Government urged to limit free drugs for seniors

By David South

Today’s Seniors (Canada), May 1993

Another blow may be coming to seniors on top of last August’s cuts to the Ontario Drug Benefit Plan (ODBP). Health minister Ruth Grier has been advised to terminate the policy offering free drugs for Ontario residents over 65. 

Assistant deputy health minister Mary Catherine Lindberg says the 13-page report from the Ontario Drug Reform Secretariat urges the government to replace universal coverage with a system based on income. 

The government argues that fiscal problems, a desire to make wealthy seniors pay, and a need to extend the program to the working poor has driven them to consider the move, while critics argue it will hurt modest-to-lower-income seniors. They say costs could be better contained by keeping universal coverage and attacking the source of escalating costs: pharmaceutical manufacturers and doctors who over-prescribe or misprescribe. 

Concession

If implemented, the cuts will represent a concession by the NDP on the once-sacred principle of universality. Just last year, former health minister Francis Lankin said, “I believe strongly in universality, and we’re not looking at ending it for drug coverage of seniors.”

The proposed plan calls for single people, regardless of age, who earn over $20,000 a year, and families earning over $40,000, to pay a premium of up to $300 for drug coverage. 

Those earning less than that amount will have to pay for their own drugs until they reach a limit tied to their income to become eligible for free drugs. 

The government says this changes qualifying for coverage from age to income-based. 

In a recent interview, health minister Ruth Grier wouldn’t be specific about what plan she would go for. But she agrees with the report’s authors that the drug plan needs reform. 

“While the drug plan makes drugs available in an open-ended way to everybody over 65,” says Grier. “In many cases it doesn’t help the low-income family with parents in minimum wage jobs and has a child needing constant drugs. And when we reform the system we aren’t just looking at how we can contain costs, but also how we can make it fairer. The underlying principle of all that we are doing is equity and fairness.”

The drug benefit plan, which also covers welfare recipients, hit $1.2 billion last year out of an almost $17 billion health budget. That was an increase of 13.8 per cent from 1991, but lower than the 18.1 per cent average for the last 10 years. 

David Kelly at Toronto’s multi-service agency Senior Link suggests the government go after the drug industry for wasting money promoting drugs and duplicating research projects. 

According to the industry advocate Pharmaceutical Manufacturers Association of Canada’s own statistics, drug companies spent $186 million on “marketing” in 1990 while $286 million actually went to research and development. 

The federal government’s own Patent Medicine Prices Review Board, in an internal study leaked to The Globe and Mail, found Canada to have some of the highest drug prices among the seven industrialized nations. 

Anger

Seniors organizations and agencies almost overwhelmingly expressed anger over the report, seeing it as another attack on universality of medicare. They feel the government isn’t being creative enough solving fiscal problems. 

“I strongly disapprove,” says Sara Wayman, chairperson of the Ontario board of Canadian Pensioners Concerned. “The concept of universality when it comes to services is a basic democratic principle we support strongly. People who earn $20,000 a year are still struggling to make ends meet. This would represent a real hardship. 

“We also feel strongly that the high medical costs that everybody is talking about aren’t really due to universality. They are really due to the high cost of drugs, and because there has been a restraint of generic drugs by our legislature.

“They are tip toeing around the medical profession. I hope people will speak out.”

Kelly feels savings could be reaped by taxing back any benefits given to wealthy seniors, while maintaining the universality of programs. 

“The group they are talking about is very tiny,” says Kelly. “And so the cost savings to the government are going to be really minimal. A whole process will have to be set up to decide who gets free drugs, and what you get is another layer of bureaucracy everyone has to go through. Studies have shown this adds to the net costs of government in the long run.”

Seniors falling through the health care cost cracks

By David South

Today’s Seniors (Canada), December 1993

When Orangeville senior Donald Potter was told he was too old to receive a bone marrow transplant, he paid $150,000 to get one in the United States. 

His case, recently made public by provincial Conservative leader Mike Harris, has raised the disturbing issue of health care rationing for seniors. 

Potter, who has Hodgkin’s lymphoma, says he was told the cut-off age is 55; since he was 64 at the time he needed a transplant, he was told last February it was too risky to obtain the procedure. Faced with a few months to live, he went to Rochester, New York, where bone marrow transplants were done on patients into their late 70s. 

Money

Potter believes the real issue is money. The government doesn’t have enough, so he couldn’t get the treatment that could save his life. 

Cost-cutting resulting from the provincial government’s social contract and expenditure control plans has left physicians with the quandary of serving more people with less money. This dilemma has led them to prioritize who gets services, though physicians maintain such decisions are based on many factors other than age, including lifestyle, prognosis and effectiveness of the therapy. 

Transplants

Bone marrow transplants are a particularly emotional issue for Premier Bob Rae, who in early October was driven to tears handling questions regarding rationing of this service. His brother died of lymphatic cancer in 1989 after a failed bone marrow transplant for which Premier Rae was the donor. 

“I can’t knock the system that hard, I just don’t feel the government spends the money properly,” says a calm and unresentful Potter.

Many seniors are frightened when they hear the government needs to make cuts, fearing they could be the first to go when it comes to allocating rationed services. 

“From the perspective of seniors it is a very scary time right now,” says David Kelly of Toronto’s Senior Link, a community social service agency. “Everything is being questioned, all our social services. Instead of looking at how to solve the problems, we’re just going to cut out things, and that’s going to be our solution. It doesn’t necessarily work.”

The issue of rationing services based on age is a dicey one. Ministry of Health spokesperson Layne Verbeek says the schedule of benefits makes no mention of age; and he’s right, because that would be unconstitutional. But when a doctor is presented with a fixed budget and a bulging sack of patients, the physician on the hospital ward has to decide who gets treated and with what. How a physician does this is theoretically based on a combination of factors, but doctors also have prejudices and misconceptions. 

Rationing

Many argue such queuing is a dangerous departure from the belief that the sick deserve to be treated. 

“Part of the problem is that few would admit to rationing on the basis of age alone,” says bioethicist Eric Meslin of Toronto’s Sunnybrook Health Science Centre. “Most clinicians I’ve spoken with and worked with recognize that age alone is not a relevant criterion. But most clinicians would agree age does play a role in thinking about limiting care.”

Meslin admits the idea of denying health services based upon age alone has been making the rounds among health care professionals. 

Ethics

“There has been a debate in the last seven years in North America over whether age-based rationing is ethically acceptable,” says Meslin. “There is of course a spectrum of views, including the very extreme that says after a certain number of years you have obtained your benefit from society and you should step aside and allow others to make use of those resources.”

Meslin doesn’t feel good about going through any kind of health care rationing without a public debate over society’s values and what to expect from the health care system. 

And he is adamant that anybody who focuses solely on attacking the high costs of high-tech medicine and an aging population is making a value judgement about how society should spend its money, not stating a fact.

“A clinician who chooses to discriminate based on age alone is not only unethical, but unconstitutional. Having said that, no clinician worth their salt would be telling the truth if they did not consider who the patient was in the fullest sense of the term, including their age. However, not giving treatment because they are 80 is a numbers game; there isn’t good enough data to support it.” 

Meslin suggests a public debate on rationing services needs to take place. 

Needs

“We need to ask the elderly population what they want. It may be that they don’t want the kind of things the researchers and clinicians believe they want.”

Kelly at Senior Link believes cuts to free drugs are already one example of rationing. 

“There are a lot of ways we can go about changing our social services without cutting income support or access to medication. The same goes for what procedures will be performed,” says Kelly. 

Potter’s case graphically shows the human cost of the heavy hand of bureaucrats in a public system trying to save money. But the high cost of U.S. health care also leaves a bad taste in Potter’s mouth. 

“In the States, the cost is horrendous. At least we have that protection. But I happen to be one of the unfortunate ones that fell into the wrong slot. And there’s a lot of people like me.” 

Private firms thrive as NDP ‘reinvents’ medicare

By David South

Today’s Seniors (Canada), August 1993

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 accomodation 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 accomodation 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 accomodation 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 adament 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.”  

Changing health care careers a sign of the times

By David South

Hospital News (Canada), June 1992

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 a 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.” 

Feds call for AIDS, blood system inquiry: Some seniors infected

By David South

Today’s Seniors (Canada), July 1993

HIV-tainted blood transfusions given in the early 1980s have left some seniors with AIDS, but it is feared many are unaware of their HIV-positive status. 

Between 1979 and 1985 - before testing of blood products for HIV became mandatory - 266 transfusion recipients and over 677 hemophiliacs are known to have been infected in Canada, according to the Centre for AIDS Statistics. 

But the final numbers are unkown - estimates range from 400 to 1,000 cases of HIV transmission among the 1.5 million Canadians given blood products during this time. 

This uncertainty is fueling public concern. With such a serious public health danger, many are shocked by the confusing messages being sent by governments, the Canadian Red Cross Society and hospitals. 

But it took the report of an all-party Parliamentary subcommittee on health, released at the end of May, to shock the federal government into calling for a public inquiry into the blood system. The report is highly critical of the decision-making process involved in blood collection and distribution. 

“We have members of our group who are seniors,” says Jerry Freise, spokesperson for advocacy organization HIV-BT (Blood Transfusion) Group, whose wife was infected with HIV due to a blood transfusion. “And many of them went for years being misdiagnosed and treated for something other than HIV. Others have gotten sick, and one died without knowing it because nobody told him. 

“A classic case is Kenneth Pittman who was infected in 1984. The Red Cross found out in 1985 and they allegedly took two years to tell The Toronto Hospital. The hospital took two years to tell his doctor, and his doctor decided not to tell anybody. 

Infected

“Another couple, a lady of 59 and a man of 64, called us April 1. She found she was infected, and the reason she took a test is because her husband turned out to be HIV-positive three weeks before a transfusion in 1983. He had gone for years without a diagnosis from doctors.” 

This runs counter to the Red Cross’s story. 

“Whenever a blood donor tests positive for HIV antibodies, we go back and trace the prior donations,” says spokesperson Angela Prokoptak at the Society’s national office. “The Red Cross supplies blood to hospitals, so we know which units went to which hospital. But the hospital must go through their records to find who they transfused. 

“After identifying the recipient, the hospital contacts the recipient’s physician, and then they have them tested. There are of course limitations.

“Since 1987, the Red Cross has been advising people who may be concerned to consult their physician for counselling and advice.”

But subcommitte member Chris Axworthy, an NDP MP, found that hospitals and the Red Cross hesitated to notify former patients for fear of lawsuits. He says the federal government should show some leadership and stop passing the buck to other agencies and departments. 

Only two hospitals in Ontario - Toronto’s Hospital for Sick Children and Princess Margaret Hospital - have tried systematically to contact former patients. 

Ontario health ministry spokesperson Layne Verbeek says it is a laborious and costly task for hospitals to notify former patients. “We’ve always informed people if they are thought to be at risk, but many hospitals aren’t in the position to trace. If people are at risk or have doubts, they should be tested.”

Verbeek says recent media coverage has caused an increase in the number of people seeking HIV blood tests - requests for the test doubled after the Sick Kids hospital went public. The provincial government’s lab went from 700 tests per day to 1,300, but Verbeek says that has started to taper off. 

The ministry of health is happy with the number of people coming forward to be tested, says Verbeek. 

But Friese says the different players are more concerned about lawsuits than informing the public. He is especially upset at the Red Cross for not taking a leadership role in disseminating information. 

“The Red Cross and the medical system have failed miserably to contact people. Even today they are reticent to tell people they were part of a risk group and should get treated.” Friese feels the various governments and the Red Cross are leaving the job of informing the public to his group and the Canadian Hemophiliacs Society. 

Beat the drums

“It’s my job to beat the drums for the media while I’m dealing with my wife being infected? That’s my job, when these are the ministers of health?”, Friese says with anger.

The effect of AIDS on seniors isn’t new to US-based National Institute on Aging researcher Marcia Ory. She and colleagues helped sound the alarm back in 1989 with the book “AIDS In An Aging Society: What We Need To Know.” In the US, over 10 per cent of AIDS cases have occurred in people over 50. 

“Surprisingly, people have ignored older people and the AIDS issue,” says Ory. “You had older people in hospitals who might have complained about fatigue which was thought to be age-related. Older people aren’t as likely to be diagnosed as early because of the assumption that they are not at risk from AIDS.

“We don’t want older people in general to be overly fearful, but we want them to acknowledge the possibility, and to engage in good preventative practices if they are at risk.” 

Ron deBurger, director of AIDS prevention for the Canadian Public Health Association, would like assurances that the security of the blood supply has improved. 

“The subcommittee came to the right conclusion asking for a public inquiry,” says deBurger. “I would hope the terms of reference are broad enough to take a look at the whole issue of the safety of the blood supply, not only in terms of what happened in the past, but, more importantly, what’s happening today.”

Other than hemophiliacs, who require large quantities of blood, deBurger believes anybody who received one transfusion has a small risk. “If you had blood once, I think the odds are pretty long that you are going to end up with tainted blood. But AIDS does take eight to 10 years to manifest itself, and we might still be picking up pieces for the next four to five years that we don’t know about yet.” 

Friese recommends that anybody who received blood or blood products between 1979 and 1985 get an HIV test. If their doctor says it isn’t necessary, they should call the AIDS Hotline about anonymous testing. 

Anybody who has tested positive for HIV and would like support and counselling can call Robert St-Pierre of the Canadian Hemophilia Society at 1-800-668-2686.

For information on anonymous testing call the Ontario government’s AIDS Hotline in Toronto at 416-392-2437. For support write HIV-BT Group, 257 Eglinton Avenue W., Suite 206, Toronto, Ont., M4R 1B1.