L102 - Tue 28 Jan 1986 / Mar 28 jan 1986

HEALTH CARE ACCESSIBILITY ACT (CONTINUED)

SPRAY PROGRAM

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The House resumed at 8 p.m.

HEALTH CARE ACCESSIBILITY ACT (CONTINUED)

Resuming the adjourned debate on the motion for 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.

Mr. Cousens: We are continuing this debate. I probably would have been able to finish last night had it not been for interruptions from the third party. However, I would have had to rush through some points, and I do not want to do that because we are dealing with one of the most important issues in Ontario today.

We are dealing with the confidence the people of this province have in the health care system. We are seeing the confidence of the people of our province virtually shattered by the way this government is running roughshod by bringing in legislation that sets a new pattern and new precedents for the way in which government is going to deal with issues and with the people of this great province, without conciliation and without discussing issues with people.

We have done it with the pharmacists through Bills 54 and 55. We are legislating new rules that are going to change the way pharmacists have traditionally dealt with their patients. It is another example of this government at its worst.

We saw the government come in with a budget that had nothing for the business people of this province, but at the same time it increased the province's deficit. That again is the government at its worst. We will see an increase in inflation and a lack of support for the business efforts needed to pay for the things we are talking about in Bill 94.

When we saw this government arbitrarily bring in the spills bill, we saw a government that had lost a sense of responsibility for the balance that is needed between people who are interested in running a business and in doing the right thing. I say shame on them.

Bill 65, which was discussed today, provides for the settlement of first collective agreements. It is the government responding to a situation no one liked, to what happened at Eaton's. However, it is another way of forcing the people of Ontario to say: "Maybe we should get on a bus. Maybe we should head out of this province. Maybe we should go elsewhere." They did that in Quebec a few years ago; they came to Ontario. Are we going to start driving business people from our province to somewhere else because we do not have an environment where they can run a business and make a living?

Today, the Minister of Community and Social Services (Mr. Sweeney) had a rehash of an announcement made by the government previously in power, without any significant change and without acknowledging the authors of the programs. It is ludicrous.

I am upset. As an opposition, our hands are tied and there is little we can do. However, I say this much: I will speak up and I will make clear, at least in this House and to the people of my constituency, what is happening in this place so people can become aware and involved and can protest. Their time will come, because the government will be in power for only so long. There will be an election and the people will have a chance to speak up.

We see the same kind of confrontation again today. I am leading up to it, but it is all part of the context in which we are living. We are dealing with a government that has lost sight of the people of the province. Who knows? Perhaps we are going to have to pay a fee to go fishing, and then all kinds of Liberal inspectors will come out to make sure we have our licence.

I can just see it. Our good friend the member for Waterloo North (Mr. Epp) is going to end up having a summer job tracking down fishermen who do not have a licence. To me, there is something damnable in the fact that the government has a chance to do something worth while for the people of Ontario, and what it is doing now through all these actions is bringing in changes that our people in this province do not want, did not expect and will find upsetting.

I am leading up to what I want to get warmed up on. I came to this House tonight when I should have been at the John Aird dinner -- I paid $50 to attend that dinner for the mentally retarded and for the work that is going on there -- because I felt compelled as a legislator to be here to speak on these issues.

We are moving into an age of socialization, and Bill 94 is another example of a government that has gone socialist. It is going totally off on the left end of the spectrum, especially when we see what the Minister of Housing (Mr. Curling) brought in with this housing legislation. Why do it? The people of Ontario did not need that.

I do not mind seeing the positive action of building more housing units. We need them; God knows we do. However, I venture to say that with this kind of further intrusion into the whole fabric of our society, making this a more socialized province, we are losing the balance that has made us strong, the balance that said on the one hand, that free enterprise can thrive and reign, and on the other hand provided for the social needs of our people.

That is the balance that Bill Davis, John Robarts and George Drew had. It is the balance that the people of our party had, and still have. This is the balance that is missing in the legislation before us in Bill 94. The government is saying there: "Damn the cost; damn the long term. Go for what seems to be expedient now because the media want it or because some group of people in the New Democratic Party said, `Let us put it in the accord.'"

I want to get to that, because I was thinking on the way down that the accord did not require this government to be so punitive to the medical profession. All the accord asked for was the banning of extra billing. The government is taking it a step further and saying, "It can only be our way," unlike any of the other provinces that have allowed flexibility for the doctors to do something other than exactly what the government wants. I will get to that. It might take me a while to do it.

I also believe that when we have a government that says it is so open, it makes for a sense of distrust on this side with the kind of regulations and controls that are going to be brought in. The Premier (Mr. Peterson) is a nice person. I do not believe anyone here would disagree. I worked with him on the pension committee for some 72 meetings, and anyone who knows him cannot help liking him as a human being. However, I do not like it when he says he has an open government and everything is going to be nice and cosy, and yet the cabinet ministers across the way have not even submitted their conflict-of-interest guidelines. Something is the matter with all of them if they are not going to follow the simple rules.

Out of one side of his mouth he says one thing, and out of the other nothing happens. There is no follow-up; there is no truth. The lack of sincerity in that action causes people to ask: "What is this government up to? What are its long-term plans? What is its long-term goal? It says one thing and then does not do it."

Bill 94 dealing with doctors is saying nice things. The government says it wants to negotiate; but will it? Will it deal with them with candour, with integrity, with a sense of intelligence and a with sense of respect for the involvement they have had in health care in our province in the past?

I venture to say it will be much the same as the Premier with his conflict-of-interest guidelines: "Yes, we are going to be open. We are going to do everything right." However, when the day comes that our good friend the member for Leeds (Mr. Runciman) digs and finds that none of them has submitted his interests and that a potential conflict of interest appears in the case of the Minister of Northern Development and Mines (Mr. Fontaine), one has to start hearing the people of the province of Ontario say, "Woe unto them for what they are doing to us."

I do not know what they are going to do, but they have taken the programs our party laid out, stolen them, rehashed them and regurgitated them.

8:10 p.m.

Hon. Mr. Bradley: On a point of privilege, Mr. Speaker: I am wondering what the honourable member is saying about members of the cabinet. Was it that they have not submitted their conflict-of-interest guidelines? Is that what the member said? I thought that was what he said, which would not be accurate in my case. I handed mine in a long time ago.

Mr. Harris: On the point of privilege, Mr. Speaker: As late as this afternoon not one single, solitary cabinet minister's disclosure had been tabled, as it was to have been tabled, with the Clerk. The minister may have them tied up somewhere in his system where they are being reviewed --

The Acting Speaker (Mr. Morin): The point of order has been made.

Mr. Harris: -- but we will have no knowledge of that until they are tabled.

Mr. Cousens: The point is obviously true and valid. Although I have a great deal of confidence in the Minister of the Environment (Mr. Bradley) about some things, he has obviously failed to meet the terms and guidelines delineated by the Premier this week. In that sense, he has failed to live up to the guidelines given him. I am saying that is part of the context in which we now are living in Ontario; the government says one thing and does another.

What, then, can the doctors do if they are to believe this legislation, that it is supposed to be put forth in trust and is supposed to provide something that is not there?

You are going to drive -- not you, Mr. Speaker; although you are a member of that party, I respect you. I know you probably have nothing to say about it. You probably did not even know what the government was going to do, because it was done by four or five of your members in consultation with the New Democratic Party, and then they rammed it through. I do not hold you responsible. Indeed, most of your caucus did not know what was going to happen. You probably would not have done it if you had known the serious ramifications it was going to have on health care in our province.

This is going to drive out doctors, specialists and business people. They see it as another example of the government taking control of the whole world we have come to love and know as Ontario. The government might as well start driving buses around the province, saying: "Move away, people. We will give you a free ride out because there is no free ride in Ontario. You are going to pay for it through the nose, through the ears and through every other way. It is going to be an expensive place to live."

I am sorry I did not finish last night, but as I have tried to look at the rationale for this, I have never been more concerned about what the government is doing than with Bill 94. It represents the very worst I could ever have expected from that party. In that sense, I am riled up from the very bottom of my toes and I want to speak out. I have a number of points to make in defence of my view.

I am making these remarks for the people of my riding, who want a quality health care system and who want to be able to depend on the services they have come to know, so they will have accessibility that is affordable according to their needs. If this legislation is going to cause disruption to that, then because health is so important I am compelled to speak out on it now. I do not want to do it two or three years from now.

I do not think the members opposite are aware of how unhappy the people of Ontario will be. My friends should not go by the polls. The polls give them a sense of comfort because they think the people are supporting them. They also should not go by the media who are saying, "We like what you are doing."

I have never seen a government receive so much lovely support from the media. It is false support. They should not rely on it. The people of this province know better. They do not believe half the stuff that is printed in the Toronto Star or the Globe and Mail. When one starts getting the kind of promotional material the government is able to feed them and they are able to print, there is little doubt this government feels comfortable.

However, the people of Ontario know who is going to have to pay for these decisions. They are the ones who will cause this government to rue the day and to rethink what it has done. By then it will probably be too late, and we will be entrenched in a form of social democracy this province has never known.

I felt badly last night that I was not able to do justice to the presentation made by a number of doctors. I gave presentations from my constituents. I read a number of letters, most in support of the position I am espousing. I made reference as well to a number of constituents who support the view that the Minister of Health (Mr. Elston), the Premier and the coffee group are pushing through. I respect that there are differing opinions on how we should handle this whole medical situation in Ontario.

However, have we listened carefully enough to the doctors and what they are saying? Have we heard enough from them to appreciate the consequences? On Dateline Ontario on January 23, Dr. Earl Myers, president of the Ontario Medical Association, said, "I do not know why, in their wisdom, they decided that is the way they are going to do it." He was talking about Bill 94 and its consequences.

He also said: "Behind the Iron Curtain you can see a doctor privately if you do not like lining up in a clinic. In Sweden you can see doctors privately, in Italy and Israel. It is the same all over the world. This is the only place you cannot; where a doctor must be in the system 100 per cent."

Mr. D. R. Cooke: The member should read us some of his letters from nondoctors.

Mr. Cousens: I did that last night. I gave them to Hansard so it could give the names and addresses correctly. They will be in Hansard, which the member gets; he will probably read it, knowing how conscientious he is. I respect the fact that he is an honourable and respectable man. Through what I state tonight he may become converted and join the member for Humber (Mr. Henderson) in protesting the government's decision to implement Bill 94 the way it is doing.

If he is able to bring about amendments to this punitive, nonconciliatory legislation that will help cause a breakthrough and understanding of what is best for the long-term interests of Ontario, then he will be one of those eligible to replace the member for Parkdale (Mr. Ruprecht) as a Minister without Portfolio or one of the other members in front of him. In fact, he is eligible now, in my humble opinion.

I would like to bring in some of the remarks. I have here a letter from Paul Randall, a physician who works in York Central Hospital, Richmond Hill, and who is very active in the medical association. At my request, he has put together a number of thoughts that reflect his views and those of a number of medical practitioners in my riding on this bill. I am going to read excerpts from his letter. I touched on it last night, but I did not take out the points he made and I feel I did a grave injustice to what he was trying to say.

"I should like to point out that physicians are the most accessible components of the health care system. The medical staff of York Central Hospital has provided, since the hospital opened, 24-hour, seven-days-a-week coverage on call, in person or by pager, within a 15-minute drive to the hospital."

I do not think anyone in this building or in this chamber can think of too many professionals who are on call the way they are, with the education, training and responsibilities they have. They are on standby constantly for the wellbeing of other people at sacrifices not only to themselves but also to their wives and families.

8:20 p.m.

He goes on to say, "I am sure you are aware some call schedules are provided at considerable restriction on personal and family life." I do not know whether many members know how many doctors have gone through marriage breakdowns. The cost they pay is a personal one that goes far beyond that of just time. It goes into family life, the very fabric of who they are as human beings, because when they start out -- and I think most doctors are like this -- they are dedicated to the wellbeing of our society.

He goes on to say, "Each and every surgical specialty -- anaesthesia, obstetrics, internal medicine, paediatrics, radiology, pathology, family practice, emergency medicine -- all the hospital services are covered in this way."

The honourable members opposite should try to tell me what group in the medical profession does not give that kind of full-time dedication to its work. They all do.

"Why do we do this voluntarily?" he asks. If they were to be paid for each minute they were putting in it might be different, but in the letter -- and I will go through it -- there is so much of what the doctors do for which no cost or bill is associated.

"It is because we have a strong sense of professionalism and a well-organized, co-operative and a loyal medical staff."

It starts with these people who have that dedication, who make our system as strong as it is.

"We wish to provide good care to our patients and provide good service to our hospital, especially the emergency department. We are very accessible and available."

I do not know how many members have ended up in the emergency ward of a hospital. I have. I have taken my children there and I have gone there myself when I have not been 100 per cent healthy. It has been most gratifying to know before I went there that I would get good care and good attention.

"Secondly, I should like to point out that we as doctors also co-operate amongst ourselves and with the hospital administration to improve access to hospital facilities."

Co-operate: that spirit of co-operation starts from within and it starts from the kind of environment that has been created by government and by the administration so that people want to give of themselves. The day one comes along and starts ordering professionals to do things is the day one will not get the same amount from them. However, if they do it out of a sense of duty, out of a sense of conviction that it is the right thing, then one will get so much more from them in a quality way.

"We do this by voluntarily participating on hospital committees: the rehabilitation committee, admission committee, discharge committee or block booking, to name a few. Our surgeons do as much surgery on an outpatient basis as is medically safe so as to minimize the load on inpatient beds."

I know, because I was pressing the member for Don Mills (Mr. Timbrell), Keith Norton and the member for St. Andrew-St. Patrick (Mr. Grossman) for more hospital beds for my riding. Our growth, which is phenomenal in the York region -- we are growing at more than 300 people a week in the south York region -- is causing capacity problems in our hospitals and in all our services that have to be responded to. However, in order to meet the needs of the people who are there currently, the doctors are giving extra of themselves so they can meet the needs of the people who are coming to them for care.

He goes on to say: "Our medical staff has taken the initiative in certain modern diagnostic equipment -- namely, the Doppler scanning, the holter monitoring -- buying and funding the necessary equipment for these services."

Think about it. How many communities have had doctors from within that community who have come out and, with their own funds and their own means, contributed to buying equipment to make that happen? Will they ever do it with the social medicare system we are talking about today? Why should they? Now the responsibility is taken away from them and the government is going to be responsible for it all.

Mr. Wildman: Does the member want a capitalist medicare system?

Mr. Cousens: I would like to see more than we have. There is no doubt that something is significantly wrong with this legislation, and I would not be up here trying to burden members with my thought process if I really did not believe it.

He says: "Contrast this accessibility with some of the problems we face at York Central Hospital, which of course is under Ministry of Health budgeting and control. First, despite the fact that York Central Hospital has 251 active beds and eight intensive care bed units, we still have no respiratory technology service, although all other hospitals in Ontario of a similar size and level have such a service and consider it essential."

I have talked to previous ministers about this. I have talked to a senior administrator about it. Right now there is not sufficient money in the budget to provide it for this hospital, and yet I guarantee, by the decision of Bill 94, there will be less money to spend on essential services such as the respiratory technology service because the money will have to be spent elsewhere. The $50 million we get for the province is peanuts compared to what we will have to pay out to the doctors to appease them and satisfy their concerns.

He says: "We have applied for this extra service, but it has not yet been funded. This is accessibility for the critically ill and post-operative patient." If the government is talking about accessibility, let us make sure those patients under the care of our medical system in Ontario have the things they need. Other things are still needed, rather than this punitive legislation before us tonight.

I appreciate that Dr. Randall has taken the time to put a number of these considerations forward so that the members of the Legislature and the people of Ontario can understand that life is not rosy out there. It is not easy to run a hospital or provide the service, but one has to provide an environment so that service is in the context of "the patient comes first."

He goes on to talk about this. "The lack of beds to admit patients for elective, necessary surgery often leads to cancellation of that surgery." I referred to that last night in my speech when I was talking about the British health system. They have waiting lists far longer than ours. The waiting lists we now have, which are objectionable to all of us, will increase and there will be more people lining up to receive necessary health care.

However, they will not receive it because the government has suddenly changed the dynamic. It has suddenly put the doctors and physicians where they will not be as inspired or motivated to do what they have voluntarily done out of a sense in faith in the system. We are also going to have too little money to put where it is needed.

Concerning a lack of beds for elective surgery, he says: "Obviously, patients must plan for their hospital admission, organizing around a job, providing baby-sitting and necessary family arrangements, and if there are insufficient beds on the day of their admission, their surgery and admission will be cancelled, often at the last minute. It does not take much imagination to appreciate the emotional upheaval that delay of important surgery may have on the patient and his or her family. It may also incur financial cost and inconvenience to all concerned."

This is not common now, but it will be in the future. It is part of the cost of Bill 94. He goes on to describe why there are two causes for this problem, "...one being many emergency admissions. Our emergency department now handles twice the volume it was built for." How many of us are used to being in that kind of environment where we do not have the facilities and services we have come to take for granted for basic things?

"Second, there are always a number of patients, usually elderly, who are awaiting placement in chronic health care facilities or nursing homes, who are occupying active care beds. At any one time, the average number at York Central is 17." Again, this is accessibility: lack of acute and chronic care beds, lack of attention to the needs of the elderly.

Mr. Wildman: Why do we not have those beds after the Tories were in power for so long?

Mr. Cousens: Part of the problem is that our area is growing so fast that we are talking about a hospital which could double in size --

Mr. Wildman: We have that problem all over Ontario.

Mr. Cousens: -- and to the credit to the minister and the government --

The Acting Speaker (Mr. Morin): This is not question period.

Mr. Cousens: However, it is an important question he asked. I respect the member for Algoma (Mr. Wildman) at times.

8:30 p.m.

This government is already providing the funding for the Markham Stouffville Hospital to help relieve some of the overcrowding we have. It does not begin to solve the overall problem of underfunding for health care which exists now. We need more money for it. Let us not sidetrack that money into an area which will be a bottomless pit that will never be filled because there will not be enough money to satisfy the need the government is creating through this bill.

He goes on with his main point: "Third, with our increasing volume in the emergency department, it is woefully apparent that we lack a patient care facility to treat the fracture clinic and minor surgery patients who, for example, number 250 per week."

Fortunately, medical science is making great strides in providing more and more service for the people of this province. There are ways of doing things differently than we did them in the past. Let us allow the flexibility to do that and give people a chance to optimize the services available in our health care system. That means an investment in extra facilities. The money for those extra facilities will not be available if we put it all into the salaries of doctors who will not be working as hard or doing as much.

"Fourth, it has long been the opinion of our obstetricians that we should be capable of performing caesarean sections in our delivery suite for the safety of the mother and that of the foetus. Unfortunately, this new program has not been funded. Therefore, expectant mothers are wheeled, often in considerable distress with their baby in possible danger, up a long corridor to the operating room where the caesarean section is performed. Is this accessibility?"

Is the accessibility that is being given as one of the main reasons for Bill 94 really a reason, when people are already being denied accessibility to the quality health care we want to have? We should have our priorities in place. If it is accessibility, let us make sure we are doing something for accessibility and not just tampering with the system and undermining some of the very ingredients that will provide ongoing accessibility.

"Fifth, the lack of availability of computerized axial tomography scanning on a reasonable time schedule continues to thwart our attempts to provide good care. As York Central Hospital does not have a CAT scanner, we must refer our patients to other hospitals in the Metro area. At present, the wait for an outpatient scan is two to three months; for an inpatient scan, one to seven days."

If one of the Liberal cabinet ministers needed one, I am sure he or she could get it on the same day, but I am not worried about them.

The Minister of Health is coming in. I welcome him to the House. He has probably been listening in the back room, trying to keep track of all the things that are going on, but it is good to see him here at last for this important debate.

Mr. Ashe: He does not care at all.

Mr. Cousens: I know he does not seem to care. He is busy talking to his friends and making light of one of the most important pieces of legislation this government has brought before this House. The future health care of this province is in jeopardy and people are making light of it and not taking it seriously. That is why we are here; to present the facts and the situation so that people fully understand the ramifications of this pernicious bill.

He continues: "Some patients have to be admitted to hospital so as to expedite the performance of the scan as they medically cannot wait safely for three months to have it done. A CAT scan has been part of our diagnostic armamentarium for the past 10 years. It is not a new-fangled frill. This is accessibility."

We have an awful lot to do not only to maintain a health system but also to build upon it. I do not for a moment pretend it was perfect in the Tory days and has suddenly changed with the Liberal days. I do not think there has ever been enough money to do it exactly right.

We want to make sure that every hospital is able to provide state-of-the-art services to all patients, rich, poor or whoever they are, so anyone who enters one of our health care systems in any hospital knows they will have the best treatment available in North America or the world. That is the reputation we have had up until now. That reputation is about to be thrown out the window if we proceed any further with Bill 94.

He says: "Sixth, with regard to outpatient therapy at the hospital, there currently is and has been for a long time a waiting list to treat patients with whiplash, arthritis or low-back pain of four to six weeks." Think of that. A waiting list of four to six weeks for whiplash, arthritis or low-back pain. "People for evening appointments wait eight weeks," he says. "Speech therapy for preschool and school-aged children takes three months to attain an assessment of that child and one year for necessary treatment. Is this accessibility?" Is this accessibility? It is not.

If that is one of the reasons touted by the government for pushing this legislation through, it fails to know what accessibility is. It means to have the services and ingredients available in the context of a hospital so the people who are there are able to get the service they need.

"Doctors, nurses, therapists and hospital staff are blamed for the inconvenience and delays from inaccessibility to the system by disgruntled patients. Doctors are then forced to be apologists for central planning and inefficiency by the Minister of Health and the government's fiscal policy, which ensures this inaccessibility." Paul Randall is saying it well.

"Yet the medical profession of Ontario is faced with a threat to their professional freedom in the form of the Health Care Accessibility Act. We are insulted. We are outraged. After all our efforts to staff hospitals adequately and run them as efficiently as possible, we are told that our so-called extra billing is a threat to access to the health care system in Ontario. Nothing could be further from the truth."

I have to table the contents of Dr. Randall's letter because he represents something of the view I am trying to make. I want to put on the record as well that I do not think doctors are perfect. I do not think Dr. Randall is perfect. I have had people in my constituency office who have complained bitterly about lack of understanding from their own doctors.

There are weaknesses in our medical system, such as a failure to understand the mental health needs of people in this province. It is through that failure to understand that we are now seeing a new emphasis in government programs to encourage mental health, and I encourage that. In fact, I thank the Minister of Health for his support for the mental health program in York region. He recently allocated $100,000 for our mental health association's program.

We are talking about accessibility and something that is free for all. Dr. Randall asks in a postscript, "Why is it that the government does not provide free ambulance service?" I am surprised the New Democratic Party did not put that in the accord. The member for Algoma could have said, "What about poor people who want to get a ride to the hospital and who legitimately need it?" As it now stands, they have to cost-share the ambulance cost.

Mr. Wildman: We disagree with that.

Mr. Cousens: Does the member disagree with that? Sure he does, because that is the very point he is coming at in the extra billing.

Mr. Wildman: That is right.

Mr. Cousens: Someone might never get to a hospital if he ends up having to pay part of the cost. Logic would say, why not eliminate the extra billing for ambulance rides and the extra billing for chronic care?

Mr. Wildman: Move an amendment to the bill.

Mr. Cousens: I am surprised the member has not done so and maybe this is the reason he is going to vote against the bill. There is still hope. The NDP is not all bad or dumb.

Let me bring out a point that is in the Globe and Mail today about charging for ambulance rides and chronic care. There is an excellent article by Kenneth McDonald in the Globe and Mail on page B25. Probably few members read the business section and it might be helpful if I bring in some of the points he raises having to do with financial incentives -- that is a new term for some -- on health care.

Mr. Mackenzie: Will the member hold off if we agree to read it?

8:40 p.m.

Mr. Cousens: I will save the member the trouble. I would like to make a small excerpt of three or four paragraphs. It ties into the point Paul Randall makes. The government is allowing extra billing for ambulance rides, and if it is going to do that, what is the difference from having extra billing for doctors? Where has the logic gone? They are all quiet over there. They are continuing to clear their glasses, clear their throats or blow their noses, things they are good at, but when it comes to thinking they fail to think about the disincentives of having financial incentives for people when it comes to health care systems.

Mr. Wildman: My mother used to say two wrongs do not make a right.

Mr. Cousens: The member's mother was probably more right than he has ever been.

Mr. D. R. Cooke: The member said earlier that doctors do not need that. He is full of goodwill.

Mr. Cousens: The logic is still the same for both. Let us just lay it on the table to understand the breakdown in logic that exists here.

Mr. Epp: The member is saying the doctors are in this for the money, is that it?

The Deputy Speaker: Order. The member will please address the chair. Do not pay any attention to the interjections.

Mr. Cousens: I thought it was something intelligent for a change. One never knows.

Here is the quote: "Canadian politicians have fostered the illusion of free medical care for so long that they are afraid to shatter it. Yet some form of financial incentive or fee at the point of consumption would do much to relieve pressure on the system.

"For example, controlled studies by Rand Corp., a US think-tank, have shown that a deductible or a copayment, limited to $150 a year, reduced the use of health care services by about 30 per cent compared with a system of free care.

"Anyone who could not afford to pay a fee could be excused the charge, but the rest could contribute, as Dr. A. W. Pratt, of Burnaby, BC, has suggested, `simply by making the benefits paid by a provincial medicare plan taxable in the hands of the beneficiary to a limit of, say, three per cent of taxable income. As some of the patient's own dollars would be at stake, both patient and physician would be more circumspect in their complaints and in their claims.'

"Sooner or later, more of the cost of health care will have to be borne directly by its users. Although that will check demand, a lasting cure must await removal of governments' monopoly and the admission of other methods to compete with it."

It can be done. There is a way around this legislation that says we want to have accessible health care for all under one grey government system that can allow, for those who can pay or those who can be more involved, some disincentive, some reason to be involved in the costing of the program and some way of helping to lower those costs. When people go and put a small amount out of their own money, they think about it more. When it is government money that is paying for it, they think about it less.

I am digressing. An example of something that is free and uncontrolled, that has a little bit of money to it and where there is lots of control is the buggies one gets at the grocery store. Members are going to think I am losing my marbles; I am not. It ties in to Bill 94.

If one goes to most of the stores, one can take the cart out of the store and leave it out in the parking lot. It is there, and one can bang into cars all over the place. A new method was developed by a grocery store at the north end of Yonge Street, and I saw it not very long ago. To get a cart, one puts in 25 cents. One uses the cart and when finished with it, one takes it back, pushes it through this little button again and gets one's quarter back. Everybody puts his cart back where it was. There is control, there is regimentation and no one is taking advantage of the system, because a little bit of people's own money is there to protect those carts.

If just a little bit of each citizen's money were involved in the health care system, might it not --

Ms. Gigantes: Twenty-five cents or something?

Mr. Cousens: I do not know how little it is going to be, but if there were a small disincentive, would it discourage some of those who might take advantage of our health care system? Instead of going and putting it out themselves, instead of its being totally free, might they not come back then and say: "Maybe I will not go. Maybe it is just a headache like the one I had last time. Maybe it is something I can just handle this way, or maybe there is another way of doing it."

I am going off on a tangent, but that comes out of the points raised by Dr. Randall. The government extra bills patients for ambulance rides. What is the difference between extra billing there for someone trying to get to a hospital and the extra billing that goes on now by doctors?

Do members know why that extra billing is there? It is because people were taking advantage of those ambulance rides when they were free. I do not know whether they were intoxicated, wanted a ride somewhere or what their reasons were for using that service. However, they found by having a small fee -- and I support a small ambulance fee for those who can afford it -- it kept people and will continue to keep people from abusing a free system.

The day the ambulance ride becomes free, who knows what will happen? Our own Sergeant at Arms might be coming to work by ambulance. The Minister of Health might be coming here on a regular basis in an ambulance. The government will need to have a lot more ambulances when it removes the disincentive.

I have a number of other letters to which I would like to refer from other doctors in my riding. I refer now to Dr. Robert Alexander, MD, CRCS, FRCS, who is an eye physician and surgeon in Richmond Hill. He wrote this letter this week to the Minister of Health. He says:

"It is my observation that during my 20 years in practice there are more uninsured people in this province now than ever before. One major problem that the physicians in this province have, which I think must be remedied, is that five per cent of the patients that are seen do not have a valid OHIP number. For one reason or another, the subsequent result of this is that we do not get paid at all for our services."

How is the government going to remedy this problem? Has anyone raised it before?

Mr. McClellan: Yes. We will eliminate the premiums.

Mr. Cousens: I guess that will be the next step. That is the way we are going to go. I have taken the member for Kitchener (Mr. D. R. Cooke) off my list for cabinet since he applauded that one.

Dr. Alexander goes on to say: "The compensation board presents a similar problem. A patient comes to my office, states that his injury happened at work, I then treat him and I bill the Workers' Compensation Board.

"Approximately four or five months later, I find that his or her coverage has been rejected as it is the opinion of the Workers' Compensation Board that he or she was not injured at work. Surely the Workers' Compensation Board's arm of the government could make their decisions more efficiently.

"We then submit the claim to OHIP, and if the claim exceeds the six-month cutoff that is put upon us by OHIP, then the physician is out of luck." The system obviously needs repairing in other places than in the place we are approaching it in Bill 94.

Dr. Alexander goes on to say: "These are two very important and very common problems that the Ministry of Health has refused to deal with over the years. It is totally unsatisfactory, both the response in the past and the situation that is now present in this province. I hope that you will see fit to solve these problems promptly."

Who knows? We may see a solution to it, but it may not matter if members say the next position will be that people will not need an OHIP number, people will not be paying OHIP and so the costs will escalate even more. I do not know where the government is going to find the money.

I have a letter here from Dr. B. W. Granton in Richmond Hill. He too is talking about the Health Care Accessibility Act. He says: "I am, according to the above, being conscripted to serve on the vessel Medicare, which is floundering. The above comment is reinforced by the recent report re the inadequacies in mental health and cancer management in the province. These defects in the hull are a few of many.

"Mr. Peterson as Premier, your minister of the admiralty, Mr. Elston, and your provincial and federal predecessors have assumed responsibility for a vessel which you cannot afford and are incapable of commanding without the cooperation of the crew. You and your fellow politicians, not the crew, have opted out.

"You have promised safe passage to the passengers. You are obviously unable to fulfil this promise. You and I will some day be passengers on this vessel. Let us hope that it does not flounder while we are on board."

I think it is a beautiful analogy and a true analogy. I think it reflects the opinion of many who are afraid of what will happen with our health care system when this bill becomes law and when in the process the medical people in this province are forced to evacuate, move out and give up the ghost. I thank Dr. Granton for his comments.

8:50 p.m.

I have a letter from a doctor whom I have known for a long time. He is also a very dear friend and one who has probably given as much of his life as many of the doctors have in rural ridings and communities. This is Dr. Jim Outred, a doctor in the town of Markham, a great diagnostician, a brilliant man and a dear friend.

He wrote to me in late December, and we did have a chance to talk at a few parties during the Christmas holidays. It has to do with a solution to this state of confrontation now taking place through the process launched by the introduction of Bill 94. He was looking for another way for the government to respond to the needs before us.

Mr. Cureatz: Did he find a solution?

Mr. Cousens: He had one.

Mr. Cureatz: What was it?

Mr. Cousens: I am glad the member asked. I would like to share it with him.

First, he had to understand what the health care accessibility bill is all about. Every one of us has had some trouble with those words, "health care accessibility bill." It is going to be something that makes health care more inaccessible than ever before.

He says: "It has united the profession against the government because it represents a deliberate intrusion into the relationships with our patients. Do Messrs. Elston and Rae wish to forbid any voluntary payments made by our patients?"

Is there an answer on that one, Mr. Elston? Let me read it again, "Do Messrs. Elston and Rae --

The Deputy Speaker: Would the member refer to all other members by their ministerial name or riding name.

Mr. Cousens: Would the Minister of Health nod appropriately then as I am going along? Is it his intention to forbid any voluntary patients?

Hon. Mr. Elston: I am having a hard time refraining from nodding off.

Mr. Cousens: I appreciate that. I would like to put one thing on the record. Not once have I ever said a word against the Minister of Health. He is a man of integrity, a good man, and I have always liked him. Concerning this whole democratic process in which we are involved, the day we start indulging in personal attacks on an individual is the day I do not want to be part of it. I have too much respect for his contribution to his riding. I just do not like what he is doing right now. That is what has provoked me to speak on this subject; it is a debate that is most significant and does not have a thing to do with the fact we happen to be friends as well.

Going back to the letter from Dr. Outred, he says: "Many of the general practitioners have been very lukewarm" -- in other words, they are not all that keen -- "in their support of the association's pro extra-billing stances, because patients have been receiving unexpected bills from anaesthetists; patients referred to specialists have been asked to bring $55 in advance; and there are no opted-in obstetricians and gynaecologists to deliver our patients. We have now been squeezed out of that field because malpractice insurance has risen to such an extent as to make it totally uneconomical."

I will not get into the whole business of insurance in medicine. The Minister of Consumer and Commercial Relations (Mr. Kwinter) has done enough to wreck the rest of the whole province. There is going to be another whole series of battles we will be fighting in this House when it comes to insurance and the medical system.

Dr. Outred goes on to say: "I think it is high time that federal and provincial governments began to define what is negligence and the perimeter of actions that should be permitted. A vast number of laboratory tests and other examinations are carried out in the name of defensive medicine which are a total waste of time and money."

Here is a medical practitioner who is aware there are some things going on where new efficiencies need to be found. The $50 million we are talking about is nothing compared to the amount of dollars that could be saved through better planning in use of the funds we are already putting out there.

The doctor goes on to suggest: "I would like to propose some amendments to that act which might represent the middle road and be acceptable to physicians and patients. Extra billing should be changed to optional billing, the definition being that the patient alone has the option of paying it. Whether he pays it or not is none of the business of the Ontario health insurance plan or the politicians. It is just a moral responsibility on the patient, but no more."

The member for Algoma laughs. I do not laugh. At least it is another option, and that is a lot more than the present Minister of Health has given.

Mr. Wildman: The member should call it masochistic billing.

Mr. Cousens: There is a member of the New Democratic Party calling it that. I hope it is printed with his name beside it because I happen to be dealing with a man of integrity who believes in people and trusts them. He is not in the business of medicine for the money; he is in there for other reasons that have to do with serving people. It is a suggestion. Has it been discussed or thought about? It has been thought about by the member for Algoma; otherwise, he would not have given us such a goof-off.

Mr. Ashe: NDP means no down payment.

Mr. Cousens: He continues: "Optional billing will not be permitted until OHIP benefits have been received by the physician.

"The $10,000 fine will only be applicable to physicians who attempt unilaterally to collect this extra money from the patient by use of collection agencies, etc.

"As this money is being truly paid by the patient, it should not be subjected to the terms of the Canada Health Act.

"Anaesthetists should have benefits raised by 15 per cent to about 90 per cent to 92 per cent of the Ontario Medical Association's fee schedule, the money to be derived by cracking down on the horrendous expenses of emergency departments. These unfortunate people have little opportunity to reach any proper relationships with their patients.

"When optional billing is rendered, the physician should state his normal fee and the benefit received from OHIP, and the optional bill would be the difference of the two.

"If we are to become civil servants, as the present act decrees, then the accrual computation of our income for tax purposes should be abandoned."

Dr. Outred is just trying to provide us with a working alternative policy which might capture a middle ground. He makes some other comments. I am going to read the sentence. I do not like it but let me just put it into the record. He says:

"I am trying to provide you people with a working alternative policy which might capture the middle ground, as I think the present government members, without Ian Scott, are complete amateurs."

The member for St. David (Mr. Scott) has a fan somewhere. Here is a doctor who is at least trying to come up with a solution.

Dr. Outred says: "I am afraid that more severe strikes among the medical profession will certainly ensue unless amendments are made."

That is all I am asking for in my presentation, that amendments will be found and made and that the government will find a solution, in a working relationship of trust without emotion, which will allow the doctors and the Ministry of Health to sit down and negotiate a more meaningful position.

I have another letter from a very scholarly and good doctor in our riding. His name is Dr. J. A. McPhee, MD, CC, FP, in Richmond Hill. He says:

"It is with complete dismay that I survey some of the recent legislation regarding health care in the province of Ontario. It is amazing that there is general agreement that the health care system in Ontario is recognized by everyone as probably the best, most acceptable in the world, and yet the government of Ontario feels that it has to tinker with it.

"Why do politicians feel that the most personal, intimate, life-and-death care given to the people of Ontario has to be brought completely under bureaucratic control? How can the government believe that it will inspire and motivate a highly intelligent and caring group of people, such as health care workers, by passing such oppressive legislation.

"I am sure that it has been pointed out that the only alternative to the opting-out mechanism as a safety valve will be a trade union sort of arrangement with the threat of such work actions as strike. How would you like to have your health care delivered by Canada Post?"

That is what he is talking about. How would we like to have our health care delivered by those fellows who deliver our mail?

9 p.m.

Mr. Ashe: The only thing worse would be to have it delivered by the New Democratic Party.

Mr. Cousens: It has not had a doctor in its ranks, has it?

An hon. member: Yes.

Mr. Cousens: Who?

An hon. member: Dr. Shulman and Dr. Godfrey.

Mr. Cousens: It is too bad their party did not listen to them.

Interjection.

Mr. Cousens: Dr. McPhee says:

"As a young man of 18 years, I was called upon to go to Europe to fight an evil regime led by a man called Hitler. Most of the young men who went with me did not return. It was our hope that our actions and sacrifices would allow us to live in a society free of the kind of arbitrary action which you are about to impose on pharmacists and physicians. It is undoubtedly going to cause people in this province to lose confidence in the health care system, because now you have the pharmacists angry and the doctors will be unhappy. You may say that some 85 per cent of the population approve of your actions. In reply, I would like to point out that 85 per cent of the German population approved of Hitler."

Mr. Wildman: Is the member calling the Minister of Health Hitler?

Mr. Cousens: No. He has not grown a moustache.

Dr. McPhee goes on:

"Also, a large majority of Canadians approved of imprisoning Canadians of Japanese origin and confiscating their property from 1941 to 1945. This is called dictatorship of the majority and is generally considered by social philosophers to be as evil as any dictatorship.

"Since 1953, I have been conducting the practice of medicine in a conscientious manner, working hard to maintain a high standard of care. I worked hard to establish a local hospital of high quality and assisted in founding Blue Hills Academy, a residential school for disturbed youth. I am heavily involved in a committee of York Central Hospital board of trustees for the next three years. Suddenly, I find that my income is about to be legislated down by 25 per cent. By legislation, I now will be receiving the same remuneration as someone who graduated in 1985. Is this fair? Is this what is intended by this legislation?

"I hear that the motivation of the legislation is to assure accessibility to the health care system for all. This, of course, is just an excuse, because the factor which is denying access is underfunding by government. Some examples of this can be readily found.

"Recently one of my patients was neurologically impaired. He urgently required a CC scan. The first available appointment was six weeks in the future. His problem deteriorated so that he needed admission to a neurological hospital unit. This took three hours of our local specialist's time, calling several units in Toronto and begging for facilities to care for this patient. Is this accessibility?

"In our own hospital, our ophthalmologists have run out of interocular implants to treat our patients with cataracts. There is no more money in the budget for further lenses and there will not be any more unti1 April 1986. Thus, our patients who cannot see will have to wait four months or more before they can start treatment for their condition. Is this accessibility? Many more examples can be found.

"If you, the legislators, can conscript physicians and pharmacists, no one in our society is safe."

That means the businessman, the businesswoman, the people who are out there trying to make a strong economy and the people who are trying to build a province for their children and young people will begin to see this no longer as the place they want to live, work, have their families or retire, but as a place that is really in danger.

Dr. McPhee goes on: "Although I have never been opted in and practise in a town with many opted-in physicians, I have had to close my practice in order to practise high-quality health care. Every day I have people call my office asking to become my patients even though there are opted-in physicians available. The proposed Health Care Accessibility Act will of necessity make it impossible for me to practise the kind of health care that I have been able to practise under the present system. I will have to see more patients per day to maintain my gross income. This gross income, by the way, helps support four families: my own and those of my employees.

"For the sake of the very nature of our society, our democratic tradition and values, think about what you are doing and the precedents you are establishing.

"Yours truly, J. A. McPhee, MD."

He sent a copy of this to the Minister of Colleges and Universities (Mr. Sorbara), and I trust the minister will have shared it with the Minister of Health. It is an indication from another physician whom I know to be genuine and good and conscientious, as are the vast majority of the physicians of this great province. He does his service for our community only because he believes in his art and in the healing process and because he believes he has something to contribute.

Why do we want to come between him and his patients? Why do we want to come into his soul in a way that is going to make him feel differently towards his art form, towards his sense of service and towards his obligations?

Other doctors in my riding have in their offices form letters, which they are asking be sent to the Minister of Health and by which they are trying to explain to their patients the so-called Health Care Accessibility Act, 1985.

They raise the commonly asked questions and the commonly held perceptions of what these questions are: "What is opting in and opting out?" That is one of the questions. I do not need to read this into the record, but there are some 15 detailed questions having to do with the practice of opting out, injustices in the present system, whether doctors would be called civil servants, the problems for physicians and whether doctors will leave the province.

The doctors are having to carry out an education program so their patients will understand the ramifications of Bill 94, because the public at large does not generally understand it. Members of the public just do not know and probably will not know until five, eight or 10 years from now, when they may be sick and will need care, which will not be there in the way they think it will be. Or they may find out in the months ahead, in the negotiations the Ministry of Health tries to carry on with the doctors of this province, that the doctors are no longer easily worked over the way they were in the past.

Last night I had the good fortune of referring to some comments that are part of the history of our province; comments on how Mr. Robarts, Mr. Davis, Dr. Dymond and the member for Don Mills (Mr. Timbrell) all did an outstanding job in conveying the very spirit of what the health care system is and how it should be conducted.

Now we see this bill coming in. We have not had a chance to realize what is happening in the other provinces of this country. If we were to look at the other provinces, we would see that they have been able to solve the whole problem that arose because of the Canada Health Act. Each province has been able to look at this problem and has been able to come up with some solutions to it.

Knowing we are Canadians first and have to abide by federal legislation and guidelines, we hope we will always do that. When each province was forced under the Canada Health Act, it meant each province would begin to work out a way with its doctors to institute that all-party-approved legislation in Ottawa. The Conservatives, the New Democratic Party and the Liberals all supported it. The provinces now are in the process of following through on it.

9:10 p.m.

British Columbia is an example of a province that has gone into this. The showdown between the British Columbia Social Credit government and that province's 5,000 doctors occurred long before the Canada Health Act was discussed. In 1981, the British Columbia Medical Association and the government began negotiations over a fee schedule and the proposed ban on extra billing.

The doctors had voted 94 per cent in favour of extra billing and did not consider it a bargaining point. The Minister of Health tabled a bill that would expel any doctor who extra billed from the medical services plan. Furthermore, it would impose binding arbitration on fee disputes.

Negotiations resumed and the government withdrew the bill. Subsequently, both sides agreed to a 40 per cent increase in fees over two years. The identical bill was reintroduced with the arbitration clause deleted. It was passed on June 26, 1981. In 1983, the doctors received a 4.2 per cent increase, with no increase in 1984-85.

The relationship between the doctors and the government in British Columbia has not been a smooth one. Doctors were angered by the minister's actions in 1981 and by an attempt in 1982 to roll back their fee increase to six per cent from 14 per cent for the last seven months of their contract.

The British Columbia Medical Association and the board of directors offered to give the government $30 million worth of free service. In exchange, the doctors would be allowed to claim a loss in income of $8,000 as a tax deduction, and the fee schedule would be maintained as a base for new contract negotiations. The proposal split the doctors, and the British Columbia Medical Association held two special general assemblies to sort out the matter. Finally, it was barely passed.

After the original ban on extra billing, the British Columbia Medical Association took the decision to court. In May 1985, the Supreme Court of Canada denied a request for leave to appeal a lower court ruling against extra billing, thus ending any further court action. Therefore, the extra billing debate in British Columbia had been put to rest before the Canada Health Act became law. The province did sustain financial penalties over hospital user fees, but not over extra billing. Therefore, when the federal government legislation was passed, they were able to continue to receive the money. There was no punitive action by the federal government.

Alberta is quite a different story. Alberta's 2,800 doctors found in their government a staunch ally against the Canada Health Act. All kinds of comments were made by the doctors in Alberta. The Minister of Hospitals and Medical Care was one of the strong fighters against Mme Bégin's action. It is the only province that continues to have complete choice of billing methods. The doctors can bill the insurance plan for the authorized fee and the patient for the extra, or they can bill the patient for the full amount and he is then reimbursed for the portion covered by the plan. This allows the physicians to have the benefits of extra billing and the security of a government-backed plan.

The situation in Alberta is a bit more extreme than Ontario ever had. A time was coming in Ontario when our then Minister of Health, the member for Lincoln (Mr. Andrewes), Keith Norton and the various ministers, were prepared to sit -- was Keith the Minister of Health at one time?

Hon. Mr. Elston: Yes, he was.

Mr. Cousens: I thought he was. They were prepared to sit down and negotiate with the doctors and Ottawa to find some way of working this out. In Alberta I see another reaction that says, "We are not even going to touch it." The pot of gold they have is not going to last for ever. The day will come when they will have to face up to some way of working it out.

I am in favour of negotiating and working things out. I am in favour of seeing that we have something equitable. However, I am not in favour of Bill 94, because it gives only one option: "You will do it our way or no way, and if you do not do it that way, you will get fined up to $10,000." That is what I do not like about it. It homogenizes the entire system of health care. That is not where it would have gone had this party been preparing the legislation. I am inclined to think there is still time for the Minister of Health to change.

Saskatchewan has its own approach. It was the promise of being allowed to opt out and bill direct that brought Saskatchewan's doctors into medicare after a three-week withdrawal of services in 1962. Ever since, it has been considered the physician's right to opt out and bill direct. In Saskatchewan, extra billing is different from --

An hon. member: That is incorrect. They do not --

Mr. Cousens: No, they cannot -- oh, they can as long as they do not go over the amount.

An hon. member: That was a trick question.

Mr. Cousens: Then I passed the test. I would not want the member for Algoma (Mr. Wildman) to lead me down the garden path.

In Saskatchewan, doctors can operate within the plan and accept plan fees, they can opt out and charge their own fees, or they can remain in the plan and bill the patient directly, who is then reimbursed. There are three ways of doing it.

In 1984, things had changed a bit and the government was adamant that extra billing would have to end because it was losing $2.5 million a year. Also, polling that had been done in Saskatchewan showed a number of the public opposed to the fact of extra billing. The Saskatchewan Medical Association realized it had to sit down with the government, extra billing would be taken away and the doctors would have nothing in return.

Negotiations were carried out in Saskatchewan between the then minister, Graham Taylor, and the president of the Saskatchewan Medical Association, Richard Twanow, during the spring of 1985. An agreement was reached in May entitled Saskatoon Agreement II. The document banned extra billing and changed the method of negotiation for settling physicians' fees.

Mr. Wildman: Why would the doctors not do that here?

Mr. Cousens: The one thing I want to tell my friend is that in Saskatchewan, physicians can still opt out, but their patients are no longer entitled to reimbursement from their plan. In Saskatchewan they at least have given that option.

Mr. D. S. Cooke: Then the member wants the Quebec system.

Mr. Cousens: I am not sure which system I want. At least I want to see some discussions and negotiations. That came out in what Dr. Myers said. He said: "If you had let us negotiate, we could have said that senior citizens would not have extra billing. There would be other ways in which we could have handled the rest."

In the past, Ontario has been a leader when it came to legislation, programs and doing things right. Now we are at the wrong end of the totem pole; we are at the bottom. We are not leaders; we are doing it the other way.

In Manitoba, prior to the Canada Health Act, the 1,900 doctors practising in that province had to opt out of medicare completely if they wished to extra bill. Then they billed their patients directly, who were reimbursed by the plan amount. Once the Canada Health Act was introduced, the Manitoba government supported the extra-billing ban but made it clear it was willing to negotiate a fair settlement with the doctors.

An agreement was reached early in 1985 whereby the doctors agreed not to extra bill. In return, the government gave the medical association a 1.76 per cent fee increase, a $500,000 supplement for low-fee services and a three-year trial offer to negotiate fee increases through binding arbitration.

Quebec is quite another scene. I have talked to a number of Quebec physicians who indicate a different culture exists in that province. The 13,000 doctors who practise medicine in Quebec have always operated under a slightly different system from that in the rest of Canada.

First, the doctors are unionized; therefore, they have regular contract negotiations with the provincial government over wage increases, as does any union and its employer. They treat themselves very differently in relation to the government.

Second, physicians in the province cannot extra bill, but they can opt in and be paid by the plan, they can opt out and have the plan pay the patient, or they can be nonparticipating and set their own rates, but their patients will not be reimbursed by the province's insurance plan.

Mr. D. S. Cooke: That is not how it works in Quebec.

Mr. Cousens: The member had better go and find out. My facts are true and solid. If the member disagrees, he can take the floor and give me his facts.

9:20 p.m.

Mr. D. R. Cooke: What about the fact that we have lost $400,000 in Canada Health Act grants since the member stood up?

Mr. Speaker: Order.

Mr. Cousens: I am prepared to see that we do what we can to recover the money from the federal government, but I am also prepared to see that we negotiate with our doctors and come up with a program that is not just arbitrarily forced upon them but is something that has been negotiated in good faith by all sides.

The Maritimes has its own system. In Nova Scotia, extra billing is referred to as billing above tariff. In 1983, 58 per cent of the province's 1,400 physicians were billing above tariff to the annual tune of $14 million. Unlike other provinces, the discussions between the provincial government and the Medical Society of Nova Scotia were relatively amicable, thereby enabling Nova Scotia to become the first province in Canada to respond to the Canada Health Act. It is interesting how they were able to work it out. Both sides seemed to be able to sit down and talk with one another. They were able to participate in the discussion and dialogue and through that come up with a solution.

By the way, I would like to give credit. I am most grateful indeed to Cathy Fooks, one of the research officers in legislative research, who has done a tremendous amount of work in analysing what has happened in the other provinces. It has been through her work that I have gained a marvellous insight as to what is happening in the other provinces.

In New Brunswick, both opted-out and opted-in physicians can extra bill. Opted-out physicians bill the patient directly and the patient is then reimbursed, and opted-in physicians bill both the plan and the patient. At present, New Brunswick has not responded to the Canada Health Act. I am sure they will work out something. There is a good Conservative government there. I know they will find a way to work things out and it will not become the kind of socialized arbitrary stance we are seeing from this government.

Newfoundland has a system where only opted-out doctors may extra bill their patients who are then reimbursed by the plan amount, so there is no problem in Newfoundland.

Just for the record, in Prince Edward Island, doctors can opt out and bill patients directly or they can remain in and practise selective-servicing opting out. That is, they select which services they charge more for. There is not much problem there.

There is no extra billing in the Yukon and the Northwest Territories, as all physicians are opted in and do not charge more than the plan dictates.

These are just a few comparisons that exist. Ontario is one of a great confederation of provinces. We want to see this province be part of the whole federation of provinces and part of the Canada Health Act. I am anxious to see something happen so we can recover moneys due to us, but there are ways of doing that, ways that do not require the approach suggested by Bill 94.

Unfortunately, because we ran out of time last night and because of the number of points that doctors had made, I felt compelled to raise the view they had shared with me. It is important to keep that in perspective, along with the perspectives of patients and of politicians who care for the future. I do not want to see myself as one arguing for any one group of people except the citizens in my riding and the great people of this province.

All I want to see for them is a quality health care system, available to all and accessible to each one, a health system that responds to some of the very basic things that make it universally available to all people, a system that is portable, so that as Canadians, if we are sick in another province while travelling, we know we are going to be covered for it.

We want to have a program that is truly accessible, that allows access not impeded by direct or indirect charges, so that people who need it but cannot afford it will have the best available. They have that now. We are changing it in order to collect this. I can see us changing it to find ways of working it out, but I cannot and will not accept the proposals before us. There is still time for the Minister of Health to modify this legislation and bring in amendments. It is my prayer and my hope that common sense --

Mr. Haggerty: So the member is opposing it, is he? He is voting against it finally.

Mr. Cousens: Yes. The honourable member is asking whether I oppose it. I spent some time last evening laying out a number of the reasons why the government is bringing it in and failing to understand all the ramifications behind it. I am opposed to it and I believe that when the people of this province see the effect it will have --

Hon. Mr. Elston: But the member is also opposed to extra billing. Is that not also what he said?

Mr. Cousens: I do not think anyone who cannot afford the health care system should be charged for it.

Mr. Haggerty: Something different now.

Mr. Cousens: It is in there now so the people who have not had the funds, who have not been able to afford it, could receive that medical attention.

Mr. Mancini: How is the member going to find out whether they can afford it?

Mr. Cousens: The member for Essex South (Mr. Mancini) should get his limo. He comes in here and thinks he has the answers. I will bet he did not even know a thing about this until it was tabled in the House, because most Liberal MPPs had no idea it was going to turn out this badly. They have to face up to the fact that they are going to go up for re-election.

I am not going to be goaded on by the remarks of these people. I stand on what I say. I stand on behalf of the people of the riding of York Centre in Ontario. I am proud to be their member in this House and I am not afraid to stand up for them and speak against this pernicious and damnable bill.

Mr. Ramsay: It is a pleasure to rise in my place tonight, and somewhat a surprise. I was not sure I would have the opportunity to rise in my spot tonight and speak on behalf of the people of Timiskaming in support of this legislation, which will finally bring an end to extra billing in Ontario.

Each side of this issue has stated that this is an issue of principle. The doctors say the issue involves the principle of professional freedom, and the government says this bill addresses the principle of universal access to quality health care regardless of a person's income.

Let me first address the issue of extra billing by quoting from the Hall commission report, which was tabled in September 1980. This is the only quote I am going to read tonight, unlike the previous member, who quoted almost verbatim from this report. However, I also thank the legislative library service for producing this very worthy piece of research.

Mr. Wildman: It was not the member's own research?

Mr. Ramsay: I do not think so. To quote the Hall commission:

"The practice of extra billing is inequitable. Not only does it deny access by the poor, but it also taxes sick persons, who besides paying premiums are already paying the major cost of the system through their taxes. Provinces have the power to outlaw extra billing and should do so."

I asked myself why this was a problem at this time, when the Canada Health Act was passed a few years ago and was given royal assent in April 1984 in the federal Parliament. That legislation gave a deadline to provinces to put an end to the practice of extra billing or face the penalty of losing transfer payments in an amount equal to the amount that was extra billed in that province. I asked myself, "Why is this a problem at all?" It is a problem because extra billing should never have been allowed in the first place.

The principle of universality has been compromised for too long and we have allowed it to develop into a two-tiered system, a system that today still favours the affluent over the poor. The doctors say that no one is denied health care and that if a patient cannot afford it, all he has to do is ask the doctor to reduce the bill. Ask, beg or confess that, for whatever reason, one as an individual does not have sufficient funds to pay for health care? Today we feel that health care is a basic right for everybody and it should not be delivered on the basis of one's ability to earn money in this society.

9:30 p.m.

I do not want my constituents to have to beg to a doctor for a reduction in the fee. I want my constituents to be able to be referred to any doctor in this province and feel they have just as much right as anyone else in the province to the service that doctor provides; that no matter what their earning capacity may be, they have earned the right of access to that service by virtue of being citizens of this great province of ours and not because they are affluent.

I had a case in my riding that I brought to the minister a few months ago. It is a prime example of the situation that exists. It is unfortunate the medical profession has characters like the doctor involved in this case. The charge is not only more than the rate of the Ontario health insurance plan, it is way more than the rate of the Ontario Medical Association.

The OHIP fee for the operation in question is $1,700. I can only guess that the OMA rate is somewhere around $2,300 or $2,400. However, the doctor's bill was $3,000. That left $1,300 for my constituent to pay. I feel that is wrong.

This is what the legislation we are talking about tonight is going to rectify. Let us look at the principle the doctors are citing: the right of professional independence and freedom from government in dealing with patients. They feel this will lead to total dependence upon the government for their remuneration.

Doctors are living in a dream world when they speak like this. Are they forgetting they are also citizens of our land who, like all of us, have moral and social obligations as well as professional considerations? Do doctors not realize that, because of the necessity of the services they provide, the delivery of health care is a societal issue?

Like education, it is society that decides how essential services will be dispensed. Because of the essential nature of health care and because doctors have a monopoly in providing it, government has a right to be involved and to determine the availability, terms and conditions of that service.

However, we have a problem. What do we as government do to work with our physicians so they can progress and prosper in their profession? The problem is the image some doctors have of their profession; that of a professional relationship that provides a service for a fee in the marketplace, with the patient defined as a consumer of that service.

However, this is not the reality of health care in Canada in 1986. It seems that only in Ontario has the medical association been blind to this and refused to meet with the Minister of Health. The OMA should be concentrating on the real issue here: how much its members should be paid under our public health insurance scheme.

It should surely not be beyond the negotiating skills of the minister or the OMA to reach an accommodation that will recognize a physician's education, training, experience and skill, as well as those with exceptional abilities.

We have much to talk about. Let us get this legislation to committee so we all have a chance to discuss it. As legislators, let us be open to discussion. I say to the physicians of this province: "Bring forth your concerns and ideas because, as legislators, we need your help and advice. Now is the time for dialogue, not the rhetoric we have been hearing in the last few days. Bring your ideas and advice. Give us this help so together we can preserve the best health care system in the world, which I think we have."

Mr. Henderson: I and many of my physician colleagues have long been concerned about abuses in the practice of so-called extra billing by a few physicians in Ontario.

I commend the leadership and determination of the Premier (Mr. Peterson) and the Minister of Health in their vigorous pursuit of a solution to this problem. I believe their reaction to the abuses of extra billing is understandable and I am not unsympathetic to the spirit and principle of the course the minister has chosen.

Yet I fear Bill 94, the Health Care Accessibility Act, is not a good solution to this problem. I rise this evening to differ from my colleagues' view, not so much about the principle, the intent and perhaps in some sense the goals of this legislation, but about the timing and the specific proposals for attempting to achieve those goals.

Perhaps there are things about health care that can best be said by a private member on a matter of personal conscience. I therefore rise to speak against the measures of this bill.

Liberal candidates in May 1985, and I was one of them, campaigned on the promise of negotiations with the OMA to take action on extra billing. As a physician-candidate long troubled by the abuses of extra billing, I did not have difficulty standing on our party's platform. However, to me one of the operative words in our promise was, and is, "negotiate."

The problem with extra billing, in my opinion, is that some patients may not be able to obtain treatment services in certain areas and in certain fields of practice except from practitioners who extra bill substantially. Some physicians have shared my concern about this and some were pleased with, though wary of, a government that promised the situation would be addressed.

Accordingly, before the election call last year, I prepared some notes outlining some possible approaches to the problem of extra billing that I felt might contribute to a solution that would largely satisfy my party and my future political colleagues, yet would allow physicians the sense of professional freedom and autonomy I believe to be vital to their capacity to do good work.

Shortly after my election, I circulated a think-piece to my caucus colleagues outlining in a similar way some ideas for a proposed middle ground in a potential impasse between government and physicians. I believed then, and still do, that the problems of extra billing could be solved. I looked forward to participating in the solution. My optimism rested on a firm foundation of clinical experience, for I am no newcomer to health care and to the health care system.

I have well-developed clinical principles and a well-developed clinical conscience. I have worked in general family practice and in specialty practice. I have practised in a community general hospital, an academic teaching hospital, three government hospitals, a university clinic and a university clinical institute. I have been in private practice in two different cities. I have published widely and my contributions have been cited, noted and to a degree honoured on six continents. I have even been a medical missionary.

I have known and appreciated the challenges and problems of practice and creative work in all those fields of endeavour. I know the problems of practitioners and I know how those problems impede good work.

I believe I know what succeeds and what does not succeed, and I believe I know the difference between succeeding and appearing to succeed in each of those settings. Perhaps in one way that is the heart of the issue, for appearances, which matter very much in politics and government, are treated by clinicians as but surfaces to be probed for underlying truths.

Furthermore, I have training and qualification in public health administration, medical economics, international health and medical care delivery from Johns Hopkins University. I believe I know whereof I speak. Without wishing to sound immodest, I believe I am about as qualified as most people in Canada to know what does and what does not succeed in health care services delivery.

While I am a newer member of this Legislature, I have a very well-developed clinical conscience, a very well-trained social awareness, and I believe that since last May I have a mandate, indeed an obligation, to speak in a way that can be heard on matters crucial to the health care of the people of Ontario.

9:40 p.m.

Doctors may not be a popular group in society these days. Fortunately, that is not the issue. What is at issue is the health care of Ontario and the democratic right of two people to negotiate a simple, contractual agreement with each other, perhaps with certain safeguards provided by the state to guard against monopolistic fee-setting, but essentially at arm's length from the state.

Those who seek to weaken the substance or the impact of my remarks this evening may say that I am arguing a physician's point of view and defending my medical colleagues. That is not the case. Some members will recall that only a few days ago, in discussing in committee the 1984 report of the Workers' Compensation Board, I was quite critical of the role of physicians. I do not hesitate and will not in the future hesitate to be critical of my medical colleagues when that criticism is warranted.

Tonight, however, I am defending the people of Ontario from the threat of a weakening of the health care system. I am arguing a people point of view because I believe in their good health and their right to pursue a creative lifestyle of their own choice with vigour and energy. I believe in their health and wellbeing.

I am also arguing for democracy and freedom. I am arguing that it is not advisable for the state in peacetime to conscript physicians or any other group in society and compromise their democratic freedoms and circumstances, other than in a temporary state emergency.

The apparent permanent civil conscription of virtually an entire profession in peacetime is a serious and disturbing matter. I feel conscience-bound to oppose it. I believe such a step to be unwise and I would argue that point just as vigorously for any other group as I would argue it for physicians. This bill proposes to compromise the right of two citizens to negotiate a simple contract with each other. I cannot favour that.

To me, personal liberty is not just a slogan. I speak of personal liberty because it means a great deal to me. As a practising physician and counsellor, I devoted myself to helping people liberate themselves from a tyranny of neurotic conflict and suffering from within. I cannot, therefore, support legislative measures that compromise personal liberty from without. To me, freedom is not negotiable.

I am a Liberal because I believe in individuals, but I am also a professional who believes in professionalism. One cannot improve the health care system by seeming to alienate and demean the professionals that one relies on to provide the services and the leadership that help make the system work.

Let us think about that. Do we really want the practice of medicine to become a state monopoly? Let us think about what we know about state monopolies on this continent and elsewhere, how they work and how they do not work. Is that the kind of family doctor that one wants to have? Is that the kind of surgeon or anaesthetist one wants to have? Does one want his or her physician to be a man or woman who feels alienated, angry, constricted, legislated, regulated and stifled? I hope one does not.

I defend the right of any citizen or group to freedom from conscriptive state control, whether it be physicians who want to be free to practise their art, smelter workers who want a safer, more hospitable work place, machinists who want to fight for a fairer wage, or workers who simply want to bargain and negotiate in good faith with an employer who is willing to bargain with a sense of openness and fair play.

Management could hardly sit down to negotiate with a union and say: "We are going to negotiate you a three per cent raise this year. As soon as you agree, we will start negotiating the means by which we will bring it about." If the union says, "No way," the company could hardly say: "See, they would not negotiate. We were willing; they were not."

That is not my idea of negotiation in the context of freedom and democracy. I hope I am defending the democratic right of citizens. I am not defending doctors. I am a legislator and a Liberal who happens to know the health care system at first hand and very well, not a physician who happens to be in politics.

However, I am very worried. There has been a breakdown of dialogue between physicians and government which bodes ill, in my view, for the health care of Ontario. The relatively complete failure of government and the Ontario Medical Association so far to find a basis for discussion on matters of mutual concern, including extra billing, exemplifies that breakdown of dialogue. Each side blames the other. Surely the prescription for that breakdown is renewed efforts towards dialogue, not severe legislation. I campaigned on a platform of negotiation with the physicians of Ontario, not on a platform of their conscription.

I am worried about unconscious bias and attitude in the shaping of this legislation. Lawyers are prominent in the Ministry of the Attorney General. Educators are prominent in the Ministry of Education. Men and women with business experience are prominent, I am sure, in the Ministry of Industry, Trade and Technology. Yet physicians who represent the mainstream of clinical experience and wisdom are, one suspects, often not close to the drafting of policy and legislation to do with the health care of Ontario.

Paradoxically, physicians are sometimes viewed as having a conflict of interest in matters of health care, but they are primarily highly trained experts to whom we should listen very carefully. These problems do not originate by any means with this government. They are inherited problems. They have evolved in Ontario over several decades, yet they are being perpetuated, I believe, in the measures of the Health Care Accessibility Act, Bill 94.

There will be those in this Legislature and outside who may try to use my remarks this evening to criticize and embarrass the Premier and the Minister of Health. They have no support from me in so doing. I am a proud Liberal and a happy member of the Liberal caucus. I believe I speak as a committed Liberal in reflecting a point of view this evening that is in the mainstream of the Liberal way of flexibility, compromise and negotiation. Indeed, that is precisely what I am calling for.

I believe the Premier and the Minister of Health are sensitive men offering excellent leadership to our province. The popularity of this new government attests to their vigour and their courage in government. I do not differ with them on a matter of principle. I differ with the specific measures of this legislation and with its timing. As an experienced clinician, I feel conscience-bound to recommend a different course. Here are my views:

l. I do not propose to lobby for physicians. The only valid yardstick by which to measure the wisdom of health policy and legislation is the criterion of what is best for the people of Ontario. However, though health care is a political issue, we overlook at our peril that it is also and primarily a clinical issue by which people will live or die.

2. I do not wish to defend so-called extra billing. Excellence in helping service rests on the wish of men and women to be their brothers' and sisters' keepers. It is an important milestone in human civilization that access to first-rate medical care has become a right, not a privilege. Extra billing, as presently practised, may threaten equality and accessibility, although, to be fair, physicians' services are already more equal and more accessible than virtually any other area of professional endeavour.

9:50 p.m.

3. The billing practices of physicians are imperfect; so are the billing practices of lawyers, dentists, architects, psychologists and practitioners of many or most other areas of professional endeavour. Still, improvements in the billing practices of physicians are required, and we should try to achieve that without compromising excellence of service.

4. Medical practice rests on a historical tradition, thousands of years old, of physicians dealing directly with patients at arm's length from politicians and government. The proposed Health Care Accessibility Act, in my view, substantially alters that historical tradition. I fear it does so with too little real dialogue, consultation or negotiation with physicians representing the mainstream of seasoned clinical endeavour.

5. Rarely in the history of democracy, in my view, has any legitimate profession been so curtailed by the state in its freedom to negotiate a simple contractual agreement with a client. Insurers, even government insurers, rarely try to dictate the value of goods or services. Rather, they spell out the amount of coverage.

6. Should this bill become law, I can think of no other profession that will have its fees so much set by government, no other profession that will be forbidden by the state from negotiating a simple contractual arrangement with a client, no other insurance that will try to arbitrate the value of goods or services and no other professional who can be fined $10,000 for charging a few dollars more than the insurance rate for a service.

I feel it is not advisable to regulate, control and perhaps demean the providers of life-and-death clinical services to that degree. The measures and the timing of the Health Care Accessibility Act are, in my view, excessive and ill-advised.

7. The Health Care Accessibility Act, with its $10,000 fines and other severe measures, will have the effect, perhaps not fully intended, of placing physicians and other clinical services under the rather direct control of politicians and government, in effect conscripting them to the state.

8. Experiments in other jurisdictions whereby physicians have in effect become employees of the state have not fostered first-rate clinical care. When all the doctors in a particular society are controlled and accountable to the state, they are not able to do their best work. Do we want our children to get medical treatment from a state monopoly?

9. As a politician, I know the pressures my colleagues and I face to provide short-term, easy solutions to complex matters. I know of our vulnerability to rapidly changing social forces. I know of our tendency to plan on a time frame of one electoral term. Yet in clinical work the price of ill-advised innovation or policy change can often be patient deaths, sometimes on a very large scale.

10. Clinical care and the economic and social issues surrounding clinical care are complex. It is not advisable for all physicians to be directly accountable to politicians vulnerable to periodic renewal or withdrawal of their electoral mandate. Rather, there should be a co-operative partnership.

11. Perhaps physicians, like the judiciary, should retain an arm's-length relationship with politicians and government. That may be especially so because physicians, unlike the judiciary, serve not the state but individuals and families. Physicians should, accordingly, retain a large measure of accountability to the individuals and families they serve, with suitable safeguards provided by the state. An arrangement whereby all the physicians in a society report to government is ill advised.

12. With the recent emergence of third-party payment in the funding of clinical services, there is need for a review of the whole relationship between physicians and government. Failing such a review, there is danger that the medical treatment component of the health care system, where methods and programs may be life-and-death matters that must stand the test of time, may become subject to short-term shifts in political fashionability that would endanger clinical continuity and safety.

13. These considerations have not, in my view, been adequately addressed. The Health Care Accessibility Act proposes to alter fundamentally a system that has stood the test of time for thousands of years and that has fostered development of a health care system which is, though imperfect, perhaps the finest and fairest in the world. Compare health care with legal services, where justice is sometimes a luxury affordable to the rich. Of course, improvements in health care funding may be required, but the Health Care Accessibility Act in its present form is excessive and ill-advised.

14. The Ontario Medical Association states that it has long taken the position that there are many problems in the health care system needing to be addressed. It wishes to negotiate about all of them. Extra billing can be on the list. Perhaps we could respond to its willingness and negotiate in earnest with Ontario's physicians, respecting their traditions and expertise and treating physicians as partners in the delivery of health care services.

Physicians have real concerns and real fears about the health care of Ontarians. We should try harder to appreciate their views. It is not good enough in a democracy to say to a group of respected and highly trained professionals, or for that matter to any group: "No. We will negotiate only the means by which we now propose to achieve your compliance with our view. Other matters will have to wait. Your view is not legitimate."

15. Such a stance by any name is not negotiation. A labour union would not tolerate being treated in an analogous way. How could a government say, "We want to negotiate, but our position is non-negotiable"?

16. It is not advisable to give the matter of extra billing sole billing in the scenario of problems in the health care system and to try to deal with it out of context. There are many problems in the health care system of equal importance. Selective inattention is not in the long term a safe or useful response to a complex set of problems. Clinicians know that. They forget it at their peril.

17. There has been a serious and almost total breakdown of dialogue between physicians and government. Each side blames the other. I believe the health care of Ontarians will suffer as a result of that breakdown of communication. This impasse calls for discussion, not legislation.

18. Before we rewrite a 5,000-year-old, doctor-patient tradition, we should have more discussion. This is not a situation where two equally interested parties are discussing how to solve a problem. Rather, by the measures of this bill, one group of people in society tells another to change the way it and its colleagues have earned their living for 5,000 years.

Some honourable members objected to my use of the word "draconian" last week to describe the measures of this bill. They should pick their own words. I feel rather strongly about it.

19. Liberal candidates in the May 1985 election wisely and rightly promised to negotiate with physicians. Let the negotiations begin. That is the end of my numbered points.

10 p.m.

A few weeks ago I hosted a television panel on extra billing with panellists who included Dr. Ted Boadway, one of the Ontario Medical Association executive staff and the executive director of the Ontario Health Coalition, a group firmly opposed to extra billing. We began with totally divergent viewpoints. After an initial 10 minutes of sparring, we got down to serious discussion. By the end of the show, we had several distinct areas of agreement and a feeling among the panellists that compromise was possible and that we were well on the road towards some degree of rapprochement. We tried to approach the problem of extra billing as soluble in a mutually satisfactory way. I wish the government and the Ontario Medical Association could do the same.

I believe the point of view I state is very sensible, wise and Liberal. It may be that the right of a few professionals and citizens to negotiate a simple contract with each other on terms not dictated by the state is a useful safeguard in the health care system of a democracy. That point of view at least deserves our very careful attention.

I think about the birth of our first child in 1978: a series of prenatal visits, a confinement, a troubled labour, an expert diagnosis, decisive action, a painless caesarean birth of a delightful and deeply cherished baby boy and a postnatal visit, all from a world-class specialist in a world-class Toronto hospital.

I remember a total bill of $250 for the whole pregnancy, delivery, caesarean section and postnatal visit from that doctor, who trained for 12 to 14 years before he saw a decent income.

That was the OHIP rate from a practitioner who chose at that stage of his career to be opted in. That was his entire fee.

What a bargain. What a system. What a doctor. What expertise and quality of care. What price can anyone put on what he did for us? Being a doctor myself, I know the kind of outcome we might have had were it not for his skill, dedication, expertise and freedom to be and become what he is. What price can anyone put on that? If his bill had been $10,000 or $20,000, it would still have felt like a bargain to me.

Ironically, about the same time, I had to have a nonmedical professional consultant look over a one-and-a-half-page, plain-English letter of agreement with somebody. He made some minor changes in phraseology that seemed as though they might have taken five minutes in front of a Dictaphone and he billed me $250.

All of us, myself included, have had to struggle with the results of polls on extra billing. However, I have reminded myself that when people answer a pollster, they answer off the cuff, often on whim, off the top of their heads, so to speak. Given a choice between paying a little more or not, few people, as a first response, wish to pay more.

Perhaps when they think about it, things look a little different to them. When people do that, they may consider the quality of care and then say, "Let us err on the side of excellence, of safety in patient care." They know about the almost 90 per cent of doctors who are opted in now, in a free, democratic society where they can make a choice. They may know about the 95 or 96 per cent of patient visits that are billed directly to OHIP now at OHIP rates.

I believe we can improve those figures, but let us remember what kind of care occurs in the National Health Service of a mother state. Let us remember the black-marketing temptations, the under-the-table traffic and the so-called gift offers towards doctors from patients who want good care in some socialist states. We have the finest health care in the world, and we have it at fair rates -- at bargain-basement rates by comparison with many American cities.

Much has been made of the Canada Health Act, by which, if that legislation is found to be constitutional, our federal government can and does withhold transfer payments from provinces that do not prohibit so-called extra billing. Frankly, I object to that. For one thing, the constitutionality of the Canada Health Act is not yet assured. For another, health is a provincial matter. The Ontario government is more than entitled -- indeed, it is obligated -- to argue a point of view on behalf of the health care of Ontario. As for the withheld transfer payments, we should insist on receiving now the funding that is rightfully ours for the health care of the people of Ontario.

I doubt the people of Ontario care very much whether health care in Ontario is funded directly from the revenues and coffers of Ontario or from a combination of federal and provincial funding; it all comes from the pockets of the same taxpayers. If the province has to fund it entirely, the people of Ontario will expect a commensurate downward adjustment in their federal taxation. What federal government can afford to ignore the fiscal rights of Ontarians?

Let us not try to save another buck on health care. Let us save it somewhere else. I believe in the right of Ontarians to world-class, state-of-the-art health care. I believe in equality, universality, comprehensiveness and assured access. We almost have that now in health care in Ontario. We have excellence as well.

Let us improve what we have by negotiating with physicians. Physicians do have something worth while to say about the health care system in Ontario. Physicians have a clinical conscience, but they also have a social conscience, as witnessed by the outstanding work of Drs. Chazov and Lown and the many members of Physicians for Social Responsibility, recent recipients of the Nobel peace prize.

Let us address this problem of extra billing because it is a problem sometimes, in some places and in some fields. Let us address that problem decisively and with vigour, but let us not wreck our health care system in the process. Let us fine-tune a world-class system and make it better. Medical treatment is too important, too life-or-death, too critical for solutions that reject the mainstream of seasoned professional input.

Sometimes the state can say to the people: "Wait a minute. Have you really thought about this? Have you really thought it through?" Sometimes the people can say to the state: "Wait a minute. That is not the kind of state we want to have. We want to have an open, liberal, flexible, democratic state where problems are resolved by negotiation, reason, maybe compromise, and certainly mutual understanding and respect."

I praise and commend the leadership and the determination of the Premier and the Minister of Health. I know their commitment to the health care of the people of Ontario. However, I speak against the measures and the timing of this bill, and I recommend their reconsideration of it.

I hope that we, as a party and as a government, are strong enough to accommodate creative divergence on matters of personal conscience and social policy, which are crucial to the health of more than eight million Ontarians. I hope we are strong enough to be flexible and compromise.

However, even if changes do not occur, perhaps for me to be the object of a little confrontation among my colleagues will be a reasonable price to pay for a chance at forestalling a major confrontation in the health care system of Ontarians.

10:10 p.m.

If psychology teaches us nothing else in politics, it teaches us that no group in society is likely to contribute to its fullest if it feels its collective needs, feelings, views and expertise to be unattended or ignored. Such a course is a certain formula for rage and a probable formula for inhibition and paralysis. Perhaps there are rare occasions in government when we have to make that choice and pay that price. This is not one of those times. We need the good work of doctors, and angry doctors do not do good work.

Not surprisingly, I have been asked rather often these days to suggest exactly how I would approach the problem of extra billing; so I am going to do that. I offer a principle and a suggested step. The principle is that those with power use the least amount of power necessary to solve a problem. I fervently endorse that principle because it is both humane and good politics. It is humane because none of us, I hope, likes to ride roughshod over the freedoms of others. We should spare no effort to take any problem as far down the road to solution as we possibly can by discussion, negotiation and agreement, not by legislation.

We see how effectively this Legislature works because we have minorities and we have an accord with some of the opposition, rather than a subjugation of the opposition to the force of a voting majority. Minority government works because no one has enough power to enforce his will. We have to co-operate, and many people feel the Legislature works a lot better that way.

The same principle applies to the relationship of government with a profession or with any other group. Accords work better than power. It is good politics to use as little power as possible because no government, whatever its immediate popularity, does well by alienating any group in society or any sector of the electorate more than is absolutely necessary to achieve some goal of social justice. It is good politics to make many friends and few enemies, to restrain the use of power.

That is the principle: Use as little power as one absolutely must to solve the problem and go as far as one possibly can by discussion, negotiation and agreement.

This is my suggested step. Let us sit down right now with the Ontario Medical Association and negotiate as much as we possibly can agree together to do to solve the problem of extra billing. The OMA knows the problems and abuses, and I think it is willing to address them and might be willing to take action.

These negotiations can be tough and the bargaining can be hard, but let us see what we can agree to achieve by working together. Let us do that, do it now and agree together to changes in policy, regulations or even legislation. After that, let us sit down and decide how serious a problem still remains. After we have gone as far as we possibly can down the road to negotiation and compromise, perhaps then it may be necessary to go a little further by the power of legislation.

The former Prime Minister of Canada, Pierre Trudeau, once campaigned on the issue that he would negotiate with the provinces to patriate the Canadian Constitution and that if the negotiations failed, he would do it with the people over the heads of the provinces. He campaigned on that promise. Ultimately, that was how he had to proceed, but many years of attempts to reach negotiated agreements preceded that final use of power.

Surely it is one thing to use power to shift the balance of power between federal and provincial jurisdictions and quite another to use power to legislate away the rights and freedoms of individual people, and individual people are what liberalism is all about.

I recommend this course. I even recommend it to my friends and colleagues in the New Democratic Party, because if we legislate and overpower physicians today, which group in society will follow, which group of workers, which group of civil servants, which union, let alone which profession? Who will be the next object of seeming conscriptive legislation?

In short, let government first sit down with doctors in Ontario and say: "Okay, we have a problem here. Let us talk about it and find a solution together." Let us not say: "We have a solution. Let us agree that you accept our solution and talk about the problem later." That is not negotiation where I come from.

Let doctors sit down with the government and say: "Okay, we understand where you are coming from on this. We see that problem. We will help find a solution." I believe I know and understand doctors. They say to me: "We know there is a problem with extra billing, and we will be happy to sit down and talk about the problem and about possible solutions. Just start with a clean table and a somewhat open mind. Do not ask us to negotiate when we feel under threat."

Perhaps I know and understand politicians too. They say the people demand action on the problem of extra billing and we have a duty to act. Some of them even say: "We were willing to negotiate with the OMA and they were not. That is a fact. It is that simple."

It is not that simple. I know something about communication professionally. A communicative breakdown is never that simple. Communication under pressure is always loaded with latent meaning, assumed meaning, unconscious meaning, double meaning, hidden meaning and latent agenda. Communication is complex.

That is not an opinion, because, to borrow the language of some of my colleagues, it is indeed a fact. To say that we were willing to negotiate and they were not is at best a huge oversimplification. Possibly it is dead wrong.

Some of my colleagues in government say an absolute ban on extra billing is a matter of principle and the principle is non-negotiable. In truth, however, the non-negotiable ban on extra billing is not a principle at all, but a chosen tactic or strategy for solving a particular problem as perceived by particular people. The OMA says: "Why not look at some other tactics and strategies too? There may be better ones."

However, the principle is that there are problems and abuses in the matter of extra billing which need to be addressed. I have no trouble at all with that principle and the OMA might well embrace it too, if we could persuade both sides to back away from positions that seem to threaten power and confrontation.

Surely, if both doctors and government are willing to negotiate, we can forget about who was or was not willing to negotiate before. Let us willingly get together now and do it.

The Premier is said to have said last week that he might phase in a solution to the problem of extra billing. That is a great idea. Phase I could be taking action right now on whatever steps we and the doctors can come to agree on to solve the problems and abuses which have developed around so-called extra billing.

Phase 2 could be deciding after that whether and how much of a problem still remains, and whether we have to use power -- or, if one likes, legislation -- to solve it.

Phase 3 could occur when we tell the federal government what we are going to do -- notice that I said "tell," not "ask" -- and demand now our share of withheld transfer payments or else fair treatment for the taxpayers of Ontario.

10:20 p.m.

I believe the OMA would agree to the approach I have outlined. It is a fair beginning. I hope we as a government will seriously consider it.

The heart of the issue is whether physicians and government will be collaborators on health care, working and consulting together with reasonably good will to the benefit of all Ontarians, for quality health care will be very hard to preserve, whatever the equality and accessibility, if physicians feel coerced, legislated, alienated and offended.

Believe me, if Bill 94 becomes law, they will and their feelings will not go away in a few months. Surely the goodwill of the mainstream of medical practitioners is crucial to the satisfactory, let alone excellent, functioning of the health care system.

I am a loyal Liberal and a happy member of the Liberal caucus. My leader, the Premier, and the Minister of Health have shown great leadership in their demonstrated concern about extra billing and in their stated intent to negotiate a satisfactory solution. I am confident that, in the end, wisdom will prevail.

The Deputy Speaker: The member for Nipissing.

Mr. Harris: Thank you very much, Mr. Speaker.

[Applause]

Mr. Harris: Keep that up for six minutes. I am not quite ready.

I am not particularly pleased to rise and join in this debate, because I am not particularly pleased that this debate is taking place in the Legislature. I am not particularly pleased that this is the forum in which the government has chosen to deal with the matter of extra billing. I am particularly disappointed at the title of the legislation. I do not even have the official title in front of me --

Mr. Epp: If that is all that is bothering the member --

Mr. Harris: The government will change the title, will it, if that is all that is bothering me? The title is An Act regulating the Amounts that Persons may charge for rendering Services that are Insured Services under the Health Insurance Act.

The claim of the minister that this is going to improve access disappoints me. I particularly agreed with most, if not all, of the comments by the member for Humber (Mr. Henderson), which I thought were put forward in a pretty straightforward and unbiased manner. He has echoed many concerns that many of my colleagues on this side of the House put forward in this debate; that surely this legislation is not the way to deal with a group of professionals in Ontario; that surely, in the words of the member for Humber, we should strive to use as little power as is necessary to achieve the objectives we strive to achieve on behalf of the people of Ontario.

I thought he put it very well when he described this legislation as being an excessive use of power. It is heavy-handed and threatening legislation. I share the concern about allowing this legislation to proceed in Ontario. It is not in isolation for one profession. Bills 54 and 55 legislate solutions to the difficulties the pharmacists are having with the Ministry of Health in arriving at reasonable compensation for the products they sell, prescriptions that are necessary to the health care system.

If it were the only example, some might say the government has a particular hangup about extra billing, that it is not the type of legislation we might expect to see in dealing with other groups but is an isolated example. Some might say it is part of an accord or agreement, or that for some principled reason the Liberal Party feels obligated to proceed whether or not it honestly feels that is the best solution. Some might say that for some reason or other in this case it feels compelled to proceed in this manner in dealing with the doctors of the province.

If it were only that, one might be able to sell that. It is not excuse enough, but one might be able to sell it.

However, it comes on the heels of draconian legislation dealing with pharmacists. What are pharmacists? What is the history of pharmacy in Ontario? I bring out that example because it involves the same minister, the same Premier and the same government, and it ought to give fear to all in Ontario, be they professional groups, small businessmen or any collection of people who do business in Ontario. It is not whether they do business with the government in Ontario; they just wish to do business in Ontario. I concur with others who have said that unions, that groups of workers ought to be very concerned.

With the first little problem that came up with pharmacists, and we concur it was a problem, immediately heavy-handed legislation was introduced in the Legislature. We have what is admittedly a small problem in what has universally been acclaimed as probably the best health care system in the world; it is one of the best in the world. We again have this type of legislation.

I would like to speak at some length about why I feel this legislation is inappropriate at this time. As it is 10:30 p.m. and we have another performance to proceed with this evening, I will move we adjourn the debate.

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

The Deputy Speaker: In accordance with our announcement this afternoon, I deem a motion to adjourn to have been made, and will call the order of business as announced earlier.

10:30 p.m.

SPRAY PROGRAM

The Deputy Speaker: Pursuant to standing order 28, the member for Nickel Belt (Mr. Laughren) has given notice of dissatisfaction with the answer to a question given by the Minister of Northern Development and Mines (Mr. Fontaine). The member has up to five minutes to debate the matter and the minister may reply for up to five minutes.

Mr. Laughren: The reason I wanted to engage in this debate is that I was truly dissatisfied with the way in which the question I asked was handled by the Minister of Northern Development and Mines. I might just as easily have said I was dissatisfied with the answer by the Minister of the Environment (Mr. Bradley) too, but at least the Minister of the Environment made an attempt to answer; the Minister of Northern Development and Mines did not.

I happen to believe the Minister of Northern Development and Mines has an obligation to speak up on this particular issue, namely, the spraying of northern Ontario's forests. The Minister of Natural Resources (Mr. Kerrio) and his entire ministry have already taken a very pro-chemical-spraying stance. He said he intended to spray up to 30 per cent in chemicals. I feel very strongly and my party feels strongly that that is a wrong decision and that no chemical should be used. If any chemical is used at all, it should be the biological spray bacillus thuringiensis.

The promotional booklets put out by the Ministry of Natural Resources are basically a selling job for chemical sprays and for spraying on the whole. The fact sheets put out concerning the chemicals are, in my view, completely misleading. I will explain very briefly why. So far all the proposals in the various districts of the province have called for some use of chemicals.

It is my position that the chemical sprays are not needed and that they do not work. There are dozens of valid studies which question the safety of the chemicals being proposed. As well, the Ministry of Natural Resources is not giving residents, particularly those of northern Ontario, an opportunity to make their voices heard in a fair way, because they are not being presented with unbiased facts.

We know that the budworm egg count is down dramatically all across the province this year, and last year only Bt was used in the spraying program.

Mr. Harris: Very successfully.

Mr. Laughren: Very successfully used. The ministry used a figure of a success rate of 80 per cent for Bt last year. I am particularly concerned about the fact sheets put out on the chemicals. For example, in talking about fenitrothion, they used such expressions as, "No lethal effects have been detected on soil organisms, plant foliage, etc." I do not think that is the only way one judges whether it is completely lethal. They state that fenitrothion is not stored in the body tissues, not associated with Reye's syndrome. There are a couple of studies that indicate it is. This is what I find so misleading and offensive.

The resource sheet says, "Aminocarb has been the major chemical used for spruce budworm control in Ontario since 1976. In 1984 Aminocarb was used for budworm control in Newfoundland, New Brunswick, Quebec, Ontario and the state of Maine." What this sheet does not say is that both Maine and Quebec announced last year that they would no longer use this chemical. The ministry has deliberately selected the year before these two jurisdictions announced they would not be using it.

When discussing the fact sheet on Bt, the biological spray, there is a section on this fact sheet entitled, "Why do we not always use Bt?" There is nothing on the other sheets for the chemicals that asks why do we not use this chemical or why should we not use that chemical. Only on Bt does it say, "Why do we not always use Bt?"

It is clearly an attempt to head off any attempts by people who are concerned about the use of chemicals and to allay their concerns. I do not believe it is the role of the Ministry of Natural Resources to lay before the public, particularly in northern Ontario, biased information to lead them down the path of pro-chemical spraying. I think that is grossly misleading, unfair and insults the intelligence of people all across the province.

Hon. Mr. Fontaine: First, I want to remind my friend that I am not the Minister of Natural Resources. I am the Minister of Northern Development and Mines. Everything he has just told me should have been asked of the Minister of Natural Resources.

He has a few more open houses to do. After that, I will make my own decision with cabinet. That is my answer to my honourable friend.

Mr. Harris: What we want to know is, what is your position on the use of chemicals?

Hon. Mr. Fontaine: That is my business. I do not have to discuss this with the member. I will discuss it in cabinet, and that is it.

The Deputy Speaker: Order. The member for Nipissing (Mr. Harris) is not in his seat and should not be interrupting.

The House adjourned at 10:36 p.m.