History of the Medical Reform Group: 1979 - 1996
After the Health Care Accessibility Act
In the aftermath of the doctors' strike, the MRG continued its lobbying
activity in other areas. A political alliance, including the MRG (led by
Joel Lexchin and Bob Frankford), was unable to prevent the Mulroney government
from passing amendments to the Patent Act. This legislation extended the
patent length, a move made in response to pressure from the multinational
pharmaceutical manufacturers. A happier conclusion followed the activities
of the pro-choice movement, in which the MRG (led by Mimi Divinsky and Miriam
Garfinkle) has participated for a number of years, when the Supreme Court
of Canada struck down legislation limiting women's right to abortion. Free-standing
abortion clinics such as those established by Dr. Henry Morgentaller were,
for the first time, legal. The prominent role in this struggle played by
MRG member Nikki Colodny is worth noting.
The Ontario government struck a committee to examine privatization within
the health care system. Our brief to the committee pointed out that private
medicine in the United States was considerably more expensive than public
medicine in Canada, and explained the reasons. Other MRG submissions during
this time period included briefs to the Evans Committee on health care, and
the Schwartz Commission on Legislation for the Health Professions. Brian
Hutchison, Pat Smith, and Catherine Oliver were the major contributors to
a superb, carefully researched, and powerfully argued brief to the Task Force
on the Implementation of Midwifery in Toronto. The MRG presentation to this
group was very well received, and the recommendations of the Task Force was
consistent with the MRG's position that midwifery has an important potential
role in Ontario.
December 1986 marked the beginning of a new phase for the MRG Newsletter.
Haresh Kirpalani began a leading role in editing the Newsletter, soliciting
"think pieces" and discussions of controversial issues from the membership.
This increased the interest and value of the Newsletter, which was renamed
"Medical Reform".
In 1987 MRG concern with the growing number of Canadians with Acquired
Immune Deficiency Syndrome led to the formation of an MRG AIDS working group.
This working group brought issues to do with confidentiality, education,
and drug treatment to the MRG, and has been active in the community.
The MRG and Resource Allocation
The evolution of the MRG in the 1988 to 1990 period was profoundly influenced
by the changing political environment. Cost control in the health care system
became the major priority of the provincial government. Fee increases to
physicians were essentially put on hold, and the OMA responded by a campaign
that suggested that government funding constraints were compromising the quality
of care. Episodes suggesting suboptimal care (patients waiting excessively
long periods for cardiac surgery, an intensive care unit bed not being found
for a woman who subsequently died) began appearing with increasing frequency
in the press.
These developments suggested that if the MRG was to make a significant
contribution to the most important current debates, a focus on issues of
resource allocation was required. This position was initially taken most
forcefully by Michael Rachlis. Michael's own career was evolving, and his
publication of "Second Opinion", a critique of the Canadian health care system,
elicited widespread interest. Michael became famous, and it is hardly an
exaggeration to say that any conference or meeting on health care was incomplete
with his participation as a keynote speaker. He was widely quoted in the
lay press as an alternative voice from that of organized medicine. His statements
stressed the extent to which health was determined by factors outside of
health care, and the inefficiencies in the delivery of health care.
In the meanwhile, the MRG was responding to Michael's suggestion that
resource allocation was the primary current issue in the system. In the
latter part of 1988 a resource allocation working group was formed. The
major players in this effort included Andy Oxman, Haresh Kirpalani, Rosana
Pellizzari, and Gordon Guyatt. In its efforts to achieve a coherent position,
the working group struggled with what proved to be a series of complex issues.
From the beginning of its deliberations, Haresh Kirpalani had a major impact
on the direction the group took. Haresh had been a first-hand witness to
the way in which Margaret Thatcher had used arguments about the limited gains
from medical interventions to justify starving the National Health Service.
He had seen how her underlying goal, to undercut the NHS and foster the
growth of privately funded health care, had been achieved. Haresh alerted
the Resource Allocation group to the dangers of "Thatcherism", and the need
for us to recognize the dangers of reductions in funding for healthcare.
Haresh's compelling arguments increased the group's discomfort with the
position Michael Rachlis was taking in public. Eventually, the group endorsed
the position that excessive stress on the limits of health care in achieving
health, and on the inefficiencies in the system, could provide support for
forces that would be inclined to reduce health care expenditures to the point
where high quality care for all would be compromised.
For the next 18 months, issues of resource allocation became the focus
for the MRG semi-annual meetings. In the spring of 1989, the Friday night
session at the semi-annual meeting was framed as a debate between Michael
and Gordon Guyatt. While well-attended and interesting, the debate was a
disappointment in that a clear delineation of the areas of controversy and
disagreement did not emerge. The subsequent meeting provided the forum for
a general discussion of issues of resource allocation.
Following the meeting, the resource allocation group further developed
their position with a series of "think pieces", each accompanied by a resolution,
which were published in "Medical Reform". These resolutions were debated
at the semi-annual meeting in the autumn of 1989 and largely endorsed by those
attending.
The activities of the Resource Allocation Working Group did little to
dispel the sense of lack of direction within the group. Steering Committee
membership was falling, and public statements by the MRG were virtually
absent. The autumn semi-annual meeting was poorly attended, and the position
of the Resource Allocation Working Group appeared poorly understood by many
members; the clear consensus the working group had been hoping for had not
emerged. This led to a sense of crisis, and an expanded meeting of the Steering
Committee was held at Haresh Kirpalani's in January 1990. The issue on the
table was "should the MRG disband". It was pointed out that membership had
been well maintained, and many who had been polled informally were very upset
at the thought of the group disbanding. There was an unequivocal decision
that the group should continue, though clear solutions to the problems of
lack of energy and direction were not forthcoming.
The Steering Committee decided that fundamental disagreement about resource
allocation issues remained, and required resolution if the group MRG were
to move ahead. At the Spring semi-annual meeting the discussion was initially
organized around a debate between Ralph Sutherland (taking the position that
health care was a minor contributor to health, that resources should be
shifted outside of the health care system to other social expenditures, that
two-tiered medicine should be accepted, and that "capping" was a useful cost
containment strategy) and Gordon Guyatt (taking the position of the resource
allocation working group), followed by small group discussions around how
the MRG should respond to specific issues appearing in the press. The Resource
Allocation Working Group had further clarified its position. Haresh's concept
of "Thatcherism", the attempt to cut social and medical spending and drive
the system toward a two-tiered structure reliant on private funds, and the
need to defend against Thatcherism, appeared helpful in communication the
working group's concerns.
The result of the discussion was a discovery that despite some fundamental
differences in viewpoint, there was a great deal of agreement, and that a
clear response that represented the MRG's view to issues currently appearing
in the press could be easily formulated. This consensus aided MRG representatives
in their subsequent statements to the media.
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