Legislative Assembly of Ontario

MINISTRY OF HEALTH

CONTENTS

Wednesday 3 June 1992

Ministry of Health

Hon Frances Lankin, minister

Michael Decter, deputy minister

STANDING COMMITTEE ON ESTIMATES

*Chair / Président: Jackson, Cameron (Burlington South/-Sud PC)

*Vice-Chair / Vice-Présidente: Marland, Margaret (Mississauga South/-Sud PC)

Bisson, Gilles (Cochrane South/-Sud ND)

Carr, Gary (Oakville South/-Sud PC)

*Eddy, Ron (Brant-Haldimand L)

Ferguson, Will, (Kitchener ND)

*Frankford, Robert (Scarborough East/-Est ND)

*Lessard, Wayne (Windsor-Walkerville ND)

*O'Connor, Larry (Durham-York ND)

Perruzza, Anthony (Downsview ND)

Ramsay, David (Timiskaming L)

*Sorbara, Gregory S. (York Centre L)

Substitutions / Membres remplaçants:

Sullivan, Barbara (Halton Centre L) for Mr Ramsay

Waters, Daniel (Muskoka-Georgian Bay/Muskoka-Baie-Georgienne ND) for Mr Bisson

*Wessenger, Paul (Simcoe Centre ND) for Mr Ferguson

*Wilson, Jim (Simcoe West/-Ouest PC) for Mr Carr

*In attendance / présents

Clerk: Greffier: Carrozza, Franco

The committee met at 1547 in committee room 2.

MINISTRY OF HEALTH

The Chair (Mr Cameron Jackson): I'd like to call to order the standing committee on estimates. We're reconvening the estimates of the Ministry of Health. Of our 10 hours, we have seven hours and 48 minutes remaining. When we adjourned yesterday the first round had been completed with opening statements and the minister's response. At this point, I would like to begin by asking the committee how they wish to proceed with the second phase of estimates. Mr Sorbara, you're never at a loss for words.

Mr Gregory S. Sorbara (York Centre): I'd like to hear the statement again; I hear it was so good. I wasn't able to be here so maybe we could just have it again. It was an award winner.

Hon Frances Lankin (Minister of Health): I'd probably even make it longer this time.

Mr Sorbara: I'm at your pleasure, Mr Chair. I'm sitting in here for our critic who couldn't be here, so on a number of occasions I'm going to defer questions so that some of the time can be spent by Mrs Sullivan, who is far more knowledgeable on these estimates than I am. But I'm at your disposal and I would be willing to cooperate in any way possible to complete this ordeal.

The Chair: Your enthusiasm is noted. We could proceed with time allocation by caucus or with just general questioning, or with the Chair proceeding with supplementaries, and we could work in various areas of the estimates. But unless the Chair is given guidance by the committee, the Chair will rule.

Mr Jim Wilson (Simcoe West): Mr Chairman, my preference would be to go by time allocation by party and to proceed as the estimates briefing book is outlined, through each vote section, and ask the specific questions in each section.

Mr Larry O'Connor (Durham-York): Thank you, Mr Chair. I guess we have this discussion every time we have a new minister before us and there's always a little different procedure taken every time. The Chair has been fairly accurate in keeping time and making sure that all caucuses have an opportunity to speak, so I'm willing to leave it in the hands of the Chair. It might be a little easier for us MPPs who aren't as aware of the ministry as perhaps our critics are, and we may ask questions that don't necessarily follow within the votes and might throw us off a little.

Mr Sorbara: Or make any sense.

Mr O'Connor: That too.

The Chair: I would recommend then, given that by prior agreement we will be adjourning today at 5:30 there are roughly three half-hour blocks at our disposal. If that is your pleasure it will get us through today. Perhaps we could begin with Mr Wilson. We would attempt to follow the three prescribed votes in the estimates but we would as usual stack the votes so that any member wishing to go back into a section may do so during the remaining seven hours and 40 minutes of estimates. Is that agreeable to the committee?

Hon Ms Lankin: Could I ask a procedural question?

The Chair: Certainly.

Hon Ms Lankin: I just wanted to check with respect to some of the questions that were raised in the introductory statements by the two party critics, whether for example Mr Wilson, who is going to begin today, would like to officially and formally table questions that he wants answers to, or whether at this point in time he would like me to answer orally any of the questions he may have alluded to or raised in his remarks. I just wasn't sure whether he would be following up those specific questions in a vote-by-vote way.

Mr Jim Wilson: My intention is to go through the sections as outlined in the briefing book and to raise questions on a need basis stemming from my opening remarks. The ministry will have the opportunity as we proceed to answer those specific questions.

The Chair: For clarification on the procedural question, it is helpful where staff have been asked to prepare certain responses that they be done in a written form where possible; they can be distributed to the members of the committee, and this assists everyone and serves the time of the committee best. If any of those responses which are written are immediately given to the clerk, he can then in turn distribute them. That is the most helpful procedure for the committee.

Hon Ms Lankin: Then, if I understand, what we may do this afternoon as questions are tabled, if we can answer them directly at this time I'll undertake to do that; if we can provide further information or we don't have the answer with us today, we will provide that at a later date in writing.

The Chair: That's agreeable. I appreciate your cooperation in that regard. If we may then, Mr Wilson, if you'd like to proceed.

Mr Jim Wilson: Minister and colleagues, I propose to start on page 39 of the estimates with vote 2001-1 and ask a number of really technical questions on ministry administration, communication services, the operating budget. It is my understanding that $513 million in salaries and wages has been budgeted in 1992-93. My first question is, could you tell us how many people this figure encompasses for each of the three programs -- ministry administration, health system management, and population health and community services -- and the average salary of those employees? I'd also request the breakdown for each of the last five years.

Hon Ms Lankin: Do you have these questions in writing as well? We're taking notes furiously as you're speaking very quickly, but if you have them in writing that would also be of assistance to us.

Mr Jim Wilson: Yes. I know I mentioned yesterday that we would try to table them in advance, but it may take us a few more moments to get them actually photocopied and to you, Minister. We'll endeavour to do that. I know my colleague Margaret Marland has questions too.

The Chair: If I can make a point here, it's important, first of all, if Mr Wilson wishes questions to appear on the record of Hansard that they be read into the record. To the extent that he wishes to give you prior notice of those questions he will endeavour to do so, but simply tabling questions will not appear on the record. I remind members that that is part of the process if that is what they wish to do with their time in estimates.

Mr Jim Wilson: I will attempt to live up to my commitment of yesterday. Unfortunately I don't think it would be possible to have them today; we had a very busy evening last night and a very busy day today. We will attempt by the next time the committee meets to actually have the specific questions, but for today I think you're going to have to bear with me in entering them on the record and trying to answer them with whatever information the minister can provide.

The Chair: This half-hour is your time, Mr Wilson. Please proceed.

Mr Jim Wilson: Those are my questions, Mr Chair. Do I expect an answer from the minister as we proceed or --

The Chair: Minister, you're invited to respond.

Hon Ms Lankin: Without prior notice I am not able to give a response as to what the records are of employees' salaries and average wages and numbers over the last five years, so we will have to respond in the next sitting.

Mr Jim Wilson: In this section I guess what we're in a general sense quite interested in is the number of employees. Perhaps you can tell us, Minister, in general terms what the increase has been in your staff relevant to this section and the cost to the taxpayers. I assume you have notes on the vote item. Perhaps you'd like to comment in a general way on increases in staff over the past time you've been in office.

Hon Ms Lankin: I can tell you in general terms that the administrative vote within the ministry is one we have spent considerable effort in looking at how we control and how we'd make better use of dollars in that area.

One of the things that has been difficult to determine as I have tried to look at this vote line is the actual number of people who are employed working doing work, because as I started to uncover years of salary restraint that have been applied across the Ministry of Health, I found that much of the work was in fact being done by consulting physicians and being paid out of ODOE dollars, other direct operating expenses, rather than salary dollars. That was very noticeable in the information technology area, and I think you referred to that as one of the areas you had some interest in.

You will see in breakdowns a dramatic decrease in moneys within that area. We're looking particularly at the strategic plan for information technology and at a complete revisiting of the directions the ministry was headed and the way in which we accomplished that. So you will see a major decrease there, and a large part of that is doing away with consulting physicians that were in fact performing full-time work. We're attempting to convert some of those to full-time positions where that's what they were -- they were working side by side with civil servants but being paid at a higher rate, at a consulting rate -- trying to ensure that those dollars are secured in the salary lines but trying to get at an accurate reflection.

The deputy, in the reorganization of the ministry, has also given an indication to his senior management to work over the next year to two years to look at the issue of organization and layering of management layers within the ministry to determine if there are areas in which we can more efficiently utilize staffing resources. You'll know, of course, that this is a goal right across all the ministries which has been announced by the Chair of Management Board, and we will be working on a plan to comply with that direction as well.

Mr Jim Wilson: But in your ministry's administration program, I find it slightly ironic that the ministry is projecting a 1.2% increase over last year overall and that you've budgeted for a 13.7% increase in the offices of the minister and deputy minister for this year. It's a tremendous rise in costs.

Hon Ms Lankin: Can you point to the actual vote line you're referring to so I can stay with you?

Mr Jim Wilson: It's contained in the vote section; I can't give you the actual vote line at the moment, but the figures are accurate. Let's do it in a general way then. There appears, anyway, to be a tremendous increase in administration costs for both your office and the deputy's office.

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Hon Ms Lankin: I think in general terms that that might be explainable if you're looking at estimates to estimates, or more particularly actuals to estimates, over the course --

Mr Jim Wilson: Actuals to estimates?

Hon Ms Lankin: Actuals to estimates. I think it would be entirely explainable as the period in which both the deputy and I were new to the positions last year and were in the process of hiring staff into the positions. In both offices there were vacant positions for a time, so there were actually significant dollars saved in last year's envelopes for those two offices; there was underspending. So when you see estimates over the actual spending, what you will see is what appears to be a dramatic increase. It's actually spending to the envelope level.

Mr Jim Wilson: You mentioned in the House, in response to the questions regarding the hiring of Jack Layton, that you have an envelope assigned to your office for staffing. The question I wanted to ask you in the Legislature in response to the answer you gave there was, do you feel compelled to spend all of the money assigned in the envelope?

Hon Ms Lankin: No. In fact, as you can see, in the estimates last year compared to the actuals, you'll see there is --

Mr Jim Wilson: Yes, but that's last year. You're projecting a tremendous increase for this year.

Hon Ms Lankin: If I could answer your question, Mr Wilson; you'll have to listen in order to hear the answer.

The actuals last year showed an actual underspending of the envelope for the minister's office. The estimates this year indicate again the envelope and the amount that will be spent under that envelope will only be determined by the time we get to the end of the year.

I can tell you that I'm not staffed up to full complement. That's one of the reasons we have undertaken to hire Mr Layton in a consulting position for 30 days to assist us. I expect to continue throughout the course of this year to manage the budget of my own office as effectively as I can, and if I can achieve underspending again, I will. I don't think it will be to the degree we saw last year, because I should be fair and point out that a significant part of that was because of a number of positions it took me a while to hire staff into when I came new into the portfolio. But having said that, there are still positions we have chosen not to fill. We have not hired up to the full complement that would be possible under the minister's envelope.

Mr Jim Wilson: I gather from that you would have fewer special assistants and that direct political aides to yourself would be fewer in number than perhaps the Liberal administration that preceded you.

Hon Ms Lankin: I think you would have to look at two things. Since the change in governments, there has been a restructuring of the ministers' envelopes, depending on the size of the ministry. Before that they were a standard size, whether it was a small ministry or a large ministry.

Second, under the Liberal administration there was a significant practice of bringing people into the civil service and seconding them into the minister's office as political staff but being paid through the civil service; they didn't appear under the minister's envelope. But sometimes people were actually civil servants who were seconded into the minister's office, so I don't think you would be able to do an actual person-to-person or envelope-to-envelope assessment that way.

I would indicate that as a result of the change in the structure of ministers' envelopes reflecting small and large ministries, however, the Ministry of Health does have more political staff, special assistants, assigned to it now than it has in the past, and some small ministries would have less.

Mr Jim Wilson: How many would you have?

Hon Ms Lankin: What I can respond to you with -- and I don't have the number in my head -- is what the standard minister's envelope provided when we came into government in terms of the number of special assistants, and the revisions that were undertaken and the increased number that provided to the Ministry of Health.

Mr Jim Wilson: Thank you. I think Mrs Marland has a question.

Hon Ms Lankin: We do have a couple of other answers the deputy could provide that might be of assistance in response to your questions.

Mr Michael Decter: Just in explanation for the $2.7-million increase, 1991-92 estimates to 1992-93, which is a $4.5-million reduction from the 1990-91 actuals and is a very modest increase from last year's interim actuals. We're actually flat between the two years on what we actually intend to spend and we're down $4.5 million from the year before last.

The major component of the $2.7-million increase, $1.5 million of it, is a conversion inside our information technology division. We had been relying to a substantial degree on contracted staff. We have accepted a proposal from that division to convert a significant number of staff, at a cost of $1.5 million, to regular public service. That will save us, I believe, roughly double that amount on the contract side. It's plus $1.5 million in this line and minus $3 million in the vote for the information technology division. That is the single largest piece of this.

The envelope for the minister's office staff is set by Management Board. We simply incorporate it in the estimates for the ministry.

Mrs Margaret Marland (Mississauga South): I'd like to ask the minister a general policy question. I would like to know what you feel personally about universal access to health care. Do you believe in universal access to health care?

Hon Ms Lankin: On many occasions you have heard me defend the principles in the Canada Health Act. I think the concept of universality is an important one embedded in our national health system and the health insurance system. It's not a principle that is applied throughout all of our health care system. There is a difference between our hospitals and our insured services and some of our non-insured services out there where we already have systems of copayment. We can use chiropractors as an example; it's only a partially insured service. In an ideal world universality of access to free health care right across the system would be a laudable goal. What I am trying very hard to do is to preserve within the system what we have now under those parts of medicare that do have universal access, where there is no user fee or copayment structure.

As we look at the shift from the traditional health care system to a new, reformed health care system, I think it's important from the point of public policy for us to keep in mind that as we shift, we need to shift some of these principles of universality accessibility, portability and non-profit administration to a reformed system as well, even if that system begins more and more to lie outside the traditionally insured medicare system.

Mrs Marland: You just used the terms "copayment" and "user fees" in the same sentence, so you agree that they're one and the same?

Hon Ms Lankin: I think there is a difference in semantics only in terms of how the public would look at it. The traditional use of the word "user fee" has been with respect to the medicare or the insured services and is viewed as a takeaway from that universally accessible program. The concept of copayment, which exists in many of our programs -- for example, in nursing homes and in many provinces with respect to the drug benefit plan, although not in Ontario -- is in essence the same thing in terms of an individual making a monetary contribution towards a program.

The reason the terms, I think, have been used as different terms is with respect to those services that are covered under medicare or the national health care system and are protected by the principles in the Canada Health Act. That protection lies in the fact that if a provincial government, for example, introduced user fees to insured services -- to doctors' services or hospital access services -- the federal government would in fact wield fiscal penalties on the province to bring it in line or to get it to conform to our national health care system. This was the situation we faced in Ontario when the previous government had to move to end extra billing and took that step' otherwise we would have faced a fiscal penalty from the federal government.

Mrs Marland: Would you agree that when we have non-insured services we do not have universality of access? Maybe I should explain why I'm asking that. If you have non-insured services it follows that there isn't universality of access, because the people who can afford the non-insured service get it. So if it means that we then have two groups in society, the people who can afford it and the people who cannot afford it, the logical conclusion of that equation is that we don't have universality of access.

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Hon Ms Lankin: In the broadest sense of what you've said I agree with you completely. I think we have to be fair and honest and acknowledge that this exists today. If you are poor and by choice would like to access chiropractic services, that is not an insured service under the medicare system in this country. In Ontario, we have as a province decided to make a contribution towards recognizing that service and helping people access it. Physio and other services are like that; they are not covered. I think you have to go back to the history of medicare, which was an insurance system for medical doctors' services and hospitals. The combination of those two things defined the services that have universal access. There are lots of other health care services that are not covered under universality of access that exist in our system today.

Mr Jim Wilson: I'd like to move to vote 2002 now, the health system management program. The other questions I have on the previous vote I will submit in writing; they are a couple of pages in length and they are technical in nature.

Hon Ms Lankin: What page are you on, please?

Mr Jim Wilson: Just into vote 2002; it's a fairly general question at the moment. In the health system management program, both yesterday and repeatedly you've made the comment that actually you've transferred 3.4%, or a $242-million increase in operational funding for hospitals. This figure was also contained in the budget supplement paper. The 3.4% increase for 1992-93 -- and I'll give you an opportunity to comment on this -- was calculated on the basis of the previous year's actual expenditure rather than the way it's normally calculated, in my opinion, which is comparing one year's estimates to the next.

Hon Ms Lankin: That's a 2.3% increase.

Mr Jim Wilson: Okay, but you often quote a 3.4% increase. Just let me finish. Earlier this year the Treasurer announced a 1% increase in transfer payments to hospitals, and that 1% amounted to $73 million for 1992-93.

Hon Ms Lankin: That's correct.

Mr Jim Wilson: More recently you announced that hospitals would have access to $95 million from the transition fund. To me the combined total then comes to $168 million, which is your 2.3% increase.

Hon Ms Lankin: That's correct.

Mr Jim Wilson: I would note that this is below the level of inflation and not, as you've stated on more than one occasion, above the level of inflation. I guess you're referring to the 3.4%. If you look at the Ontario Hospital Association's financial management services, they claim that hospitals were actually shortchanged by $74 million for 1991-92 fiscal year, the difference between actual expenditures on hospital operations and the amount of published estimates for 1991-92. Therefore, the $242 million or 3.4% funding increase actually counts the $74 million twice, if you follow that.

Hon Ms Lankin: No, I would disagree with you.

Mr Jim Wilson: Well, how do you come up with your 3.4%?

Hon Ms Lankin: If you look estimates to estimates, there would be no reason to file actuals with people, if you say that's the increase they're receiving. It would seem to me that if you want to calculate what we project the hospitals will receive in additional funding this year over what they received last year, you have to use the actuals as your base.

The estimates of what we are going to transfer over what the hospitals actually received last year makes up the 3.4%. You're quite right: In estimates of what we thought we were going to spend in hospitals last year to what we project this year it's 2.3%. We underspent what we had projected last year largely due to new programs that didn't get up and running. To say that that therefore counts the money twice is incorrect.

There are expansions of programs we had budgeted for that hospitals weren't ready to undergo, that they weren't ready to implement; others are with the reviews we'd undertaken in a number of areas of capital expenditures; others are where we've cut back on increasing operating costs. We were able to bring that number down for expenditures last year as a result of better management but also as a result of just simply timing on some matters. Those programs, we hope, are getting up and running and we expect to spend those moneys this year. That's part of the second part of the announcement made following the Treasurer's global budget announcement. Those are real dollars that will be transferred and you can't discount them by going back to last year's estimates.

Mr Jim Wilson: On the operating expenditures for the health system management program, they are down 0.09% for psychiatric services, down 3.2% for health insurance and benefits and 1.3% for the assistive devices services over last year's estimates. Can you account for where the savings will be realized in those areas, particularly --

Hon Ms Lankin: Can you give me the three lines you're referring to?

Mr Jim Wilson: Under health system management program: psychiatric services, health insurance and benefits, and assistive devices.

Hon Ms Lankin: You were going to say "particularly with respect to" --

Mr Jim Wilson: I'm interested in all three, but in particular -- I'll be speaking tonight to the OMA and the reproductive technologies section. Going back to Margaret Marland's comments yesterday regarding in vitro fertilization and other reproductive technologies, there's still a very large concern out there and when they look at the budget estimates, they wonder if you're going to achieve some cost savings in health insurance and benefits on their backs.

Hon Ms Lankin: None of the cost savings contemplated are related to the delisting of services. I think I made that clear yesterday as well. I'll make a couple of general comments, then I'll ask the deputy to assist me.

Particularly with respect to the assistive device services, we've found as we looked at this vote line an interesting scenario in which, year over year, the estimates that were tabled showed growth in the program; but in fact, each year, if you looked at the actuals over the last significant number of years in this program, there was significant underspending. There is very effective management in this program, and the way in which the dollars were being utilized, even with expansion of the program, saw significant underspending from the estimates.

I felt it was about time we tried to reconcile what we were actually spending in the program with what we were estimating we were going to spend. So that percentage actually doesn't represent a decrease in spending of real dollars; it represents a more accurate reflection of what we are likely to spend and it's a decrease in the way these moneys had been projected in the past.

Mr Decter: If I could speak first to the psychiatric hospitals: As set out on pages 80 and 81, the major reduction in the psychiatric hospitals is in the ODOE area. The ministry had complied with an overall government initiative to reduce ODOE, the non-salary budget, by 10%, and in the case of the psych hospitals that's where the major reductions of some $6.5 million have come. There are some employee benefit increases and some grievance award moneys that would flow from the collective agreement between the government and the bargaining agent, but the reduction is achieved largely in supplies and equipment, services, transportation and communication.

With regard to the health benefits reduction, the out-of-country annualization would be the single largest piece. That detail is contained on page 86. The other major event is that there were two one-time payments made to physicians as a result of the agreement last year, of 2% and 2% for the 1989-90 and 1990-91 years; those are non-recurring.

That sets out in detail the various changes. Without any of these policy changes, the expectation would have been for an increase of some $400 million. All of this is affected by negotiations that are ongoing between the OMA and the government, so these are more truly estimates than some of the other areas. Until that agreement is settled we will not be able to be completely precise, as the ministry hasn't been able to be completely precise in other years.

For the measures listed as 1991-92, those numbers are precise; those are our best calculations. The 1992-93 initiatives depend in significant measure on negotiations that are still ongoing. Those are the explanations in the OHIP line. I think it important to note that the majority of them are not new initiatives that affect physicians in the province. They're either things they knew about last year, the one-time settlement or the out-of-country changes where we're actually repatriating work into the province.

With regard to assistive devices, the detail is on page 96; these are largely management measures to achieve cost saving in the program. They go in the direction of looking at fixed contributions on some devices and some savings that have been achieved simply through --

Mr Jim Wilson: Can you explain some of them? I have a fair bit of correspondence. It appears -- and this is the criticism -- that unilaterally and behind closed doors there were rules introduced to tighten the assistive devices program and some of the criteria. Do you want to comment on that? We had the case you mentioned in the House. We had mentioned children with heart monitors, oxygen services. I'm sure they are not the right examples at this time.

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Hon Ms Lankin: Actually they are not, because the case of the heart monitors was a change made back under the previous government, so it wouldn't fall into the category of concern that you were pointing to.

It's interesting, because I have received some letters with respect to the proposed changes in the rules around mobility devices, as an example, and in some of those letters there has been the tone you suggested, an accusation that there has not been consultation. But after direct discussions with the director of this program and having reviewed the discussions that have taken place, the various groups representing persons with disabilities and stakeholders for this program area have in fact been involved in fairly extensive discussions around the application of guidelines with respect to mobility devices and some of the other proposed changes: looking at trying to introduce incentives for recycling and the ability to purchase recycled wheelchairs and others. So from my review of the record of activity with the director of that branch, significant consultation has been undertaken.

With respect to the issue of oxygen, a couple of things: Here I think you're really talking about the Ontario drug benefit program, not the assistive devices program. I would briefly say that the reviews of the program over the years have pointed out some of the problems with the rules around access to oxygen and the need for good clinical rules around access to oxygen.

The other thing we did, which was where the biggest cost saving was, didn't have to do with restricting individuals' access; it had to do with negotiating a deal with the suppliers of oxygen. What we found when I looked at this program in the ministry was that Comsoc, which has a similar payment scheme for recipients of social assistance, had negotiated a deal that was significantly better than the rate the Ministry of Health was paying to the same providers out there for the tendering contracts of these services. We simply negotiated a better deal, and we've got a lot of cost savings as a result of that.

Mr Jim Wilson: Thank you. I wonder, Minister, if you could provide us with a list -- if you want to take note of this -- of the capital projects that have been approved by your ministry since your government's coming to office in September 1990, the amount of money allocated for each project and the date of approval, plus the projects you have. We've discussed at length in the Legislature projects like the Collingwood hospital and the hospitals in Simcoe county in my own area of the province. I think it would be useful for members to know how many capital projects have been approved, the amounts and what's on your plate now in terms of the review you're going through, so I ask you that.

Also, I understand -- correct me if I am wrong -- that the ministry has done a survey on the impact of the nursing settlement last year on the job losses, particularly the nursing sector in hospitals. Have you undertaken a study on that? You mentioned yesterday in your remarks that the figures will show that the layoffs haven't been as severe as predicted; I assume you mean a number of these people have been absorbed into other settings. Do you want to comment on that?

Hon Ms Lankin: I can give you a preliminary comment on that. I can't provide you with the numbers today; we are still in the process of working on those numbers at this point in time.

The comments I made with respect to the actual number of individuals laid off being significantly lower than what had been projected does not come as a result of people being absorbed into other settings in the community, which I think was perhaps a misunderstanding that arose yesterday. What I'm talking about is the individuals not having been laid off from the hospitals, regardless of the predictions, first of all, and then announcements of layoffs that would occur.

As a result of very hard work -- and work to be credited -- in the hospital sector by hospital management working with workers in district health councils to review recovery plans and look for alternative ways of finding expenditure reductions in their budget areas, they have been able to mitigate against a large number of those layoffs that had been predicted and even those layoffs that had been actually announced. They've also been able through attrition, through early retirement, through not filling positions, many of those other tools available to management to manage through deficit situations, to avoid direct layoffs of individuals. I will, as soon as those numbers are available, ensure that members of the Legislature in general are made aware of them.

The Chair: In one minute remaining, a final question in this section.

Mr Jim Wilson: I was interested to note one of the figures that stood out, which may seem insignificant to some, but it was actually brought to my attention by some nurses. The transportation and communication services are up 100% for hospitals this year. Any comment on that?

Hon Ms Lankin: I don't have directly. Can you show me again the line you were referring to?

Mr Jim Wilson: I'm sorry, Minister, I don't know the exact line because my notes don't quite correspond to the book. They will by next Monday.

Hon Ms Lankin: Then I'll undertake to give you a response on Monday as well, okay?

Mr Jim Wilson: Thank you.

Mr Sorbara: It's nice to be doing Health estimates, actually. It's the ministry that spends the lion's share of the provincial budget. I have some comments to make and some questions. I guess I want to start off in the same place my friend Mr Wilson started off with, as soon as the minister has completed her consultation.

Hon Ms Lankin: I'm sorry. I was just trying to find the line Mr Wilson was referring to in case I could provide him with an answer today.

The Chair: Minister, it would be helpful if your deputy took care of that and at this point your attention could be focused on Mr Sorbara.

Hon Ms Lankin: I understand the point you're raising, but I think I have some misunderstanding about the question and I need to get clarification if we're actually going to be able to answer it, so if I could just quickly do that. Mr Sorbara, I'm sorry; I don't mean to interrupt.

Mr Wilson, you were talking about transportation and communications. Was that public hospitals or are you talking about psychiatric hospitals under the government?

Mr Jim Wilson: It's public hospitals, from what I understand.

Hon Ms Lankin: Okay, we'll look into that.

The Chair: In future, Mr Decter has the opportunity to talk to any member of this committee, as do all the staff you have assembled here. You have the right to approach any of them once we're no longer in session and clarify any of the questions, and that's certainly helpful. But in terms of the flow of the estimates, if we could stay on where we are able to respond, and points of clarification can come by staff. That helps the process all the way around. Please proceed, Mr Sorbara.

Mrs Marland: On process, we can have written answers in the future to these questions if they're not available now, right?

The Chair: That is correct. Please proceed, Mr Sorbara.

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Mr Sorbara: I want to begin with the minister's office. I was struck by your comment that there was a practice in the previous administration of seconding ministry staff into ministers' offices. I was in that administration for five and a half years, and I can't recall one instance of that. Is there something I wasn't aware of or some information I wasn't aware of that you are aware of; if so, can I ask you where you got that information?

Hon Ms Lankin: Directly within the Ministry of Health, I have worked with members of the civil service who had from time to time been seconded into the minister's office. Actually, I think it's a practice that is useful and helpful to both the minister and to the civil service in terms of bridging relationships between the two offices and understanding the nature of the work and the demands that are required. Since I have been in office, I have had two members of the civil service come for a number of months to work in my office. It was a very general practice, from what I can see looking at names on the list of people who were in political staff positions within the former minister's office under the Liberal government and who are now members of the civil service. It works both ways, I think.

Mr Sorbara: I'm rather surprised here, because the general practice of the transition from one administration to another is that information relating to the operation of the previous administration is not available to an incoming administration. Are you telling me that lists and procedures of the previous administration were routinely provided to you in your new administration?

Hon Ms Lankin: In the government phone book, yes. I've looked at the lists of names of people who were employed by the former minister and have met many of them in the civil service today.

Mr Sorbara: But was information provided beyond that about how --

Hon Ms Lankin: The only direct information that would have been provided beyond that was meeting individuals and discussing with them the fact that they had been employed directly in the minister's office. This was not a political staff person who went into the bureaucracy; this was someone who was seconded for a period of time.

Mr Sorbara: You just take it from that -- I think I'm quoting you now -- that there was a general practice of seconding members from the civil service into ministers' offices.

Hon Ms Lankin: I have had other ministers confirm for me the same thing in their experience in their ministries.

Mr Sorbara: My goodness. I'd like to see more evidence of that, because it was an infrequent practice. I don't criticize the practice. I just tell you that it was an infrequent practice.

How many people work in your office?

Hon Ms Lankin: I don't have the exact number right now. I think there's about eight policy staff in total.

Mr Sorbara: How many people work in your office altogether? Do we need a government telephone book to find that out?

Hon Ms Lankin: I would have to take a quick look at a staff list.

Mr Sorbara: About how many? You have an executive assistant; you have eight policy advisers?

Hon Ms Lankin: Maybe six or seven. Do we have a list? Let me tell you directly. There are 16 people directly employed in the office, one person on a secondment from the civil service and my driver.

Mr Sorbara: So 16 plus one plus one; that's 18 people.

Hon Ms Lankin: That includes the receptionist and secretaries and policy staff.

Mr Sorbara: It always does. Would you mind running through the titles? Executive assistant, eight policy advisers --

Hon Ms Lankin: Let me tell you the exact number. Seven policy advisers, one of those being a seconded person from the ministry doing liaison, so seven in total but six in terms of the minister's direct envelope. Then there are a number of general assistants who do case work, secretarial work, as well as my driver, who's a general assistant; receptionist, secretaries and two executive secretaries.

Mr Sorbara: Would you be surprised if I suggested to you that this is the largest minister's office in the history of the government of Ontario?

Hon Ms Lankin: No. In fact, I would acknowledge that and did acknowledge that earlier in that there was a Management Board decision to reorganize the envelopes to ministers' offices; large ministries like the Ministry of Health, which of course is responsible for the expenditure of over a third of the Ontario government's budget, were given increased numbers of staff to assist the minister --

Mr Sorbara: I'd say they were.

Hon Ms Lankin: -- while other small ministries had their staffing numbers decreased.

Mr Sorbara: Well, we're not here to examine the staffing of other ministries, but I can't imagine how you could get much smaller than an executive assistant, a legislative assistant, a policy assistant and clerical and secretarial staff, which was typically the organization of a minister's office. But I take you at your word that some of them are smaller than that now. We'll be interested in looking at that in other estimates.

Can you table a copy of Jack Layton's contract? Can we get that today or tomorrow?

Hon Ms Lankin: We can certainly bring that back. I don't have it with me today, but we can bring that and table it for the members.

Mr Sorbara: Right. Minister, what is he going to do? What in the world is he going to do? I think he's going to be a federal candidate pretty soon and there's nothing wrong with that: He's a politician; he'll probably make a very good candidate. But what is he going to be doing for you?

Hon Ms Lankin: The Public Hospitals Act is in dire need of rewriting and updating. There has been a period for a couple of years now of a review of the provisions of that legislation. That was a task force that was established that had representation from the hospital sector, from some of the workers' groups, from consumers and the medical profession. It was a task force group that has spent a lot of time in subcommittees studying this legislation and coming forward with a very significant piece of work in recommending broad, sweeping changes to the Public Hospitals Act.

Having received this report, of course, I'm in a position where I'm going to have to develop policy recommendations from that for my colleagues to consider with respect to the legislation and government position on legislative change to this piece of legislation. Prior to drafting legislation and making policy decisions, I felt it would be helpful to have a once-around review of those task force report recommendations, have an opportunity for not just myself but other members of the Legislature to hear some opinions, some thoughts from people: "Is this task force report heading in the right direction? Does it miss the mark completely? Don't look at it, start again, scrap it? Or are there are some good ideas here we can build on, but here are some other areas we want you to look at?"

In deciding how to do that and trying to do it in an expeditious manner that was not going to take us a long time and drag this on -- because we did want to be able to try to move and develop a legislative package -- I requested my parliamentary assistant to conduct six hearings around the province in which we would also involve the local MPPs from any surrounding ridings who were interested in coming in to hear what people had to say. I thought it was also an opportunity for members of the Legislature to have some exposure to this piece of legislation. I didn't know a lot about it myself; there's a lot to learn to come up to speed to be able to think about the legislation the government will table.

In setting up those meetings -- we're doing it over a fairly short period this summer -- I wanted to ensure that we had the opportunity to hear from a broad range of participants. We have met with the Ontario Hospital Association around these changes. They have been out organizing their regional structure, regional forums with hospitals, educating them about the task force report recommendations and getting their feedback. They'll be feeding that in through these public hearings, as well as directly to the ministry in writing.

Some of the other organized groups are able to prepare themselves and be ready for this kind of comment as well. But we felt -- I felt particularly; this is certainly important to me in the way I approach legislation -- that it was important, if we were talking about the relationship of hospitals to their communities, governance structures, boards, how they get elected, what their accountability around program delivery is back to the community, that there is a way to facilitate community development and participation in this.

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With respect to the workload and the staff I have right now and what we are trying to handle with the major reform initiatives we have ongoing, I needed some assistance in trying to reach out to groups and encourage and facilitate their ability to participate. Facilitating their ability to participate is first of all making contact, letting them know about the hearings coming up, talking to them about what the nature of the reform recommendations are, whether they're interested in participating in this; and then taking the next step to set up meetings, if they're interested, in which ministry staff will come out and brief individuals and give them information on the task force report recommendations, some of which are quite technical and quite extensive.

That kind of organizing: to help community groups, targeting on women's organizations, representatives of visible minorities and aboriginal groups, reaching out to municipal councils that have interests in these issues but aren't often directly represented in the hospital board debate -- they're more represented through district health councils and public boards of health -- trying to facilitate that kind of participation. I actually think Mr Layton will be able to help in that way and be able to facilitate that.

One of the concerns that has been raised by members of the opposition in question period is that somehow we have hired someone who is going to oversee this process and is going to prohibit individuals from participating. In fact, it is exactly the opposite that we hope to achieve by this. Certainly we continue to work with hospitals and other organized groups to ensure that they will be there, but they have an organized voice. What we're trying to do is ensure that there's also an opportunity for other community groups that depend on hospital services and care about their hospitals to participate in this discussion.

Mr Sorbara: Madam Chair, you'll forgive me if I say that I find it somewhat unfair to the opposition in trying to get some answers if the answers are going to be so very long, but it's at the discretion of the minister, obviously. I'm not going to interrupt.

The Vice-Chair (Mrs Margaret Marland): It's also somewhat at the discretion of the Chair.

Mr Sorbara: Sure. I leave it in your hands and those of the minister. I'm not prepared to interrupt, but I think the answer went beyond a simple question about what he is going to do. You're telling me that with the largest ministry staff of any ministry -- larger, frankly, than I think the Premier's office in the previous administration, but I may be wrong on that -- there wasn't some time available for someone to do that task. I think that's a simple yes or no.

Hon Ms Lankin: You may think it's a simple yes or no, but I would like to give you more of an answer than that.

Mr Sorbara: There you go.

Hon Ms Lankin: I do take your point about giving long answers. I'm often criticized for that, even by the Speaker in the Legislature, so I'll try to keep that in mind. The situation I face right now with respect to the staff I have and the policy areas they're working on is that there are a tremendous number of long hours being put in and good work being put in, but the ability to spare someone to go out and do this kind of organizing at this time, when we need these hearings up and running over the next month, was limited. This is assistance I am authorizing, out of unspent staffing dollars within my minister's office envelope, to my parliamentary assistant in ensuring that he and the other members of the Legislature have a good process in the hearings.

Mr Sorbara: I simply say to you this is not an envelope in the traditional terms; this is parcel post, this is enormous. For the record, I note that there is a $10.6-million communications envelope as well. Presumably some of that money has historically been spent on that sort of thing. I understand Bob Cohen is the director of communications in the Ministry of Health?

Hon Ms Lankin: Rhea Cohen.

Mr Sorbara: Oh, Rhea Cohen. I thought it was Robert Cohen. He's another great civil servant who has been the director of communications for a number of ministries.

So Mr Layton gets $300 a day. As I figure it -- rough figures -- that's about 75 grand a year. How does that compare with the salary of other members of your staff, say your executive assistant? How much does your executive assistant earn?

Hon Ms Lankin: The range of salaries for executive assistants and special assistants I'd have to get from Management Board and table with you. I don't have those figures in my head.

Mr Sorbara: You don't know what your executive assistant earns?

Hon Ms Lankin: Not directly, no. I think the salary for an executive assistant would exceed that figure you referred to of $75,000. But let me indicate to you that this contract is for 30 days.

Mr Sorbara: I appreciate that.

Hon Ms Lankin: If you took a special assistant's salary and included in lieu of benefits and certain other elements, it may come close to that, but it would probably be slightly under that on an annualized basis.

Mr Sorbara: Just as a point of information, is the contract with Mr Layton directly or with his consulting firm?

Hon Ms Lankin: I believe it is with him directly, but we'll have to check that when I table it.

Mr Sorbara: You're going to table the contract. Okay. That is the sort of minor political stuff we deal with in estimates from time to time.

You are responsible for the largest budget in the province, as is every Minister of Health in every province; what is it, some $17 billion and change this year? Is that right?

Hon Ms Lankin: That's right.

Mr Sorbara: Through the budgetary process and other announcements you've made, you have suggested that there is a whole series of initiatives under way to come to grips with the cost of health care in the province. Is that right? This year it's a 2% solution as far as the Ministry of Health is concerned. Is that right?

Hon Ms Lankin: I don't know what you mean by a 2% solution.

Mr Sorbara: Overall the budget is going to increase by only 2%. Is that right?

Hon Ms Lankin: We are attempting a number of reform initiatives which get at improved quality but also get at the cost-effectiveness and sustainability. I think my general answer to you is, yes, I would agree with your characterization that we're attempting to look at costs and try and bring costs under control, but it's broader than that as well.

Mr Sorbara: Do you expect that in the future we are going to see absolute reductions in the health care envelope in Ontario?

Hon Ms Lankin: I wouldn't project that in the near future. Looking way out into the future would be --

Mr Sorbara: In the life of your administration, are we going to see a slower growth in the cost of health care, or are we going to see an absolute reduction -- that is, a statement by the Minister of Health in the Legislature saying, "Mr Speaker, this year we are going to spend $1,000" -- or $1 million or $1 billion -- "less"? Will we see that in the life of your administration?

Hon Ms Lankin: No. You'll see a slower growth in the Ministry of Health's budget. In particular, given the fiscal situation we're in this year and next year, what you will continue to see is a slower growth in some of the large vote items within the Ministry of Health like hospitals and physicians' services.

Mr Sorbara: Hospitals are going to be getting, relatively speaking, less money than --

Hon Ms Lankin: Community health.

Mr Sorbara: Less money than they otherwise might have expected in the growth periods of the 1980s, but not less money in absolute terms.

Hon Ms Lankin: That's right. As you know, the announcement we've made for the next two years, out from this year, looks at a projection of 2% and 2%. I want to be very careful to say that this is the first time we've tried to do multi-year projections and that we are working with hospitals to try to move to a multi-year budgeting process if we can. This is something hospitals have been demanding for a long time to try to give them some sense of certainty and ability to plan out and to manage. As a manager, I think anyone would be able to identify that it would be advantageous. It's a bit dicey in the first year to try to make those projections, but hopefully we'll be right.

Mr Sorbara: But these projections take you basically to the end of your term, don't they?

Hon Ms Lankin: Yes.

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Mr Sorbara: I simply want to suggest to you that other governments have made those, not directly in the way your government has in this instance. I also want to suggest to you that other governments, having done that, have seen fit, as the time for the consultation with the people comes closer, to announce initiatives that augment the allocation, in particular in areas where there is a political interest to do so.

Are you telling us now that we will not see specific, perhaps targeted, initiatives that put money in the hands of hospitals or doctors or community health that go beyond the transfers, or are you going to stick to your guns on this? Is it going to be 2% or are we going to see 2% plus some sort of sweetener two years down the road when we're out of the recession and we're going into an election?

Hon Ms Lankin: My expectation with respect to the hospital sector is that the number will be 2%.

Mr Sorbara: What about --

Hon Ms Lankin: If I could finish my answer.

The Vice-Chair: Excuse me, Mr Sorbara. You are interrupting the minister quite a bit.

Mr Sorbara: There is no doubt about that. I've only got a few more minutes and I'm trying to keep the answers short.

Hon Ms Lankin: No, that's not exactly what you're trying to do.

Mr Sorbara: No, I --

Hon Ms Lankin: The 2% outlook is one in which, I do want to caution, is the first time we have done a sort of public announcement of where we think something will be going. On the numbers we have and the projections from the Treasurer with respect to the economy and the fiscal situation of the government, that is the outlook and that's what I expect will happen. That's with respect to hospitals.

I do think you will see an accelerated rate of growth from what we've seen last year to this year, for example, in the next couple of years in community health. That would have been my hope, to be able to achieve that kind of reallocation of resources. Also, some of those resources will be reallocated to other determinants of health which lay outside of the Ministry of Health, and I spoke a bit about that in my introductory comments, Mr Sorbara.

Mr Sorbara: Okay. Have you ever heard of a person called Ted Ball?

Hon Ms Lankin: Many times, yes.

Mr Sorbara: Can I just read you something he wrote? Then I'd like your comments. I'm quoting from an article in a publication called Health Concept Consultants, which seems to be the name of his firm as well. He says:

"The Ontario health care system is on the precipice of a truly dramatic change. The entire system is about to undergo a fundamental restructuring and a downsizing that could in fact be breathtaking in scope. Beds will be closed, accessibility could be threatened, jobs will be lost, physicians' incomes will probably decline in a number of specialties and citizen entitlement to OHIP benefits may be reduced.

"In the next two years, the system's managers, hospital administrators, citizens' boards, health care professionals, planning bodies and public servants at the Ministry of Health will be put to a real test. Their collective challenge will be to manage the transformation and downsizing of the system in ways that do not threaten patient care."

Just skipping a paragraph that doesn't bear on the point that I'm trying to make, the next paragraph reads:

"The first thing that we all have to recognize is that this is inevitable. The status quo is simply not a viable option any more. The coming crisis in health care that we've all heard about over the past decade has now arrived. It's here. The crisis is right now."

Then he goes on to argue for joint planning.

Is Mr Ball wrong in the assertions he makes in this article?

Hon Ms Lankin: I think Mr Ball is making a tremendous contribution to the public debate on this issue, and I agree with the characterization of the possible range of things that could happen. If I could take his introductory comments and interpret them, if I may take the latitude of doing that, as I understand them from him, having talked to him on many occasions, I think he was most articulate in an National Film Board production most recently where he said medicare is in danger and the danger is if we just try to let the status quo continue.

In his words, "If we don't change it, we'll lose it," and I think the range of things that could possibly happen and how they might change, and our ability to manage that and to do it in a way that sustains a good health care system, a high-quality health care system, and that allows us to in fact enhance quality of services, is the challenge he's talking about.

Mr Sorbara: I appreciate that, but I'm trying to understand whether or not you agree with this assessment of our health care system or if you have a different assessment. He says the system is going to be restructured and downsized.

I know the political rhetoric about, "We're going to enhance quality and also come to grips with costs and we're going to do restructuring in partnership," but the issue here, at least the one I'm trying to get at, is, are we going to be downsizing the system? If we're going to be downsizing the system, then the projections of reduced rates of growth are not on. If we're going to be downsizing the system, we're going to spend less money. We're going to have a smaller, maybe better, system but we're going to have a smaller system. That's what he's arguing here. Is he right or wrong in the case of Ontario?

Hon Ms Lankin: I guess I have to disagree, not with what Mr Ball has said but with your interpretation of what he is saying. The downsizing he's talking about refers to the traditional health care system or what people who have been involved in wanting reform in the system for the last 15 years refer to as the illness treatment system, talking about hospitals and the way in which we've utilized hospital services and talking about physicians' services and restructuring and downsizing with respect to that aspect of health care.

I think when we talk about the health care system, we're actually talking about a much broader aspect than that, and I think you will see growth in certain aspects of the system in terms of primary care services delivered in the community, long-term care services and a number of other investments indeterminate of health which lay outside the traditional health care system.

Where I take exception to the numbers and the way you portray them, to talk about downsizing the hospital sector, which we have seen already with respect to beds, there's a lesser reliance on acute care beds in the hospital system, but hospitals are providing more services on an outpatient and ambulatory basis. We're downsizing one part of the hospital system, not the whole hospital system. In fact, we think we're delivering services in more cost- effective ways. So costs will continue to increase there but not at the double-digit rate or the 9% to 10% rate that hospital budgets have been increasing over the last 10 years.

Mr Sorbara: I've got a whole bunch of other questions, Madam Chair, but I'll restrict myself to one.

The Vice-Chair: We'll have to wait with bated breath, I'm sorry, unless you can do it in 30 seconds.

Mr Sorbara: You think you're sorry. Yes, I can do it in 30 seconds. The question is quite simple. I'm wondering whether the minister, when she calculates the cost of health care in Ontario, includes in her analysis of what we're spending and how much it's costing for health care the $3.2 billion, $3.3 billion or $3.4 billion, depending on whether you're talking about 1990, 1991 or 1992, annually spent by the Workers' Compensation Board in Ontario.

Hon Ms Lankin: In terms of the ministry vote and the actual ministry budget, no.

Mr Sorbara: It's not part of the ministry vote; I appreciate that.

Hon Ms Lankin: But in terms of what we spend on health care and costs to the health care system, there are significant other areas in addition to workers' compensation.

Mr Sorbara: Such as?

Hon Ms Lankin: Road safety, the results of accidents that are being paid out and supported through the private insurance system, as well as the workers' compensation system results of accidents. I think you ask a question that underlies some of the arguments I've been attempting to make, taking from the work of the Premier's Council, the former government and others, that determinants of health and where we need to invest to keep people healthy often lie outside the traditional health care system.

Mr Sorbara: Perhaps if the Chair had indulged us with more time, we could have pursued that.

The Vice-Chair: Thank you, Madam Minister. Mr O'Connor, you have the floor.

Mr O'Connor: The question I have is a little more general. I suppose we've been pretty general up to this point with some of our questions.

Mr Sorbara: You're always gentler with your ministers than we are.

Mr O'Connor: The question I have is one that keeps being brought up by constituents within my riding; my riding is largely a rural riding with lots of seniors. It relates to the OHIP changes in rules as far as the snowbirds are concerned. Many constituents reside in trailer parks and travel, and they're really concerned about this half a year, 183 days. They run into a lot of difficulties. Some of them relate to the fact that those who have very large mobile trailers they pull behind their trucks -- these are people who have sold their modest homes -- when they come up to Ontario again they can't get into the parks until the long weekend in May; come Thanksgiving weekend, of course, all the water and hydro are shut off at the campsites. So what happens is that these people are left out in limbo and are caught in a predicament. Of course, that doesn't point out the opportunities they may have to visit friends and family, because they are mobile, in other provinces in Canada.

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The problem happens when they decide they're going to go to Florida for an extended period during the winter months. It's probably more healthy for them to be there than to be risking heart attacks shovelling snow. I just wondered if you could address some of the rule changes that affect seniors. I have a large constituency of seniors and I'd just like you to comment on it because it's something that does get raised with me on many occasions; in fact, during my town hall meetings it's probably number one on the list, in recent months anyway.

Hon Ms Lankin: I'll talk first about the changes with respect to eligibility, because I think that's primarily what you're talking about, as opposed to the changes with respect to what we'll pay for in claims that come while people are out of the country. I'll ask the deputy to fill in any areas I may miss as I go through this.

When we moved from the OHIP number to an individual health card system in Ontario, a whole number of issues around eligibility for health insurance and coverage and the health card were able to start to be addressed; we had had such a mess in the system before with respect to the number that covered families and there was a lot of abuse and there were a lot of complaints. I know members of the opposition NDP caucus years ago stood up and there was a large furore when they brought forward names of dogs and cats that held OHIP numbers. The previous government responded with a major undertaking to move to an individual health registration card, a health number, so a number of issues around eligibility were raised and are being addressed on an ongoing basis in looking at the rules.

The question of residency is, what does residency mean, and if you need to be an Ontario resident to be eligible for health insurance, how is that defined? One of the rule changes I think you will hear from people that perhaps is affecting them is that we went from a requirement that people had to be present for four consecutive months in Ontario to a requirement that people had to be resident in Ontario -- primary residence in Ontario -- for a six-month period. It doesn't need to be consecutive, but for six months over the course of a year.

I think the question for us here is with respect to who we cover and what benefits we provide to individual Ontario residents and how you define a resident. We've determined that that definition should be someone who is resident here in the province for six months of the year, half of the year, and that his primary residence is here, as opposed to an individual whose primary attachment is to another part of this country or another country with respect to the taxes he pays, with respect to sales taxes, his purchases, the economy he supports, which is all part of what generates revenues that support our health care system here.

The issue you raised specifically around the trailer parks gives rise to how we determine if someone has a permanent residence or is living in a permanent residence here. I think that needs to be done in individual circumstances. I don't think there are blanket rules you can set around that. I believe this question was raised because someone was concerned that if he lived in a trailer, would that be determined not to be a residence? I think that's a situation where an individual would need to seek advice and clarification and sort out his own situation with OHIP, and if he disagrees with the eligibility ruling by OHIP officials, there is an appeal process.

I've only just recently been made aware of the issue of those individuals who have mobile residences they live in, in two different areas -- they live in them in the States and they live in them when they come back to Ontario -- and their problems with respect to a permanent address for the summer months in Ontario being restricted by dates of opening and closing of particular parks and whether that compromises them under the six-month rule. We've asked the ministry to take a look at that.

Mr O'Connor: I guess some of the concern is that in some cases they travel back and forth. If the time lines you have are set in stone, what happens to people on their way back, who get into the mountains in Tennessee and go into Ohio and there's a snowstorm taking place? Do they then park their trailer, or do they risk life and limb to get to Ontario because they want to make that 183-day deadline? It's something that concerns them. Later on in the session I suppose we'll see some petitions being tabled, because my constituents are very concerned about it.

Hon Ms Lankin: I really would want to assure you and hope you would assure your constituents that no one should be driven to risk life and limb to try to meet that kind of deadline. First of all, we are talking about situations we become aware of through a person's claim and the claim is rejected. The issue is whether their insurance would cover them for something that happened in the States if, on receiving the claim and based on past records, it would appear to us that they were out of the country for an extended period. So the actual situation you raise is one I hope you would reassure people about.

I think the bottom line is the question of who are we going to cover. It doesn't matter where you draw lines. There is always someone on one side of the line and always someone on the other side of the line. I would hope we would all consider, in times when we are trying to stretch our precious resources around health care as far as we can, that we want to ensure we have a policy that is defensible about who are our residents and who it is we cover. This is a system contributed to by taxpayers, both employers and individuals. Certainly the employers' health premium doesn't cover the costs of our health care system; it's one contribution. Individual taxes paid into the consolidated revenue fund, lotteries, federal transfers, all sorts of things are relied upon in order to finance this system.

I think we owe it to our society to have a system that can meet the needs of people who are defined as active residents of our community. That means we have to make some decisions about who is a resident of our community. It seems to me that there is a choice for those individuals, that perhaps they spend five months in Florida and a month visiting people in other parts of Canada and six months in Ontario. People can organize their lives around this as well.

Mr O'Connor: We could belabour the point. The concern is, though, that the provincial parks we operate aren't open for the six months, if they have sold everything they own to take up that mobile way of life when they've retired and want to travel.

One point was raised recently at a public meeting when I was talking with some seniors who live in a land-leased community; this is a suggestion you can take with you and maybe talk about later with some people within the ministry. What about the possibility of OHIP coming up with a program that would be along Blue Cross lines? The brokers for Blue Cross and Green Shield take a huge percentage in carrying charges -- I think it's up in the 40% range; it's enormous -- and their costs are very prohibitive to seniors who want to travel. There would be savings for those constituents that maybe would allow them to spend a little time abroad. Maybe it would be possible for the ministry to do that.

I don't know whether that would be feasible. That was a suggestion made by a senior in my riding. I thought it was very creative of them to think of suggestions. I did raise the issues that you've raised, that we do have to make sure the health care system we're providing is for the residents of Ontario. These people who have paid taxes all their lives in Ontario and are very proud to be Canadians are trying to help out as well. They're not trying to be a drain on the system; they're trying to be creative. That was a suggestion that maybe there could be some cooperation. I don't necessarily need an answer from you on that, but maybe just a suggestion that you can take back to your ministry and take a look at.

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Hon Ms Lankin: I appreciate the suggestion.

Mr Robert Frankford (Scarborough East): I want to continue, in a way, on increasing revenues. There are two areas I want to get into, but I probably only have time for one. You've set up an industrial strategy -- or what's the term for it?

Mr Decter: Health economic development.

Mr Frankford: I think it is looking at devices and so on. I'd also like to draw your attention to an article that was in the Globe about three weeks ago about encouraging cross-border shopping by Americans, to use health care here. I've met briefly with the authors of that article since then. I understand that some cross-border shopping does take place already; we're basically talking about hospital care, procedural care. I believe something like a dozen hospitals are doing that. I think that figure doesn't appear anywhere in the estimates, but it would be interesting to know the extent to which it's taken place already. That's one approach, a more procedural, higher-tech approach, which I think is taking place.

Now, there are other types of health care which can be offered here. What occurs to me, looking at the amazing business opportunity that exists with 35 million Americans uninsured all over, but certainly a significant number in the border areas, is that there's clearly a lack of bread-and-butter primary care. I believe some of this is already taking place in Sault Ste Marie, where you have a tailor-made arrangement with the Group Health Centre.

One could easily see ways of building that, and this also of concern to people like my neighbour here --

Mr Wayne Lessard (Windsor-Walkerville): From Windsor; don't forget Windsor.

Mr Frankford: -- from Windsor, where the market from Detroit I think would present another remarkable opportunity for economic development, in both hospital and non-hospital care. I'm aware there are potential problems with two-tier systems, but I think this is all manageable with the right policy decisions. I wonder if you'd like to express any thoughts about the potential revenue from the US.

I'll just throw in that because our system is so superior a growing number of US planners keep on coming here, so we're getting tourist revenue. Last week I had the privilege of sitting down with Dr David Himmelstein, who's with Physicians for a National Health Program. He is a strong enthusiast who's written extensively and points out the enormous waste in their system of a privatized, highly bureaucratized system. There's $20 billion or something enormous just going in the paperwork there, so there is considerable interest in selling knowledge of our system, which I think is another thing that is happening anyway. I'd like to hear anything the ministry is doing to develop that.

Hon Ms Lankin: I think I'll let the deputy respond.

Mr Decter: A couple of comments: There is revenue earned by Ontario hospitals from US patients and other providers. Most of that is simply tourists visiting who need care, but our leading hospitals in tertiary care are among the best in the world.

I was recently at a meeting -- 14 countries represented -- and two of the managers of the largest US health maintenance organizations took me aside to say how much they appreciated their ability to send extremely complex cases to the Hospital for Sick Children in Toronto. They also said it was great quality and that it was a bargain, so when I got back I had a chat with David Martin at Sick Kids', who said he might consider raising his rates since they seem to think it's a bargain.

So there is some of that. There are some difficult issues in there and the issue has been raised with us by a number of hospitals. We've asked the Ontario Hospital Association to have a look at general policy in this area.

Obviously, in pursuing that opportunity our concern would be that we might create a two-tier situation where an Ontario resident might not be first in line for treatment. We felt the hospital association might be able to give us some assistance there, and I believe it is working on those policy issues.

On the second point, we do get an enormous number of visitors from other countries with very serious interests. We have almost weekly ministerial or senior-official level delegations. We are endeavouring now to marry them up with expertise in Ontario. RMC Resources Management Consultants is, I believe, engaged in about a $200-million assignment in Poland to assist that country in developing its health care system. In the nine months I've been in the ministry, we've had visits from at least a dozen countries. It does represent a significant business opportunity for consulting firms in Ontario to provide expertise.

We, as a ministry, provide as much information as we can as a public service because we're very proud of our system, but there is a business opportunity. Our health economics development group is very new -- we started it in January -- so it's still finding its feet. They have the view that there is significant potential for Ontario firms to assist globally. Many countries have great respect for Canada's health care system for what it has achieved.

Mr Frankford: If I can just add -- I think I mentioned it -- I would assume that what one could really do well in is selling health insurance. The people in Detroit or the people in Sault Ste Marie, Michigan, could well benefit from a plan which allows them accessibility to facilities over here. Of course that could bring in an incentive to keep them healthy, which I think is good policy in any case, but it also has the potential of not tying up our expensive procedural things but allowing them access to very basic things. I think of things like prenatal care, which is another disaster across the border.

We have tremendous opportunities overall. If one looks at places like Windsor or St Catharines, we are looking for movement from the manufacturing sector to the white-collar sector. I think there are tremendous job creation activities for the ordinary working folk, not just for consultants going to eastern Europe, who no doubt are competing with consultants from Harvard business school and elsewhere. I don't know if you want to comment.

I have another area I'd like to get into. The other area for revenue is around natives. I think I'm correct in saying that treaty Indians or status Indians are guaranteed payment for their care by the federal government.

Mr Decter: That is constitutionally the case. I think historically it has not always been the case that the government of Canada could be seen to have lived up to its obligations fully. There are a range of agreements and shared arrangements where the province has done things sometimes -- and I think it goes back to Minister Timbrell's day -- out of sheer frustration that the federal government was not willing to move. There were provincial investments in nursing stations in aboriginal communities and so on. It is a mixed field; I think that would be the most accurate description.

Mr Frankford: I think I'm correct, and I gather from your remarks, that it's a field where we probably could get more revenue if we knew how to go about it, and that we're actually entitled to it.

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Hon Ms Lankin: I think actually it becomes an issue of importance in the discussions between the aboriginal community, the first nations, and ourselves about the future delivery of health care services and our attempt to work with them to develop an aboriginal health strategy.

I think aboriginal communities would see it as a very negative step for the provincial government to attempt to receive moneys from the federal government for services that are currently being accessed. I believe they have a government-to-government relationship with the federal government in which they are and have been for many years attempting to fight this issue of adequate financing.

I think it would be seen to be a very negative step for the provincial government to step into that debate, and also for requesting compensation for services that are provided, but in general there have been tripartite discussions between the aboriginal communities, the Inuit and the Metis, some of the first nations and others who have sat down with the federal government and with representatives of provinces and territories to start to talk about the directions that need to be taken with respect to aboriginal health, and about how so many issues have fallen through the cracks between the federal constitutional responsibility and the provincial lack of resources to be able to expand delivery of services.

Mr Frankford: I assume this ties in with the overall constitutional discussions. Although the obligation is clearly there for status Indians, there are significant other populations whose status is not guaranteed at present, but the constitutional discussions could well include them.

Mr Decter: There has been an expansion of the status population due to federal legislative changes. It is the case in some parts of Ontario that the federal government pays directly for health facilities, a hospital, for example, and we actually pay money to them for non-aboriginal citizens who are treated in those hospitals. It's a bit of a two-way street. It is an area that has historically lacked much clarity and there's a real reluctance on the part of the federal government to bring much clarity to it.

I think it's also fair to say that provinces really, at the end of the day, other than presenting bills that won't be paid, have only the lever that I believe none of them would resort to, which is to deny treatment. That's certainly not something that's ever been countenanced here, so one is left trying to sort it out more on the upside, that is, what investments will be made by both governments to provide better services to those populations rather than, in a sense, fighting over who owes whom what for past services.

Mr Frankford: Do we pay for Anishnawbe and any other community health centres or do they?

Mr Decter: We do. There are some community health centres that are targetted to the aboriginal population. Those are paid for by the province, as are the other CHCs.

Mr Frankford: But could we not make a case that they should?

Mr Decter: I think one can make a very formidable intellectual case. It tends to get overwhelmed by the rather larger issues around health care finance between the two levels of government.

The Vice-Chair: Dr Frankford, Mr Lessard wanted to ask a question, and there is agreement that the minister will leave at 5:30.

Mr Lessard: Does that mean she'll be here for a few minutes to respond to my question?

Hon Ms Lankin: I will undertake to give you a very brief response.

Mr Lessard: Okay, great. My friend Dr Frankford has given such a good pitch for Windsor that I feel I really don't even have to follow up on that. I just wanted to express my interest as a representative from Windsor with respect to the prospects of increased revenue for hospitals in Windsor from US clientele.

One of the parts about sitting on the estimates committee that I really enjoy is having the opportunity to hear from various ministers their vision for the future in different areas. It gives us a rare opportunity to hear that, because I know, Madam Minister, that your time is so limited and your responsibilities so extensive that we rarely get this opportunity.

My layman's perspective of the historic growth in spending in health care over the years is that is has been the result of the view of previous governments that the more you spend on health care, the healthier people will be. We've found now that that's not really the case, and as a result we're kind of stuck with paying the bill.

I know we're going to have to undertake a lot of different changes in health care in the coming years and I know one area where we can make some changes is with respect to community health centres. I know we have one in Windsor as well, and I wonder if you can indicate whether you think this is something that we may see in the future: a trend towards greater expansion of community health centres in providing health care.

Hon Ms Lankin: I'll try and keep this answer very brief; it's something that maybe at a later time you will want to pursue.

In general terms, I think we have stressed the importance of developing a community health strategy for delivery of primary health care services. We believe that within that strategy -- and we're in the process of working with groups like community associations, community health centres, health service organizations and others to develop that framework right now -- community health centres will be an integral part of that.

I mentioned in my introductory comments that we've never done much evaluation very well in the health system in Ontario, or in Canada for that matter, and that extends not just to institutions and physician services but to our community-delivered services as well. We have an intellectual commitment to the shift to the community and there's a lot of research and data that suggest this will be good, but as we've experimented with some of these models in Ontario like community health centres and health service organizations, we haven't also put in place the evaluation mechanisms to determine what the delivery service outcomes are. So we're working with those constituencies to develop that kind of evaluation tool right now.

I don't believe that anything we find out from that evaluation would actually lead to a lesser commitment to enhancement of community health clinics; it might reshape ho they're organized and what services they deliver. We hope to be with the community developing, I guess, a commitment for growth over the next five years so that we have stable and continued growth. As you know, we have limited resources so it's not a period of large spending boom time in terms of new construction and new services. But we think it's important to keep a commitment of steady and predictable growth in this sector while we are trying to develop a vision for delivery of primary health care services that sees a greater mix of health care providers involved in that, that involves physicians as one of a team of health care providers who can in community settings deliver services that are paid for in a manner that lies outside of the fee-for-service system that we see under OHIP currently.

The Vice-Chair: Thank you, Minister, and thank you, members of the committee. We meet again next Tuesday following routine proceedings.

The committee adjourned at 1728.