 So I'm Sheila Wildman, Associate Director of the Health Law Institute, and it's my great pleasure today to introduce Professor Colleen Flood. Colleen is a professor at the University of Ottawa and a university research chair in health law and policy. She's inaugural director of the Ottawa Center for Health Law, Ethics, and Policy. From 2000 to 2015, Colleen was a professor in Canada Research Chair at the Faculty of Law University of Toronto, and from 2006 to 11, she served as a scientific director of the Canadian Institute for Health Services and Policy Research. Colleen's well-known to many of us here, not least because the former sad decline into the relative torpor and obscurity that followed. She was Associate Director of the Health Law Institute in 1997 to 1999. That was a period in which she accomplished many brilliant things here at DAL, including launching this seminar series. In truth, Colleen has made tremendous contributions ever since those original glory days across a range of areas of scholarship and public service. Her research focuses on comparative health care law and policy, public-private financing of health care systems, and health care reform. In doctrinal terms, she's made important contributions to constitutional law and administrative law in work addressing a range of accountability and governance issues. Among Colleen's recent scholarly achievements is her 2014 co-edited book, The Right to Health at the Public-Private Divide. That's published with Cambridge University Press. And more recently, a venture to which a number of us here at DAL contributed the 2016 volume, Law and Mind, Mental Health Law and Policy in Canada, which Colleen co-edited with Jennifer Chandler. An extraordinary teacher as well as a scholar, Colleen has helped launch the careers of countless health lawyers, policymakers, and academics in Canada and beyond. And she continues to devote herself to fostering conversations and building understanding of health law and policy across Canada, across disciplines, and globally across borders. So without further ado, we're so glad Colleen could wing in to speak with us today. OK, hi, everybody. I apologize for this rather croaky kind of voice that you're going to have today, but I'll do my best to speak through it anyway. And thank you so much, Sheila, for such a lovely introduction and to Constance and everybody at the Health Law Institute for inviting me to participate today. And I always come back here with such love in my heart and remembering starting my academic career here and walking through the botanical gardens and actually leaping in the air and clicking my heels together like Dorothy thinking, wow. I have a job. This is so awesome. So and I always love coming back here. It's my academic home. So I'm going to talk to you today about charter challenges to public Medicare and in particular, the Can-Be Challenge, which is ongoing now in British Columbia to laws protecting public Medicare. But before I do that, we can't really start any talk these days, I think, without reflecting on this development. And I think President-elect Trump is just part of a phenomenon around the developed world where we're seeing the election of right-wing leaders and parties coming to power and a surging backlash against globalization, against the welfare state, and against perceived inequities. And rather than improving life for all, the impetus is to drive a wedge further between those with and those without and to further marginalize the vulnerable amongst us as scapegoats for all the problems that bedevill us. And I think in this context, the importance of Canadian social programs that in gender equity and solidarity, for another word, between us really can't be overstated. And so more than ever at this time, I think these shared social programs that bring us together rather than drive us apart are what we need. And Canadian public Medicare has long stood as an icon of Canadian citizenship of our inherent connection with each other and the most basic enterprise of ensuring access to health care when we are at our most vulnerable, when we're being born or giving birth, when we're sick or disabled, and when we're dying. So into this, we have these constitutional challenges that are happening to public Medicare. First, having some time ago, and many of us in this room spilt a lot of ink over it, in Quebec, the case of Shayuli and the Supreme Court of Canada in that case ruled that a law banning private health insurance did not meet the requirements of the Quebec Charter of Rights and Freedoms. On the Canadian Charter, it was a bit of a draw. But it's largely been taken as a precedent that the laws that currently protect public Medicare may not survive constitutional scrutiny. And there's a consequence of which a number of constitutional challenges have been launched all across the country. The proponents of privatization have figured out that the law that bans private health insurance overturning that isn't enough to really liberalize and allow a large private market to flourish. They need to attack other laws that protect public Medicare. That, in and of itself, is not enough. And that's exactly what they're doing. And this occurrence that we see of challenges to public Medicare is part of a larger global phenomenon that Sheila mentioned, a book that I worked on a couple of years ago, about litigating the right to health. There are people around the world litigating a right to health. And often this is what we would call a positive right to health, where it's demanding from governments that they act, that they provide care, that they deliver timely care, that they cover vulnerable people. And this has more or less different effects depending on the country. But in Canada, it's interesting. We've taken quite a regressive stance on this idea of litigating a right to health. Litigation is not a right for everybody to have timely right to care in Canada, but only those who are able to pay for it, either through private insurance or out-of-pocket payment. So this kind of regressive effect that we're seeing in litigation of health rights in Canada. So human rights proponents, I think, hopes that the Canadian Charter, litigation of health care rights under the Canadian Charter, would be a way to ensure rights of those who are most vulnerable, to help people who needed better health care. But in fact, the opposite has become true. It has become a way to litigate for rights for those who have more rather than less. So now we see, after that first hammer blow from Shauli, I think we're seeing or hearing the sound of shattering glass and that glass is public Medicare, coming from the Canby Clinic Challenge in British Columbia. Canby is a private for-profit clinic that is owned largely by a chap called Dr. Brian Day. I'll show you a bit more of him in a minute. He used to be the head of the Canadian Medical Association for a little while. And they've been providing private health care, medically necessary care. It seems illegally for quite a while. So delivering for private payment, hips, knees, joints, these kinds of things for private payment. And finally, they were audited by the BC government. It's part of that audit. They've fought back saying we haven't done anything illegal because the laws that prevent us doing what we're doing are unconstitutional. So this is the old kind of argument that, it's okay that I've broken the law because the law is an ass kind of thing. So the law is unconstitutional. It's fine that we've broken the law. But you'll see here from this long list of things that they're challenging, it's not just the law that bans private health insurance. So there is a law that bans private health insurance NBC and they're challenging that as they did in Shaulia. So the question will be whether there is a finding on the charter definitively this time. Like I mentioned last time in Shaulia was a tie. So whether this time it will be found unconstitutional and overturned. But they noted that in and of itself will not liberalize or allow a really significant large private market. Because if I have private health insurance or I can buy private health insurance, I'm not going to do that unless there really is a market that I can buy from. I need doctors that are actually prepared to provide private services. How do I do that? Well, they say we need to have physicians to be able to extra bill. Extra billing is where doctors charge you more than the tariff that they received from the public sector. So the government gives them, you know, 60 bucks or something for a consultation. They want to charge you another potentially 60 or whatever on top of that. That's called extra billing. They want to ban the law that prohibits user charges. Similar idea, but this is where the insurer, the public insurer or the private insurer actually charges you a payment that you have to make out of pocket. The law that says that physicians have to make a choice. You can practice privately if you wish to, but you can't be in the public system at the same time. And this really inhibits a lot of doctors from going private because this is where they make most of their money. They want to stay in the public system. They don't want to go private. Some will opt out and some have opted out and I can show you some statistics around that. But few. So we're keeping most of your manpower inside the public system. They want that law overturned so that doctors can work both publicly and privately. They can provide a public hip and a private hip at the same time. And they can charge you more for your public hip and they can charge you whatever they want for the private hip. And then finally, they want to overturn laws that say, look, if you go private, there is a law in BC that for some physicians, it's all a bit complicated, depending on whether you're enrolled or not enrolled. But for some physicians that go private, they say, look, you can go private, but you have to, the prices that you can charge are limited. You can't charge whatever you want. You have to charge the public fee. So they want to overturn all of these. They're arguing that they're unconstitutional and breach of section seven of the Charter of Rights and Freedoms. Okay, so that's, so just to be clear, these are laws that are in British Columbia. Similar laws are in most provinces, variations of these laws in most provinces in Canada, it's confusing because they're all a little bit different, a little bit messy, but they've all been passed in order to comply with the Canada Health Act. So the derivative of the Canada Health Act, this is basically an assault on the Canada Health Act. It's a good thing now that the federal government has now asked for intervener status. So once the Trudeau government was elected it asked for intervener status. So it is now actually participating in the trial kind of late in the day, but at least they're there now. So, so section seven guarantees life, liberty and security of the person for the pointy-headed lawyer people in the room, you know that, for others, what is that? Life, security of the person. So life, you know, if you have to wait too long, arguably your life could be jeopardized, although that's actually very unusual in the Canadian context, but security of the person, where you're having to wait too long, and the anxiety and the stress and the worry that your condition may deteriorate, that your cancer may accelerate, that you just don't know, that sort of state of fear is undoubtedly a real one. So this is what we say when section seven is engaged because of wait times in the public healthcare system. So that's the core of this case is that the public in BC are waiting too long for public healthcare. And because of that, section seven is engaged and the government has to defend itself. My right to life or security of the person is in jeopardy and the government has to show why that is okay somehow, why that's reasonable in the circumstances. This stuff about wait times though is really complicated. So BC doesn't meet its own wait times targets. These targets are largely dreamed up by physicians and half the time I have no idea why they are what they are. But there's that. So they're holding BC government to its own sort of set of wait times targets that have been set by physicians. They're also relying on the Fraser Institute survey data. The Fraser Institute sends out survey to all the physicians in Canada, about 20% of them respond. I think they have put them in a draw for like a $20,000 gift basket or something. But they still only get about 20%. But nonetheless, every year they report that wait times are terrible. The chicken little, the sky is falling every year. And but I think anybody that knows anything about wait times data will tell you that this is absolutely terrible data. But then there are the evidence of about six patient plaintiffs in this case. So Dr. Day has enlisted some patients as you kind of need to do because it doesn't really look that good if you're just a wealthy physician coming to town to say we need more private healthcare under section seven. Just as Shayuli found a patient, Dr. Zellie Otters, Dr. Day has found some patients. And their stories are real. And of concern, they are patients that have fallen through the gaps of the public healthcare system who arguably should have been treated in far more timely way and the systems didn't meet their needs. And so those compelling stories are there. And undoubtedly it is true that there are problems with wait times in the Canadian system at large. We're certainly not doing as much as we could on this with the resources that we have. And we will be found wanting on the score despite the problems of measuring wait times and all of that kind of thing. So the system, I think, I think they're gonna find that section seven is engaged. Now, let me see if I can make this work. Oh, no, I can't make this work. Oh, yes, I can make this work. So this is Dr. Day talking about this. In his thesis, I agree that, I disagree that it's a human right to be able to access healthcare. And so far the constitutional law experts in the US and Canada have agreed that you can't have a right that imposes something, makes an imposition on another individual, namely me. But let's, I think we have to put this in perspective. We're not talking about a judge deciding what is right. We're talking about you as an individual being able to choose for yourself. And I was on just a few months ago on CBC again. I keep getting asked by CBC who is about the only media outlet that's not on our side. And they said, you know, I made some remarks along the lines I've made today. And the interviewer said, well, are you calling the Canadian health system a communist type system? I said, absolutely not. I said, absolutely not. I said, you know, Vietnam, Laos, Communist China, North Korea, Cuba. None of them have laws like this. We are way to the left of any of those communist countries. Yeah. So you see his stance on this and the laws that they're challenging are very significant. If they overturn the law on extra billing, think about what that means. That means potentially that every time you go to a doctor, you're gonna have to pay out of pocket, everybody. There's no public system left as we know it. So clearly if they strike down those laws as they're asking for, this would be a radical assault on public Medicare. You can hear, he's saying these are crazy kinds of laws. I think that's actually completely incorrect. But at trial, their strategy's got a lot more sophisticated than that rather large claims he was making in that fireplace chat. So he's got a lot more sophisticated and they're being very reasonable. They're being very nuanced in what they're asking for so they can get the foot in the door. So the court will feel that what's being asked is not too terrible. Okay, so I'll just show you how they're gonna do that. So first of all, the law is overbroad. So the law that stops all physicians working in the private sector that prevents any extra billing is overboard. Other countries allow some private on the top and they seem to perform better than we do. So it's not minimally impairing in kind of constitutional terms. And this is usually where governments fall down on the minimally impairing stuff. So we're definitely exposed on that. The law preventing private care is arbitrary. So principles of fundamental justice in section seven. There's going to be no harm to the public system and this is a common argument that is made about private care because most a lot of us in this room, instead of bugging a public system, we'll now go over to the private sector, right? So that's good, right? Like if Brad and I are out of the public system and we're over in the private sector, there's more room for you guys in the public system. But the trouble with that is that it doesn't allow for the diversion of medical manpower from the public to the private, right? So all the doctors and nurses are like, sweet. Like I'm going to look after Colleen and Brad over there because they're pretty healthy and they can pay a lot out of pocket. So why wouldn't I do that? I'm going to go over there. But the argument that they have in response is a lot better than they've ever had because they say, look, there's no loss of medical manpower to the public system because the public system doesn't let us work enough these days, right? We only get like a day of surgery time. The hospitals are restricting us. Us orthopods setting up downtown Vancouver. We, you know, we only get a day. We want more days of surgery. If you gave us more days of surgery, we'd be working in the public system. So there's no loss because we're twiddling our thumbs and we could be working in the private sector at that time, right? So this is a very strong argument. That they have, which counts as most of the concerns about diversion of resources. The trouble is, of course, it's not true for everybody. It's not true for everywhere. So the Royal College of Physicians and Surgeons reported recently that 17% of new specialists and subspecialists positions said they can't find work. So you're having some surgeons in particular training, particularly orthopods and that sort of stuff, not being able to find work. But then on the other hand, you know, this is just relatively recent data as well from BC's Medical Help Wanted, right? Like they need 447 physicians and family medicine, internal medicine, emergency medicine, all these sorts of things. So unless this is just limited to orthopods, what you will see is more of a diversion of folks from emergency medicine, psychiatry, pediatrics, family medicine to the private sector. Lots of folks like to live in downtown Vancouver and downtown Toronto and downtown Halifax and hardly anybody wants to live in Sudbury. Well, there's gonna be a huge problem of dislocation and relocation and further problems of the distribution of resources. But the fact that you've got people that are going, wanting, looking for jobs is going to be a factor that plays into this court case undoubtedly. So again, here's part of the sophisticated trial strategy. It's not just we want to bring the hammer down on public Medicare as he sort of has said in other spaces. No, no, no. We want to keep public Medicare, we support public Medicare, it's a great thing. We just want it for elective surgery. Now, overturning all the laws doesn't necessarily mean that's going to come to pass, but they're saying to the court, well, that's not your problem. All right, you overturn all these laws, then you boot it back to the government, the government's going to have to figure it out. But they can figure it out because other countries have. Good luck with that. But anyway, I'll talk about that a little bit more. But no, no, we don't want to overturn all of public Medicare. Public Medicare is great for looking after really sick, poor people that we don't want to look after, basically. The expensive stuff, right? We want to keep it for that sort of thing. We don't really want physicians, we don't want physicians to extra bill in the public system. So yeah, you won't get charged if you're in the public system in our ideal world. But if you're coming to us privately, we're going to extra bill you, because we need to get money from you to run our clinics. All right, he really needs that. He needs to be able to extra bill in order to finance the clinic. All right, now, the trouble with this, and that might sound kind of reasonable, but who owns the clinic? These doctors own the clinic. And the high profits that they make from their facility fee by charging you $50 for a sponge, that is going to pay the physicians. And the more that you pay the physicians, the more drift that you will get from the public to the private or the relative price. And it says, look, you know, and we're not crazy. We want to keep the public system vibrant and healthy. And so we're open to regulation of physicians to make sure that we have enough happening in the public system. But again, court, it's not up to you to figure that out. You just leave that in the hands of the government, they'll figure that out. So this all sounds really reasonable and sort of sensible and thus doable. So you see how this trial strategy has really changed quite a bit from when their first sort of statement of claim was overturning all these laws. So the government is on the back foot. The government is going to have to defend a system that is clearly has a lot of problems. All right, the system isn't working well. People are not getting the healthcare that they need. So the first thing they could try to argue is, look, these laws banning private health insurance got nothing to do with why people are waiting. It's got, there's no causal link, right? There's no relationship. But we don't think that one will probably fly, to be honest. A more perhaps better argument maybe that the government's objective here is not just to ensure some reasonable stand in the public system, but it is actually to ensure equity. It is actually a goal of ensuring that everybody receives a similar level of healthcare. And I think this is probably the best argument the government has. But the plaintiffs are going, applicants are going hard at that because there are some exceptions to this that have been built in from the very beginning of Medicare, for example, around workers' compensation. So there's a carve out for workers' compensation where people who are heard at work are prioritized and actually workers' comp buys faster, quicker care from private plants. And so the applicants are saying, the system is already flawed, the government doesn't really have this objective because they permit this. Although it's actually a historical anomaly and it really is very different from a private insurance world. People aren't thrown out onto the market and having to buy private insurance, they're not risk rated, the employers pay for it. It really is a public plan, but it's kind of a two-tier public thing. But they're gonna go hard at this objective as not being real. And this is actually really important. Like, if the court says that the government's real objective here is just to ensure some reasonable standard in the public system, then we will see permission to engage in some kind of two-tier system because reasonable just means enough. The other thing that the government, the attorney general is arguing, which is kind of controversial, is that to the extent that the patient plaintiffs have been waiting too long, it's not the fault of these laws, again the kind of causation argument, but the fault of their doctors. Which Dr. Day is tweeting about this big time and sticking it to the doctors kind of thing. But the argument here is that if patients are in jeopardy of actual harm, if their condition is gonna deteriorate, then it's a duty, ethical and legal duty of the physician to reprioritize their list and to put that person up the top of the list. They shouldn't be waiting longer than in a situation where there's real harm. So probably the most poignant patient plaintiff is this kid, young kid, Wally Khalifa. And he required, or it seemed he required urgent surgery for scolosis. And to cut it long story short, his mother was incredibly concerned for him and she was kicking in doors, trying to get him the surgery that he needed in BC. He didn't get the surgery and so they ended up going to the states and getting the surgery and as a result of that, he is paralyzed. Now, his physician has been testifying in court that actually, they didn't wanna operate because of concerns that he would be paralyzed. But the applicants are saying he is paralyzed because the public system took too long. So we'll have to see, but the physician is saying, look, I did my job. Like I did consider where he should be. It wasn't actually that he had to wait too long for the public care, but just that we had these reservations about whether or not we should be operating. But there are very limited number of specialists who provide this kind of surgery in Canada. They're trying to get more of these specialists in the NBC. So again, you have this shortage issue. If you're gonna allow it privately, then you are gonna be diverting limited resources. But this is a controversial argument and we'll have to see if it flies or if it backfires for the government because taking on physicians is often quite dangerous, I find. The other argument is a concern about dual practice. So should we permit dual practice? The government will argue, look, you're gonna divert resources. They're gonna say, well, no, we won't because we're not being able to operate, we don't get enough operating time at the moment. So this one is more dubious. Conflicts of interest, like come and see me in my private clinic where I make a whole lot of money. I can treat you faster, but they could say, well, you can regulate that. If you're concerned about conflicts of interest, you could regulate that. Rising costs. So if we can pay top dollar in the private sector, that is gonna put pressure on prices in the public system. All right, so if I'm an emergency physician and I can make $750 an hour over it in the private clinic and only $300 an hour in the public clinic, either I'm gonna go to the private clinic more or you're gonna have to pay me more. So it's gonna put pressure on prices to go up in the public clinic, prices go up, costs go up. So there is that concern, but I believe this to be true and that does have effect on real people. It means we can do less stuff with limited public resources, but it's hard to say someone, Rome is burning, someone's dying. The courts don't usually love arguments about costs in response to a section seven claim. It's too abstract. Who are these people anyway? So there's that. This is just an example from a case from New Zealand just to show you what can happen. Back in the day in New Zealand, they had long wait times for eye surgery. And so the idea was we bring in some Australian surgeons to help reduce the cost. This was problematic for all sorts of reasons, not least because they were Australian, but they're gonna bring them in to help bring down the wait times, right? And the surgeons in New Zealand did everything they could to stop this. They didn't want the wait times coming down and you see why. So this is a comment from one of the surgeons. He wrote, well, this will have a devastating effect on my private practice with markedly reduced number of private cataract referrals and cataract operations at Southern Cross Hospital over the years. There are more people opt for public hospital surgery. My ongoing commitment to the public hospital service now and in the future is I'm still prepared to assist just as I did when I performed those extra 66 outpatient clinics. So he's admitting, all right, you're wrecking my market because unless I have a long wait times in the public hospital, I don't get the demand for my private sector clinic. And actually they were found to be in breach of the Commerce Act, a competition act in New Zealand with their behavior. So there are other problems with private health insurance and I probably won't go into this in great detail, but the claimants say, look, and it's true, like about 66% of us already have private health insurance. So it won't be just about the wealthy because most Canadians have private health insurance and private health insurance could be used to pay for this additional more timely care, right? Wrong. Well, first of all, it doesn't cover that right now. So we're talking about a massive expansion of private health insurance. Who pays for private health insurance? Yeah, or stick your hand up because you do. You do through reduced wages and salaries if your employer is paying for it because if they're paying for that, they're not giving you an increase in your salary and wages. The government does because they give tax deductions for employers when they're buying private health insurance as a part of doing business. To the extent that employers can't just pass it on to you or I, they're gonna wear it, that's gonna result in a dragon employment and potentially lost productivity. So there are a lot of things that are going on with us. It's not all rainbows and ponies. Not the least of the rich, of course, that many people don't have private health insurance and it is the folks in this room that do, right? So the middle class and relative wealthy that will have private health insurance. And then there's the problem of extra billing. This is a direct violation of the Canada Health Act. We see all around the world that requiring or demanding that people pay out of pocket for care at a point of service means that they don't go get the care they need, right? Even if it seems ridiculous, like a $5 charge, like why aren't they going? That is enough to put off people from going to get the care they need. And we see it again and again. So for example, in France, France, I love France. It's so complicated. And everybody says, you know what? We should have a lovely French healthcare system just like we should have French Champagne or Caviar. You know, it just sounds good, right? So, but in France, you have to pay out of pocket at point of service, 30% out of your pocket. Everybody, even if you're insured. Then you get your insurance covers it back. So 91% of the French have private health insurance to cover this copayment. Poor people, obviously, find this a bit tough because they've got to pay 30% of some pretty big bills out of pocket. That's pretty hard for them, just full stop. And then some of them don't have private health insurance. So now the French government is publicly subsidizing poor people to buy private health insurance to cover the copayments. So you've kind of got this circular thing. But the ones that aren't insured consume 20% less healthcare. So just a bit poorer, no, just a bit less poor than the poor consume 20% less healthcare than the ones who are covered, right? Adjusting for everything under the sun, obviously. So, but we come back to this. We come back to this, which is that Brian Dane can be a putting Medicare on trial. They're not putting the laws on trial. They're putting Medicare on trial. And from what I see, it's really hard to resist this. It's hard for the government to resist this line of attack. It's hard for others not to be sucked into this vortex because there are problems with Medicare. But you put Medicare on trial, we've found wanting we've lost this case, no doubt. So here's this very colorful slide which you can now spend in a half an hour looking at. But basically, you see that up the top, Australia's fourth, Canada 10th. Thank God for the United States right at the end because without them, we would be last. You may actually praise Trump because with Obamacare, that was probably gonna change. But with him back in charge, it's probably, back in charge, in charge, it's probably gonna stay 11. So we might hold our 10th, please. But this is not good. And this is the data that will be presented in court. It shows that we're not performing well, but you take a look at some of this though, right? So it's not just timeliness of care. We suck at timeliness of care. We're the worst, 11th. But look at other things, efficiency, even equity, cost-related access, that's the best one. I mean, fifth on that, even with no out of pocket payment. But look at safe care, 10th. 10th out of 11th. What has that got to do with these laws? Absolutely nothing. But our system is not performing well. Quality of care, 9th, right? Overall, our system is not performing well. People are feeling it. And the easy thing to do, and this is the faulty logic, is Canadian Medicare. What makes us special is we don't have payment at point of service, that's what's unique. Oh, we're not doing very well. Oh, okay, so if we change that, then we'll do very well. It's just rubbish. Like, it's got nothing to do with quality of care. It's got nothing to do with safe care. It may have something to do with timeliness of care, but even then, I don't think it's got anything to do with that. It's got nothing to do with these factors, but that's being blamed, right? So you blame that, putting Medicare on trial and we're gonna lose. Now, what the attorney general, I think, should say, but can't say in this, is the way a charter challenge is framed is that it assumes the government has some interest in these laws, right? So the law criminalizing assisted suicide or the law making consumption of marijuana illegal. So the law that protects public Medicare. Government, you know, the idea is you can't have it both ways. You can't have a terrible public healthcare system and prevent people buying privately. This is not actually the reality of this. The politics of public Medicare is that many provincial governments would be very happy to kiss a goodbye. Why should they defend this thing that just results in a gigantic pain in the butt for them? Disgruntled doctors and nurses who want more money, unhappy patients, wealthy unhappy patients who are constantly complaining. It's absorbing more than 50% of provincial budgets. You know, this idea that governments are actually gonna be staunchly defending public Medicare, that's not the case. But that's the assumption in a charter challenge that government has some interest in this. And I would actually suggest to you that's not necessarily the case. They might be real happy to say, good, now all those wealthy, wingy people can go and they will be, you know, throw themselves in the market and knock themselves out and we won't have to worry about it. And we'll just have to deal with, you know, people who aren't as politically strong, who are left back in the public healthcare system. So I think that's the interesting thing that's going on here. The politics of Medicare, the politics of Canada is changing like we've seen around the world. And the baby boomers who have had it all have a lot of money in their pockets. They've got good pensions. They often have healthcare covered and they want what they want and they're gonna get it. That's the reality. They want what they want and they're gonna get it and they're not prepared to share necessarily to improve the system for others. So that's pretty depressing. A few people have said to me, oh man, you're so depressing these days. So I'm trying to write like a paper called Silver Linings. You know, so what could be the Silver Lining here? And, you know, the Silver Lining is that, you know, a court decision is just one part of a process. So you get a court decision, so say they win and they overturn some of these laws in BC. Well, that's at the end of the game. So then governments get to respond. Federally, provincially, they get to respond. So this in constitutional terms is what we call dialogue theory. So the court says one thing. Court says, hey, you've gone too far here. The government says, oh, how nice of you to tell me that. Let me fix that, right? And now, of course, now fixing this in the Canadian system is obviously incredibly difficult because we're dealing with positions who are very, very strong, advocates, hospitals here, all of this kind of thing. Nurses are very difficult, but there is that potential that, and a lot of my human rights right to health folks would say, no, no, no, it's all gonna work out, right? Because what this will do will be inspire governments to really, you know, move and make timely care improve the public health care system for everybody. And I think, you know, that's the optimistic view is that governments will react to this, that they will respond, and they will put in place, for example, a few things that I'm gonna talk about soon as possible ways to improve the system. But there are a lot of things that are pushing towards privatization. There's a lot of force, the aging population, the desire not to pay more taxes, federalism, the way that it works in Canada because provinces are paying so much out of pocket, sorry, so much of their revenue stream to public health care. And just across the country, you see, no, here's support for Canadians being allowed to buy private health insurance for medically necessary treatment. We were up around 80% or more in some provinces. For doctors being allowed to work in the private system, over 50%, close to 55% in Quebec. Now, this is a little bit interesting. This is showing at least a difference between 2005 and 2013. A lot fewer people think that will actually help. So they think you should be able to, you think you should be able to buy it, but they don't think it'll actually do anything, but maybe that's the Canadian way. This is the really worrisome thing. That private insurance would improve access to health care services for everybody about income level. People over, who are in over $50,000, way more of them think that it's gonna improve access to health care for everybody. Well, let's be honest, for them. And here's some other things. So Toronto Hospital, for example, Bob Bell, who's a good bloke, and I understand their situation, they're desperate for money at the hospital level, but medical tourism, let's bring it all in. Saskatchewan has introduced new legislation to allow for private pay MRI clinics. And again, it's all kind of reasonable. They say, well, you buy your private MRI and there's kind of a tax on it that goes back to the public system. So it's all fine. Private plasma donor clinic opened up in Saskatoon. Quebec has a proposal to basically regulate extra billing. So this is where they're charging you 50 bucks for the tissues and that kind of thing as part of your care, right? So before you get your publicly funded care or your publicly funded psychiatry care, you have to pay like a fee for the clinic, right? So this kind of loss leader business. Doctors opting out in Quebec. So despite Shayouli and the government's response, which I won't go into, but was a relatively clever response, since then, the idea of privatization has been normalized and you've got 273 GPs opting out in Quebec into the private sector. A lot of people in Quebec can't get a family doctor. So what do we need to do? You tell me. So the first thing we need to do is make sure that people don't fall through the cracks. People will fall through the cracks of any healthcare system. It's, you know, there's no system is perfect. It's impossible. But we need to have, I think, a means and a measure whereby, you know, if my family doctor or my specialist secretary hasn't called the other specialist secretary and I'm waiting for six months, which is actually what happens, right? And I'm too polite to call up and kick their ass. Like that's not me, believe me. But a lot of people are like that. They just patiently wait thinking that the system is actually working for them, whereas it's really a couple of receptionists that haven't talked to each other. But you need some mechanism to sort that out. And my vote is for a patient on-board person with teeth, so that if I'm, for some reason, I'm falling through the cracks, I've got somewhere to go and I can say sort it out. And that person can then like send me, you know, maybe to a private clinic, to the states or wherever I need to get the treatment or to make sure that it happens. You can't just leave people hanging out there without recourse. And you can't, you know, so that's the second thing. The first thing, the second thing is that we have to start thinking about what to do if these laws are overturned. What will be the response that provinces and the federal government can take? So if they have to find some other set of laws to protect public Medicare, we want them to actually find laws that will protect public Medicare. And not just say, case or answer, right? So we've been doing work, for example, on looking at things like contracting. So contracts, I'll talk about that in a minute. I'll come back to that in a minute. And then the second thing is to work on fixing large-scale systemic reform that we need in public Medicare. Huge, which is to figure out financing for long-term care and home care, figure out financing for community pharmaceuticals. These things are causing huge problems in our acute care healthcare system because we're not covering them well, right? So it's actually the opposite of what you think. The reason our healthcare system isn't performing well is not because we haven't privatized, it's because we have. So I'll just talk about these two last things and then I'm gonna wind up, because I've got five minutes. So we should think about contracting. And this is what I tell physicians. You better be careful what you wish for. So if you think you're gonna make a whole lot of money in this new system, you might be surprised because the government could react in a way that says, well, great, you know what we're gonna do? We're gonna put you all on contracts. We're gonna have to move some of you, a lot more of you to salary than we've ever done before because that's how in systems with two-tier healthcare, they actually ensure free public care. They have physicians working on salary in public hospitals, right? Not fee-for-service salary. That's gonna be a big change and I imagine that most of all of the physicians that you know are on strike tomorrow about this, but that will have to be how it moves if you're gonna do that, you're gonna retain some core free public healthcare system. And so we've been studying all the contracts in England, Ireland, Scotland over time. And it's interesting how they've evolved as well. They've gone beyond just sort of regulating how much time that doctors spend in the private sector and much more about quality, safety, all those sorts of things that you see that we're falling down on. Doctors hate it because this is like significant managed care. Here they are protesting the junior contract doctors. But I think this is what we have to think about. So this is the story to doctors, be careful what you wish for. And then as I said, putting Medicare on trial we're gonna be found to be wanting, but it's not because of laws inhabiting privatization but because of our failure, of our public system to expand. We have an adequate long-term care and home care. We have bed blockers, which are basically a terrible term for elderly people who are stuck in hospital that don't have somewhere to go. They can't get into long-term care and there's not adequate home care. So they're blocking up the beds and hospitals for other people that really need it. We don't fund community-based pharmaceuticals. There's really good research in Ontario showing that about 800 people under the age of 65 who with diabetes die every year in Ontario from want of access to community-based pharmaceuticals. We know that because that number changes dramatically once they turn 65 and then they have drug insurance. 800 people dying from want of access to insulin, which Canadians invented. That is ridiculous, right? So I can get my bunion removed. Full public funding of my bunion removed in Ontario but we don't fund insulin for people with diabetes. We don't cover mental health. We don't cover dental for kids. We do everything wrong. And for everything left out, we take a US-style approach to healthcare. So we think we're really awesome compared to the United States but for everything that is left out of the Canada Health Act, it's US-style. We have private health insurance. We have out-of-pocket payment. We salvage our conscience by paying for the really poor and the elderly and there's always a gap and it's inefficient. It's expensive and it's terrible. So we have to figure out ways that we can expand public Medicare and we have to do this creatively because no one wants to pay more taxes and I feel the pain of the provinces. They're like, dudes, we're already paying 50% or more. We're crowding out social services and education and everything. So we've got to think about more creative ways of financing this, things like CPP payments and that kind of thing. Ways that people feel okay paying into sort of a fund that aren't tax dollars and we've got to do that urgently but this is large-scale systematic reform and that's going to take a while, right? So, there you go. We do need to, just finally, so we fund bunions but we don't fund insurance. So you see maybe why we're on trial, right? That's just bad. So how can our system of laws and policies permit that to happen? We need to reform the Canada Health Act. We need to reform provincial legislation. We need to have a better process for deciding what to fund and not fund. We need to be constantly re-evaluating what we're funding and not funding. Defunding old stuff that doesn't work as well. That doesn't mean it isn't good but we might have new priorities. It might be robotics. It might be stem cell therapy. It might be some new drug. Whatever, we need to be constantly re-evaluating it. We need to accept that not everything's going to be funded. People who think that everything and a handbasket's got to be funded are nuts. That's a technical term. And unless we permit our governments to be able to say no to things, we will pay top dollar for everything. Our governments have to be in a position to be able to say no. And unless we empower them to do that, we will pay top prices for pharmaceuticals for everything. So we've got to be able to do that. And we need a system that's kind of constantly reflective and evolving so that it meets our needs. So Canada Health Act is, what is it? Like it's 50 years old. Yeah, it's old. So we need to be constantly re-evaluating and moving it forward. So it meets our needs now and into the future. So there's a big battle lining up. I don't actually like our chances that much but what the hell? Oh, here we go. I'll stop it. I'll play it. Okay, far away. David. I have a comment to ask the bad people who arrive at waiting times. And some longer waiting times are bad because people get better. But the way they arrive at the waiting times is they stratify patients by risk. So for example in cardiology, we had that circumstance in Nova Scotia. We know that people with certain characteristics are more likely to die unless they get cognitive impairment. So that's how they arrive at waiting times. It is an arbitrary visit. And the suffering is a separate question. But the more important question I have for you all is we know that in Canada, the currency for excellent care is social capital. So the evidence is very clear that wealthy, well-connected and well-spoken people get better care. They have shorter wait. They have fewer mistakes. And they get better care, including if there was a presentation recently in community health and academicity. So equity is the purpose. And we still don't have equity. I would think that part of the issue is how you solve that problem with a publicly funded system. We've got to see the four parts of the Canada Health Act that affect people everybody agrees with. The public administration part seems to be the barrier. So in Nova Scotia, for example, when communities want to get primary care doctors, they're not able to get it. Even though their doctors want to work, and they want to work it, they currently pay $30 dollars and they're happy to do it. But how do you deal with that part? I'm not worried about the absolute people because they're going to find ways to pay for what they need to get. They're going to do black markets or whatever. Yeah, so on your first point about there are problems in the healthcare system, inequities, argument that wealthy people can manipulate the system. So there's always a puzzling argument to me because this is the argument as well that Dr. Day and others make. So we have problems in the healthcare system so let's make them worse. I'm not saying that, I'm saying how do we make it better? I'm saying that it's a tragedy. You see, poor people getting screwed in this. I know, but this is how it's being used though. It's not being used to argue. I don't care about Brian's that. I don't know what we're doing. Well, anyway, I'm sorry. No, no, no, but that's, you know, so this is part two of the talk, right? Which is about how do we improve the healthcare system? And I agree with you, you know, in my vision of reforming healthcare, that you try to actually get decision making away from politics as best as you can. And I was talking about this with Brad, who's coming with me to the private clinic, last night that's, you know, part of the problem is that the one thing that governments love to do is re-disorganize the governance system when they come in. You know, so if it's a left-leaning government, they come in and say, we need more community participation and they put in a whole bunch of new little community units. And if it's a more right-ling one, we don't need any bureaucracy and blah, blah, and then they get rid of it all and put them back in another one, just one or something. And the trouble with that is you don't have any stability. And you need to have governments pause off decision making so you can get long-term systemic decision making that over time says, you know, we should really be trying to spend more on prevention, promotion of health, less on acute stuff, but you know, any kind of granny that's running off to or grandpa running off to an ambulance, some problem, the government feels it has to react because otherwise we won't get elected again. That's actually a good way to run a healthcare system. And it's kind of like, I actually like some of the European models of financing, which they call social health insurance. And so it's more like a CPP idea. So you pay into it, your employer pays in some, and it's managed arms length. And the thing about that is results in stability. So you don't kind of get the funding going like this because you know, actually people are pretty prepared to pay for health no matter what else, right? It doesn't matter that there's a recession, right? That they, you know, given their kind of druthers, they would not yank all the funding out from hospitals and physicians. They would keep it in there because it's the one thing they will pay for. So you tend to get more stability with those sorts of systems. When you have a tax financed, you know, government controlling it, they go into panic attack whenever there's something coming on the horizon and they cut and slash, and that's terrible from a stability perspective. And it leads to kind of the public also feeling like the system isn't working for them, too much politics about the healthcare system. So I think we would be actually better to shift more to these other models. And so that we're exploring some of this for financing community-based pharmaceuticals and long-term care, because I think that is a better way over time for us to try to shift our system. But the nice part about it is also arm's length governance. Yay! Yes. What you stressed is the income and positions and how that's organized and how they're charged. There are two other important concepts which you just touched on a minute ago. One is pharmacare. Canada pays the second highest cost for drugs in the world. Guess who's top? The USA. Secondly, the cost of hospital care. Every year in this country, 1% of the province, 1% of people die. Those 1% that die take up 25% of the healthcare costs in hospitals. We have no hospice in Nova Scotia. Not one. There are people lying down stretches because they can't get anywhere else to go. And they're wasting valuable money when they couldn't be elsewhere. Why don't we do all day and do something about it? Yeah. And so the problem, like I feel the pain of provincial governments though, like and I agree, we need to do something about it, but you have to understand they're in a really difficult situation when they're paying 50% and more of total revenues to healthcare. And so people like me come along, you need to spend more. And they're like, okay, yeah, yeah, that's lovely. You know, they're just not gonna do it. So that's why I'm saying we have to actually figure out other kind of creative solutions for them. The feds have to help with this. The provinces are just dying on the vine. Other governments, so for example, like the New Zealand government or the Australian government, where it's a one level of government is really responsible for healthcare. They're paying something like 13 or 14% of their total revenues to health, right? Provinces paying like 50%, but that's because of federalism, right? The way that Canadian federalism works in health. And that's making it really difficult for the provinces to move. So there are all the logical and reasonable arguments we can make under the sign about, yeah, you should be funding hospice. You should be funding this. And they're like, look, we can barely fund what we're doing. All right, we hear what you're saying. Yeah, long term, we might make some savings, but I've got to get elected again. All right, I've got a three year horizon. So we've got to break that log jam. That's really important. We need the feds. Well, we've got some feds who are interested to come to the table. We've got to have more creative discussion about how we're gonna finance this, not just from the public first from tax revenues because that's not gonna work. It's not gonna fly. And we need to have better governance structures. And then I think we can start to move in this regard to get better funding for long-term care, for home care. That's a replacement for long-term care. I completely agree with you. Yeah. So what you're discussing was, there's been no switches to the example. They're all the same. It's a zero sum game in terms of funding for public health care. So is- Well, that's an overstatement, but close. It's really difficult. Yeah. Yeah, it is difficult. But I guess just considering that, some of the jurisdictions are implementing things like health technology assessments or more cost-benefit analyses for what programs get funded, where that's not something that's done here, that's not something that's done in a lot of the provinces. So to what extent have you seen implementing these more analytical frameworks for assessing programs as benefiting the budgeting process for places? How could some more like infrastructure benefit from that? Well, I think we have to do that across the board. We need to be, as I said, constantly evaluating, not just new stuff though, because that's the, you know, then it's just like, oh, anything new, we're not gonna put in. You actually have to be evaluating the old stuff. And so new things should be treated on par with the older stuff. And that is uncomfortable for people. It's difficult because you may be defunding stuff that people like and they used to have. But I think as long as the process is just and it's reasonable, then, you know, why should these people's lives be more valuable than those people's lives? It doesn't make any sense to me. So you have to be constantly evaluating how important the technology or the new service or the old service or the new technology is, and bringing in new things and defunding old things. And that ability, as I said, to say no means you have to less and frequently say no to things. Because you can say to the old folks, well, look, you're not as, this isn't as good as this new product or this new service or this new way of doing things. But if you give us a reduction in the price, we could still keep you in the public plant. All right, and so that's what you see where you have systems that permit that. They actually quite infrequently have to delist things. They just negotiate a better price. All right, so that's, but you have to have that power to say no in the first place. Yes. Oh, sorry. Okay, I'll come to you in a minute, sir. Sorry. Yeah. I'm in your position, but is there a much bigger difference in the fact that we're already paying, I mean, half the pages last year, now we're going to put this through. Yeah. I've got a six-month rehab that I'm going to pay for next month. Yeah. Is there much argument that the government is that people are already paying this? Yeah. Out of the new fare system? Yeah. I'll be forwarding, first, we're already paying, but I just need to hear from them. Yeah. Look, there is evidence for that. And again, we can talk to them to their blue in their faces that, you know, from a societal perspective, it makes sense to invest more in these areas. But they're like, okay, but we have to pay doctors and we have to pay hospitals. And by the time we've done that, we don't have any more money left. And so, you know, it's a longer-term investment strategy that's needed. That's just simply not, you know, seen as really doable within the kind of public fisk as it is. So as I say, we've got to get creative. We've got to enable that kind of expansion. We've got to figure out how to do that outside of tax revenues. We've got to get decision-making away from politicians who are only interested being there for three years and have more, you know, structures that permit that. And that will not be fun, right? That does mean that people will, you know, you'll probably be out protesting saying, don't close my hospital, right? But actually to get like hospices and things like that, some hospitals might have to close, right? So it's about relocation of resources and that's always not very comfy. Or we get new funds in, right? So, and I say, we can maybe able to get more funds in if we are willing to invest in these other kinds of quasi-public ways of getting money in, but not tax dollars. Yes, sir, sorry about that. Well, one thing Halifax does have a hospice. But it's actually replacing the equivalent of hospice, which is on one floor in the U.K. Right. That's over here. So they're moving it out of, you know, okay. But regarding your answer to the person on the floor about which new ideas could be used or not, I think the evaluation of any new and different things are very complicated, but they could be brought down to just three things. Evaluating on the literature. Does it increase access to healthcare? Does it contain or reduce costs? Or does it increase quality of care? If it does any of these three things which without worsening the others, it should be okay. And I'm going to give you an example of a couple of things that satisfy all three of them, which are really good things. But first of all, though, regarding the day case, if you use those three criteria, a big argument of kids, especially with those seven patients, is that it is providing access, increased access. But if you use a hypothetical thing where there are a hundred patients waiting for an operation, and you take the hundred person in line and pays money, and goes and gets it done ahead, you're not increasing overall access because each of those other 99 are being pushed back on. So he would say that that's not the case, right? Because his cue here for the public system is for the operating theater over here. And that's only one day a week. And so the other four days of week, he can be down in his private clinic. He can be in the public system. He's taking nurses and the doctors of the public system. He's only the same total number in Canada. So he's subtracting from the public system. He could do two things within the public system. He could have an office, make an endeavor to find out, as you say, with an ambulance and then those seven patients who should have been given higher clinical, because of their clinical situation, higher priority on the wait list. Maybe they were, maybe their clinical situations actually were, and they were fixed in line and because there were clinical. In any event, he can, could do that within the public system. Also, the workman's compensation and bounties and so on and people working who need to get back earlier and get precedence, they should be able to work that out in the public system. They should take the workman's compensation into the public system and enter the prior access in the wait list there. Yeah. So I think that it is actually a difficult term. It's a strong argument that he has on that, to be honest. And I don't, I think that it's a problem that, you know, we, getting people back to work if they've had a workplace accident is valued when you actually have to pay out of pocket the costs of their compensation for working. But if you're ill, right, you're still, you're still, as an individual, you're still off work and waiting. And so if the government had to pay that cost themselves, they probably would be a bit more attuned to wait times. So that's the part of the problem. But yeah, we'll just go on and get some other questions. Yeah. Can I follow up more efficiently? If I'm on the long term, do you think you're going to see changes to many things in rule and that's before shutting down services and rule communities? No, I didn't say that. Okay, maybe. But maybe. Maybe people have a little bit of a different part that there'll be at least a lot of strain on rule communities we're having to. Oh, I see. Yes, if they allow a private tear, because I think like a lot of people want to live in downtown Toronto, and if I can set up a clinic in downtown Toronto now. I don't know about really that, but you were talking about, I think I was just following up the question before previous question. About shutting hospitals? About basically how governments are going to have to make conversations about closing hospitals. We need to mess with parents. I know one of these main situations affecting both budgets and health policy in and around Canada is how to deal with declining rule communities. Yeah. So, because, not a lot of us have the will to do that, all of these ways that you can make state rule healthcare more efficient. Yeah. So I'm not necessarily saying it would be in rural communities at all, that's where, in fact, it might be the opposite. But there are all sorts of things that I think, if you had better governance structures, that you would be making decisions about where to invest most to get better bang for your buck, better health outcomes. And I think maybe what you're saying is that, with another factor that has to be considered in that decision making is maintaining a rural community's full stop, right? Is that what you're? Well, it's just that, again, health care is naturally good again, but I was talking to you from my end, and one of the issues with health care is how to get people on a bunch of places under control is consolidating rule of medical services. Yeah. Which has been met with plenty of political opposition. Yeah. And is there a way, for example, like governments can try to avoid having as much opposition as possible while getting medical costs under control? Well, I think, again, that if governments are truly making decisions that are in the long-term interests of the communities, that they should be able to sell that. But I think the worry is that sometimes they're not making decisions in the long-term interests of the community from a population health perspective because they just have a short-term budget crisis. So, like I say, if funding is devolved more to arms-length agencies with longer-term horizons, so I don't know the particular circumstances of what you're talking about in Nova Scotia, whether this is, it really is true that you could make these cuts and there wouldn't be a significant impact on access to care and that sort of stuff, that it makes sense. Sometimes it does because people are very, like they love their local community hospital, but it turns out loads of people are dying there. And then they're like, well, yeah, but we still like it. And it's kind of like, well, dudes, you really, you know, you would be better off actually as paying for you to come to a big hospital where they do a lot of turnover, for example, in pediatric oncology or cardiac surgeon. You know, some of this stuff you have to do like thousands of these operations a year or so to really get good at it. And if you're only doing one or two, you're very likely to kill the person. So you can't understand why they have an affinity to a community hospital because it sort of breaks in mortar. But you know, I think you have to make the case. And I think it comes better if it's not from the government also saying, well, we're in a budget crisis. You know, they're like, yeah, are you only cutting it because of the budget crisis? As opposed to, you know, actually we're cutting it because we want to invest in quality care and safe care and we're going to put in place other sort of, you know, primary care teams and then we're going to helicopter you out as we need to in certain situations, whatever it is, right? So I think that's the trouble is that you have to have kind of trust of the public. And then I think, I believe that the public are more amenable to listening to evidence. Yes. In the church you showed earlier, striking contrast was a great brick in our kingdom. Yeah, number one. Yeah, well, surprisingly, I didn't think that would be... All those bad teeth and stuff. Like how did they... How did they become so good at it? Yeah. I'll do more. Yeah, okay, so it's a great question. So England, Canada, like we need to become England. So this is part of the day argument as well. England has a two-tier healthcare system. Now, the interesting thing about England, say, 20 years ago, England had huge wait times in the public system. They were years and years and years long, way worse than Canada's system. Two-tier healthcare, they had Harley Street consultants and they would sort of come to their public clinic and see you and I met this guy who's now quite elderly and he tried to research this. He couldn't get anyone to fund this. He was worried about the private clinicians like moonlighting and the private sector. Nobody wanted to fund it because everyone liked the status quo. And so he actually hired private detectives to follow the physicians to show that they'd just been an hour down in their public hospital and then like the rest of the day in their Harley Street kind of clinics. And they made a big BBC show about this. It's really fun from like the early 80s. Two-part series, tracking these with private detectives, tracking these Harley Street consultants. So that was back in the day. And then, but Blair came in and Blair decided that he was gonna fix the NHS. And he invested money, he brought in capacity, actually bought in private clinics but into the public healthcare system. So they're not privately financed. Mobile kind of caravans that go around and do your eyes in rural areas, right? Big time. People didn't like this but it worked. Bought in capacity into the public healthcare system. They had a thing called targets and tariff. Targets for wait times and terrorized if you didn't meet them, right? So terror for the management. Yeah, you wouldn't be paid. Your salary, your income is tied to meeting these wait time targets and they bought it down. And so the maximum wait time, the maximum wait time for most things in the UK is eight weeks. That's the maximum. So the average is under a month. You're gonna get from where to go, right? And this is just from systematic, hardcore, physicians don't like it, but it works reform. And they will say, oh well, you can't do that because you're gonna, like the wait times means you divert resources from other places. Yeah, but the thing is if you don't deal with people's concerns about wait times, you're gonna lose your whole public healthcare system, right? Because the middle class and wealthy are not gonna put up with it unless you meet their concerns about timeliness. So they did. And now they're number one. And they have contracts which aren't just about public and private, but they're actually really holding the docs feet to the fire about quality and safety and all of these kinds of things, right? So doctors don't like it, but it's management. Yeah, it's a terrible word, isn't it? Right, like normally. Oh, we got it still. No, no, I was thinking if we take it right to the, right to the half hour, there's two people who've had their hands up for a bit, one for the right over there, and then the men to the back. Okay, hi. Hi. So speaking about the idea of protecting the public nature of our healthcare system, but also transitioning towards more efficient, what role would a positive, right under the chart for healthcare play in that? Would it play towards making sure everyone has like an equity to strive for? Or do you think that we use as a double-edged sword to also argue for more private access to them? Well, I think a positive right implies that we would all have a right under the public healthcare system to timely care, for example. And so I've never actually been a very strong proponent of a positive right to healthcare, but I've become more of this in the wake of these charter challenges to a private right to healthcare. It seems to me that we actually have to develop a right to a positive right to healthcare almost as an antidote. I don't really think this is a great place for courts to be. I don't think that they actually have a great knowledge about what is and isn't appropriate here, but given what we're dealing with with charter challenges, I think, unfortunately, this is where they gotta go. But I think from a court's perspective, they need to be very deferential to government-running public healthcare systems where they're trying to achieve equity objectives. So if, in my will, they're making decisions about what to fund and not fund, delisting old things, adding new things, there's flux in the system, and people are bringing challenges about that, I think the court needs to be extremely deferential to say, look, as long as you follow it a reasonable process, we're not gonna second-guess you. And you see that has happened in jurisdictions like Israel and the UK where courts saying, look, as long as you follow a just, fair process for decision-making about what's in and what's out, we won't second-guess you. But where governments are doing things that are wholesale regressive, so for example, introducing copayments at point of service, so 30% copayment at point of service to try to, I think, courts should look at that really closely. There may be a reason, right? Maybe the economy's gone, like, fall into some massive recession, but what that means is that people will die from not being able to access the care that they need, so you better have a pretty good reason. So basically in my world of positive rights to healthcare, yes, but extremely deferential to governments that are trying to do their best and manage a public healthcare system where it's inter-relational, we are in this together, and if you get something, I might not get it. And I know that courts necessarily are the best place to second-guess that, as long as there's a robust and fair process. But where governments are up to shenanigans and they're basically trying to cut off the vulnerable or basically make things a lot worse, then I think courts could take a closer look. Sorry, there was someone else up the back. Yeah, I'm sorry, I think you've come up. Sorry about that. So before I thank you, formally, one second, formally thank you, and I just want you all to be aware of our next seminar coming up on January 20th, it's Sharon Batt and Adrienne Froome-Burman speaking on patient advocacy in the drug regulatory process in Canada and the US. So that's January 20th. Please join me in thanking Colleen for the opportunity.