1. The Role of the Federal Government in Health and Healthcare American Society of Neurosurgeons Hon. Carolyn Bennett, M.D., M.P. St. Andrews-by-the-Sea, New Brunswick June 9, 2014

2. The Role of the Federal Government in Health and Healthcare An Accidental Tourist in Politics Hon. Carolyn Bennett, M.D., M.P. Patient as Partner Doctor Multidisciplinary Hospital Community Social Determinants of Health Non Quo Sed Quo Modo

3. The Role of the Federal Government in Health and Healthcare Sir Michael Marmot Hon. Carolyn Bennett, M.D., M.P. “The worst thing for a physician is to help someone get well and then send them straight back into the situation that made them sick in the first place” - Sir Michael Marmot, Chair, WHO Commission on the Social Determinants of Health

4. The Role of the Federal Government in Health and Healthcare Canadian Institute of Advanced Research Hon. Carolyn Bennett, M.D., M.P. 25% health attributable to health care system 15% biology and genetics 10% physical environment 50% social and economic environments HEALTH VS HEALTH CARE

5. The Role of the Federal Government in Health and Healthcare The Goal of Medicare Hon. Carolyn Bennett, M.D., M.P. Sharing risk getting people the health care they need when they need it Solidarity Keeping people well not just patching them up once they get sick

6. The Role of the Federal Government in Health and Healthcare Health of Canadians Hon. Carolyn Bennett, M.D., M.P. Health Care delivery - Provincial Except Federal Government is the 5 th biggest provider First peoples, military, veterans, RCMP, corrections Health of Canadians – shared Health promotion, disease prevention Social determinants of health Regulator Research

7. The Role of the Federal Government in Health and Healthcare The Tyranny of the Acute Hon. Carolyn Bennett, M.D., M.P. As long as citizens think of the sickness care system whenever they hear the word ‘health’ we are not going to be able to reorient health systems.

8. The Role of the Federal Government in Health and Healthcare Sustainability = Prevention + Quality Hon. Carolyn Bennett, M.D., M.P. PREVENTION Decrease the demand side QUALITY Increase the cost effectiveness on the supply side

9. The Role of the Federal Government in Health and Healthcare Health Goals for Canada Hon. Carolyn Bennett, M.D., M.P. As a nation, we aspire to a Canada in which every person is as healthy as they can be: physically mentally emotionally spiritually

10. The Role of the Federal Government in Health and Healthcare Hon. Carolyn Bennett, M.D., M.P. Social Determinants of Health vs Choose Health (modifiable risks)

11. The Role of the Federal Government in Health and Healthcare Citizens as Partners Hon. Carolyn Bennett, M.D., M.P.

12. The Role of the Federal Government in Health and Healthcare Canada Health Act Principles Hon. Carolyn Bennett, M.D., M.P. Universality: The plan must entitle 100% of the insured population (i.e. eligible residents) to insured health services on uniform terms and conditions Comprehensiveness: The plan must insure all medically necessary services provided by hospitals and physicians Accessibility: The plan must provide, on uniform terms and conditions, reasonable access to insured hospital and physician services without barriers Portability: Residents are entitled to a certain level of coverage when they are in another province within Canada (or when they travel within Canada or abroad) Subject to negotiation among provinces Public administration: The health insurance plan of a province must be administered and operated on a non-profit basis by a public authority accountable to the provincial government This says nothing about delivery, which can be (and often is) private Provinces are free to ignore these principles, but may have federal dollars withheld under the Canada Health Transfer

13. The Role of the Federal Government in Health and Healthcare Public Health 101 Hon. Carolyn Bennett, M.D., M.P.

14. The Role of the Federal Government in Health and Healthcare Hon. Carolyn Bennett, M.D., M.P. Do you think we should have a: A) strong fence at the top of the cliff B) state of the art fleet of ambulances and paramedics waiting at the bottom ???

15. The Role of the Federal Government in Health and Healthcare Hon. Carolyn Bennett, M.D., M.P. Would you prefer: A) Clean air B) Enough puffers and respirators ???

16. The Role of the Federal Government in Health and Healthcare Hon. Carolyn Bennett, M.D., M.P. Would you prefer that that wait-times were reduced by: A) A falls program to reduce preventable hip fractures B) Private orthopedic hospitals and more surgeons ???

17. The Role of the Federal Government in Health and Healthcare Hon. Carolyn Bennett, M.D., M.P. Governments should boast about: A) How much they spent on the sickness care system B) The health of their citizens, leaving no one behind ???

18. The Role of the Federal Government in Health and Healthcare Health vs. Healthcare Hon. Carolyn Bennett, M.D., M.P. My first rotation as a final year med student Night after night – subdural haematomas Has public policy changed the lives of neurosurgeons? Seatbelts, helmets, airbags?

19. The Role of the Federal Government in Health and Healthcare The Citizen and the Constitution Hon. Carolyn Bennett, M.D., M.P. The U.S.A. Life Liberty The pursuit of Happiness Canada Peace Order Good Government

20. The Role of the Federal Government in Health and Healthcare Hon. Carolyn Bennett, M.D., M.P. U.S.A: Health care = a market commodity Medicare and Medicaid CANADA: Health care = a universal common good for all citizens of all ages, all conditions All universities are public and heavily subsidized by both levels of government

21. The Role of the Federal Government in Health and Healthcare OECD Data, Health Incomes, 2011 Hon. Carolyn Bennett, M.D., M.P. MeasureCanadaU.S. Life expectancy at birth (2011) 81.178.7 Pot. Years of life lost <69 (per 100,000) (2011) 3926 (males) 2505 (females) 5814 (males) 3447 (females) Infant mortality per 1,000 live births (2011) 4.96.7

22. The Role of the Federal Government in Health and Healthcare Infant Mortality Hon. Carolyn Bennett, M.D., M.P.

23. The Role of the Federal Government in Health and Healthcare Healthcare Costs as a Portion of GDP Hon. Carolyn Bennett, M.D., M.P.

24. The Role of the Federal Government in Health and Healthcare Hon. Carolyn Bennett, M.D., M.P. The Moral-Hazard Myth The bad idea behind our failed health-care system. Malcolm Gladwell, The New Yorker August, 29, 2005 Do you think that people whose genes predispose them to depression or cancer, or whose poverty complicates asthma or diabetes, or who get hit by a drunk driver, or who have to keep their mouths closed because their teeth are rotting ought to bear a greater share of the costs of their health care than those of us who are lucky enough to escape such misfortunes? The moral-hazard argument makes sense, however, only if we consume health care in the same way that we consume other consumer goods, and to economists like John Nyman this assumption is plainly absurd. We go to the doctor grudgingly, only because we’re sick “Moral hazard is overblown,” the Princeton economist Uwe Reinhardt says. “You always hear that the demand for health care is unlimited. This is just not true. People who are very well insured, who are very rich, do you see them check into the hospital because it’s free? Do people really like to go to the doctor? Do they check into the hospital instead of playing golf?”

25. The Role of the Federal Government in Health and Healthcare Hon. Carolyn Bennett, M.D., M.P. One implication: Canada does not have `Socialized Medicine` It has a system of public financing of certain categories of health services These services are delivered by private (albeit often not-for- profit) providers This system of publicly-financed hospital and medical insurance is referred to as “Medicare” Dr. Raisa Deber, PhD University of Toronto

26. Hon. Carolyn Bennett, M.D., M.P. The Role of the Federal Government in Health and Healthcare Who Pays for Health Care, 2011 Total Health Expenditure 2.7 Trillion $187 Billion Per capita $8508.00 $4,665.80 % GDP 17.7 11.2 % publicly 47.8% 70.4% paid Seniors, disabled, poor, veterans tax, no ext-billing % privately 52.2% 29.6% paid employer/personal insurance drugs, dental, vision, home Uninsured/ 16.1% universal coverage for Underinsured 52% doctors and hospitals U.S.Canada

27. The Role of the Federal Government in Health and Healthcare Woolander and Himmelstein Hon. Carolyn Bennett, M.D., M.P. NEJM: ‘for profit hospitals are 25% more expensive (admin costs) JAMA 1999: ‘for profit’ HMO’s rated lower on all 14 quality indicators as measured by the National Committee for Quality Assurance Johns Hopkins study dialysis patients For-profit clinics 20% greater mortality For-profit clinics 26% less referral for transplantation

28. The Role of the Federal Government in Health and Healthcare Profit… as a motivation Hon. Carolyn Bennett, M.D., M.P. results in PROFIT QUALITY OR COST

29. The Role of the Federal Government in Health and Healthcare Alberta Bone & Joint Health Institute (non-profit) Hon. Carolyn Bennett, M.D., M.P. A time of urgent need Model tested on hip and knee replacements Putting patients at the centre Delivering health care in a multi-disciplinary team environment Encouraging patient choice with innovative compensation models Aligning efforts across health regions Diverting services to single-purpose focused facilities from overcrowded hospitals Making all publicly funded health services evidence-based Improving efficiency and asset utilization, and reducing demand on taxpayers Ensuring the public health care system is sustainable A satisfying journey through the health care system Significant improvement in patient and health care provider satisfaction, driven by A decline of approximately 80% in consultation waiting time A decline of 90% in surgery waiting time A decline of 30% in hospital stay Faster recovery and enhanced patient engagement, accountability and education More efficient utilization of scarce - and expensive - health care resources including major gains in the number of surgeries per day per operating room

30. The Role of the Federal Government in Health and Healthcare Achieving Health Reform’s Ultimate Goal Hon. Carolyn Bennett, M.D., M.P. How Successful Health Systems Keep Costs Low and Quality High U.S. Senate Committee on Aging Sept 30, 2009 1.INSURANCE COMPANIES 30% of US costs – almost a third – go to insurance companies. These insurers set premiums, design packages, assess risk, review claims and decide who to reimburse for how much. But they don’t deliver health care.

31. The Role of the Federal Government in Health and Healthcare Hon. Carolyn Bennett, M.D., M.P. 2. ADMINISTRATION: Our single payer system is simpler, allowing us to run the administration of our offices and hospitals with much fewer staff – about 4%. We don’t have to deal with multiple payers, or chase bad debts. We don’t have to charge higher fees to compensate for unpaid for procedures Public Contractors Model: not a publically delivered model. Doctors and nurses are not civil servants.

32. The Role of the Federal Government in Health and Healthcare Hon. Carolyn Bennett, M.D., M.P. 3. PHARMACEUTICAL PRICE CONTROLS: Although drug costs are rising in Canada as in the US, we’re able to exercise more control over the cost of drugs as a result of our Patented Medicine Prices Review Board.

33. The Role of the Federal Government in Health and Healthcare Hon. Carolyn Bennett, M.D., M.P. 4. MALPRACTICE INSURANCE: The not-for-profit Canadian Medical Protective Association covers medical malpractice for all Canadian physicians with comparatively low premiums. Doctors’ remuneration does not have to reflect those extra costs and our justice system has successfully kept the awards in a reasonable range.

34. The Role of the Federal Government in Health and Healthcare Hon. Carolyn Bennett, M.D., M.P. 5. EVIDENCE-BASED CARE: From vaginal births after C-sections to, lumpectomy, to x-rays for sprained ankles, applying evidence to determine the appropriateness of tests and procedures translates into fewer unnecessary tests and procedures and less defensive medicine. We are committed to moving from the error of pure cost- containment approach of the early 90s into true evidence- based cost effective care.

35. The Role of the Federal Government in Health and Healthcare Hon. Carolyn Bennett, M.D., M.P. 6. PREVENTION: Diseases are cheaper to treat if they’re caught early, and since all Canadians are insured, they’re more likely to have pap smears, mammograms and other early detection visits and tests, than US patients who are not covered.

36. The Role of the Federal Government in Health and Healthcare Hon. Carolyn Bennett, M.D., M.P. 7. FAMILY MEDICINE: A long-standing speciality in Canada, family doctors are trained to help patients navigate their care; We interpret the difference between what patients think they `want`, and what they actually `need`. A point of first contact, a trusted coach to explain the evidence and the choices.

37. The Role of the Federal Government in Health and Healthcare The Goal: Preventing the Preventable Hon. Carolyn Bennett, M.D., M.P. Most appropriate care In the most appropriate place By the most appropriate person (paid and unpaid)

38. The Role of the Federal Government in Health and Healthcare Hon. Carolyn Bennett, M.D., M.P. “We are not tinkers, who patch and mend what is broken. We must be watchmen, guardians of the life and health of our generation, so that stronger and more able generations may come after.” Dr. Elizabeth Blackwell (First woman physician North America)

39. The Role of the Federal Government in Health and Healthcare Hon. Carolyn Bennett, M.D., M.P. For a copy of these slides and additional resources and links, please visit: http://carolynbennett.liberal.ca/blog/present ation-role-federal-government-health- healthcare/ http://carolynbennett.liberal.ca/blog/present ation-role-federal-government-health- healthcare/