Romanow heard it all: spend more, spend less; privatize, don't privatize . . . ============================================================================== * Barbara Sibbald If Roy Romanow was listening when Canadians spoke to him this spring, he learned that privatization is the saviour of medicare and its nemesis. That the system must expand and that it must contract. That for-profit care must be fought tooth and nail, and that it must be embraced. ![Figure1](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/166/13/1703/F1.medium.gif) [Figure1](http://www.cmaj.ca/content/166/13/1703/F1) Figure. ![Figure2](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/166/13/1703/F2.medium.gif) [Figure2](http://www.cmaj.ca/content/166/13/1703/F2) Figure. ![Figure3](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/166/13/1703/F3.medium.gif) [Figure3](http://www.cmaj.ca/content/166/13/1703/F3) Figure. Essentially, he received so many opposing messages during his 18-city tour that Canadians have to wonder what compromise solution he can possibly concoct by the time his final report is released in November. Will he call for governments to spend more, or to produce a leaner, meaner system? By the end of his tour, the only sure thing was that he won't be able to please everyone. The main question emerging for Romanow is simple: Exactly how much can Canada afford to spend on health care? The provinces aren't really sure, but they say Ottawa should be paying more — they want $8 billion added to the current federal contribution. At the same time, many patient and citizen-advocacy groups were making loud pleas for increased spending. But can we afford it? The public's answer, judging from the 6 meetings attended by *CMAJ* correspondents from March to May (see [www.cma](http://www.cma) **.ca** **/cmaj** **/romanow** **.htm**), seems to be a resounding yes. There were, of course, a few dissenters who maintained that privatization is inevitable: the Canadian Taxpayers Federation, for example, and some individuals, such as Senator Wilbert Keon, made this argument. But the majority — at least the majority of those attending these meetings — had no use for privatization. The Canadian Public Health Association, Assembly of First Nations and Canadian Labour Congress (CLC) were among groups denouncing privatization. They say it will exacerbate poverty, diminish access and increase inequity. Romanow, Saskatchewan's former New Democratic Party premier, also opposes large-scale privatization: “I believe strongly that our health care system is in need of renovation, not demolition.” Some argue that private funding is actually more expensive than public because of higher administrative costs and the need to turn a profit. The CLC's Nancy Riche summed up that argument: “If we can't afford to pay publicly, we can't afford it privately either.” However, there were also words of warning. “What technology can provide may go beyond what any country can pay for,” Dr. Bernard Langer, president of the Royal College of Physicians and Surgeons of Canada, pointed out. But when Romanow asked how Canadians should decide which core services get public funding, Langer replied: “I'm dodging the question.” So where does Canada draw its fiscal line in the sand? And who draws it? No clear answer emerged from the hundreds of presentations Romanow heard, but many speakers did call for expanded coverage. The College of Family Physicians of Canada said pharmacare and home care should fall under the medicare umbrella, while others called for more preventive measures and a move away from the disease model of medicine. The Yukon Registered Nurses Association, meanwhile, expanded the definition of health to include a massage after a hard week's work and sending a native elder to gather herbs for a cleansing ceremony. Should these be covered too? Any federal decision that limits medicare coverage — or expands it, for that matter — is bound to create a political maelstrom. This became clear during the Quebec sessions, when speakers said Ottawa has no place in the sick rooms of the nation. “We reject any intrusion of the federal government in the management and organization of the health care system,” said Jean Charest, leader of the provincial Liberals. His message? Just give us the money, *merçi*. One positive result was proposals to stop the bickering and politicking between Ottawa and the provinces. The National Council of Women advocated a dispute-resolution or -avoidance mechanism, while the CMA proposed a Canadian Health Charter to define the rights and responsibilities of patients, professionals and governments. CMA President Henry Haddad said the charter would “reaffirm the basic social contract that is medicare,” define the roles of various governments and set national standards. Rather than holding forth on the nitty-gritty of privatization, user fees, expanded services and the like, Romanow may in the end choose to take the high road and make broad philosophical recommendations. After all these hearings across the country, however, there is no clear indication which direction this high road will take. — *Barbara Sibbald*, CMAJ (With files from *Brad Mackay, Donalee Moulton, Susan Pinker, David Square* and *Susan Zettle*.)