—Coquitlam, BC]

Mr. Speaker, I am pleased to rise to speak today to the Reform Party's motion on the future of health care and medicare in Canada and the nature and extent of the federal involvement in that. The motion states:

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.

The Reform Party believes that a fundamental responsibility of government is to safeguard the well-being of Canadians. Principle 10 of our statement of principles says: "We believe that Canadians have a personal and collective responsibility to care and provide for the basic needs of people who are unable to care and provide for themselves".

The Reform Party also believes that the current health care system is inefficient and insufficient in providing this essential service to Canadians. The current system must be reformed to guarantee the continuation of care and the ability to address the future real demands of our health care needs for everyone's benefit.

As for the benefits now of parents, my parents, the people in the House, people across Canada, our children and our grandchildren, we need that ongoing credibility of a system that right now is itself sick.

Throughout my speech I will compare and contrast the Reform and the government approach toward securing the future of our health care system. One area that reveals this contrast between the Reform approach and the government approach is the issue of consultation. The motion urges the government to consult with Canadians and health care stakeholders about the future of medicare.

In its much touted red book, the Liberal Party committed itself to "establish a national forum on health in partnership with the provinces and health care experts to find innovative ways to control health costs while keeping medicare publicly funded and accessible for all Canadians". It sounds good but to this day the government has broken its promise. It has not fulfilled the commitment it has made, a commitment to consult with Canadians about the future of medicare and the roles that will be played by the federal and provincial governments and other health care stakeholders. Because of the heavy handed approach of the federal government in this area, the provinces have refused to participate.

Consultations are not always what they appear to be or what they are announced to be by the government. For instance I would like to remind the members here of the travelling committee that was to consult Canadians on social policy reform. What happened? A flawed attempt and a report that was delayed and delayed and ultimately shelved.

Reform on the other hand has long advocated that the federal government actively consult Canadians on vital and important national issues such as the health care system. We believe consultation must take place at all levels, with patients and users, with physicians and health care professionals, with administrators of those systems and with provincial governments. We do not believe in the top down, Ottawa says, approach. We believe that Canadians need to be part of the decision making process, especially in an important system like health care.

This Reform commitment to consultation is reflected in the motion being debated today recommending that a consultative process about the future of health care be actively and honestly pursued.

Another area that reveals the contrast between the Reform and the government approach is the area of federal funding. As noted in the motion, federal funding for health care has fallen from 50 per cent to 23 per cent over the last years.

Health care was originally implemented in 1957 with the Hospital Insurance and Diagnostic Services Act. The federal government adopted this act under pressure from the provinces, some of which had provincial insurance schemes. The act established a shared cost system providing universal coverage and access to hospitals to all residents of participating provinces. By 1961 all provinces had joined this plan.

In 1977 this act was replaced with the Established Programs Financing Act. This transferred money from the federal government to provinces for both health and post-secondary education funding. In 1984 the Canada Health Act came in prohibiting extra billing and user fees and thus imposed financial penalties on provincial governments which would violate these things.

The history of health care politics is essentially the history of the federal government demanding and expecting more and more from provinces and providing those provinces with the diminishing ability and the flexibility to meet those expectations.

The present government has been in office for less than two years and it is definitely continuing this trend. In 1995 the government announced it was replacing the established programs financing plan and the Canada assistance plan with the new Canada social transfer. Under the previous system this money was transferred separately. The Canada social transfer will be a block fund provided through cash payments and transfer points.

Under the new system federal funding for health care will be reduced. In 1995-96 the federal government will transfer to the provinces some $29.7 billion, approximately at the same level that was the case for 1994-95 funding. Under this new system funding under the Canada social transfer for 1996-97 will be reduced to $26.9 billion and further reduced in 1997-98 to $25.1 billion. The government's approach to reforming health care is to cut funding without consulting or receiving input from Canadians.

In February Reform announced a taxpayers budget prior to the government's budget. In it we would give provinces additional tax room through the transfer of tax points, providing that the provinces participate in an annual federal-provincial health consultation. These regular consultations would ensure a two way communication between the two levels of government which would benefit and make better our health care system.

A first priority between the federal government and provinces would be to agree on core versus non-core services. Core services would be required to be maintained at a certain and a common standard across the country. Such things that would be necessary for core would be deemed desired by most Canadians and required by the key players in the health care field, rather than bureaucrats in Ottawa.

These services must be financially sustainable and available over a long period of time. All such services would be covered regardless of Canadians' ability to pay. Non-core services, on the other hand, would be decided also by Canadians and would be those the federal government does not have the responsibility to fund, but would be the responsibility of private funding or through insurance. Reform's approach is bottom up, not top down consultation.

As we would reduce federal cash transfers by some $800 million we would at the same time increase revenue levers and flexibility for the provinces with a transfer of tax points to those

provinces so that over time they would raise more revenue to be allocated to their health care system.

Funding for health care systems would increase over the medium and long term, steadily into the next century. This would give greater peace of mind to Canadians. It would give better flexibility to demoralized provinces and the result would be a better medical system for everyone. Our approach safeguards health care for the future while the government's approach leaves the future of health care uncertain in reality and in the minds of Canadians.

The shortfall in funding and uncertainty is of particular concern to residents of B.C. The government's planned federal funding for health care in B.C. does drop significantly. Federal transfers in 1995-96 to B.C. are approximately $3.6 billion. This is funding for health care, education and welfare under the Canada assistance plan and established programs financing. In 1996-97 under the new Canada social transfer scheme funding to B.C. will drop to $3.2 billion. Clearly something has to give. Clearly such an approach will put the resources of the provincial government under great strain.

I have heard some comment today about simplistic rhetoric. I recall the government during the last election using what I would say is worse than simplistic rhetoric, scare tactics. I remember signs within my riding: "Save Canada-Save Medicare". That kind of rhetoric when the government now puts our medical system at risk is a testimony to what I say is unfair representation by the government.

[The Acting Speaker (Mrs. Maheu)]

Unfortunately the time has expired. Questions and comments.

[Hedy Fry, Liberal, Parliamentary Secretary to Minister of Health]

Madam Speaker, the hon. member made the comment that provinces obviously do not like the system and the way the Canada Health Act was imposed by the government on British Columbia when it was breaking the act.

I would like the hon. member to name one province that has not supported all the principles of the Canada Health Act roundly within the last four months. I would like to know which ones have not supported the federal government in ensuring the Canada Health Act is effective and taking whatever steps are needed. All of the provinces, as far as I am concerned, have supported the concept. They believe in the system and in the Canada Health Act. They support the five principles.

The last meeting of provincial health ministers with the federal health minister reiterated that. Alberta said it will support those principles.

[Sharon Hayes, Reform, Port Moody—Coquitlam, BC]

Madam Speaker, I do not want to look to the past but to the future concerning the workability of the Canada Health Act and whether it is the provinces or Canadians who look to the care of their health system.

I have talked to health professionals in my riding and they are wondering how certain services will be addressed. I suppose we could get into debate. Do Canadians want unlimited access and attention for any or all complaints or health concerns, a system that gives service to all the people all of the time? Do they want long waiting periods? These kinds of things from the citizens of Canada are coming to provincial and federal tables to be addressed. What we see is a system which will not be able to answer these things in future years.

I know of men and women facing uncertainty. They are waiting for tests to determine the extent of an undiagnosed situation, perhaps cancer. They have sleepless nights. Seniors are waiting for months with a decreased ability to walk or breathe while they wait for operations.

I do not see how the government can say the present system will continue to work with decreased funding to the provinces with inflexible guidelines which will not allow caregivers to give the care needed by Canadians.

[Beth Phinney, Liberal, Hamilton Mountain, ON]

Madam Speaker, the hon. member says she does not believe in top down Ottawa directives to health care authorities in the provinces. How exactly does she see the Canada Health Act and its five principles of accessibility, comprehensiveness, universality, portability and public administration as constituting top down direction? The provinces and the territories administer the health care system, not Ottawa.

[Sharon Hayes, Reform, Port Moody—Coquitlam, BC]

Madam Speaker, I thank the hon. member for her question. Rather than a constant delivery of services, what we see in the health care system are differences between provinces. There are different expectations among users at the present time.

This would probably be more focused on the real needs of Canadians if Canadians had a part in the process of deciding which services they want to fund. For instance, we have heard today that Quebec is no longer funding psychiatric services. I know Canadians who expect that service to be funded. There are other parts of Canada in which funding for abortions is available. I know Canadians who disagree with that. Is it a top down decision or is it a grassroots decision that these kinds of procedures are being funded?

It is in those kinds of areas where-

[The Acting Speaker (Mrs. Maheu)]

I am sorry, the time has expired.

[Maria Minna, Liberal, Beaches—Woodbine, ON]

Madam Speaker, I am grateful for this opportunity to talk about medicare and the Canada Health Act. I want to explain how and why the government supports medicare and why we on this side of the House will continue to support it.

The Reform Party asks whether we have the will to uphold the principles of the Canada Health Act. There are no grounds for dire predictions that the federal government will not be able to uphold the Canada Health Act or that Canada's health care system will disintegrate as a result of the budget.

Let me remind the House how clear the budget speech was on this matter. The Minister of Finance said no change would be made to the Canada Health Act. The Minister of Health was equally clear when she spoke to the Canadian Hospital Association last March: "There is no change in the government's commitment or in my commitment to uphold and enforce the principles of the Canada Health Act". As the Prime Minister said in Saskatoon, for Canadians these principles are not negotiable.

The new transfers will be a block funding arrangement. That may worry some members but let us not forget that block funding for health and post-secondary education is 18 years old. The established programs financing funding mechanisms put in place in 1977 were a block funding arrangement. There is no requirement for the provinces to spend the money on health. What there is and what was nailed down in 1984 when the Liberal government passed the Canada Health Act is the requirement that provinces deliver health care services in compliance with the five conditions of the act or face a deduction from the money transferred to them.

Nothing in the budget will change the government's technical ability to enforce the Canada Health Act principles. The enforcement mechanism remains the same. If deductions from transfer payments are necessary they will be made.

Canadians can rest assured that Canada's social and health transfer will not reduce federal ability to enforce the principles. We will enforce them because these principles of universality, accessibility, comprehensiveness, portability and public administration are ultimately rooted in our common values. They are Canadian values such as equity, fairness, compassion and respect for the fundamental dignity of all. We will also enforce the principles of the Canada Health Act because they support an economically efficient health care system.

It is worth reminding opposition members the principles of the Canada Health Act are not just words. They have meaning. I want to touch briefly on each of these principles.

The first principle is universality, although residents in a province must be insured by the provincial health plan to receive federal support. What this really means is that we all must have access to services. People cannot be deinsured because they might be costly for the system to cover. We cannot be turned away at the hospital door because we have not paid our quarterly tax bill or provincial premium. If we need health care we will be treated the same as anyone else.

Accessibility on uniform terms and conditions is the second principle. It means we should not face any financial barriers in receiving health care: no extra billing, no user charges, no facility fees, no up front cash payment. If the service is medically necessary we will get it at a time defined by medical considerations, not by the size of our wallet.

Next is comprehensiveness. This principle recognizes Canadians have a range of health care needs and that those needs should be met. Scratch the surface a little more and we see that comprehensiveness again means we practise fairness. It would not be fair to ensure only some medically necessary services and not others. I do not believe we can, nor should we try to, choose at the federal level which service is medically necessary. We should continue to interpret the Canada Health Act as required coverage of all medically necessary services.

The government will continue to take the position that if a province ensures any part of the cost of a service, it is an indication it believes it to be medically necessary and all of the costs must be covered.

Justice Emmett Hall in his original royal commission on medicare recommended a very comprehensive package. Liberal governments of the 1960s, 1970s and 1980s accepted the concept of comprehensiveness, although not quite as broad a concept as Justice Hall's. Liberal governments in the 1990s will not turn their backs on this principle.

The fourth principle is portability. It means Canadians maintain their health plan coverage when they travel or move. The portability principle is rooted in one of the fundamental elements underpinning our federation. It recognizes our right of mobility. Canadians are free to work and travel anywhere in the country without fear of losing their health insurance coverage.

Portability is what makes our national health insurance truly national. Each separate health insurance plan may be provincial in origin but is recognized nationally in every province across the country.

The fifth principle is public administration. Our health insurance plan must be operated by provincial governments on a not for profit basis. In my view this principle never seems to get the same attention as the others but it should. It is at the core of our ability to contain costs in the system and thus to deliver quality care at an affordable price.

One would think that of all five principles, the Reform Party would be able to relate to this one. Public administration is the means by which we ensure all the other principles. When health insurance is operated and funded through government, we can guarantee that health care is universal, accessible, comprehensive and portable because we have direct control over it.

It is through public administration that we also demonstrate our collective responsibility for our health care system. Canadians are responsible for paying for their health care system. We do it collectively through our taxes. We pay so that everyone can benefit according to need. We have agreed to provide this most essential of human services together. We must not lose that.

Public administration also demonstrates something else about Canadians, our pragmatism. We want value for money and administering health insurance publicly is the best way to get it in health care. We need only look to the experience of our American neighbours to compare the efficiency of public administration with private administration.

Not only does public administration make sure more of our health care dollars go toward patient care, government can be more successful than the private sector in keeping health care costs under control.

In 1993 we spent about $72 billion on health care. This represents 10 per cent of our gross domestic product. The public component of that 10 per cent has been growing at less than 2 per cent. Compare that to private health spending, which has been growing at 6.4 per cent.

Over the last three years per capita spending on the publicly administered part of our system has been declining. Since our GDP has been growing, it is safe to predict that in 1994 and 1995 we will come in with less than 10 per cent of GDP devoted to health care.

Saying the federal government wants to maintain the principles of the Canada Health Act is not enough. We have to know the public is behind us. We all know that as politicians we cannot escape the will of our constituents. They put us in office and they can take us out. The same is true for the government. Canadians are all saying one thing to us very clearly: they want us to enforce the principles of the Canada Health Act.

In Canada's health care system there are no first or second class citizens. We enjoy rights and privileges as Canadians that are the envy of the world. We can live wherever we want in Canada and have access to health care when we need it.

The many values that make up Canada's social fabric are reflected in the five principles of the Canada Health Act. They reflect the Canadian concern for justice and equity in our health care system and they are not going to disappear. Canadians, including I am sure everyone in this House, will not allow that to happen.

As I said a moment ago, we only need to compare ourselves with the United States. They have been trying for years to get a health care system. They have a private health care system that people purchase from private companies. They spend between 13 per cent and 14 per cent of their GDP on health care. What does this extra money get them? There are 38 million people who are not covered at all, and millions more are minimally covered. That does not sound like a great exchange: more for less. Therefore, I do not see what good privatizing our health care system will do.

I also want to point out there are countries that have allowed extra billing. I know of one, Italy, that has allowed and allows to this date extra billing and private clinics. However, it may happen that a person is in a public hospital. The doctor will say: "I need to do a surgery, which is very expensive; I can only do it if you come to such and such a clinic, but it will cost you so much money". That is setting up two classes of services: if you pay more, you get served faster, and maybe that specialist will treat you there.

In this country it does not matter if one is poor or rich or even homeless. If you require assistance or surgery you choose the specialist or the doctor who will treat you. That is what a comprehensive and accessible medicare should be about. We need that kind of security, that kind of stability. Our health is the most precious thing we have, allowing us to do all of the other things we want to do. We talk about unemployment. If people are insecure about their health they cannot study, they cannot train, they cannot work.

This gives Canadians a sense of stability. They do not have to worry or lose their homes and become paupers because they are ill or their children or parents are ill.

Yes, we have a new world. We have a much larger population of seniors. We need to look at different treatments. That is true. That does not mean in any way retrenching one bit on the principles of health care, not one bit. I would never support any such direction. We must look at new treatments and new ways of assisting people.

Preventative medicine in this country must become the norm, and not, as it is now, a reaction. We are still treating symptoms in many cases, and not dealing with preventative medicine. If we were to deal aggressively with that over and above the costs we now have, we would lower health costs in this country considerably. We should be looking at how we can improve our medicare system and our health system and its delivery through preventative and other measures, and not diminish the principles of health care. That is totally unacceptable. This government would never support that.

We need to redouble our efforts to make sure even programs like psychiatric services are considered to be fundamental services. We have far too many children who are on waiting lists. Yes, a province has decided that is not a necessary service.

Maybe we need to look at that. It is a preventative service. This is what I mean by looking at innovative ways of dealing with the cost of medicare, not denying Canadians the right to access medicare.