Jean-Yves Duclos should push for full medical portability for his Quebec constituents

“Fortunately, we live in a nation where provinces can support one another.”—Saskatchewan Premier Scott Moe The past 18 months have taught us that we can never let down our guard. Saskatchewan, once the “birthplace of medicare” is now the epicentre of the pandemic in Canada. In October it had the most residents per capita in ICU beds, more than any other province at any point in the pandemic. The Canadian Armed Forces have been sent in and by October 31, at least 24 patients had been transferred to ICUs in Ontario. Of note is that the Saskatchewan government provides accommodation and expenses for loved ones to visit relatives in Ontario hospitals. Yukon, despite a very high vaccination rate and the most generous paid sick leave plan in Canada suffered a surge of cases in June, and by July 2 had the highest per capita rate of COVID-19 in the country. Also in June, Manitoba suddenly had the highest rate of new cases in North America. It sought assistance from the Canadian Armed Forces, requested surplus vaccines from the United States, and transferred 51 patients to Ontario, two to Saskatchewan, and two to Alberta. There has been a recent surge in Nova Scotia. New Brunswick, which had been spared, lifted its COVID-19 restrictions before hitting its goal of vaccinating 75% of eligible residents, and now is suffering a major spike in hospitalizations. The Campbellton health region recently reported the highest death rate in Canada. Alberta, like Saskatchewan, eliminated most public health restrictions in early summer, has also requested the CAF to assist in its own surge. Ontario offered to accept ICU patients but so far none have been transferred. All this is made possible due to the portability provisions of the Canada Health Act. For out-of-province transferred patients, hospitals in Ontario receive, above their global budget from the Ontario Ministry of Health, a daily ICU rate that is surprisingly variable—$1,857 at University Hospital, London, $4,653 at University Health Network, Toronto, $1,713 at Hamilton General Hospital, $4,381 at Health Sciences North, Sudbury, and $4,848 at the Ottawa Hospital. This is ultimately reimbursed by the home province or territory of the patient. Read: Quebec politicians decry Legault's black list of doctors as an abuse of power Quebecers are fortunate to be part of Canada. For example, Health Sciences North in Sudbury charges “non-residents of Canada” such as Americans $8,762 per day in the ICU; the Ottawa hospital charges $7,275. This does not include physician fees. In contrast to the situation in Europe, in Canada, one can freely go to another province or territory to seek treatment. This occurs frequently for West Quebec patients. Sometimes persons from areas with a long wait for diagnostic services travel to large cities in another province. They do not require prior authorization from their family physician or provincial health authority, and their home province or territory ultimately pays for physician and hospital expenses. The European Health Insurance Card (or U.K. Global Health Insurance Card) provides access to health services in any of the 27 EU countries, Iceland, Liechtenstein, Norway, and Switzerland. However, it does not cover costs if one is travelling for the express purpose of obtaining medical treatment and does not guarantee free services. Because of the Reciprocal Medical Billing Agreement (RMBA)—signed by all territories and provinces and most provinces—physicians can bill OHIP or their own provincial health plan, receive their normal fee, and their own ministry of health turns then collects from that of the patient. This is required by the Canada Health Act, which was passed unanimously in 1984; thus all Quebec MPs voted for it. Yet Quebec has continued to ignore this portion of the CHA. Its patients must usually pay the MD directly and after many weeks receive partial reimbursement from their own province. Travel insurance is an inadequate solution, as it is often unavailable for services supposedly covered by provincial health insurance and policies may also exclude complications of a previous illness. Over many decades, all federal health ministers have been reluctant to force Quebec to obey the Act Justin Trudeau made no mention of this in his December 2019 mandate letter to former Health Minister Patty Hajdu. A Toronto Star editorial stressed that building the new Liberal cabinet entailed both symbolism and substance. Once again, Trudeau has achieved gender parity. Quebec has nearly a quarter of Canada’s population and now is represented by 10 out of 38 cabinet ministers. Read Dr. Shaver on: A delicate question The new Federal Health Minister, Jean-Yves Duclos, is symbolically from Quebec City. As a lasting legacy to his fellow Quebecers, he should strongly encourage Christian Dubé, Quebec Minister of Health and Social Services, to sign the Reciprocal Medical Billing Agreement. Many years ago, Quebec refused to sign the RMBA for fear that west Quebec physicians would complain that they were being paid less for the same service than their counterparts in Ontario. However, from 2005 to 2015, the incomes of Quebec MDs have doubled. There is no longer any excuse not to sign. Although Quebec currently seems to be over the worst of the fourth wave, recall that for the duration of the pandemic, it has had the highest rate of COVID-19 deaths per capita of any province. If Quebec were to agree to fully portable medical benefits, if the situation worsened and overwhelmed ICUs in New Brunswick, it would allow those patients to be transferred to Quebec. Should a new variant emerge, and a surge of severe cases occur in Quebec, its full medical portability would facilitate transfer of patients to hospitals in Ontario and other provinces. In addition, Quebecers would enjoy accessible medical care across Canada when travelling on business or visiting friends and relatives. This also applies after a permanent move to another province or territory, in which they are currently “covered” for the first three months only by a Quebec medicare card that few MDs will accept. As the holiday season approaches, I urge Justin Trudeau to include this issue in his mandate letter to Jean-Yves Duclos—a symbolic but concrete action that would benefit his constituents and promote national unity. As the Toronto Star editorial concluded, “Trudeau has now set the table for his third term in office. As usual, he scores high on symbolism, but the record is still to be written on substance.” Justin Trudeau should not wait for another wave of the pandemic to impact Quebec. As former U.S. President John F. Kennedy stated, “The time to repair the roof is when the sun is shining.” Ottawa physician Dr. Charles S. Shaver was born in Montreal. He is past-chair of the Section on General Internal Medicine of the Ontario Medical Association The views here are his own.

Jean-Yves Duclos should push for full medical portability for his Quebec constituents

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