Debates of April 27th, 1995

Supply

[Preston Manning, Reform, Calgary Southwest, AB]

I have two comments. I appreciate the fact that the member is concerned about superficiality. I would earnestly suggest if she reads the speech the Prime Minister gave on this subject in Saskatoon and if she reads the speeches that have been given by the Minister of Health, we have a superficiality that betrays the government's position today.

With respect to core services, we think core services should be those services deemed essential to the health care of Canadians as defined by health care users, practitioners, local administrators and provincial governments.

I explained in my speech specifically that we should not try to say what those services are. That is what got Ottawa into trouble in the first place. It made a commitment to a whole range of services which it could not continue to fund.

At every public meeting and meetings with the medical community that I have had where I have put this health care matrix up, you can get an excellent discussion and definition from those people if you put up that matrix. I suggest that if the minister and the member want to know, go and ask the people whose opinion on that definition is the one that counts.

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

Madam Speaker, certainly from what is before us in the opposition motion on the national health care system the leader of the Reform Party has made it clear at least today that he is for a multi-tiered system. Therefore it is now clear to Canadians that the Reform Party wants to destroy the medicare that we have today.

[Lee Morrison, Reform, Swift Current—Maple Creek—Assiniboia, SK]

You destroyed it.

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

They can say anything, Madam Speaker, but Canadians are serious. They are not laughing about medicare. Canadians want to preserve medicare.

Does the hon. member believe that the single tier system is the best system in the world in terms of cost effectiveness? If the member does not believe that, I would refer him to the report of the Surgeon General's office in the United States. It has shown that indeed we have a lot of savings by having a publicly administered single tier system.

The second point is when the member spoke about health care funding I am not clear as to his understanding of funding for health. Does it mean only public spending on health or private spending on health? I can see from his speech that he would like to shift the cost of health care spending from the government to private individuals, the citizens. However, he has no proposal whatsoever that will contain the cost of proper health care spending which is the critical question facing Canadians to preserve our medicare system.

[Preston Manning, Reform, Calgary Southwest, AB]

In response to the first question: Is the current system the most cost effective in the world? No, it is not. This is obvious. This is not a matter for debate. Study after study has indicated that the costs are out of control with respect to the Canadian system and therefore it cannot be the most cost effective.

The fact that more and more Canadians are seeking health care outside the Canadian system itself is evident that there is something wrong.

The government itself professes a great abhorrence of the American system. We do not agree with the American system. We are not advocating anything of the kind. However, because of the actions of the government, it is driving more and more Canadians to subsidize the American system to the tune of hundreds of millions of dollars a year because they will not stay on the waiting lists here.

The hon. member is a physician himself. Has he ever sent a patient to get health care in the United States because they could not get it here or were on a great waiting list under our current system?

[The Acting Speaker (Mrs. Maheu)]

I am sorry, the time has expired.

[Diane Marleau, Liberal, Minister of Health]

Madam Speaker, I would like to thank the leader of the third party for setting forth in his party's motion a proposal which I would qualify as almost perfect, almost perfectly wrong that is. The proposal demonstrates clearly that Reform Party members do not understand how the Canada health system functions, what challenges it faces, what is being done to address those challenges, and what solutions are realistic and make sense to Canadians.

In his medicare proposal and in his pronouncements on the Reform Party's views, the leader of the third party has managed to put together a package that will simultaneously increase bureaucracy, decrease flexibility, maximize federal interference in provincial jurisdiction and most of all, increase the cost of health care in Canada.

How would the Reform Party pay for this? It is simple: It would push people into buying private insurance, if it is available and if they have the money for it, to cover things which are presently covered by medicare. Worst of all, it would tax the sick by permitting and even encouraging user fees.

The Reform Party proposal and pronouncements are not a prescription for a healthy medicare system. They are a prescription for disaster. Before dealing with the specifics of this motion and of Reform's thinking on medicare, let me question the proposals of the Reform Party.

Reform's so-called budget proposed surrendering additional tax points to the provinces for health care. How precisely does this square with its concern about a falling federal share of cash contributions? Certainly not well at all. How would the Reform Party deal with the fact that tax points yield different revenues in each of the provinces? It obviously has not thought of that.

How would that party enforce the conditions and criteria of the Canada Health Act? It certainly appears it would not.

What, if any, evidence do members of the Reform Party have to support their expectations that provinces would agree on a common level of basic or core health services everywhere in Canada as they state they would on page 48 of their so-called budget? Are they not aware that a number of provincial ministers of health have already indicated that such an approach is simplistic and they have no interest in developing a national list?

Which is the federal role? To determine core services, as the motion states, or to have provinces agree on a common level of core services as stated in Reform's so-called taxpayers budget? How would the leader of the third party coerce the provinces?

The Reform Party obviously has no answers for these questions. That is the reason its arguments have no basis in fact and are almost perfectly wrong. It is soapbox rhetoric which could lead to the destruction of medicare, and we are not going to have any of it.

Take this motion, for example. In dealing with federal contributions to provincial health insurance plans, the hon. member mixes apples with oranges. He does it all the time, so this is nothing new.

The federal share of funding for health care was never 50 per cent of total provincial government health expenditures. As a result of cost sharing during the 1960s and early 1970s the federal share nationally accounted for roughly 50 per cent of provincial expenditures for hospital and medical care only. Even then provincial governments were spending on health programs for which the federal government did not share costs.

Let us look at some real numbers, not those fabricated by the Reform Party. In 1975-76 after medicare was introduced the federal contribution nationally amounted to 39 per cent of total provincial health expenditures. In 1992-93 the federal contribution, the sum of the cash in transfers to the provinces for health, represented 32 per cent of total provincial government health expenditures.

Another way to look at the numbers is to examine the federal share of total health expenditures in the country. On this basis the federal share dropped from 31 per cent in 1975-76 to 24 per cent in 1992-93.

Let me repeat it again, so that, hopefully, Reform members will understand eventually. In dealing with federal contributions to provincial health insurance plans, the Reform Party leader is mixing apples with oranges. The federal share of funding for health care was never 50 per cent of total provincial government health expenditures.

As a result of cost sharing agreements reached during the sixties and the early seventies, the federal share nationally accounted for roughly 50 per cent of provincial expenditures for hospital and medical care only. Even then, the provincial governments were spending on health programs for which the federal government did not share costs.

Let us look at the real figures, not those fabricated by the Reform Party. In 1975-76, after medicare was introduced, the federal contribution nationally amounted to 39 per cent of total provincial health expenditures. In 1992-93, the federal contribution, that is the sum of the cash payments and tax transfers to the provinces for health, represented 32 per cent of provincial government health expenditures.

These are all real and public numbers. They should be the Reform's numbers because they are the facts.

Provinces administer the health care system. I want to make it clear and acknowledge in the House what I have said elsewhere. Provinces and territories are doing a good job of containing costs but historically the costs of provincial health plans increased in a less controlled manner. It is in part because of this that the federal share of health expenditures has fallen over time. If health costs had risen at the average rate of OECD countries the federal share would be substantially higher.

Expenditures in the public sector are being controlled. Our cost control problems are now in the private sector. Pray tell, why would we shift more to the private sector so we can have even higher and less control of costs?

In 1993 Canada spent $72 billion on health care. This represented 10 per cent of our gross domestic product. Hon. members are aware that with the exception of the United States, Canada's health expenditures are the highest of any industrialized nation.

There is enough money in the system. It is a question of how better to spend the money we have. Of the $72 billion spent in 1993 approximately $52 billion was spent in support of public health services while the other $20 billion was spent in the private health sector. Lately the public component has been growing at less than 2 per cent. On the other hand, private health spending has been growing by more than three times that rate.

The public sector or single payer system has enabled the provinces and territories to better control the rate of increase in the growth of health expenditures in the public sector. The World Bank's 1993 world development report noted the cost effectiveness and control advantages of public sector involvement in health: "In general the OECD countries that have contained costs better have greater government control of health spending and a larger public sector share of total expenditures".

The OECD review of health reform and development in Canada also recognized the advantage of a significant public sector involvement in health. From the 1993 OECD economic survey of Canada: "The structure of Canada's single payer health system lends itself to effective supply management and control. It seems the problems of the current system are not related to its publicness".

With respect to health expenditures in 1994, preliminary estimates by my officials indicate public health expenditures declined in aggregate by about 1 per cent in 1994, while private expenditures increased at about the same rate as 1993. Under these assumptions total health expenditures in 1994 were approximately $73 billion for an aggregate increase of less than 1 per cent, or about $600 million. Expressed as a percentage of GDP, total health spending probably declined to about 9.7 per cent in 1994.

There are a number of reasons we have been more successful in controlling health costs in the public sector than in the private sector.

We have in each province a structure which provides the same coverage to everyone. It is not necessary, therefore, to assess individual risks. Payments to providers are made in a simple but efficient manner. Financing of the system is simple; everything possible is done to reduce costs. In fact, researchers from Harvard University found that Canada only spends 1.1 per cent of its gross national product on health care management.

If we spent as much as the United States do on that, health care expenditures would increase by $18.5 billion. Americans spend almost two and a half times as much as we do on that. And there is no evidence that spending more would improve the health of Canadians.

The second reason we are in a better position to control costs is that there is only one purchaser in our provincial health insurance plans. Governments have great clout when it comes to negotiating the level of costs of services. They can set overall budgets for hospital and physician services. In fact, they have done so, as indicated by the figures I quoted.

As Minister of Health I want Canadians to continue to have access to high quality health care at a price they can afford. That is why I am working with my provincial and territorial colleagues as well as other stakeholders to address cost drivers in both the public and private health sectors. So much for the first part of Reform's motion.

Let me now deal with the second part which calls for a listing of core services. There is a remarkable degree of congruence between the provinces. Among them there is broad agreement as to what constitutes the core of ensured physician and hospital services. There are some differences from province to province

but these simply demonstrate the flexibility which provinces can and do exercise in providing a range of additional benefits to their residents. That is not wrong. That is a strength of our system; a system characterized by sound consensus on what are core services or medically necessary services.

The list of covered procedures and services of necessity must be flexible. That is because the way we deliver health care and the opportunities which new technologies and procedures create dictate changes need to be incorporated over time. There is almost no service not medically appropriate in some cases.

For example, plastic surgery may be considered medically necessary when it is intended to correct a medical condition. Reconstructing a nose to correct a breathing problem is labelled cosmetic surgery but clearly it is a medically necessary procedure.

Other examples include removal of minor skin lesions when cancer is suspected and tattoo removal in the case of abuse or prisoner of war experiences.

For the most part in Canada we have left the definition of medical necessity to professionals, not bureaucrats. The medical necessity of a service is determined at the point of delivery of the service. That is what the Canada Health Act has allowed. It is based on the medical needs of the patient, not the financial means of the consumer. That is the way it should be; this is simple fairness.

Canadians do not want cash register medicare. This stands in sharp contrast to what is happening with managed care in the U.S. There, third party insurers tell physicians what they cover and what they can or cannot do for their patients. So much for clinical freedom.

This reality is one of the major reasons why a significant portion of doctors who leave Canada to practise in the U.S. do come back home.

The Reform Party says it stands for smaller government, less bureaucracy. Therefore I find it strange it is suggesting a process that would actually increase bureaucracy. Let there be no doubt, producing the list of medically necessary or core services would involve more bureaucracy.

Medical necessity is an integral part of the understanding and operation of the Canada Health Act. It is at the very heart of the principle of comprehensiveness.

In the Canada Health Act the words medically necessary are used in conjunction with other conditions. This ensures that once a service has been determined to be medically necessary and insured by provincial health insurance plans it is accessible in uniform terms and conditions by all residents of the province and available to them when they travel across the country.

In a manner of speaking, these become rights of Canadians. These are rights the Canada Health Act is there to protect. Canadians expect they will have medically necessary services available without point of service charges. They are right in this expectation. This is why facility fees for medically necessary services in private clinics are unacceptable and why I took steps to address this problem in January.

A rigid list of medically necessary services encourages the development of a second tier of health care delivery. It promotes privatization and shifting the burden of costs from society to individuals. These costs would then be borne by patients or by their employers.

Reformers, who profess to know what is good for business, should ask business people what they think about this idea. Let them talk to the owners of small businesses, the independent entrepreneurs who account for so much economic growth in our country, who have tried to buy insurance to cover the health cost of their employees. They know how costly it is already and they appreciate how much more expensive it would be if they had to cover more services and medically necessary services as well.

I ask Reform Party members, in particular the member for Macleod who is a physician, to tell us which services they think are not medically necessary, which services they think should be deinsured and which services they think individual patients should pay for.

Even the premier of Alberta is unable to provide a list of what these should be. The government's agenda is a national one. It is aimed at doing what is necessary to renew our health care system to make it more efficient and effective. It is an agenda based on better health outcomes, not better incomes.

The motion before us urges me to consult with provinces. Since becoming Minister of Health I have made it clear I want to work with provinces and territories and I have. I have met my provincial colleagues. I talk to them on a frequent basis. We have arrived at a consensus about the need to support the principles of the Canada Health Act. Perhaps he should consult with more provinces than he has.

I am prepared to continue this collaboration. Our next regular meeting is scheduled for September, but I have already told the provinces that I am ready to meet with them earlier. There is no lack of willingness by this government and this minister to work with the provinces, the territories and others to ensure that Canadians continue to have the very best health care system in the world.

[Preston Manning, Reform, Calgary Southwest, AB]

Madam Speaker, the minister concluded her remarks by expressing her desire to co-operate, collaborate and work with the provinces, and we applaud that. That is constitutionally correct and is the only way the system will be fixed.

However in the course of her remarks she used an unfortunate phrase. I trust it was a slip of the tongue when she asked rhetorically how we can coerce the provinces into national standards if we do not retain the present system.

Surely the minister is aware that she is losing her capacity to coerce the provinces as federal cash transfers decline. She is also aware that it is possible to have national standards without coercion as we have, for example, in the field of education where there is the universal standard that everyone under 16 years of age gets a free education. That was established as a national standard without any national education act or coercion on the part of the federal government.

This talk of coercing the provinces into national standards as her financial position weakens is completely contrary to the spirit of federalism and what she said later on. I should like to give the minister an opportunity to withdraw that statement and indicate that she did not mean in any way, shape or form to say she favours coercion of the provinces, which is a polite word for blackmail, into national health care standards.

[Diane Marleau, Liberal, Sudbury, ON]

Madam Speaker, my response to that is to go on to say that again they do not listen to what I am saying. I have asked the Reform Party to explain how it would coerce the provinces into having a uniform list of core services, and it certainly has not answered that. Its type of top down solution is not exactly what I am talking about.

We are getting a strange mixture of things from the Reform Party. On the one hand I heard the leader of the Reform Party go on at length about allowing the provinces to have more flexibility to allow those in the regions to be better able to deliver services. On the other hand his party is asking us to work with the provinces to develop a hard line definition of what is covered and what is not. There would be a list and we would need a whole series of bureaucrats to make sure it is really this and not that and therefore would not be covered. It always astounds me because the Reform Party cannot have it both ways.

By the way, we enforce principles not standards. The Canada Health Act talks about five fundamental principles. Those principles have served us very well.

The type of fear mongering and statements made by the leader of the Reform Party saying that our health care system is not doing well are wrong. While I will admit that changes are needed and we have to continue to work on it, the idea is for us to shape the future of medicare. That is what the provinces, working along with the federal government, are very much working on to deal with the new technologies and to ensure the dollars spent on health go directly to those things that are most needed.

Change is difficult. It is not easy. Throwing more money at it will not make it better. We will end up with a system like the one in the United States. That is exactly what the Reform Party is promoting.

[Grant Hill, Reform, Macleod, AB]

Madam Speaker, the minister has gone on at great length to talk about our proposal for a definition of core essential issues. She said that this was some kind of nefarious scheme that had never been thought of or heard of in Canada before.

Could the minister explain when the Prime Minister said shortly after the budget on the Peter Gzowski program that we must return more to basics in our health care system? That is not an exact quote but very close to an exact quote.

Could the Minister of Health explain what the Prime Minister was referring to when he said that we were trying to do too much with our public funding? That is not a question the minister should be able to dance around and avoid. It is a fairly straightforward question.

[Diane Marleau, Liberal, Sudbury, ON]

Madam Speaker, the Prime Minister has been a member of Parliament for 32 years. He does not need lessons on medicare from the Reform Party. Let us make that perfectly clear. He was here when medicare was brought forward. He saw the growth and the best of medicare. That is why he is such a staunch defender of it. That is what we are talking about.

The member for Macleod talks about core or medically necessary services and having lists. Certainly they are things that have been talked about. The premier of Alberta talks about them all the time and he has not been able to come up with a list.

I would understand if the member for Macleod would agree. After all, he is and was at another time in his life a physician. Does he not believe it is far better for physicians, medical practitioners, to make that determination when they have someone before them? They look at the evidence before them and know what is medically necessary or not, or they should know.

With the help of the Medical Research Council and many other agencies we are proposing to look at evidence based outcomes. Many procedures have been performed that perhaps do not have any real value. Those kinds of procedures should not be performed any more. We need to do a lot more research in that field. A lot of it is being done and we will continue to do it. We are proposing clinical guidelines so that there are fairly uniform ways of determining.

When we hear about an excessively high rate of hysterectomies in one area versus another area when the composition of the communities is essentially the same, there is something wrong. We will work at addressing some very serious discrepancies, but that is not to say that we should have a strictly defined list. I still believe that patients, along with their physicians and their caregivers, should be the ones to determine what is medically necessary.

[Paul Forseth, Reform, New Westminster—Burnaby, BC]

Madam Speaker, I have a question for the Minister of Health. Canadians are faced with a fundamental dilemma: there is less government money to go around to support medicare as we know it yet everyone wants to preserve medicare.

How do we reallocate tax dollars and in general bring more resources to bear on medicare in a climate of economic restraint? A lot of our problem is really not internal to medicare but rather the fiscal climate within which it is trying to operate.

Could the minister clarify the larger fiscal climate that affects medicare and the solution to that dilemma? How do we address the overall funding shortfalls for medicare that are getting worse every day? It is a national problem. What will the federal government do about it?

[Diane Marleau, Liberal, Sudbury, ON]

I have said and I will repeat that there is enough money in the system. However I will say there are some areas where we have to set our priorities. Medicare is a priority. It is a priority for the federal government and it is a priority for most provincial governments. They have to base their financial decisions on their priorities.

We are doing it here. We are working at setting our fiscal house in order because we understand we have to do certain things to preserve and protect the very sacred programs which are constitutive to our identity.

That is what medicare is. It defines what Canadians really are and it shows the values of caring and sharing which have helped to build this great country. We will continue supporting these solid values.

[Pauline Picard, Bloc, Drummond, QC]

Madam Speaker, I welcome this opportunity to rise in the House and speak to the motion presented by our Reform Party colleagues, a motion that concerns Canada's health care system. Although we are aware of and condemn the federal government's unilateral withdrawal from the funding of health care services in Canada, the Bloc Quebecois cannot support this motion.

It is true that, as far as funding for health care is concerned, the federal government has betrayed the provinces by reneging on its commitments. It is true that, by continuing to impose its standards in an area over which the provinces have jurisdiction, while refusing to pay the real cost, the federal government acts like the charming host who invites you out to dinner but leaves you with the bill. We agree with our Reform Party colleagues that we should condemn, loud and clear, the present government's shameful withdrawal of funding from health care programs.

By continuing the work started by the previous Conservative government, which it deplored at the time, the present government has made the advent of a two-tier and two-speed health care system unavoidable throughout Canada. That is the tangible result of these harsh but insidious unilateral cutbacks in transfer payments to the provinces for established programs financing. However, the Bloc Quebecois could never support a proposal that the federal government become involved in determining core and non-core services, a prerogative exclusive to Quebec and the other provinces.

To establish a national list of core services would be a denial of the authority of the provinces to determine the kind of care they feel is necessary to maintain the health of the public that depends directly on the provinces for those services. Another reason why we cannot support this motion is that the Reform Party proposes to open the door wide to private insurers. Although federal cuts in funding for the public health care system in Canada has led to a proliferation of private clinics across the country, the Bloc Quebecois cannot support the advent of a two-tier system, one for the rich and one for the poor.

The present government's position on the management and funding of Canada's health care system is at best ambivalent. To me, it is clear the federal government can no longer afford its ambitious plans for managing the health care system. The trouble is, it does not come out and say so to the taxpayer, since by cutting spending unilaterally in a jurisdiction it appropriated at the time, the federal government has shifted the responsibility for breaking the bad news to the provinces. It takes credit for giving us the best health care services in the world, but it will no longer provide funding to maintain the standards it has set and compensate for the tax room it appropriated to pay the real cost of the system.

We should not be surprised that the health care system is coming apart at the seams, and mainly because of the federal government's withdrawal of funding. However, the government should be frank and make this clear to the taxpayers, instead of trying to camouflage the whole situation with its new Canada Social Transfer. It should stop trying to fool the public and give the impression that the whole might be better than the sum of its parts.

When the total amount of transfer payments is reduced in the Canada Social Transfer, it means there is less money for

education, less money for social assistance and less money for health care. One would have to be very naive to believe, as the Minister of Health seems to think, that this new approach will make it possible to safeguard Canada's health care system without involving a major departure from its main principles.

In its last budget, the government introduced several measures which are a threat to our social programs. It cut transfer payments by $7 billion, which amounts to offloading $7 billion of its deficit onto the provinces.

The most recent cut in transfer payments is just one more in a series of unilaterally announced cuts over the past few years, a practice the members of this government used to protest loudly against back when they were in opposition. Between 1977 and 1994, the federal government's share in social program funding-health, education and social assistance-dropped from 47.6 per cent to 37.8 per cent. The latest budget follows suit with a draconian cut to the federal government's funding share, which will have sunk to 28.5 per cent by the end of the next two years.

After so many years of offloading to the provinces, the federal government still has not learned that cutting transfer payments is not helping to fix the financial problems of all of the governments in Canada. By insisting on governing areas over which its own Constitution gives the provinces exclusive power, the federal government is preventing the country from finding any real solution to its financial crisis, both at the federal and provincial levels.

We are clearly witnessing the dismantling, the crumbling of the health care system as we have known it up to now. The very essence of the motion before us today bears witness to this. It also confirms the dismal conclusions drawn at the provincial health ministers' conference, which was held in Vancouver earlier this month.

We all know that Quebec and the other provinces are facing a dizzying increase in health care costs. This increase is due mainly to the following factors: an ageing population; new, more expensive, medical technology, and a significant increase in spending on pharmaceutical products.

In the last budget, like other budgets before in which transfers were frozen, the government substantially cut transfers to Quebec and to other provinces for health care. Regardless of whether these transfers are lumped with others in one envelope called the Canada social transfer, the effect is the same: less money will be available for health care and, in this way, the government is eating away at the foundations of our health care system.

Nobody in this House can ignore the radical changes being made across the country to the health care system as we know it. A two-tier and two-speed health care system is no longer a prediction, but a reality.

I cite as proof the Prime Minister's latest statements, in which he quietly and furtively introduced the new concept of guaranteeing Canadians basic health care services only. By alluding himself to essential minimum standards, which are neither identified nor formulated, the Prime Minister is acknowledging the evidence emerging everywhere in Canada of a two-tier and two-speed health care system.

The two-tier health care system is evidenced by a trend, which is well established in the system and which, without drastic change, will become the norm. There will be a basic service covered by health insurance and there will be the full specialty service paid for by user fees, private insurance or some other financial arrangement.

The two-speed system is already well established throughout Canada: slow public service for those without the means to pay and quick private service for those who cannot afford to wait, but who have the means to pay the cost of a private clinic.

During his budget speech, the Minister of Finance solemnly stated, and I quote: "The conditions of the Canada Health Act will be maintained. For this government, those [principles] are fundamental". The government is maintaining the obligation to meet national standards, but, in the same breath, it is cutting the means to maintain them.

It is shameful double talk: we want to go to heaven, but nobody wants to die. The government says it is up to the provinces to organize themselves and all that. It would have us believe that this is flexible federalism.

How can the government still think and argue that the provinces will keep the same health services for the public? How will Quebec and the other provinces successfully apply the five main principles of the Canada Health Act, which Ottawa is requiring them to do as it dumps billions of dollars of deficit on them through cuts to social programs?

The government should be strong and come clean with Canadians by telling them that, unfortunately, because of its errors in the past, primarily in the Chrétien and Lalonde budgets, it no longer has the means to maintain our health care system as we know it. But no, the government is deceiving the people by hiding the spectre of the demise of social programs due to so many years of bad management, of diluting provincial jurisdictions and of wastage, because it used its spending power to centralize and unify.

Quebec and Canadian taxpayers hand significant sums of money over to the federal government, and a portion of it was always set aside for health care under the 1977 agreement. The problem is that, for the past 12 years, the federal government

has not been returning the amount due the provinces to them, thus diverting money intended for health care. Instead, it transfers to the provinces the deficit it has accumulated because of its inability to bring its own expenditures under control. The federal government must be sensitive to and, more importantly, aware of the fact that, by increasing the tax burden of the provinces in this way, it is creating a two-tier health system.

We believe in the general principles of universality, comprehensiveness, accessibility, portability and public administration of health care. What we denounce is the fact that these five general principles are now seriously threatened in Quebec and all the provinces by the federal government's failure to honour its commitments.

Reducing or freezing federal transfer payments jeopardizes our health system. When it was first passed, the legislation governing established programs financing provided that 45 per cent of health costs were to be paid via Ottawa. However, because of the economic crisis in the early 1980s and the catastrophic condition of public finances at the federal level, the federal government began unilateral withdrawal action that will result, in 1997, in federal contributions being half of what they used to be. This withdrawal from financial commitments, repeatedly described as unacceptable, unfair and inconsistent by the Quebec government, did not lead to less interference from Ottawa. Not only does Ottawa continue to impose national standards, it interferes through parallel programs, thereby causing costly overlap.

This results in constant pressure toward the introduction of user fees and other billing methods, the curtailment of coverage for certain services, a service tax on drugs, bed closures and major budget cuts in hospital centres as well as disgustingly long waiting lists in several areas.

This is to say that the very foundations of our health system, namely free care, universality and accessibility, are in jeopardy. What does the minister think of her government's withdrawal from its commitments and the hardship caused to provincial health ministries? I think that, if she pays any attention to what goes on in her own department, the minister must be fully aware of the serious implications of such action on our health system. She must certainly see that all the leaks in the system will inevitably lead to a two-tier system, a two-speed system.

Since she took office, the hon. minister has repeated over and over that the Canadian health system is the best in the world and that she cares so much for the health of Canadians that she would never give up the five general principles laid down in the Canada Health Act.

Reality, however, is something else altogether. If she does not, as she claims, sacrifice these five general principles laid down in the Canada Health Act, her colleague, the Minister of Finance, on the other hand, certainly does not mind doing so.

By taking the axe to established programs financing, the Minister of Finance is eviscerating the health care system, principles or no principles. They may swear that they are committed to the principles set out in the legislation, but if they do not provide the money needed to enforce them, what will happen? The principles will fade away one after the other, slowly but surely.

I freely admit that the Minister of Health may be committed to the principles that guided the implementation of what she always likes to refer to as the best health care system in the world. However, I think that this commitment, however profound, did not weigh very heavily in budget decisions. It must be recognized that the minister failed miserably in her attempt to secure the funds needed for the smooth operation of the health care system.

In fact, the Minister of Health renounced her responsibility. When the 1994 budget was tabled, she announced with great pomp that the National Forum on Health promised in the red book would be held under the chairmanship of none other than the Prime Minister himself. The health care system was supposed to be spared until the results of these widespread consultations were known. Although the Minister of Health succeeded in holding her forum, which was supposed to solve all the problems, the Minister of Finance for his part did not beat around the bush. Saying to hell with the forum, with consultations and reforms, he decided that the remedy lay in blind, uniform, unilateral cuts across the board.

The Minister of Health, who, like us, must see a two-tier system developing across Canada, should have the courage to rise in this House and denounce her government's unilateral cuts.

It is not true that user services will remain the same. It is not true that the provinces, to which the federal deficit hot potato has been passed on, will perform miracles with shrinking resources. The minister should agree with this analysis since it reflects her own interpretation delivered in this House on March 9, 1992, when she was a member of the opposition.

What we must realize is that, by perpetuating the mistakes of the past, the government is moving toward the position held by the Reform Party, that is, a two-tier health care system that is partly public and partly private. The difference is that the Reform Party does it directly and openly by tabling a motion, whereas the government does it in an underhand and hypocritical manner by refusing to face reality and admit that it can no longer afford to pursue its ambitions.

The government finds itself in that position because it does not have the will to cut elsewhere in its spending and to review its fiscal policy. The government is prepared to sacrifice health, but it does not hesitate to maintain useless and costly duplica-

tion, as well as family trusts, or to pay for costly ministerial suites, among other things.

Whether it is through the government's approach or the one proposed by the Reform Party, the Bloc Quebecois cannot support the destruction of our health care program. If the federal government no longer has the means to meddle in this field of provincial jurisdiction, it should completely withdraw from it and leave it to the provinces, with the tax room that goes with it. In doing so, the government would at least save the administrative costs of the federal programs which duplicate similar provincial initiatives. Both the federal and provincial governments would benefit, not to mention Canadians, who would definitely get more for the same amount of money.

The failure of the health care program reflects the failure of a centralizing federalism. That program can no longer be a great tool to promote Canadian unity, as this government would so dearly love. Let us do without symbols which we cannot afford. Let us be realistic. The federal government must stop trying to impose its utopian vision of an egalitarian Canada and withdraw from those sectors, including taxation, which fall under provincial jurisdiction.

This is the Bloc's position and this is why we reject the motion.

[Diane Marleau, Liberal, Minister of Health]

Madam Speaker, first, I would like to thank the hon. member for taking part in this debate and for having made a speech here, but I think that she may have missed one or two things in mine. First, Canada is second in the world regarding the overall sums spent on health care. No expert, no economist anywhere would tell us we should be spending more. Not a one. We know that we could even do more with less.

I am sure that Quebec's Minister of Health agrees with me on this point, because, this year, he is proposing a half billion dollar cut, $545 million to be exact, I believe, to the health care budget of the province of Quebec. So he too probably realizes that we do not need to pump more money into the health care system, but to better manage the amounts we do put into it. These things need to be said because this year's transfer payment has not been reduced but increased.

The Canada Health Act gives the provinces a lot of leeway. In fact, they already have all of the freedom they could want, except to levy user fees or charges for hospital care or medical help.

The fact that the Canada Health Act prohibits user fees is important, and Canadians should appreciate that this legislation can help them, especially when they are sick.

The hon. member talked about overlap. The federal government only employs 25 people to administer the Canada Health Act. Is that overlap? In my opinion, we are doing quite a good job, because we are working very closely with the provinces to avoid overlap, especially in the area of health care.

The hon. member made a fine speech, but what I really want to know is the following: Does the Bloc Quebecois support the principles of the Canada Health Act or does it envision a two-tier system? Does it want to bring in user fees? Exactly how does the Bloc Quebecois intend to do things better or to change things? Does the Bloc Quebecois acknowledge that the Canada Health Act has served Canadians very well and that we absolutely must build the system of tomorrow on the values it contains?

[Pauline Picard, Bloc, Drummond, QC]

First of all, Madam Speaker, I want to thank the minister for her questions.

I would like to remind her of the position of the Bloc Quebecois. In 1977, when the five main criteria in the Canada Health Act were adopted, agreements were concluded with the provinces. The gist of these agreements was that the federal government would transfer to the provinces the money they would need to administer the health care system.

With respect to the cuts I mentioned earlier and to what I said in my speech, I would like to point out to the minister that she misunderstood entirely what I was trying to say, because I always said the Bloc Quebecois supported the five main principles of the Canada Health Act. However, we object when the government cuts transfer payments and then asks the provinces to do more with less money, when we know that the-

[An hon. member]

Oh, oh.

[Pauline Picard, Bloc, Drummond, QC]

Exactly, if you had not cut transfer payments, Mr. Rochon would not have been able to-

[Some hon. members]

Hear, hear.

[Pauline Picard, Bloc, Drummond, QC]

Madam Speaker, I would like to quote from the speech the minister made in 1992: "Cutting back on the transfers in these areas has not contributed to better management of our health care system. We have literally forced our deficit onto the provinces and said to the provinces they have a choice: they can either increase their taxes or cut back on their services. What we have seen in many cases is a mix of the two".

In the same speech, the minister also said: "Cutting back on the transfers in these areas has not contributed to better management of our health care system. They have only contributed to the cutbacks and to the fear that we feel now across the nation, as the middle income group, which is the largest group of Canadians, are frightened and afraid of what is going to happen to them in the future. Will there be a health care system for them, will they be able to get the drugs that they need at the prices they

can afford to pay when they need them, when they get to be a certain age. There is this feeling that perhaps the federal government is letting go of its responsibilities in this matter".

[Paul Szabo, Liberal, Mississauga South, ON]

Madam Speaker, in the comments of the hon. member for Drummond, the statement is made that the federal government is attempting to keep Canada together by using medicare. The member should realize that medicare is not a vehicle to try to keep Canada together. It is one vehicle that has kept Canada together and makes it the best country in the world.

The five principles of the Canada Health Act are universality, accessibility, portability, public administration and comprehensiveness.

I ask the member which of those principles she does not support and why does she feel medicare is not working?

[Pauline Picard, Bloc, Drummond, QC]

Madam Speaker, the Bloc Quebecois agrees with the five main principles of the Canada Health Act. However, and I repeat, we do not agree with dumping the deficit onto the provinces by reducing transfer payments to them, while they are facing increased health costs. The government reduces the payments and then tells the provinces they have to manage the health care system as usual, as the act provided in 1977.

I myself do not want a two-tier or a two-speed system. However, if things continue the way they are going, the provinces will be forced to find a way to manage to serve the public and administer the health care system, because they cannot manage it with the cuts in the transfer payments. This is what is happening, and the government keeps on cutting. The effect of this, at the moment, is that it is better to be rich and healthy than poor and sick.

[Eleni Bakopanos, Liberal, Saint-Denis, QC]

Madam Speaker, it is unfortunate the Bloc Quebecois can only repeat that it is the government's fault. How is it that the Minister of Health in Quebec cut $454 million from his budget, when the federal government's transfer payment actually went up? The blame need not always be placed on the federal government, because provincial governments make their own choices. The choice the PQ minister and government made was to cut in the area of health care on the backs of the poor, just like you said.

[Pauline Picard, Bloc, Drummond, QC]

Madam Speaker, why did Mr. Rochon, the Quebec Minister of Health, have to cut his administration in order to continue to manage certain forms of health care? Because there was a shortfall of $8 billion.

[An hon. member]

There you have it.