Couillard flip-flops on pro-private report

QC docs cheer Castonguay ideas, but gov't wavers on bold reforms

By Sam Solomon

Health Minister Philippe Couillard's reaction to the Castonguay report has left some experts scratching their heads Photo credit: Francis Vachon

Quebec's rush to reject outright entire sections of the politically explosive Castonguay commission report on the financing of the province's ailing health system, released on February 12, has left chief commissioner Claude Castonguay feeling "disappointed."

Despite Health Minister Philippe Couillard's initial wholesale dismissal of the report's suggestions for new sources of revenue for the healthcare system — raise taxes and implement a post hoc user fee — he and his fellow ministers have since haltingly admitted that some of its pro-privatization ideas might actually be sound. "If we're going to eat an elephant, we're better to do it one mouthful at a time," quipped Premier Jean Charest to reporters.

FUNDING FUSS
"There are two dimensions to the whole question," Mr Castonguay explained, speaking to NRM by phone, "sources of revenue on one hand and sources of expenditure on the other." While the ideas are controversial, he's confident he's got the support of the Quebec public. "People at large feel something has to be done and expect change," he says.

His commission's report, officially titled Getting Our Money's Worth, proposes to control costs by tying healthcare spending grown to GDP growth, about 3.8% per year (last year health spending went up 5.8%). The government has embraced that idea, even though Quebec spent less on healthcare than any other province last year, according to a 2007 report by the Canadian Institute for Health Information.

Other cost-saving measures include reviewing the scope of public insurance coverage, expanding the role of the private sector in the delivery of care and permitting people to buy private insurance for publicly insured procedures (beyond the currently allowed hip, knee and cataract surgeries). The government has refused to support that last suggestion.

The recommendation to allow physicians to run "mixed" public-private practices, which are currently prohibited, was initially panned by Dr Couillard but he has since changed his mind, saying the idea is possible — but only after the current physician shortage is alleviated.

The recommendation that's been getting the most attention is the modified user fee. The report suggests a $25 to $65 fee per visit to be charged at year's end, with low-income families exempt. The report also suggested the government raise the provincial sales tax 0.5% or 1%. Both these report recommendations were quickly dismissed by the government.

The report also recommends devolving day-to-day administration from the ministry to the regional health authorities and adopting case-based funding method for hospital budgets (the model promoted by CMA president Dr Brian Day). Both ideas have been greeted warmly by finance minister Monique Jérôme-Forget. The report also urges public coverage for home care and nursing homes.

The health ministry plans to release a comprehensive response to the Castonguay report to clarify some of their more tentative positions.

DOCTORS' SUPPORT
The Quebec Medical Association (QMA) and the groups representing the province's GPs, specialists and residents, which all back most of the report's recommendations, aren't discouraged by the government's unsure position.

"I think it's more a political way than a reasonable way," says QMA president Dr Jean-Bernard Trudeau of Dr Couillard's quick dismissal of the response. "It's a very quick comment from Dr Couillard, but I think he'll begin to decrease his reaction." Dr Trudeau says the QMA will prepare a full response and and release the results of a survey of its membership on their reactions to the report this summer.

"Already people are starting to step back a bit and to downplay some of their initial comments," notes Dr Martin Bernier, the president of the Federation of Medical Residents of Quebec.

The report is not without its critics, however. Dozens of unionized healthcare workers protested a speech by Mr Castonguay the day after the report's release, and leading Quebec health law experts Marie-Claude Prémont and Antonia Maioni have spoken out against it, citing threats to the Canada Health Act principles of universality and accessibility. Federal Liberal leader Stéphane Dion and Canada Health Act co-author Monique Bégin have also expressed their concerns.

Fervently pro-privatization Quebec opposition leader Mario Dumont, of the Action démocratique du Québec party, told the Montreal Gazette that Dr Couillard's negative reaction to the report was "absurd" and is now threatening to vote against the budget, which is expected to be released later this month, and possibly topple the minority government unless elements of the Castonguay report are adopted.