The diagnosis of the father of the health insurance

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The ex-minister of the liberal government Claude Castonguay has granted an interview to our reporter Fatima Houda-Pepin in Brossard, on the 13th of February last.

Fatima Houda-Pepin

Monday, 26 February, 2018 01:00

UPDATE
Monday, 26 February, 2018 01:00

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Our health system is sick. To make a proper diagnosis, who better to talk about than that which has been the main architect of its implementation, the first holder of the ministry of Health, minister of Family and social Well-being, in the government of Robert Bourassa, from 1970 to 1973?

Known as the “father” of health insurance, it has played a key role in the design and implementation of the network of health services and social services in Quebec, while continuing to be an informed observer.

I met him, on February 13, in Brossard, for an interview background, on the context in which Québec has adopted this system, changes are made and the reasons that led to its current crisis.

FHP: Mr. Castonguay, explain to us the context in which the health system has been put in place in Quebec, it was at the beginning of the 1970s?

CC: Yes, it was during this period that the government of Robert Bourassa had passed the health insurance Act, the Act respecting health services and social services, the social assistance Act, the professional Code and the Law on the protection of the mentally ill, that they used to send in the large asylums.

FHP: But this was not done smoothly, as there has been a doctors ‘ strike?

CC: Yes, in 1970, after the adoption of the Law on health insurance, the medical specialists had refused to engage in negotiations. They had the strike and suspended their services. Finally, in October of the same year, in the midst of the October Crisis, the government had been forced to adopt a special law, requiring them to return to work, under penalty of severe sanctions.

FHP: Essentially, what was the claim of medical specialists at that time?

CC: They did not want health insurance.

FHP: Why? What this plan was he threatening to them?

CC: They were afraid of the controls of the State and wanted to keep their freedom of practice. I also think – although this has never been said that they were afraid to tax on the income. They were afraid that we return back and that they are asked of the tax not paid. It should not be forgotten that before the Law of insurance, doctors were paid a fee, and it was not clear if all these revenues were accounted for and reported to the tax. So there was this dimension that was never said openly, but that was part of their concerns.

FHP: So, the basic infrastructure of the health system has been put in place under the government of Robert Bourassa and the specialist doctors have been forced to return to work. And then?

CC: Yes. The Act respecting health services and social services came in 1971. It was extremely important law. We started from zero, we established the foundation of the system, its structure and its operation. It was necessary to draft the legislation and submit it for consultation. We had received tons of memories, we listened to the representations of the groups, made the necessary adjustments and finally, in 1972, the act was passed.

FHP: It was you who were the minister of Health at that time?

CC: Yes, I had left at the end of 1973, just in time for the election of the 29 October 1973.

FHP: AT what point in time local community service Centres (CLSC) have been integrated in the health network? It was in the health bill?

CC: No, it started before. CLSCS already existed, informally. The government has funded and launched other, even before the health bill is passed.

FHP: Why the doctors were not enthusiastic about the formula of the CLSCS, which are, however, front-line services and a gateway to the health network?

CC: They feared that the State exercises too much control over their practice and that they eventually become employees of the government. In addition, the CLSC were perceived as agents of change in quebec society, which is reassuring not.

FHP: You have been a main supporter in the establishment of the health system in Quebec. Is it that we can say that the worm was in the fruit to the extent that the doctors had, at the starting point, the big end of the stick?

CC: No, they were not the big end of the stick since we had signed an agreement with the general practitioners, and forced the return of medical specialists at work.

But there was a resistance deaf. The establishment of the health care system was a colossal task. It required several changes in a short period of time. Imagine, they had to build new schools, build hospitals in underprivileged areas, and allocate significant resources to the financing of services, the procurement of equipment and recruitment of staff.

There was also a tricky problem to solve, the integration of the hospitals, owned by religious congregations, in the public network.

So we negotiated with all the religious communities, the separation and the transformation of hospitals into for-profit corporations, community-based, a time-consuming task. Therefore, it was not just the appearance of the reports with the doctors.

FHP: The health system has evolved a lot since then. You have been on the front line for its implementation, you continue to follow his iniquities. What is it that does not work, according to you, in our system? Why are so many horror stories?

CC: The question is very complex and has several components. There is the fact that the cost of health care, but also those social services have steadily increased, at a rate higher than the increase in the collective wealth. There is also the growing costs of drugs, the frequency of use of care, and the specialization of staff, the introduction of new technological equipment, etc

Governments have attempted to establish controls to contain costs, which is a good thing, but the government is no longer limited to the control of costs. He came to wanting to control everything in the health care network.

It is rendered to an ultimate level where the current minister of Health has taken over almost all the powers, and is above all the boards, without worrying about anything.

So, this excessive power has led to a politicisation of the network, where the cost increase and the under-performance of the system. Citizens are justified in thinking that they do not have for their money. Studies, such as those of the OECD, the show. That is why we are here, today.

FHP: So, for you, the centralization of power in the hands of the minister of Health, is the basis of what does not work in our health system?

CC: This is one of the big problems: the centralization, the controls, the politicization… it is at the point that the culture of the health system, that we had established to involve all stakeholders, motivate them, avoiding controls excessive and coercion, has been completely evacuated.

The excessive control of Dr. Barrette has pushed for the adoption of punitive laws, such as law 20 and law 30, with coercive measures that threaten the doctors of lawsuits and reduction of their remuneration. However, just adopted, the government was obliged to dismiss them, and mandates that were overseen by the minister of Health have been entrusted to the Council treasury.

FHP: You made reference to the negotiations with the doctors?

CC: Yes. And then, all of a sudden, the minister of Health was sidelined, and the laws 20 and 30 have been suspended. The government is not even returned to the national Assembly to make the necessary changes. He has simply decided not to apply.

FHP: What is therefore the view that you take, today, on the network, its structure and organization of health services and social services?

CC: The fact that boards of directors have virtually no role is damaging to the network. It is necessary to rebalance the system, undo these large sets called the CUSSS, to have a system based on the hospitals that have their own autonomy, CHSLD, which have their autonomy, clinics, etc

It is necessary to reconstitute the boards of administration, with a genuine authority on their institutions and enable them to manage their workforce, without interference from above. Look at what this model has to be created as the crisis at the nurses!

Then, replenish, therefore, the system as it functioned before.

It is necessary to make the necessary adjustments where it is needed and make the institutions responsible accountable and subject to assessments instead of imposing purely arbitrary decisions.

FHP: The government is attacked from all sides for the additional compensation of $ 2 billion dollars that has granted the government Couillard, and will reach $ 5.4 billion in 2023. How is the situation in other provinces?

CC: first, the financing of health care is a problem everywhere in the world. The population is aging and the overall costs of health are rising. The remuneration of doctors is an important element of this increase. The doctors have always wanted to maintain their autonomy and see themselves as self-employed instead of as doctors involved in health insurance. The federations of doctors have managed to capture the monopoly of negotiation of the working conditions of doctors, they have a monopoly for all practical purposes on this negotiation. And it is at the point where any change in medical practice and in the organization of health care, it’s part of the negotiations with these two federations. It is beyond the scope of the simple bargaining of their working conditions, it is a monopoly.

FHP: They arrogated to themselves a sort of right to watch over the whole system?

CC: Not more than a right to look, everything must be negotiated with them before this to take effect at the practice level, the distribution of health care.

FHP: This power enlarged of doctors is a unique case in Quebec, or is everywhere like this?

CC: It is everywhere the same. People want to have confidence in their doctors and the doctors have a lot of influence with their patients. Rare are the governments that venture to control their professional practice.

In Quebec, probably due to the presence of Dr. Barrette, it has taken on the dimensions of the singular, as it has always been, in 15-20 years, medical doctors as ministers of Health. And so the minister of Health always sees the medical profession in a particular way, because himself being a doctor, it is almost a conflict of interest.

From there, you can see the conditions are extremely generous that have been granted, all the more that, in addition to having a doctor as minister of Health (Dr Bar), you have a prime minister that he is (Dr. Couillard), and a secretary-general of the executive Council of the government as it is (Dr. Iglesias). We even had a quartet when Dr. Bolduc was minister of Education.

Dr. Barrette had entered into an agreement with Dr. Couillard and Dr. Bolduc; he was convinced that the remuneration of doctors in Quebec had to be at least at the same level as that of doctors in Ontario, a company a lot more prosperous… and the conditions that have been negotiated were such as in fact, not only have we caught up with Ontario’s doctors, but they were overwhelmed.

FHP: You speak of Dr. Barrette when he was president of the Federation of medical specialists? This principle may not hold the road, because Ontario is a richer society than Quebec, is not it?

CC: Yes, it is a false principle. If it had to be paid, all trades, all professions at the same level as Ontario, at a given time, it would blow up. It may not support the comparison.

FHP: For the remuneration of doctors, is that this imbalance is unique to our health system or is it found elsewhere in the western countries?

CC: The canadian health care system is quite different from that of OECD countries. In the OECD countries, coverage of care is much broader. You have not only the medical and hospital care that are covered, but also dental care, eye care, etc, people pay a mandatory contribution of the order of 25 %.

FHP: Is this what you are referring to, for example, the Caisse nationale de Solidarité in France?

CC: France, Germany, Switzerland, Belgium, etc, people pay part of their care, so it balances out. Here, we just have hospital and medical care that are covered and we request that they are 100 %, this is a totally different situation.

FHP: what Is the model of the mandatory contribution to 25 % with a wider coverage is a model that could take hold in Quebec?

CC: Not. We can’t carry this model as such. Our health system has a performance problem that must be addressed before thinking cover dental care and other.

FHP: Does that with the rising costs and the aging of the population, one has the impression to be in a vicious circle. How to get out?

CC: It is possible to have a health care system whose costs would be much lower, compared to other jurisdictions. There may also be a higher performing system. There is a lot of room for improvement, even if reduce the rising costs of health care at the same level as the increase of the collective wealth remains a real challenge.

It was a difficult period to go through, but we can make it happen. It is necessary to put our resources in the right places. For example, we can invest more in home care and support to family caregivers, instead of at the hospital and host in the CHSLD.

Hence the importance of having more tasks to nurses and to invest in the social determinants of health: prevention, nutrition, healthy lifestyle habits, housing, education, working conditions, etc

FHP: And the reform of Dr. Barrette, why do you feel that it has not worked?

CC: The situation in Quebec is quite special. It doesn’t make sense, all these problems of access that we have to see a family doctor. Even when you succeed to put your name on a list of doctor, there is nothing that guarantees you that you can have an appointment or a treatment… not to mention the engorgement of the emergency, the time limits in the interventions, reports of treatments, etc

FHP: Dr. Barrette, which led to its reform, beating the drum, just to say that it is complete. It will reassure you?

CC: We don’t know where the Dr. Barrette wanted to go and where it wants to go. You remember, at the time of the election, in 2014, it promised a 50 super clinics, among others; there is one that has been created.

So where is it that he wants to go? No one knows exactly… one Thing is for certain, you have a high level of dissatisfaction in the population with respect to it. It is very clear.

FHP: In relation to the nurses, they came out to say that they are exhausted, the health system made them sick. That has to be done to support them, even the nursing staff?

CC: You have seen that in some hospitals, particularly English-speaking, managers form teams instead of having a doctor who is the boss and the nurses who are at the service of the doctor. When you have a better workforce management, you do not need to impose the additional time required. They offer shifts of 12 hours, makes them work, and alternately, the day, afternoon, evening or night. We can not manage the functioning of schools as complex, from the office of a minister. This is what the Dr. Barrette has tried to do and it is a failure.

FHP: Change of subject: What do you think of the legalization of marijuana?

CC: It’s been 50 years since we discussed it. It started from 1968. The young people were smoking marijuana.

FHP: But there was not people who hid their money in tax havens?

CC: No, after 50 years, all of a sudden, since its election, the government, Justin Trudeau has made marijuana a national priority, so that God knows that we have other problems to deal with. It is necessary to quickly implement the legislation by June-July.

And we see that it is much more complicated than they thought it would. Especially among young people, this can have very negative effects. Marijuana is not a problem in itself, it is also necessary to measure the impact for a lot of people, because this is a threshold that you must cross before you go on to other drugs. And that, too, is a problem.

In addition, it is the provinces who have to organise it all. For Ottawa, it’s easy enough to say “let’s go”. Me, I find that it goes much too fast, without a real impact study and without measuring the consequences.

FHP: I thank you very much, Mr. Castonguay, for the time that you have spent. It is always interesting to exchange with you.

This interview was conducted on February 13, 2018 to Brossard