As the father of Quebec medicare, former health minister Claude Castonguay is not cut from the same cloth as, say, Tommy Douglas in Saskatchewan. Unlike that passionate politician, Castonguay is a practical actuary by training and temperament. But he was, in fact, a visionary in many ways. In the 1960s, when he prepared the background for Quebec's original health-insurance laws, Castonguay travelled the province and identified a real need to improve access and to find a more equitable way to finance health care. He felt that harnessing the power of the state would provide an effective capacity for the collective pooling of risk and financing through public health insurance. In Castonguay's mind, he was proposing logical solutions to pressing social needs, not flogging ideological tenets for partisan uses.
It may well be, however, that in his latest recommendations on health-care financing unveiled this week, Castonguay has done just that.
His report was commissioned as part of a working group set up by Quebec Finance Minister Monique Jerome-Forget with the mission of finding new ways to stabilize health-care budgets and finance future needs. Castonguay was assisted by two other members appointed by the opposition parties, the left-leaning Parti Québécois and the right-wing Action democratique du Québec.
From the start, it was expected that Castonguay would promote a greater role for the private sector in the health-care system. Since leaving politics, Castonguay had become a keen critic of health-care inefficiencies and their untenable burden on the public purse. He often spoke publicly of the need for increased private investment and the development of a parallel private system as the only way to salvage the health-care system in Quebec.
The report, entitled Getting Our Money's Worth, speaks directly to his concerns. Even though the mandate was to look at health-care financing, the report also covers health-care organization and the need for better productivity in the system. For example, in suggesting better information technology, continuity of care and more investment in primary care and home care, the report echoes reform initiatives that are being considered in other provinces.
But the Castonguay report goes further than that in suggesting a need to reconsider the contents of the health-care basket and which services and treatments are cost-effective. There also are recommendations to rework governance by giving hospitals more leeway in the purchasing of services. Taking a page from British health reform, Castonguay recommends that money should "follow the patient" through the system rather than being stuck inside complex bureaucracies.
It is the recommendations devoted to health-care financing, however, that are stirring up a storm of controversy in Quebec. First off, there is the question of stabilizing the public financing of health care by raising the provincial sales tax and creating a health-care "premium" based not only on income but on the frequency of use of the health-care system. While Castonguay took pains to insist this is not a "user fee," it is hard to explain how a fee based on use can be considered anything other than just that.
Then there is the even more incendiary issue of creating the conditions for a parallel private market for health care in Quebec. The Supreme Court decision in Chaoulli v. Quebec in 2005 already forced the Quebec government to revise its health-care laws to allow for private insurance for cataract, hip and knee surgery. The Castonguay report goes further, recommending the insurance industry be able to cover a larger range of services for those not willing to wait but able to pay. And, as the coup de grâce, Castonguay suggests that the "wall" between public and private medicine should definitely come down, allowing physicians the ability to practise both in the public system and in the private market.
No wonder the headlines were screaming: "A bombshell lands in the health-care system" and "The end of free health care in Quebec." And no wonder the PQ appointee to the committee, Michel Venne, refused to endorse the financing section of the report. Labour unions and patients rights groups began speaking out immediately. Radio talk shows were flooded with callers disgruntled at the idea of more taxes and user fees.
Within hours, Philippe Couillard, the Quebec health minister, announced that the government had no intention of revising the private-public mix of funding. For the past several months, the minister has faced a relentless barrage of criticism about the lack of primary care physicians, the creation of public-private partnerships in health-care clinics and the rise of health-care "brokers" charging "finder's fees" to patients looking to access a doctor or diagnostic tests.
Couillard's rapid response clearly shows the political stakes around privatization. Like the "third way" in Alberta, appeals for more private sector involvement for physicians and insurers are political non-starters.
In Quebec, the political risk is even more acute with the Liberal government in a minority situation. Perhaps the government felt that a report on health-care financing could co-opt the ADQ's base. More likely, it has shown that Quebecers are still not yet ready to swallow such drastic medicine.
The other political matter at stake is, of course, federalism. One of the report's most devastating critiques is lobbed at the Canada Health Act. All three political party appointees agreed that the CHA was doing more harm than good for the evolution of provincial health-care systems, and that it needs to be modified to reflect modern realities. And while Castonguay insists that the report abides by the spirit of the CHA, many health-care analysts would beg to differ.
With a federal election in the wings, the Conservative government clearly does not want to fight this kind of a battle with Quebec, or with voters, over the future of the Canada Health Act.
Still, if Quebecers think that this report will be shelved alongside many others, they may want to think again. And if Canadians outside Quebec consider that what happens in Quebec doesn't resonate elsewhere, they may want to reconsider. As with the Chaoulli court case, Castonguay's report will have lasting impact on the debate over health-care reform in Canada. Not only does it add fuel to that combustible fire by providing heavy artillery to proponents of privatization, it also throws down the gauntlet to the federal government over the worthiness of the Canada Health Act.
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Antonia Maioni is visiting scholar at the McGill Institute for Health and Social Policy.