Health Minister Philippe
Couillard's reaction to the Castonguay report
has left some experts scratching their heads
Photo credit: Francis
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.
"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.
Claude Castonguay's road to
The report's author, Claude
Castonguay, is the former Liberal health minister
who helped bring universal healthcare to Quebec
in the 70s. Known as "the father of Quebec medicare,"
he went on to work as an insurance executive and
serve as a Tory Senator. He's famous in Quebec
for his change of heart about the viability of
universal healthcare. He now feels that Quebecers
expect too much from the system and that current
demands have made it unsustainable.
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
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.
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.