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The Globe and Mail

Do Canadians have what it takes to transform medicare?

Year after year, the general council meeting of the Canadian Medical Association gets an inordinate amount of media attention.

The main reason is that doctors like to bicker and, better still, they butt heads on Canadians' fetish topic, health care.

Annually, there are heated exchanges about the state of medicare and fierce debates about how to fix it; invariably there's a left-right split, with one camp touting more privatization and another singing the praises of publicly funded care.

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But something happened this year. The discussion was tepid. The only angry outbursts were directed at journalists who reported on a CMA-commissioned (and poorly received) report that said all funding methods should be considered, including user fees and co-payments.

"We have to say unequivocally that Canadian doctors do not support user fees. We support the Canada Health Act," one delegate said angrily. There was no rebuttal. Just applause.

This is a far cry from a couple of years back when Dr. Brian Day, who owns a private clinic in Vancouver, was CMA president and waxing poetic about the benefits of a parallel private system and calling for the Canada Health Act to be gutted.

Doctors, it seems, have moved beyond the tiresome and circular public-private debate. They have come to the realization – or more accurately have become willing to admit publicly – that most health-care systems have a mix of private-public delivery and a variety of private-public payment schemes, and that's not what matters.

What matters is that care be accessible, equitable and of high quality and that the system be designed with patients in mind. Canada's medicare system, while it looks good on paper, does relatively poorly on all those counts.

So now doctors are talking transformation, specifically the need to fundamentally shift the design of the health system from one centred around hospitals and physicians delivering acute care to one centred around doctors and community-based organizations delivering chronic care and preventive medicine.

To do so effectively, there is a need to extend prescription drug coverage (some form of pharmacare), to expand home care and build more long-term care facilities and make them affordable.

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This modernization won't come easily – hospitals will resist and so will some physicians – it won't come cheaply and it could be politically explosive.

That's because the only way governments are going to be able to afford this transformation is if they cut as much spending as add. Essentially, they will need to decide what's covered by medicare and what's not. As Dr. John Haggie, the president-elect of the CMA, said, the public has to make some tough decisions on "what they need and what they want to build into their health system."

But getting politicians and policy makers to embrace this painstaking exercise isn't going to be easy.

The opening that exists is the upcoming renewal of the Health Accord, the deal that sets out how Ottawa will distribute $30-billion or so in health dollars to the provinces.

The new buzzword in health care has become accountability. Health professionals like physicians have all sorts of new accountability measures and they figure what's good for the doctor should be good for the administrator.

What the CMA wants is that federal-provincial transfers come with strings attached: Use it to transform the system fundamentally or lose it. It's the kind of shock treatment medicare needs.

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It's also an opportunity for Stephen Harper's Conservatives to make their mark on health care, in a way no one has done since the Liberals introduced the Canada Health Act in 1984.

Between now and 2014, we will see if they attempt this gambit or merely sit back and let the erosion of medicare continue.

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