In Québec, health care is the sleeper issue

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Headlines throughout Québec’s raucous election campaign have highlighted emotionally charged issues, such as a new charter on secularism, a potential referendum on independence and new regulations promoting the use of French. Nonetheless, surveys show that voters routinely list health care as the top issue facing the province’s next government.Quebec Flag IconpngCanada Flag Icon

With three former health ministers leading the three top parties in the province, including Liberal leader Philippe Couillard, a former neurosurgeon, there’s no election better placed for examining how to improve Québec’s health care options.

The provincial government’s role in the health care system began in 1961, when it signed up to the federal Canadian single-payer health care system and began reimbursing hospitals for medical services. A decade later, in 1971, Québec first agreed to reimburse services for non-hospital costs, and the provincial government began opening its own health clinics. Today, health care costs consume 51.8% of the province’s budget, excluding debt service. Governments of the past decade from both major parties have routinely increased health spending, even while attempting to rein in spending for other areas.

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Even before the Parti québécois (PQ) started slipping in the polls, Québec voters already disapproved of Pauline Marois’s performance as premier by a margin of nearly 2-to-1. It’s hard to believe that perceptions about her government’s performance on health care didn’t play a huge role in that. Though the PQ’s support started crumbling with a series of mishaps that brought a new independence referendum into direct focus, voters were already pre-disposed to flee Marois, who hasn’t kept her 2012 campaign promise to roll back an unpopular health tax introduced, ironically, by the Parti libéral du Québec (Liberal Party, or PLQ) that now is now projected to win a majority government after Monday’s vote.

Marois served in many ministerial roles during previous PQ administrations, including not only health, but finance and education — she became known as the ministre polyvalente (the minister of everything). When she served as minister for health and social services between 1998 and 2001, her most enduring legacy was by introducing subsidized daycare (initially, $5 a day; today, $7 a day; $9 by 2015) in Québec.

Her government has championed ‘Family Medicine Groups,’ which were introduced in the early 2000s as an alternative to hospitals and ‘local community services centers’ (CLSCs) for primary care services, and Marois hopes to expand their number to 300. 

The leader of the center-right Coalition avenir Québec (CAQ), François Legault, a former PQ official who served as health minister for just 15 months between 2002 and 2003. Legault introduced a raft of reforms as education minister in the late 1990s to standardize the measurement of performance. He attempted to introduce similar reforms as health minister, especially measures to evaluate Québec’s health care system.

Now, as the leader of the CAQ, he wants to introduce greater efficiency to Québec’s health care system by eliminating regional health boards, maximizing the role of nurses in providing health care and changing the current fee-for-service method through which doctors are paid, thereby aligning doctors’ incentives with the long-term health of their patients.

But it’s Couillard, the new Liberal leader, who has the most illustrious background in health policy. Before entering politics in 2003, he worked as a neurosurgeon in St-Luc and Sherbrooke in Québec throughout the 1990s and early 2000s, with a four-year stint in Saudi Arabia in the mid-1990s. After winning his first political race to become the MNA for the provincial riding of Mont-Royal, former premier Jean Charest made him Québec’s new health minister immediately after the election.

During the 2003 election, health care was the driving issue of he campaign. Charest lambasted the PQ government for its performance on health care, and he promised to reducing waiting lists and generally improve health outcomes.

Couillard, who served as health minister for the next five years, amassed a more substantial record on health policy than either Marois or Legault, devoting ever more funds to health care, prohibiting smoking in public places and building new hospitals, including for the University of Montréal and McGill University. It’s not surprising, perhaps, that Couillard quickly became one of the Charest government’s most popular ministers. Overall, Charest did succeed in reducing many wait times for many surgeries, but sometimes at the expense of other wait times.

But Couillard’s exit as health minister prompted some of the most biting criticism against him. He negotiated the terms of his employment with his future employer while he was still a minister, drawing a debate on ethics and conflicts of interest. More seriously, however, Couillard planned to set up a health-care consulting firm four years ago with Arthur Porter, the former head of the McGill’s health center, who now faces criminal charges for fraud from his time at McGill. It didn’t help Couillard earlier this week when Porter, who is now fighting extradition from a Panamanian jail, offered his support for Couillard’s campaign.

In 2010, Charest’s government adopted a controversial annual health tax, initially $25 and now $200 (though the poorest residents are excluded). Despite promises to end it in the 2012 election campaign, Marois’s government has nonetheless retained the tax as it’s struggled with Québec’s budget deficits.

Couillard argues that he can balance the provincial budget through savings elsewhere, thereby allowing him to phase out the health tax over four years. Given the role that health care has played over the decades in growing Québec’s public debt, it seems like a dubious pledge — unless Couillard expects that, like Charest before him, he can win even more federal funds from prime minister Stephen Harper (or a potential prime minister Justin Trudeau).

Charest also attempted to institute an even more controversial user fee, which would have required a $25 payment for each doctor visit, functioning as a deductible capped at 1% of annual income. Critics howled at the plan, and the Charest government quickly dropped the idea, though it attracted interest across Canada, with both the federal and other provincial governments trying to find ways to pay for ever-expanding health costs.

When a commission headed by Claude Castonguay, a longtime Québec politician, recommended the $25 user fee in 2008, Couillard rejected it out of hand. But two years later, long after Couillard was back in the private sector, finance minister Raymond Bachand  identified the the user fee as a way to bring provincial finances under control. Bachand challenged Couillard last year for the PLQ leadership, but he lost handily to the former health minister and subsequently resigned from Québec’s Assemblée nationale (National Assembly) last August.

Couillard, during the campaign, has also championed Family Medicine Groups, and he has promised to open ‘super clinics’ that would be open 24/7. Couillard hopes to increase the role of nurse practitioners in providing health care (a move that nurses and doctors unions would certainly oppose) and spend more money on home care, thereby reducing the amount that the government pays for long-term facility care.

Despite the massive funds devoted to health care, problems continue to fester, the Montreal Gazette reports:

Despite increases in medical-school enrolment over the past five years, more than 10 per cent of the Quebec population does not have access to a family doctor, according to the Fédération des médecins omnipraticiens du Québec. In Montreal, more than 300,000 residents are in need of a general practitioner. Most Montreal emergency rooms are still filled to more than 150 per cent of their capacity, with dozens of patients being treated on stretchers in hallways for up to two days.

Eight years after the Quebec government — Liberal at the time — set wait-time guarantees of no more than six months for hip and knee surgery, more than 400 Montrealers are wait at least a half year for joint replacements…. Antonia Maioni, director of the Institute for the Study of Canada at McGill University, noted that surveys have shown that Quebecers spend more time than people in other parts of Canada to find a family doctor or a specialist.

Another hot spot is the propensity of residents in west Québec (Outaouais) to seek out hospitals in Ontario, mostly in Ottawa, the Canadian capital, for serious health care issues. While it’s understandable that most local residents would prefer the expertise normally found in hospitals in a city like Ottawa than in smaller cities, like Gatineau or elsewhere in the Outaouais, reports show that Outaouais residents use Ontario health care more often than Québec health care, as Kelly Egan highlighted in the Ottawa Citizen this week:

According to figures from Quebec’s health insurance plan, more than 55,000 Outaouais residents visited Ottawa hospitals in 2012 for some kind of medical service. We are, truly, an integral part of West Quebec’s sick bay. The Montfort, for Pete’s sake, delivered about 700 babies from Quebec mothers last year….

We shan’t get all weird and alarmist about it and perhaps this is a natural effect of living in a federal state of regions. We help Quebec, Manitoba helps us on the western flank, Alberta helps British Columbia, and so on. The smaller city (Gatineau) is never going to have the complex care centres (cardiac, pediatric) that Ottawa does. It’s not a French-English thing.

The Quebec government does reimburse for the costs in Ontario but we’re told that a) they are slow-pay artists and b) many of their fee rates are lower than ours, so doctors are less than enthused.

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