The Promise and Potential of CHCs: Building on the Legacy of Douglas and Hastings

Michael M Rachlis MD MSc FRCPC LLDCanadian Association of Community Health Centres

September 26, 2013 Saskatoon www.michaelrachlis.com

Outline• Historical overview of CHCs in Canada• Where are we now• Where are we going• Why Canada need CHCs and CHCs need

Canada -- a few comments from a CHC veteran

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Historical analysis of CHCs in Canada

• From medical regulation to Mackenzie King’s promise of medicare (1867-1919)

• From Mackenzie King’s promise of medicare to SK Hosp Insurance (1919-1947)

• From Saskatchewan Hospital Insurance to medicare (1947 to 1962)

• From SK Hospital Insurance to EPF (1962-1977)• From EPF to the Banff declaration (1977-1992)• From the Banff declaration to Romanow/Kirby/FPT

Accord (1992-2004)• Since Romanow/Kirby/FPT Accord (2004 onwards)

From medical regulation to Mackenzie King’s promise of medicare (1867-1919)• Medical regulation (especially the creation of the

College of Physicians of Ontario in 1866) hands society’s authority over medical practice to allopathic doctors

• Allopathic physicians use this authority to exclude other practitioners and protect the autonomy of individual physicians

• The CMA and the OMA protest the establishment of the VON and fight contract medical practice

• World War I leads to the establishment of the Federal Dept of Health and Liberal leader Mackenzie King’s promise of medicare

War focusses governments on health

From Mackenzie King’s promise of medicare to SK Hosp Insurance (1919-1947)

• Provincial associations consolidate control over medical practice through control of hospital privileges

• A few alternatives to FFS private practice develop• During the depression doctors want public funding for

the poor AND private practice for others• Western provinces flirt with public health funding• In 1943 the CMA briefly supported public health care• The CCF wins government in Saskatchewan in 1944

and implements public hospital insurance in 1947.

From Saskatchewan Hospital Insurance to medicare (1947 to 1962)

• Saskatchewan debates the form of its medicare plan• UK establishes the National Health Service in 1948• Labour (and some employers) support group practice– In the US, Kaiser-Permanente and Group Health Puget Sound

pioneer pre-paid group practice– In Sault Ste Marie Ontario, the United Steelworkers and the

community start organizing for Group Health• Morris Fishbein, JAMA editor calls group practice communism• The pro-medicare coalition advocates for medicare AND a

different way of delivering services

Medicare runs into the politics of the cold war.

The American Medical Association gives $1 M to the SK College of Physicians and Surgeons to fight medicare.

From Saskatchewan Hospital Insurance to medicare (1947 to 1962)

• The federal government passes hospital insurance in 1957• Saskatchewan passes medicare legislation in 1961 and

implements it July 1, 1962• Ninety percent plus of Saskatchewan doctors strike • Citizens rally, UK doctors arrive, Community Health Service

Associations create Community Clinics• After 23 days, the strike is settled• Saskatchewan has been through a civil war. The CCF has

little appetite to change the way the doctors do their work.

From SK Medicare to EPF(1962-1977)

• In response to Saskatchewan medicare, Prime Minister Diefenbaker appoints Justice Hall to chair a Royal Commission on Health Services

• Hall recommends broad coverage including home care & drugs but the 1966 medicare legislation only covers physicians’ services

• Ottawa pays half the costs of provincial hospital and medical insurance plans

• In 1971, Canadian Ministers of Health appoint Dr. John Hastings to review the CHC model

The ‘60s new social movements spur medicare and the development of CHCs

From SK Medicare to EPF (1962-1977)

• The Hastings Report on the Community Health Centre is established for three reasons– Concerns about rising costs– Better primary health care promises to reduce hospital costs– CHCs also show promise in providing higher quality, “people-

centred” care

• The report recommends, “The immediate and purposeful re-organization and integration of all health services into a health services system…” and the whole enchilada

From SK medicare to EPF (1962-1977)

• Most provinces have some response to Hastings. Manitoba, Ontario, Quebec, & BC start to develop them

• Initially the medical profession is neutral but within a short period of time the CMA and provincial affiliates strongly oppose CHCs

• In Ontario in 1975, there were 11 CHCs and up to 60 in some form of development. The program is frozen.

• There were over thirty CHSAs in Saskatchewan in 1963 but only five community clinics survive.

• In 1977, the Feds implement the Established Programs Financing Act signaling the start of their exit from health care.

From EPF to the Banff declaration (1977-1992)

• Ontario tries to kill off CHCs until health minister Larry Grossman appoints Fraser Mustard to renew them.

• Ontario CHCs slowly start to grow.• Minister Elinor Caplan (with deputy Dr. Martin Barkin)

tries to get every MD off FFS. CHCs grow rapidly.• Quebec’s CLSCs grow rapidly and become cornerstones

of the province’s system.

From EPF to the Banff declaration (1977-1992)

• Very little happens elsewhere– Ontario’s docs strike in 1986– Provinces are paralyzed with fear of their medical associations

• In 1992, the FPT Ministers release the Barer-Stoddart report & the Banff declaration. Ontario and feds co-host a conference on MD resources.

“Corporate rationalizers” see the potential leverage for change from patients and the public

From the Banff declaration to Romanow/Kirby/FPT Accord (1992-2004)

• Nothing happens after Banff and Barer Stoddart except medical school enrollment is cut 10%

• The Chretien government axes public spending. The provinces cut health care.

• Most provinces have major reports on health care. They create regional health authorities. There are few new models of primary health care practice.

• The doctor/population ratio falls. Family docs exit comprehensive care.

• Wait lists lengthen

From the Banff declaration to Romanow/Kirby/FPT Accord (1992-2004)

• The feds put more money into health care in 1997, 2000, 2002, and 2003.

• Senator Kirby puts out reports on health care. Chretien appoints Roy Romanow to chair a Royal Commission on Health Services. Both Kirby and Romanow stress primary health care and say “new money should buy change”.

• In 2004 PM Paul Martin signs the health accord with the provinces -- $41 B over 10 years – no deliverables

• The focus is on wait lists for acute care services

Since Romanow/Kirby/FPT Accord (2004 onwards)

• Governments throw money at health care• After the provinces get the money with no

deliverables, providers take almost all of it for income• Some wait lists decrease but accessibility problems

continue• Some provinces talk about a “family physician for all”

Where are we now?

Current received wisdom

• Health Care costs are wildly out of control• My fellow baby boomers and I will really

deep six Medicare as we get older• The only alternatives are to either hack

services, go private, or better yet do both• We need an “adult conversation” about

whom gets tossed out of the life raft

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Tada! The End!

What’s my/our story?

• Health Care’s share of our economy is not “out of control”• The aging population won’t break the bank• There are affordable solutions to all of healthcare’s

apparently intractable problems – the 2nd Stage of Medicare– The real issue should be how we spread these proven

innovations• Re-focusing on patients and families, primary health care

reform including community health centres, and other community based services like home care are the key to health reform.

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Health Care costs are not out of control

But Health care hasn’t been starved either

19751978

19811984

19871990

19931996

19992002

20052008

2011 f / p

0

2

4

6

8

10

12

14Public Private Total

Canadian Health Care Costs as % of GDP

% GDP

Data from Canadian Institute for Health Information NHEX 2012

198119831985198719891991199319951997199920012003200520072009

2011 f / p

0%1%2%3%4%5%6%7%8%9%

CANADAProvincial Government HC Exp as % of GDP

% GDP

Data from Canadian Institute for Health Information NHEX 2012

1975

1977

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

2005

2007

2009

2011

f / p

0%5%

10%15%20%25%30%35%40%45%50%

ON CAN

%ProgExp

Data from Canadian Institute for Health Information NHEX 2012

Provincial Government HC Expas share of Program Spending

19911993

19951997

19992001

20032005

20072009

2011 0

10

20

30

40

50

60

Govt outlays as % GDP

% GDP

Data from: http://www.fin.gc.ca/frt-trf/2012/frt-trf-12-eng.asp

?

The shrinking Canadian public sector

• Overall Canadian government revenues have fallen by 5.7% of GDP from 2000 to 2011, the equivalent of over $100 Billion in foregone revenue

• At 38.4% of GDP, Canadian government revenues are at their lowest level since 1980– Just 3% of Canada’s GDP, could either eliminate all

2012 Canadian government deficits OR fund: first dollar universal pharmacare, long term care and home care AND regulated child care for all parents who want it AND free university tuition AND 15,000 units of affordable housing units AND the new fighter jets

“It is not the aging of our population that threatens to precipitate a financial crisis in health care, but a failure to examine and make appropriate changes to our health care system, especially patterns of utilization.”

Dr. William Dalziel. CMAJ. 1996;115:1584-6

32

2126

34 3540 40

52 55 55 5663

0

25

50

75

100

After-Hours Care and Emergency Room Use

Percent

31 32 3339 40 40

47 48 49 5058

Difficulty getting after-hours care without going to the emergency room

Used emergency room in past two years

Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

Where are we going?

There are affordable solutions to all of Medicare’s apparently

intractable problems: The Second Stage of Medicare

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We need to change the way we deliver services“Removing the financial barriers between the provider of health care and the recipient is a minor matter, a matter of law, a matter of taxation. The real problem is how do we reorganize the health delivery system. We have a health delivery system that is lamentably out of date.”

Tommy Douglas 1982

“I am concerned about Medicare – not its fundamental principles -- but with the problems we knew would arise. Those of us who talked about Medicare back in the 1940’s, the 1950’s and the 1960’s kept reminding the public there were two phases to Medicare. The first was to remove the financial barrier between those who provide health care services and those who need them. We pointed out repeatedly that this phase was the easiest of the problems we would confront.” Tommy Douglas 1979

Catching Medicare’s second stage

“The phase number two would be the much more difficult one and that was to alter our delivery system to reduce costs and put and emphasis on preventative medicine…. Canadians can be proud of Medicare, but what we have to apply ourselves to now is that we have not yet grappled seriously with the second phase.”

Tommy Douglas 1979

The Second Stage of Medicare is delivering

health services differently to keep people well

From 2006 to 2011 Ontario increased family doctors pay by $1.3 Billion. There were slight improvements in the numbers of Ontarians with family doctors but no change in the % who could access their family doctor the same day or the next day. There were also no decreases in use of walk-in clinics or ERs.

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The summary of the evidence:

• New capitation models (FHOs, FHTs, etc) have the healthiest and wealthiest patients. CHC patients are the sickest and face the most socio-economic challenges. FFS and mainly FFS models (FHG) are in between

• New capitation models have the highest adjusted use of ERs. CHC patients have the lowest adjusted use.

Why are we still waiting for the Second Stage of Medicare?

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“There is a remarkable consistency and repetition in the findings and recommendations for improvements in all the information we reviewed. Current submissions and earlier reports highlight the need to place greater emphasis on primary care, to integrate and coordinate services, to achieve a community focus for health and to increase the emphasis on health promotion and disease prevention. The panel notes with concern that well-founded recommendations made by credible groups over a period of fifteen years have rarely been translated into action.”

Ontario Health Review panel 1987

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Canada’s system of independent physician private practice is the

biggest elephant in the room

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Does the Canadian state believe it has the legitimacy to restructure the way doctors do their work?

Why Canada needs CHCs and CHCs need Canada• CHCs provide better primary health care and reduce

ER utilization• CHCs also focus on community/population health• Reformed private practice isn’t the (only) solution • We can be more effective together• Pendulums don’t just swing one way• What are we going to do when the NDP/Liberals gain a

majority of seats in Parliament?

First things first! Primary health care reform is the key to health

reform

Why is integrated primary health care so important?

• Canada has problems with access, chronic disease management and prevention, and population health

• Primary health care is the key for access, chronic disease management and prevention, and population health

• Primary health care = sustainability

“Only through the practice of preventive medicine will we keep the costs from becoming so excessive that the public will decide that Medicare is not in the best interests of the people of the country.”

Tommy Douglas

It’s a new morning for CHCs!

Summary:

• Health Care costs are not out of control• The aging population won’t break the bank• Medicare was and is good public policy• Problems developed because we failed to

follow the original vision for the 2nd Stage of Medicare

• CHCs are the key to Medicare’s 2nd Stage• Canada needs CHCs and CHCs need Canada

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Courage my Friends, it is

Not Too Late to Make a Better

World!

Tommy Douglas(paraphrasing Tennyson)