Defiant former health minister blows the whistle

Diane Marleau says back-benchers must defend health care for ordinary Canadians

By: Colleen Fuller

  Former federal health minister Diane Marleau says it may be up to Liberal back-benchers to save medicare from "the powerful and the influential."
  In an exclusive interview this week, Marleau told Straight Goods that she fell from grace in the Liberal government because she bucked the spread of private health care.
 

The people making the rules "want to please their friends, the powerful business lobby."

  She said Canada's medicare system is under siege and concerted back-bench pressure is needed to force the federal government to fight for its preservation.
  "It all goes back to the rules being made by people who don't understand the system, people who have always had good jobs and been healthy." The people making the rules "want to please their friends, the powerful business lobby. [The fight] is between those people and ordinary Canadians."
  As health minister, Marleau says she had to fight a rearguard action against officials in her own ministry, and, more importantly, her own government who wanted to drastically reduce funding for health care.
  In 1995, ministry officials negotiated - apparently behind Marleau's back - a deal with Alberta to allow private clinics and doctors to top up their public payments with user fees for community-based hospital services. As Marleau was on her way to a health ministers' meeting in Victoria, her deputy minister presented her with the deal which would overturn the policies she had been advancing. Marleau refused to sign the agreement.
 

"Look at what they did to me," says Marleau, recalling the rumours spread about her competence on Parliament Hill in the wake of her confrontation with the tobacco industry in 1995. "They called me weak."

  By the end of the year, with apparently little support in the Cabinet, Marleau was ready to impose a $7 million fine on Alberta, which, in turn, charged that "The Canada Health Act's interpretation has been changed". Prime Minister Jean Chretien, meanwhile, was publicly outlining his own vision of medicare as a "no frills" plan covering only "major surgery". In this environment, Marleau's days were numbered, and soon she was pulled from the health portfolio. She would be swiftly sent to the back benches.
  "Look at what they did to me," Marleau said, recalling the rumours spread about her competence on Parliament Hill in the wake of her confrontation with the tobacco industry in 1995. "They called me weak. It started because of the tobacco lobby… I was on the warpath [against] the tobacco manufacturers. That's where it started. What you get is not what's really there."
  Marleau is also critical of the influence that the Department of Foreign Affairs and International Trade (DFAIT) now wields over domestic health care policy. There is substantial pressure from the World Trade Organisation (WTO) and other bodies to bring Canada's health care system in line with liberalised global trade, by granting access to the Canadian medical market to private, foreign health care provides.
  "There is a lot of fear about this, that it [trade and industrial strategies] will infringe on our medicare file," Marleau told Straight Goods. "We are being told 'no, it will not.' But it's a real concern for a lot of us.... I worry that we do things that we think won't have any consequences, but they will have.... The WTO comes back and interprets things in ways that we didn't anticipate."
  In a wide ranging discussion, Marleau also defended measures she took as health minister in the mid-90s, aimed at upholding the principals of the Canada Health Act. Some of those policies have since been overturned by a federal Liberal government intent on appeasing the provinces and cutting costs, with the result that a private, parallel health care system has since taken root in Alberta, and in Ontario.
  Marleau's defence of the principles of medicare led her to clash with one of Canada's most aggressive health care privatisers, Alberta Premier Ralph Klein. It all started in 1995, when Alberta was caught allowing private eye surgery clinics to charge patients a so-called "facility fee" of $1,275 per eye. Marleau, who was health minister at the time, was alarmed by this development. So, launching the opening salvo in what would prove to be her political Waterloo, she sent a letter to her provincial counterparts pointing to a developing trend "toward divergent interpretations of the [Canada Health] Act."
  These differing interpretations arose because the Act, which had been passed in 1984, lacked a set of regulations and policies that clarified the specifics of the bill and guaranteed the Act's enforcement.
  Introduced by then-health minister Monique Begin just before the Liberals were defeated by Brian Mulroney's Conservatives, the Canada Health Act outlawed extra-billing and user fees, and called for the provinces to respect the "principles of medicare" in order to qualify for federal funds. Working in tandem with legislation known as Established Programs Financing (EPF), the Canada Health Act essentially told the provinces: no compliance, no cash.
  But when the Mulroney government came to office, it never quite got around to putting the regulatory meat on the bones of the Canada Health Act. Today, the legislation is still remarkably free of any kind of regulatory framework.
 

"I was trying to forbid user fees" - Marleau

  The political climate had also changed by the time Marleau was appointed health minister in 1993. The provinces were in revolt over reduced cash transfers. Their message to Ottawa had become: no cash, no compliance.
  And so, when Marleau took action on the private eye clinic in Alberta, she became the first elected federal official to force provincial compliance with the Act. "I was trying to forbid user fees" from being applied to hospital services, Marleau said. But what, exactly, was a hospital service - and for that matter, what was a hospital?
  Marleau told Alberta and the other provinces that a "hospital" was any kind of facility that provided acute care, rehabilitative or chronic care. That meant that doctors couldn't charge extra fees for services delivered outside the four walls of a hospital. In fact, she said, Canadians should receive all medically necessary health care without user fees regardless of where it was delivered.
  According to Marleau, facility fees for physician services delivered in clinics were illegal - and so was extra billing for hospital services delivered in the community or in the home. Such an interpretation would also have banned income testing, sliding fee scales, top-ups, and upgrades.
  Today, Marleau remains adamant that the hard line she took with Klein was necessary to protect the fundamental principles of the Canada Health Act.
  "The intent of the CHA was to cover medically necessary interventions of any kind," she says. "I felt that that meant not only those that were in a hospital setting - that while the practice of medicine had changed, it didn't exempt them [the provinces] from delivering the medically necessary services whether they were in a hospital or not."
  Others in Ottawa apparently didn't see it that way.
  "The position of the government was that you can't fight with the provinces; we have to be nice to the provinces," Marleau recalls. "While I know that the population doesn't want us to fight with the provinces, they also want us to stand up for what we believe in.... I thought I'd been elected by people and not by provinces. I thought that standing up for something that Canadians believe in was what they wanted me to do."
  And the former minister (who was soon demoted to the Liberal back benches, after losing the health portfolio to David Dingwall in January, 1996), is openly critical of her government's decision to include its health transfer payments to the provinces within the new Canada Health and Social Transfer (CHST), introduced in 1996. The CHST poured all the federal transfers for health and social services into one drastically reduced fiscal pot - placing the decision about cutbacks on provincial shoulders.
  "I never thought they should put health in the CHST," states Marleau. "I was against it right from the beginning. The feeling was that we didn't have the money to set out separately for health care. I really fought for that [a separate health care transfer]. It didn't happen."
  In fact, the inclusion of health funding in the CHST has been one of several policies that have eroded Canada's medicare system since the Chretien Liberals took office.
  Folding health transfers into the CHST precipitated nine changes to the Canada Health Act. Although David Dingwall claimed, in his annual CHA report to Parliament in 1996, that "the consequential amendments to the Canada Health Act did not affect any of the criteria or conditions of the Act, nor any of the provisions for their enforcement," in reality the amendments led to major change.
  For instance, under the guise of the CHST, the government repealed Section 6 of the Canada Health Act, which had required the provinces to provide what's known as "extended care", in exchange for receiving federal health funds. As well, provinces were to report to the federal government on the accessibility of extended care services. Extended health services would include such things as nursing homes and in-home health care.
  "I was aware they'd got out of that [extended health care]," reflected Marleau this week. "Extended health got pushed aside because there wasn't any money."
  From the back benches, Marleau continues to speak out for a strengthening of the principles of medicare.
  "We have to work out a real medicare system with the point of entry being the same [for everyone]," she asserts. "Let's not kid ourselves: it's about power and influence and it's about trying to represent all the people. The powerful and the influential don't need government to speak for them. It's the others who need us to speak for them."
  Marleau vows to fight on within the caucus and within the party. "We will bring this up on a regular basis," she insists.

Vancouverite Colleen Fuller is an independent health researcher, a member of the board of directors the Council of Canadians, and a research associate with the Canadian Centre for Policy Alternatives (CCPA). She is also author of "Caring for Profit: How Corporations Are Taking Over Canada's Health Care System" (New Star Books/CCPA).

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