Ronald Kustra says yes
Executive director of the Association of Canadians for Sustainable Medicare
Several years ago I chatted with two passengers seated next to me in the airplane. From rural Alberta, they were travelling to a private clinic in Vancouver because the woman had been waiting several years for surgery with no operating-room date in sight. A grandmother, she could no longer play with her grandchildren. So she and her husband had saved about $10,000 for private surgery.
Stories like this inspire the chattering classes to natter about “rich people queue jumping,” to harrumph about the alleged evils of the private sector, and to build a Potemkin village to hide the realities of Canada’s publicly funded, government-controlled healthcare monopoly known as medicare. Canada is the only country in the world where private healthcare is legislated against, discouraged and vilified. Specifically, the elephant in the room is private hospital care and private physician services, which would offer choice to Canadians wishing to escape the rationing of the medicare straitjacket.
Medicare’s performance is substandard, with one word—rationing—as its leitmotif. Regardless of a government’s political stripe, rationing is how it attempts to control healthcare expenses. If a government doesn’t provide a healthcare service, theoretically there’s no cost. The exceptions are the ongoing costs patients incur while waiting, plus financial hardship and family stress. Yet postponing or denying care through rationing is offered as a moral and ethical alternative to a patient-centred mission statement. Hypocrisy, or perhaps delusion, allows medicare’s troops and politicians to swear allegiance to the sweet serenade of patient-centred care while putting the rights and needs of individuals at the mercy of the whims, rules and red tape of the medicare monopoly.
Hospitals offer three levels of care: Emergency (immediately required); Urgent (the window is counted in days, not hours); and Elective (not life-or-death; the procedure can be scheduled, though it may take a year or more). “Elective” makes it sound like the procedure isn’t really necessary; you can elect to have it or elect not to. The implication is that your health won’t be adversely affected. But what happens if you elect not to have cataracts removed? What happens if you elect not to have your arthritic hip or wonky knee replaced? As the Supreme Court has noted: Being pencilled in on a wait list is not access to care.
The Canada Health Act legalizes queue-jumping for three groups: the military, WCB clients and federal prisoners. A fourth group—professional athletes—enjoys preferred access with team doctors etc. The response from the medicare elite and politicians is hear/see/speak no evil. I understand why pro athletes require timely access. But why shouldn’t ordinary Canadians, like the woman I spoke to on the plane, have the same timely access? Instead, the federal and BC governments, with union support, have squandered an estimated $20-million in legal fees (in the Brian Day case) to quash patient choice.
Dr. Tom Noseworthy says no
critical care physician and president/CEO of the BC Academic Health Science Network
With uncertainty in federal funding and a new government and politics in Alberta, some people are asking whether Alberta should allow more private health care. To answer this it’s first necessary to distinguish between privately funded and privately delivered care. Charging for “medically necessary” doctor and hospital services is illegal in Canada. These are publicly funded; that is, paid for by the government. This single-payer component of medicare, with universality based on citizenship, is enshrined in the Canada Health Act. It’s also essential to both cost-control and equity. Evidence shows that privately funded health care, while faster, is not less expensive and is not of greater quality. It would not be sound public policy for Alberta to pursue privately funded healthcare.
With political sentiments echoing former times in Alberta and the costs of the healthcare system ever rising, the Kenney government has pledged to look seriously at expanding privately delivered publicly funded services; in other words, to turn to for-profit delivery of services paid for by the public. This would not violate the CHA, which calls for public administration and makes no reference to delivery.
If the question were “Should Alberta allow more private delivery of healthcare,” a few critical questions must first be answered to ensure that we preserve the access and equity provisions in medicare. What would we contract out, and what is that service’s actual cost in the public system? If the for-profit option seems less expensive, why is this? Is it due to real efficiency and productivity, or are the savings illusory because the for-profit provider cherry-picks “easy” cases, which are less expensive, and leaves the most complex and costly cases for the public system? How will quality standards be met, and who will be accountable? Who will make the profit and who will bear the risks? Will the for-profit system siphon off public resources and expertise? Once the public system stops delivering a service, is it hard to start it again, at which point service provision has been “taken hostage” by the private system?
Before Alberta considers the direction of more private healthcare, it needs to review the evidence of value associated with for-profit delivery (where and how it works best) and determine best practices and approaches. After examining deals currently in place, only then would the government be in a position to cautiously test more for-profit delivery. Private delivery may have a place, but it would be no Holy Grail.
In my mind, putting money and energy into strengthening the publicly funded and delivered healthcare system will pay a greater dividend than increasing for-profit delivery. Most health services in the public system perform at-scale as well as or better than privately delivered ones. As an added benefit, publicly funded and delivered healthcare is more equitable, particularly for the disadvantaged in society, who can least afford to be excluded.
Ronald Kustra responds to Dr. Tom Noseworthy
“Governments can no longer have it both ways—they cannot fail to provide timely access to medically necessary care in the publicly funded healthcare system and, at the same time, prevent Canadians from acquiring those services through private means.”
—Standing Senate Committee on Social Affairs, Science and Technology (the Kirby report, 2002)
Canadians depend upon and deserve a publicly funded healthcare system that provides timely access to hospital and medically necessary services. That’s the promise of the Canada Health Act.
Private healthcare—especially private, for-profit—is the bête noire for medicare monopolists. Founded more than half a century ago, our healthcare monopoly has become an icon of social policy. According to the Alberta Premier’s Advisory Council on Health (the Mazankowski report, 2001): “In almost every other public and private area, monopolies are simply not accepted.” Claude Castonguay, the father of Quebec’s medicare system, in his 2008 report observed: “Our healthcare system is a monopoly installed at every level with the culture inherent to monopolies, whether public or private. The culture is based on regulation and budgetary controls, closed to the outside world, impermeable to real change, adaptation and innovation. It is a culture that favours inefficiency.”
For decades, governments of all political stripes have ignored the consequences of their failure to practise fiscal discipline and their failure to be bold and creative in retrofitting medicare for the 21st century.
Dr. Noseworthy asserts the “single payer of medicare… [is] essential to both cost control and fairness.” But according to the US-based Commonwealth Fund, whose slogan is “Affordable, quality health care. For everyone,” Canada is doing poorly in terms of both cost control and equity. In its 2017 report comparing the performances of different healthcare systems, the fund ranked Canada’s ninth out of 11 systems—sixth in “care process” and “administrative efficiency”; ninth in “equity” and “health care outcomes”; and tenth in “access.” (Timely access is a component of quality.) The 10 other countries all have a hybrid approach with both public and private payers/funding and providers/delivery.
In the early 1980s Alberta spent 30 cents of every dollar on healthcare. Today it is around 41 cents. Former NDP health minister Sarah Hoffman has warned it will be 67 cents by 2035 if the status quo persists. This will squeeze the ability of other departments to provide services and programs, many of which impact health, such as affordable housing, income support, seniors, public education, universities and colleges, environment, roads and bridges, arts and culture etc.
Over the years, public support for private care has been trending upward. A survey released last year found 75 per cent of Canadians agree “patients who have been on provincial healthcare waiting lists longer than the maximum recommended waiting period for their condition” should be allowed “to pay for private treatment.” Support was strongest in British Columbia and Quebec, both at 80 per cent, Ontario at 78 per cent, Alberta/Saskatchewan at 70 per cent and the Atlantic provinces at 67 per cent.
Waiting for healthcare cost Canadians over $2-billion in 2018. Albertans waited an average of 14.9 weeks for treatment after being seen by a specialist; the Canadian average was 11 weeks. Alberta wait times for 13 specialties were higher than the Canadian average.
Dr. Noseworthy declares that private-sector-funded health care “is no less expensive” and savings from private-sector health care are “illusory.” However, the private sector’s performance was outstanding in two major projects—Alberta’s Hip and Knee Joint Replacement Project and Saskatchewan’s Surgical Initiative.
It’s also often said that the public sector provides superior quality care. This implies that regulatory bodies such as the College of Physicians and Surgeons of Alberta are lax in their oversight of the private sector. Physicians would disagree with this assumption. Meanwhile even a government expert witness in a long-running BC court case, Dr. Ian Turnbull, acknowledged he was “not aware of any study” suggesting the quality of care is lower in private facilities. He is a past president of the Canadian Medical Association.
Public healthcare is often defended for being “more equitable.” But a key dimension of equity is intergenerational equity. By posting deficits and running up debts, governments are offloading today’s healthcare costs onto the next generation. In 2018–2019 Alberta budgeted more than $1-billion for general debt servicing costs. Assuming Alberta Health’s share mirrors its 40 per cent of the budget, its debt would be over $400-million. What is equitable about foisting this financial burden on our children and grandchildren?
Giving patients choice and creating a “Health Care Guarantee” would give real meaning to the expression “patient-centred care.” The Kirby report recommended: “For each type of major procedure or treatment, a maximum needs-based waiting time be established and made public. When this maximum time is reached, the insurer [government] pay for the patient to seek the procedure or treatment immediately in another jurisdiction, including, if necessary, another country.”
Medicare is “…closed to the outside world, impermeable to real change, adaptation and innovation. It is a culture that favors inefficiency.”
Dr. Tom Noseworthy responds to Ronald Kustra
We know from international comparisons that Canada doesn’t have a high-performing health system and that we’re in the top third of healthcare expenditures in OECD countries. Accordingly, let me be the first to agree that Canada’s system needs serious improvement. Where there’s disagreement is on how to fix it. Critics often argue that to improve access, quality and costs we must allow more privately funded services. They refer to this as “increasing choice for consumers.”
Truth is, private care improves access only for those who have the cash or insurance to privately purchase services and willingness to pay. US, Canadian and comparative research has shown that private healthcare is faster but not automatically better, and costs are often higher. In short, while it is a necessity and never-ending challenge to improve publicly funded healthcare, privately funded care doesn’t accomplish that at the population level. How can that be? Simply put, privately funded healthcare can only create better outcomes for some people—those who can access it. Moreover, the outcomes are not necessarily better. Take the case of private kidney dialysis centres in the US. As compared to publicly funded centres, referrals for transplants happen less frequently in private facilities. Why? Transplants take you off dialysis and you are no longer a paying dialysis customer.
In Canada the lens through which patients often view the system is what they can see—access and ability to “get in.” What’s the waiting time? As disconcerting and harmful as long waits can be, it’s important not to judge a whole system on the basis of individual examples. That said, we can and should do better. As we strive to do so, we must preserve the true victory of Medicare: universality, or the fact that everyone is included. It took almost 120 years for Germany’s health system to achieve universal inclusion. Moreover, to achieve greater universality, every European country has increased its proportion of government spending that supports healthcare.
In Canada, we don’t ration by excluding people as the US system does. Exclusion is a form of implicit rationing—rationing you can’t see, like the person who isn’t able to get health insurance and who delays care or goes without it entirely. Canada engages in explicit rationing—rationing that one can see, such as lineups for services, which are in the public eye. We should be reminded that every country in this world rations healthcare—implicitly or explicitly—and no place offers everything to everybody. Hence, every system has inequities, including Canada. In our case they are particularly apparent among First Nations, immigrants and vulnerable populations. We can all agree that these need attention and improvement. Disagreement comes over the solutions.
While it may be true that flying to a clinic in Vancouver will get an individual patient faster service, at the population level private pay for service will not improve most Canadians’ access and will not reduce costs. For example, don’t look to private healthcare to take on the most complex cases, such as half of those over 65 years of age who suffer from multiple chronic diseases. Don’t expect private clinics to improve access and care for priorities, such as immigrants, First Nations and other vulnerable populations. Instead, look for it to cherry-pick the less complex cases (less costly/more profitable) and to avoid social and health inequities.
Hence, I have two suggestions for governments facing high healthcare costs and considering the expansion of privately delivered services. First, stop the annual spending increases that exceed inflation—the envelope for healthcare should not encroach on everything else. Secondly, experiment with publicly funded but privately delivered services, such as non-hospital surgical facilities. Beyond this, and expressly to deal with the access challenges, I would institute waiting time care guarantees for scheduled services such as hip and knee replacements, as has been done in England and Scandinavia. Then, if access does not improve, those managing the system will face consequences. If you want to see improved performance in the head offices of a health system, tie waiting time measurement to job security and watch wait times shorten, as they have done elsewhere. If the waiting time guarantee is not met, the patient could choose to go elsewhere to a clinic that privately delivers publicly funded services on contract, with clear parameters on cost and quality.
A good example of differing delivery mechanisms exists in cataract surgery in Alberta. Most cataract surgeries in Edmonton are done at the Royal Alexandra Hospital, whereas many in Calgary are done at private clinics such as the Gimbel Eye Centre. Each works well, but differently. What is the same in this example is the payer—the citizens of Alberta.
As soon as a healthcare system moves away from a single payer for necessary services, it begins to lose its ability to control costs and starts excluding citizens who are unable to pay. Inequities, hidden or apparent, become more commonplace. Therefore, I’d rather we put our efforts into improving the public system we have instead of developing a workaround. If that Vancouver clinic is part of the solution, then start publicly funding it.
We can all agree that medicare is in need of continuous improvement. The “treatment” of private healthcare does not fit the “diagnosis” that the publicly funded system isn’t working well enough. It is worse than the problem it was meant to fix.
