A Strong and Free Canada

Preston Manning

November 2005

Well I would like to say thank you Brain on behalf of all of us for you work in organizing this conference and thank you for the invitation to attend and to speak.  One of my favourite leadership models, maybe because I come from the West is the Scout.  I think of the cavalry Scout John Buford who picked the high ground at Gettysburg during the American Civil War or Jerry Pots who was the famous Metis Scout that lead the Northwest Mounted Police when it came to the West.  What exactly is the role of the Scout?  It's to ride ahead of the main company, around the next hill and over the next bend in the trail and to look out for danger on the one hand and opportunity on the other.  And the most difficult part of the Scout's job is not going out on the trail.  It's coming back and trying to convince the people around the campfire that have not been over the next hill or around the next bend that if you go this way there's danger and maybe disaster but if you go this way there is good grass, good hunting and good water.

Now, I left parliament in 2002 and Mike Harris left the Ontario Premier's office in the same year.  We teamed up under the auspice of Fraser Institute to do some scouting on the major public policy frontiers of our country and one of them is health care.  So what I would like to do this morning is to briefly share with you a scouting report on alternatives to the Canadian health care system.  Its in greater detail in the Fraser Institute publication called "Caring for Canadians", I think there is copies of it at the back.  Then I would like to get onto an action plan for getting out of the current cul-de-sac that Canadian health care finds itself in and onto the improved system of the 21st century.  As Mike and I looked at the current Health care system we couldn't help but noticing its most distinguishing feature, which Brian has already referred to, and that is the waiting line. We observed, for example, in 2005 Canadian's can expect to wait 17.7 weeks, more than 4 months after the general practitioner or family doctor has said that a specialized treatment is necessary. That wait is fully 90% longer than it would have been 12 years ago, back in 1993.

In looking for alternatives, as Brian has also said, it moves us to look at a field further than Canada and survey the health care systems of other countries.  Mike and I have not spent a lot of time looking at the American system or the Mexican system or any system that does not provide universal coverage given the great importance of that to Canadians.  With the help of the Fraser Institute we looked at the Health care system of 2 dozen other industrialized countries that all offer universal coverage.  Access to primary health care for every citizen regardless of their ability to pay.  So I am comparing Canada not against the American system, not against the Mexican system, against systems that have the characteristic that we feel is essential to Canadian Health care and here's what we found.

Canada spends more on heath care than any other country in the OECD with a universal system with the exception of Iceland and Switzerland.  While Canada ranks 3rd amongst expenditures per capita on health care in those countries we placed no where near the top in either access to or quality of health care that we actually get.  More specifically we rank 24th out of 27countries in terms of numbers of doctors per capita.  24 out of 27 with respect to access to advanced medical technology we ranked 13 out of 22 countries.  With respect to access to MRI's 17 to 21. With access to CT scanners, 17 to 12.  In access to mammograms and tied in dead last with 16 nations in access to lithotripters.  Infant mortality rates 20th place with number 1 being the lowest rate, breast cancer mortality 10th place with number 1 being in the lowest place.  Potential years of life lost to disease 8th  on the list.  We found that all of these countries with universal access systems will out perform Canada in access to doctors, access to the latest technology outcomes have mixed systems.  Public and private delivery systems, public and private insurance payment systems.  Sometimes working together, sometimes competing to provide faster access to better care at lower costs.

When I go back to Ottawa every now and then to chat with my MP friends around the parliamentary campfire here's what I tell the ones that will listen.  We have got 3 options.  There are 3 trails. One is the status quo, we can keep following the trail we are on now but really what we're doing is providing universal access to an inferior system at higher costs.

Then there always is the Southern trail.  We could look south and try to imitate the US systems.  Why would we do that it leaves millions uninsured, it is more costly than ours. There is no political champion for that alternative in Canada.

Then there is the third option that we could suggest is the middle way, Canadians like the middle way - why did the Canadian cross the road?  To get to the middle.  This ought to appeal to us - offered by countries as diverse as Sweden, Japan, Australia and France of providing universal access to primary health services regardless of ability to pay and providing a mixed approach, public and private to delivery payment and insurance.  If they ask our opinion on which way to go that's the one that we say.

How would you get there in terms of specific recommendations?  Three things - we recommend ending Federal transfers in support of Health care to the provinces with Ottawa vacating the equivalent tax room to the provinces.  In other words, let the provinces free to experiment and give them the revenue to tax through.  Focus - it doesn't mean there is no role for the Federal Government, focus responsibility on support Health Science and research and coordinating a national response to national health care threats such as those posed by SARS, BSE and predicted pandemics.  Allowing the provinces freedom of choice to health care consumers by providing, as I say public and private options for delivery payment and insurance.

Now, that's our prescription.  It's in that Fraser Institute publication.  What I want to spend my time on more this morning is a call to action.  We have a package, Mike and I and the Fraser Institute of health care Reforms that we think would deliver better health care.  Perhaps you don't agree and you have another package, that's really what this conference is about, to get the best ideas out on the table.  But suppose at the end of the day despite the differences of opinion among us we were able to come up with a package of health care reforms that this group felt would significantly improve our health care.  My question to you as a Scout who gets restless hanging around the campfire, the status quo too long, is "What's next?" more discussion, more papers, another book, another documentary, another conference.  What's next?  This country is in danger of discussing itself to death on some of the most important issues facing us.  So what's next?  What is the plan of action that would move us beyond the status quo into the implementation of a package of health care reforms, whatever that package is and would allow us to achieve the Health care system in the future.

I want to give you two suggestions from moving beyond discussion and coming up with good ideas.  I think we're good at that.  To the action side.  I think a couple of sessions later on are going to deal with the Chaoulli decision and how that can be followed up.  I won't deal with that but I would be very interested in the suggestions that come out of that.  Let me give you two suggestions that are more political.  The first one is there should be a concerted effort by the people in this room and our friends across the country to make it possible for health care reform to be debated clearly and responsibly in the Canadian political arena.  Let me explain what I mean.  Being a political person and a lover of parliament I would be delighted if a real intelligent debate of the options of health care reform could occur in the parliament itself or in the legislature, or in the democratic political arena, particularly in the context of elections.  Unfortunately, that real debate will not and cannot happen in these arenas because of a tragic flaw in how we do politics in this country and the situation will not change unless and until we face up to that flaw and fix it.  One of the most enduring characteristics of Canadians is our moderation and tolerance.  Our wariness of extremes.  But because this is so in the political arena the quickest most efficient way to discredit your opponent or any idea that they're putting forward is to label it and its proponents as extreme then to argue not against the position but against the extreme or the caricature of that position.  This is a distinguishing characteristic of Canadian politics and it's rooted in - what's sad about it is its rooted in our moderation.  It works because we are a moderate and tolerant people.

Let me illustrate by telling about an exchange I had with Bob Ray, the former NDP Premier of Ontario at the University of Toronto dialogue on the democracy deficit a few years ago.  This event was set up, not as a debate, but as a dialogue.  Bob and I had a very cordial change of views even though we differ strongly on a number of points.  But we got talking about what would happen, what would have happened if this exchange had taken place during an election campaign, if the issue had been health care reform and if Bob and I were representing our respective parties in the traditional Canadian partisan manner.  Well suppose in that scenario that Bob had said, "I believe in National Health Care standards administered by the Federal Government"; a not unreasonable proposition although, I would disagree with part of that.  How would I most likely react in the heat of an election campaign to that statement as a political opponent of Bob's?  The first thing that I would do is fall off my chair in mock horror and turn to Bob and say, I can't believe Bob here wants to trample on the rights of the province.  He wants to establish a Federal dictatorship in the area of provincial jurisdiction.  Of course this is not exactly what Bob said but I am taking Bob's fairly reasonable position even though I disagree with him and I am not arguing against that because I can't maybe win quickly that way.  I take his position push it to the extreme and I argue against the extreme and then Bob, not to be outdone, let's say a little bit later, does likewise. I say "I believe that Canadian health care would be improved if we preserved universal coverage but provided a mixed approach to delivery payment and insurance".  Now this time Bob falls off his chair and says, "Manning here wants to privatize Canadian health care, Americanize it".  Can you what he is doing?  He takes my position - which is a reasonable one whether you agree with it or not.  Now he doesn't argue against that, but he argues against the extreme.  So our little health care debate generates into an argument between Federal dictatorship and an American system which - even the people on the platform - none of them believe it and the poor public is sitting there looking like this and saying – why should we vote for either of these idiots.  We told the pollster that health care was our number one concern but these people are not even debating it.

Now can that flaw be fixed?  This is the single, greatest, reason why there is no meaningful health care debate and there won't be in the next Federal election despite Canadians being told this is the number one issue.  Is there anything that can be done to fix it?

Well yes there is but it takes resolve and leadership from outside the partisan political arena to do so.  Leadership from people like you, if you're prepared to do something about the problem.  For example, if you're called upon to chair a debate about health care among the political party candidates in the next election, or maybe should I say when you organize the health care debate in your constituency and appoint yourself as chairman. If the candidates start to behave in the manner I just described, as they will, whether you talk to the national leaders and the candidates in your constituency, do something about it.  What do you do?  I have been the chairman of a couple debates like this particularly since I got out of the pond, what you do is you stop the debate.  And you say to the people do you see what's happening here.  You know you came here to listen to viable options on health care reform and these people are talking about things that nobody in the room believes.  You tell the debaters if you don't stop this and start discussing the actual options I am going to shut down the debate and I am going to tell the media why we did and you won't get halfway through that ramp before the audience will be nodding and clapping their hands and that will send a message to these people who are campaigning for their support clear and louder than anything else one can do.

Now the second suggestion I wanted to leave you with has to do with using an issue campaign to reform health care.  A campaign not organized by political parties but by a coalition of interest which might include people like yourself.  What is an issue campaign?  Well it's like an election campaign.  It has a finite duration.  It has a beginning and it has an end.  You can often recruit people to get involved.  You say - look I am not asking you to give me 20 years of your life I am asking you to give me the next 6 months to see if we can move this health care package along.  It has, like an election campaign, a campaign team, a campaign manager and a plan and a strategy and a major fund raising effort, and a volunteer effort and a grassroots effort to go along with it but its primary object is not to get someone elected, its object is to get your issue.  In this case health care reform or "Saving Medicare" as you define it, higher on the public policy and priority list than it was when you started.  Or to get your solution the same universal coverage plus the mixed approach higher on the public priority list than it was when you began.  So that when the federal politician or the provincial politician sends out their pollster as they all do the pollster comes back – you know he says 2 out of 5 people are saying this issue is a big thing with them or 3 out of 5 people are saying - why don't you look at that particular package.  The great advantage that you people in the health care field have is that your issue is already high in the polls and in the consciousness of voters.  You don't have to work to get it out.  Your challenge is to get support for a particular course of action higher on the agenda and in the public mind and thereby as a way to influence the political people.

What does the organization of an issue campaign involve?  Let me just quickly review some of the key elements and I will illustrate with respect to my package of reforms but you can stick yours in there.  The idea is to get a package of reforms up.  An issue campaign involves coalition building, identifying other interest groups who share your objectives and you can be persuaded to join you in a concerted effort to advance.  The days are over if they ever existed, when one organization, certainly a political party, has all the right ideas, and all the right people and all the resources and all the right messages all at the right time in order to advance this idea.  The coalition building is a better way to actually organize an issue campaign or to push a package of reforms and the people of the coalition don't have to agree on everything but they have got to agree on the 3 or 4 things that are at the heart of the issue campaign.

An issue campaign involves putting together a competent campaign team.  That should include representatives to your coalition but more important it requires people with skills to run a campaign, an experienced campaign manger, somebody that's run one before.  Perhaps an election campaign but you're using it now for issues.  A good fundraiser, an exceptional strategist, a volunteer coordinator and a host of dedicated grassroots supporters.  An issue campaign requires a strategy and a plan and the better the strategy and the plan the more successful the campaign is likely to be.  This involves such considerations as the following - where to start.  If the object is health care reform where the provinces do have primary jurisdiction in what provinces are the conditions most favourable to get voter and provincial government support for your package and your reform.  If you had to decide today and look at the different provinces you would say starting with Quebec because Quebec is further down that road.  The federal government -  because of the political situation - will not come down with a hammer on Quebec the way they would on Alberta and British Columbia.  The reason they don't shut down those clinics in Hull is because they told them if you try and do that we'll get into court and we'll make sure that our client will get up and their client lists include how many deputy ministers, how many senators, how many members of parliament go there.  Quebec has got a good foothold there.

Timing, when to launch.  This is a strategic question. Sometimes the best time for an issue campaign is just prior to the provincial or federal election so that your issue and your package gets up and becomes an issue in the election.  If your campaign requires an educational effort that often is better to launch it in between elections when you have got more time to advance your conditions.

Position it.  On the health care issue if you want to push the reforms I have been talking about, if you want to avoid a polarization over public versus private.  In this country you don't win that.  If that debate gets into this is about public versus private.  About this time last year the Fraser Institute requested by former pollster Dr. Andre Turcotte to ask Canadians this question – should health care services in Canada be provided by government only, primarily by government, by the private sector only or mostly by the private sector.  A question that presents the options in that polarizing form.  And predictably – I believe what was the answer?  80% of Canadians said only or mostly by government.  Present the question and that's the answer you'll get from Canadian on Health care.  When Dr. Turcotte raised the same issue but framed it in a non-polarizing way – should Health care services in Canada be provided primarily by the government or by a public private mix – 44% of Canadians said by the mix?  In other words, positioning your reform package is the middle way.  Not public sector dominated, private sector dominated, not the American system or our system but a middle way is a strategy that resonates with Canadians around than turning them off.

A successful issue campaign requires effective communication strategies and messages.  Who are the targets of your health care reform message?  Not just the special interests that stand to benefit in the short run but that vast constituency of Health care users who suffer from the deficiencies of our present system and you will be the beneficiaries of your policy.

What are the myths and misconceptions about health care that need to be dissipated before you health care message will be received and understood.  Dr. Day put some of them up on the screen.  They include the myth that Canadians already have the best Health care in the world.  They include the myth that we do not have multi tiered health care already.  They include the myth that the only option to status quo is the American system.  These are myths.  These are the noise that competes with your message if you want to mythicize the arena before you pump your messages into it.

Who would be the best spokespersons for our critique of the present system?  The most effective critics of a deficient system are not always the experts but those who have been victimized by it, voices from the waiting line.

A question a politician always asks if you're trying to communicate a new idea is out of who's mouth would our health care reform messages be most credible.  One of the saddest things is discovering it's not your mouth that is the most credible mouth it is somebody else at the public would trust more.  So you get the message coming out of the mouths of the person that would be most trusted on that subject as far as thinking and strategy.

Most important of all what is the call to action.  What does one what want recipients of health care reform message to do and this is the biggest challenge with Canadians.  Canadians will sit around and discuss things until the cows come home but you have got to give them something to do.  What do you want them to do?  Join this coalition.  Ask these three questions of every candidate for public office in the next election.  Call this talk show or that editor or write to this newspaper.  Distribute 100 of these pamphlets on health care reform.  The aim of an issue campaign is not to generate more discussion but action that generates pressure to get acceptance of your reforms.

It systemic reform of this kind really possible in Canada.  Do issue campaigns really work?  Can they be made to work in pursuit of health care?  In the end you would have to be the judges.  All I can tell you from my experience is this.  A number of years ago a few people (5) got together in Calgary and said ... "We're going to change the national legislature, yes us.  We are going to make balancing budgets such an issue that no politician or party or government in the country can avoid it.  We're going to toughen up the Federal governments approach to the Quebec session and we're going to make democratic reform at least an item on the national political agenda".  This was our card.  We created a campaigning vehicle.  In our case it started as an association and in our case it actually turned into a federal political card but we under took issue campaigns on all of these issues.  This was not initially to get elected.  This was to get our issues higher up.  Sometimes in coalition with others and sometimes on our own.  We made all kinds of mistakes and did not achieve everything we hoped to achieve, but after 10 years we did manage to get 2.5 million people.  We started with 5 and we got 2.5 million people to a least mark an X by the names of people who were committed to these things.

Now whether you agree with my particular positions on health care or my particular form of political action isn't the point.  The point is that our democratic system with all its flaws and no one has been more critical of how to operate this country than me against each and all of us certain tools with which to influence public opinion and public policy.  They're not rocket science and they're not new.  Freedom of speech, freedom of association, freedom to try to persuade your friends and your neighbours we ought to do this rather than that.  Freedom to try to persuade the governments that this is the policy of the route we should go rather than that.  These tools can be used by supporters of political parties to get their candidates elected to office.  But they also can be used by non-partisan groups.  In fact, in today's climate they are probably more affective when they are used by non-partisan groups outside the political arena to achieve their objectives.  These tools of democracy, I believe can be used to accomplish good things for Canada to make real health care reform not phoney caricatures of priority in the next federal and provincial elections and to dramatically increase public and political support for those health care reforms which you believe are necessary to give Canadians the best health care in the world.

Thank you very much.