Hospitals have fixed budgets and must not run over them the way the mega-hospital has been doing, Gaétan Barrette warned. You can't just keep accepting patients and treating them once the money has run out. It won't be tolerated.

Barrette, who is a doctor himself, might not be the canniest of politicians. Usually, Canada's elected leaders at least publicly play along with the fiction that every Canadian receives proper treatment, free of charge, in a timely manner.

First, there is no "Canadian health-care system." There are a bunch of health-care systems, one per province, with all the inherent inefficiencies that suggests, partially funded by the federal government, which is supposed to oversee things, but gave up ages ago.

The Conference Board of Canada says that if you live in Ontario, you get better health care than you do if you live in Quebec, where you will pay far higher taxes.

Second, the system is somewhat corrupt; if you have influence or an elite education or some "in," you'll get better care than a fellow who doesn't.

None of that, of course, is to mention all the Canadians who head to an American city (or somewhere like India) and pay, in order to circumvent Canadian waiting lists for other procedures.

Third, the idea we'll be cared for in our dotage is aspirational, not anchored in law.

The oldest boomers are now 70, and it's at age 75 that people really start to soak up medical care. So will the system expand to accommodate the surge in need that's coming?

Livio Di Matteo, a health-care economist at Lakehead University

Canadian law actually forbids the private purchase of medically necessary care.

But everyone knows you can pay for a private MRI scan in many parts of the country if you don't want to wait nine or 10 months or longer for one in a hospital.

And if you don't want to languish in unbearable pain, there are places in Canada where you can buy a private hip replacement or orthopedic surgery. By and large, the federal government just pretends it doesn't see.

The federal government, which has been increasing its health-care transfers to the provinces by six per cent a year, wants to cut back, claiming the provinces haven't been spending it all on health care anyway.

As Di Matteo puts it: "If you are willing to let people cross the border and do it, why not give them the option in Canada, where they live" and save them the trip?

Doctors remove a cyst from a male patient's knee at the Cambie Surgery Centre, a private clinic in Vancouver that's at the centre of a landmark case before the B.C. Supreme Court. (Darryl Dyck/The Canadian Press)

While the findings and recommendations are not binding, Smith said they highlight the challenges faced by African Canadians for the international community and hopefully put more pressure on Ottawa to rectify the inequities. "The situation is only going to get worse," Smith said. "We have families in the community torn apart at an alarming rate. "The future looks pretty bleak for our young people."

The UN delegation was in Toronto, Ottawa, Montreal and Halifax to meet with government officials, community members and rights groups to identify good practices and gaps in protecting the rights of black people. "We had been trying to secure a visit to Canada for a long time. It's a great joy that we were officially invited here," the working group's chair Ricardo Sunga told the Star in a phone interview Tuesday. "We look at Canada as a model in many ways when it comes to human rights protection.

We appreciate Canada's effort in addressing discrimination in various forms, but no country is exempt from racism and racial discrimination." Despite the wealth of information on socio-economic indicators in Canada, the investigators criticized the "serious" lack of race-based data and research that could inform prevention, intervention and treatment strategies. "The working group is concerned that the category 'visible minorities' obscures the realities and specific concerns of African Canadians," its report said. "There is clear evidence that racial profiling is endemic in the strategies and practices used by law enforcement. Arbitrary use of 'carding' or street checks disproportionately affects people of African descent."

The overrepresentation of black people in the criminal justice system was of particular concern for the group, who found African Canadians make up only 3 per cent of the population but account for 10 per cent of the prison population. In the last decade, the number of black detainees in federal correctional facilities has grown by 71.1 per cent, it warned. Among other findings by the UN experts: Across Canada, African Canadian children are being taken into child welfare on "dubious" grounds. Forty-one per cent of children in Children's Aid Society of Toronto's care were black when only 8 per cent of children are of African descent. The unemployment rate for black women is 11 per cent, 4 per cent higher than the general population, and they earn 37 per cent less than white males and 15 per cent less than white women.

A quarter of African Canadian women live below the poverty line compared to 6 per cent for their white counterparts. One-third of Canadian children of Caribbean heritage and almost half of continental African children live in poverty, compared to 18 per cent of white Canadian children. Chris Ramsaroop, an advocate with Justicia for Migrant Workers, hopes the report will raise awareness of the plight of African Canadians. "We need every opportunity to hold the feet of the federal and provincial governments to the fire," he said. The UN experts recommend a national department of African-Canadian affairs to develop policies to address issues facing black people and implement a nationwide mandatory disaggregated data collection policy based on race, colour, ethnic background and national origin.

Odion Fayalo, of Justice is Not Color Blind Campaign, protests racial profiling before a Toronto Police board meeting. • René Johnston/TORONTO STAR file photo

Neighbors held a fundraising drive, gathering nearly $10,000, but by then the bills were so great that the money was gone within a week.

Scott D. Ramsey, MD, is the director of the Hutchinson Institute for Cancer Outcomes Research7 in Seattle. Health economist Veena Shankaran, MD, is a medical oncologist and an associate member of the Hutchinson Institute for Cancer Outcomes Research.

"We are in frequent contact and continue to co-operate" with U.S. authorities, Valeant said in a written statement. "We do not comment on rumours about investigations, and cannot comment on or speculate about the possible course of any ongoing investigation. Valeant takes these matters seriously and intends to uphold the highest standards of ethical conduct." A Pearson lawyer, Bruce Yannett, declined to comment. Dan K. Webb, a lawyer for Schiller, didn't immediately comment. Spokespeople for the FBI and Preet Bharara, the U.S. attorney in Manhattan, declined to comment. Jonathan Rosen, a lawyer for Philidor, didn't respond to requests for comment.

Prosecutors are examining the actions of J. Michael Pearson, Valeant's former CEO, and Howard Schiller, the ex-CFO who became interim CEO during a medical leave by Pearson, according to the people, who discussed the confidential proceedings on the condition of anonymity. Prosecution of individual executives could go beyond just those two, one person said, adding that Philidor executives could also be charged.

While the precise contours of the government's case against Valeant aren't clear, allegations of questionable company practices have emerged in the past year as lawsuits and government investigations mounted. Pearson, the former CEO, was a key architect of Valeant's growth over the years. He stepped down from his role last spring and continues to work as a consultant to the company from a Valeant office near his home, according to the people familiar with the matter. Schiller was blamed by Valeant for "improper conduct" that led the company to restate its earnings for 2014 and 2015, an assertion disputed by Schiller. He stepped down as CFO in 2015 and left the company board this year.

U.S. prosecutors in Boston and Philadelphia are also said to be conducting separate inquiries of Valeant. Boston's investigation, according to a person familiar with the matter, focuses on Valeant's payments to charities that then helped patients make co-payments for the soaring cost of Valeant drugs, some of the most expensive on the market. The Philadelphia case is examining Valeant's billing of government health-care programs for the company's drugs, another person said. The U.S. Attorney's Office in Boston didn't respond to a request for comment. Michele Mucellin, a spokesperson for the U.S. attorney in Philadelphia, declined to comment. Valeant said in October 2015 that federal prosecutors in New York had issued subpoenas seeking information on the company's drug distribution and pricing decisions. It later disclosed an investigation by the SEC. Judy Burns, an SEC spokesperson, declined to comment. Short-sellers first raised questions about Valeant's accounting practices and relationship with Philidor a year ago. As it turned out, Valeant had offered Philidor executives tens of millions of dollars in incentives to sell its products at a time when the relationship between the companies was still secret, according to hundreds of pages of evidence released by U.S. Senate investigators this year. Though they were nominally separate companies, Valeant was Philidor's only client, a class-action lawsuit in New Jersey alleges. Valeant ultimately acknowledged its financial control of Philidor.

In February, Valeant restated its results for 2014 and 2015, disclosing it recorded $58 million in revenue from Philidor earlier than it should have.

"The plaintiffs state that the negligence of the defendants was the sole cause of Mrs. Scott's death and the losses the plaintiffs suffered as a result of Mrs. Scott's death," the claim states. In the negligence claim, her sons - Bruce Findlay Scott, Glenn Carne Scott, and Thomas Andrew Scott - allege that the retirement home hired incompetent staff, failed to screen staff and failed to properly instruct and supervise its staff. The claim says the retirement home also failed to ensure that staff had the right equipment and did not have a proper program of inspection for the maintenance and use of mechanical lifts. The claim also states that the retirement home "knew that its staff ... were using toileting slings to transfer residents, and that this practice posed a serious threat to the health and safety of its residents, but did not take adequate steps, or any steps at all, to stop this practice." The Scott sons also claim that the retirement home failed to warn their late mother about its "dangerous conditions."

The Ottawa Jewish Home for the Aged has not yet filed a statement of defence but is expected to do so. The Scott brothers' claim, which has not been proven in court, is seeking $225,000 in damages for loss of care, guidance and companionship as a result of their mother's death, plus funeral expenses. The Scott brothers have also named the retirement home's staffing agency in the lawsuit.

5. Most physio clinics are now fee-for-service. The two local clinics which accept patients under OHIP coverage have waiting lists of up to nine months. 6. Patients are denied day surgery unless they have (or can hire) someone to spend the first night post-surgery with them. 7. Costs of equipment and supports have skyrocketed and the government no longer funds a local lending cupboard where people used to be able to pay a refundable deposit for the loan of a walker, cane, wheelchair, bath seat etc. Crutches are now $40 and the cost of an air cast is a minimum of $140 plus tax.

Back in 2014 the health minister urged us to report any indications of creeping two-tier coverage. Over the past two years letters and e-mails to his office have not earned the courtesy of a reply. But one recent letter, forwarded to the minister by our local MPP, did elicit a prompt response. After salutations the minister's assistant courteously and concisely advised that "the ministry receives correspondence from people all over Ontario who offer advice and insights on various issues. Hearing those views is essential to help shape a province that reflects the needs and concerns of all Ontarians. Thank you for writing."

In bureaucratese this can be interpreted as meaning "The ministry has received your correspondence and appropriately filed your letter in the colossal, specially designated parliamentary shredder." Christmas is approaching. It appears that, unless the Health Minister is visited by Three Spirits, we may soon have many more Tiny Tims in our neighbourhoods --people who could have been fit, healthy and often employable had they been able to afford prosthetics or medications or therapies to strengthen and heal their traumatized bodies.

And the priceless legacy of free universal health care, so courageously fought for and won for all of us by the incomparable champion of the disadvantaged Tommy Douglas, will be lost forever. Carol Winter McDonnel St.

If it seems like Big Pharma has escaped accountability for its role in perpetuating the nation's deadly opioid epidemic, those suspicions are not unfounded. According to a former top Drug Enforcement Administration (DEA) official, the industry's influence over Congress has successfully quashed efforts to regulate the pharmaceutical drug market aiding an unprecedented addiction to legal drugs.

Much of the friction at a meeting of federal, provincial and territorial health ministers in Toronto two weeks ago stemmed from the Liberal government's plan to adopt the former Conservative government's decision to slash funding in half as part of a new health accord starting next April.

He said regional "piecemeal innovations" that need to be scaled up include British Columbia's tracking of medications that allow various doctors to electronically check a patient's prescription history.

Ontario has been a leading province using multi-disciplinary teams including physicians, nurse practitioners, counsellors and other professionals as part of a primary-care model, he said.

We know that funding some non-physician-provided community mental-health services is something that Canada ought to move forward on in a more concerted fashion," he said, adding that like doctors, counsellors should be allowed to bill the public system. "That's a new service-provider group and it's threatening in some sense to some of the current service providers."

Ontario Health Minister Eric Hoskins predicted that the reduction in the annual "escalator" to three per cent would result in a "declining partnership." Yet considering Ottawa contributes only 23 per cent of the average provincial health budget, the three per cent difference in the annual "escalator" translates into a reduced rate of increase of only 0.69 per cent! Much of this is mere political bluster! Is it not finally time to revisit the Canada Health Act and fine-tune it?

As Konrad Yakabuski has stated (Globe and Mail, Oct. 19), "As long as the provinces remain bound by the Canada Health Act, which constrains their ability to dramatically alter the way health care is paid for and delivered, any new conditions on the use of federal transfers are only likely to further weigh down an already overly bureaucratic system."

When it was passed in 1984, it was understood that the federal government would pay half of health costs. Now it covers less than a quarter. Thanks to Ottawa's admission of refugees and migrants, overall growth of an aging, sicker population, new diseases, and new technologies, the provinces must shoulder an increasing burden.

Yet as Bacchus Barua (Ottawa Sun, Oct. 21) has stressed, more efficient health care systems in Europe allow a greater role for the private sector, use co-payments and user fees (with exemptions for the poor and elderly) and fund hospitals according to activity, not by global budgets, which have been frozen in many provinces.

MDs could be required to work - perhaps 25 to 30 hours per week - in the public system in order to receive government reimbursement for malpractice insurance. Most MDs would confine their practice to the public system. They deserve fair treatment. Thus Philpott should amend the CHA to mandate binding arbitration when provincial negotiations fail.

For those not a member of a "special group," the main option for timely care may be to go to the United States. This provides employment to American doctors and nurses and profits to U.S. hospitals. Would it not make more sense to allow all Canadians to spend their after-tax discretionary income on their own health in their own province?

Frozen hospital global budgets have caused excessive wait times for knee and hip replacements as operating rooms are often not functioning at full capacity. According to a 2013 survey, 15 per cent of Canadian surgeons considered themselves underemployed and 64 per cent cited poor access to ORs. Hence if orthopedic surgeons had access to additional "private" OR time, wait times could be shortened. If hospitals were permitted to operate electively on Americans and other foreign patients, this would bring in extra revenue for hospitals and relieve the strain on provincial health ministries.

Philpott has vowed to do more than just "open the federal wallet." She admits that "innovation" is required. Yet governments are being constrained by blindly adhering to certain parts of the CHA. Despite denials by politicians, a "two-tier" system has always existed. Federal prisoners, WSIB patients, members of the military and RCMP, politicians and professional athletes usually obtain more timely care - often at private facilities.

When the premiers meet with Prime Minister Justin Trudeau in December, besides discussing funding of the new Health Accord, they need to revisit the CHA and begin putting forth proposals as to how best to amend and modernize it. Where wait times are excessive, certain diagnostic services and surgical procedures should allow for private access for all Canadians - not just a select few.

This would utilize expensive equipment and provide new employment for nurses, technicians and surgeons. It would provide extra revenue - from both inside and outside the country - that would help to keep universal public health care sustainable and accessible for all Canadians. Ottawa should then enforce all sections of the CHA on all provinces and territories.

Ottawa physician Dr. Charles Shaver was born in Montreal. He graduated from Princeton University and Johns Hopkins School of Medicine. He is currently chair of the section on general internal medicine of the Ontario Medical Association.

The main reason for these counter-intuitive reactions to increased demand is the way hospitals are funded. As in most of the rest of Canada, hospitals in Quebec currently receive their funding in the form of global budgets based essentially on the amounts they spent in the past. This kind of lump-sum funding leaves hospitals with a tough choice: Limit admissions or go over budget. There is no incentive for hospital administrators to innovate and become more efficient, since an innovation that reduced expenditures would lead to an equivalent decrease in the hospital's next budget. On the other hand, an innovation allowing wait times to be reduced and more patients to be treated entails increased pressure on the fixed budget.

Almost all other industrialized OECD countries fund their hospitals to a large extent based on services rendered. With such activitybased funding, hospitals receive a fixed payment for each medical procedure, adjusted to take into account a series of factors like geographic location and the severity of cases. The more patients a hospital treats, the more funding it receives. Generally speaking, in countries where activity-based funding is widely used, there is more competition between medical facilities and quicker access to care. Health Minister Gaétan Barrette has said that the Quebec government wants to adopt activity-based funding for medical facilities in the health network. This would make a lot more sense than demanding that MUHC doctors refer oncology and ER patients to other hospitals, as the Health Ministry is currently doing.

But getting rid of Quebec's anachronistic funding of its hospitals through global budgets, while a step in the right direction, should be accompanied by other, complementary measures such as mandatory quality reporting for hospitals. Giving patients and referring doctors access to the information they need in order to determine the best hospital for each case would allow for some healthy competition, leading to quality improvements throughout the system, as has happened in Germany in recent years.

If Brian Day's constitutional challenge now being considered by the British Columbia Supreme Court is successful, two other European measures could also come to Canada: allowing a market for private insurance to develop, and allowing doctors to practise both in the public sector and in the private sector.

International experience confirms that the presence of a mixed health care system is not incompatible with health care services that are accessible to all. Indeed, such measures could improve access to health care by encouraging entrepreneurship without undermining the principles of equality and universality that Canadians hold dear. Jasmin Guénette is vice-president of the Montreal Economic Institute.

Last week, the Parkland Institute - which is based out of the University of Alberta - released its report Losing Ground: Alberta's Elder Care Crisis. It was an update of another Parkland report from 2013. The report states that as of March 31, 2016, there were 14,768 longterm (LTC) beds in Alberta and 9,936 designated supportive living (DSL) beds, as well as 243 palliative care or hospice beds.

The number of LTC beds in Alberta has been relatively stagnant - Alberta only has 377 more LTC beds than it did in 2010, an increase of only 2.6 per cent. The number of DLS beds, on the other hand, has increased by 4,770 or 92.3 per cent. As well, the number of continuing care beds classified as DLC as opposed to long-term care beds grew from 26 per cent in 2010 to 40 per cent in 2016.

That means nearly half of the continuing care beds available in the province for elderly Albertans do not have a registered nurse on-site and are not subject to minimum staffing requirements. "Losing Ground" also examines who is operating the LTC beds in the province. About 21 per cent are operated by Alberta Health Services (AHS) or a regional health authority. Another 10,808 were run by for-profit corporations and 8,881 were run by non-profits. In the last seven years, Alberta has lost 333 beds in public facilities while private, for-profit facilities have added 3,255 beds.

The issue is that publicly-run LTC facilities generally provide more health care to residents than privately-run or non-profit facilities. On average between 2011 and 2013, registered nurses, licensed practical nurses and health care aids in public facilities provided four hours of direct health care to residents compared to three and 3.1 hours per day in non-profit and private facilities respectively. The report stresses that all facilities are required to provide 4.1 hours of care per day to residents, which means they are all falling short due to a lack of staff.

The report also notes that the NDP government has fallen far short of its election commitment to open 2,000 new long-term care beds by the end of 2019, including 500 new beds in 2015. The growth in the older population, coupled with a stagnant number of new LTC beds and move towards private care, means the availability of beds for Albertans over the age of 85 has nearly been halved since 2001. "This drop has greatly reduced the province's ability to meet the care needs of its most frail seniors," said report author David Campanella, in a release.

Minister's response In an e-mail, Minister of Sarah Hoffman said they know there is a huge demand for longterm care and dementia beds that stems from "years of neglect" on the need for affordable spaces for seniors under the previous government. "As a result, we are building spaces and putting in the beds Albertans need as we committed to do in the election and we are doing it collaboratively with communities and community partners." Hoffman said that last year, the province did a thorough review of all proposed Affordable Supportive Living Initiative (ASLI) projects, and implemented important changes to proposed projects to address the needs of Albertans.

Every new approved ASLI project has since opened with higher numbers of dementia and long-term care beds than originally planned, she said. "With ASLI now ended, we are developing a new capital program for long-term care with criteria to ensure the right level of care and the right methods of delivery are expanded," said Hoffman. She noted they have $365 million earmarked for senior care in the current budget and that will improve access for families across Alberta. Following the report's release, the Canadian Union of Public Employees (CUPE) issued a statement that it is disappointed by the lack of progress being made reforming the province's system of senior care.

CUPE Alberta president Marle Roberts said the union, which represents 2,600 long-term care workers throughout the province, has repeatedly asked the current and previous Alberta governments to shift its focus to publicly-delivered services. "This study confirms what others have indicated before - caregivers in public facilities have more times for patients and deliver better outcomes," said Roberts.

We are disappointed that the number of private beds continue to increase, while the number of public beds has dropped ... We are letting patients down by not offering them the care they need," she added.

A report from the Parkland institute claims there has been a trend away from publicly- run long-term care beds, such as those at the Westlock Continuing Care Centre (seen above). The number of long-term care beds offered by private organizations or non-profit organizations, on the other hand, is on the rise.