The Straight Goods
Friday, March 10, 2000
UPDATED DAILY
(Monday - Friday)
Defiant former health minister blows the
whistle
Diane Marleau says back-benchers must defend health care
for ordinary Canadians
By: Colleen Fuller
Former federal health minister Diane Marleau says it may be up to Liberal
back-benchers to save medicare from "the powerful and the influential."
In an exclusive interview this week, Marleau told Straight Goods that she
fell from grace in the Liberal government because she bucked the spread of
private health care.
The people making the rules "want to please their friends, the
powerful business lobby."
She said Canada's medicare system is under siege and concerted back-bench
pressure is needed to force the federal government to fight for its
preservation.
"It all goes back to the rules being made by people who don't understand the
system, people who have always had good jobs and been healthy." The people
making the rules "want to please their friends, the powerful business lobby.
[The fight] is between those people and ordinary Canadians."
As health minister, Marleau says she had to fight a rearguard action against
officials in her own ministry, and, more importantly, her own government who
wanted to drastically reduce funding for health care.
In 1995, ministry officials negotiated - apparently behind Marleau's back -
a deal with Alberta to allow private clinics and doctors to top up their public
payments with user fees for community-based hospital services. As Marleau was on
her way to a health ministers' meeting in Victoria, her deputy minister
presented her with the deal which would overturn the policies she had been
advancing. Marleau refused to sign the agreement.
"Look at what they did to me," says Marleau, recalling the rumours
spread about her competence on Parliament Hill in the wake of her
confrontation with the tobacco industry in 1995. "They called me
weak."
By the end of the year, with apparently little support in the Cabinet,
Marleau was ready to impose a $7 million fine on Alberta, which, in turn,
charged that "The Canada Health Act's interpretation has been changed". Prime
Minister Jean Chretien, meanwhile, was publicly outlining his own vision of
medicare as a "no frills" plan covering only "major surgery". In this
environment, Marleau's days were numbered, and soon she was pulled from the
health portfolio. She would be swiftly sent to the back benches.
"Look at what they did to me," Marleau said, recalling the rumours spread
about her competence on Parliament Hill in the wake of her confrontation with
the tobacco industry in 1995. "They called me weak. It started because of the
tobacco lobby
I was on the warpath [against] the tobacco manufacturers. That's where it
started. What you get is not what's really there."
Marleau is also critical of the influence that the Department of Foreign
Affairs and International Trade (DFAIT) now wields over domestic health care
policy. There is substantial pressure from the World Trade Organisation (WTO)
and other bodies to bring Canada's health care system in line with liberalised
global trade, by granting access to the Canadian medical market to private,
foreign health care provides.
Were Diane Marleau and medicare shown the door?
Photo credit: CP Picture Archive (Tom Hanson)
"There is a lot of fear about this, that it [trade and industrial
strategies] will infringe on our medicare file," Marleau told Straight Goods.
"We are being told 'no, it will not.' But it's a real concern for a lot of
us.... I worry that we do things that we think won't have any consequences, but
they will have.... The WTO comes back and interprets things in ways that we
didn't anticipate."
In a wide ranging discussion, Marleau also defended measures she took as
health minister in the mid-90s, aimed at upholding the principals of the Canada
Health Act. Some of those policies have since been overturned by a federal
Liberal government intent on appeasing the provinces and cutting costs, with the
result that a private, parallel health care system has since taken root in
Alberta, and in Ontario.
Marleau's defence of the principles of medicare led her to clash with one of
Canada's most aggressive health care privatisers, Alberta Premier Ralph Klein.
It all started in 1995, when Alberta was caught allowing private eye surgery
clinics to charge patients a so-called "facility fee" of $1,275 per eye.
Marleau, who was health minister at the time, was alarmed by this development.
So, launching the opening salvo in what would prove to be her political
Waterloo, she sent a letter to her provincial counterparts pointing to a
developing trend "toward divergent interpretations of the [Canada Health] Act."
These differing interpretations arose because the Act, which had been passed
in 1984, lacked a set of regulations and policies that clarified the specifics
of the bill and guaranteed the Act's enforcement.
Introduced by then-health minister Monique Begin just before the Liberals
were defeated by Brian Mulroney's Conservatives, the Canada Health Act outlawed
extra-billing and user fees, and called for the provinces to respect the
"principles of medicare" in order to qualify for federal funds. Working in
tandem with legislation known as Established Programs Financing (EPF), the
Canada Health Act essentially told the provinces: no compliance, no cash.
But when the Mulroney government came to office, it never quite got around
to putting the regulatory meat on the bones of the Canada Health Act. Today, the
legislation is still remarkably free of any kind of regulatory framework.
"I was trying to forbid user fees" - Marleau
The political climate had also changed by the time Marleau was appointed
health minister in 1993. The provinces were in revolt over reduced cash
transfers. Their message to Ottawa had become: no cash, no compliance.
And so, when Marleau took action on the private eye clinic in Alberta, she
became the first elected federal official to force provincial compliance with
the Act. "I was trying to forbid user fees" from being applied to hospital
services, Marleau said. But what, exactly, was a hospital service - and for that
matter, what was a hospital?
Marleau told Alberta and the other provinces that a "hospital" was any kind
of facility that provided acute care, rehabilitative or chronic care. That meant
that doctors couldn't charge extra fees for services delivered outside the four
walls of a hospital. In fact, she said, Canadians should receive all medically
necessary health care without user fees regardless of where it was delivered.
According to Marleau, facility fees for physician services delivered in
clinics were illegal - and so was extra billing for hospital services delivered
in the community or in the home.
Such an interpretation would also have banned income testing, sliding fee
scales, top-ups, and upgrades.
Today, Marleau remains adamant that the hard line she took with Klein was
necessary to protect the fundamental principles of the Canada Health Act.
"The intent of the CHA was to cover medically necessary interventions of any
kind," she says. "I felt that that meant not only those that were in a hospital
setting - that while the practice of medicine had changed, it didn't exempt them
[the provinces] from delivering the medically necessary services whether they
were in a hospital or not."
Others in Ottawa apparently didn't see it that way.
"The position of the government was that you can't fight with the provinces;
we have to be nice to the provinces," Marleau recalls. "While I know that the
population doesn't want us to fight with the provinces, they also want us to
stand up for what we believe in.... I thought I'd been elected by people and not
by provinces. I thought that standing up for something that Canadians believe in
was what they wanted me to do."
And the former minister (who was soon demoted to the Liberal back benches,
after losing the health portfolio to David Dingwall in January, 1996), is openly
critical of her government's decision to include its health transfer payments to
the provinces within the new Canada Health and Social Transfer (CHST),
introduced in 1996. The CHST poured all the federal transfers for health and
social services into one drastically reduced fiscal pot - placing the decision
about cutbacks on provincial shoulders.
"I never thought they should put health in the CHST," states Marleau. "I was
against it right from the beginning. The feeling was that we didn't have the
money to set out separately for health care. I really fought for that [a
separate health care transfer]. It didn't happen."
In fact, the inclusion of health funding in the CHST has been one of several
policies that have eroded Canada's medicare system since the Chretien Liberals
took office.
Folding health transfers into the CHST precipitated nine changes to the
Canada Health Act. Although David Dingwall claimed, in his annual CHA report to
Parliament in 1996, that"the consequential amendments to the Canada Health Act
did not affect any of the criteria or conditions of the Act, nor any of the
provisions for their enforcement," in reality the amendments led to major
change.
For instance, under the guise of the CHST, the government repealed Section 6
of the Canada Health Act, which had required the provinces to provide what's
known as "extended care", in exchange for receiving federal health funds. As
well, provinces were to report to the federal government on the accessibility of
extended care services. Extended health services would include such things as
nursing homes and in-home health care.
"I was aware they'd got out of that [extended health care]," reflected
Marleau this week.
"Extended health got pushed aside because there wasn't any money."
From the back benches, Marleau continues to speak out for a strengthening of
the principles of medicare.
"We have to work out a real medicare system with the point of entry being
the same [for everyone]," she asserts. "Let's not kid ourselves: it's about
power and influence and it's about trying to represent all the people. The
powerful and the influential don't need government to speak for them. It's the
others who need us to speak for them."
Marleau vows to fight on within the caucus and within the party. "We will
bring this up on a regular basis," she insists.
Vancouverite Colleen Fuller is an independent health researcher, a member of
the board of directors the Council of Canadians, and a research associate with
the Canadian Centre for Policy Alternatives (CCPA). She is also author of
"Caring for Profit: How Corporations Are Taking Over Canada's Health Care
System" (New Star Books/CCPA).
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