It isn’t the nicest thing to think about, but if accident or illness strikes, you could end up receiving unwanted treatment.
But in 1994 things will change. The living will or advance directive – a document clearly stating a patient’s wishes about how they want to be treated – will become part of the doctor-patient relationship.
A trio of acts passed last December – the Advocacy Act, the Substitute Decisions Act and the Consent to Treatment Act – allow, albeit in rather vague language, for Ontarians to set out in advance which medical procedures they would or wouldn’t accept and let’s them name a proxy in case they are incapable of expressing their wishes.
This vague language – intended to allow patients to customize their wishes – means that writing a living will can prove to be a troubling and confusing experience.
To aid decision-making, the University of Toronto Centre for Bioethics is offering advice through a “model” living will.
The centre’s Dr. Peter Singer has geared the “model” to meet Ontario legislation and to offer a guide for anybody who doesn’t know where to begin.
“We put a lot of detail in the advance directive about states of incompetence people get into, and also the sorts of procedures providers might recommend in those health states.”
Singer sees living wills as an effective tool aiding patients to control their own health care.
“Unless the doctor is a longstanding friend it’s hard to know what patients want. As a practicing doctor, I have run into an incompetent person where their family member has no idea what sort of wishes the person would have wanted. The goal of a living will is to provide the personal care the patient would want.”
But there is a danger. Dr. Singer urges the need for informed and detailed language in a living will.
“If I have a couple minutes to make a decision I need a document that gives me a lot of confidence that this person wouldn’t want this treatment.”
In an emergency, the doctor might not even know of the living will’s existence. Dr. Singer advises giving a copy to your family doctor, lawyer, or proxy, and keep one with you at all times. When so-called “smart” health cards come along, Dr. Singer would like to see the living will recorded on the magnetic strip along with other health information.
Many of today’s seniors fought for Canada’s internationally-admired public health system. But more and more people are becoming worried that the combination of health care reform, funding cutbacks and free trade is fuelling the growth of a second tier of private medical services serving the well off.
The provincial government sees things differently, arguing Ontarians no longer expect government to pay for everything and rather than eroding medicare, the NDP is reinventing it.
Whichever way one looks at it, private insurance companies, homecare providers, labs and other services designed to make money are becoming more and more involved in the health care business.
Operating in the territory outside the guidelines of the 1984 Canada Health Act – which sets out the principles of medicare for the federal government to enforce – the private sector has room to expand, at the same time as OHIP coverage is scaled back from more and more services.
Janet Maher, whose Ontario Health Coaltion (OHC) represents doctors, nurses and other health care workers, worries for the future of medicare.
“A number of things like accommodation services – laundry, food services – are in the grey area of the Canada Health Act,” says Maher. “So with all these fees that are being introduced, by the strict letter of the law, there is no way to stop them. But as far as we are concerned the spirit of the Act isn’t being observed.”
In its current reforms, the government of Ontario is emphasizing paramedical professions like midwives who fall outside the CHA and aren’t covered by OHIP. The turn to community-based services means that people have to rely more on services and providers that aren’t covered under the CHA.
Maher says privatizing accommodation services is a recent phenomenon, the result of hospitals finding creative ways to trim their budgets.
“It’s a new area that hospitals are taking bids on,” she says. “The other thing around the accommodation services is that because they are not categorized, strictly speaking, as health care services, none of this is exempted in the Free Trade Agreement from U.S. competition.”
A recent report by two British Columbia researchers tries to put together this complex puzzle. Jackie Henwood and Colleen Fuller of the 7,500-member Health Sciences Association of British Columbia recently charged that a combination of free trade and budget-slashing governments is eroding the universality of medicare and ushering in a two-tier system.
Fuller and Henwood identify the Free Trade Agreement as the culprit. While the health care industry created more jobs than any other sector of the Canadian economy between 1984 and 1991, they point out the job growth has been concentrated in the private sector since free trade was implemented in 1989. And they expect worse under the proposed North American Free Trade Agreement (NAFTA).
“NAFTA will accelerate trends towards a privatized, non-union and corporate-dominated system of health care in Canada.”
One provision of the Free Trade Agreement has also made it possible for U.S. companies to compete against Canadian firms in health care. Chapter 14, “health-care facilities management services”, allows wide-open competition.
Under NAFTA, provisions will bind all levels of government to consider for-profit health care companies on both sides of the border on equal footing with public providers when bidding for services, and entitles them to compensation if they can prove to an arbitration board they’ve been wronged.
“That represents a substantial encroachment on the democratic right of local, provincial and federal governments to make decisions,” says Cathleen Connors, who chairs the national wing of OHC, the Canadian Health Coalition.
It’s this plus health care cutbacks – federal and provincial – that’s resulting in service and job cuts and bed closures in the public sector and an increase in privatization, say Henwood and Fuller. These opportunities have not gone unnoticed by private companies south of the border.
One such company is American Medical Security Inc. (AMS) of Green Bay Wisconsin. After hiring Canadian pollsters Angus Reid to do a survey, AMS saw a profitable market in offering American hospital insurance to frustrated Canadians awaiting surgery. Sixteen per cent of those polled said they wanted this service; that was enough for AMS.
“One thing that comes across loud and clear is that Canadians for the most part are happy,” says spokesperson Carrie Galbraith. “They know they are taken care of during an emergency. But they are willing to pay a little extra if they need care.”
So far, AMS offers its plan to Ontario, B.C. and Manitoba, with Toronto its best market. Galbraith says plans are in the works to expand to all of Canada except the territories.
Unfortunately, like most private health plans, AMS cuts its losses by avoiding what Galbraith calls “adverse selection” – anybody with a known serious health problem need not apply.
Here in Ontario, private for-profit home care services take in close to half of all OHIP billings. Many clients pay out of their own pockets for additional services.
The Ontario health ministry doesn’t keep statistics on the extent of the private home health care sector, says spokesperson Layne Verbeek. But the Ontario Home Health Care Providers’ Association, a trade group, estimates private homecare companies now employ 20,000 and serve more than 100,000.
“It’s a market situation,” says Henwood. “If the services aren’t available to people within the public sector, they will go outside of it. We’ve seen this in other countries like England, where they had a public system and now have a parallel private system. If you erode a system enough that people get angry, they are going to start to look for alternatives, and the people with the greatest liberty are those with money.”
But in a recent interview, health minister Ruth Grier was adamant this scenario wouldn’t be allowed to take place in Ontario. She strongly disagreed that medicare is being weakened due to recent changes, and said the government has actually “reaffirmed its commitment to medicare.”
It’s search and destroy time at Ontario’s ministry of health: search out savings and destroy inefficiency and waste. But many remain apprehensive that not all the cuts are going to be logical and fear the province’s health and well-being will be affected.
As part of the social contract deal, the Ontario Medical Association must find $20 million in cuts from the list of services covered by OHIP. The OMA and the provincial government are currently haggling over which procedures and examinations will be cut.
“We look at services that aren’t medically necessary,” says health ministry spokesperson Layne Verbeek. “Because we were wealthier in the past, we were able to cover some services. We aren’t in that position now. But I don’t see how eliminating medically unnecessary treatments will affect the population.”
The fallout of the Rae government’s attempts to reign in costs and recover lost revenues may take years to unfold, but it is already apparent that Ontarians will be paying more.
“Access to necessary treatment should not depend on a person’s ability to pay,” says health policy critic Carol Kushner. “What disturbs me about any delisting program is that virtually every medical service could be termed medially necessary. There are very few services that are an out-and-out waste of time.
“We often point to the fact that Ontario spends $200 million a year treating the common cold. Well, most of that is a waste of time. But delisting even that kind of service would be a detriment to the public’s health, because a small group of patients really do need to see a doctor when they have a cold.”
OMA spokesperson Jean Chow says it’s too early to pin down the exact cuts that will be made. “It’s a little premature to try and speculate what the final list will be.”
The newly-created Non-Tax Revenue Group is hard at work finding fees, fines and penalities the government can add or hike to boost revenue from this source from $5 billion to $10 billion a year.
The spring budget saw the first hit, with the addition of $240 million in non-tax revenue.
A radical reshaping of medicare is taking place. Private sector services – for which consumers pay directly or through insurance companies – now make up 34 per cent of Ontario’s health care funding, compared to 42 per cent in the United States, according to a recent study by the Canadian Medical Association.
Health minister Ruth Grier has also floated the idea of widespread hospital closures. Both the Toronto and Windsor district health councils (DHCs) are carrying out feasibility studies on “reconfiguration.” The ministry is remaining tight-lipped about which hospitals will get the chop.
“One suspects there’s room for efficiency – there are a lot of empty beds in a number of different places,” says ministry spokesperson Verbeek.
“All hospitals are being reviewed, with a view to closing one or two hospitals,” says health planner Lisa Paolatto, who is working on a feasibility study on “reconfiguration” for the Essex County District Health Council, along with Toronto’s DHC.
Closing hospitals could present a serious political hot potato for the government. In Britain, the Conservative government is still recovering from the bad feelings surrounding proposals to close world-renowned hospitals in the London area. The public feels great loyalty to local hospitals, a feeling that has been further fostered by hospital charities that raise millions a year from the communities’ good will.
“This is going to open up new discussions of money between doctors and patients,” says Kushner. “Seniors are a unique group in Canada because they remember what it was like before medicare – what it was like not to be able to pay for the doctor, to forgo treatment that they thought was necessary. They understand the financial hardship that could occur if they were unlucky enough to have a family member who needs expensive medical treatment.”
Ontario’s health care system is in the midst of a big change. But where are the new jobs going to be and how can health care workers prepare for the coming crunch?
“Anybody who thought they could progress through the health care system until retirement is in for a shock,” said Ruth Robinson, a national health care consultant for Peat Marwick Stevenson and Kellogg management consultants.
Radical changes are taking place in the health care system and it looks like traditionally safe occupations are in for a shake-up.
“Hospitals are being pressured to change fundamentally,” said Ms. Robinson. “The net effect is fewer jobs. A lot of people will have to think about new careers.”
In the Ministry of Health working document entitled Goals and Strategic Priorities, released in January, the fundamental shift from treatment to disease prevention and health promotion is laid out in generalities.
The goals range from health equity for aboriginals, women, children and AIDS patients to better management of costs to development of a stronger health care industry that will jump start the economy. And they range from the reorganization of professional responsibilities to promotion of services outside institutions with the goal of keeping people out of hospitals.
One thing is clear, the talk is about big changes. But talk is cheap to laid-off health care workers looking for new jobs.
The provincial government’s recently passed, but yet to be proclaimed, Regulated Health Professions Act will have serious repercusions for all health care providers.
“Traditionally, doctors have an exclusive domain over a wide area,” said Charlie Bigenwald, executive director of health human resources planning at the Ministry of Health. “Even though other people could do things, they had to be delegated by a doctor. With the legislation, we have pushed back what doctors can do. This means there will be more opportunity for a wider variety of health care workers to get into those areas.”
Midwifery is one of the benefactors of changes in regulations. The Ministry of Health is looking into having a university-based program for midwives.
Ms. Robinson predicted nurses and middle management will suffer the most in the change to community-based health care.
“Nurses will need to get a bachelor degree if they hope to compete for jobs,” she said.
As for middle managers, who often have clinical skills, they will have to reconsider staying in health care, she said. “They will disappear significantly. They can advance themselves by getting back to clinical skills or consider management positions in non-health care areas.
“There is nothing to be ashamed of about career changes these days,” she added.
In the shift towards community-based care, opportunities will arise for health care workers who can offer creative solutions to improve service delivery.
“For nurses, we currently have something called the Nursing Innovation Fund where individuals can apply for a wide variety of developmental things like attending workshops, conferences and training programs. We process 2,500 applications a year,” said Mr. Bigenwald.
The Ministry of Health hopes the future sees a health care system that adds to the province’s economy rather than drains it.
“We spend $17 billion a year on health care. We never looked at the health care system as an economic motor in the past. The question we are asking right now is ‘why can’t an Ontario firm make the carpets, beds, sutures etc?’, said Mr. Bigenwald.
Ms. Robinson said “Governments are running out of money and can’t increase funding. They will be looking for more partnerships in the private sector. In this climate, creative solutions to health care delivery have a great opportunity.”
David South Consulting 
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