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New
Green
Alliance
An
Alternative Approach to
Health
in Saskatchewan
Comments
on the Report of the Commission
on Medicare
Presentation to the Standing
Committee of the Legislature on Health
by the New Green Alliance
July 10, 2001
I. Principles of the New Green Alliance and Medicare.
The New Green Alliance is a new
Saskatchewan
political party formed in 1998. It is affiliated with the Green Party
of
Canada and has fraternal links with similar parties in Australia, New
Zealand,
and Western Europe.
Members of the New Green Alliance formally
endorse and subscribe to a basic set of principles. Among them are the
following which are most appropriate to the question of government
policy
on the health of our citizens:
Social
and
Economic Justice. We believe in
the right of every person of working age to
socially useful and environmentally sustainable work, access
for every person to free
education and health care, as well as adequate food, clothing
and shelter.
Participatory
Democracy. All citizens must
be able to directly participate as equals in
the environmental, economic and political decisions that affect
their lives.
Co-operation and Mutual Aid. We believe in the concept of a
co-operative
rather than
competitive human society.
Decentralization.
We
must return power and
responsibility to individuals, communities
and regions. We must encourage the flourishing of regionally
based culture, rather than
a dominant mono-culture. We must have a decentralized democratic
society with our
political, economic and social institutions locating power on
the smallest scale that is
efficient and practical. We must reconcile the need for community
and regional self-
determination with the need for appropriate centralized
regulation
in certain matters.
(Appendix A)
II. Structure of the Commission on Medicare.
The Commission on Medicare was appointed
by the government
of Saskatchewan on June 14, 2000. Kenneth J. Fyke was appointed as the
sole commissioner. We did not agree with the structure of the
Commission:
(1) It was designed to be an insider review of the medicare
system
by a professional
health civil servant and administrator.
(2) The staff was drawn primarily from the Departments of Health
and Finance.
(3) No public hearings were held.
(4) The questionnaire which was circulated to households, and
used to direct the focus group meetings, was highly
structured
and the options present to participants was designed to
lead
people in a particular direction.
(5) The time line for the commission was too short to do a
complete
job.
(6) The central focus of the terms of reference and the
subsequent
report was on the
need for greater efficiency and for cost reduction.
Our preference was for
a different kind of commission
with a different mandate:
(1) A broad inquiry on what was needed to promote good health
and health care services for all of the people of
Saskatchewan.
(2) A commission that represented our society, including women
and Aboriginal people.
(3) Public hearings around the province.
(4) A commission independent of the Departments of Health and
Finance.
(5) The use of social scientists who with expertise in the broad
area of health in general.
Most people are well served by the present
medicare system. Recent public opinion polls show that the great
majority
of people believe they have receive good treatment when ill. It is our
belief that the Commission should have focused on problem areas within
the Saskatchewan system. This would have included:
(1) The health of Northern people and their health services,
with a particular focus on
the Aboriginal population.
(2) Health services in rural areas.
(3) How to improve the health of low income people.
(4) The growing numbers of elderly people and their needs.
(5) The impact of health care "reforms" on women as the primary
care givers.
III. Position of the New Green Alliance.
Prevention promotes wellness
When the NDP was elected in 1991 it proclaimed that
there would be reforms in the health care system in Saskatchewan which
would emphasize "wellness." Most people believed that this would mean
an
emphasis on the prevention of illness. That was the common sense
response.
But that is not what we got. We have a system which continues to
concentrate
on providing cures to people who are sick or injured.
There is an enormous body of evidence available
that demonstrates that poverty, inequality, status, employment, and
work
environment are the key factors in determining good health. The report
of the Fyke commission mentions this briefly in Chapter III but offers
no strategy for dealing with the core problem. To the New Green
Alliance,
this must be the central focus of any health policy based on wellness.
Beginning in the 1960s, Dr. Michael Marmot, director
of the International Center for Health and Society at University
College
London, began the Whitehall I study of the health of British civil
servants.
This classic study revealed that the higher the job classification, the
lower the rate of death, regardless of the cause. Inequality is the
most
important factor in determining health. (Marmot, 1996; Kawachi et al,
1999;
Berkman, 2001; Daniels et al, 2000)
Numerous subsequent studies have reached the same
conclusion. A recent study by the CPRNs Health Network concluded that
"among
factors that influence health over a person's lifetime, the health care
system, itself, is far less significant than the social environment.
Measures
of health status, like mortality, morbidity and self-assessment, all
vary
according to socio-economic measures like education, social class,
occupation
and income." People's health status "closely parallels their
socio-economic
status, regardless of the quality of the health care system available
to
them." (Glouberman et al, 2000)
Poverty, inequality and racism
There is good research on the effects of
racism on
African Americans. We suspect that these findings would also be
relevant
for the case of racism against Aboriginal people in Saskatchewan. Those
experiencing racism suffer larger and longer-lasting increases in blood
pressure than when faced with other stressful situations. Social
exclusion,
residential segregation and other expressions of institutional racism
magnify
the impact of low socioeconomic status. (Geronimus et al, 1996; Krieger
and Sidney, 1996; Krieger, 2000)
Yet across Canada, including Saskatchewan,
government
taxation and spending policies have focused on cut backs to social
programs
coupled with reduced taxation on corporations and those in the higher
income
brackets. As Statistics Canada (March 2001) recently reported, this has
resulted in greater income and wealth inequality in Canada. A new study
by Andrew Heisz at Statistics Canada has found that low income
intensity
rose by 10% over the period from 1993 to 1997. Saskatchewan has
the
highest infant mortality rate of any Canadian province. This is one of
the most widely used standards of determining poverty and inequality.
Unfortunately,
the elimination of poverty and inequality has been a low priority
for our provincial government for the last two decades. And there
are no recommendations for change in the Fyke report. (Raphael, 2000;
Heisz,
2001)
Prevention works:
better health, lower costs
A good system of prevention is the only way to
reduce
the costs of medicare while improving the health of Canadians.
Ironically,
wealthy Western governments are starting to look seriously at Cuba to
see
how a poor country can maintain a healthy population while spending
relatively
very little on a health care delivery system. The infant mortality rate
in Cuba is lower than the United States (or Saskatchewan) and life
expectancy
is the same as in the industrialized West. Yet on a per capita basis
they
spend a fraction of what we do on a medical care system.
In October last year, a team of specialists
from the British
Department of Health and 100 general practitioners went to Cuba to see
what they could learn. They concluded that Cuba's success was due to a
combination of healthy food, adequate housing for all, the absence of
automobiles,
and neighbourhood clinics with adequate nurses and doctors.. Family
practice
stresses prevention. Rural people have access to the same levels of
care
and support as urban people. An extensive, affordable child care system
and universal K-12 education is very important. Children in child care
services and elementary schools are fed the equivalent of two meals a
day.
(Boseley, 2000)
In August 2000 Dr. Carolyn Bennett, Liberal MP and
professor of family and community medicine at the University of
Toronto,
made a similar tour of Cuba. She reached the same conclusions. The
Cuban
health care system was less expensive and better than that in the
United
States, she argued, because of its emphasis on prevention and the
elimination
of absolute poverty. (Bennett, 2000)
The necessity of good air,
water, food and housing
Good health also depends on a good environment.
People need clean air, good water, nutritional food, and good quality
housing.
The New Green Alliance would put a greater stress on these factors in
an
attempt to prevent illness.
Here in Saskatchewan we believe we have good air.
Our smaller communities have less air pollution, and the wind blows
away
the smog from our vehicles. This gives us air which is much better than
in the larger urban centres. Yet Environment Canada's list of the
leading atmospheric polluters includes fertilizer producers, food
processing
plants and feed lots in Saskatchewan. When farmers are applying
herbicides
and insecticides, our air quality declines. (Ewins, 2001) In 2000
Agriculture
Canada tested rainwater across Alberta over the summer and found
herbicide
traces in all samples. Some samples showed 2,4-D at 53 parts per
billion,
which is one half the Health Canada guideline for drinking water.
(Duckworth,
2001)
We have much more to worry about when it comes to
our water. A 1997 Canada-Saskatchewan Green Plan study found high
levels
of nitrates in most of the wells tested in this province. Pesticides
were
found in 10% of the wells in the Kindersley area and 45% of those in
the
Outlook-Davidson area. A 1998 study by the National Hydrological
Research
Centre in Saskatoon found herbicide and insecticide residues in all 21
farm dougouts they tested.
Of course, we are much more aware today of the
problem
of safe drinking water in Saskatchewan, following the North Battleford
disaster. The Safe Drinking Water Foundation in Saskatoon insists that
testing for water quality in rural Saskatchewan and the North is
inadequate.
Furthermore, simply adding more chlorine can add to the problem, for
when
chlorine is combined with organic acids it produces trihalomethanes
(THM)
which are cancer-causing agents. (Peterson, 2001; O'Connor, 2001;
Silverthorn,
2001)
Ontario, Quebec and Alberta have also been
struggling with the problem of ground water contamination from
intensive
livestock operations. We may be facing that problem here. Livestock
manure
run off was the cause of the Walkerton, Ontario disaster. As John
Lawrence,
director of the National Water Research Institute stressed in a talk in
Saskatoon recently, we have got to look at intensive livestock
operations
"as basically industrial process plants instead of farms." Excrement
from
large hog barns, spread untreated over the land, contains not only
nitrates
and phosphates but copper, nickel, and manganese used in feed
supplements,
as well as parasites, bacteria and viruses, including salmonella,
campylobacter,
e.coli, cryptosporidium, giardia, cholera, streptococcus and chlamydia.
(Duckworth, 2001; "Big Farms", 2001; Thu and Durrenberger, 1998)
Good health depends on good, nutritional food. The
New Green Alliance would argue that the most nutritious food is that
which
is fresh and grown locally. Food loses its nutritional value when it is
stored and transported for long distances. It loses nutritional value
as
it is processed. Of particular concern to us is the use of hormones to
promote growth in beef, the widespread use of antibiotics in feeds to
promote
growth of poultry and other animals, and the feeding of rendered animal
wastes to domesticated livestock who are normally vegetarian. We
see no benefits to farmers or consumers from the introduction of
genetically
engineered foods.
People living in Northern Saskatchewan have more
severe health problems than the rest of the Saskatchewan population.
One
of the causes of this situation is the lack of good food at affordable
prices. Whereas the provincial government ensures that the cost of
alcoholic
beverages is the same in the North as it is in the south, they have
been
unwilling to take action to provide food for the same price. We could
look
to Mexico to see how basic food was distributed to low income people
through
a system of state-owned stores in low income neighbourhoods. We would
shift
government support from industrial agribusiness to ecological farmers
who
produced for a local market. (See Bonanno et al, 1994; Goodman and
Redclift,
1991; Magdoff et al, 1998; Goodman and Watts, 1997)
Good housing is fundamental to good health and
wellness.
This has been widely recognized for some time. (See Shlay, 1995) It was
a focus of attention in the Golden report on low income housing and the
homeless in Toronto. The connection with health is very evident:
"people
who are homeless or living in sub-standard housing are at much higher
risk
for infectious disease, premature death, acute illness and chronic
health
problems than the general population is. They are also at a higher risk
for suicide, mental health problems, and drug or alcohol addiction."
(Golden,
1999)
When asked to comment on why Saskatchewan has the
highest infant mortality rate of all the provinces, Pat Atkinson,
Minister
of Health, said it was due to poverty in the north and particularly
among
Aboriginal people. Clay Serby, when he was minister in charge of
housing,
said that the province needed around 40,000 new residences for low
income
people. Both have admitted that poor housing and overcrowding are a
major
problem in Northern Saskatchewan. But very little is being done to
solve
this serious problem. This should be a priority area for the
Saskatchewan
government.
Additional services are
needed
There are other important issues which are not
really
recognized by the Report of the Commission on Medicare. The whole issue
of mental health is ignored. There is no mention of the health status
of
people who are incarcerated in the Saskatchewan penal system. The issue
of the health of the Aboriginal community is marginalized.
The National Forum on Health, which reported in
1997, called for the creation of a national pharmacare program and
affordable
home care. Unfortunately, the new Social Union, so strongly supported
by
former premier Roy Romanow, now makes it nearly impossible for the
federal
government to introduce these federal-provincial programs, strongly
supported
in public opinion polls. The Forum also called for a national child
care
program and an integrated program to eliminate child poverty. (Gray,
1997)
There is also a need for a dental program and an
insurance program for vision care. Many low income people do not have
coverage
under union contracts, work plans or private insurance programs. A
recent
Statistics Canada survey found that only 46% of the Saskatchewan
population
visited a dentist over a one year period, well below the Canadian
average
of 60%. Cost is the major barrier. (Rogers, 2000)
For the medicare system as a whole, prescription
drugs take about 15% of spending on health, behind only the costs of
hospitals
(32%) and above the cost of physicians (14%). The cost of drugs
has
been increased because of the changes to the Patents Act following the
implementation of the North American Free Trade Agreement. Generic
drugs
are on average are priced around 50% of the cost of protected brand
drugs.
Unfortunately, the Fyke Commission dodged this important issue.
We believe it is necessary for the province of
Saskatchewan
to take on the monopoly drug corporations. Profits for these
corporations
are very high -- in the range of 18% to 27% of revenues. Their spending
on research and development (6.5% to 19.8% of revenues) is far less
than
they spend on advertising and marketing (15% to 39% of revenues).
Furthermore,
much of their research is paid for by governments, universities and
private
foundations. (www.phrma.org)
We believe that the Saskatchewan government should
follow the lead of Brazil and South Africa and become the purchasing
agent
for the provincial medicare system. This includes searching the world
for
the lowest prices.
The impact of the NDP
government's reforms
The cut backs to the provincial pharmacare program
have been very hard on many people. For example, low income seniors are
paying more of the cost for prescription drugs than any other province.
Those on GIS here pay on average $460 a year for prescriptions. Quebec
is second at $360. ("Province's Seniors," 1999)
There is also the issue of the writing of
prescriptions.
It is alarming to learn that the number of children being prescribed
Ritalin
has increased ten fold over the 1990s. It is astonishing to learn that
the number of prescriptions written for antidepressants in this
province
has increased from 349,000 in 1998 to 419,400 in 2000. There is
something
fundamentally wrong with our society and the sickness care system when
the answer to health and wellness problems is to put everyone on drugs.
(Warick, 2001)
The New Green Alliance strongly supports the
community
clinic approach to providing health care services. They provide the
integrated
approach recommended by the Fyke Commission, and they can include
holistic
medicine. This form of delivery of services has proven to be less
costly
than individual practice by doctors. The key to success of the
community
clinics is that they are co-operatives run by their members. We believe
that local, community control should be promoted whenever feasible.
Primary
health services are best provided by community clinics. In our opinion,
they are preferable to individual private practice, doctor-owned
walk-in
clinics or regional clinics owned and operated by the provincial
government
or their subsidiaries, the health districts.
Today, the health care delivery system is run by
the government. Physicians, nurses and health care workers have input
into
the system through their representative organizations. But the general
public who pay for and use the system have little influence over how
the
system operates or its basic principles. The New Green Alliance
advocates
the creation of an ongoing, funded, representative, overview committee
that would allow the citizens as a whole to have a say in how the
system
operates.
There is a widespread concern today in Saskatchewan
over the health care reforms that were introduced by the NDP government
in the early 1990s, and in particular the role of the health districts.
Some of those concerns are as follows:
(1) The new changes were driven by the goal of cutting costs
rather than creating a new system to improve the health of people.
(2) The abolition of 500 local health boards and their
replacement
by 32 appointed health district boards was a dramatic move towards more
centralized control.
(3) The new health districts have no control over revenues or
budgets.
(4) The new health districts have encouraged the introduction
of privatization of local services.
(5) The new health districts have resulted in different health
services offered in different areas of the province.
(6) The new health district system resulted in the Dorsey Report
and the denial of the democratic right of workers to choose their own
trade
unions.
(7) There is less local public participation in the health care
system under the new reforms built around the health districts.
Proposals of the Fyke
Commission
The general thrust of the Report of the Commission
on Medicare is to continue this system and to promote even more
centralization
of power. For people living in rural Saskatchewan, there will be even
less
control over the health care system.
Kenneth Fyke is concerned primarily with
creating
a
"more efficient" way of delivering the present system of treating
sickness
and injury. The goal is to hopefully be able to cut the budget for
health
care by 30 to 35%. This, in our opinion, is the fundamental problem
with
the approach of the commission.
First of all, the proposals involve a shifting of
health care costs from the public area to the private sector,
particularly
the family, and more particularly to women, who are the primary care
givers.
In rural areas, more costs will be shifted to families.
Furthermore, this approach ignores the importance
of family, friends, community and history to the health and well being
of human beings. It reflects the general shift in social services away
from the Keynesian welfare state with its fundamental policy that good
health care and social well being are citizenship entitlements in an
advanced,
industrial society. It is a rejection of the modern Keynesian goal of
lifting
the burdens of family care giving from women and putting more of these
burdens in the public sector. It reflects the new dominant ideology of
neoliberalism.
We live in an agricultural economy. The urban
centres
in this province benefit greatly from agriculture as finance and
agribusiness
interests take most of the income earned by farmers for their labour.
Wealth
flows from rural areas to urban areas. The New Green Alliance believes
that the urban sector of the province can afford to give back some of
that
wealth to the rural areas in the form of good government services.
Financing the health care
system
The basis for the position of the Commission on
Medicare is that health costs are rising fast and that this trend
cannot
be maintained. The mandate asks the Commission to investigate this
area,
but it has not.
The data here is very clear. Health care spending
in real terms (discounted for inflation, in $1986) stood at $1,200
million
in 1991, the last year of the Progressive Conservative government of
Grant
Devine. The budget was cut by the new NDP government and did not
surpass
the spending of the Devine government until 1998. (See Appendix)
Health care costs as a percentage of the provincial
gross domestic product stood at 6.4% in 1991. They fell to a low of
5.1%
in 1997 and have risen slightly to 5.3% in 2000. Thus, as a percentage
of our GDP, we are certainly not spending too much on medicare, and it
is not rising. (See Appendix)
The main problem for the government is the decline
in revenues. Provincial revenues as a proportion of the provincial GDP
have fallen steadily from 24.9% in 1991 to 19.0% in 2000. This reflects
the reduction in resource revenue taxes and taxes on corporations and
small
business, reduction in wealth taxes, and reduction of income taxes on
those
in the higher income brackets. You cannot maintain the same levels of
services
if you are going to reduce taxes. (See Appendix)
It is for this reason that the New Green Alliance
has taken the position that we should maintain the progressive tax
system
of the Keynesian welfare state. We should also move in the direction of
restoring the taxes and royalties on resource extraction industries. In
this respect, our taxation policies are similar to those we had in the
province during the NDP government of Allan Blakeney (1971-82)
In an economy fundamentally based on agriculture
and the extraction of natural resources, we cannot provide good social
services, including health care services, unless we are willing to tax
the resource industries.
IV. Specific proposals from the Commission on
Medicare.
The New Green Alliance endorses a number of the
major
proposals from the Commission on Medicare:
(1) There is no need for health care premiums or users fees.
These are regressive taxes that are unnecessary. Alternatives revenues
are available.
(2) Continued commitment to the five principles of the national
Medicare system: comprehensiveness, accessibility, universality of
coverage,
public administration, and portability.
(3) The need to look at the fee for service system and doctor's
incomes. Why is it that doctor's incomes in Saskatchewan are 36% above
the national average and higher than those in any of the four western
provinces?
(See CIHI data in Appendix)
(4) We need research on special prairie health problems,
especially
those associated with living in the North and rural areas.
(5) We support the team approach to medical services, using the
Saskatchewan Community Clinic model.
(6) Telephone service can be helpful but it is no substitute
for good, local health services.
(7) The quality control proposals have some merit but must
involve
patient and general public participation.
The public and the media has focused its attention
on the proposal of the Commission on Medicare to reduce the number of
rural
hospitals, eliminate hundreds of acute care hospital beds, and
consolidating
the rural health districts into 9 or 10 larger units.
The New Green Alliance does not have a formal policy on the
health
care districts. Our policy is set at the Annual General Meeting, and we
try to reach a consensus on all major issues. But there is a consensus
among our members and supporters that the present health care district
system is not working and is unacceptable as it stands, for the reasons
cited above.
Perhaps a majority of our member favour the
abolition
of the health districts. This is the position supported by the majority
of Saskatchewan adults, as reflected in recent public opinion polls. It
was the position taken by Chris Axworthy in his campaign for the
leadership
of the NDP. It is widely believed that it was his position on health
districts
that made him the preferred candidate among voters in general as well
as
NDP voters.
There are a number of members of the New Green
Alliance
who believe that the present system of rural health districts should be
retained, but only if they are transformed. They must have adequate
funding.
There must be local, democratic control. They cannot just be the
managers
of the provincial government which is off loading its responsibility
for
cutbacks onto local boards with appointed members. People in rural
Saskatchewan
have also witnessed the loss of front line health workers and their
replacement
by more administrators. We know full well that this has angered people
in rural areas. As the Commission reports, there is little local
interest
in the health boards. People see them as having no real control
over
important matters.
In conclusion, as you can see the New Green Alliance
has a perspective on wellness and health care services which is quite
different
from the general thrust of the Report of the Commission on Medicare.
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Appendix A:
Principles of the New Green Alliance attached.
Appendix B:
Provincial Health Services: A Comparison. The National Post, May 9,
2001, A-8. Table from Canadian Institute for Health Information.
(1) $185,454 is the average that a Saskatchewan family doctor
bills the provincial health plan. The Canadian average is $177,589.
This
is the third highest in Canada, behind Ontario and Prince Edward
Island.
(2) $252,570 is the average amount a Saskatchewan specialist
bills the provincial health plan. The Canadian average is $239,322.
This
is the third highest in Canada behind Ontario and New Brunswick.
Appendix C:
Table I. Health Care spending in Saskatchewan, 1991 -
2000.
Spending as a percentage of provincial Gross Domestic Product
has declined from 6.4% in 1991 to 5.4% in 2000.
Table II. Saskatchewan Provincial Revenues, 1991 - 2000.
Provincial revenues as a percentage of provincial Gross Domestic
Product have fallen from 24.9% in 1991 to 19.0% in 2000.
Table III. Saskatchewan Resources and Royalties. Average
Annual
Figures $millions.
Royalties and taxes as a percentage of resource sales have fallen
from 26.3% during the Blakeney government to 9.9% during the
Romanow
government.
-Resource revenues as a percentage of total provincial revenues
have fallen from 32.6% during the Blakeney government to 10.2%
during
the Romanow government.
Ben Webster
Leader
New Green Alliance
Drafted by John W. Warnock, secretary, Regina Area New Green Alliance
Group.
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