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The Crisis in Health Care Presented to:
REFERENCES APPENDICES: Appendix A Statement of Principles of the Medical Reform
Group of Ontario ********************************************************************************** INTRODUCTION The Medical Reform Group of Ontario is a newly-established organization
of almost two hundred Canadian physicians and medical students;
two-thirds of our members are from Ontario. We formed in the midst
of mounting public concern about the future of health care in Canada,
uniting around three principles: As physicians and medical students we are vitally concerned with
what we see as the crisis threatening the health care of the people
of Ontario and of Canada as a whole. The Charter of Health for Canadians
proposed by the Royal Commission on Health Services in 1964 states: We believe that the goals of the Charter of Health for Canadians
have not been met. We conclude with an exploration of other factors which affect the health status of Canadians, but which lie beyond the economics and organization of medical care delivery.
Hospital and medical insurance programs were introduced in an attempt
to correct inequalities in the access to medical care by eliminating
direct costs to patients. However, their introduction did nothing
to alter the way in which health care is delivered, nor to change
the power structure within the health care system. Indirect evidence indicates that health insurance has not eliminated
differences in the health status of differing income groups. For
example, a Toronto survey compared public health indices- death
rate, tuberculosis rate, infant death rate, and still-birth rate-
for two public health districts in Toronto, one in a middle and
upper class district and the other in a working class and welfare
area. Prior to the introduction of health insurance, all four indices
were higher in the working class and welfare area. For the first
seven years after the start of the provincial medical scheme (QMSIP),
the decline in three of the four indices was greater in the middle
and upper class area. If medicare did not equalize the health status of differing income
groups, did it result in equal access to health care facilities?
Three studies1,2,3 examined this question using data collected before
and after the introduction of Medicare and another looked at the
distribution of health care after Medicare.4 Although Ease of access to doctors' offices influences who goes to see doctors.
People in low income areas rate proximity as a very important factor
in choosing a doctor.5 If they have to travel a long distance and
spend money for public transit and babysitters, they are just as
likely to use their time and money on problems they may perceive
as more pressing.6 And in 1968, of 769 paedia-tricians in Canada,
only twelve percent were located in lower income areas.7 Even if there were equal access, there still would not be equal
care. Most doctors either have middle class origins, or have acquired
middle class values during their training. It has been shown that
physicians report less interest, more frustration, and less satisfaction
dealing with lower class patients.8 For the same problem, doctors
will spend up to fifty percent more time with patients from the
highest social class than with those from the lowest.9 The amount
of information that a doctor gives out seems to be influenced by
his or her perception of the patient's economic status.10 As noted
above, the wealthy receive a larger proportion of doctor-initiated
services than do the poor. Although specialists' services may not
result in better care, referrals are made on the assumption they
will. Similarly, at a time when it was believed that extra time
in hospital was beneficial, wealthy women were kept in hospital
longer after giving birth than were poorer women.11 These class differences create tension between middle class doctors
and their working class patients. A study of senior citizens covered
by Medicare in an eastern U.S. city, found a strong negative correlation
between economic status and discontent with medical services in
the clinic these people were attending.12 Another study done in a downtown Toronto public housing community found that 47 percent of the population felt that they understood their own health better than most doctors.13 Income and social class restrict equality of access to health care.
Medicare itself has not corrected the inequities of health care
delivery to different social classes; the premium system, opting-out,
and cutbacks exaggerate these problems. Three provinces, including Ontario, still collect premiums for
health insurance. The rate in Ontario of twenty dollars per month
for a single person and forty dollars per month for two or more
in a family , is the highest in Canada, more than twice that of
any other province. The other provinces finance health services
from general revenues; some provinces add on regular user charges,
at least for certain services. It is often argued that some people are wholly or partially exempt
from paying premiums. For example, in Ontario, those over the age
of 65 and families with taxable incomes of less that $3500 pay no
premiums. Single people are exempt if their taxable income is below
$3000. Families with taxable incomes between $3500 and $50 and singles
with incomes between $3000 and $4000 pay only half of their premiums.
There are two flaws with such premium assistance plans. First, a family on partial premium assistance will be paying between
4.8 and 6.9 percent of its taxable income on health insurance, and
a family with a taxable income of $5000 will pay 9.6 percent. Meanwhile,
a 'typical' urban family with an income of $18000 will pay only
3.3 percent of its taxable income for health insurance. The premium
system of payment is clearly a regressive form of taxation. Secondly, the premium assistance program does not work. The Ontario
Select Committee on Health Care Financing and Costs (1978) found
that only about one-third of those eligible for full premium assistance
(162,000 of 487,000), and almost none of those eligible for partial
assistance (fewer than 1000 of 160,000) were receiving it. Yet another obstacle to complete coverage for low-income families
is that the OHIP administration demands a full three months' payment
at one time. These payments must be made two to three months before
the insured period. Many individuals and families on low incomes
find it difficult to budget for the $60 or $120 every three months,
and instead spend their money on more immediate needs such as food
or clothing. The Medical Reform Group is concerned about the substantial numbers
of Ontario residents without OHIP coverage. Data from nine community
health centres in Ottawa and Toronto indicate that in October 1979,
of 44,000 regular patients who had originally presented with an
OHIP number, approximately 6,000 were uninsured. These centres are
in areas with large numbers of the so-called 'working poor': people
who earn too much to be eligible for premium assistance and yet
who do not have a job-benefit package which includes payment of
health insurance premiums. The percentage of people from lower income groups without OHIP coverage is undoubtedly higher than that from higher income groups. Unfortunately, the Ministry of Health in Ontario does not publish data on the breakdown of insurance coverage by income group. Our experience strongly suggests that the coverage is less than 95 percent among significant groups of the population, and thus a far cry from "universal".
Nearly twenty percent of Ontario's physicians, and up to seventy-five percent of those in certain specialties, have opted out of OHIP and charge patients directly.15 It is important, there-fore, to review the effects of 'user charges' as revealed in other Canadian settings and as accepted by various official inquiries in to such matters. Decreased Services to the Poor. Studies of the Saskatchewan
attempt to collect 'deterrent' or user fees for health services
from 1968 to 1971 and the 1977 OHIP experience of patients in opted-in
and opted-out practices, reached similar conclusions: Inflationary Effect on Health Care Costs. The above studies
also challenge the claim that user charges result in cost reduc-tions
to the health care system. The 1977 Ontario figures, for example,
showed that "in addition to whatever additional charges may
have been involved for the patients of opted-out physicians, these
doctors provided on average more expensive services to their patients."18
This finding reflects in part the 'physician feedback effect' which
occurs when physicians try to maintain their incomes in the face
of lower volume (as some patients are deterred by user fees); doctors
generate demand by doing more 'optional' services or even over-servicing.
To quote the Saskatchewan conclusions, "the evidence of a greater
volume of complete examinations provided during the co-payment period
suggests that physicians may have engaged in some substitution of
higher-priced for lower-priced services."19 Such physician behaviour reflects the potential in the present
system of physician remuneration for 'physician abuse', leading
to cost inflation. In fact, most authorities in this field find
little evidence of the 'patient abuse' so often cited by medical
associa-tions as a major cause of unnecessary costs for unnecessary
services. Wolfson, in his review of the 1974-1975 OHIP records,
states that "to the extent that abuse does exist in the system,
these results indicate that it is more likely to originate with
the physician through over-servicing than with patients through
over-utili-zation."20 In addition, as Barer, Evans, and Stoddart,21 point out, extra-billing and add-on fees unilaterally and arbitrarily determined by physicians can only inflate total health care costs to society because government-physician negotiation of total costs for physician services is by-passed, and doctors alone are in control. Unequal Geographic Distribution of Increased Health Care Costs.
Development of a Second Rate Health Care System for the Poor. The opting-out phenomenon in Ontario has already fostered a two-tiered system of health care via the reappearance of the 'private' and 'public' patient streams in many hospitals. Many university specialists are taking advantage of their long-standing privilege of being opted-out in their offices and opted-in in the teaching hospital outpatient clinics. In response to physician pressure, even specialists in non-teaching hospitals were recently given this privilege in a little-publicized ruling by the Ontario Ministry of Health. This phenomenon represents a move towards the return of that objectionable twin system of care which was wide-spread before Medicare: high continuity personalized care by the consultant in his private office versus low continuity 'public clinic' care in teaching hospitals by the house staff on duty, with or without the consultant's direct supervision. In areas where all the specialists are opted-out, the extra-billing for private office care forces some patients to attend the public clinics whether they wish to be educational cases or not. Of course, there must be 'teaching cases' in any health care system, but these should be determined on the basis of the nature of the case and informed patient consent, not by patient income. Our view of the effects of opting-out in Ontario concurs with that
of the Select Committee of the OntarioLegislative Assembly in its
October 1978 Report on Health Care Financing and Costs: "In summary, having weighed all the evidence presented to it very carefully (94 witnesses and 189 written Briefs -ed.), the Committee concludes that user charges for medical care are inappropriate at this time."23 In fact, the Medical Reform Group of Ontario would go further and say that the present opting-out situation is completely unacceptable. It is clearly contrary to the spirit of the Hall Commission Report of 1964 and the Medical Care Act passed in 1966, which guaranteed reasonable and fair access to care to residents of all provinces with public health insurance.24
The large number of cutbacks in health care services represents
a fourth major obstacle to "reasonable access" to and
"universal coverage" for health care in Ontario. While
the inflation rate runs at 9.8 percent and is likely to increase
further, the Ontario budget allowed only a 4.18 percent increase
for health spending last year. Although there have been many adverse effects of cutbacks, hospitals
have taken much of the burden; constituting two-thirds of insured
health costs, they are an obvious target. Extensive closures of
active treatment beds have taken place across the province, based
on the Government's revised bed/population ratios of 3.5/1000 in
the south and 4.0/1000 in the north. Evidence relating these figures
to community needs is meagre. The full effect of bed closures is
difficult to quantify as the deficits these closures cause are largely
qualitative. The evidence is anecdotal but nonetheless compelling. As physicians, we have time and again been faced with the frustration
of being unable to admit sick patients to hospital because there
are no beds available. Long waiting lists have led not only to great
inconveniences, but also to overtly dangerous situations. Overcrowding
is but one manifestation of the effects of cutbacks. Patients are
routinely placed in wards ill-equipped to handle their problems
because of the shortage of beds in the appropriate wards, and the
number of 'corridor admissions' has risen markedly. Other detrimental
practices related to cutbacks include the rerouting of ambulances
to more distant hospitals, and a move to discharge patients prematurely. Chronic care patients are also not receiving the care they require.
Many people who should be in a nursing home wait six months to a
year for that service, and in the meantime cause a great strain
to their families; their presence at home may mean that a wage-earner
must give up a job in order to provide care. Other chronic care
patients occupy active treatment beds inappropriately and at great
cost to the taxpayer. Staff reductions at hospitals have been another serious problem.
Over the past three years, many jobs have been cut and the loss
of more is expected. Cutbacks have thus meant not only deteriorating
patient care, but also rising unemployment, restric-tions on wages,
and demoralization of health care personnel. These cutbacks in health care are not in the best interests of
the people of Ontario. The percentage of the provincial budget allocated
to health care continues to decline. The situation had become sufficiently
serious by early 1979 that the Federal Minister of Health expressed
concern that the increases of health care funding provided by federal
block grants were not being fully transferred into health care by
Ontario. The Medical Reform Group of Ontario has taken the position that health care spending be increased to at least keep pace with inflation; that until alternative facilities exist, bed cuts be stopped and wards reopened to alleviate waiting lists for care; and that the large numbers of layoffs of hospital workers be reversed. The extent to which the principles of "reasonable access" to "universal coverage" for health care for Ontario residents is being threatened by these cutbacks must not be minimized. PART II: SOME SOLUTIONS TO THE CRISIS IN HEALTH CARE SERVICES A. Alternatives to the Premium System of Payment Canadian provinces have differing methods of financing health care
insurance programs. Ontario funds its plan through a combination
of premiums (the highest in Canada), general revenues, and per diem
charges for some services (such as extendicare and chronic care).
As discussed earlier, many people, particularly the 'working poor',
are finding it difficult to provide themselves and their families
with health insurance coverage because of its high cost in this
province. Many of those who are eligible for premium assistance
are not receiving it because of poor advertising of the plan. Some
never make the initial application for OHIP coverage. Some of the inequities of the present Ontario system could be easily
remedied. The premium assistance program must be more widely advertised,
or tied to the Income Tax Act. The three month advance payment could
be eliminated. And the threshold for the premium assistance plan
must be raised to reflect family finances in the 1980's. However
the premium system goes against the spirit of universal accessibility
embodied in the original Medical Care Act and Diagnostic Services
Act. A better method of financing the health insurance program might
be to increase corporate and personal income tax levels in Ontario,
with a system of tax credits for those least able to afford the
increase. This scheme would ensure universal coverage with no need
to advertise specific programs, eliminate the need for a separate
bureaucracy for the collection of premiums, and most importantly,
guarantee a progressive system of financing health care. It is worth
noting, incidentally, that the percentage of tax income from the
corporate sector has dropped dramatically: in 1962 it contributed
62 percent, in 1979, only 29 percent. At present, one-third of health care funding in Ontario is derived
from premiums. Nonetheless, this system is regressive in our analysis
and our experience. It has led to a failure of the principle of
"universal coverage". The Medical Reform Group believes
that OHIP premiums must be abolished, and that funding for health
care must come from progressive forms of taxation. B. Methods to Alleviate Physician Discontent The discontent with the OHIP system registered by many Ontario
physicians stems from both economic and philosophical considerations.
However, equally important as a cause of constant and loud complaint
are a variety of OHIP practices and policies which appear, to some,
designed to harass the physician. Many of these policies, furthermore,
are detrimental to the practice of good medicine. The Medical Reform Group advocates that OHIP support and experiment with other methods of paying physicians. While fee-for-service remains the major mode of payment in Ontario, however, we urge that improvements be made in the manner of its adminis-tration. Paperwork: Each OHIP billing card must be completed by hand, with multiple details for each patient visit. Claims are processed slowly and cards are regularly rejected and returned to the physician if there are any errors or omissions, however minor. The long processing time on claims should be reduced: at present, it may take months to correct records or resolve disputes. The paperwork load could be further reduced if a plastic card were issued to all OHIP subscribers to be used on forms. Finally, doctors should be paid a paper-processing fee, similar to that now paid to labs. Patient and Practice Profiles: Physicians can improve their methods of practice, undertake patient and practice research, and compare their practices with those of their colleagues using practice profiles. In Ontario, practice profiles are available only for a fee, and then only several months after the period to be studied has ended. A free profile service would aid in research and in modifying practice patterns to meet the needs of specific practices and patient populations. Preventive Medicine: Although both physicians and governments pay lip-service to preventive medicine, fee schedules do not reflect this 'concern'. The physician is penalized for spending more than minimal amounts of time per patient. Preventive medicine involves counseling, teaching, and answering questions, and cannot be practiced without taking time. Under existing OHIP fee schedules, a physician must bill for psychotherapy or counseling (with a 'false' diagnosis) in order to be remunerated for spending time on these services. Broad categories under "Preventive Counseling" should be introduced, including areas known to produce stress and illness: poor diet, work-related stress, occupational hazards, child-rearing, family problems, immunization for travel, family planning, infertility, pregnancy and birth, etc. Extended Care: Patients requiring chronic care, home care,
nursing home care, or public health assessment may generate hours
of unpaid time as the physician contacts agencies, social workers,
and families in order to secure services. More money and effort
should be expended on providing a variety of well co-ordinated levels
of care for the patient in the community and in non-acute beds,
in order to relieve pressure on doctors' time and to reduce the
numbers of inappropriate placements. Although many of these considerations may appear minor, their collective effect is not. The provincial government has not been responsive to practical administrative details that would avoid physician irritation and improve patient care. The adminis-tration of the system has been a significant factor in the increase in the numbers of physicians opting out and moving to sunnier climes.
Option A: Raise the OHIP Benefits (Fees) to Physicians:
If the main reason for doctors' opting out were financial, raising
OHIP benefits would theoretically convince doctors to re-enter OHIP
and stop extra-billing. But doctors also opt out for philosophical
reasons. Wolfson in 1975 found that a major difference between opted-in
and opted-out physicians was that the latter were likely to be "more
individualistic and conservative in their attitudes toward the role
of government in health services."25 Many recent statements
by the Ontario Medical Association confirm that an important objective
of opting-out is to re-establish the consumer-provider relationship
that once characterized patient-physician interactions. A central
component of this traditional relationship is the direct monetary
transaction between patient and doctor, without government intervention.
Physicians who advocate opting-out are in fact asking for provider
control over the total price of physician services. Some seem to
believe that they are simple entrepreneurs, offering services in
a free market, much like the corner shoe repair man. The vehement philosophical objections to OHIP voiced by some of our opted-out colleagues indicate that raising OHIP benefits alone wouldn't convince all physicians to opt back in. Option B: Limiting the Use of Publicly Funded Hospitals to Doctors Who Are Opted-in: While the Medical Reform Group of Ontario believes that doctors should not be able to make uncontrolled private profits through their use of publicly-funded facilities in hospitals, limiting the use of such hospitals to opted-in physicians would be an indirect and awkward method of bringing doctors back into OHIP. First, it would apply pressure primarily on physicians who use hospitals extensively. A large number of urban general practitioners and some specialists make little use of hospitals, and the bulk of health care services are delivered outside of hospitals. Secondly, limiting hospital use could well lead to pressure for the construction of private hospitals along the lines of the American model. Finally, there is a practical problem in enforcing such an arrangement: group practices could leave only one physician opted-in to do hospital admissions for the entire group by referral; the group could share total incomes, thus circumventing the measure entirely. Option C: The Quebec Option: The system currently employed
in Quebec limits Medicare benefits to those who receive their care
from opted-in doctors. Therefore, patients who see opted-out doctors
are entirely responsible for the costs of any services rendered.
Under this system, a physician must be either 'all in' or 'all out'
of the plan. This kind of legislation, while attractive as a direct attack on the problem, would almost certainly provoke a major confrontation with a small minority of physicians. Some of these doctors might be tempted to try practicing 'entirely out' of the OHIP system, at least as an initial strategic manoeuvre, in response to the legislation. Others would threaten to leave the country. In geographic areas where most or all of the available physicians in a given specialty might take either of these actions, serious hardship could result for all but the most wealthy patients. Option D: Legislating All Doctors Into OHIP: This option
would differ from the Quebec option in that 'entirely opted-out'
physicians would not be allowed to practice at all. A physician
could not bill a patient directly. Such legislation is most unlikely
in Canada, given the fact that since the advent of Medicare, physicians
have been free to practice entirely outside public health insurance
plans. There may be no need for such restrictive legis-lation: after
the introduction of the present system in Quebec, only a few physicians
in the province chose to opt out completely. No one of the above methods appears entirely satisfactory, and
some combination of methods may be the best solution. For example,
a politically feasible and reasonably acceptable solution might
be a combination of legislation modeled on that currently used in
Quebec, combined with substantial fee increases to doctors This discussion has focussed on an acute problem of the present system of physician payment. The Medical Reform Group believes that it is also necessary for governments to more actively examine and implement alternative methods of physician remuneration, Only in this way can we eventually achieve a health care system which provides quality care for all in a setting which is satisfying for both doctors and patients.
Fee-for-service has been the major method of remunerating physicians'
clinical services in Canada, while other systems of payment have
been largely ignored. Yet the literature regarding the experiences
of other countries with different payment systems does not validate
the high esteem accorded to fee-for-service.27,28 The major alternatives to the fee-for-service method of payment
are salary and captivation. In most countries some combi-nation
of all three methods is used. A salaried physician receives an annual wage and is expected to
provide medical services during a specified period of time. Salary
is a common method of payment throughout the world and is used in
Canada to pay certain public health physicians, radiologists, anaesthetists,
and pathologists. A salary system is easy to administer and paperwork
is minimized. The patient is not deterred by financial barriers,
and both physician income and the health budget expenditures for
physician services are predictable. Capitation systems are less common in other countries, but generally
have worked well. Under these systems, the physician receives a
single payment for each person on his or her roster. This payment
covers services for an extended period of time. The physician provides
all necessary care that he or she is qualified to provide for that
person, and any additional services are referred. Capitation has
been most frequently used to pay general practitioners, although
in some countries it is also used to pay specialists. Like a salary
system, capitation provides a predictable income for the physician,
alleviating the worries of generating an adequate income. Capitation
is somewhat less easy to administer than salary, but less burdensome
than fee-for-service. Capitation, moreover, encourages continuity
of care. Since it is to the physician's advantage to maintain a
healthy population, preventive medicine is encouraged. Under fee-for-service, a physician is paid for each medical procedure
or visit. Many physicians have traditionally favoured this system
because it allows the greatest measure of control over the amount
of income that can be generated. A physician can increase his or
her income in one of two ways under this system: by increasing the
number of services provided or by increasing the fee charged for
each service. With the advent of public health insurance, the option
of increasing the fee per service was limited, leaving physicians
who wanted to substantially increase their incomes with the alternatives
of opting-out or increasing the number of services provided. Either
of these options creates problems for the patient. Fee-for-service is a difficult system to administer and the total
expenditures for physicians' services are less predictable; planning
is more difficult. Preventive medicine is not encouraged: a healthy
population generates fewer patient visits, and the physician's income
is therefore decreased. Fee-for-service encourages unnecessary rechecks
and office visits for problems that could readily be managed over
the telephone. Besides adding an extra cost to the health care budget,
an extra cost to society is incurred through the loss of patients'
working time. Opponents of salary and capitation argue that without the financial
incentive provided by fee-for-service, physicians would be encouraged
to underservice and to minimize their work load. There has never
been convincing evidence to substantiate this idea; the available
evidence in fact seems to refute it.31,32 No system of payment is ideal and any system is open to abuse. Nonetheless, the predominance of fee-for-service as a method of paying Canadian physicians can no longer be construed as in the best interests of patients and physicians. There are, at present, few opportunities to practice under an alternate payment system in this country, and none of these are adequately publicized, promoted, or funded. The Medical Reform Group of Ontario believes that combinations of the above three systems should be actively encouraged: many physicians would welcome the opportunity to practice under a salary or a capitation system. We urge the creation of such opportunities.
We have concentrated thus far on what we see as the imme-diate problems facing health care delivery in Ontario. But the roots of these problems lie deeper, in many widely-spread areas. We are convinced that the solutions to many of the problems that we are currently facing lie outside the realm of the delivery of medical care. Education of the Public: Health and medical knowledge is too important to be left in the hands of the few who are fortunate enough to become physicians or other health care workers. Basic health and medicine should be a central part of public school education. The need for medical intervention in minor ailments could be obviated, and informed participation in ongoing medical treatment would be possible. Furthermore, a critical knowledge of the complex of factors which shape health, and of the economic, scientific, and philosophical forces that shape the treatment of disease, would have profound effects on health policy priorities in the future. Education of Physicians: Medical education does not reflect
the needs of the practitioner as much as it does the interests of
academics and researchers. Common diseases- the daily run of colds,
flu-, sprains, and bruises- receive little consideration in medical
training, and the role of psychosocial factors in the causation
of disease is virtually ignored. The cornerstones of preventive
medicine- occupational and environmental health, nutrition, the
role of social class or geography- rarely receive more than passing
mention in medical school curricula. Nor do doctors receive the education required to critically evaluate
the barrage of new information they will face once they leave medical
school. It is a disturbing truism that a physician's prescribing
habits come to reflect more and more the claims of pharmaceutical
company detail men, and less a critical scientific evaluation of
the available methods of therapy. Mechanisms should be developed
to ensure the continuing education of practicing physicians, with
emphasis not only on the awareness of new advances in medical technology,
but also on the critical appraisal of these advances. Intimately linked with the content of medical training is the selection of trainees: admission policies must be modified so that medical school classes more accurately reflect the cultural, racial, class, and sex composition of society. Even the mechanisms for the selection of medical students should be reassessed. The Role of Other Health Workers: More use must be made of the experience, skills, and commitment of other health workers. There is a need for innovative methods designed to break down the rigid hierarchy of authority that characterizes working relationships within the health care system, and to promote the ideal of a team approach to patient care. The specialized skill and perceptions of all health care personnel, from physiotherapists to orderlies to nursing staff, should be more completely integrated into day-to-day patient care. Many of the tasks now performed by physicians could be at least equally well done by paramedical personnel. Control of Health Care Institutions and Health Policy: The
administration and policies of health care institutions must better
reflect the wishes of those they serve and those they employ. Hospital
boards or district health councils, for example, too often represent
a sinecure for the privileged; they rarely reflect the composition
of the community. Democracy and accountability must be introduced
into the health care delivery system. There is a need as well for mechanisms to be developed so that issues of health policy- research priorities or the planning of services, for example- could be opened to public input and scrutiny. Funding of Preventive Programs: At present in Ontario, only 3.1 percent of the health budget is earmarked for "community health", and even much of this small sum does not go to preventive programs. In the face of mounting expenditures on technology-intensive, treatment-oriented facilities, there is a need for increased spending on preventive programs which might reduce the need for medical intervention. For example, widespread antenatal programs aimed at high-risk mothers could prevent some of the complications that neonatal intensive care units are designed to treat. More money must be channeled into programs to prevent ill health; all too often, sophisticated medical technology can do little to correct the consequences of problems which are readily amenable to preventive measures.
The final quarter of the twentieth century is witnessing a profound transformation in our consciousness of the dimensions of health and disease. We are learning, for example, that 80 to 90 percent of cancer is environmentally-induced, and that perhaps a third of all cancer can be linked to substances in the workplace. We are learning that infant mortality is less a matter of bad genes than it is a problem of poverty, malnutrition, and inadequate antenatal care. At the other end of the scale, we are faced with the problems of providing the aged with humane care during life, and death with dignity. On all fronts we are being challenged to shift our focus beyond the individual and his or her problems, to the complex of factors that gives rise to these; health care is becoming less and less the private concern of the individual, and more the public concern of the whole society. It is beyond the scope of this brief to explore in depth the policy implications of these issues. We believe, however, that in the coming decade, new mechanisms must be developed to respond to the many challenges facing health care. As a young and rapidly-growing organization of physicians and medical students, the Medical Reform Group of Ontario wishes to add its voice to those of the many Canadians who believe that the ideal of publicly-funded, high-quality, accessible medical care for all must be preserved, and that as a society, we must seek new ways to make our health care system more responsive to the needs of all Canadians. REFERENCES 1. P.E.Enterline, et al. The Distribution of Medical Services Before
and After "Free" Medical Care - The Quebec Experience,
New England Journal of Medicine, 289: 1174, 1973.
We recognize that our concerns extend beyond the immediate issues,
and that in seeking change, we must examine the intellec-tual, social,
political, and economic underpinnings of the prevai-ling philosophy
of medicine, particularly those which transform health care into
a saleable commodity. We have, therefore, joined together to publicly express our concerns.
The Medical Reform Group of' Ontario is a democratic, non-sectarian
organization of progressive physicians and medical students dedicated
to the following principles: 1. Health care is a right. 2. Health is political and social in nature. 3. The institutions of the health system must be changed. The Medical Reform Group is committed to allying itself with the
struggles of other health care workers on an independent fraternal
basis. The Medical Reform Group is not affiliated with any political party;
our common base is our commitment to the above principles. APPENDIX B OPTING OUT OF OHIP Resolution adopted by the Medical Reform Group of Ontario October 14, 1979. WHEREAS the Ontario Medical Association has actively encouraged opting out of OHIP by all physicians in the province, and the use of a fee schedule substantially higher than OHIP benefits, WHEREAS, although the O.M.A. position is that opting out will result
in better quality of patient care, the underlying reasons for the
O.M.A. stand on opting out are as follows: WHEREAS opting out results in: THEREFORE, the Medical Reform Group APPENDIX C FUNDING OF HEALTH CARE Resolution adopted by the Medical Reform Group of Ontario October 14, 1979. WHEREAS the percentage of the Ontario budget spent on health care continues to decrease, WHEREAS many existing community projects are being cut, or forced to close, WHEREAS there have been massive hospital bed closures which have not been compensated for by opening more appropriate facilities, and massive layoffs of hospital staff that have adversely affected the quality of care, WHEREAS OHIP premiums constitute a form of regressive taxation, with lower income citizens paying a higher proportion of their incomes in premiums, BE IT RESOLVED THAT BE IT RESOLVED THAT the MRG pass the above resolution as statements
of principle, and to serve a guidelines for future work in these
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