2.20.2006

the great debate

Recent news from Quebec reminded me that it's been a long time since we talked about health care. Wmtc readership has changed a lot since the last time I blogged about it, so I think it's time to re-open this can of worms.

Last June, when the Canadian Supreme Court ruled that Quebeckers could purchase private health insurance, I was confused by some of the strong reaction - and strange interpretations - to the ruling. I asked for readers' help, and a discussion ensued (a little more here).

Now Quebec has issued its response to the ruling.
The Quebec government promised yesterday to provide hip and knee replacements and cataract surgery within six months of a patient's diagnosis and said it would pay for the procedures to be done at private clinics if necessary.

This would make Quebec the first province to guarantee access to certain health procedures and would open the door to a greater role for private health care in Quebec.

"We're putting the private sector to work for the public," Premier Jean Charest said at a news conference. "What we are announcing today is a new era in the delivery of health and social services for the population of Quebec -- a new era of guaranteed access to care."

The proposals are the government's formal response to a Supreme Court of Canada ruling in June that Quebeckers should be allowed to buy private medical insurance if basic medical care is not provided in a timely fashion. The province was given one year to speed up care or lift the ban on private insurance, a move that would have led to parallel systems of private and government-funded health care.

"We chose to maintain the principles of the public health-care system within which the private sector can play a role," Mr. Charest said, adding that Quebec could serve as a model for the rest of the country. "Other Canadians may choose to go down that route."

Under the proposals, the government promises to provide cataract, hip and knee surgery within six months of the day a specialist recommends the operation. If government-funded hospitals cannot perform the procedure within that time, the government will pay to have it done at certified private clinics affiliated with a hospital.

If the operation cannot be done anywhere in Quebec within nine months, the government will pay to send the patient outside the province, including to the United States.
For many Canadians, the mere mention of the world "private" in the health care debate brings cries of "They're privatizing the system!", or worse, "They're Americanizing it!". To me, this seems short-sighted (not to mention ignorant of what "Americanizing" would mean).

I understand the arguments about a slippery slope - that any introduction of private health care into the public system can be a wedge to drive in more and more, until the system falls apart. But fear of that slope also amounts to fear of change. And change may be necessary. It usually is. If we know what we want to guard against - that is, if we know our priorities - we should be able to avoid the pitfalls.

All countries with national health insurance have a mix of private and public delivery. According to all sources I read, most other countries (the UK, Australia, New Zealand, France, Israel) have a more balanced picture, with a greater percentage of private care in the mix. Yet those countries maintain their public health system, and, to my knowledge, have not been accused of "Americanizing" health care.

If a Canadian wants to shell out her own money for an MRI, or purchase private insurance to fund a hip replacement sooner, then they're no longer waiting, and the queue moves more quickly for those who don't want to or can't afford to do that. And how can a government tell people they can't spend their own money on their own health?

To fears of siphoning off the best doctors into the private sector, leaving the public sector with the dregs, I say, make sure that doesn't happen. One can easily imagine mechanisms to guard against that, such as requiring doctors spend a certain percentage of their time working in the public sector, or some similar means.

Maintaining national health insurance is clearly a top priority for Canadians, as well it should be. And most people agree the system, while an excellent one, needs some improvements. Improvements mean change. Yet say the word change, and people panic.

I find myself out of step with leftist thinking on this one. I'm very interested in hearing your thoughts.

Late addition: This op-ed by two Senators in today's Globe And Mail makes a good case for more solutions like the one proposed in Quebec.
A care guarantee to count on

by Michael Kirby and Wilbert Keon

The myth that the Canada Health Act requires health-care services to be publicly delivered -- not just publicly funded -- is finally dead.

As a result, Canada is on the verge of a truly constructive health debate that holds promise for real progress on what concerns Canadians most -- ensuring they have timely access to quality care when they need it.

This myth, combined with unwarranted fears about an imminent slide into a U.S.-style health-care system, has kept important policy options off the table for far too long.

Roy Romanow perpetuated the myth when he declared that health-care delivery is a "moral enterprise." There is no doubt Canadians cherish their publicly funded single-payer system because it ensures access to health care based on need, not ability to pay. But there is no moral imperative that this care be delivered exclusively by a publicly owned provider.

Beginning with the October 2002 health-care report by the standing Senate committee on social affairs, science and technology, several events have helped dispel the myth. The most important of these was the Supreme Court of Canada's decision last June in the Chaoulli case.

The focus of that case was not the phony issue of who delivers services, but rather the very real one of whether or not Canadians have the right to timely access to the care they need, regardless of the provider -- public or private, for-profit or not-for-profit.

The Supreme Court clearly set out the choices confronting Canadians.

Governments must either live up to their end of the medicare bargain and deliver timely access to care, or they must allow individual Canadians to purchase the medically necessary care they need for themselves. To do otherwise leads to violations of Charter rights that guarantee the security of the person.

In recent weeks, the governments of Alberta, British Columbia and Quebec have all indicated that they recognize their obligation to provide timely service. The health-care discussion paper released last week by the Quebec government is particularly encouraging to us as it embraces precisely the same solution -- a health-care guarantee of timely service -- that the Senate committee recommended in 2002. The care guarantee was also advocated by the Conservative Party in the recent federal election.

A care guarantee ensures that people receive the care they need within evidence-based, clinically determined wait times. It thus prevents two undesirable outcomes. ...

Senator Michael Kirby was the chair of the standing Senate committee on social affairs, science and technology when it released "The Health of Canadians: Recommendations for Reform, in 2002"; Senator Wilbert Keon, a physician, was a member of the committee.
Read more here.

14 comments:

Carrie said...

To fears of siphoning off the best doctors into the private sector, leaving the public sector with the dregs, I say, make sure that doesn't happen. One can easily imagine mechanisms to guard against that, such as requiring doctors spend a certain percentage of their time working in the public sector, or some similar means.

And that IS a real problem. As for making sure it doesn't happen, there is absolutely nothing that can be done to prevent it. We've lived through our doctors leaving in massive numbers, attracted by aggressive U.S. incentives. We've lived through former attempts to control doctors. That's not the answer.

It seems to me, based on reading Canada's history and having grown up here, that we've built our country in party by looking at the USA and realizing what NOT to do. We're losing that.

I understand your thinking and sympathise, but the fact is that is not Canada. We provide for each other without putting each other at risk. To introduce private health care will definitely put others at risk. It's not a good idea but it seems like, especially with Quebec and now the West ready to sell out Canada for their personal provincial preferences, it's about to change anyway.

As for being in a state of panic, again, if you grew up here (and I absolutely do not mean any offense by that) you would understand the value of our healthcare system. Everyone gets care. We don't want USA style medical practice here. It doesn't work and it won't serve ALL Canadians.

L-girl said...

Carrie, despite your claims to the contrary, you are causing offense here. People who live in Canada, but didn't spend their whole lives here, can still have informed opinions.

I have spoken to many Canadians who grew up in Canada who agree with me. There are a few who post regularly here.

you would understand the value of our healthcare system.

Really, how could you say this. I grew up in a country where millions upon millions have NO access to health care. Don't you think that makes me understand why Canada's system is so excellent?

We don't want USA style medical practice here.

No kidding. Did I advocate that?

This is a great example of what I mean. Say the word "change" and the next thing you hear is "we don't want USA style health care". Change doesn't have to equal that.

Rather than stop up your ears and go on about how your Canada doesn't exist anymore, why not propose some solutions?

You should be able to have this discussion without playing a nativist card. Millions of Canadians didn't grow up here - and their opinions are as valid as yours.

Put together with your comment in another thread that there is "too much immigration, too much multiculturalism", causing the end of your Canada, that's pretty damn offensive.

Wrye said...

Note the gratuitous knock on Westerners' and Quebecois' patriotism, too. I may disagree with Rob on many points, but he's not imagining the peculiar way that some have of assuming Canada=Ontario.

Carrie, I have met a great many people who were born here who couldn't find their own ass with a spotlight, a proctologist and a copy of Gray's Anatomy. Surely you have noticed this yourself. I hardly think it serves as a meaningful requirement for participation in the national discussion.

Anyway, defining the debate as an all-or-nothing, black and white proposition does run the risk of becoming a self-fulfilling prophecy. There is a vast spectrum of options between the US and Canadian models, and while there are definite forces and vested interests wanting to drive us as far down that spectrum as possible, the US system is understood to be a failure even within the US. No province--and healthcare is still a provincial responsibility--is going anywhere near adopting the US model wholesale.

Carrie said...

As I said, I was not intending to cause offense.

I have not stopped up my ears.

As for "gratuitous knock on Westerners' and Quebecois' patriotism", I'm not even going to dignify that with a response.

As you have spoken to many Canadians about this issue, so have I.

As for my earlier comments, you are making assumptions apparently because I have explained myself as well as I could at the time. Since you've decided I am offensive, without benefit of 'discussion', which your post invited, then I'll leave all of you to it.

In terms of offense, your comment and Wry's were both extremely offensive to me.

Take care of yourselves.

L-girl said...

As I said, I was not intending to cause offense.

It takes more than intentions. You come to the blog of a recent immigrant and say (a) that there's too much immigration in Canada and (b) that only people who grew up here can understand these issues... and you think because you say "no offense," I won't be offended? You're smarter than that.

As for my earlier comments, you are making assumptions apparently because I have explained myself as well as I could at the time.

The floor is always open for more explanation.

Since you've decided I am offensive, without benefit of 'discussion', which your post invited, then I'll leave all of you to it.

And you know that's not what happened. I did not "decide you were offensive". I took offense to the words you wrote, plain and simple.

There's plenty of room for discussion. All you have to do is discuss. If you'd rather stomp off in a huff and claim you were misunderstood, that's your choice. As far as I can tell, you were understood perfectly.

L-girl said...

I have met a great many people who were born here who couldn't find their own ass with a spotlight, a proctologist and a copy of Gray's Anatomy.

A Wryebrarian observation if ever there was one. :)

I hardly think it serves as a meaningful requirement for participation in the national discussion.

I used to preface anything I said about Canada with apologetic phrases - "in my limited experience", "I know very little about this, but..." - but I've given that the boot.

Learning about Canada has been the focus of my life for several years now, an exploration many born and raised here probably never undertake, not feeling the need as I do.

Everything comes with the usual "in my view" preface - as it does for all of us - but I'm now realizing that I needn't be afraid to give my observations and opinions, just because I'm new in town.

Hrrumph. :)

orc said...

>> If a Canadian wants to shell out her own money for an MRI, or purchase private insurance to fund a hip replacement sooner, then they're no longer waiting, and the queue moves more quickly for those who don't want to or can't afford to do that. <<

The only problem I can see with that is that if people can buy out of the system and pay more for private care, what's to stop doctors from catering to the higher-return from private care by subtly running down the services they provide to the socialised system? And then the provincial governments might find themselves in the unhappy situation of having to either chase rates or end up with many doctors refusing to accept patients from the government system.

The way that Quebec is proposing to do it looks, from an outsiders prospective, like it might avoid that pitfall by the simple expedient of leaving things single-payer, but I don't see that it leaves much of a carrot for the businesses that want to set up private clinics.

L-girl said...

The only problem I can see with that is that if people can buy out of the system and pay more for private care, what's to stop doctors from catering to the higher-return from private care by subtly running down the services they provide to the socialised system?

That would be a big concern. I would think, for starters, this would only apply to procedures for which there is a long waiting time.

But even in that case, there would have be mechanisms to prevent what you're talking about. I'm wondering how it's done in other countries that have both private health care and national health insurance.

I think the Quebec plan sounds like a creative (possible) solution.

sharonapple said...

To fears of siphoning off the best doctors into the private sector, leaving the public sector with the dregs, I say, make sure that doesn't happen. One can easily imagine mechanisms to guard against that, such as requiring doctors spend a certain percentage of their time working in the public sector, or some similar means.

Mixing seems to make the situation a bit worse. In Manitoba patients could got to private clinics for cataract surgery or $1000. Doctors who worked strictly in the public health care system had a wait time of 10 weeks. When a doctor worked in private clinic and in the public system, their patients in the public system waited 21-26 weeks for treatment. It's possible though, that this could be because of a doctor spending more time at the private clinic than at the public health system.

http://www.umanitoba.ca/centres/mchp/reports/reports_97-00/waits2.htm

If a Canadian wants to shell out her own money for an MRI, or purchase private insurance to fund a hip replacement sooner, then they're no longer waiting, and the queue moves more quickly for those who don't want to or can't afford to do that.

One study comparing wait times in UK and New Zealand, which have parallel profit and public system, their wait time in the public health system is longer than in the Canada public system. Also a study in Australia argues that the more private care in a region, the longer the wait times in the public system.

http://www.aushealthreview.com.au/publications/articles/issues/ahr_29_1_0205/ahr_29_1_087-093.asp

The way that Quebec is proposing to do it looks, from an outsiders prospective, like it might avoid that pitfall by the simple expedient of leaving things single-payer, but I don't see that it leaves much of a carrot for the businesses that want to set up private clinics.

It's a good plan. 'm not against private hospitals, just for-profit hospitals.

Profit hospitals costs more than any others (in one study profit hospitals billed $625 more than non-profit hospitals per patient) -- but you don't get superior care. The death rate is high in profit hospitals than non-profit and public hospitals. In studies comparing them, 88 studies showed non-profit hospitals are better than profit hospitals, 43 argued there's no difference in care, and only 18 studies said that profit hospitals are better. One creepy study of half a million dialysis patients, people were more likely to die in profit hospitals, and patients were less likely to be refered for kidney transplants (yikes).

Wrye said...

It's a good plan. 'm not against private hospitals, just for-profit hospitals.

Thou hast hit the nail on the head, there.

Fundamentally, this is an exhausting topic. I don't know what I can add other than this: the demographic shift and rising pharmaceutical costs coming at us are anything but theoretical, and I don't think we can ride out the status quo for thirty years until the last boomer ascends to heaven accompanied by strains from The White Album and the hossanas of subsequent generations who'll finally be able to get full time work. If we can trade some space for time, though, I think we'll be okay. So we need to think about this carefully and not get stampeded by the profiteers and lobbyists.

I used to preface anything I said about Canada with apologetic phrases.

To apologize is Canadian. But so are lumberjack sports. It's knowing how to balance the two approaches that's key.

L-girl said...

Fundamentally, this is an exhausting topic.

I had a feeling this might be too exhausting for everyone to thrash around.

Wrye and Sharonapple, thanks for your comments. Sharon, those are very interesting points, and they certainly are (for me) counter-intuitive, so they're important to know.

I agree that for-profit hospitals mixed in with public hospitals can be a disaster. It certainly is in the US.

Anyway, I'll try revisiting this some other time. :)

teflonjedi said...

This is a great example of what I mean. Say the word "change" and the next thing you hear is "we don't want USA style health care". Change doesn't have to equal that.

"People can be very frightened of change" (spoken by a great Canadian)

Canada's got a great system. Unfortunately, the world changes, the population changes, the needs that people have from the system change. We're all kidding ourselves if we say that the system won't need ongoing, continuous improvement.

Al said...

This fear of syphoning off doctors to a private system has been happening for years---to the U.S. Last year was the first year in at least 20 years, more doctors came to Canada from the U.S. than left for the U.S. The word I hear in the profession is that the HMOs in the U.S. have become so authoritarian that many of our Canadian docs figure they may as well come back home. Where will the doctors come from to provide the service in the private system? From the U.S. and other countries. These are the physicians that don't like bureaucrats telling them how to practice medicine. The doctors now practicing in Canada are so used to a pay check coming from the government they are unlikely to switch, if they were going to do it, they would have done it already. Its the young doctors that the public system has to bid for, and make no mistake, it's a world wide auction.
One thing is for sure, the status quo is not an option! If any of you are really interested in what is happening in Canada's health care system you can read for hours on my blog site.(www.primaryhealthcare.blogspot.com)

sharonapple said...

An interesting comment from a blogger on how public and private interests have made France have the best health care system in the world (as ranked by the WHO).

Klein, Chariest and Campbell’s plan on two-tier Health Care is a joke. Supporters of Two-Tier health care generally point to France as a model for Two Tier Health Care, yet the follow Britain lead.

The World Health Organization Ranks France as the number one nation in health care delivery, while Canada is 33, the United Kingdom has dropped to 38 from 34 and the United States is 36. Obviously Britain isn’t the formula to follow; we are better off following the Americans. Yet all three primers are following them. New Labour when it came to power it did what Margaret Thatcher was unable to which was expand the role of the private system in Britain. New Labour set up a Parallel Public Private System. The private system is now in direct completion with the Public Sector and as predicted it has destroyed the Public System in Britain by siphoning away good doctors and nurses from the Public System and sent it to the Private System.

In France on the other hand the Private and Public Sector do not work in competion with one another. Instead they work together. The Private Sector simply bills the Government for surgeries and all non-cosmetic procedures (like a HMO). By having the private sector involved in this fashion it allows for hospitals to be built without the need for government funding. In France the Public Sector simply is mostly an insurance system, although they do build hospital in areas where the Private Sector isn’t interested in making hospitals. By law the Private Sector cannot charge for surgeries and other services, but they can charge user fees if the person wants something extra. An example of that would be, instead of having basic hospital food (like the ones we get here), you can get something nicer, like a turkey dinner or whatever you can safely eat; or you pay extra to be put on a floor with extending visiting hours (of course there would be more). Usually the profit goes to improve the quality of healthcare.


http://ahayer.blogspot.com/2006/02/two-tier-healthcare.html

A bit more on France's health care.
http://72.14.207.104/search?q=cache:PCL3MngMlmcJ:www.nchc.org/facts/France.pdf+france+health+care+WHO&hl=en&gl=ca&ct=clnk&cd=11