By Colleen M. Flood
and Bryan Thomas
The University of Ottawa
A legal challenge to Canada’s medicare system has given new focus to the much-needed debate about how health service is provided in this country.
The Supreme Court of British Columbia is hearing the long-anticipated challenge to the publicly-funded Canadian health system. The plaintiffs – led by Dr. Brian Day of Cambie Surgery Centre – allege that medicare violates Canada’s Charter of Rights and Freedoms by forcing patients onto long wait lists for care.
By way of remedy, Day and his colleagues aren’t asking the government to reduce wait times for all patients. Too bad.
Instead, they ask the court to overturn the law that stops the sale of private insurance covering medically-necessary care. They also ask the court to overturn the law against dual practice that requires doctors to choose to work for the public system or work for the private sector. They also want to overturn prohibitions on extra-billing so physicians can charge whatever they wish for the care they provide, in public hospitals or in private clinics.
Examining what this legal challenge could mean for Canadians, the question, ‘Who benefits?’ is a good place to start.
The physicians spearheading these challenges certainly stand to benefit handsomely.
Most physicians are locked into fee-for-service rates negotiated with the provinces. If the Cambie case succeeds, scores of private buyers will join the bargaining table, driving up prices for physician services and diverting resources to the highest bidder irrespective of medical need.
The physicians involved in the trial protest they have only medicare’s best interests at heart. They point to the many western “European” nations that have two-tier health systems, purportedly the envy of the world. If only Canada would allow greater private payment, we are told, the invisible hand of the market would lead us to join their ranks.
It’s not that simple.
Proponents of the “European” model of health care never tell us if it’s the French, Irish, English, Dutch, German or Italian model we should follow – and they are all distinct.
In England, for example, specialists in the public system are salaried and contractually bound to a full-time 40-hour work schedule, leaving them little time to moonlight in the private sector.
A contract binding specialists to 40 hours a week in the public system is viable in England, where physicians are salaried. It’s not viable in Canada, where physicians have grown accustomed over a half-century to a much higher level of independence.
Indeed, any Canadian government that attempted to force large numbers of physicians from fee-for-service payment to salary would find itself in the middle physician strikes and further constitutional challenges.
What about the Netherlands?
Private insurance plays a very large role there so perhaps it’s the kind of two-tier system we’re looking for. But in fact, there’s no separate public system with a private tier: in the Netherlands, the private health insurance system, heavily regulated, is the public system.
The law requires that all Dutch adults buy private health insurance (and their employers contribute). The market is heavily regulated to achieve access and equity goals. And private insurers must offer coverage to everybody and cover almost everything. This means private insurers can’t cherry pick the healthy and wealthy.
When the Cambie challengers and proponents of privatization speak of a two-tier system, they insist there would be a free public health-care system left with just a small private tier on the top. That’s clearly not the Dutch model.
In a complex system like health care, it’s purposefully naive to suppose Canada can easily shop among the models of western Europe. Selecting features from European systems and pasting them into Canadian medicare will not magically give us a “European” model.
It’s certainly true that Canadian medicare is in need of improvement. All sides agree. And Canadians need to be assured that medicare can deliver timely care when they are in greatest need.
A patient ombudsman in each province – with real teeth – would be an important start to help patients get timely, quality care.
Canadians pay a great deal of tax towards our health-care system. We deserve timely care and we shouldn’t have to throw ourselves at the mercy of the markets to get it.
Colleen M. Flood is a university research chair in Health Law and Policy and inaugural director of the Centre for Health Law, Policy and Ethics at the University of Ottawa. Bryan Thomas is a research associate at the Centre for Health Law, Policy and Ethics at the University of Ottawa.
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