The Future of Health Care in Canada

THE HONOURABLE ROY ROMANOW
FORMER PREMIER OF SASKATCHEWAN
COMMISSIONER OF THE ROYAL COMMISSION ON HEALTH CARE

19 February 2003

First of all, I apologize for my sore throat. It hit me about 72 hours ago and the long flight from Saskatchewan last night and yesterday, hasn't made it any easier. Now that's always bad news for a politician, when he or she can't speak, but very good news for the audience. Probably not a long speech. The other side of it is, that since Allan J. MacEachen will be responding, the deal is that if I can't finish, we'll all have the treat and the delight of hearing one of Canada's greatest orators of all time, deliver this speech. That's the deal as you recall Mr. MacEachen. Although it was sprung on me before I came here today, the president, Dr. Riley said, “well, you know, Allan J. will be speaking.” And I said, you didn't tell me that before I left Saskatchewan. I would not have come otherwise. But, indeed, it is a pleasure to be here at this beautiful campus, beautiful St. F. X and a very, very leading academic institution in this country. The President was kind enough to mention some of my previous misdemeanors and activities, one of which was to co-author a book on the making of the Constitution called Canada, Notwithstanding. I want you to remember that please, its called Canada, Notwithstanding. There were three of us who wrote it and we all had a five hundred dollar advance for writing this book. Each one of us. And I thank you very much, Mr. President, for not saying 'popular book', because we got our final accounting about four years ago, and it went like this. Paid to you in advance for Canada, Notwithstanding, five hundred dollars. Your share of royalties due to book sales $125, you owe us $375. Now, the reason that I say that is in case you want to help a poor prairie politician out of debt and you can't sleep at night, remember its Canada, Notwithstanding.

Well, ladies and gentleman, it is a great pleasure and a great honour for me to be here tonight. I only wish that my voice was stronger. Having completed the work of the Commission on Health Care in Canada, the chance to address a gathering in the name of Allan J. MacEachen is, indeed, both an honour and a privilege for me, and an invaluable opportunity to talk a little bit about the highly principled quest of bringing greater social justice to Canadians everywhere. Mr. MacEachen, Allan J. as he is affectionately known among friends and admirers, must harbour a very special devotion for this never-ending mission. Because, as has been pointed out, as Minister of Health in the Pearson and Trudeau governments in the 1960s, he was absolutely instrumental in bringing to life the national and thus the universal aspect of insured, publicly funded medical coverage in Canada as an expression of Canadian values. The commitment of those governments to implement a more just, more equitable health care system has proven to be, in my mind, a defining moment in Canadian history. A defining feature of what it means to be a Canadian. And as a parliamentarian, Mr. MacEachen's legacy is one of fairness, of relentless commitment to justice, and of deep respect for the democratic process and a deep understanding of the values of Canadians everywhere. All of which, I hope, in some way, over a long period of time, the work of my Royal Commission might be, at least in part, associated.

Allan J. MacEachen has called the implementation of Medicare the most cherished contribution to citizen wellbeing under his tenure. And the passage of time and continuing allegiance of Canadians to our healthcare system has reinforced this sentiment, I believe. In addition to being among the best medical systems in the world, Canadian Medicare is and always has been emblematic of the possibility of infusing politics with compassion, of sustaining a long term commitment to each other as fellow citizens. The scrutiny of healthcare today is carried out in appreciation of the precious inheritance handed down by a great, great generation of progressive leaders, a generation that understood the pragmatics of bringing about monumental social change. Mr. Allan MacEachen, I say to you, that you stand at the very forefront of those progressive leaders in Canada. Well done!

As Mr. MacEachen himself wrote in Tom Kent's anthology called In Pursuit of the Public Good, “Policy conception is one phase. Final implementation is another.” If I may be so immodest, I might add, “and final implementation is never final.” Progress attained is never guaranteed. It is always a work in progress. And thus it is today, with the task before all Canadians and their governments to modernize and to preserve this most cherished of our programs.

Keeping those words in mind, as the President has said, this evening I want to talk to you, briefly, about modernizing and sustaining our 21st Century Canadian Healthcare Plan. It is now less than 24 hours since the budget speech, two weeks since the premiers and the Prime Minister met to fashion the so called 'Health Accord', and just under 80 days since I submitted the Commission’s final report to the Prime Minister. As Allan MacEachen knows better than most, time in politics is a relative thing. A day can seem like a lifetime, a month can seem like an eternity. And for me, 80 days has been almost like two or three eternities. And so, however, when attempting to assess the greater significance of political decisions made, or the consequences of those not made, perspective is everything. Grand gestures can ultimately seem inconsequential while small incremental steps forward can prove the precursor of dramatic, lasting, important change. So how can or should we assess the significance of these very recent events for the future of our country's healthcare system? Do they herald a new era of positive transformation or are they a continuation of erosion through indifference and neglect - and perhaps even purposeful will - of one of our country's greatest national achievements. Well, in my remarks tonight, I will try and answer briefly some of these questions and I'm going to begin by examining the 2003 First Ministers Health Accord and its congruence with my commission's report. I will also comment on some of the specific elements of yesterday's budget by Mr. Manley before offering some suggestions for next steps. So, let me begin.

Last year, it was a great honour to lead what, speaking somewhat immodestly - I always felt modesty was a false commodity in any event - it was my pleasure to lead probably the most comprehensive, inclusive and exhaustive effort ever to engage Canadians in a national dialogue in the future of our healthcare system. Tens of thousands of Canadians participated, speaking passionately, eloquently and thoughtfully about how to preserve and enhance the system. And I want to say that since that report has been tabled, as witnessed by the large overflow crowd that we have tonight, the respect for transparency, objectivity, the breadth of perspective and listening to the people have been the hallmarks of this process which continues right to this day. Now I served on the front lines as a premier and my sense is that Canadians wanted several results from premiers and the Prime Minister two or three weeks ago, beyond the obvious goals of timely access to quality care on the basis of need - important as that is. What were the goals that Canadians sought from first ministers? Well, I would say the following: first, Canadians wanted closure, closure on the increasingly divisive debate of the 1990s, about Medicare's sustainability and Medicare's future. They wanted to know that the system would be there for them when they needed it, what it would cost, what insured services would count regardless of where they were in Canada. And whether such things, which crept into the debate - like user fees, two tier health care, private for profit delivery - were inevitable, as many of the commentators and others predicted. So they wanted closure to that part of the debate.

Second, Canadians wanted the policies and programs that define Medicare to reflect our collective values, and for the system to be more accountable to them as the stakeholders, to you as the stakeholders. You pay for it, you use it, the program belongs to you, and reflects Canadian values. They wanted a window on the decision making process and the ability to monitor results across the system.

Third, Canadians wanted decisive action to stabilize Medicare. And then, to address the immediate concerns that we were eroding confidence in its future: timely access to quality care, health professionals (numbers and working relationships), and such things as advanced diagnostics, MRI, Cat Scans and the like. And finally, I think, Canadians wanted Medicare modernized to reflect the realities of today's health care needs and challenges. They wanted 24-7 access within their own communities and preferably under a single roof, to an integrated basket of primary healthcare services. They wanted more emphasis on prevention and on wellness and lifestyle. With 1 in 5 Canadian families now caring for somebody at home – 1 in 5! – they are looking for assistance. With advanced diagnostic services, MRI's as I say, increasingly available from 'Private for Profit' providers, with prescription drugs, the fastest growing component of overall health spending, they wanted progress on all of these fronts. They knew it couldn't be done overnight because we didn't get into these problems overnight, but they wanted the game plan laid out.

So, how well does the 2003 Health Accord address these 4 or 5 issues? Well, I would say overall, quite well. Let me briefly deal with each one in turn, beginning with the desire of Canadians for closure on the debate of sustainability and above all a desperate plea to all of our political leaders to end the bitter intergovernmental bickering and wrangling that has been witnessed the past decade over Medicare. One of the key objectives of my recommendation was to try and change the dynamics of the increasingly dysfunctional federal-provincial relationships by eliminating from the battlefield as many things as possible for governments to fight over. So as a first step - I got the idea from the Ecumenical Council of Canada - I proposed something called a health covenant: a consensual, non-legislative document by all governments that would allow them, the governments, on your behalf, to publicly reaffirm their commitment to Medicare and its values, and to work together on its national dimensions. The goal was to make progress towards a cohesive and viable national health care system. Not what we are increasingly seeing: thirteen separate systems, 10 provincial, 3 territorial - add the federal, 14 separate systems - of uneven quality and uneven capacity. The covenant also would have defined the respective entitlements, but also responsibilities of individual citizens, and the health care providers, and governments with regard to healthcare. My personal hope was that this covenant might come to serve as a kind of de facto preamble or some sort of an interpretive clause to the Canada Health Act of 1984, that great statement of our principles and what Canadian healthcare was all about. Well, the good news is that the 2003 Health Accord reaffirms the commitment to the five principles of the Canada Health Act as they currently are. It reaffirms in writing the values that Canadians hold and states its belief in transparency and accountability. But it does not include the covenant. Nonetheless, the other good news is that it includes more general statements of intent in regard to insuring timely access, to effective health services based on need. And then, and this is very significant, it states (the Accord does), and I quote directly from it the following, “Our health system is sustainable and affordable and will be here for Canadians and their children in the future.” Sustainable and affordable: this isn't Roy Romanow speaking. It is the Prime Minister and the 10 premiers in writing and while I would have said, and hoped, that there would have been more precision - it would have been very welcomed to have more precise words in this regard - this nonetheless is an extremely positive development. And it behooves any public figure now, very poorly, to say that having agreed to this in black and white, they are going to walk away from it. They've made the judgment that it is sustainable. It is sustainable and we as Canadians have got to insure that their commitment is honoured in that regard.

Now while the first ministers reaffirmed the principles of the CHA, and brought some closure to the debate over private-public delivery, which is raging also in Canada, the Accord, I have to say frankly, does little to clarify this debate of how much private sector delivery there should be in healthcare delivery. Now in fairness to the Prime Minister and the premiers, this highly contentious issue is very complex and never formally on their agenda. But I tell you my friends, sooner or later – and sooner rather than later – it will have to be dealt with in a comprehensive way. As Canadians know, at every stage of my work throughout the entire fact-finding research and public hearings, I expressly and repeatedly encouraged those advocating a greater private sector, for profit role in the delivery of health care, to bring forward the evidence and to do so, to show how it would reduce wait lists, how it would make the system more affordable, how it would conform to values that in our time of greatest need, illness, we should all be treated equally whether we are rich or poor, regardless of gender, regardless of colour or beliefs. Bring forward the evidence to prove that the outcomes and the quality is as good if not better. At the end of the 18 months, that evidence was not forthcoming and that evidence today remains notable by its absence. But nonetheless, the debate still now goes on in the backrooms. And so I say to all Canadians and to those who are arguing this from a decision-making level, keep in mind that in today's era of complex, multilateral agreements and globalization, decisions taken in one province with respect to more private delivery of healthcare, for example, will have implications across all of the provinces and will have implications for every Canadian. And those who advocate this, not only to the standards of quality of care and effectiveness, must remain cognizant that the Canadian view of healthcare is this: healthcare is a moral enterprise; a moral enterprise and not a business opportunity!

Now another of the problems is the existing dynamic of delivering health policy. The different levels of government and sometimes different provincial governments begin from different starting points; different starting points on simple issues of fact. So I recommended the creation of a Health Council of Canada (if I use the term HCC, that's what it is for short), to bring together under a single roof the caregivers – doctors, nurses, everybody that is important, and they are all important in the healthcare field – to bring forward the governments and also bring forward representatives of the public. Fourteen people are recommended; there can be some better models and the structure, which was set out in the report. This streamlined entity, the Health Council of Canada, would act to resolve disagreements and misunderstandings amongst the tripartite – the public, the caregivers and the governments – but also give patients and providers a say, a meaningful say, in how the system operates. As important, it would set goals and standards and then monitor whether or not those goals and standards are met; something which we now don't have as Canadians. The purpose of the Council would not be to foster, as somebody said, a ‘watchdog agency’, which I find a highly pejorative term and in some ways inflammatory. This is not a watchdog of one level over another but rather it would foster collaboration and cooperation amongst governments and the Canadian public, to improve accountability to us as the users and the owners of the system in every way going. Here my vision for the Council is that it will serve as a focal point for gathering information and these common indicators. In time, it would act as a fact finder, resolve disputes and interruptions under the Canada Health Act. To reinforce the right of Canadians to monitor the health system’s progress, I also proposed - just to nail this down - that we should amend the Canada Health Act to add a sixth new principle, accountability.

Now the language of the 2003 Health Accord of the First Ministers gives reason for some guarded optimism here. I've already mentioned the general commitment of the Prime Minister and the premiers to, “enhance the transparency and accountability” of health care, but it is a little more positive than that in the Accord. In the Accord, and I quote, it says the following: “First ministers recognize that Canadians want to be a part of the implementation of this Accord. Canadians want to be part of it. Accordingly, they agree to establish a Health Council to monitor and make annual reports on the implementation of the Accord, particularly its accountability and transparency provisions.” The Accord - I'm taking about the First Ministers Accord - then commits the governments to establish such a Health Council within 3 months. Obviously, the Council’s eventual terms of reference, its governance structure, its composition, all of these are going to be very key; its autonomy and quality to determine its effectiveness. Well, at this stage I would have preferred that they already would have implemented a health council. But, nonetheless, what is important is that there is a commitment. And while it is not entirely clear whether the council is intended to monitor all key aspects of the health care system, as I envisage it should, or merely the new spending reinforced in the Accord, time will only tell. What I need to say here, at St. F. X., is to encourage the First Ministers and above all the public of Canada, to make sure that healthcare providers, representatives of the public and the governments, move and move within the three months to make a truly effective Health Council of Canada, making health issues and outcomes - not only dollars, but outcomes - accountable to all Canadians as a right of citizenship and as a right of democracy in a democratic society.

Now let me turn to the question of whether or not additional resources have been invested into the system to make headway on the priority concerns, and to transform the system. Now here I want to begin by applauding the decision to do away with the old CHST, the Canada Health and Social Transfer. It wasn't at that time only, it started before the (1995) CHST. But around that time, federally and provincially, including when I was Premier, public spending for health care began to dip very dramatically. Up until that time, since Mr. MacEachen's time, it was pretty well on track as projected. Then there's a huge deficiency in spending, a very big deficit, followed by the consequence: cutbacks on nurses, on doctors' positions, on MRI's and, everything abhorring a vacuum, the arrival of “private for profit” delivery (for example, MRI's and diagnostic care). So the CHST did not work. You couldn't account for it, and the amount of money under the CHST was dramatically cut back to the provinces and the provinces too were cutting back. What is good about the Accord is that the Prime Minister and the Premiers have agreed now to have a Canada Health Transfer (CHT): alone, free standing, dedicated. This is a decision confirmed in yesterday's budget announcement. This is good news. And it may be good news for more than just health. It may be good news too, Dr. Riley, for institutions like this university; for education and social programs where we can monitor exactly where the money is going in order to make sure that it achieves results. But returning to health, this is a very important first step toward making the system more transparent.

But the next system step must be to go further than that. In addition to doing away with the CHST, there is a desperate need for adequate, stable, and predictable funding. Adequate, stable, and predicable funding is absolutely essential! My idea was, and I recommended, that by the year 2005-06, Ottawa cover a minimum of 25% of provincial health spending on Canada Health Act expenditures. And this would be provided in the form of a dedicated cash-only transfer. I picked 25% because that's the historic norm. You hear the premiers talking 50-50 but it is not right; it’s 50-50 of everything (including tax transfer and cash). I'm talking about cash transfer and the figure is 25%. I also proposed with this platform, that there would be an escalator clause for five years, stable and predictable, with everybody knowing what the money is. They would know what the federal share is, be able to plan accordingly, track inflation, and keep pace with it that way. Taking account of tax points that were permanently transferred to the provinces back in 1977, the 25% cash transfer would restore Ottawa's historic share of CHA-covered health spending and bring stability. I firmly still believe in that concept. Well, what would this new funding mechanism (the one I recommended) achieve? One, it would remove another possible irritant from the volatility of inter-governmental relationships and provide for accountability. Two, the federal and provincial governments would be working from the same numbers. They would not be continually negotiating the size or growth of the federal transfer every two or three years. In short, to repeat again, funding would be adequate, stable and predictable.

I also recommended that the 25% Ottawa portion of that funding - by 2005-06 - be targeted, specially targeted in a number of areas over two years, and only over two years, for rapid transformation, coupled with the creation of the Health Council of Canada, to monitor the transformation and to monitor the spending. Now why targeted? Our system is in desperate need of reform. Under the CHA, all that is covered is hospitals and doctors because that's the way they did business in those days in healthcare: back in 1960-61, when Saskatchewan invented Medicare, if I can describe it that way, and at the time that Mr. MacEachen introduced the federal bill in 1966. But it is changed radically now. The targeted funding is designed to deal with the structural changes required and to kick-start them. Transforming the system by revitalizing primary healthcare delivery is very important. So is putting into the basket of services homecare services, and services for the mentally ill. Those who suffer from mental illness were the orphans of our Medicare system. Prescription drug treatments, as I've already said, is the fastest rising component of healthcare. The issue of advanced diagnostics. All of this would transform the system to be more effective and more efficient and to be brought into the values-insured concept of the CHA. And you'd say to the premiers, “look, we want your cooperation to agree to these changes with these kinds of conditions.” I know the premiers don't like the word condition or conditions, but that is what it is.

To entrench these changes I also recommended that the Canada Health Act should be amended. We have accountability, and now we would amend it to include in addition to hospitals and doctors, homecare, clarified diagnostics, the MRI's, and over time bring in prescription drug coverage, because that is the cheapest way to do it with the best health outcomes, as the evidence of the report clearly shows. This would acknowledge that healthcare today is more than it was thought to be in 1984 or 1977 or 1966 or 1962; more than doctors and hospitals. Keeping in mind, as I say, that these are the fastest growing areas - drugs and homecare – this would insure that Ottawa was financially responsible for paying its share of the system's expansion. This is very important.

And now I turn to yesterday's budget. Yesterday's federal budget notes that federal funding for healthcare will increase from $15.5 billion in 2000 to a forecast $31.5 billion, 15 to 31 billion by 2010. That's a large amount of money and kudos to the federal government for advancing it. But, while also announcing it, it is unclear what the base will be for calculating the new CHT, the new Canada Health Transfer. For example, to explain my point, on the base, the budget calls for an immediate $2.5 billion cash infusion to the provinces through the old CHST until it is done away with. And it confirms the $16 billion over five years for the health reform that the First Ministers recommended, somewhat along the lines of the transformative change that I've talked to you about. The $2.5 billion can be used by the provinces to spend as they see fit, ostensibly for healthcare. But there is no effective guarantee of this other than hard public scrutiny. It would appear, though, that the $16 billion will then be rolled into the CHT, buying transformation as it is rolled in. But the reality is that while there is significant money on the table, the total amount of federal dollars for the CHT today and in the future is going to fall short of the 25% historic Medicare bargain. This ultimately means that ‘top-ups’ of money of variable amounts is what faces us. It will mean that we'll end up having to negotiate on an ongoing basis to ensure continued progress, rather than a floor with an escalator. In areas like homecare and prescription drugs, with all the concomitant risks of inter-government squabbling, and the damage that it does to the confidence we have in our Medicare system. And above all, the damage that it does to the unity of this great country of ours. This is hardly any way to build a new transformed healthcare system, let alone a way to build a unified, strong Canada. And so in future meetings, I argue today, the First Ministers must recognize the benefits of a fixed, indexed federal funding share and of changing the Canada Health Act to insure all levels of government are paying a fair share for the planned natural expansion.

Now let me turn, very briefly, to the specifics of the Health Accord and try and address the issue of whether sufficient money has been allocated to stabilize. First, as I noted, the Accord provides for an immediate $2.5 billion and this will address some urgent needs. But I want to stress this: the absorptive capacity of the healthcare system can be infinite. The additional dollars on the table will make a difference and I welcome that. But they'll be sopped like a blotter, right away, without transformative change.

Second, I'm heartened by the willingness of the First Ministers and their Accord to proceed beyond the simple focus on hospitals and doctors, for the reasons that I've talked about already. I'm also glad to see a collective commitment to set national objectives on homecare, again for the reasons that I've talked about. To be sure, I would have preferred to see more focused funding for rural and remote communities. This was not included in the Accord. And, at least, some funding distributed on a population needs basis, something which the very distinguished former premier of Nova Scotia, the Honourable Russell MacLellan, present here, fought for, together with the Atlantic premiers and even other premiers in the west. It is a difficult one, but it is an important issue.

Now having said all of that, I do want to say this in fairness. I want to acknowledge that the $1.3 billion that's been allocated to First Nations health goes beyond what I recommended. Indeed, we are still at the early stages of a longer term reform process, and this should be a welcome step that has been taken. And in assessing the adequacy, let me make a third point. On the broader issue, Ottawa has provided for less than the provinces were seeking, less than what myself and Mr. Kirby’s Senate committee were seeking, albeit with fewer strings attached. Moreover, as yesterday's budget announcement makes clear, the pace of change will be significantly slower than I think many of us hoped for. While $16 billion is being invested in healthcare reform over the next 4 years, most of that money will be back-loaded at the end of the 5 years; some up front, but most back-loaded, and very little money will actually flow this fiscal year. More to the point, in the absence of clear, measurable objectives, it is difficult to glean from yesterday's budget how these new funds will be spent or what improvements they will produce. As I keep repeating, I am not making a plea here for more money, far from it! The issue is not more money. Adequate money, yes! The issue is money plus, money that buys transformative change. Again, there is room for guarded optimism. Yesterday, the Minister of Finance, Mr. Manley, took great pains to emphasize the federal government's commitment to greater transparency and accountability for how tax dollars are spent. I think that's a wonderful statement and a great value. Presumably, that same commitment, that same principle will extend to health spending to ensure that Canadians obtain an effective Health Council of Canada and the effective results of which I have already spoken. But one last word on this. More sobering is that some provinces - I'd even change the word to say more troubling - is that some provinces have already dismissed this large amount of money and the First Minister's Accord as being inadequate. Inadequate both in terms of quantum and inadequate in terms of meeting certain outcome targets to which they've agreed. They may be right. Their parting shot, that they will be back at the table next year and the year after that, with new money demands, emphasizes the urgency to change the bases on which our healthcare system is funded in order to prevent this continual, ongoing, once every two or three years wrangling, and wrangling behind closed doors. Being blunt about it, in my judgment Canadians are fed up to here with that kind of an approach and they demand a resolution now at this crucial time in our history and development.

So, to summarize, the outlook is not bad. There's been some very good positive changes made. I wish when I was premier in September of 2000, we had signed an accord something like the one they signed in 2003, even with my criticisms. We would have been further down the road to transformation and reform. We didn't do it! So this is good progress. But, we need a CHT, health transfer cash which is stable, predictable and adequate. We need to change the Canada Health Act, with accountability and put the CHT in there, to modernize our healthcare system by expanding the transformative changes I've talked about. And we need, desperately, a new Health Council that provides Canadians with a say in setting health priorities and provides a clear picture of who’s paying for what in our healthcare system, and with what results. These three objectives, as I see it, are integrally linked together as a package. They are not ad hoc recommendations and they cannot and should not be cherry picked.

And so, as I close, where do we go from here? I'm well aware that the First Ministers did not and realistically could not give full consideration to all of the issues affecting Medicare. I've been at those meetings. The focus was on money, setting broad policy directions, taking preliminary steps toward reform and accountability and I’ve made the judgment call “not bad” - a pretty substantial and ambitious agenda for a one day meeting. But I would be remiss if I did not at the very least mention that other health policy issues require the urgent attention of our policy makers - those I've mentioned plus others, very briefly. A priority must, of course, be placed on bringing the territorial governments into the fold, to make the Canadian family whole. And my hope is that the meetings scheduled for tomorrow, between the Prime Minister and the territorial leaders, will yield positive results, for those Canadians who face many of the most difficult economic and social challenges of all Canadians. We've got to work to resolve the murky and confusing jurisdictional issues that are impeding progress on aboriginal health in Canada. Friends, in almost every category of health outcome, Canada stands near the top. When it comes to aboriginal people, the gap between the rest of us and aboriginal people's health is very large. To be sure, progress is made, but the gap remains very large. It is an outrage that in a country as rich as ours and compassionate as ours, that those at the bottom end of the ladder should suffer these kinds of inequities when it comes to this precious gift of life. And while the contribution has been very good, this requires a determined resolution by all Canadians to resolve and to resolve quickly.

We've also got to experiment with population-needs formulas; I've talked about that. Let’s look at a new national drug agency. Let's take a look at some aspects of the drug patent law; I put that in my report. Let's take a look at integrating medication management within the primary healthcare system; somewhat technical terms but all of which speak about making drugs effective: the right drugs for the right illness, and affordable to us as our right as Canadians. And then we have to deal with population health, wellness. When we talk about healthcare, if you're like me, you talk about it when you've lost your voice already. It's too late! We should be talking about wellness, and prevention, and lifestyles. Primary health, I've mentioned that, needs to be stressed. It needs a determined effort.

I close here this way, friends. I'm acutely aware that the support of Canadians for the healthcare system, our healthcare system, is not given freely. Support is given in exchange for a commitment that governments stand fourscore behind the values that have made this one of the greatest countries in the world in which to live. And that the specific changes will ensure high quality care is there when they need it. Progress will be made if we support the values that as Canadians we care for each other in our time of need. Goodness knows it’s difficult to look after oneself when you're ill without having to worry about your economic situation or your home situation. Canadians subscribe to the notion of looking after each other inter-regionally. I hate this term but to make my point, the ‘have’ and the ‘have not’ regions. We're into this together, to share. And we're into this because we believe in intergenerational transfer. Sometimes I get questions saying, “oh well, it's an aging population.” Some youngster will ask me, “why do I have to worry about it?” Why? Because mothers and fathers and grandparents looked after us, as we will look after the children that we raise - as intergenerational, interregional principle and value. First Ministers have made great strides toward realizing these values and it's an important milestone. And this is probably one of the quickest-moving Royal Commissions in a long while. But this is not the end of the story. It is only the beginning because as I say, “progress attained is never progress guaranteed”. Progress attained means progress always pursued and it means the next generation of Canadians, of young students in this room, and others, recommitting themselves to fashioning a modern-day Canada which has all the hallmarks of this caring and sharing society that we are.

And so, in the coming weeks and months ahead, I say to you bluntly, and forgive me for putting it this way, that it’s up to you. It’s up to Canadians to be vigilant to ensure their elected leaders implement not only the spirit and the letter of what they've done, but that they go further, wherever necessary, to refit the system for the 21st century. It's up to you to be vigilant. It’s up to you to make sure that the goal is nothing less than to make Canadians the healthiest people in the world. It’s up to you to be vigilant that our effective healthcare system reflects and respects our values and strengthens our collective, united citizenship. That there is no difference, me being a Canadian of Ukrainian background from the prairies of Saskatchewan, speaking to young men and women and others right here in Antigonish, this beautiful part of the world, in this great university with a great history. We are all Canadians! It’s up to you to be vigilant.

And let's not be fooled by some of the so-called new thinking. This is where I got attacked continually and still do - “oh well, Romanow's in the box!” I say we're all in the box. You don't like my values or approaches? These aren't mine, these are what Canadians told me. You have another set of values, a different box, a different set of solutions? We are all in a box. “We have to innovate,” they say. How do you innovate, I say? “Try a little ‘private for profit’ healthcare delivery; take the pressure off the public system.” That's a new idea? A new idea? Let Allan J. MacEachen tell you about how new that idea was. In Saskatchewan, we innovated with ‘private for profit’ healthcare and had that for 60 years or some longer period, and when people got ill, unless it was the kindness and the mercy and the charity of others, they lost their farms and they lost their homes and they lost their livelihoods. And above all, they lost their dignity. And they want us to return to something “new” like that? Be vigilant against those arguments and those words. And by the way, it isn't supported by the evidence either!

I can't think of any better words to site, than those that as I sited at the very beginning, of our special guest, the Honourable Allan J. MacEachen. His thoughts in an interview several years ago speak, I think, to today's challenge of renewal and meaningful reform. Our special guest said the following, and if you remember anything of my talk to you tonight, remember the words of Allan J. MacEachen when he said this. “Helping those who need help most was and still must remain a government principle of action. It constitutes a beacon in the shifting sands of public taste. And we ought to always keep it in mind in assessing the legitimacy of public policy.” Helping those who need help most, a beacon in the shifting sands of public taste. And like in so many things, this great Canadian who sits here in front of us was right when he said it, and he is right now. And I predict that for as long there is - and there will be for a very long time - a strong and united Canada, he will be right. Thank you very much for listening to me. Good luck and God bless.