L088 - Tue 14 Jan 1986 / Mar 14 jan 1986

HEALTH CARE ACCESSIBILITY ACT (CONTINUED)

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The House resumed at 8 p.m.

HEALTH CARE ACCESSIBILITY ACT (CONTINUED)

Resuming the debate on second reading of Bill 94, An Act regulating the Amounts that Persons may Charge for rendering Services that are Insured Services under the Health Insurance Act.

The Deputy Speaker: The member for Cochrane South.

Mr. Pope: Mr. Speaker, I am glad you are in the chair. I seem to have trouble with some of the others, including a gentleman who is walking along the back row now. I am also glad the member for Brampton (Mr. Callahan) is here tonight. He is always a happy participant in the debates in which I am involved.

I know the parliamentary assistant has kept copious notes on my remarks before the dinner break and the Minister of Health (Mr. Elston) has already been informed of them. I want to assure the minister my remarks have nothing to do with the name of the restaurant he dined in.

Hon. Mr. Nixon: He means the Golden Bull.

Hon. Mr. Elston: The appointment for which I was late after my other meeting.

The Deputy Speaker: Order.

Mr. Pope: We are debating the bill.

The Deputy Speaker: At this point when you have the floor, the minister has no place in debating the bill.

Mr. Pope: I take it back; I prefer your predecessor, Mr. Speaker.

The Deputy Speaker: Carry on.

Mr. Pope: I know the member for Scarborough-Ellesmere (Mr. Warner) was interrupted in his activities a few minutes ago, but I will try to summarize my concerns about this bill briefly.

Before the dinner break, I had read into the record a letter that Dr. Dale of West Hill had sent to all his patients and a letter he sent to the member for Durham-York (Mr. Stevenson) with respect to no longer providing obstetrical and gynaecological services to the Uxbridge Cottage Hospital. I mentioned the concerns of the member for Durham-York and some of the people of the Uxbridge area about that.

That was an example of some of the concerns people are feeling across the province, not about the provisions of the bill the minister has introduced, but about the atmosphere of controversy -- I will not say confrontation -- that surrounds this bill and what will happen in the Legislature over the next one or two days.

That will give members some indication of how long I am going to speak. I do not mean one or two days. The member for Windsor-Riverside (Mr. D. S. Cooke) is going to be on tonight. I can guarantee him that.

I want to indicate that there is some concern growing. To what extent it will grow I cannot say. I have some concern about my home community, which the minister addressed in his opening comments; but it is more than that. I want to reiterate in one sentence what I was trying to say before supper. I think it will take only one sentence. Everyone acknowledges, not that we have a perfect health care system, and that is the reason for some of the legislative changes, but that we have one of the best systems in North America.

Its foundations are historic and relate to the respect and the involvement of individual professionals as private practitioners, not public practitioners, and to an atmosphere of cooperation and consultation among the various people who deliver health care services to individual citizens of this province.

My viewpoint, and I think that of our party, is that whatever we do and whatever changes have to be made, we would be the first to admit that issues of accessibility and universality, as two of the five principles of the national health care system, have to be addressed by this government and the Legislature. While we are prepared to address and support moves to improve accessibility and universality, we think one has to move in the context of the existing professionals and their organizations in this province as they now exist.

I would be the first to admit it is a very difficult negotiation. I have had a little bit of experience in that but, somehow, we have to find a way to cut through the confrontation and the public relations battles and try to start solving some of these issues in direct negotiation.

How that can be done is a very difficult question but we have to start. Maybe it will be by a signal from the Premier (Mr. Peterson). Maybe he will give that signal tonight in Timmins when he meets with representatives of the Porcupine District Medical Society. It is hard to tell. I hope some of them are at the reception and get a chance to talk to him.

I believe there is a common feeling between this government and the members of the Legislature, as well as the professions of this province, that somehow we have to find a way to have universally accessible, affordable medical care available to every citizen of the province, no matter where he or she lives. How we do that together as a society, and not just in this Legislature, is something about which we are all concerned.

I put on the record very briefly some concerns that I have regarding negotiations. I read some notes from the Ontario Medical Association. We have had only one meeting with it on this matter, in early December. We do not have an ongoing liaison at all.

I have some concerns about the actual state of negotiations from the association's as well as from the government's perceptions. I have some concern about the overall state of relationships, not just with the Ministry of Health but also, because of some of the things the Attorney General (Mr. Scott) has been saying, between the government generally and the professionals of the province. It is not that they are the be-all and end-all, but some of these issues have to be solved through negotiation and accommodation.

Because we are unique in Ontario, we do not want the British medical system. We cannot have the medical systems other provinces have because we have world-class professionals at the Toronto General Hospital, the Hospital for Sick Children and other hospitals in communities across the province, including the University of Western Ontario Hospital in London. We have world-class physicians. I know when the minister gets into the negotiations, and maybe he already has, he intends to take account of that.

It is not the same. The Quebec model the Premier apparently favours --

Mr. Wildman: Is the member saying we do not have world-class doctors in Montreal?

Mr. Pope: If the member wants to listen for a second, he might learn something.

The Quebec model, which the Premier indicates he may be favouring, is not the answer in Ontario because not only does it have complete opting out or opting in, but encompasses it on a physician-by-physician basis as opposed to the individual recipient. Also, they have accompanied that with a ceiling on salaries. As a result, under the existing fee schedule, the very best professionals are encouraged to work six or seven months a year and take the rest off because they have exceeded their ceilings.

I know for a fact that some of the best specialists, the world-class specialists in Montreal, have opted to work six or seven months and not provide medical services for the rest of the year. I am not necessarily saying I agree with that conclusion or their decision, but that is the consequence of combining the Quebec system with a ceiling on total incomes for medical specialists.

Ms. E. J. Smith: We have not done that.

8:10 p.m.

Mr. Pope: I am not saying that. We do not have the Quebec system and we do not want it, not only because they are all opted in or opted out, but if we examine the Quebec system, we will find there is a similarity to what is happening now in Britain, which is getting a public medical practice system and a private medical practice system.

Ms. E. J. Smith: I do not buy that.

Mr. Pope: I do not care if the honourable member buys it or not, it is happening in Quebec. When the Premier of this province talks about the Quebec model, what I am trying to tell him is that the Quebec model includes ceilings. That was part of the negotiated or imposed settlement. It is not a rational way to handle world-class medical specialists in this province. It is not the answer; there has to be another answer. I do not opt for the Quebec system in its entirety.

If we want to sever off differ parts of that system, that is another issue. I do not necessarily buy the Nova Scotia system. I know the Minister of Health has heard from some practitioners in this province and from the Maritimes with respect to their problems with the Nova Scotia system.

Ontario is unique. That is what sets it apart from Saskatchewan and Manitoba, and even from the Maritimes. It is unique not only in Canada but also worldwide. The medical specialists we have in this province are very special and play a role beyond their boundaries. Whenever the negotiations start with this minister and the OMA, and specialty groups as well outside of those negotiations, I hope these kinds of things are rolled into the discussions.

Hon. Mr. Elston: Realizing that the specialty groups may not agree with the association.

Mr. Pope: Oh, always; and realizing as well that some specialty group representatives are part of the OMA negotiating team and they are often caught in the conflict between the position they are adopting on behalf of the OMA and the position their fellow specialists may be taking with respect to certain selected fee items. I know of the difficulties of those discussions.

I know the minister has had some discussions with individual practitioners in the province. I feel the public discussion of extra billing should not have necessarily taken place through the health councils. He has heard of the reaction of the health councils towards that kind of a political issue being discussed at open forums sponsored by health councils. He has heard that from the providers who are members of the health councils as opposed to the --

Interjection.

Mr. Pope: I do not think it is causing difficulty, but I heard it and I think the minister did as well.

Mr. McClellan: Why did Brian Mulroney support extra billing?

Mr. Pope: The honourable member probably had this discussion --

Mr. Callahan: That is Ottawa.

Mr. McClellan: I would really like a response to that.

Mr. Pope: The member for Brampton and the member for Bellwoods (Mr. McClellan) are urging me to deal with the federal Canada Health Act. I will be quite happy to do that. I am very glad the members for Brampton and for Bellwoods are here tonight because I would like to get into some detail.

Mr. McClellan: We are always here.

Mr. Pope: Not everyone rejoices in that fact, I might add.

Mr. McClellan: Including me.

Mr. Pope: But it is part of their obligation. They have to be here.

I would like to get into some of the history of the Canada Health Act, but the minister may want me to move on.

Mr. D. S. Cooke: Is the member voting for it?

Mr. Pope: The honourable member will have to wait with bated breath. Will he please hold his breath until the vote?

Mr. McClellan: That is because he does not know yet. The Tories do not know how they are voting on any bill on the Orders and Notices. Do you know that, Mr. Speaker?

Mr. Pope: There is the fount of all knowledge not only about his own party and the government of this province, but also about the Conservative caucus.

Mr. McClellan: I am just repeating what the member's House leader told us.

Mr. Pope: Oh, I see.

We all understand the history of the Canada Health Act, the history of the deal in 1968. The minister and the member have probably heard about it. The member has probably heard about it from the doctors of this province, the Ontario Medical Association --

Mr. McClellan: The member means Mulroney.

Mr. Pope: I will bet he has not talked to the OMA about this. He is laughing; I know he has not. He does not want to inform himself.

Interjection.

Mr. Pope: The member for Brampton wants to interrupt again. Perhaps he has the same attitude towards the doctors of this province as he has about the pharmacists. He said they sold only peanuts and chocolates in their stores, as I recall the discussion on Bills 54 and 55.

The members are aware of the provisions of the Canada Health Act and of the requirement for the withholding of funds from transfer payments to the provincial government to the extent of extra billed dollars. I assume that this minister, and maybe the other members of the third party and the government, have informed themselves of the negotiations between Ontario and the federal government during the past year and a half in an attempt to resolve this impasse and at the same time address the issue --

Ms. E. J. Smith: Is the member saying the federal government may back down on its position?

Mr. Pope: The member should talk to the minister. This is a very important issue for the doctors of her community. For her to sit back there and pose questions when a simple discussion with the minister would have informed her about the background of this issue I find incomprehensible. It means that her party and her caucus have not had a full discussion of this bill. If they had, she would have known there had been a number of meetings, both in federal and provincial conferences and bilaterally between Ontario and the federal government, on this issue. Dr. Heseltine could fill her in on all of this.

Ms. E. J. Smith: I know it well.

Mr. Pope: The member should inform herself on the background of this issue. She really should and she will find that, recognizing the provisions of the Canada Health Act, there are ongoing attempts by her minister to resolve this issue in a way that will accommodate the medical profession of this province and satisfy the requirements of the Canada Health Act.

The member will know that universal accessibility relates to certain defined specialties in certain regions of the province. She will know that a number of doctors who are extra billing, including some in her community, do not get the money in their own pockets. Instead, that extra billed money goes to cover operating costs for institutions and for medical research. I presume that when the member discusses this in cabinet she puts some of that on the record, and she would not have the minister standing there saying the doctors are lining their pockets from extra billed dollars when she knows it is not true.

Ms. E. J. Smith: He does it voluntarily.

The Deputy Speaker: Order.

Mr. Pope: Any discussion with Dr. Heseltine would have told the member that.

I am trying to proceed quickly.

The Deputy Speaker: Perhaps you could speak through the chair and maybe that would cut down on the interjections.

Mr. Callahan: Be careful. He will say things about you, Mr. Speaker, and you will not be able to speak back.

Mr. Pope: I already have. I have already said I prefer my colleague from across the House after that first ruling.

I have talked about the concerns of doctors in different parts of the province and about how they are communicating with their patients and with the Premier and the Minister of Health. For instance, Dr. Brennan of the Kingston General Hospital division of cardiology wrote to the Premier on January 13, 1986, indicating his concerns as a professional carrying on business in Kingston. I will quote just one paragraph and then I will move on, because I know the Speaker does not like extensive quotes.

"In 10 years that I have been in practice in Ontario, following six years of medical school and eight years of post-graduate training, I have attempted to furnish to as many patients as I could handle the best medical care I was able to provide. Accessibility of patients to me by appointment has been limited only by constraints of time. It is possible to deal adequately with only a limited number of patients in a given period of time. Accessibility to me in a medically urgent situation when I have been on call has been absolutely unrestricted, an average of 100 hours per week, 52 weeks per year.

"No patient has ever complained that I have been unavailable when needed or that I was too highly paid for my services. Indeed, not only have I always accepted the OHIP rate for my services as payment in full, but also the terms of my appointment in the faculty of medicine, Queen's University, including a provision whereby all my professional income above a negotiated ceiling goes to the university."

I know the member for London South (Mr. E. J. Smith) has the same experience from the doctors whom she knows connected with the University Hospital.

"I am aware, of course, that the vast majority of my patients have no idea what I have been paid for looking after them, but I cannot recall one who asked. I infer, therefore, that in terms of accessibility and fees charged, my patients have been satisfied with the service I have provided.

8:20 p.m.

"You and your government state, however, that there is widespread dissatisfaction among the people of Ontario over the way in which doctors are paid and that excessive fees are hindering access to good medical care. If my patients truly support your position, then I feel betrayed and emotionally unrewarded for the services I have rendered.

"In my practice, I attempt to establish a doctor-patient relationship based on mutual trust and confidence. If I am to believe that you are carrying out the wishes of my patients in order to remedy a fault in my practice about which no patient has complained to me, then obviously I have lost that trust and confidence. Without it, my only rewards for looking after a sick patient are the fee I receive and the intellectual satisfaction of solving a medical problem, i.e., of treating a disease rather than a patient. This is not the climate in which I wish to practise medicine. I cannot believe that this is the climate in which the people of Ontario wish medicine to be practised."

He goes on to indicate he is not a political activist and the letter represents his first attempt to exert any direct influence on those who make the laws at any level of government.

"My financial interest in the proposed legislation is much less than that of an average Ontario doctor, as noted above. I am otherwise just an average medical practitioner striving to maintain a high standard of practice against increasingly formidable odds, and an average citizen of Ontario who is appalled that a small group of citizens whose value to society is acknowledged to be high is in danger of having his economic freedom forcibly removed for the good of society. A society which will tolerate this is not a good society and does not deserve to be free." It is signed by Dr. Brennan.

Ms. E. J. Smith: Are you forgetting the first-class hospitals we give them, equipped with the finest laboratories, which are far superior to those in American hospitals? If doctors were aware of this, they would not leave this province.

Mr. Pope: I know the member for London South believes that this practitioner or cardiologist is uninformed and does not understand the issues. I know she believes that the doctors in Timmins are uninformed, even though none is extra billing and all were opted in. I know she believes that William N. Dale, an obstetrics and gynaecology specialist, is uninformed.

The fact is that doctor after doctor across this province believes there is unnecessary confrontation and a misrepresentation of their professionalism to the people of Ontario. That is their feeling and it is the responsibility of this government. It has to answer for the same kind of attitude in the negotiation and discussion exhibited with respect to the pharmacists of the province.

We are talking about the general quality of health care in Ontario, about one of the best health care systems in North America that was built on the contributions of individual professionals, be they doctors, pharmacists or anyone else in the health care system. We are talking about them being the key element in delivering the high quality of health care in this province. They do not feel this government is talking to them. They feel this government has misrepresented the issue of their professionalism and that it does not care to discuss the issues with them.

The government can complain all it wants that these doctors do not understand, in the same way they complained the pharmacists do not understand. They can expand their attacks on the professionals of the province to include whomever they wish, but we believe the fundamental issue for this Legislature to address is the quality of the health care system. It is a quality based on the professionals, on the doctors and pharmacists. If the government wants to throw that quality away to score political points, it is on its head. We stand for the patients who want a continuation of high-quality health care.

Hon. Mr. Riddell: Let the doctors pay for their education and their hospitals. Let them collect their fees.

Mr. Pope: That is as good a statement from the member for Huron-Middlesex (Mr. Riddell) as the statement he made to the member for Durham York yesterday. It is just about as relevant to the discussion in this Legislature as his statement yesterday about the absence of the member for Durham York.

Mr. Wildman: Jake Epp is the Che Guevara of Canadian politics. Did not the member for York Mills (Miss Stephenson) call him a terrorist?

Mr. Pope: I love it when the members of the third party exhibit such a confrontational attitude and such a lack of understanding of the role of the doctors in the province. I am just surprised that the Liberal Party of Ontario has opted to go along with that kind of mentality. We have one of the best health care systems in North America. The Liberals are going to throw it away because they are following the third party's dictate.

They have to work with the professionals of this province to improve the quality of health care and universal accessibility. That is not done by confrontation. Yes, we are concerned about improving accessibility. We know the specialties and the locations. We want to see a resolution of the accessibility issue. We want health care to be universal, accessible and affordable. The issue is resolved through negotiation with a specialist group and the Ontario Medical Association.

This crew wants to dictate professional life and health care in this province. No one else has a role to play except these ideologues. The government has fallen into bed with them and its members should be ashamed of themselves.

Interjections.

Mr. Pope: The problem with the member for Ottawa Centre (Ms. Gigantes) is that she does not know when she has lost.

Ms. E. J. Smith: I am interested you are not opposed to the principle.

Mr. Pope: I never said I was.

Interjections.

Mr. Pope: I am saying there is needless confrontation, for which the government is responsible, that can affect the quality of health care in this province. If the member for London South does not think it is important, she should go up to Timmins tonight with her leader and talk to the community. She does not have enough guts to go up there.

Ms. E. J. Smith: I know some doctors in Timmins pretty well.

Mr. Pope: So do I. They happened to run for her party. They were campaign managers and fund-raisers and they all voted to opt out because they are tired of this government that talked to them before it was in power and will not talk to them afterwards. Go up and talk to those great supporters and see what they think now about the great Liberal Party that listened to them.

Talk to Graeme Cunningham, whom her leader quoted during the last election campaign. Talk to John Sullivan, who was the Liberal candidate in 1981. Talk to Peter Richardson, his campaign manager. Talk to the chief of staff of St. Mary's General Hospital, who was his fund-raiser. Ask them what they think now of the Liberal Party of Ontario, which will not listen and talk to them, and then tell me her party has done a good job of resolving the health care issues of this province. What a bunch of hypocrisy.

Hon. Mr. Elston: That is the wrong word.

Mr. Pope: Is it? I will withdraw the word if it is wrong.

Hon. Mr. Riddell: I like the member better when he is steamed up.

Mr. Pope: Is that so? Keep talking.

Hon. Mr. Riddell: I am going to sit in the House if he is going to carry on like that.

Mr. Pope: It is better than sand castle day in Grand Bend, is it not?

Hon. Mr. Riddell: It is really getting interesting.

Mr. Pope: I saw him in a parade in Grand Bend on sand castle day.

Mr. Warner: Is this your windup?

Mr. Pope: It was going to be, but I guess I can go on for a while if the member would like. I was just getting to the Magna Charta.

The issue we see as a party is that we have a high quality health care system but it can be improved. We are anxious to participate in discussion with everyone involved in the health care system to improve it. We want to make sure we have universal accessibility. We want a national health care plan and one in this province that meets the goals we all share. We think it can be done with respect for, and communication and negotiation with, all of the professionals who are involved in delivering it.

We think this government, unfortunately, for whatever reason, has opted to pursue its own agenda without consultation, without negotiation. It has proved it beyond a doubt on Bills 54 and 55.

Ms. E. J. Smith: How did the member vote on that?

Mr. Pope: The member had better go back and read Hansard. I know she understands everything about these issues.

The Liberals talked to the pharmacists on November 7, an hour before they introduced the bill. I know the members opposite understand all that, as well as the state of negotiations with the Ontario Medical Association. They understand what is now going to happen with the optometrists of this province. They understand the concerns of the Ontario Dental Association about the dental care plan and how they are all going to be opted in and not allowed to extra-bill. I know they understand the concerns of the chiropractors and nurses of this province. I know the members opposite understand the concerns of all these professionals who have given us this high-quality health care program, but based on what we have seen to date, they do not give a whit about those concerns. They are going to move ahead with their own agenda and their own ideas. There will not be any negotiations. They are putting in jeopardy one of the best health care systems in North America.

8:30 p.m.

Mr. Callahan: We can blame 42 years of --

Mr. Pope: After 42 years we had one of the best health care systems in North America and everyone knows it, so the member for Brampton need not give me that nonsense.

We are all ready to work to improve it, but it should be done through co-operation and negotiation, not confrontation. There are not going to be any negotiations. Section 3 of the bill says there will be discussion about a mechanism for negotiation. There are no negotiations going on now about fee schedules or with specialty groups. The minister has not even agreed on a mechanism to negotiate, so how can he be negotiating?

Is he going to renegotiate the Ontario health insurance plan rate with respect to the $80 million? Is he going to remove the problems of the specialty groups with respect to specific fee items in the OHIP schedule in the hope of ending the accessibility problem using that? Is he going to undertake all the steps he can take as Minister of Health to break the impasse, at least to get into fee negotiation to show he is willing to take the first step on that issue before the legislation is passed, as a sign of good faith that he is willing to negotiate and talk to the Ontario Medical Association and the other specialty groups?

I did not hear that from the minister today in question period. I heard him say he would look at mechanisms for negotiation. I know he says I misinterpreted his remarks, but I read section 3 of the bill and I understand what it says. It does not say there will be negotiation but that he is going to discuss a mechanism for negotiation.

With respect to specialty groups, there has to be direct negotiation on individual fee items. That may put specialty groups at odds with the OMA and it may cause division, but some of these issues have to be addressed in that context.

I hope the minister will consider my remarks in the spirit they were meant. None of us has anything to gain from confrontation. We will not support or condone any actions that affect patients in this province. We want to see high-quality health care continue and we want the doctors involved in it.

Mr. Wildman: Will the member vote against the bill?

Mr. Pope: The member for Algoma is still hung up on a tree nursery. Why does he not go back and study his notes on that?

We want to see negotiation with the doctors to end this impasse. We want to protect the doctor-patient relationship, as well as the accessibility and quality of health care for each and every Ontarian. The basis of that has to be the ongoing private, not public, relationship between the doctor and the patient. That is the foundation of the medical care system and always will be, no matter how the members opposite try to deny it, undermine it or ignore it.

That is the foundation of health care in this province and always will be. That is what we want to see continue. We do not want to see it deteriorate. We do not want to see world-class doctors working six months a year because of ceilings; we do not want to see confrontation; we do not want to see doctors who have always opted in and never extra-billed now deciding to pull out of the system. We do not want to see that and I know the Minister of Health does not want to see it either.

The governing party and its coalition partners have to spend more time with the professionals of this province trying to address these issues and resolve them before legislation comes in. That is the main point I want to make. Before the minister introduces the legislation, he should get into the detailed negotiation.

No matter how tough it is or how much he is turned off by the OMA or any other group, he should keep at it. He should get into the issues he can agree on and keep the doors open and get going on some of the other issues that we in this Legislature all have a common interest in resolving.

There are a lot of other issues I could talk about, the specific provisions of the Canada Health Act and the dollars being withheld --

Mr. Polsinelli: We want to hear about that.

Mr. Pope: The Minister of Labour (Mr. Wrye) would like me to go on talking. I could talk about a number of negotiations and discussions --

Hon. Mr. Elston: That was not the Minister of Labour.

Mr. Pope: It was not the minister? Sorry.

Mr. Polsinelli: Tell us how the federal Tories voted on the Canada Health Act.

Mr. Pope: Okay. In fact, I have more notes and I can go on at some length.

Hon. Mr. Elston: No, we will accept it as read.

Mr. Pope: He wants me to describe it.

Hon. Mr. Elston: Just tell us what page it is on.

Mr. Pope: It is 4(a) in his briefing notes, and it is in some detail. It goes right back to 1967 and 1968.

Hon. Mr. Bradley: Did the member get a photocopy of the briefing book?

Mr. Pope: No, it is my personal property.

Mr. Polsinelli: It did not go to the shredder?

Mr. Pope: No, nothing from any ministry I was involved in went to the shredder. I will put $20 on it.

The Deputy Speaker: Order.

Mr. Pope: That party made a great thing about the Attorney General of the day ordering 40 shredders, and all 40 of them were for provincial courts under the Young Offenders Act. It was a great political gimmick while it lasted, but it was untrue, like a number of other things that are being said.

We do have some concerns that we are going to be sharing in full about the state of the relationship of this government with the professionals who are providing health care. We have some concerns about accessibility and universality as well as about the other three elements of the national health care system, which everyone has agreed are necessary. We are going to be talking during the course of this debate about accessibility and universality, about the limits of access to specialty groups and about how we think this might be resolved.

I do hope that during the course of debate on this bill the minister will seek an opportunity, wherever it may be, to meet with the Ontario Medical Association and its negotiators now that second reading is being undertaken, to talk about the principles of the bill and to seek some dialogue with the OMA, which has not happened as yet. I did read into the record before supper some of the OMA's comments in the one meeting we have had with it, its comments on the negotiations and how they are at variance with the government's.

Our party is anxious that the quality of the health care system and the goal of universal accessibility be maintained, and that somehow this confrontation, which could affect the quality of health care in the province -- not that it has but it could -- be resolved by the minister and the government. If he can do the latter he will have the support of all the members of this Legislature. I would urge him to spend time in doing it. It would be worth a lot more to him and to the people of this province than all the briefings he gets every morning from his staff in the Ministry of Health.

Hon. Mr. Elston: Not every morning.

Mr. Pope: It is not every morning any more? I do think it is urgent, not just from my own riding's point of view but also from what we are hearing across the province, that we spend time doing this during second reading of the bill.

My colleagues will be talking about their own individual problems and concerns in their own areas of the province. I can tell members that I am losing specialists in my riding. We are losing specialists in northeastern Ontario, not just Dr. Covington but many others who have been travelling recently to different states in the United States to negotiate new financial arrangements because of their concerns about what is going to happen.

Hon. Mr. Elston: It is not just money in their pockets; I hope the member will tell me that.

Mr. Pope: The minister will have to discuss that with the doctors who are leaving, and I hope he does.

Hon. Mr. Elston: There are some historical problems we have to fix.

Mr. Pope: Yes, there is a historical problem and there are a number of reasons for the history of that problem. However, we do feel that if there is not some resolution or some amenability of this government towards the professionals who are delivering health care, then in some parts of Ontario, and specifically in northern Ontario, the impact will be felt first.

The minister will not see a rapid deterioration, if any at all, in the urban centres he addressed in his opening statement on December 19 as the accessibility issue. He will see a decline in accessibility in other regions of the province because the professionals and the specialists will not be there. That is my feeling unless we can turn around the attitude of confrontation we have.

With those remarks, I know that my friend the member for Windsor-Riverside wants to carry on the debate.

8:40 p.m.

Mr. D. S. Cooke: The remarks of the member for Cochrane South sound like a replay to me. We just went through the whole thing with the drug bills. He spoke for two and half or three and a half hours and never said during that time how he was going to vote on Bill 54. He has not said during the past hour or hour and a half in which he spoke how he is going to vote on this bill; he may end up coming down on the side of his conscience and support this bill.

I cannot imagine that the member for York Mills, otherwise known in Ontario as Bette "Opt Out" Stephenson, can possibly bring herself to vote for this bill after the words she used the day the bill was introduced.

After listening to the Conservative Health critic on this very important bill, I get the impression his solution is that we will end extra billing and bribe the doctors with the $50 million we save so as to avoid some kind of confrontation. I strongly believe that the deal the former Minister of Health, the member for St. Andrew-St. Patrick (Mr. Grossman), now his leader, worked out should be adhered to for the rest of the agreement and that we should not use the $50 million to bribe the doctors to comply with this bill.

We should follow the agreement that was signed, under the leadership of the Progressive Conservative Party, between the Minister of Health representing the government of Ontario and the Ontario Medical Association. That agreement should be lived out for the remainder of the two years. It was completely separate from the issue of extra billing. The Conservatives signed an agreement they apparently felt was a fair fee schedule, and that fair fee schedule should be adhered to by this Legislature. At the end of the two years, we can talk with the OMA about the fee schedule.

As Health critic for the New Democratic Party, I am extremely proud to be here tonight to speak in favour of a bill on which our party stood alone for 15 years in supporting the ending of extra billing. In 1970, my party passed a convention resolution that reads as follows:

"Be it further resolved that a New Democratic Party government will:

"1. Establish a machinery for the determination of fee schedules for physicians and other professional personnel, leading to the elimination of unilateral price determination by professional associations and of extra billing of patients.

"2. Take steps to effect a more rational distribution of health personnel and facilities to make health care services more readily available to underdoctored and otherwise disadvantaged areas.

"3. Encourage financially and otherwise the development of community health centres in which consumers and physicians working in a group practice environment may establish a mutually satisfactory arrangement for the provision of health services.

"4. Otherwise explore ways and means for a more efficient, just and economical system of the organization and delivery of health services."

It was 15 years ago that my party went on record with that policy. Today we are seeing the first major step towards the implementation of that policy. We as New Democrats can take pride in and credit for this piece of legislation.

Throughout the 1970s, it was this caucus that raised cases in the Legislature as examples of individuals who had been hurt by lack of action by a government that was too tired to act on behalf of consumers, patients and doctors in this province. We acted and raised cases of individuals who were being hurt by a policy, by a party and by a government that was committed to support of the Ontario Medical Association, but sure as heck was not committed to support the health care consumers of this province.

It was the New Democratic Party that in 1979 introduced the largest petition ever circulated in Ontario and presented in the Ontario Legislature, with the signatures of more than 250,000 people opposed to extra billing in this province. Today, it is very clear from polls that have been done and by talking to our own constituents that there is a consensus in Ontario and that consensus is overwhelmingly in favour of making extra billing illegal.

This party feels, and always has felt, that health insurance is a mechanism to equalize accessibility to the health care system but that equal access could never be achieved until extra billing was outlawed. We now take one step forward, a major step forward, to equal accessibility to our health care system.

Doctors in this province have said they believe in accessibility, as the Health critic for the Conservative Party has said, but I would like the Ontario Medical Association and the Conservative Party to explain to me how we can have equal accessibility as long as extra billing is legal in this province.

What about the history over the past 15 years of the Progressive Conservatives and, for that matter, the Liberal Party? What has been their position?

Until very recently, the position of the Premier, formerly the Leader of the Opposition, was that extra billing was a necessity; it was a release valve or safety valve for the medical profession. It was only leading up to the last election that he changed his mind. I suggest he changed his mind because a consensus had been reached in this province. He saw the writing on the wall and decided it was important for political reasons to take that position.

The Leader of the Opposition (Mr. Grossman), a former Treasurer and a former Health minister, said extra billing was not a problem in our province; the only people who were extra billed in Ontario were the wealthy. That is what the member for St. Andrew-St. Patrick said in the past.

The position of the Conservative Party implied that individuals who could afford to pay would pay extra bills. If they could not afford to pay, the solution for the patients in this province was to go to the doctors and spill their financial woes. Then the doctor might administer his or her own means test -- whatever the criteria may be -- and they could get services at the OHIP rate. Again, it would be completely up to the doctor.

We in the New Democratic Party, on the contrary, believe the relationship between a doctor and a patient should not be interfered with by finances. The only way that can be done is by the elimination of extra billing. The doctors in this province, the Conservatives and, until recently, the Liberals have said the relationship between doctor and patient could develop more readily if extra billing were allowed. That is the position the independent physicians have taken. I do not understand the rationale of that. I do not understand how the relationship is enhanced by having to pay direct and by having to pay extra to a doctor.

Financial consideration should play absolutely no role at all when a person is concerned about his or her health care. Again, the only way that can be dealt with is if extra billing is eliminated. The Liberals in the past, the Conservatives and the OMA have said extra billing is a minor annoyance; there are only a few doctors in the province who extra bill. Our party has said consistently that if one person is deterred from using the health care system because of financial considerations, then there is something wrong with the system and the system has to change to accommodate that individual.

The startling fact is that, under the present system, $1 million a week extra was charged to patients in Ontario under the Conservative regime and under the Liberal regime until now. At the same time, the federal government held back that $50 million a year. In effect, the people of this province paid $100 million a year because of extra billing.

These are millions of dollars that individuals will never get back. The government will be able to collect its money that has been withheld under the Canada Health Act, but the individuals who have been extra billed because of inaction by the Conservative government in the past will never be able to reclaim their money. That was never supposed to be the case under the Canada Health Act, which was supported by all three political parties at the federal level.

8:50 p.m.

Let us look at some of the examples of what extra billing and opting out has meant in Ontario. I do not have the absolute up-to-date statistics, but the last statistics I was able to find in my extra billing file indicate the following are opted out in Ontario: ophthalmologists, 36.6 per cent; obstetricians and gynaecologists, 28 per cent; urologists, 25 per cent; orthopaedic surgeons, nearly 20 per cent; anaesthetists, 19 per cent -- and in many cities in this province, 100 per cent of the anaesthetists have opted out, as was the case in London and in many of the teaching hospital areas -- plastic surgeons, 16 per cent; and psychiatrists, 16 per cent.

Those are the statistics that indicate the real problem. The problem is not with the family doctor or the general practitioner opting out. The problem has been with the specialists opting out, which has caused real problems, especially in certain pockets of the province.

I can give the minister some other examples. In the city of Toronto, from the last statistics I have available, 169 of 191 anaesthetists were opted out; in the city of York, seven of the eight were opted out; and in the city of North York, 25 of 29 were opted out.

Obstetricians and gynaecologists: In York, all were opted out; in the city of Scarborough, 13 of 18 were opted out; in North York, 19 of 26 were opted out; in Toronto, 88 of 143 were opted out.

Psychiatrists: 136 of 354 in Toronto were opted out, and in North York, nine of 34 were opted out.

Other specialties: For ophthalmologists, 76 of 128 were opted out.

That gives an idea of how many are opted out in certain specialties. There is a problem with accessibility to certain specialties in pockets of this province. Those doctors did not say to their patients, "Can you afford to pay me a little extra?" They did not say, "Can you afford to pay me 50 per cent extra?" as was the case in some of the examples raised in the Legislature. Those individuals had to come up with the money or go without the services, without food or without whatever the case was. They had to squeeze their budgets to pay for health care.

In the 1960s, when we brought in health insurance in this province, and in the 1940s, when Tommy Douglas started it out west, the purpose of health insurance was to take away that disadvantage for low-income people. The Conservatives allowed that to erode year after year because their friends were in the doctors' offices; their friends were the doctors of this province. The doctors were the ones who donated thousands of dollars to the Conservative Party. They were the allies they were willing to defend.

We in this party have felt that the principle of accessibility, the principle of health insurance and medicare, which Tommy Douglas started, was worth defending. That is why this bill tonight is so important.

On March 23, 1984, the Treasurer, now the Leader of the Opposition, stated:

"The honourable member would presume that the doctors are extra billing the people less well off in society. I know many of those doctors and I know many of the patients, and I say that in the vast majority of cases they are extra billing the better-off in society."

It goes back to what I was saying. The Leader of the Opposition, then the Treasurer, was under the illusion that the only people being extra billed in this province were the wealthy. All of us had many cases of individuals who would call us and say they were being extra billed and tell us about their concern. The Leader of the Opposition's solution was: "Call the OMA hotline. They will solve the problem." Ninety-nine per cent of the people of this province have never heard of the OMA hotline, let alone been able to call it.

The then Treasurer presumed it was the right of the medical profession in this province to be able to have a means test of its own and determine who could and who could not afford to pay extra. That did not always work. Many of our senior citizens and many of our low-income families did not want to pour out their financial woes to doctors. They should not have to do that, nor should any politician have expected they would want or would have to do that.

I want to go through some cases. One of the things we did as a party was place ads in the paper a couple of years ago. We suggested to people it would be helpful if we knew their individual experiences with extra billing. Many of those cases were raised in the Legislature. The acting Minister of Health at the time, Mr. Wells, indicated the OMA would deal with every one of those cases on an individual basis. To my knowledge, of those cases that were raised in the Legislature, not one of them was ever dealt with satisfactorily by the OMA.

One example is a letter that was written by a Dr. Greenaway, who is located in Amherstburg, near my home community. The letter is entitled "An Open Letter to All Patients." It goes back in history. I bet this letter was written just a couple of years ago. It says:

"Since July 1, 1975, Dr. J. R. Greenaway bills all patients directly for the services rendered and he does not accept payment directly from OHIP. He has taken this step for the following reasons:

"(a) Direct patient billing reminds you and us that we are working for you and not for the government."

I have no idea what OHIP has to do with whether one is working for the government or for the people of this province. OHIP is simply health insurance, and obviously, just as if it were in the private sector, health insurance is something we purchase to protect ourselves in case we have a health problem; so (a) does not make any sense at all.

"(b) Direct billing allows us to meet rapidly rising costs of practice and to maintain a wide range of high-quality services to you."

All this means to me is that extra billing means one is going to pay more and that the doctor wants more income. Therefore, his rising costs simply mean he is going to get every cent he can get out of his patients. This is the same doctor --

Mr. Villeneuve: The member does not believe in rising costs? Unbelievable.

Mr. D. S. Cooke: Has the member for Stormont, Dundas and Glengarry read the agreement that was signed by OHIP, the OMA and the previous Minister of Health, the member for St. Andrew-St. Patrick, whereby the average take-home pay for doctors in this province is $120,000? I do not know about the honourable member, but he used to think people could live on a minimum wage of $4 or less per hour. Doctors sure as hell can live on $120,000 a year.

That is a pretty fair income that was negotiated by that party's Minister of Health during its reign as the government. If the member is saying the OHIP fee schedule is unfair, the only person he has to blame is his leader, who negotiated that OHIP fee schedule.

Interjections.

The Acting Speaker (Mr. Morin): Order.

Mr. D. S. Cooke: This letter goes on to say --

Interjections.

The Acting Speaker: Order. Address the chair.

Mr. D. S. Cooke: I suggest that the member for High Park-Swansea (Mr. Shymko) look under his desk or something. He is always thinking there are conspiracies. He might want to check underneath his desk to see if there are any commies or anything else he has referred to.

Mr. Shymko: Stop that nonsense.

Mr. D. S. Cooke: This letter goes on to say: "Certain other services, such as house calls, night office visits and Sunday visits, will cost you more than the OMA schedule. You will be informed of these charges prior to receiving your services. Payment at the time a service is rendered unless other arrangements are made with business office. A service charge of 1.5 per cent per month will be charged on overdue accounts.

"We are willing to reduce our fees in certain circumstances for welfare recipients, pensioners with no other income and patients truly unable to pay the difference. Please discuss this with the doctor at the time of your visit."

That is the means test clause, where this doctor determines whether one can afford to pay extra. I ask the member for Stormont, Dundas and Glengarry and the member for High Park-Swansea whether this is the kind of relationship between a doctor and a patient that they defend back in their home ridings, the kind of position the OMA has taken in the past.

9 p.m.

I will give another example; it involves an individual who lived in the town of Tecumseh and had orthopaedic surgery to correct a foot problem. This individual was laid off at Chrysler Canada in 1983. He had been paying some debts over an extended period, and he had this surgery done. The total bill was $653; OHIP paid $504. The individual had to pay $149.18 out of his own pocket. This person was on unemployment insurance. There is no mention here that the doctor was so concerned that the charges would be dropped. This individual had to pay. There is an example that was raised in the Legislature, the name of the family was given and the OMA was totally unable to deal with that case.

Here is the case of an individual in Guelph who had to go see a urologist. He was on a fixed pension. The total cost for all the visits and surgery was $1,482.10. OHIP paid $1,042.77; the individual had to pay the difference of $439.33. It so happens that in Wellington county, where Guelph is located, all the urologists -- there are two of them -- were opted out at the time. The only option this individual had -- both he and his wife were retirees -- was to come all the way to Toronto for the services.

I ask the member for Stormont, Dundas and Glengarry and the member for High Park-Swansea where the accessibility is for these individuals. There was $150 extra. All the urologists were opted out. This case was raised in the Legislature. That person still had to pay the $440. The government was unable to deal with the case, as was the OMA.

Here is a letter that was sent out by a group of orthopaedic surgeons to patients:

"To our patients:

"Since October 1, 1978, the doctors in our practice have dealt directly with our patients and have been billing them directly for all medical and surgical services rendered in this office, at the hospital, at the hospital clinics and in the emergency room.

"Payment for all professional services rendered by the doctors in this office is the responsibility of the patient and his or her family if it is a minor. Fees for all office visits are to be paid at the time the service is rendered. Fees for all clinic visits and emergency room visits are due and payable upon receipt of our statement.

"Surgical procedures: Before all elective surgery procedures, your doctor will inform you of the total cost and the amount of the approximate benefits to be paid directly to you by OHIP."

Members of the Conservative Party might remember that the only way we could get doctors in this province who were extra billing even to tell their patients ahead of time was to change the Health Disciplines Act to make it a matter of professional misconduct. Then the doctors followed the law.

"Total payment for surgical services is payable at the first post-operative visit. In turn, an insurance card will be promptly filled out and sent on the patient's behalf to OHIP. The fee schedule in this office is above the OHIP benefits, which are paid directly to the patient by OHIP. Surgical fees will be discussed with the patient."

The letter goes on, basically in line with the Health Disciplines Act, to give some examples of what their charges are. For example, for a consultation -- just to visit the office -- the doctor's fee is $50, while OHIP's benefit is $35. For a specific assessment, the charge is $35; OHIP pays $25.

In my home community, virtually all the orthopaedic surgeons are opted out. This is the norm. This is the major clinic in my community. If individuals need to see an orthopaedic surgeon, they either pay these extra fees or they travel to London or Detroit, both of which would cost a substantial amount of money, either in travel fees to London or because they are on a completely different system in the United States.

I want to use this example. On June 7, 1985, an individual received a letter from a Dr. J. H. Moran, managing partner of Don Valley Anaesthetists. The letter, in part, stated the following:

"It is also apparent that you are misinformed, as there is only one schedule for medical services in Ontario and it is that published by the Ontario Medical Association. OHIP publishes a list of benefits payable under the health insurance plan. Under the circumstances," this individual "had the option of requesting the services of a physician who was willing to discount his fees or reschedule his services."

In other words, this doctor is saying: "My schedule is the OMA fee schedule, minimum. If you want to get something at the OHIP rate, then you have to come to me and beg for it. I might give it to you at the OHIP fee schedule or I might refer to you another doctor." Talk about arrogance. This is the most arrogant letter I came to on going through the entire OHIP extra billing file we have accumulated over the past few years.

I have another example involving an individual up in Sudbury who had to go see an ophthalmologist down here in Toronto. The individual had to pay $920.88 in extra fees. The family's annual income was $18,000. When this case was raised in the Legislature with the acting Minister of Health, Mr. Wells at the time, his response was that this family wanted to go to the best ophthalmologist in the province. It happened to be very serious surgery, but he said if she wanted the services at the opted-in rates, she should have gone to a less-qualified ophthalmologist.

The member for Stormont, Dundas and Glengarry shakes his head and says that is right.

Mr. Villeneuve: He will be going to the US.

Mr. D. S. Cooke: We in this party believe that everyone should be able to go to the best in the province.

Mr. Villeneuve: He will be in the US.

Mr. D. S. Cooke: We will see what happens. In the little town of La Salle, not too far from my riding, I remember raising a case in 1977. All three doctors opted out, and eventually most of the doctors went to the US. I cannot remember all the specific examples -- the member for Windsor-Sandwich (Mr. Wrye) might -- but they received a fair amount of press locally.

The opted-out doctors who moved to the US are all back in our community performing their services and they have all opted in. They found the pasture was not so green on the other side of the border and they found it is quite expensive to opt out and to have bill collectors operating in their practice. OHIP is not such a bad service for both the patients and the doctors.

I suspect that over the next number of weeks and months we are going to have a lot of interesting debate within the Legislature and within the committee. I suspect doctors will be putting a lot of ads in newspapers and doing whatever else they think is in their self-interest.

I have seen only one ad so far put in the newspapers by that rather left-leaning association called the Association of Independent Physicians of Ontario. I think these people have hired the same consultants the Ontario Pharmacists' Association hired because, when I read this ad, I really do not know where they are coming from.

The ad reads: "The Ontario government has so misrepresented the facts surrounding the issue of extra billing that many possible consequences to its proposed legislation are being totally ignored. One of those consequences could be a loss of freedom of both patients and doctors." Heaven knows what they are referring to there.

Mr. Villeneuve: The member does not care about that.

Mr. D. S. Cooke: Tell me what freedom patients are losing. Tell me what is wrong with health insurance. That is what we are talking about. We will see how the member for Stormont, Dundas and Glengarry votes on second reading.

We heard all his gobbledegook on second reading of Bill 54 and Bill 55 but when push came to shove, he voted in favour of the bill last night. If we had been thinking last night, we would have called for a division and made those turkeys stand up and put their mouths where the time has been spent over the last few weeks.

Interjections.

Mr. D. S. Cooke: All they wanted was enough time to get the cheques cashed from the pharmacists over the last few weeks, to get their donations in for the end of the fiscal year.

"One of the consequences could be a loss of freedom for both patients and doctors, freedom that now enables a patient to choose his or her personal physician without losing the benefits of prepaid medical insurance, freedom that now gives an individual physician the right to determine whether or not the OHIP fees provide adequate compensation." That is a freedom that is being taken away from the doctors.

We should recognize that the Ontario Medical Association is an organization that is very capable of negotiating on behalf of the doctors of Ontario. They have done rather well under the OHIP fee schedule. All we are suggesting is that OMA members should live by the same rules the Chrysler workers live by in my riding. When they sign an agreement, they are not able to go back into the factory the next day and say: "My union has negotiated a deal. I voted against that deal so I am going to opt out and charge $14 an hour instead of $10." They are not able to do that.

Mr. Villeneuve: The member is talking about democracy of unions. Come on; there is no such thing.

9:10 p.m.

Mr. D. S. Cooke: Is the member going to tell me that the OMA is not a union? It is the strongest union in this entire province.

Hon. Mr. Bradley: He says the unions have no democracy.

Hon. Mr. Wrye: Put that on the record.

The Acting Speaker: Order, order.

Mr. D. S. Cooke: I gather the member for Stormont, Dundas and Glengarry is trying to indicate that the unions of this province, and the United Auto Workers in particular, are not democratic bodies. Is that what he is saying?

Mr. Villeneuve: That is right.

Mr. D. S. Cooke: That is what he said. Okay. Let the record show the member has made that statement. In addition, let the record show it is obvious the member for Stormont, Dundas and Glengarry does not know what the blazes he is talking about.

Maybe he thinks his caucus is a democratic body. Judging by the way it has operated so far in opposition, I suggest that not only is it not democratic, but that it is also not very well organized. It cannot even make decisions on these bills before we start debating them on second reading.

Mr. Villeneuve: We do not have a union.

Mr. Warner: Maybe his party needs one.

The Acting Speaker: Order, order.

Mr. D. S. Cooke: There was a survey conducted by the Family Service Association of Metropolitan Toronto.

Mr. Shymko: The biggest union will not be able to go on strike. What will the member do then?

Mr. D. S. Cooke: What will the member for High Park-Swansea do? I heard his Health critic --

The Acting Speaker: Order. This is not question period. Come back to the topic. Address your remarks to the chair and we will listen very attentively.

Mr. D. S. Cooke: Thank you, Mr. Speaker. The questions the members of the Conservative Party have asked tonight have been better than any of the ones their leader has asked in question period since he became leader. It is kind of fun answering questions. I know that before I am finished in the Legislature, I and my colleagues who are here tonight will have the opportunity to answer those kinds of questions when we are in government.

In 1984, the Family Service Association of Metropolitan Toronto did a survey. It stated that 84 per cent of its clients had been extra billed. It also surveyed the economic background of its clients. It found that 19 per cent were unemployed, 48 per cent lived below the poverty line and 90 per cent earned less than $30,000.

The $30,000 figure is important because the member for St. Andrew-St. Patrick indicated, when he was Treasurer, that people who could afford to be extra billed earned more than $30,000. This survey showed that 90 per cent of these people were earning less than $30,000 and 84 per cent of the total client group at this social agency in Toronto had been extra billed.

The facts are clear. The then Treasurer of the Conservative Party did not know what he was talking about. He wanted to defend the Ontario Medical Association rather than defend the consumers and patients of this province. His party is continuing that line.

I am very thankful, because of the accord we signed with the Liberal Party and because of an election that came about last year, that the Liberal Party changed its position. As a result of that, we have this legislation here tonight.

As I said, over the next number of weeks the OMA will kick and scream. I am sure it will appear before the committee. It will initiate tactics such as those it initiated in Timmins. All I can say is that this party's expectation is that the government of the day and the Minister of Health will take a tough line with the doctors of this province.

He will say, as my leader requested today, that if doctors want to play the games they are playing in Timmins, then we will have to change the regulations and say that the consumers of this province, the users of our health care system, will not have to pay up front. They will not have to pay the doctors until they have received their money from OHIP.

If the doctors want to use those kinds of tactics, the government will have to respond in kind. If the doctors want to respond in a responsible way, then we can deal with this issue in a grown-up and responsible way and look at specifics of the bill and see if it can be improved.

I disagree with the Conservative critic who said tonight that this bill does not have a framework for negotiations. I can understand the difficulty the Minister of Health has had. It was pretty difficult to negotiate a framework for negotiations when the OMA refused to discuss with the government, or anyone, anything related to the ending of extra billing in this province. Quite correctly, the government has put into this legislation a mechanism which allows it to negotiate with doctors and other professions. It has put into this bill the framework for negotiations.

It would have been nice had the government come to an agreement with the OMA and, whether or not there would have been binding arbitration or the doctors' equivalent to Bill 100, which is the teachers' negotiating bill, it would have been built into the legislation. In view of the fact the OMA refused to negotiate, the proper approach has been taken.

Tonight, we in our party celebrate the introduction and the debate on second reading of this bill. We pay particular tribute to people who have led the fight for the New Democratic Party over the last number of years, people such as Donald MacDonald, Stephen Lewis, Michael Cassidy and now our leader the member for York South (Mr. Rae), all of whom have seen the end of extra billing -- in Donald MacDonald's case, the initiation of health insurance and then the end of extra billing -- as a centrepiece of equity within our health care system and universal access to it.

Today marks an achievement for the New Democrats and a major achievement for the people of this province. The Tories and the OMA can fight as they will over this legislation, but the fact is it will pass and extra billing will end in 1986, and it is about time.

After we pass this legislation, we have to take the next step, which is to start looking at the true vision of medicare Tommy Douglas had. That envisions community-based services, the expansion of the community health service and health service organization program. It looks at the incorporation of a multiprofessional health care system in which institutions and doctors no longer control the majority of the spending in this province. We look to a community-based service in which all professions -- doctors, nurses, social workers and psychologists -- work hand in hand together and their skills and all they have achieved in their education are used to the utmost. Only when we achieve that system will we have a truly efficient health care system.

The member for Stormont, Dundas and Glengarry can say that is socialized medicine. I really do not have any idea what he means by that. He says a psychiatrist should be treated in the same way as a psychologist. Both are professionals and both have a role to play in our health care system. All I am suggesting is they should both be recognized under the Ontario health insurance plan so that patients who need the services of either can have access to both.

Under the health care system that member's party has put into place, people do not have access to psychologists unless they have a lot of money or can see them in a hospital. We are suggesting there are a lot of professionals in the health care system who can contribute. Under the Tory system, the only people who have been able to contribute have been doctors. We cannot afford this system which relies on institutions and doctors. The alternative is more efficient, economic and humane and will increase accessibility to the proper services I know this party wants to see available to all the people of this province.

9:20 p.m.

I look forward to the passage of this bill for two reasons. It will increase accessibility and it is a just bill that needs to be passed as quickly as possible. I also look forward to the passage of this bill because it is time we got the extra billing debate behind us so we can deal with other important health care issues that are pressing all the legislators of this province. It is time to get on with those issues in the health care system.

I encourage the Legislature to pass this bill as quickly as possible, get it out to committee and report it back here. Extra billing will soon be a thing of the past, and the sooner the doctors and the Conservatives of this province accept it, the better off all of us will be.

Mr. Shymko: It is quite obvious from the eloquence and extensiveness of the debate that it is quite possible, and I would say probable, that this will become a major and key issue in the upcoming election. There is no doubt about it.

Since this may well be the case, it is important that we be fair and give credit where credit is due. I concur 100 per cent with the remarks made by the member for Windsor-Riverside, who I believe said that his party raised this issue 15 years ago. For 12 years, they fought on this issue. It is only recently that the party currently in power was enlightened in seeing what it perceives as the wisdom of banning opted-out physicians from the plan we have. In fairness, we should give credit where credit is due. We must realize that public opinion knows very well who initiated this legislation and to whom the credit should be given.

Many of the members are familiar with one of the most eloquent journalists in Canada, a staff reporter of one of the main papers in this great metropolis of Metropolitan Toronto, a journalist probably widely read as bedtime reading by members of the New Democratic Party, whose words I would like to quote from the day following the announcement and first reading of the bill. This journalist gives credit where credit is due. Let me quote the eloquence with which these statements were made publicly to enhance the opinion of the public in this province so that it would not be swayed in not seeing the right perspective on the issue.

"Queen's Park is awash with socialism. The government, run by a nonelected NDP, is hell-bent on turning this haven of free enterprise, this province of wealth dedicated to excellence, into a socialist state where the lazy, the incompetent and the irresponsible are lionized and subsidized, while the hard workers, the shakers, the creators of wealth are shackled and hogtied by oppressive legislation."

Credit is given where credit is due, my dear colleagues.

Mr. Wildman: Who is this journalist?

Mr. Shymko: This journalist is well known, well respected and widely read every day by my honourable colleagues. It is a guessing game. Have they not guessed yet?

Mr. McClellan: Lubor Zink.

Mr. Shymko: Very close, but not it. Let me continue and they may come up with the name. I will read two more sentences. Since this journalist is so widely read by them, I am surprised they have not guessed the name yet.

The journalist continues: "I am angry -- angry at the Premier of Ontario, David Peterson, whom I always admired as an honourable man, for allowing himself to be led by the nose by one Bob Rae and his little band of pinko pygmies. Oh, what politicians will do to stay in power: lick socialist boots, sell their souls, do anything."

These are the words of Laura Sabia, quoted from the Toronto Sun, December 24, 1985. I cannot be as eloquent as some journalists. I do not have the colour and the ability to embellish words in giving credit in a fair, equitable and just way to the party that initiated this legislation 15 years ago. I am sure the party is very proud of that, as journalists are proud to remind the public and the citizens of Ontario of where this legislation originated.

I would like to refer to one part of the article that is on a serious note. This is what Laura Sabia says: "In the announcement that was made by the minister, he arrogantly declared that patients are being denied access to medical care because of extra billing. What a distortion of truth."

I read the minister's statement to the press on December 19, and to say that extra billing by physicians represents a serious threat to the publicly financed and publicly administered health care system of this province is stretching it a little too far. We all know, and let us admit, what the reality is out there.

There is a crisis in the health care system. The Premier so eloquently stated the concern about the federal government's established-program financing cuts in terms of the position we took as a government, led by the former Premier Bill Davis, and by the former Premier the member for Muskoka (Mr. F. S. Miller). Honourable members recall the remarks we made on the other side of the House in the debates on the issue of EPF funding, the cuts and the concerns we had, whether the government in Ottawa was Liberal or Conservative. We admire the position taken by the Premier. The problem is $1.7 billion in cuts, $50 million a year. That is the problem: fiscal constraints.

The crisis is capital funds for our hospitals, hospital beds, chronic care beds, acute care beds and nursing homes. This is the crisis; this is the issue. So they find a scapegoat, and who is the scapegoat? Opted-out physicians, a scapegoat to accommodate, perhaps, one of the terms of the pact -- I do not know; the unholy alliance -- to accommodate something that another party had raised many years ago. So let them give the other party credit and not take the credit for making scapegoats out of the medical profession in this province.

I would have been the first to back this legislation 100 per cent had we seen that there was consultation with the medical profession. There was no consultation with one of the biggest unions, to quote my honourable friends on the left.

Someone has mentioned a 17,000-member union. I do not know whether the doctors consider themselves a union, but let us look at the actions of the doctors in the medical profession in Quebec. They went all the way before certain changes were made. They went on strike, and we may well see strike action by the medical profession in Ontario. What will my honourable colleagues from the New Democratic Party do then? Will they support the strikers or will they support the scabs? I do not know. It will certainly be a very interesting ideological situation.

9:30 p.m.

We are backing one fundamental concept that the members opposite have always backed, and that is consultation, with unions, with workers, with professionals. There was no consultation. What consultation does one have when one tells the people one supposedly consults with: "We have made our decision. This is the decision. This is the action we will be taking. For the sake of the image of consultation, we will sit down and talk about it but we have decided. We have made our decision already. It is predetermined"?

That is what concerns me and it should be a concern to every member of this Legislature. I recall very well the words spoken time and again by the members of the Liberal Party when they were in opposition, "Consultation is primary before any legislative action is taken." None was taken, not consultation with the federal government nor consultation to look at some other option. There are many variables. This is not the only solution to the dilemma. Do not make scapegoats out of one profession.

It is hypocrisy to focus on one profession exclusively, to make its members civil servants while leaving the rest untouched, perhaps because the Premier and the Attorney General are not members of the medical profession. I do not know, but I listened to the remarks of my colleague the member for Cochrane South (Mr. Pope) who said there was no consultation, but there was a desire to meet, to dialogue and to discuss on the part of the medical profession.

I would like to quote from a speech made at the annual meeting of the Saskatchewan Medical Association in Saskatoon by Dr. William Vail, urging doctors not to allow political expediency and bureaucratic control to run the health care system. Dr. Vail is an opted-out physician in Ontario and has had many prominent positions of responsibility, including that of president of the Ontario Medical Association. This is what Dr. Vail said, and I would like the Minister of Health, if he has the time now he is present in the House, to listen to the doctor's remarks.

"The Ontario Medical Association believes firmly that the privilege of opting out is a fundamental freedom of our profession, and by losing it we move one more step, like the old story of a camel moving into the Arab's tent, closer to socialized medicine in the full sense of the word." Not just the typical cliché, but in the full sense of the word.

"The OMA knows that opting the profession in will not make the services of physicians more accessible." The next part is to my colleagues from the New Democratic Party. "The NDP, a few years ago, promised a horror story a week about the poor widows, the orphans, the underprivileged who were denied medical services by opted-out physicians and extra billing, and they could not find them." They could not find the story a week they had promised.

"You and I know that the OMA is right. It has nothing to do with accessibility. It is simply and purely political rhetoric. It has all to do with reducing our ability to be a free and independent profession so that we can be advocates for our patients and to be able to work on their individual behalf, in other words, to ensure that they have access to the best diagnostic and treatment services that our profession can deliver." That is what they are trying to reduce by this legislation.

"We do not need another post office system," says Dr. Vail. He goes on to quote some other examples, not just the post office system. I might as well read the rest of the sentence: "... we do not need another aircraft industry, we do not need another bank fiasco or another tuna fish incident." I am being very objective in supporting every word addressed by Dr. Vail.

To complete the remarks, and I hope the minister is listening -- I am sure he is involved with another conversation which is perhaps more relevant than the remarks of a member of the Legislature -- but "I would like to say political expediency and bureaucratic control must not run the health care system. I repeat; political expediency and bureaucratic control must not run the health care system in this province.

"What the doctors of Ontario want is to sit down with the new Minister of Health, and look at and solve the multiple problems of health care delivery. They want to sit down. The Ontario Medical Association is more than willing to discuss the billing practices and patterns of practices of physicians in Ontario, including the utilization of medical services. How can they do this when the sword of emasculating legislation is poised to drop at any moment?"

These remarks were made on November 8, 1985, and Dr. Vail did not know that a few weeks later the sword would fall, as it has now.

He goes on to say: "Meaningful discussions must always take place in a co-operative atmosphere, and the end result of those discussions should not be prejudiced or predetermined."

I think my colleagues on the left will agree with this. The member for Oakwood (Mr. Grande) is pointing to the party in power.

Mr. Grande: I was pointing to the Speaker. The member should speak to him.

Mr. Shymko: I understand, but the member's party has more influence, as I remind him, on the party in power than we do. He knows that. His party signed a pact. It has some influence. They have listened to its proposals after 12 years of public, determined efforts on its part. They have listened. We have a piece of legislation which is the result of its influence, so the member should not point his finger. Talk to them, because that approach is not the one I know his party would support and certainly would have initiated had it been on the other side. I am sure it would have consulted, particularly with a body or an institution it describes as being the biggest union in Ontario, namely the 17,000 members of the Ontario Medical Association.

I would like to conclude Dr. Vail's remarks: "I think it is also interesting that, at this moment, filed before the courts, is a challenge to the Canada Health Act on a constitutional basis" -- as the minister knows very well -- "and also a challenge to the provinces on the basis of the Charter of Rights." It will be quite interesting if, indeed, the Supreme Court rules that what the government is doing is unconstitutional. I will refer to this challenge later.

Hon. Mr. Elston: The challenge to the Canada Health Act is on the basis of the federal government --

Mr. Shymko: It is because of the federal government's action that he is introducing this legislation. The minister knows that very well.

Hon. Ms. Caplan: It was supported unanimously by the Tories.

Hon. Mr. Elston: What the member said is not right. It has nothing to do with the Canada Health Act.

Mr. Shymko: It is because of fiscal policies. Had Monique Bégin not introduced that amendment, this would never have happened. The minister knows that. He would have been very careful about listening to the so-called advice from the third party.

Interjections.

The Deputy Speaker: Order. It is a little noisy in all quarters. Certain comments are coming from members who are not in their seats.

Mr. Shymko: The question is not the $10, $15 or $20 that a patient is paying to an opted-out physician or a specialist.

Hon. Mr. Elston: Yes, it is part of the question. That is a deterrent.

Hon. Ms. Caplan: That is the question.

Mr. Shymko: That is not the question. They will make more money now by all being opted in, according to the minister's proposal, because all a doctor has to do now is just walk through the hallways of a hospital and charge his fee. The minister knows that. He knows very well what is happening in other jurisdictions where there is a black market in health services and people charge extra. One pays under the table. That is what is happening.

Hon. Ms. Caplan: That is unprofessional. Is the member telling us the physicians are not performing their duties? Is he saying they are billing for services they are not rendering? That is not proper.

The Deputy Speaker: Order.

Mr. Shymko: The government will have a dual system.

Interjections.

The Deputy Speaker: Order.

Mr. Shymko: If the minister does not even allow me to make any comments --

The Deputy Speaker: Order. The minister is not debating; he does not have the floor and therefore cannot make any comments. The standing orders state that a member may not be interrupted when he has the floor. The member has the floor. The minister will get his chance to debate later.

9:40 p.m.

Mr. Shymko: It takes a while to get used to being on the other side. The minister has been very eloquent, very active and vocal on this side of the House. It is a Pavlovian reaction, a Freudian slip or whatever. It is in his blood and he has to react.

I would appreciate it if the minister would allow me to make my comments. Later on, as we wrap up the debate, I am sure he will have an opportunity to make his comments and to answer some of my questions. Even the NDP is tamer. My colleagues from the New Democratic Party are at least more ethical in their behaviour in allowing me to go on and make my remarks. I thank them.

The issue is the freedom of our society's self-governing professions. There is no doubt that is what the issue is all about. What we begin to see is a trend set by this government against our professions. I do not know and, for the life of me, I cannot understand why. It started off with the judges. The lawyers were next with the elimination of the QC appointments. They were followed by the pharmacists, and now we have the doctors. Who is next? To make them all civil servants -- and I do not refer just to doctors -- or tame servants of the state may well be the intention of some party. I do not know. Is that the minister's intention? He might as well be specific about it.

If the minister is going to make all the doctors in this province civil servants, why is he excluding dentists? I know he has a denticare plan; denticare may be next. Why is he excluding chartered accountants? The next thing he should introduce should be an accountant-care system. Why does he not include engineers with an engineer-care system or, I guess, engicare? He has a practising psychiatrist in his caucus, the member for Humber (Mr. Henderson). I guess psychocare will be next; I mean he has opted out.

What surprises me is that we do not have judicare, a system where all lawyers' salaries probably would be geared to the legal aid schedule of fee payments. That would be an interesting proposal. If the minister asks the citizens of Ontario whether they would prefer a judicare system where lawyers are paid according to the legal aid clinic fees or this problem of opted-out physicians, he will have an answer very quickly.

The reason may be that we have a number of prominent lawyers in cabinet, the Attorney General and others; I do not know. The leader of the third party is a lawyer by profession; that may well explain why we do not have a judicare system in this province.

In terms of popular opinion, the tendency of this government, backed by the NDP, is to be populist, popular; to favour anything that is a popular issue. However, it will get caught because it will boomerang on it. It is already beginning to boomerang.

With respect to populist issues, judicare is the thing to do. Get all the lawyers in and make them all servants of the state, civil servants, with a standard fee, not even negotiated, set on the same schedule as legal aid.

There is a hypocrisy in why he focused on doctors and left out the other professions. I would like an answer, either from the minister or perhaps from the Premier some day, as to why lawyers, chartered accountants and some of the other professions are excluded.

Hon. Ms. Caplan: They do not deliver medical services.

Mr. Shymko: They deliver services to society that are just as important in many ways as the medical services. Denticare is apparently next on the list, or is that one of the broken promises? I am not too sure. I think it is one of the broken promises. Is it $560 million of broken promises? Anyway, let me continue; I would like to point out some facts.

Mr. Grande: Where does the member stand? How is he going to vote?

Mr. Callahan: How is he going to vote?

The Deputy Speaker: Order. The member for Stormont, Dundas and Glengarry, the member for Oakwood and the member for Brampton are interrupting the member who is speaking. Will they please be quiet and stop interrupting.

Mr. Shymko: I want to tell the member for Brampton, who was intrigued as to how I will vote, that it is for me to know and for him to find out. It is a guessing game. It may not be too difficult. I am expressing serious reservations and concerns.

I would like to know where and in what direction this government is heading. Where are we heading as a society? Are we moving in a direction where professions are eliminated and all fees are set by the state? That may well be the direction desired by the New Democratic Party; I do not know. However, I would like to have an answer.

There are some facts we all know and are all aware of. However, they have to be reinforced during this debate. We must be reminded that when medicare was established 18 years ago -- three years before the New Democrats initiated their policy on opting out -- the New Democratic Party supported the concept of a medicare system in this province. Eighteen years ago the NDP agreed, as the doctors agreed and as the Progressive Conservative government of the day agreed, that we would have a medicare system, provided doctors could retain their right to opt out of the plan.

Mr. Wildman: Who did that?

Mr. Shymko: The NDP supported it. They supported this 18 years ago; not 15 years ago, but 18 years ago. They should check the record.

They had no serious concerns about the opting-out clause, and they believed we should honour, as I believe today we should honour, what I will describe as a social contract, to quote Rousseau, which is so important in the political realm of things. I will tell, in language the New Democratic Party understands, what a social contract is all about. A social contract is a commitment to society. It is a trust established between the ruling government and the people, in this case what the NDP describe as one of the biggest unions in this province, the Ontario Medical Association.

There is another thing I would like us to be reminded of. Let us look at some of the figures for opted-out doctors. The number of doctors who are opted out is decreasing, and we all know that. In March 1979, 18 per cent of doctors had opted out, but in December 1984, the figure was 13.1 per cent. I think the figure today is close to 11.5 per cent or 12 per cent.

It is decreasing every day. Why make a tragedy out of it? There may be a sunset situation where, a few years from now, the opted-out doctors will diminish in terms of the percentage of their numbers. Why make them scapegoats and move in the direction of making all the doctors civil servants, destroying their independence and their autonomy? if this government had followed the example of Saskatchewan, where there was a voluntary decision on the part of doctors to join a plan and to accept these changes --

Mr. Wildman: As I recall, there was a strike over medicare in Saskatchewan.

Mr. Shymko: It was voluntary. They sat down, negotiated, talked and consulted. They came up with an answer and a change. However, that is not the case in Ontario. We remind the honourable members who have made this government possible that, for some reason, consultation is not on the agenda of the procedure this party follows. We must be reminded that only 12 per cent or so of doctors are opted out and that less than five per cent of the total claims processed by OHIP cover services are performed on an opted-out basis.

9:50 p.m.

Let us talk about a burden, a threat to patients: the inability to pay. As members know, many doctors who have opted out do not charge rates in excess of OHIP rates; they have opted out on a point of principle, nothing else. Most general practitioners have not opted out; that is pointed out by statistics. Specialists usually take a patient's ability to pay into account. That is true; we must admit it. They look at a patient's ability to pay in every case. So to talk about gouging, about unfair practices and about tragic situations is stretching it a little too far, and the minister knows that.

The possibility of opting out gives physicians a way to deal with problems in the OHIP fee schedule without withdrawing their services. The Premier said this is called a safety valve; that is his own description of opted-out physicians. It is a way for them to deal with problems in the fee schedule without withdrawing their services.

There is often a time lag between the discovery of a new medical procedure and its inclusion on the OHIP schedule, and opting out gives doctors using the new procedure a way of dealing with this time lag. The minister knows this very well. His own leader called it a safety valve. Why is he eliminating this safety valve? It is a very good example.

Here is another point: Opting out provides doctors who are more experienced and highly skilled with a way of having this recognized. A Toronto Star editorial spoke about merit pay as a possibility to look into. I am sure the members of the New Democratic Party are considering as one of their amendments the notion that the contribution of a doctor who has practised for 20 years should somehow be recognized and distinguished from that of someone who has just finished medical school and is practising on his first day. There has to be some recognition, and the opting-out system has provided for this.

The ability to opt out also ensures that first-rate doctors will remain in Ontario. If doctors are denied the option, specialists are most likely to leave, and they are the hardest to replace. The member for Cochrane South told me today that three prominent specialists in Timmins have left for the United States. There is no other provincial jurisdiction to go to. Members know very well that when Quebec banned opting out by physicians, more than 300 specialists left Quebec for Ontario within the first three months following that legislation.

The minister knows that 66 per cent of all the doctors from jurisdictions where opting out was banned remained in Ontario and other provinces -- British Columbia, Alberta and perhaps New Brunswick -- while the remaining 34 per cent probably left for the United States; we do not know. However, once Ontario closes its doors, they will leave by the hundreds. Tell the patients and the citizens of the province that the government is not jeopardizing the health care system.

Hon. Mr. Elston: The member is wrong again. He does not have his facts right.

Mr. Shymko: Maybe the minister has had a dialogue with some enlightened power since he seems to have all the answers; I do not know. He knows everything. However, there is a lot that is unpredictable in life, particularly in political life.

Mr. Wildman: That member's party should know.

Mr. Shymko: There is a great deal of unpredictability, as is so well pointed out by my friend. The changes that have occurred can happen again. The leader of the third party has stated publicly that some day he will become the Premier. Can members imagine it? Things are possible. Nothing is sure; nothing is predictable, and the minister knows this very well.

Instead of trying to end extra billing by negotiating a complicated fee schedule high enough to satisfy everyone, it is better, in my opinion, to establish a general fee schedule at average rates and allow the few who have problems with it to opt out, a much simpler formula without the cataclysmic impact that this legislation will have on this province. The minister knows this.

The minister knows very well we took many steps when we were the government to ensure that extra billing did not compromise accessibility to health services. He took over and he knows what steps had been taken to assure accessibility by this party when we were in power. Let me remind the minister and the citizens of this province, some of whom may read Hansard and my remarks --

Hon. Mr. Elston: Not if they have any sense.

Mr. Shymko: That may be stretching it a little too far.

Mr. Gregory: The member can always print it in his newsletter.

Mr. Shymko: I may print some of my remarks in my Queen's Park report.

Some of the steps we took included establishing a province-wide telephone system that assisted the public in locating opted-in doctors and a joint Ontario Medical Association and Ministry of Health committee that reviewed patient complaints about billing. We had regulations under the Health Disciplines Act which provided that doctors who extra bill must notify their patients in advance of treatment and of the amount of the extra fee. The minister knows all that.

In other words, medicare was designed as a floor plan to ensure that everyone could afford adequate health care. The system as it stands now will not accomplish that goal; it may jeopardize that goal, and that is my fear.

I want to talk about some of the background on the whole issue of extra billing. My colleagues know the introduction of medical insurance in Ontario was predicated upon the absence of interference with either the professional freedom of physicians or the patients' freedom to select their physicians. In other words, it was to preserve the freedom of patients to select their physicians.

The freedom of choice is something we do not want to talk about for some reason. Physicians have always been free to choose whether to participate in the Ontario health insurance plan. Patients have always been entitled to receive benefits at the rates set out in the OHIP schedule of benefits or, if they so wish, to add the $10, $15 or $20 extra because they went to an opted-out physician. The details of that policy are well known.

There have been protective measures. We know, for example, that opted-out physicians can receive payments from the plan -- they still can, before the bill passes into law -- for certain services if he or she is affiliated with an opted-out association medical group. The association and the opted-out physicians accept the plan payment rate exclusively, in full, without additions, under the following conditions: namely, services to persons in an outpatient hospital or any other clinic department or public hospital; services to persons in nursing homes, homes for the aged, sanitariums, children's mental health centres, psychiatric hospitals, psychiatric facilities, approved homes, homes for special care -- I could go on and on.

There have been remarks about the number of members of the Legislature present in the House. It is surprising that on this crucial issue, which may well be the issue of the next election, there are only three members of the governing party sitting in the House tonight.

Mr. Gregory: Three?

Mr. Shymko: Three; the minister and two members. There are more members of the New Democratic Party present than there are members of the governing party. That is shameful. Oh, someone is lurking behind, but he is welcome to come in and listen to my remarks.

10 p.m.

What we see are various options available to protect special categories of people.

There are geographical considerations that are very important in the delivery of our health system. I would like to remind members of that and to welcome the Speaker to listen to the eloquence of the remarks made by all members of the Legislature on this very important issue. Approximately 1,500, or about 77 per cent, of the opted-out physicians in the province are located in the seven major centres of our province, which contain about one half of the province's population.

In other words, the Golden Horseshoe, which includes Toronto, Oshawa and Mississauga, contains approximately 60 per cent of all the opted-out physicians in this province. Because of the general supply of practising physicians in these urban areas, particularly in what I refer to as the Golden Horseshoe, patients have ample access to services at the opted-in rates. There are choices available. That is guaranteed. There is no problem with access, as everyone knows.

Likewise, only about 23 per cent of opted-out physicians are located outside the seven major centres. Thus, half of the province's population residing in rural settings are served by proportionately more opted-in physicians than in our metropolitan areas. There is an equity, a fairness, of access. That geographical consideration has to be stressed as this debate continues.

What we see as the issue is what I would describe as a danger. I would not describe it as excessive, oppressive legislation, but I would mention the danger of excessively oppressive legislation that will destroy the self-governing nature of our professions, which we all know for centuries have been part and parcel of our free enterprise system, bastions of free society, the avant-garde in the progressive changes in western civilization.

If one studies history, one knows very well those who led the French Revolution, which initiated many of the progressive changes following it, were the free, self-governing, independent, autonomous professions. That is the best assurance today against the encroachments of absolute power. Be it in the 18th century or the 20th century, the first action of any totalitarian regime, be it of the right or the left, is to make the professions state servants, slaves of the state, and to destroy their economy totally. That is history and a fact.

Mr. J. M. Johnson: On a point of order, Mr. Speaker: There are only two Liberals in attendance and one more is coming. I do not see a quorum.

Mr. Speaker: A quorum is present. Would the member continue.

Mr. Shymko: Let me tell a story on this whole question of totalitarian regimes. Whenever I refer to it, I get snide little remarks from some members, but I had an opportunity to speak with an individual, an architect by profession, who came from one of the socialist regimes where the professions are totally eliminated.

They are all servants of the state and they all get paid 120 roubles a month. Whether one is a doctor, a lawyer, an engineer or an architect, it is 120 roubles a month. I asked him, "How on earth could you afford to leave your jurisdiction and come to see this great country of ours on a salary of 120 roubles a month?" He said, "The way I survive and financed my ticket is that I build monuments in cemeteries for the deceased of top party brass." For one monument, he collected 1,000 roubles, almost a year's salary.

He told me there was an underground economy. He said, "The only way all our doctors and dentists survive is by the underground economy, the black-market fee service our medical profession uses in order to survive." That is an extreme example, but it is the direction in which we may be moving, because if one looks at some of the jurisdictions in Europe, there is indeed a black market. Talk to some of the physicians in the United Kingdom and in West Germany and they will admit it.

Ms. E. J. Smith: What about rent controls?

Mr. Shymko: Sure. Rent controls -- an excellent point. Absolutely. The vacancy rate that exists today is a problem. People pay up to $2,000 to $3,000 just to get access to an apartment. The problem will not be to get access to a five-minute visit with a doctor on an assembly line system of medical care; the problem will be that to get 15 minutes, 20 minutes or half an hour with one's doctor, people will be shelling out money under the table -- $50 or $60. It is happening. Honourable members know it is happening in Europe today.

Mr. Wildman: On a point of order, Mr. Speaker: Is it really in order for an honourable member of this House to impugn the integrity of the medical profession in this way?

Mr. Speaker: It is in order for a member to express his or her point of view.

Mr. Shymko: That is the last thing I would do. I am pointing out the dangers and the realities that exist. Our doctors are concerned about this possibility. This is why they do not want to have a system in place --

Interjections.

Mr. Shymko: That party has lawyers in its caucus. They can read every week how many disbarred lawyers there are in this province. Sure, we are not infallible. Temptations are there. Just look at the record; read the papers. It is a possibility that I do not want to see and that no one wants to see. At least we have what the present Premier has called a safety valve -- a phrase coined by the Premier. Opting out for physicians is a safety valve, even for such terrible temptations or possibilities --

Hon. Mr. Bradley: On a point of order, Mr. Speaker: Ordinarily on second reading, speakers indicate how their party is going to vote. This speaker has not done so. Perhaps you can instruct him to do so.

Mr. Speaker: Order. I do not know whether the member was trying to place a question there or what, but I do not believe that is a point of order.

Mr. Shymko: I would not mind answering the question, but we will have to wait for the circumstances when that honourable member will be on this side and will be asking questions. Imagine the gall of trying to force me to take a position.

Mr. Polsinelli: He means he has not been instructed yet.

Mr. Shymko: I am open. I have concerns. I have a dilemma. I want the minister to help me. I am trying to assist him in expressing the concerns and some of the contradictions and pitfalls of the legislation.

Hon. Mr. Bradley: Those members flip-flopped on the Workers' Compensation Board.

Mr. Shymko: There will be options. We will talk about options in a few minutes. I have a whole set of options for the minister, but give me time; this is only my introduction. We have time. If members do not have time to sit down with the members of the medical profession and discuss this legislation with them, at least give time to honourable members.

10:10 p.m.

Let me go back to my architect friend. I said: "This is a dilemma. You earn 120 roubles a month. How can you survive with this underground economy?" He said: "There are resolutions to this problem. When Mr. Chernenko was the head of the Politburo or the Presidium, as a former teacher he raised the fees of all the teachers in our jurisdiction. When Mr. Andropov came in, as a former head of the internal security police, he said he would raise the salaries of that group of professionals. Now that we have the present head of our jurisdiction" -- whose name escapes me; some honourable members may help -- "Mr. Gorbachov, as an engineer, it may well be that we are expecting the fees for all engineers to go up in the next few months. So I am waiting until we get an architect who will become the head of our state so perhaps my fees will increase."

I look at the member for Humber. If the member for Humber, who is a practising member of the medical profession, a psychiatrist, were the Premier, he would have been very cautious in the approach the government has taken. For one thing, he would have made sure the profession was consulted and that meetings were held, because that is the only way. There are too many lawyers in cabinet. The government needs a little more diversity, a more representative cabinet. Maybe then it will have a more realistic approach to the pitfalls of this legislation. If the member for Humber were Premier or Minister of Health, and I am sure he qualifies with his talents, he would have done a much better job.

The issue is an attack on one of the best health systems in the world, and that is admitted by every poll, including the poll taken by the member for Brampton. I have taken a poll. I will tell the members the results in a minute. I took a poll in my riding. All polls indicate that 85 per cent of the citizens of this great province say we have the best health system in the world. How many have had problems with the health system? Fifteen per cent of those polled said they had problems. The rest are happy. Why is the government making a scapegoat of the medical profession?

The issue here is the protection of the system. That is what our remarks on this side of the House are all about; to protect a system that provides accessibility with a constantly diminishing reduction of opted-out physicians to protect our patients and their freedom of choice in selecting doctors.

I will read some of the remarks from my constituents. We have Queen's Park reports. I will give the members statistics. Who will ultimately suffer? Do the members know who will suffer? The patients, because the government will lead this province into circumstances where the reality will be an environment that we find today in the United Kingdom.

Do the members want to hear horror stories? I ask my colleagues from the NDP about horror stories. They will hear horror stories about the medical health system in the United Kingdom and then we will listen to the answers. There are enough horror stories -- not once a week but one or two a day -- that we will be presenting to the members about the system in the United Kingdom. That is exactly what the NDP wants. Who will suffer? The nine million people of this province will suffer, the patients will suffer ultimately.

Mr. Villeneuve: Let us talk about the system in the United Kingdom.

Mr. Shymko: I do not have all the statistics.

Mr. Speaker: Order. I wonder if I could invite any of the members who are interjecting to come and see what it sounds like from here. Would any of you like to try? The member for High Park-Swansea is speaking. Please let the member speak.

Mr. Shymko: Let me quote Greg Parent, who has a column on medicine in the Toronto Sun, favourite reading for the members of the New Democratic Party. In an article on December 22, this is what Mr. Parent had to say:

"When Britain, at the urging of the unions, made doctors state workers, their health care system crumbled. They wound up with a system that encouraged under-the-table payments to physicians by patients who did not want to queue up to see their doctor."

I am not saying this. A prominent journalist and an expert in the medical profession is saying this.

I will continue and I ask the honourable members to listen to this. "Today the British unions are insisting on private care in their contracts because the public system they created is not good enough."

It is the unionized workers of Britain who are opting out to the private sector for private insurance and private care in their contracts. Do the members know what institution is growing at an unparalleled pace? It is the private insurance companies in Britain. It is unparalleled. Having moved in the direction in which this legislation is leading this province, they have reached an impasse where there is a two-tiered system in the United Kingdom, one private and one public, and the public is opting for the private one.

That is exactly what the government is doing. It is not a decision made by the upper oligarchy of Britain. These are choices that are being made by the working class of the United Kingdom, I remind the members of the New Democratic Party and the Liberal Party in power, under whose protection and urging this absurd, ridiculous piece of trash is being introduced.

I would like to continue by ending with this great quotation from Greg Parent.

Hon. Mr. Bradley: Are you going to weasel the way you did on the other bill? Are you voting on the bill the same way you voted on the pharmacists' bill? The party is split completely; as it is on Sunday shopping.

Mr. Shymko: I would like to ask my colleague to refrain from his remarks. "Throughout Europe where socialized medicine is the rule, strikes and under-the-table cash payments are commonplace. Even Ontario doctors who do not extra bill see this as the first step in that direction."

It is a sexy issue, a populist issue. The present party in power seems to be picking these attractive or populist issues. One takes a populist opinion poll and asks people, "What do you want in this area?" They answer, "Make the rich pay." The rich are paying now. If I were to define this legislation, it is to make the poor pay. That is what it is all about, because the rich are paying, financing and subsidizing.

Hon. Mr. Elston: That is not right.

Mr. Shymko: It is not right? Let us take a look at some figures. The minister knows very well that as a result of this Ontario health insurance plan premium rates will go up because he has to cover the increases in doctors' fees that he will then negotiate.

We may lose $50 million a year because of the arbitrary federal decision started by Monique Bégin, but now the costs will not be $50 million; they will be a minimum of $100 million and I calculate they will be $150 million. That will be the cost to the taxpayers of this province of the ban on extra billing.

10:20 p.m.

In 1981, the British Columbia agreement resulted in a 40 per cent gross increase in doctors' fees. When they banned it in British Columbia, the result was a 40 per cent increase in doctors' fees. That is exactly what the government will do to the patients and the citizens of this province. It has happened in other jurisdictions. Why does the minister not take an example? Why does he not do some research? That is exactly what he will have to do. He knows that happened in other jurisdictions. Doctors can still extra bill despite all that in some jurisdictions. The result, as I said, is to make the poor pay. That is what this legislation is all about.

Hon. Mr. Bradley: Is the member going to vote for the bill?

Mr. Shymko: Does the member know what the law now is, the present cliché of the Liberal government in power? What is popular is right. I will give him an example.

Hon. Mr. Bradley: Is the member voting for the bill? He does not want to tell us how he is voting.

Mr. Shymko: I will tell the member I am an abolitionist. I do not believe in capital punishment, but if what is popular is right the minister would have to introduce a lot of changes as a lawmaker. If he took a poll on capital punishment in his riding, I am sure the answer would be 80 per cent or 90 per cent in favour.

For lawmakers, what is popular is not necessarily just, not necessarily fair and not necessarily wise. What is popular is not necessarily conducive to the welfare of a society and does not necessarily safeguard the fundamental principles and values that characterize the essence, the nature and the fabric of this society with its free, self-governing professions whom the minister would like to change into civil servants.

Hon. Mr. Bradley: Is the member voting for the bill?

Mr. Shymko: I will tell the member that what is popular is not necessarily right. Give us enough time. The minister is going on the basis of public opinion, and public opinion may change. I mentioned a two-tiered system. This is a global village.

Hon. Mr. Bradley: Is the member voting for the bill? Why will he not tell us?

Mr. Speaker: Order. I have heard the same question repeated I do not know how many times.

Hon. Mr. Bradley: But the member has not answered it yet.

Mr. Speaker: Order. There is a tradition in parliament that any member has the right to stand and ask another member if he or she will accept the question. If he or she will not, then the member is supposed to take his or her place and remain silent.

Hon. Mr. Bradley: Will the member accept the question?

Mr. Shymko: I will accept the question when I am on the other side and that may not be long. I have taken a poll. We all take opinion polls. When I was a member in Ottawa, I took a poll on capital punishment. The results were frightening, because 80 per cent said, "Hang them." According to Edmund Burke and some of the great political philosophers, however, an elected representative is not elected to rule by referendum or to rule by opinion polls. In my case, as in the case of a number of governments, one does not legislate everything that is popular; at least I hope not.

I will give members some examples. It will boomerang. Do the members want to know about the poll in my riding, in my first Queen's Park report following the election? I had five questions and one was, "Do you favour an end to all extra billing by Ontario doctors?" I had 615 replies, of which 385 said, "Yes, we favour an end to all extra billing in Ontario" and 230 said, "No."

There were also comments. Out of 13 comments, two people commented who agreed with banning extra billing, but 11 commented who opted for the present system; in other words, maintaining the status quo. Those who wanted to maintain the status quo said such things as: "Dentists are not regulated. Why should doctors be? Specialists should be allowed to extra bill but not GPs. After such intensive training and because of the enormous responsibility and long hours, doctors should be compensated. Quality is better than quantity. Let us keep the good ones in Ontario."

This is the people talking. "Why penalize only the medical profession?" they ask. "Extra billing should not be banned. These are professionals not civil servants." Here is another comment from the people, not from me: "Let the doctors set the fees. Let the patients decide which doctor to see." It almost rhymes; a poem.

Another one: "I think extra billing prevents abuse of OHIP by patients. Let the patients pay a portion." That is an interesting comment. Another one: "Banning extra billing would reduce medical care to a uniformly low level by reducing the time physicians can devote to each patient."

This is the perception of the public; not the majority, not the 60 per cent. This is the 40 per cent, but they were the most adamant in writing comments.

Hon. Mr. Bradley: Who were they? Who was writing those comments? The member knows who they are.

Mr. Shymko: Public opinion may change; give it time and it will change.

The last one: "If specialists with many years of experience could receive extra compensation within OHIP, I would prefer ending extra billing; but you and I receive more money as we become more professional and experienced, why shouldn't they?" Perhaps there will be some amendment for merit pay, I do not know.

These are views of constituents, the people we are serving. I want to continue by referring to a Supreme Court challenge. I do not recall the remark the minister made, but it may not have any relevance to his legislation. Dr. Jim McPhee from Thornhill took up the challenge of the Canada Health Act and it is before the Supreme Court. He calls it unconstitutional.

Do members know who made the suggestion that this go before the Supreme Court? The present Attorney General, when he was the legal counsel to the Canadian Medical Association, advised that this go before the Supreme Court as a constitutional challenge; imagine that.

That is an ideal question for question period, probably by our Health critic. I cannot understand that the present Attorney General, when counsel to the Canadian Medical Association, suggested the federal legislation go before the Supreme Court as unconstitutional and as a member of the cabinet of this government he is supporting a piece of legislation which may not be constitutional because it addresses the reality of a federal government which is penalizing it by $50 million a year.

Instead of fighting established programs financing in health and post-secondary education the way the Premier has done at the first ministers' conference, for which I compliment and admire him because he followed the example of Bill Davis and the member for Muskoka, to protect the interests of this province the government should say: "The $50 million penalty per year is unfair. You should not penalize us at a time of fiscal constraint. When we can barely survive, maintaining our health care system, when capital costs for hospitals are escalating, when we can barely finance acute care beds, hospital beds, nursing home beds, you should not introduce draconian measures such as these."

That is what the Premier should be saying, not playing a little game of picking the medical profession as a scapegoat. Given the time, a few days and weeks, the people of this province will realize the silly game the minister is playing with this piece of legislation.

I would like to conclude with a remark from Laura Sabia. "We can now look forward to assembly-line medicine where doctors become state employees. When that happened in Britain, good health care collapsed. It will be collapsing here too. Research will decline and excellence will hold no value." She says doctors in Ontario are being used as scapegoats to cover up a lack of adequate hospital funding, beds and equipment. It is as simple as that. I conclude my remarks.

On motion by Mr. Shymko, the debate was adjourned.

Mr. Wildman: On a point of order, Mr. Speaker: Let the record show that the member who has spoken at great length has not once said whether he will support the bill on second reading.

The House adjourned at 10:30 p.m.