BUILDING onVALUES THE FUTURE OF HEALTH CARE IN CANADA ROY J. ROMANOW, Q.C. COMMISSIONER Final Report NOVEMBER 2002 BUILDING onVALUES THE FUTURE OF HEALTH CARE IN CANADA National Library of Canada cataloguing in publication data Commission on the Future of Health Care in Canada Building on Values: The Future of Health Care in Canada – Final Report Commissioner: Roy J. Romanow. Issued also in French under title: Guidé par nos valeurs : l’avenir des soins de santé au Canada Includes bibliographical references. Issued also in print format. ISBN 0-662-33043-9 Cat. No. CP32-85/2002E-IN 1. Medical care – Canada. 2. Public health – Canada. 3. Medical policy – Canada. 4. Health services administration – Canada. II. Romanow, Roy J. II. Title. RA412.5C2S52 2002 362.1'0971 C2002-980275-X November 2002 TO HER EXCELLENCY THE GOVERNOR IN COUNCIL By Order in Council P.C. 2001-569, I was requested to inquire into and undertake dialogue with Canadians on the future of Canada’s public health care system, and to recommend policies and measures respectful of the jurisdictions and powers in Canada required to ensure over the long term the sustainability of a universally accessible, publicly funded health system, that offers quality services to Canadians and strikes an appropriate balance between investments in prevention and health maintenance and those directed to care and treatment. I am pleased to report that my Commission’s multi-faceted consultations with Canadians demonstrated their commitment to the original ideals of medicare as well as their willingness to change basic practices and approaches in order to make the system as a whole more sustainable for the 21st century. I have relied upon their experience and wisdom as well as the best research and evidence available in coming to my conclusions and recommendations. I have been honoured to have the responsibility of working to fulfill this mandate and I am pleased to submit for your consideration the Final Report of the Commission on the Future of Health Care in Canada. Respectfully submitted, Roy J. Romanow, Q.C. Commissioner iii CONTENTS MANDATE . xi A MESSAGE TO CANADIANS . xv EXECUTIVE SUMMARY . xxiii 1SUSTAINING MEDICARE . 1 What is Sustainability? . 1 Health and Health Care Services . 2 Health Care and the Canadian Constitution . 3 Medicare and Beyond . 4 Private For-Profit Service Delivery: The Debate . 6 Needs and Outcomes . 9 Performance of the Canadian System . 9 Responsiveness to Specific Illnesses . 14 Disparities within Canada . 16 Anticipating an Aging Population . 20 Resources in the System: The Case of Funding . 23 Canada’s Reliance on Taxes . 24 Use of Private Insurance and Out-of-pocket Payments . 24 The Balance between Public and Private Funding of Health Care . 26 Alternative Funding Sources . 28 Sustaining Canada’s Health Care System – Looking Ahead . 43 2HEALTH CARE,CITIZENSHIP, AND FEDERALISM . 45 Directions for Change . 45 The Case for Change . 45 Establishing a Canadian Health Covenant . 48 A Commitment to Canadians . 48 Achieving the Vision: National Leadership in Health . 52 v A New Approach to National Leadership . 52 Role of the Health Council of Canada . 54 Health Council Operation and Structure . 57 Modernizing and Updating The Canada Health Act . 59 The Principles of a Modernized Canada Health Act . 60 Expanding Medicare Coverage: Short Term and Long Term . 63 Clarifying Coverage under the Canada Health Act . 64 Providing Stable and Predictable Federal Funding . 65 Introducing a New Canada Health Transfer . 65 Short-Term Funding Issues . 71 What Does This Mean for Canadians? . 72 3INFORMATION,EVIDENCE AND IDEAS . 75 Directions for Change . 75 The Case for Change . 75 Building Canada’s Health Information Technology Infrastructure . 76 Introducing Personal Electronic Health Records . 77 A Leadership Role for Canada Health Infoway . 79 Empowering Canadians and Protecting Their Privacy . 80 Expanding Health Literacy . 81 Streamlining and Improving Health Technology Assessment in Canada . 83 The Growing Importance of Health Technology Assessment . 83 Expanding Health Technology Assessment in Canada . 85 Building Canada’s Health Research Knowledge Base . 86 Taking the Next Steps to Expand Our Knowledge Base . 87 Forging Better Linkages . 89 What Does This Mean for Canadians? . 89 4INVESTING IN HEALTH CARE PROVIDERS . 91 Directions for Change . 91 The Case for Change . 91 The Current Situation for Canada’s Health Workforce . 92 The Nursing Situation . 94 Access to Doctors . 96 Paying for Nurses and Doctors . 101 International Mobility of Health Care Providers . 102 Allied Health Care Providers and Managers . 103 A National Effort Is Needed . 104 Immediate Investments in People and Change . 105 Addressing Gaps in Supply and Distribution . 106 vi Changing Roles and Responsibilities . 106 Planning for Change Over the Longer Term . 108 Improve Information about Canada’s Health Workforce . 108 Review and Renew Education and Training Programs for Health Care Providers . 109 Develop a Comprehensive Plan for the Future of Canada’s Health Workforce . ..