An Ounce of Prevention.

More money will help ease the pressures on our health-care system; but, money alone will not solve all the problems. The catch-phrase used by government officials these days is "What matters more is how, rather than how much." In other words, smarter spending is the clue not just more spending

Ottawa announced in the 1999 Budget that the provinces and territories would receive an additional $11.5 billion for health care over the five years up to 2004.

Nova Scotia's Liberal government said, in March 1999, it was going to borrow $600 million outside its budget to improve health care.

Ontario, having cut the province's nursing staff by thousands, suddenly pledged $375 million in April 1999 to hiring 12,000 new nurses.

In November 1999, the Alberta government revealed plans to spend an additional $266 million on long-term care beds.

No politician would say so in public, but the increased funding was an admission that the slash and burn attack on health-care spending of the previous five years might have gone too far. The political price of having people die waiting for surgery or because an emergency room was so busy they couldn't get in was too high. Health care in the late 1990s became the major issue on the minds of Canadians. Any politician who allowed the cuts in service to continue did so at their peril. Hence, all the sudden announcements about putting more money into the system.

But, is increased spending the answer? Dr. William McArthur doesn't think so.

Aside from being a practicing physician, Dr. McArthur is also hooked up with the Fraser Institute, a pro-business lobby group. Writing in the Fraser Forum in April 1999, Dr. McArthur declared, "The problem with health care in Canada is not a shortage of funding. The problem is with the system, a state-run, socialized system modelled on the antiquated and abandonned systems of New Zealand and Great Britain of 50 years ago. Throwing a few billion dollars at it will not solve its problems."

Having diagnosed the disease, Dr. McArthur goes on to prescribe a treatment -- a 25% user fee. Dr. McArthur quotes a Rand Corporation study, which shows that when patients have to pay a quarter of their health-care bills out of their own pockets, they use the system a lot less. But, that cuts right to the heart of the Canada Health Act's principles - every Canadian must have reasonable and equal access to necessary health care. Additional charges to insured people for insured services are not allowed.

Yes, a user fee might stop people with head colds from clogging up doctors' waiting rooms. But, such fees might also deter a poor person from seeking attention for a problem that could get very serious if not dealt with early. Of course, user fees would be waived for needy people. But, proving you are needy can be degrading and humiliating; a lot of people will simply not subject themselves to the process.

Like Dr. McArthur and the Fraser Institute, Alberta Premier Ralph Klein also has a fondness for private enterprise. His therapy for ailing Medicare is more private-sector involvement. Most people are surprised to learn that 31% of all health-care spending already goes to the private sector. Many lab tests, x-rays, ultrasound examinations, etc., are done by private companies. Prescription drugs are usually paid for by patients who recover part of the cost through additional private insurance. Physiotherapy, rehabilitation, and dentistry are usually not paid by Medicare. Private and semi-private hospital care costs extra.

The private-sector share of health-care spending has been steadily increasing since 1984, when it stood at 25%. So, what's wrong with inviting private enterprise to complement Canada's overburdened public system, asks Mr. Klein? In November 1999, he went on province-wide television to announce that the Alberta government will start contracting out some medical procedures to private hospitals. Patients won't pay for these medical services directly; they will be paid for by Alberta's health-insurance system. Several times during his 10-minute address Premier Klein made the same statement: "... there will be no two-tiered, American-style health system; no American-style for-profit hospitals in Alberta." Newspaper columnist Andrew Coyne says he counted 13 such assurances.

The next couple of weeks can't have been much fun for Ralph Klein. Many Albertans and Canadians in other provinces didn't buy Mr. Klein's prescription. The universal complaint was that this was the first step down the slippery slope to a privatized, for-profit, health-care system.

You can't examine health-care problems without dropping in on Dr. Michael Rachlis. He writes and speaks widely on health-care reform. In a Globe and Mail article in 1998, Dr. Rachlis wrote about the work of a University of British Columbia health economist: "Robert Evans has made it clear that privatizing health-care funding inevitably makes the sick and poor worse off while improving the lot of the healthy, the wealthy, and those who wish to sell health services. It also increases the price of health care, primarily by increasing administrative costs."

Federal Health Minister Allan Rock didn't like the Alberta proposal either. He wrote: "Some suggest there is a growing tension between the principles of Canadian health care and what's going on on the ground, the answer is obvious. Get new principles. Forget about equal access. Let people buy their way to the front of the line. Treat health care like a business. Make it `survival of the financially fittest.'

"I reject that answer for the simple reason that public Medicare is the superior approach ... [This] is a value judgement, based on the facts. Those facts show that none of the alternatives is as fair or as cost effective as our single-payer universal system. Its social equity reflects our Canadian values. Its cost effectiveness confers an economic advantage that makes our business sector more competitive."

(Mr. Rock's last point is borne out by a 1999 study carried out by KPMG, the international business advisors. The company compared business costs in North America, Europe, and Japan and found that Canada has the lowest business costs. A significant advantage was Canada's lower labour costs resulting from lower employee-sponsored benefits especially medical insurance.)

Minister Rock is quick to point out that he doesn't believe Canada's Medicare system is perfect as it is. His own department, Health Canada, is pushing the switch from talking about the "health-care system" to talking about the "health system." Just dropping the word "care" doesn't look like a big deal - but it is.

"Health care" means treating people when they develop an illness; "health" means looking at our entire social system.

Here's how Health Canada rather long-windedly explains things: The role of health care "must be placed in context as only one component of a much broader set of determinants of health; by shifting the emphasis of the health-care system away from institutionally-based delivery models (i.e., physicians and hospital-based care) to integrated community-based models which place increased emphasis on health promotion and prevention; and, by developing strategies for the coordinated management of the health-care workforce, including the remuneration, geographical distribution, and appropriate use of various health providers."

What does that mean in non-bureaucratic language? Probably, the biggest change will come in what's called primary care. The first contact most people have with the medical system is through their family doctor. The way these general practitioners (GPs) do medicine is going to change. The model for the future is already being given a test run in several communities.

Group practices of several GPs, working with nurse practitioners, will offer round-the-clock primary medical services. Patients will sign on with a particular doctor in a group practice and will have to go to that doctor's clinic for all their medical needs. As many as 30 doctors might be linked into a central computer system in the group practice. Nurse practitioners are specially trained and can perform many of the functions that doctors do. Patients could consult by telephone, rather than visiting the doctors' office, for routine matters. The group practices would also offer something called telephone triage. A patient calls in and describes symptoms over the telephone. The triage nurse or doctor decides whether the patient should come to the office for a more in-depth examination or tests, go to the hospital for treatment, or be referred to a specialist for further tests. Instead of a fee-for-service payment, family doctors and nurse practitioners would be on salary geared to the number of patients on their list. This is called rostering or capitation.

Saskatchewan has experience in this area. In 1993, the province closed 52 small hospitals and replaced them with what are called integrated health-care facilities. These are similar to group practices being suggested. In the fall of 1999, a study on the effects of the change showed that mortality rates declined by 6% in communities where hospitals were closed. However, in areas that retained their small hospitals mortality rates dropped by only 2%.

The group practice system gives GPs an incentive to work on another focus of the new health system - wellness.

Our health-care system has always focussed on illness; when some part of our body goes on the blink we visit a doctor to get it fixed. The concept of wellness places greater emphasis on trying to head off illness before it starts. There is an enormous amount of work that can be done in this area, and it means getting individuals to take more responsibility for their own health.

We humans have developed many habits and activities that do terrible things to our health.

Nutrition. According to the nutritionist Paule Bernier at Montreal's Jewish General Hospital, malnutrition costs Canada's health-care system more than $1 billion a year. This is a problem mostly among elderly people and is mostly preventable. But, nutrition is a huge problem among other Canadians as well. Potato chips, bacon double-cheese-burger and fries, pizza with extra cheese - Canadians, in general, eat too many of these kinds of food. A diet high in fat leads to obesity, heart disease, and early death. That poor health habit can be dealt with simply by increasing the fruits, vegetables, whole grains, fish, and lean meats in our diets, and decreasing the fat content.

Exercise. Today, 13 million Canadians are physically active on a regular basis. That's a huge improvement over 20 years ago, but it still leaves 17 million of us who are not regularly active. You don't have to run a marathon every morning before breakfast; enormous health benefits can come from regular walking, cycling, or a host of other active pastimes. Physical activity reduces stress. It also strengthens the heart and lungs, increases energy levels, helps you maintain and achieve a healthy body weight - and it improves your outlook on life.

Substance abuse. About three quarters of all Canadians drink alcohol; 6.2% of these report having health problems as a result. That means almost 1.5 million Canadians have impaired their own health by drinking too much. At some point in their lives, 23.9% of Canadians use illegal drugs; of these 17.6% report suffering adverse health effects. That adds up to 1.26 million people with health problems coming from illegal drug use.

Family physicians are already working hard on getting their patients to adopt healthier lifestyles. We can expect to be under ever greater pressure to cut down on the fat, exercise more, and lose weight. This means overcoming feelings most people have that were summed up by Mark Twain in 1897: "The only way to keep your health is to eat what you don't want, drink what you don't like, and do what you'd druther not."

David Dodge is the Deputy Minister of Health; that makes him the country's most senior health-care bureaucrat. In 1998, he said he thought it would take 10 years to completely reform Medicare into a system with greater focus on prevention. But, as the old saying goes - "An ounce of prevention is worth a pound of cure."

SUGGESTED ACTIVITIES:

1. The title of David Gratzner's 1999 book is self-explanatory "Code Blue: Reviving Canada's Health Care System." He has written that "Medicare is a system built on perverse incentives for patients to overconsume services and doctors to overprovide them." He suggests setting up Medical Savings Accounts (MSA). This is how such as system works. Today, the government spends, on average, $800 for the yearly health care of a young man. Under the new system, the government would deposit this amount into a young man's Medical Savings Account, from which he would pay his medical bills if he has any. How much any one person gets would depend on factors such as age, gender, general state of health, etc. To protect Canadians from catastrophic illnesses the public system would kick in and pay for all expenses over, say, $2,000. The bills between the MSA and the catastrophic threshold would be paid out of the patient's own pocket. In the case of the poor or chronically ill, the government would simply fill in the difference. Mr. Gratzner suggests that those who have not spent their MSA can withdraw some or all of it at the end of the year. This kind of system has been adopted in Singapore, and the United Mine Workers Union in the U.S. has negotiated health coverage under this plan. Does it make sense? Have students organize a discussion about whether Medical Savings Accounts would improve Medicare in Canada or make it worse.

2. Invite a family doctor to your class to discuss the three most important things students could do to take responsibility for their own long-term health.

3. Smoking, substance abuse, high-risk sports - people who engage in these activities are statistically more likely to consume health services. So, should they pay extra health-care insurance premiums in the same way that high-risk drivers pay higher car insurance rates? Discuss.

TO TEARS

The first commandment of Medicare is "We shall not have a two-tiered system." This means making sure that everyone has equal access to necessary health care.

In the United States, if you are wealthy you can buy the best medical attention the world has to offer. If you are poor you must make do with the overcrowded and underfunded public system. That's two tiers, and for the poor it leads to tears of grief earlier than for the rich.

We Canadians like to congratulate ourselves that our health-care system is kinder and gentler to people who have little money. But, is it?

In some ways we already have a two-tiered system. Rich folks live longer and enjoy better health care in Canada than poor folks; a recent study proves it. For every $10,000 increase in average neighbourhood income, there is a 10% reduction in the risk of death after a heart attack. Patients from wealthy neighbourhoods are also 23% more likely to get state-of-the-art treatment and their waiting time is 45% less than those from poorer areas. The 1999 study, by Dr. David Alter at the University of Toronto, challenges the notion of equal access to health care that is a guiding principle of the Canada Health Act.

SMOKE WAR

Surely, everybody knows the terrible price tobacco takes on those who smoke it. Tobacco is known to be a major cause of ten types of cancer; more than 17,000 Canadians died of lung cancer alone in 1998. Fatal respiratory and heart disease are also caused by smoking. On average, someone who starts smoking in adolescence and doesn't quit will lose 22 years of life expectancy. The total death toll from smoking-related disease in 2000 is expected to be 47,000.

But, of course, every smoker knows the statistics apply to someone else. That's why governments in Canada have been campaigning to convince smokers that the odds are pretty good that they'll become a statistic themselves.

Let's look at the program in New Brunswick.

Tobacco-related diseases are New Brunswick's number one public-health problem and cause the premature deaths of more than 1,300 people each year. So, in 1997, the New Brunswick government began a campaign to reduce the death toll.

All provincial government buildings were made non-smoking zones. This includes hospitals, schools, and community colleges.

The Municipalities Act was amended to give municipalities the power to designate non-smoking by-laws. The government stopped providing financial assistance of any kind to companies involved in the manufacture, distribution, or growing of tobacco products.

All pharmacies in New Brunswick were prohibited from selling tobacco products; all counter and self-serve displays of tobacco products were banned in retail stores.

Public awareness activities, including television commercials, focus on the dangers of second,hand smoke to children and others with existing illnesses such as asthma.

Use of a new Resource Guide to Teaching about Tobacco was reinforced in schools.

The government supports efforts by the Workplace, Health, Safety and Compensation Commission to reduce smoking in the workplace.

Partnerships have been developed with the volunteer sector and health professions to produce televised seminars to help people quit smoking, videos on how to quit smoking, and quit-smoking programs aimed at teenagers who have already started to smoke.

New Brunswick is fairly typical of the way governments are tackling the smoking problem. And these anti-smoking campaigns have had an effect. In 1981, 38.1% of Canadians were smokers; in 1997, only 28.9% were smokers.

HOW OTHERS DO IT

FACT FILE

In 1998, total health spending in Canada was $82.5 billion or $2,694 per capita; this amounted to 9.3% of Gross Domestic Product.

Britain, Australia, the Netherlands, and Germany have what they call a parallel private system. (They don't like to call it two-tier because that implies one level is higher than another; parallel suggests equality.) Their public systems provide a wider range of services than Canada's and may include dentistry or complete eyeglass coverage; or, they put doctors on salary; or, they create competitive bidding systems for regional health authorities to buy services from hospitals; or, they require a small user fee for each visit to a doctor. But, the British two-tier system has a shortage of doctors and salaries for nurses are so low that hospitals have a terrible time recruiting and retaining them. Meanwhile, specialists find there is a huge financial incentive for treating private patients at the expense of public ones. Sweden, Britain, and New Zealand have reorganized the public health-care system to create groupings of doctors or local health authorities that force hospitals to bid for service.

NO SALE IN ST-HENRI

For five years, a team of researchers worked on a program to improve the lifestyles of people in a Montreal working-class neighbourhood. The $1.5 million program included free clinics to help people quit smoking, walking clubs, and nutrition advice.

In the December 1999 issue of the American Journal of Public Health, Jennifer O'Loughlin reported on the study in St-Henri. People in low-income communities are "more concerned," she wrote, "with, and occupied by, day-to-day social and economic living challenges than they [are] about the possibility of developing a chronic disease in the distant future."

Essentially, the St-Henri project had no effect on the long-term health of the people.