Category Archives: Health System

Ontario hospital data less than timely, transparent

Posted on August 12, 2011 | 3 comments

How transparent is data from Ontario’s hospitals? And does it really tell the true story?

In July the far right Fraser Institute took a shot at Ontario hospitals claiming they lacked transparency when it comes to reporting performance indicators.

The Ontario Hospital Association shot back, claiming the Fraser Institute was likely unaware of  www.myhospitalcare.ca –an OHA site that provides data on more than 40 performance indicators.

The release quotes OHA President Tom Closson as saying Ontario’s hospitals are among the most accountable in Canada. The question is: how does Closson come to that conclusion? Is the OHA web site intended to be the evidence to support such a claim?

It’s true that there is a lot of public information on hospital performance, although what gets reported varies from hospital to hospital, the manner in which it is reported is often difficult to understand, and the information is usually less than timely.

The information is also in different places. Some of it is on individual hospital web sites. A select number of indicators are on the OHA site. Wait times information is on a Ministry of Health web site. To complicate matters, the information reporting dates are not the same on these sites, leading to conflicting data results.

It is also not unusual to see wild swings in the information reported, leading to questions about the quality of the data.

If you look up the Niagara Health System (NHS) on the OHA’s site, the infection rate for C-Difficile is similar to many other hospitals, although above the provincial average. That may have something to do with the fact that the data was collected in February of this year. Similarly, the Hospital Standardized Mortality Rate for the NHS is above average but below many other peer hospitals. These numbers don’t tell the real story – the Niagara Health System has recorded 37 C-Difficile-related deaths this year – so far.

In the age of real-time technology, is it reasonable for the public to try and make decisions based on data that is often more than six months old?

The OHA specifically cautions about using standardized mortality scores in determining which hospital to go to, instead suggesting such data should be used to track the performance of the hospital. What’s the point of standardizing such scores if they are not meant for outside comparison?

At the Local Health Integration Network board meetings, explanations over how to interpret this data are frequent. Yet the public is expected to go to web sites and understand such concepts as compliance with pre-surgery antibiotics, percentage of near miss reporting, or how inpatient weighted cases are determined. Could there not be at least a glossary and some explanatory notes to go with this data?

Try and decipher this reported action on the Peterborough Health Center web site: “Monitor and review VAP and CLI cases, rates and compliance with Safer Healthcare Now! Bundles.” Reading this, I’m sure the public can sleep more soundly now.

Clearly there is a need to provide a more simplified overview that puts this data into a more meaningful context.

Often data is hiding in plain site – on some hospital sites there is so much of it, finding what you are looking for is a considerable challenge on poorly organized web sites.

The myhospitalcare web site does provide provincial averages, but it does make it difficult to look at comparisons without going to each specific hospital location on the site.

Closson’s pronouncement of Ontario’s transparency ignores the fact that the province is the last to bring hospitals under Freedom of Information legislation. Ontario hospitals finally come under the Freedom of Information and Privacy of Privacy Act in 2012, but the OHA successfully fought to bring in additional exemptions for quality information as part of this year’s budget bill. In fact, the broad-based wording of the exemption will allow hospitals to conceal considerable information from prying eyes looking for public accountability.

Curiously, the OHA recently posted its advice to hospitals about the upcoming FIPPA deadline. You need a login and password to read it.

Ontario is also the last province in Canada to open up public hospitals to the scrutiny of the ombudsman. This is one office that has the expertise to cut through the dense jargon OHA members use in their reporting and to demand the data that isn’t publicly posted.

Last October Osler, Hoskin & Harcourt LLP raised eyebrows when they sent out an information bulletin warning hospitals that they should be “cleansing existing files on or before December 31, 2011, subject to legislative record-keeping requirements.” Osler was warning Ontario hospitals that they could face the same kind of reputation risk as e-Health if they failed to do so.

While there was shock and dismay, nobody knows to what extent Ontario hospitals took that advice to heart.

It is interesting that Closson used the word “accountable” and not “transparent” in the OHA’s defense.

Clearly there is a way to go for hospitals to be transparent in a truly meaningful way.

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P3s deserve to be an election issue even if nobody wants to talk about it

Posted on August 10, 2011 | 3 comments

“We have a responsibility to taxpayers … to build schools at a reasonable cost. That absolutely rules out P3s.” – Jane Purves, Nova Scotia Education Minister (PC) 2001 

As the coming Ontario election unfolds, it is unlikely the opposition parties will go after the dozens of public-private partnership (P3) deals signed by the McGuinty government.

The darling of governments of all stripes who want to move debt off-book, P3s have been a costly boondoggle across Canada. At a time when the public is bracing for cuts to public services, the lack of debate over the squandering of billions on such enterprises is sadly missing.

The Maritime Provinces were early adopters of so-called “public-private partnerships” to build and operate public infrastructure.

The Confederation Bridge betweenPrince Edward Island and New Brunswick was one of the first mega projects developed under the model, while Nova Scotia embarked on an ambitious program to privately build and operate public schools.

The Nova Scotia government of Russell McLellan lost an election over the P3 issue after the news media jumped all over scandals involving costly public schools built and operated under such contracts.

Secrecy, or what the corporations like to call “proprietary information,” has kept watch dogs and even government itself from prying too closely into these deals.

Remarkably, Rosalind Penfound, Nova Scotia’s deputy minister of education said of the deals in 2010: “The P3 contracts don’t allow us the ability to audit some of the provisions of the contract, so that significantly hampers some of the monitoring that we can do.”

In PEI the Federal government put strict conditions on the privatization of the Confederation Bridge project. The Federal subsidy was not to exceed the cost of its support to the former ferry service, and that tolls to the public must not exceed charges from the former ferry crossing. These rules did allow for toll adjustments based on 75 per cent of the consumer price index, and the Federal subsidy was also indexed.

In 1988 the auditor estimated the ferry subsidy amounted to between $26.7 million and $36.9 million. The subsidy to the P3 consortium was set at the high end of that scale — $35.3 million annually. In addition the Federal government also incurred direct costs: $41 million for highway improvements leading to and from the bridge, $46 million for project development, and $15 million for regional development in PEI and New Brunswick.

While P3 promoters boast they bring projects in on time and on budget, it took 10 years to discover there was a $330 million cost overrun on the $1 billion bridge.

That overrun, combined with higher than expected maintenance costs, may mean that the rules may change, a bailout may have to take place, or the Federal government may have to assume ownership – and related financial obligations — of the bridge.

The bond ratings agencies lowered Strait Crossing Ltd – the P3 operator – to a BBB (lower medium grade) in 2010.

This is what the Dominion Bond Rating Agency had to say a year ago: “Limited operating flexibility is left to weather potential future shocks or a protracted period of soft economic conditions, which prevents DBRS from restoring the stable trend on the rating prior to its discontinuation.”

Discontinuation? Yes, the company actually asked to be taken off the bond rating service.

Two major projects, two major failures.

Ontarians deserve to know what’s in all the McGuinty P3 deals for hospitals, court houses and other infrastructure development. The Ontario Health Coalition and a consortium of  unions  – including OPSEU – spent more than two years in court to get most of the details of the William Osler Hospital deal– the first privatized general hospital to open in Canada.

What we found was a terrible deal for the public. The Ontario auditor later confirmed what we already knew – the Osler cost nearly $500 million more than had the project been undertaken as a traditional public procurement.

With impending delays and high costs associated with the Osler, the government decided to make a showcase of the Royal Ottawa Hospital when it opened as a P3 in October 2006.

The project was touted as on time and on budget, but neither was true.

The hospital was originally scheduled to open in July, not October. Even in October the Royal Ottawa wasn’t ready. Fire alarms didn’t work. The wireless environment was so dysfunctional the hospital later spent $1 million hard wiring the building. Magnetic doors failed. Personal alarms were absent, putting staff at risk. To make a point about the efficiency of P3s, the hospital was occupied anyway.

The Royal Ottawa was originally planned in 2004 as a 284-bed facility at a cost of $95 million. Instead it opened as a 188 bed facility that cost $146 million.

This election, politicians of all stripes should be asked about these privatization deals.

The auditor has already warned us that health care is facing considerable austerity under the Liberal plan. The Tories are offering even less in funding.

Can we really afford to squander billions more on these boondoggles while our hospitals and community-based health providers struggle? The William Osler and Royal Ottawa are only two out of more than 150 hospital corporations in Ontario. There are more than 30 hospital P3 projects in various stages of development. And that’s just health care.

This needs to be an election issue, even if all three parties are reluctant to talk about it.

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Health care insiders dominate new “Patients’ Association”

Posted on August 8, 2011 | 1 comment

In 2005 OPSEU confronted former Ontario Health Minister Elinor Caplan with a series of anecdotes provided to us by patients in the Niagara area. The stories dealt with problems home care patients encountered when their long-time home care provider – the Victorian Order of Nurses (VON) – was replaced through a Community Care Access Centre (CCAC) competition.

None of the winning bidders had any prior experience – or staff – in the Niagara region.

Caplan had been appointed by George Smitherman to conduct a review into the competitive bidding system for home care.

At the time Caplan dismissed the anecdotes, telling us “they were just stories.” She said the nine stories we had received through an OPSEU hotline represented a handful of the hundreds of clients served in the region.

Now Caplan has resurfaced as a member of an organization that claims to be the voice for Canadian health care patients.

Begun by Sholom Glouberman, the Patients’ Association of Canada received charitable status in January and launched their first conference in February.

While the PAC claims to be a voice for patients, the minutes from their most recent meeting distinguishes them as an educational organization, not an advocacy group. However, Glouberman also writes that “patients too, need organizational support to bring their perspective to help the system change and modernize. They cannot do this as individuals.”

All of us could consider ourselves as patients, however, the PAC appears to be teeming with the kind of individuals they claim are already influencing health care decision-making, including professionals, policy makers and politicians.

The organization’s four-person board is a case in point.

Glouberman is “philosopher in residence” at the Baycrest Centre for Geriatric Care and is an adjunct professor at the University of Toronto’s SchoolofHealth Policy, Management and Evaluation.

Vytas Mickevicius, who serves as treasurer, claims to have had a career in the broader health sector, particularly with hospitals. In fact, he was the Executive lead for e-Health on the Local Health Integration Network’s e-Health Council. Along with Glouberman, Mickevicius is also an adjunct professor at the University of Toronto School of Health Policy, Management and Evaluation.

Neil Stuart serves as VP of the Patients’ Association. Some may know him as Chair of the Ontario Hospital Association’s Governance Committee, something he left off of his on-line PAC “autobiography.”

The last person on the PAC board is Dr. Elke Grenzer, who teaches at the University of Waterloo. According to the Culture of Cities website (an organization for which she is a founding member) she is co-editing a volume on the culture of birth and writing on jurisdictional disputes between midwives and obstetricians.

The group claims to have some 800 members, although 30 are up on their web site accompanied with “autobiographies.” Despite claiming to be a national organization, almost all 30 have connections to central Ontario, including several to the University of Toronto.

The list includes other academics, students, health care consultants, a lawyer, at least two physicians, two registered nurses, and several individuals who have had past connections to the Ministry of Health – including Caplan, who was Minister, and Ted Ball, who was Chief of Staff to former Health Minister Larry Grossman.

The group intends to work on patient advocacy guide, using work from Michael Decter and Francesca Grosso as a starting point. Grosso was director of policy for former Tory Health Minister Tony Clement and Decter is former Deputy Minister of Health under the Rae NDP government.

Funding for one part of their work – physician “Patients’ Choice Awards” – is provided by the Ontario Medical Association.

The PAC states that “the core of PAC’s mission is to listen to the health experiences of patients and those who care for them.”

Mrs. Caplan may need to think of this listening as more than “just stories.”

Patients Association of Canada: http://patientsassociation.ca/

Read some of the stories Elinor Caplan didn’t want to pay attention to:

http://www.opseu.org/campaign/von/storiesall.htm

More on Competitive Bidding: www.whatwillyoudo.ca

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Will auditor’s report prompt Libs and PCs to reconsider health funding?

Posted on August 5, 2011 | Leave a comment

The Liberals and Tories may want to reconsider their health care funding election pledges following last month’s auditor’s report.

Trying to neutralize the health care issue in the upcoming fall election, PC leader Tim Hudak committed to an increase of $6 billion in new health care spending over the next four years. That works out to be about $1 billion less than the Liberal plan to reduce health care spending increases to 3.6 per cent per year.

At the end of June Ontario Auditor General James McCarter questioned the McGuinty government’s projections of health care costs over the next three years.

“Our view is that, given the health demands of a growing and aging population and an average growth rate in health expenses of 7.1 per cent per year over the past eight years, assuming that health-care costs will rise much more slowly in the next three years cannot be considered cautious.”

Looking at cost assumptions by sector, only the scenario for drugs looked reasonable due to “more definitive plans to contain drug program costs,” including expanded use of generic drugs and a cap on generic drug pricing.

Much of the government’s assumptions rely on zero increases in compensation costs to both unionized workers and doctors.

The OMA agreement is presently in its last year. The auditor writes: “That there will be no increase for health care professionals when the current OMA agreement comes up for renewal in April 2012 is clearly an aggressive rather than a cautious assumption.”

Expense estimates for hospitals assume savings of $1 billion between 2011/12 and 2013/14.

The auditor writes: “The government has indicated that it will be up to hospitals to operate within their funding allocation regardless of how they manage the savings and compensation pressures they face. Therefore, if hospitals do not find $1 billion in savings and do not succeed in freezing compensation, they will likely run deficits or may have little alternative but to cut services.”

While the auditor acknowledges that funding of services provided Community Care Access Centers are far more at the discretion of government, the three year forecast calls for increases of only 2.3 per cent – about a third of the present growth rate of 7.2 per cent per year.

Similarly, it plans to reduce funding increases to long term care from 8.6 per cent per year to 4.2 per cent per year.

The auditor noted the obvious: given home care and long term care are integral to moving alternate level of care patients out of the hospitals, it is hard to see how the hospitals can save money through these transfers if the recipient sectors are being starved of cash.

As damning as the auditor’s pre-election review is towards the Liberal cost projections, consider the fact that the Tories plan to spend even less. To date, the NDP has not released any specific financial commitment towards health care increases.

Inheriting a surprise deficit from the Tories in 2004, the McGuinty government introduced the Fiscal Transparency and Accountability Act requiring the auditor to review and report on the reasonableness of the government’s pre-election report on the province’s finances.

While the past increases may appear daunting, keep in mind that these increases are not inflation adjusted and do not take into consideration levels of economic growth. While these increases in health care spending were taking place, the government managed to reduce its inherited $5.6 billion deficit and balance its budget by 2005-06. It was the global recession of 2008-09 that plunged the government back into deficit, not excessive health care costs.

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Savings that cost more

Posted on August 4, 2011 | Leave a comment

Pointing out potential savings in health care is always fraught with danger.

We’ve dramatically reduced hospital beds under the assumption that savings could be had by moving more services into the community.

Now we have overcrowded hospitals and a stubborn wait times problem that prompted a significant influx of cash from both the Federal and Provincial governments.

The Health Restructuring Commission realized that it would be better if the mentally ill were taken out of institutions and placed in community-based care. Now all our psychiatric hospitals are jammed, the justice system is seeing a significant impact in its courts and corrections, waits are embarrassingly long – especially for youth — and agencies are struggling to keep up.

Mike Harris cleaved lab services in two, giving community-based work to the private lab companies. Now the cost of sending tests to these private labs are much higher than if they had been performed in a hospital. Meanwhile hospital labs have been undermined by the withdrawal of funding that previously paid for such community-based work.

Rethermalized food was sold as a way to save money for hospitals. Now hospitals are moving away from it (with the exception of South Grey Bruce Health Centre) after realizing it negatively impacts the patient’s experience and does not contribute to wellness. Nor does it set a good example for how individuals should eat when they get out of hospital.

Seems every time a savings idea comes up, we end up either paying more in cash or the idea results in a decline in services.

The Mowat Centre’s Will Falk points out in today’s Toronto Star that much of the advantage new technology has brought to the system is not being realized because of out-of-date fee schedules between the doctors and the province.

There is no question that compensation for doctors is extremely uneven. Falk points out that cataract surgery that used to take an hour can now be done in 15 minutes, yet ophthalmologists receive the same amount to do so – about $420, or $28 a minute.

This has led to vast discrepancies in how doctors are compensated with ophthalmologists as the poster-children for this inequity.

In the last agreement with the Ontario Medical Association, there was a modest adjustment made. Under the agreement, overall, doctors will receive an increase of 4.25 per cent in 2011 – the last year of the agreement. Only half that amount will be distributed across the board. The other half will go to adjustments to doctors who have been undercompensated by the system – or what the contract describes as “relativity.” The agreement does nothing to address those who can earn in excess of a $1 million per year largely based on the advent of technology paid for by the public.

Falk suggests its time to check the bill, as we would in a restaurant. However, given the results of past governments who have elected to battle doctors, there may be more than a little reluctance to take this on.

What is more worrying is how much would be cut from hospitals, in the anticipation of savings coming, if such a revised agreement were possible.

After all, we do live in the province of cut first, ask questions later.

***

As an interesting footnote to this story, it was also reported this week that a new batch of patent expirations will lead to considerable savings on drug costs.

The Toronto Star reported August 3 that Ontario should save $2 billion over the next three years as 44 medications come off patent.

Drugs account for about 10 per cent of the province’s $47 billion public health care budget. This should also have a significant impact on private drug plans.

Seems the “sky is falling” scenario Don Drummond and others have been pounding is looking more and more ridiculous. As Dr. Michael Rachlis has pointed out, if the doomsayers couldn’t get their projections right for this year, how credible is their 20-year forecasts?

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Video: Hospital professionals target Ontario PC pledge to undermine job security

Posted on July 6, 2011 | 1 comment

Hospital professionals represented by the Ontario Public Service Employees Union have targeted the Ontario PC pledge to undermine job security through competitions for jobs public sector workers already have.

OPSEU’s Hospital Professional Division has posted a YouTube video showing the Tory platform for what it is – a terrible step backwards in worker’s rights.

“Increasingly workers are finding out they are being left out of the economic recovery,” says OPSEU President Warren (Smokey) Thomas. “Instead of addressing the issue of low wages and insecure employment, it appears that PC leader Tim Hudak is threatening to make the situation much worse.”

Substituting modern health care professionals for displaced farm workers from the dirty thirties, the video reminds viewers of what can happen when government places the interests of Bay Street ahead of Main Street.

“I think most Ontarians oppose the idea of their government deliberately creating a low wage economy in this province,” says Thomas. “By attacking job security and wages in the public sector, they are attacking all workers who are struggling to maintain their standard of living.”

Adjusted for inflation, wages for the middle class have remained stagnant for close to 30 years while the top 20 per cent of Canadians have made considerable gains. Canada’s income gap between rich and poor is among the fastest growing in the developed world.

The video was shot in Port Perry in June.

To view the video, click on the window below.

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NDP platform takes on dysfunctional home care system

Posted on June 28, 2011 | 3 comments

Ontario NDP leader Andrea Horwath recently told the media she would not be revealing the NDP platform all at once, but the party web site does already contain a comprehensive platform.

The platform includes four major headings –  Making Life Affordable; Creating and Protecting Jobs; Building Healthcare That Works For You; and Living Within Our Means.

The NDP is the only party to commit to taking on the dysfunctional home care system which the most conservative estimates suggest 30 per cent of costs are tied up with administration surrounding the competitive bidding. The NDP would conduct a review of home care with the goal of bringing back a publicly-owned and accountable system. They would also target funding to increase the supply of home care by a million hours within four years.

The NDP see fixing home care as part of unlocking the puzzle of patients stuck in hospital waiting for community-based care. They also plan to add long term care (LTC) beds to eliminate the 2,650 Ontarians presently on the wait list. A recent OHA survey did suggest there were alternate level of care patients waiting for home care, although the majority – 61 per cent – were waiting for LTC. Patients in ALC beds were also waiting for rehab, complex continuing care, palliative care, convalescent care, assisted living/supportive housing as well as placement in mental health care.

The NDP would also add 50 round-the-clock health care clinics to alleviate emergency wait times. The goal would be to increase alternative options to cut hospital emergency department wait times in half.

The NDP commits to bringing more health services back under public OHIP coverage, including the elimination of ambulance fees.

The platform includes a hard cap on CEO salaries, limiting compensation to twice the Premier’s salary. They make the point that it would still compensate CEOs at seven times the level of a nurse. The NDP would also crack down on the use of outside consultants.

An NDP government would also forgive student debt to new doctors willing to locate in underserved areas with the goal of adding 200 doctors over four years to these communities.

The party would make drug costs a priority in any negotiations with the Federal government around a new health accord.

The NDP would open up hospitals to the scrutiny of the ombudsman – something Andre Marin has been asking for in his annual reports.

Like the Tories the NDP would scrap the Local Health Integration Networks (LHINs), however, unlike the Tories, they pledge to replace them with some undetermined form of local decision-making.

No platform would be complete without a promise around prevention, and the NDP do that with a pledge to make mandatory physical education in post-secondary schools, ban junk food advertising to children and force large chain restaurants to label calorie counts.

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For US health insurance companies, the recession never took place.

Posted on June 23, 2011 | Leave a comment

According to “Health Care for America Now” (HCAN), the combined profits of the biggest health insurance companies in the US increased by 51 per cent during the recession and its aftermath. This may have something to do with premiums which rose by 131 per cent since 1999 – twice the rate of medical inflation.

As a percentage, insurance companies are spending less of the premiums on medical care and more on administrative costs, including extravagant CEO pay, marketing, lobbying and what HCAN describes as the “care-denial bureaucracy.”

Under the consumer protection provision of the US Affordable Care Act, as many as nine million customers will be eligible for rebates totalling as much as $1.4 billion.

In the first quarter of 2011 the combined profits of the five largest American insurance companies surged 14 per cent to $3.6 billion.

The US has the least efficient health care system in the developed world. Is it any wonder?

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New Ontario hotline for complaints about extra billing

Posted on June 22, 2011 | Leave a comment

Have you been illegally charged for a public health service that should have been insured under the Ontario Health Insurance Plan (OHIP)?

Yesterday the Ontario government launched a phone line and e-mail address for complaints about extra billing.

In its release, the government says there were 189 new investigations into illegal billing in 2010/11. Since 2007, about $1.3 million in illegal billing has been recovered either through reimbursements or cancellation of charges. This is on a $47 billion a year public health system.

For the average patient, figuring out whether their service should be covered or not will be a challenge, with health care providers deciding what is medically necessary and what is theoretically voluntary.

In the examples the government gives on its web site, it suggests that block fees are acceptable if payment is voluntary, does not cover insured services, and must be for a specific period of time. Users must also be given the option to pay for services that are not insured on a per-use basis.

The Ontario Health Coalition issued a release yesterday applauding the crackdown on extra billing.

“We are asking each of the provincial political party leaders to make a clear commitment to roll back the expansion of for-profit clinics and institutions, the majority of which charge patients illegal fees and undermine public Medicare in Canada,” says Natalie Mehra, Director of the Ontario Health Coalition.

Recently OPSEU raised the question of Rouge Valley Health System charging a block fee of $500 for patients in their cardiac rehab program who wish to continue past six months. The fee is not broken out by type of service, such as access to the indoor track and exercise equipment, stress tests or ongoing counselling.

Under the Canada Health Act, hospital services are insured health services. The Act defines hospital insured services as services provided to in-patients or out-patients at a hospital, if the services are medically necessary for the purpose of maintaining health, preventing disease or diagnosing or treating an injury, illness or disability. It would be difficult for a hospital to maintain that cardiac rehab is not medically necessary for the purpose of maintaining health.

It is particularly difficult for Rouge to maintain these are not covered services when its new partner in the program is Lakeridge Health, which provides a year-long cardiac rehab program.

Will the government order Rouge Valley to reimburse the $500? We can only wait and see.

To access the phone line: Call 1-888-662-6613

Or e-mail complaints to: protectpublichealthcare@ontario.ca

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NDP says they’ll scrap $45 ambulance fee

Posted on June 15, 2011 | 2 comments

The Ontario NDP say they would scrap the $45 fee paid by patients for ambulance services.

Leader Andrea Horwath said patients shouldn’t have to think twice about dialing 911 during an emergency.

More than two-thirds ofOntario’s ambulance trips require a user co-pay of $45. Ontario Works recipients, long term care home residents, individuals with disabilities or who are receiving home care are presently exempt from paying the fee.

Horwath says her own mother has thought twice about calling for a ride when she needed one.

“We have an aging population, there’s more and more seniors who are going to be in need of that kind of service,” she told the Canadian Press. “I think it’s something that’s going to take a load off their mind.”

The NDP say scrapping the fees will cost $30 million per year, something Dalton McGuinty has already dismissed, saying families have other health care priorities.

Prince Edward Island removed the fee in 2009 and New Brunswick is in the process of removing their ambulance charges.

Jamie Ramage, Chair of OPSEU’s ambulance sector, says he supports the idea, noting the $45 fee means the most marginalized individuals may be reluctant to call when they need assistance.

The NDP plan to reveal their full election platform June 24. Ontarians go the polls October 6.

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