I. Principle of the New Green Alliance and Medicare.

The New Green Alliance is a new Saskatchewan political party formed in 1998. It is affiliated with the Green Party of Canada and has fraternal links with similar parties in Australia, New Zealand, and Western Europe.
Members of the New Green Alliance formally endorse and subscribe to a basic set of principles. Among them are the following which are most appropriate to the question of government policy on the health of our citizens:

Social and Economic Justice. We believe in the right of every person of working age to
socially useful and environmentally sustainable work, access for every person to free
education and health care, as well as adequate food, clothing and shelter.
Participatory Democracy. All citizens must be able to directly participate as equals in
the environmental, economic and political decisions that affect their lives.
Co-operation and Mutual Aid. We believe in the concept of a co-operative rather than
competitive human society.
Decentralization. We must return power and responsibility to individuals, communities
and regions. We must encourage the flourishing of regionally based culture, rather than
a dominant mono-culture. We must have a decentralized democratic society with our
political, economic and social institutions locating power on the smallest scale that is
efficient and practical. We must reconcile the need for community and regional self-
determination with the need for appropriate centralized regulation in certain matters.
(Appendix A)

II. Structure of the Commission on Medicare.

The Commission on Medicare was appointed by the government of Saskatchewan on June 14, 2000. Kenneth J. Fyke was appointed as the sole commissioner. We did not agree with the structure of the Commission:
(1) It was designed to be an insider review of the medicare system by a professional
health civil servant and administrator.
(2) The staff was drawn primarily from the Departments of Health and Finance.
(3) No public hearings were held.
(4) The questionnaire which was circulated to households, and used to direct the focus group meetings, was highly structured and the options present to participants was designed to lead people in a particular direction.
(5) The time line for the commission was too short to do a complete job.
(6) The central focus of the terms of reference and the subsequent report was on the
need for greater efficiency and for cost reduction.
Our preference was for a different kind of commission with a different mandate:
(1) A broad inquiry on what was needed to promote good health and health care services for all of the people of Saskatchewan.
(2) A commission that represented our society, including women and Aboriginal people.
(3) Public hearings around the province.
(4) A commission independent of the Departments of Health and Finance.
(5) The use of social scientists who with expertise in the broad area of health in general.
Most people are well served by the present medicare system. Recent public opinion polls show that the great majority of people believe they have receive good treatment when ill. It is our belief that the Commission should have focused on problem areas within the Saskatchewan system. This would have included:
(1) The health of Northern people and their health services, with a particular focus on
the Aboriginal population.
(2) Health services in rural areas.
(3) How to improve the health of low income people.
(4) The growing numbers of elderly people and their needs.
(5) The impact of health care "reforms" on women as the primary care givers.

III. Position of the New Green Alliance.

Prevention promotes wellness
When the NDP was elected in 1991 it proclaimed that there would be reforms in the health care system in Saskatchewan which would emphasize "wellness." Most people believed that this would mean an emphasis on the prevention of illness. That was the common sense response. But that is not what we got. We have a system which continues to concentrate on providing cures to people who are sick or injured.
There is an enormous body of evidence available that demonstrates that poverty, inequality, status, employment, and work environment are the key factors in determining good health. The report of the Fyke commission mentions this briefly in Chapter III but offers no strategy for dealing with the core problem. To the New Green Alliance, this must be the central focus of any health policy based on wellness.
Beginning in the 1960s, Dr. Michael Marmot, director of the International Center for Health and Society at University College London, began the Whitehall I study of the health of British civil servants. This classic study revealed that the higher the job classification, the lower the rate of death, regardless of the cause. Inequality is the most important factor in determining health. (Marmot, 1996; Kawachi et al, 1999; Berkman, 2001; Daniels et al, 2000)
Numerous subsequent studies have reached the same conclusion. A recent study by the CPRNs Health Network concluded that "among factors that influence health over a person's lifetime, the health care system, itself, is far less significant than the social environment. Measures of health status, like mortality, morbidity and self-assessment, all vary according to socio-economic measures like education, social class, occupation and income." People's health status "closely parallels their socio-economic status, regardless of the quality of the health care system available to them." (Glouberman et al, 2000)

There is good research on the effects of racism on African Americans. We suspect that these findings would also be relevant for the case of racism against Aboriginal people in Saskatchewan. Those experiencing racism suffer larger and longer-lasting increases in blood pressure than when faced with other stressful situations. Social exclusion, residential segregation and other expressions of institutional racism magnify the impact of low socioeconomic status. (Geronimus et al, 1996; Krieger and Sidney, 1996; Krieger, 2000)
Yet across Canada, including Saskatchewan, government taxation and spending policies have focused on cut backs to social programs coupled with reduced taxation on corporations and those in the higher income brackets. As Statistics Canada (March 2001) recently reported, this has resulted in greater income and wealth inequality in Canada. A new study by Andrew Heisz at Statistics Canada has found that low income intensity rose by 10% over the period from 1993 to 1997. Saskatchewan has the highest infant mortality rate of any Canadian province. This is one of the most widely used standards of determining poverty and inequality. Unfortunately, the elimination of poverty and inequality has been a low priority for our provincial government for the last two decades. And there are no recommendations for change in the Fyke report. (Raphael, 2000; Heisz, 2001)
A good system of prevention is the only way to reduce the costs of medicare while improving the health of Canadians. Ironically, wealthy Western governments are starting to look seriously at Cuba to see how a poor country can maintain a healthy population while spending relatively very little on a health care delivery system. The infant mortality rate in Cuba is lower than the United States (or Saskatchewan) and life expectancy is the same as in the industrialized West. Yet on a per capita basis they spend a fraction of what we do on a medical care system.
In October last year, a team of specialists from the British Department of Health and 100 general practitioners went to Cuba to see what they could learn. They concluded that Cuba's success was due to a combination of healthy food, adequate housing for all, the absence of automobiles, and neighbourhood clinics with adequate nurses and doctors.. Family practice stresses prevention. Rural people have access to the same levels of care and support as urban people. An extensive, affordable child care system and universal K-12 education is very important. Children in child care services and elementary schools are fed the equivalent of two meals a day. (Boseley, 2000)
In August 2000 Dr. Carolyn Bennett, Liberal MP and professor of family and community medicine at the University of Toronto, made a similar tour of Cuba. She reached the same conclusions. The Cuban health care system was less expensive and better than that in the United States, she argued, because of its emphasis on prevention and the elimination of absolute poverty. (Bennett, 2000)

The necessity of good air, water, food and housing
Good health also depends on a good environment. People need clean air, good water, nutritional food, and good quality housing. The New Green Alliance would put a greater stress on these factors in an attempt to prevent illness.
Here in Saskatchewan we believe we have good air. Our smaller communities have less air pollution, and the wind blows away the smog from our vehicles. This gives us air which is much better than in the larger urban centres. Yet Environment Canada's list of the leading atmospheric polluters includes fertilizer producers, food processing plants and feed lots in Saskatchewan. When farmers are applying herbicides and insecticides, our air quality declines. (Ewins, 2001) In 2000 Agriculture Canada tested rainwater across Alberta over the summer and found herbicide traces in all samples. Some samples showed 2,4-D at 53 parts per billion, which is one half the Health Canada guideline for drinking water. (Duckworth, 2001)
We have much more to worry about when it comes to our water. A 1997 Canada-Saskatchewan Green Plan study found high levels of nitrates in most of the wells tested in this province. Pesticides were found in 10% of the wells in the Kindersley area and 45% of those in the Outlook-Davidson area. A 1998 study by the National Hydrological Research Centre in Saskatoon found herbicide and insecticide residues in all 21 farm dougouts they tested.
Of course, we are much more aware today of the problem of safe drinking water in Saskatchewan, following the North Battleford disaster. The Safe Drinking Water Foundation in Saskatoon insists that testing for water quality in rural Saskatchewan and the North is inadequate. Furthermore, simply adding more chlorine can add to the problem, for when chlorine is combined with organic acids it produces trihalomethanes (THM) which are cancer-causing agents. (Peterson, 2001; O'Connor, 2001; Silverthorn, 2001)
Ontario, Quebec and Alberta have also been struggling with the problem of ground water contamination from intensive livestock operations. We may be facing that problem here. Livestock manure run off was the cause of the Walkerton, Ontario disaster. As John Lawrence, director of the National Water Research Institute stressed in a talk in Saskatoon recently, we have got to look at intensive livestock operations "as basically industrial process plants instead of farms." Excrement from large hog barns, spread untreated over the land, contains not only nitrates and phosphates but copper, nickel, and manganese used in feed supplements, as well as parasites, bacteria and viruses, including salmonella, campylobacter, e.coli, cryptosporidium, giardia, cholera, streptococcus and chlamydia. (Duckworth, 2001; "Big Farms", 2001; Thu and Durrenberger, 1998)
Good health depends on good, nutritional food. The New Green Alliance would argue that the most nutritious food is that which is fresh and grown locally. Food loses its nutritional value when it is stored and transported for long distances. It loses nutritional value as it is processed. Of particular concern to us is the use of hormones to promote growth in beef, the widespread use of antibiotics in feeds to promote growth of poultry and other animals, and the feeding of rendered animal wastes to domesticated livestock who are normally vegetarian. We see no benefits to farmers or consumers from the introduction of genetically engineered foods.
People living in Northern Saskatchewan have more severe health problems than the rest of the Saskatchewan population. One of the causes of this situation is the lack of good food at affordable prices. Whereas the provincial government ensures that the cost of alcoholic beverages is the same in the North as it is in the south, they have been unwilling to take action to provide food for the same price. We could look to Mexico to see how basic food was distributed to low income people through a system of state-owned stores in low income neighbourhoods. We would shift government support from industrial agribusiness to ecological farmers who produced for a local market. (See Bonanno et al, 1994; Goodman and Redclift, 1991; Magdoff et al, 1998; Goodman and Watts, 1997)
Good housing is fundamental to good health and wellness. This has been widely recognized for some time. (See Shlay, 1995) It was a focus of attention in the Golden report on low income housing and the homeless in Toronto. The connection with health is very evident: "people who are homeless or living in sub-standard housing are at much higher risk for infectious disease, premature death, acute illness and chronic health problems than the general population is. They are also at a higher risk for suicide, mental health problems, and drug or alcohol addiction." (Golden, 1999)
When asked to comment on why Saskatchewan has the highest infant mortality rate of all the provinces, Pat Atkinson, Minister of Health, said it was due to poverty in the north and particularly among Aboriginal people. Clay Serby, when he was minister in charge of housing, said that the province needed around 40,000 new residences for low income people. Both have admitted that poor housing and overcrowding are a major problem in Northern Saskatchewan. But very little is being done to solve this serious problem. This should be a priority area for the Saskatchewan government.

Additional services are needed
There are other important issues which are not really recognized by the Report of the Commission on Medicare. The whole issue of mental health is ignored. There is no mention of the health status of people who are incarcerated in the Saskatchewan penal system. The issue of the health of the Aboriginal community is marginalized.
The National Forum on Health, which reported in 1997, called for the creation of a national pharmacare program and affordable home care. Unfortunately, the new Social Union, so strongly supported by former premier Roy Romanow, now makes it nearly impossible for the federal government to introduce these federal-provincial programs, strongly supported in public opinion polls. The Forum also called for a national child care program and an integrated program to eliminate child poverty. (Gray, 1997)
There is also a need for a dental program and an insurance program for vision care. Many low income people do not have coverage under union contracts, work plans or private insurance programs. A recent Statistics Canada survey found that only 46% of the Saskatchewan population visited a dentist over a one year period, well below the Canadian average of 60%. Cost is the major barrier. (Rogers, 2000)
For the medicare system as a whole, prescription drugs take about 15% of spending on health, behind only the costs of hospitals (32%) and above the cost of physicians (14%). The cost of drugs has been increased because of the changes to the Patents Act following the implementation of the North American Free Trade Agreement. Generic drugs are on average are priced around 50% of the cost of protected brand drugs. Unfortunately, the Fyke Commission dodged this important issue.
We believe it is necessary for the province of Saskatchewan to take on the monopoly drug corporations. Profits for these corporations are very high -- in the range of 18% to 27% of revenues. Their spending on research and development (6.5% to 19.8% of revenues) is far less than they spend on advertising and marketing (15% to 39% of revenues). Furthermore, much of their research is paid for by governments, universities and private foundations. (www.phrma.org)
We believe that the Saskatchewan government should follow the lead of Brazil and South Africa and become the purchasing agent for the provincial medicare system. This includes searching the world for the lowest prices.

The impact of the NDP government's reforms
The cut backs to the provincial pharmacare program have been very hard on many people. For example, low income seniors are paying more of the cost for prescription drugs than any other province. Those on GIS here pay on average $460 a year for prescriptions. Quebec is second at $360. ("Province's Seniors," 1999)
There is also the issue of the writing of prescriptions. It is alarming to learn that the number of children being prescribed Ritalin has increased ten fold over the 1990s. It is astonishing to learn that the number of prescriptions written for antidepressants in this province has increased from 349,000 in 1998 to 419,400 in 2000. There is something fundamentally wrong with our society and the sickness care system when the answer to health and wellness problems is to put everyone on drugs. (Warick, 2001)
The New Green Alliance strongly supports the community clinic approach to providing health care services. They provide the integrated approach recommended by the Fyke Commission, and they can include holistic medicine. This form of delivery of services has proven to be less costly than individual practice by doctors. The key to success of the community clinics is that they are co-operatives run by their members. We believe that local, community control should be promoted whenever feasible. Primary health services are best provided by community clinics. In our opinion, they are preferable to individual private practice, doctor-owned walk-in clinics or regional clinics owned and operated by the provincial government or their subsidiaries, the health districts.
Today, the health care delivery system is run by the government. Physicians, nurses and health care workers have input into the system through their representative organizations. But the general public who pay for and use the system have little influence over how the system operates or its basic principles. The New Green Alliance advocates the creation of an ongoing, funded, representative, overview committee that would allow the citizens as a whole to have a say in how the system operates.
There is a widespread concern today in Saskatchewan over the health care reforms that were introduced by the NDP government in the early 1990s, and in particular the role of the health districts. Some of those concerns are as follows:
(1) The new changes were driven by the goal of cutting costs rather than creating a new system to improve the health of people.
(2) The abolition of 500 local health boards and their replacement by 32 appointed health district boards was a dramatic move towards more centralized control.
(3) The new health districts have no control over revenues or budgets.
(4) The new health districts have encouraged the introduction of privatization of local services.
(5) The new health districts have resulted in different health services offered in different areas of the province.
(6) The new health district system resulted in the Dorsey Report and the denial of the democratic right of workers to choose their own trade unions.
(7) There is less local public participation in the health care system under the new reforms built around the health districts.
The general thrust of the Report of the Commission on Medicare is to continue this system and to promote even more centralization of power. For people living in rural Saskatchewan, there will be even less control over the health care system.
Kenneth Fyke is concerned primarily with creating a "more efficient" way of delivering the present system of treating sickness and injury. The goal is to hopefully be able to cut the budget for health care by 30 to 35%. This, in our opinion, is the fundamental problem with the approach of the commission.
First of all, the proposals involve a shifting of health care costs from the public area to the private sector, particularly the family, and more particularly to women, who are the primary care givers. In rural areas, more costs will be shifted to families.
Furthermore, this approach ignores the importance of family, friends, community and history to the health and well being of human beings. It reflects the general shift in social services away from the Keynesian welfare state with its fundamental policy that good health care and social well being are citizenship entitlements in an advanced, industrial society. It is a rejection of the modern Keynesian goal of lifting the burdens of family care giving from women and putting more of these burdens in the public sector. It reflects the new dominant ideology of neoliberalism.
We live in an agricultural economy. The urban centres in this province benefit greatly from agriculture as finance and agribusiness interests take most of the income earned by farmers for their labour. Wealth flows from rural areas to urban areas. The New Green Alliance believes that the urban sector of the province can afford to give back some of that wealth to the rural areas in the form of good government services.

Financing the health care system
The basis for the position of the Commission on Medicare is that health costs are rising fast and that this trend cannot be maintained. The mandate asks the Commission to investigate this area, but it has not.
The data here is very clear. Health care spending in real terms (discounted for inflation, in $1986) stood at $1,200 million in 1991, the last year of the Progressive Conservative government of Grant Devine. The budget was cut by the new NDP government and did not surpass the spending of the Devine government until 1998. (See Appendix)
Health care costs as a percentage of the provincial gross domestic product stood at 6.4% in 1991. They fell to a low of 5.1% in 1997 and have risen slightly to 5.3% in 2000. Thus, as a percentage of our GDP, we are certainly not spending too much on medicare, and it is not rising. (See Appendix)
The main problem for the government is the decline in revenues. Provincial revenues as a proportion of the provincial GDP have fallen steadily from 24.9% in 1991 to 19.0% in 2000. This reflects the reduction in resource revenue taxes and taxes on corporations and small business, reduction in wealth taxes, and reduction of income taxes on those in the higher income brackets. You cannot maintain the same levels of services if you are going to reduce taxes. (See Appendix)
It is for this reason that the New Green Alliance has taken the position that we should maintain the progressive tax system of the Keynesian welfare state. We should also move in the direction of restoring the taxes and royalties on resource extraction industries. In this respect, our taxation policies are similar to those we had in the province during the NDP government of Allan Blakeney (1971-82)
In an economy fundamentally based on agriculture and the extraction of natural resources, we cannot provide good social services, including health care services, unless we are willing to tax the resource industries.

IV. Specific proposals from the Commission on Medicare.
The New Green Alliance endorses a number of the major proposals from the Commission on Medicare:
(1) There is no need for health care premiums or users fees. These are regressive taxes that are unnecessary. Alternatives revenues are available.
(2) Continued commitment to the five principles of the national Medicare system: comprehensiveness, accessibility, universality of coverage, public administration, and portability.
(3) The need to look at the fee for service system and doctor's incomes. Why is it that doctor's incomes in Saskatchewan are 36% above the national average and higher than those in any of the four western provinces? (See CIHI data in Appendix)
(4) We need research on special prairie health problems, especially those associated with living in the North and rural areas.
(5) We support the team approach to medical services, using the Saskatchewan Community Clinic model.
(6) Telephone service can be helpful but it is no substitute for good, local health services.
(7) The quality control proposals have some merit but must involve patient and general public participation.
The public and the media has focused its attention on the proposal of the Commission on Medicare to reduce the number of rural hospitals, eliminate hundreds of acute care hospital beds, and consolidating the rural health districts into 9 or 10 larger units.
The New Green Alliance does not have a formal policy on the health care districts. Our policy is set at the Annual General Meeting, and we try to reach a consensus on all major issues. But there is a consensus among our members and supporters that the present health care district system is not working and is unacceptable as it stands, for the reasons cited above.
Perhaps a majority of our member favour the abolition of the health districts. This is the position supported by the majority of Saskatchewan adults, as reflected in recent public opinion polls. It was the position taken by Chris Axworthy in his campaign for the leadership of the NDP. It is widely believed that it was his position on health districts that made him the preferred candidate among voters in general as well as NDP voters.
There are a number of members of the New Green Alliance who believe that the present system of rural health districts should be retained, but only if they are transformed. They must have adequate funding. There must be local, democratic control. They cannot just be the managers of the provincial government which is off loading its responsibility for cutbacks onto local boards with appointed members. People in rural Saskatchewan have also witnessed the loss of front line health workers and their replacement by more administrators. We know full well that this has angered people in rural areas. As the Commission reports, there is little local interest in the health boards. People see them as having no real control over important matters.
In conclusion, as you can see the New Green Alliance has a perspective on wellness and health care services which is quite different from the general thrust of the Report of the Commission on Medicare.

References

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Armstrong, Pat et al. Heal Thyself: Managing Health Care Reform. Ontario: Garamond Press, 2000.

Bennett, Carolyn. "Rx for Canada: Check out Cuba," The Globe and Mail, August 31, 2000.

Berkman, Lisa. "Social Inequalities and Health: Five Key Points for Policy-Makers to Know." Kennedy School of Government, Harvard University, February 5, 2001.

"Big farms threat to water quality." Leader Post, May 7, 2001.

Bonanno, Alessandro et al. From Columbus to ConAgra; The Globalization of Agriculture and Food. Lawrence: University of Kansas Press, 1994.

Boseley, Sarah. "Cubans tell NHS the secret of L7 a head healthcare." The Guardian (London), October 2, 2000.

Daniels, Norman et al. Is Income Inequality Bad for our Health? Boston: Beacon Press, 2000.

Duckworth, Barbara. "Herbicide falling from sky." Western Producer, January 25, 2001.

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Ewins, Adrian. "Ag-related industries high on pollution list." Western Producer, April 19, 2001.

Geronimus, Arline T. Et al. "Excess Mortality Among Blacks and Whites in the United States," New England Journal of Medicine, 335 (21) November 21, 1996.

Glouberman, Sholom et al. "Towards a New Concept of Health: Three Discussion Papers." CPRN Study, September 2000.

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Goodman, David and Michael J. Watts. Globalizing Food; Agrarian Questions and Global Restructuring. London: Routledge, 1997.

Gray, Charlotte. "The National Forum Reports: Crisis? What Crisis?" Journal of the Canadian Medical Association, Vol. 156, March 15, 1997.

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Krieger, Nancy. "Refiguring ‘Race': Epidemiology, Racialized Biology, and Biological Expressions of Race Relations," International Journal of Health Services, 30 (1) 2000.

Krieger, Nancy and Stephen Sidney. "Racial Discrimination and Blood Pressure: A CARDIA study of Young Black and White Adults," American Journal of Public Health, 86 (10) October 1996.

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Magdoff, Fred et al. Hungry for Profit; Agriculture, Food and Ecology. New York: Monthly Review Press, 1998.

O'Connor, Kevin. "Cancer-causing chemical found in some drinking water." Leader Post, May 22, 2001.

Peterson, Hans. "Rural water quality testing said inadequate." Leader Post, April 3, 2001.

Peterson, Hans. "Safe water means more resources." Western Producer, January 25, 2001.

"Province's Seniors Pay Most." Leader Post, September 3, 1999.

Raphael, Dennis. "Health Inequalities in Canada: Current Discourses and Implications for Public Health Action." Critical Public Health, 10, 2000.

Rogers, Wilson. " Dental visits decaying on the prairies." Western Producer, April 27, 2000.

Shlay, Anne B. "Housing in the Broader Context in the United States." Housing Policy Debate, Vol. 6, No. 3, 1995.

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Appendix A:

Principles of the New Green Alliance attached.

Appendix B:

Provincial Health Services: A Comparison. The National Post, May 9, 2001, A-8. Table from Canadian Institute for Health Information.
(1) $185,454 is the average that a Saskatchewan family doctor bills the provincial health plan. The Canadian average is $177,589. This is the third highest in Canada, behind Ontario and Prince Edward Island.
(2) $252,570 is the average amount a Saskatchewan specialist bills the provincial health plan. The Canadian average is $239,322. This is the third highest in Canada behind Ontario and New Brunswick.

Appendix C:

Table I. Health Care spending in Saskatchewan, 1991 - 2000.
Spending as a percentage of provincial Gross Domestic Product has declined from 6.4% in 1991 to 5.4% in 2000.

Table II. Saskatchewan Provincial Revenues, 1991 - 2000.
Provincial revenues as a percentage of provincial Gross Domestic Product have fallen from 24.9% in 1991 to 19.0% in 2000.

Table III. Saskatchewan Resources and Royalties. Average Annual Figures $millions.
Royalties and taxes as a percentage of resource sales have fallen from 26.3% during the Blakeney government to 9.9% during the Romanow government.
-Resource revenues as a percentage of total provincial revenues have fallen from 32.6% during the Blakeney government to 10.2% during the Romanow government.