About those deadly Canadian wait times
Andrew D. Coates, MD
“Pursuit of corporate profit and personal fortune have no place in caregiving. They create enormous waste and too often warp clinical decision making.”
Proposal of the Physicians’ Working Group for Single-Payer National Health Insurance (JAMA 2003; 290:798-805)
In 2005 the Supreme Court of Canada ruled that the province of Quebec could not bar private health insurance from covering the same services as the province’s single payer system, if Canada’s Medicare made patients wait. The case was brought by Dr. Jacques Chaoulli on behalf of his patient who had waited one year for an elective hip replacement surgery.
A crusader for privatization of medical care, Dr. Chaoulli argued that the public system of health care financing caused Canadians to “suffer and die” while waiting for treatments. The Supreme Court of Canada found that waiting for surgery was a violation of the patient’s human rights. The province of Quebec, in turn, passed a law to allow the sale of private insurance to cover three specific elective surgeries that had wait lists: hip and knee replacement and cataract surgeries.
Thanks to his crusade against the Canadian single payer system Dr. Chaoulli became the darling of the insurance industry and well-funded ideologues hired to champion profiteering at the expense of the sick. He even inspired a few free-market fundamentalists to seek constitutional grounds to abolish Medicare in the United States. Other free-market enthusiasts also took up Dr. Chaoulli’s cry that Canadians would get seen more quickly and receive better care, if only they were allowed to pay privately.
If only.
Jean-Jacques Sauvageau died in the waiting room of a private clinic in Quebec in January 2008. The clinic advertised emergency care. The subsequent investigation has led the provincial coroner to urge the Quebec College of Physicians to issue guidelines to protect patient safety at private clinics.
The physician on duty at the private clinic was Dr. Jacques Chaoulli.
The clinic’s receptionist (who had no medical training) took identifying information and asked Mr. Sauvageau to take a seat. The coroner reported that Mr. Sauvageau then waited 20 to 60 minutes, blue and gasping, his shoulders heaving with each breath. In the Globe and Mail Ingrid Peritz described his death as “a scene that combined tragedy with Monty Python farce:”
…the increasingly alarmed fellow patients could see Mr. Sauvageau was unconscious and alerted the receptionist. Dr. Chaoulli came out, did a cursory examination and concluded the patient was already dead.
He left him sitting in the chair, and told the nurse to phone 911 to report the death.
But the 911 operator pleaded with the nurse to try to revive Mr. Sauvageau. Dr. Chaoulli got on the phone and tried to argue the patient was dead; however, the 911 operator insisted…
…Eventually, ambulance medics arrived and tried in vain to revive the patient.
An autopsy later revealed that Mr. Sauvageau died of a pulmonary embolism and would not have survived anyway. But the coroner said that Dr. Chaoulli had no way of knowing that, and should have tried to perform CPR.
Catherine Solyom reported in The Montreal Gazette:
It was Sarah Swain-Lagarde, 22, who called 911 for guidance on how to give the man CPR herself. She was told to lie him down. But when she tried, the nurses told her to stop – no one was to touch the man, they said.
“I’m not a doctor … but when someone is purple and having a hard time breathing he should be helped right away,” said Swain-Lagarde, who had brought her toddler to the clinic for a high fever. “He was in a waiting room surrounded by people. He just stayed on his chair. No one did anything for him.”
Jacques Chaoulli, the doctor who took Sauvageau’s pulse around 4 p.m., testified that he also spoke to Sauvageau, listened for a heartbeat and pinched him. He examined his eyes and his extremities, which were blue, while his face was now white.
But Chaoulli said he did not try to resuscitate him.
“I concluded that this patient must have been dead already a long enough time – I had no way of knowing how long – but long enough,” Chaoulli said.
Chaoulli told a nurse to call 911 so that they could declare him dead officially, he said.
As for why Chaoulli left the body there for what he says was another 10 minutes – he explained he felt the waiting room had become akin to “the scene of a crime.” The death in a public place would require an investigation, he explained, and “the police wouldn’t want us to touch the body.”
The Globe and Mail reported that the patient’s son “said the family was still appalled by his father’s treatment:”
“An animal at a veterinarian’s clinic gets better treatment than my father got,” Michel Sauvageau said.
This case has deepened the debate over the privatization of Canada’s Medicare, for the tragedy demonstrates why medical services cannot depend upon the ‘irrational exuberance’ of the “free market.”
One Canadian blogger, Mary Soderstrom, politely observed:
Certainly in this case it doesn’t look like Chaoulli’s clinic provided the kind of excellent health care proponents of privatization vaunt. Without a doubt members of the victim’s family must be asking what would have happened had he gone to a hospital emergency room where triage teams are trained to quickly size up a situation. It’s doubtful that a man turning blue would be told to sit and wait on a chair: while there’s no doubt that it can take hours for non-urgent cases to be seen, life-threatening cases are evaluated and treated quickly in hospitals, observers agree.
Mr. Sauvageau’s death reminds us that a person in acute distress, or a person in need of a surgery or care in general, is in no position to predict what care will be required. What kind of society would take the health and illness of human beings as an occasion to shop for a bargain — or a money-making moment for profiteers? Health policies and budgets are best set by the public. The effort to reduce waiting times is no exception.
When Ezra Klein examined wait times in the American Prospect in 2007 he wrote:
Sadly for those invested in this odd knock against the Canadian system, the wait times are largely hype. A 2003 study found that the median wait time for elective surgeries in Canada was a little more than four weeks, while diagnostic tests took about three (with no wait times to speak of for emergency surgeries). By contrast, Organisation for Economic Co-operation and Development data from 2001 found that 32 percent of American patients waited more than a month for elective surgery, and 5 percent waited more than four months. That, of course, doesn’t count the millions of Americans who never seek surgery, or even the basic care necessary for a diagnosis, because they lack health coverage. If you can’t see a doctor in the first place, you never have to wait for treatment.
Last week the Wall Street Journal reported that, thanks to layoffs, 9 million people have lost their employer-sponsored private health insurance in the United States in the last year. This week the Wall Street Journal reported that the economic crisis had caused an increase in those in the United States who, as Klein put it, “never seek surgery”:
While more uninsured patients strain hospital budgets, many hospitals report fewer inpatient admissions overall. For example, 41% of hospitals reported a moderate decrease in elective procedures, and 18% said the decrease was significant.
During the same period in Canada, including Quebec, waiting times for elective procedures have improved. Ironically, Chaoulli v. Quebec strengthened the single payer system. Dr. Randall White points out on the Canadian Doctors for Medicare blog, no one in Quebec has purchased the new private health insurance. Not one.
As CBC News reported:
More than two years after Quebec legalized private medical coverage for select surgeries, the insurance industry says it has not sold a single policy.
Bill 33 was supposed to allow Quebecers to seek private insurance for faster knee and hip replacements, and cataract surgery.
Yves Millette, senior vice-president of the Canadian Life and Health Insurers’ Association, said no one is buying the policies because they are too expensive…
…Quebec Health Minister Yves Bolduc said the province has sped up wait times so much since the court ruling, it’s no wonder no one wants to pay for private coverage.
“We have such a good access to the surgeries in Quebec, that the industry knows they won’t be able to sell any insurance to anybody,” said Bolduc.
Imagine that. The province of Quebec, with its health system underfunded and in spite of a growing global economic crisis, has successfully shortened wait times for elective surgeries.
Meanwhile in the United States elective surgery is increasingly “off the table” for the uninsured and under-insured. In addition the New York Times reported in March 2009 that more than 85,000 people leave the United States each year, to travel to other countries for elective surgeries.
The waiting room tragedy that befell Mr. Sauvageau, and indeed Dr. Chaoulli, emphasizes our need for public decision-making, public financing and public health services. In the United States and Canada, as in every country, decisions over how best to share health resources belong in the public domain. In Canada we must defend Medicare against privatization. In the United States we need to enact a single payer national health program.
Single payer is not a perfect system, but it is so much better than the alternative, privatization and profiteering at the expense of the sick.