The great debate on Medicare

Private medical clinics are opening across Canada on an average of one per week, although they are technically prohibited under the Canada Health Act.

It is a situation many considered unthinkable before last June’s now famous Supreme Court of Canada decision. The court ruled that a Quebec provincial ban on private health insurance was unconstitutional when patients were suffering, or even dying, on waiting lists.

While the decision applied directly to Quebec, it has generated calls for private clinics and private insurance in provinces across the country, as governments hope to forestall similar court decisions.

In February, Lieutenant governor of British Columbia, Iona Campagnolo said in a Throne speech, “Does it really matter to patients where or how they obtain their surgical treatment if it is paid for with public funds?”

Campagnolo said the BC government’s vision for a new provincial health care system would resemble those in Western Europe, where governments pay for essential treatment delivered in both public and private hospitals. To this end, Liberal Premier Gordon Campbell recently toured Swede Norway, France and the United Kingdom to explore new approaches to improve BC’s health care system.

And Conservative Premier Ralph Klein of Alberta has recently promised legislation to permit doctors to work simultaneously in private and public institutions and to allow the building of new private hospitals.

Ordered by the Supreme Court to produce a plan for healthcare reform within a year, Liberal Quebec Premier Jean Charest has proposed that private insurance could cover knee and hip replacements and cataract eye surgery. In addition, public hospitals could subcontract to private clinics for such procedures if the hospitals were unable to deliver the services within six months.

Not surprisingly, these proposed changes to public health care, long considered politically sacrosanct and central to Canada’s national identity, have spurred vigorous public debate. While advocates of private clinics say they will shorten waiting lists at public hospitals, critics warn they will drain the public system of doctors and other health care workers. Canada already has a national doctor shortage, with 1.4 million people in Ontario alone without the services of a family doctor.

An Ontario Medical Association study said the province could have a 2,800-doctor shortage by 2010 if action isn’t taken immediately.

Meanwhile, Dr. Brian Day, president and director of the private The Cambie Surgery Centre in Vancouver, employs 120 doctors to treat the growing numbers of patients that public hospitals send them because they are too busy to treat. Dr. Day, incoming president of the Canadian Medical Association, is opening a clinic in Toronto, and plans to expand into Ottawa, Montreal, Calgary and Edmonton.

According to Dr. Day, nearly 30 per cent of health care is already private if you count dentistry and drugs. For the direct delivery of medically necessary services, “I think it needs no more than five per cent or 10 per cent,” Day told Macleans magazine.

The Canadian Medical Association (CMA) has offered a checklist of ten principles to guide the emerging debate and discussion on proposed changes to the health care system, including:

  • Timely access: Canadians should have timely access to medically necessary care and recourse should the wait time be too long.
  • Equality: access to medical care should be based on need, not ability to pay.
  • Choice: patients should have choice of physician, and physicians should be able to choose their practice environment.
  • Comprehensiveness: a full spectrum of medically necessary care should be available.
  • Clinical autonomy: the autonomous decision-making within the patient-physician relationship must be protected.
  • Quality: public and private health care sectors must be held to the same high-quality standards and should be independently monitored.
  • Professional responsibility: the medical profession has a responsibility to promote the strongest possible health care system.
  • Transparency: decisions affecting the mix of public-private funding and delivery must be made through an open and transparent process.
  • Accountability: public and private health sectors should be held to the same high accountability standards, including clinical outcomes, full cost accounting and value-for money for the use of public funds
  • Efficiency: the public and private sectors should be structured to optimize the use of human and other resources.

To date, Canada is the only industrialized country that forbids privately financed purchases of core medical services. Prime Minister Stephen Harper has not yet proposed sweeping changes to the health care system, although he has said he favors guaranteed waiting times for services. Health minister Tony Clement is reportedly looking for ways to reduce wait times, as well as to modernize equipment and increase the supply of doctors.

According to the Fraser Institute, a conservative think tank, the median wait time between a referral by a family doctor and an appointment with a specialist is now 8.3 weeks, compared to 3.7 weeks in 1993.

In a recent Ipsos Reid survey, 28 per cent of Canadians picked the establishment of patient wait time guarantees as their number one priority for the new Tory minority government.