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Colleen FloodNational Medicare Week has just passed, buoyed with optimism as a fresh-faced government takes the reins in Ottawa – elected partly on a promise of renewed federal leadership on healthcare. Yet these “sunny ways” are overcast by recent developments at the provincial level that entrench and legitimize two-tier care.

Saskatchewan has just enacted a licensing regime for private MRI clinics, allowing those who can afford the fees – which may range into the thousands of dollars – to speed along their diagnosis and return to the public system for treatment. Quebec has just passed legislation that will allow private clinics to extra-bill for “accessory fees” accompanying medically necessary care – for things like bandages and anesthetics.

Once upon a time, these moves would have been roundly condemned as violating the Canada Health Act’s principles of universality and accessibility. These days, two-tier care and extra-billing are sold to the public as strategies for saving medicare.

Under Saskatchewan’s new legislation, private MRI clinics are required to provide a kind of two-for-one deal: for every MRI sold privately, a second MRI must be provided to a patient on the public wait list, at no charge to the patient or the public insurer. Quebec’s legislation is touted as reining in a practice of extra-billing that had already grown widespread.

Underlying both reforms is a quiet resignation to the idea that two-tier healthcare is inevitable.

This sense of resignation is understandable, coming as it does on the heels of a decade-long void in federal leadership on healthcare. Throughout the Conservative government’s time in office, the Canada Health Act went substantially unenforced as private clinics popped up across the country. Even in its reduced role as a cheque-writer, the federal government took steps that undermined national unity around healthcare, switching the Canada Health Transfer to a strict per capita formula, which takes no account of a province’s income level or healthcare needs.

To reverse this trend, Canadians cannot simply wage a rearguard battle for the enforcement of the Canada Health Act as it was enacted in 1984. Even if properly enforced, the Act protects universal access only for medically necessary hospital and physician services. This is not the blueprint of a 21st century public healthcare system.

We desperately need universal coverage for a full array of healthcare goods and services – pharmaceuticals, mental health services, home care and out-of-hospital diagnostics.

Canada is unique among OECD countries in the paucity of what it covers on a universal basis despite falling in the top quartile of countries in levels of per capita health spending. Far from being our saviour, the Canada Health Act in its current incarnation is partly to blame – not because of its restrictions on queue-jumping and private payment but because it doesn’t protect important modern needs, like access to prescription drugs.

There are limits on what a public health system can provide, of course – particularly as many provinces now spend nearly half of their budgets on healthcare. But fairness requires that these limits be drawn on reasoned basis, targeting public coverage at the most effective treatments.

Under our current system, surgical removal of a bunion falls under universal coverage, while self-administered but lifesaving insulin shots for diabetics do not. A modernized Canada Health Act would hold the provinces accountable for reasonable rationing decisions across the full spectrum of medically necessary care.

Instead of modernizing medicare, Saskatchewan and Quebec are looking to further privatize it. Experience to date suggests that allowing two-tier care will not alleviate wait times in the public system. Alberta has reversed course on its experiment with private-pay MRIs after the province’s wait times surged to some of the highest levels in the country.

The current wisdom is that long wait times are better addressed by reducing unnecessary tests. A 2013 study of two hospitals (one in Alberta, one in Ontario) found that more than half of lower-back MRIs ordered were unnecessary.

Skirmishes over privatization have to be fought, but they should not distract us from the bigger challenge of creating a modern and publicly accountable health system – one that provides people the care they need, while avoiding unnecessary care. Achieving that will make National Medicare Week a true cause for celebration.

Colleen Flood is a Professor, Centre for Health Law, Policy and Ethics, . 

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