Adam Radwanski, globeandmail.com: Dr. Martin, thanks for taking the time to elaborate a bit on your call for medicare reform. You wrote this week that the absence of "competition" is holding back our health care system. Are we talking about competition in the form of different providers within the public (single-payer) system, or in the form of private fee-for-service care outside the system for those who can afford it?
Liberal MP Keith Martin: Thanks, Adam, for this opportunity.
I am referring to both. In many European countries, if a patient cannot receive care within a certain period of time, then the private sector is allowed to care for that patient. The money follows the patient, who is seen as an asset as opposed to a burden. The monies come from a mix of public and private funds, but everyone is covered and no one is hurt financially when they fall ill.
Adam Radwanski: The common argument that's made, of course, is that in that situation, relatively affluent patients would be able to get relatively timely care, whereas others would be forced to wait until the public system could serve them. Would that inequality not exist?
Keith Martin: It would not exist because everybody is treated based on their medical need, not on the amount of money they have in their pocket. The government will step into the breach to ensure that a person will receive the care when they need it, either in the public or private system. This will maximize the capabilities of both systems. The incentive to care for the patient is based on the fact that the funding - which will either come entirely from the government or be a combination of public and private monies - follows the patient.
Adam Radwanski: When we're talking about a combination of public and private monies, I assume that means private insurance plans...
Keith Martin: In the best European systems, there are a number of funding options:
1.) Publicly funded - but the providers can be public or private.
2.) A combination of public and private funds that, again, use public or private providers.
The important issue is that everyone is covered, patients are treated equally based on need, and payment is borne entirely by the state for those of modest means or is a combination of state and individual payment for those that can afford it up to a point, so that those who have chronic diseases or sustain a catastrophic medical event are not hurt financially because the state will pay for everything after a certain point.
Adam Radwanski: Which European countries, in particular, do you think we should be striving to emulate?
Keith Martin: We must have a "made in Canada" solution that takes the best ideas from Europe (and around the world). The countries we should look at are France, Denmark, Austria, Germany, Belgium, the Netherlands, and the UK. However, of the top 20 health care systems in the world, 17 are European. So we have many to choose from.
There is no one system that will enable us to provide the best care for our citizens. We should identify and adopt the best solutions we can find.
Adam Radwanski: As you wrote this week, we tend to get bogged down in fears that any reforms constitute a shift toward "U.S.-style health care." Why do we keep falling into that trap, as opposed to looking at the various European models you've mentioned?
Keith Martin: Health care has been used for too long as a political stick to club those who would like to modernize our system. Some have found it too seductive to wrap themselves up in the status quo, suggesting that this is the route to prevent Canada from adopting an American-style system, which has poorer health outcomes at a higher cost.
These same people make a profoundly flawed statement that our health care system defines ourselves as Canadians. They have trotted out the pervasive myth that Canada has "the best health care system in the world." This, however, has been a big lie, often rooted in political expediency at the expense of patient care.
The binary choice that we have only our status quo or a U.S. system to choose from is a flawed one, and ignores health systems that are providing better health outcomes at a lower cost. We must look east to Europe, rather than south to the U.S., to find the answers that will enable Canada to truly have the best health care system in the world. When this occurs, other countries will look to us for the health leadership that we can clearly demonstrate.
Adam Radwanski: In the past, that political stick has often been wielded by members of your party. What's been the reaction from your colleagues to your reform proposals?
Keith Martin: As an MP, one of my duties is to develop solutions to the challenges my constituents face. I am trying to advance solutions to one of their top concerns. I hope, by advancing these ideas, we can bring health care reform to the forefront of the political landscape.
We will see how MPs and, more importantly, the public reacts to these solutions. In the end, change will only come if the public demands it. This is, in fact, what happened in Europe when they modernized their health care systems.
The public in Canada is far ahead of the politicians in knowing what needs to be done to improve our health care system.
Adam Radwanski: To what extent would it be possible for the federal government to effect that change, beyond signalling that it would less rigidly enforce the Canada Health Act?
Keith Martin: The first step is to bring the feds and provinces together at the same table. There is no issue that keeps provincial finance ministers more awake at night than the increasing demands that health care is having on their budgets. The discrepancy between supply of money and health care demands will widen as our population ages and medical interventions become more expensive.
This is the proverbial gorilla at the dinner table that will force the feds and the provinces to work together. Collectively, they can identify best practices and work together to ensure that those best practices are shared across the country. It is the feds' responsibility to provide the legislative space and the funds to enable this to happen. It is the provinces' responsibility to adopt the practices they see as being most beneficial for their residents.
The Canadian Institute for Health Information (CIHI) can be tasked to identify these best practices. They would include the Head Start/Early Learning program for children (one of the most effective prevention models in existence). The feds and provinces must also collaborate to develop a national health care manpower strategy; a national mental health care strategy, which must include a way to address dementias; better utilization of information technology; a national catastrophic drug coverage program; and a national strategy to address substance abuse, amongst others.
Adam Radwanski: Realistically, given political considerations, that ambitious an overhaul seems some time away. Are there modest steps toward that outcome that you'd particularly like to see provinces - or Ottawa - take in the short-term?
Keith Martin: The feds have displayed negligence in not convening meetings between themselves and the provinces on health care. They can do this and focus on some of the initiatives I mentioned in my previous response. Small victories can come from these meetings that can build trust and a functional working relationship to tackle the more substantive challenges around reforming health care systems.
On the other hand, the provinces may simply choose to do what they have to do to ensure that patients are going to receive the care they need when they fall ill and that the system becomes financially sustainable.
Some easy wins would be the implementation of a rudimentary Head Start program between K-3 across the country, or using this Olympic year to fund our elite athletes as sport ambassadors who can then be used to advance physical activity in schools. This is an initiative I am working on that will provide an enduring legacy long after our 2010 Games are over. This initiative will reduce childhood obesity and ultimately reduce the burden of chronic diseases that will break the back of our health case system in the future.
Adam Radwanski: As more and more treatment options become available, many of them expensive, do public systems also have to become more selective about which ones they provide? Can every new surgery and technology be provided within the public system?
Keith Martin: The public system currently rations health care. In fact, provinces are delisting services that were previously covered. Therefore, it is those of modest means who are deprived of these services if they cannot pay for them. The more affluent will get the services today because they can afford it.
This is an egregious situation that currently exists. It is our multi-tiered system that deprives those of modest means from the care they require or harms them financially when they pay for these delisted services.
The best European models ensure that all patients are treated equally and are cared for because the money follows them from public or public/private sources. No one goes without - waiting times are negligible - and in fact services have been expanded (i.e. more extensive drug coverage).
Adam Radwanski: Thanks for taking so much time today. You've spoken out on these issues before, but was there anything in particular - other than the Canadian Medical Association's recent study comparing Canadian care to other international systems - that prompted you to go public this week?
Keith Martin: This has been a battle that I have waged for nearly 16 years. April 7 is World Health Day, so I used it as an opportunity to draw attention, once again, to the domestic health care challenges we face and to try to get health care back on the political agenda.
As a physician, who has witnessed the pain and suffering patients endure as a result of the inadequacies of our system, I can do nothing less but to fight for those solutions that will enable those patients to access quality care in a timely fashion without being hurt financially in their time of need.
Thank you, Adam, for doing this story. I hope it shakes us all out of our torpor so that patients can access the excellent care they deserve.