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The Senate Committee Study on Canada's Health Care System
Howard Chodos; Jeffrey J. MacLeod

This article describes the work of the Standing Senate Committee on Social Affairs, Science and Technology, chaired by Senator Michael Kirby.  Over a two and one half year period  the committee undertook a comprehensive study of Canada’s Health Care System.  Its final report was accorded almost as much attention as the Royal Commission on Health care that reported in November 2002, a month after the Senate Committee issued its final report.

As a vehicle for examining and launching a debate on a complex public policy issue a Standing Senate Committee has some unique features that, under the right circumstances, can prove highly beneficial to the formulation of sound public policy and can have a significant influence on government. There were many factors that contributed to the ability of the Senate Committee to contribute positively to the public policy debate and have its recommendations treated with the utmost seriousness not only by the press, but also by recognized experts in the field, and, perhaps most significantly, by government. Of course, it did not hurt that the topic examined by the Committee was the federal role in the Canadian health care system, since health care regularly figures at the top of the list of public concerns. But public interest in the subject matter alone cannot account for the Committee’s success. Factors that relate to the composition of the Committee, its strategy and its determination to see its mandate through to the end, need to be explored.

The Committee’s Workplan

At the outset, the Committee developed a clear, comprehensive work plan and executed this plan quite faithfully, although it also had to display some flexibility in order to meet its ambitious targets. The Committee first received approval to undertake a multi-phase study of Canada’s health care system in December 1999 and began its work in January of the following year. The Table below shows the timetable that the Committee followed through the six phases of its study.

Over the course of its study, the committee held 76 meetings, sat for over 200 hours and heard from over 400 witnesses in Ottawa and across the country, as well as by teleconference from four European countries, the U.S and Australia. The six volumes of the study comprise close to 1000 pages, and constitute a written record of the evolution of the thinking of the Committee’s members, a process that culminated in the unanimous adoption of a comprehensive set of recommendations.

The Committee’s plan allowed it to build up its knowledge base over time. This was particularly important both because of the complex and controversial nature of the subject matter, but also because of the varying degrees of familiarity that individual Committee members had with it. Among the Committee members were some who already had considerable knowledge of the workings of the health care system. Others, including the Chair and Vice-Chair (Senators Kirby and LeBreton), had extensive public policy experience, but had never tackled health related issues in depth.

It quickly became clear that coming to terms with the federal role in health care required a broad perspective that was impossible to acquire from any single vantage point. The first three phases of the study were designed to enable the Committee to acquire a solid understanding of the evolution of Medicare, the pressures that were now affecting the system as well as some sense of how the Canadian system compared to others around the world.

The objective of the first report was to provide factual information as well as to clarify some of the major misconceptions that recur in the health care debate in Canada. It focused in particular on the initial objectives of the federal government’s involvement in health care and also traced the evolution of health care spending and health indicators over the past several decades. The Committee’s second report reviewed the major trends that are having an impact on the cost and the method of delivery of health services, and the implications of these trends for future public funding.  The third report undertook a comparative description of the way that health care is financed and delivered in several other countries (Australia, Germany, the Netherlands, Sweden, the United Kingdom and the United States), highlighting those policies and reforms from which Canada could learn.

Based on the information gathered in the course of its hearings on the first three phases, the Committee’s fourth report served to launch a public debate on the challenges and options facing Canada’s health care system. It outlined five distinct roles for the federal government in health and health care (financing, research and evaluation, infrastructure, population health and service delivery) and identified a wide range of potential policy options for reform and renewal. This fourth report was actually released prior to Volumes Two and Three, in order to allow sufficient time for the Committee to travel across the country  and gather reactions from Canadians to the options it was considering.

These cross-country hearings set the stage for the concluding phases of the Committee’s study. The Committee had originally anticipated producing one further volume in which it would both summarize the evidence it received and elaborate its recommendations. However, the volume of the testimony and the complexity of some of the key issues led the Committee to split the projected final phase in two. It released Volume Five in April, 2002 and the final report in October of the same year. Volume Five contained a set of principles adopted by the Committee to guide it in the formulation of its recommendations, as well as the Committee’s initial recommendations on a number of topics, such as technology, research and human resources.

In Volume Six the Committee not only finalized the recommendations presented in Volume Five, but also completed its mandate by making a comprehensive set of recommendations on the funding and delivery of health care in Canada, with a particular focus on the federal role. It is worth observing that because of the jurisdictional overlaps between the federal and provincial/territorial levels of government in health care, the Committee did not limit its purview to those areas of exclusive federal responsibility. To have done so would have seriously compromised the value of its recommendations.

Building Consensus Within the Committee

A combination of structural elements and careful attention to process enabled the Social Affairs Committee to produce a final report that reflected the unanimous view of the eleven Senators on the Committee – seven Liberals, three Progressive Conservatives, and one Independent.  The experience of these Committee members in public policy and health-related issues is as deep as it is varied.  The Committee included at the time of the release of Volume Six two doctors and a nurse, two former provincial ministers of health, three former MPs, two former senior advisers to Prime Ministers, and two community activists. Not only did Committee members have a considerable breadth of health policy expertise, they also represented different regions across the country – two from Ontario, two from Quebec, five from Atlantic Canada and two from the West.

Public discussion concerning the future of Medicare has often deteriorated into a war of rhetoric. This debate has frequently polarized opinion, stifled meaningful critical evaluation of the issues involved, and has regularly left the Canadian public bewildered and angry at governments and the health care policy community. It is here that the Senate’s appointed nature yielded benefits, as the members of the Committee were able to find enough good will, despite divergent outlooks, to address the major issues confronting the health care system with a minimum of partisan bias.  Moreover, their appointed status meant that Senators were able to put controversial items on the table for discussion that might have been avoided by elected parliamentarians.

From the outset of the drafting process, careful attention was paid to building a consensus view. Drafts of chapters would circulate amongst Committee members and staff prior to being formally discussed by the Committee. This meant that problem areas could be identified early on in the process and flagged for full discussion. Debate at Committee meetings focussed on substantive policy issues, with editorial changes handled “off-line”, since, as the Chair of the Committee often told Committee members, “group edits rarely work.” Significantly, no formal votes were ever held to resolve disagreements over policy issues or the content of a recommendation. Senator Kirby preferred to resolved major differences of opinion through discussion, which often resulted in compromises in the phraseology of the text.

In order to meet its ambitious timeline the Committee often met outside of its regular sitting hours and met long into the evening. On several occasions the Committee convened even when the Senate itself was not in session.

The Committee’s consideration of the issue of user-fees provides a specific example of the evolution of its collective internal thinking process. In Volume Four, the issues and options paper, the Committee listed user-fees (payments directly from the patient to the health facility at the point of service) as a possible option for increasing the revenue for the health care system. Everyone recognized that this was a controversial issue, and Committee members themselves were initially divided over this question. However, extensive national and international evidence raised serious questions about the usefulness of this funding mechanism for Canada. Thorough discussion took place amongst individual Committee members, reaching a peak during the Committee’s cross-Canada hearings. A consensus finally emerged that the best evidence showed that user-fees are not an effective option for raising revenue and, moreover, that they can generate inequality in access to health services. As a result, the Committee recommended in Volume Five that user-fees not be considered as a policy option.

Framing the Terms of the Debate

It is no exaggeration to say that the extent of the response to the Committee’s work has exceeded the most optimistic expectations. This is not to suggest that there is anything approaching unanimous endorsement of the Committee’s recommendations. Some of these have fared better both in the public’s assessment and in their prospects for being adopted by government. But regardless of whether one agrees with the substance of particular positions adopted by the Committee, it is nonetheless undeniable that its report has had a significant impact on the debate over the future of publicly funded health care in Canada.

Public policy is created in a pluralistic environment with a seemingly endless array of issues and perspectives flooding the “marketplace” of public discourse. Successfully designing public policy requires the formulation of sound policy instruments, but it is equally important to develop mechanism for having these instruments placed on the public agenda.

In this regard, the Committee either initiated debate on a number of issues, or helped to change the way certain topics were being discussed. For example, one would be hard pressed to find much discussion of the need to protect Canadians from the risk associated with very heavy or catastrophic prescription drug expenses prior to Volume Four of the Committee’s report, where the possibility of developing such a program was amongst the options under consideration. Since then, not only has the Romanow report endorsed the idea, but so too has the Minister of Health. From nowhere, catastrophic drug coverage seems to have become the option of choice. Similarly, the Committee’s discussion of the need for a ‘care guarantee’ to ensure  that patients do not encounter unacceptably long waiting times has helped to focus the debate over what to do about excessive waiting times for diagnosis and treatment.

External Relations: Media and Government

As part of its media relations strategy, the Committee exploited the profile of Senator Kirby to gain access to influential media outlets. Senator Kirby enjoys a national profile as a policy expert and an influential opinion leader in Ottawa. This was used to promote the Committee’s work especially as the study was finding its “voice” early in the process.

At the same time, other members of the Committee participated actively in media activities surrounding the release of the major volumes of the study, highlighting both the depth of experience of the Committee members and the strength of the bi-partisan consensus that prevailed in its ranks. Three senators besides the Chair regularly took part in press conference at the national press theatre to launch key volumes, while many Committee members conducted interviews with press outlets in their own regions about the Committee’s work.

In addition, generally through Senator Kirby’s office, an active liaison was maintained with members of the media, even during the drafting stages of the report. “Background” interviews were conducted with national media reporters/ editors, opening up a valuable line of communication that paid dividends when the volumes were released. In general, this effort helped foster more extensive and accurate coverage of the Committee’s work.

The Committee’s media relations strategy had gradually become more sophisticated over the course of the study. Volume One, in particular its “Myths and Realities” chapter, drew some attention from the media, but resulted only in a few interviews with the Committee Chair. The release of Volume Four marked the beginning of greater media interest, in large part because it was seen to introduce a number of highly controversial options (such as user fees) into the public debate over the future of health care. During the cross-country hearings on Volume Four, the Committee relied on in-house expertise for media relations, with a staff member being assigned to deal with the media. This represented a step forward and led to an increase in coverage for the Committee’s activities.

However, it was clear in the run-up to the release of Volume Five that even more help would be required. It was at this point that the Committee engaged outside media relations experts to provide logistical support for arranging media “hits” and to help draft the press kits documents – press release, highlights document and backgrounders. Media interest peaked around the release of Volume Six, and the coverage following the release of this final volume was extensive and sustained.

In addition to its media strategy, the Committee also worked to keep open the channels of communication with both the federal and provincial governments. For example, prior to the release of Volume Six Senator Kirby traveled across the country to brief premiers on general issues related to the health study. This tour helped to promote the Committee’s work and undoubtedly contributed to the favourable comments from several premier’s offices following the release of Volume Six. As well, several members of the Committee met with the premiers (or the minister of health) from their respective provinces once the report was public in order to highlight how the recommendations in Volume Six could benefit their province.

There was no contact between the Committee and the Prime Minister’s office prior to the release of Volume Six, on which the PMO was briefed once the report was public

The Committee maintained an ongoing link with a number of federal officials, in particular in the Departments of Health and Finance throughout its study, and the Department of Health provided numerous witnesses to appear before the Committee at the various stages of its study.

The Committee and the Romanow Commission

The Committee had already been at work on its study for well over a year when the Prime Minister appointed Mr. Romanow as Commissioner on the Future of Health Care at the beginning of April, 2001. The Committee was then in the middle of its hearings for Volume Two, and had to decide whether the creation of the Romanow Commission should cause it to alter its plan of work. Although the Committee was concerned that the public might feel that it was unnecessary to have two federal bodies engaged in parallel studies of the same subject, it did not hesitate in deciding to pursue its own work. In the first place, there was a sense that the work done till then should not go to waste. Second, it seemed quite likely to the Committee that its approach would be sufficiently different from that of Mr. Romanow and that the public and the government would consequently benefit from having a variety of options on the table.

In fact, an argument can be made that the ongoing work of the Romanow Commission not only did not detract from the public profile of the Committee, but even served to raise it. For example, on April 25, a week following the release of Volume Five, Senator Kirby responded to a criticism of the Senate health study by Mr. Romanow, who felt there was not enough evidence to support the Committee’s conclusion that health system was not fiscally sustainable. Mr. Romanow was quoted in the National Post as saying, “I need to have some evidence as to why it’s not sustainable. The [Kirby] report implies that we’re on autopilot…[and] we’re going to get hit by another little planetary missile and that’s it, we can’t do anything about it. I just don’t believe it.” Senator Kirby defended the Committee’s work by stressing that the Committee had provided the numbers on rising costs in the health system and added that three other prominent studies of the Canadian health care system had reached the same conclusion as the Senate committee.

The specific issue over which the two men differed is less important in this context than the impact of this dispute in terms of the media attention directed at the Senate Committee. In many ways, this incident was an indication that the work of the Committee was being scrutinized on the national stage in the same way as that of the Royal Commission. In fact, coverage of the Senate Committee following this exchange increased significantly and when the Commission was subsequently featured in a story it would often be accompanied by a reference to the Committee’s work.

Comparing Costs

It is not the purpose of this paper to compare the work of the Senate Committee with that of the Royal Commission, either in terms of process or content. However, it is clear that the resources to which the Royal Commission had access, allowed it to engage in forms of consultation with the Canadian public and to secure a range of outside research that were well beyond the means of the Committee. Forty peer-reviewed research papers, three major research projects, a citizen's dialogue project, a series of research roundtables and a consultants report on the costs of home care were done on behalf of the Romanow Commission. There is no doubt that the accumulation of this body of research and evidence constitutes an important and positive legacy of the work of the Royal Commission. The Senate Committee commissioned a total of six papers of widely varying length. The Committee only had two full-time researchers assigned to it by the Library of Parliament, compared to the fourteen full-time researchers on the Royal commission's staff.

However, it is nonetheless fair to assert that despite its more constrained resources, the Committee's reports attained a high level of quality, and this has been reflected in the press commentary on the Committee's work. Given its limited resources, the Committee had to target its expenditures on outside research very carefully. It is arguable that the Committee adopted an approach that was both cost-effective, and allowed for a close incorporation of the outside research into the final report.

Thus, the Committee was able to integrate effectively the work of outside consultants into the chapters of its final report on the public funding of health care, its national post-acute homecare program and its proposal for a national catastrophic drug program. This was in large part because the Committee engaged the consultants only when it had reached a stage in its reflections where their work could be directed towards very specific ends. The Committee knew what it needed and had identified those people who were capable of producing the research it required.

Conclusion

It is clear from even this brief overview of the work of the Standing Senate Committee on Social Affairs, Science and Technology that, given the right circumstances, Senate Committees can play a unique and valuable role in critical public policy debates. In this instance, the appointed nature of the Senate was an asset rather than a liability, as it is often thought to be by critics of the institution. It meant that the Committee was able to take risks and to push the policy envelope towards the outer bounds of political feasibility. The institutional culture of collegiality and bi-partisan cooperation that prevailed created an non-confrontational atmosphere for debating a highly complex and controversial topic.

Moreover, the Committee was able to devote itself, almost without interruption, to a single topic of study over the course of two and a half years, something that would be almost unthinkable in another context. This has led to the Committee having been recognized as perhaps the key ongoing site for the public discussion of health policy. The Committee’s experience with the health care study to date bodes well for it being able to sustain this role during the thematic studies it has now set for itself, and beyond.