New legislation will allow control of medical treatment

By David South

Today’s Seniors (Canada), December 1993

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. 

US health care businesses chasing profits into Canada

Some fear corporate health care will kill equality of treatment

By David South

Now Magazine (Toronto, Canada), April 8-14, 1993

American-style private health care is slipping across the Canadian border under the noses of three provincial NDP governments, say researchers representing an association of health care workers.

Jackie Henwood and Colleen Fuller of the 7,500-member Health Sciences Association of British Columbia charge in a recent report that a combination of free trade and tightfisted government spending is undermining the universality of medicare and ushering in the beginnings of a two-tier system.

While the health care industry created more jobs than any other sector of the economy between 1984 and 1991, they point out, things have changed dramatically since the Canada-US free trade agreement came into effect in 1989. Now much of this growth is clustering in the private sector.

And they expect that this trend will continue under the forthcoming North American free trade agreement.

“NAFTA will accelerate trends towards a privatized, nonunion and corporate dominated system of health care in Canada,” says the report.

Binding provisions

Chapter 14 of the Canada-US free trade agreement opened competition for health-care facilities management services to US companies. Certain NAFTA provisions will bind all levels of government to consider for-profit health care companies on equal footing with public providers when bidding for services, and entitles them to compensation if they can prove to an arbitration board that 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 Canadian Health Coalition, which includes labour activists, nurses, doctors and other health-care workers.

This, in combination with health care cutbacks – both federal and provincial – is resulting in service and job cuts, bed closures, increased drug costs and an increase in privatization, the report says.

In the area of home care, for example – visiting nurses, physiotherapists, homemakers and other services – private firms now take in close to half of all OHIP billings. Many of their clients pay out of their own pockets for services.

The Ontario ministry of health doesn’t keep statistics on the private home health care sector in the province, but the Ontario Home Health Care Providers’ Association, a trade group, estimates that private firms in the industry now employ 20,000 people.

The industry is dominated by a small number of large firms, including Paramed, Comcare and Med+Care.

“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 pissed off, they are going to start to look for alternatives, and the people with the greatest liberty are those with money.”

Connors says that because the Canada Health Act only covers the provision of hospital and physician services, the prinicples of universality and comprehensiveness don’t extend down to community-based services like home care.

The study also found that giant US private health insurers are positioning themselves to reap profits in the fertile Canadian market.

Last week, Wisconsin-based American Medical Security Inc. announced it will begin offering American hospital insurance to Ontario residents this month, citing a demand in Canada to bypass lengthening waiting lists for medical treatment.

Giant US west-coast insurer Kaiser Permanente declared in the March 1992 issue of Fortune magazine that they have targeted Canada as the next growth market. And American Express membership now offers the privilege of health insurance.

With private health care services sprouting up like spring weeds, says Henwood, provinces are placing yearly limits on the number of private services covered under provincial health plans, thus preventing people shopping around for services, no matter what their income.

Sheila Corriveau, corporate relations coordinator at Toronto-based Dynacare, Canada’s largest full-range private health care company – which operates labs, retirement homes, homecare services and consulting services – is enthusiastic about expansion plans, and says that removing patients from hospitals into their homes has been a boon for private health-care services.

“I think the health system will benefit, because what you are really doing is off-loading the cost from the public sector and from the treasury to private enterprise,” says Harry Shapiro of Dynacare. “Private enterprise depends on its own ingenuity for survival and its own levels of efficiency.”

But advocates of the public system say the free-market option now looming is being ushered in by the very parties that Canadians have come to rely on to defend medicare.

Medicare stance

Ontario’s new health minister, Ruth Grier, however, denies her government is jeopardizing medicare.

“I want to disagree with that as profoundly as I can,” she says, fidgeting with an ashtray during a recent interview. “Our government has reaffirmed its commitment to medicare. Over the last decade, under conservative and liberal governments, health care costs have increased in double-digit figures. The system would have collapsed at that rate of growth.

“I guess I haven’t found a way of blaming free trade for failures of the health care system at this point,” she says.

But critics say in the last year alone, Ontario’s ministry of health has capped health coverage for travellers abroad, removed coverage for physical exams requested by employers, chopped hospital beds and cut back the number of drugs covered on the provincial drug plan.

Grier says that the government’s vision relies on a new view of medical care seekers as consumers who are going to take more responsibility for their own health care

“Government can’t do it all,” she says.

"US health care businesses chasing profits into Canada": Now Magazine April 1993

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