By Stephen J. Bergman
The Boston Globe
August 5, 2007

SOON AFTER HMO/managed care came to Massachusetts in the late ’80s, I got a call from a patient I had admitted to the 28-day alcohol unit at the hospital. He said that he was being discharged after three days because that was all that the HMO would now pay for alcoholism. He said the HMO representative told him to go out and get drunk again and they would readmit him.

How did this happen? Managed care let it be known through massive advertising that either doctors join up, or be left out — we would lose patients to HMO doctors. This seemed strange: Doctors did the work; without us, there was no “care” to manage. If we stuck together, we could get what we wanted from the insurance industry. Instead, doctors elbowed each other out of the way to make sure they would “get in.” We lost our clout in setting standards for good care for patients, and a work environment that would allow it.

Now, healthcare in America is a national disgrace. Forty-five million are uninsured, most are underinsured — one illness away from bankruptcy, poverty, or homelessness. Our private healthcare system is worse for patients and doctors and better for the insurance industry. Even the insured are suffering. Their doctors are rushed, mistakes are made, good care is hard to find. Private health insurance spends about 30 percent on administrative costs; government-run Medicare spends 3 percent. The single-payer national model seems inevitable.

Yet it has not happened. The health insurance industry is profitable, and a well-funded lobby. Only one of the presidential candidates (Dennis Kucinich) is sponsoring a single-payer system — the others are just whistling past the grave of medical care. However, elements of change are arising — scholars, politicians, media, pundits, and the public, and now Michael Moore, in his new documentary “Sicko,” pointing out the relative inadequacies of our system. But one piece, a vital piece, has been missing.

Change will not originate from the top. In any hierarchical system, the only threat to the dominant group is the quality of connection among the subordinate group. This is true of race, gender, class, ethnicity, and sexual preference. In three great movements of my lifetime — women’s rights, civil rights, and the ending of the Vietnam War — change came from my generation seeing an injustice and believing that by organizing together at the grass-roots level we could right an obvious wrong. And now?

I propose a doctors strike (or a healthcare workers strike, but I can only speak as a doctor). First, doctors would recruit enough colleagues to pledge that if, in two years (say, by July 4, 2009), there is not a federal law for a single-payer, universal coverage health system, we will go on strike.

At first we will be dismissed as idealistic or ungrateful nuts advocating that horror of horrors, “socialized medicine.” We may not have many members, and the insurance industry will mobilize in a way that makes the ads against the Clinton health bill look like musical comedy.

Six months pass; we remind the public that in 18 months we will go on strike. Our ranks increase — patients, realizing that it is in their interest to directly support the strike, join us — and more attention gets paid. Twelve months until the strike, we are growing in membership — other healthcare workers join, maybe even a company like General Motors that is sick and tired of paying more for health insurance than for the steel for their cars — and we spell out exactly what we won’t provide and the resulting chaos in our hospitals, emergency rooms, outpatient clinics, etc. Perhaps those in the government start to notice.

At six months, with tens of thousands pledging to strike, we may be taken quite seriously — the public understands that the consequences of a strike would be disastrous. What irony: To protect patients, doctors have to go on strike!

I predict that it will never come to that. We will put real health insurance on the books.

We are the ones who do the work. If we care for our patients, and for our Hippocratic ideals, we have no choice but to try. Our efforts, in sync with the rising tide of public and political movements, might just lift us all, leading America into the fold of those rich nations who put first things first: the health security of their citizens.

*Stephen J. Bergman, *under the pen-name “Samuel Shem,” is author of the novels “The House of God” and “Mount Misery” and co-author of the play “Bill W. and Dr. Bob.”

(c) Copyright 2007 Globe Newspaper Company.

Toronto June 26, 2007 — While there has been significant progress to improve and manage centralized information on wait times for targeted health care procedures, the data needed to see changes over time and compare wait times on a national level is not available from all jurisdictions, the Health Council of Canada says in its wait times report, released today.

Wading through Wait Times: What Do Meaningful Reductions and Guarantees Mean? reviews progress by provinces and territories in reducing wait times for non-emergency care from a patient’s perspective through a true story about Frank, a hip replacement patient.

This report is a look at one of the key public concerns about health care, set in the context of the national commitment to achieve meaningful reductions in wait times in five priority areas — cancer, heart, diagnostic imaging, joint replacements and sight restoration — by March 31, 2007.

“Clearly there has been progress, and we can see many areas where jurisdictions are doing more and reporting in more accessible ways to citizens,” said Dr. Jeanne Besner, Chair, Health Council of Canada. “Reporting wait time information to citizens on the Internet has been no small task. These information systems have considerable potential to improve patients’ experiences with waits for care.”

Approximately one in 10 Canadians sees a health care specialist each year, with many patients reporting delays in accessing care. On average, Canadians reported waiting four weeks to see a specialist, according to surveys done in 2003 and 2005. Although provinces and territories report wait times in different ways, information shows median wait times for non-emergency care have clearly declined for some services. For example:

* In British Columbia the wait time for cataract surgery has been reduced to 7.6 weeks from 9.9 weeks;
* In Ontario the wait time for radiation for cancer care has been reduced to 4.4 weeks from 6.4 weeks;
* In Alberta the wait time for hip replacement has been reduced to 12 weeks from 16 weeks and for knee replacement has dropped to 17 weeks from 22 weeks.

These and other positive developments come at the same time the volume of services has increased in targeted areas. For some services, in some parts of the country, more people are getting care more quickly.

While the information now available for wait times is not sufficient for Canada-wide monitoring, having this data in the public realm is a significant step forward and means wait lists are beginning to be managed centrally in a fair and logical way. Until recently most surgeons kept their own waiting lists and data were rarely compiled at the provincial, regional or hospital level. Unfortunately, gaps remain in the availability of wait times information and the Health Council of Canada continues to call for accelerated investments in the development of comparable data systems across the country.

Developed, in part, through interviews with leaders of innovative programs (see backgrounder), Wading through Wait Times identifies a number of factors that are critical for success in reducing health care wait times. They are:

* Support from government leaders;
* Strong program leadership;
* Full-time program staff;
* Information systems to centralize and track waiting lists;
* Adequate funding for information systems and program leadership;
* A comprehensive approach to all the changes required to reduce wait times.

In addition to reporting on progress in reducing wait times for care as agreed to in the 2004 10-Year Plan to Strengthen Health Care, this update provides Canadians with information on the new patient wait time guarantees.

“Ideally, the best guarantee is one that rarely, if ever, needs to be invoked,” said Councillor Les Vertesi, an emergency physician from British Columbia. “Jurisdictions have chosen to implement guarantees for services they already provide, or are well on their way to delivering, within the guaranteed time frame.”

As Wading through Wait Times concludes, international experiences with wait time guarantees may be instructive, but they cannot tell us what impact Canadians can expect from these policies until they are coupled with reliable and comparative data. Guarantees may play a valuable role in resolving Canada’s wait time problem. But unless access also improves for other health services, the guarantees by themselves may fall short of meeting the expectations of Canadians.

Visit www.healthcouncilcanada.ca to download Wading through Wait Times: What Do Meaningful Reductions and Guarantees Mean? and the backgrounder highlighting regional success stories in reducing wait times.

Background

The Health Council of Canada, created by the 2003 First Ministers’ Accord on Health Care Renewal following the recommendations of the Romanow and Kirby reports, is mandated to monitor and report on the progress of health care renewal in Canada. The 26 Councillors were appointed by the participating provinces, territories and the Government of Canada and have expertise and broad experience in community care, Aboriginal health, nursing, health education and administration, finance, medicine and pharmacy.

David Felix, economist
Bangor Daily News
Wednesday, August 1, 2007

John Goodman summarizes his critique of Michael Moore’s documentary on health care reform (“Sicko is no model for health care reform,” BDN, July 21), as follows: “So what are we to make of Moore and his ‘documentary’? Economists, like other scientists, study reality in order to adapt to it. Artists, by contrast, selectively focus on some facts and ignore others in order to recreate reality.” Bad economics is thus Goodman’s basic charge against “Sicko.”

This charge prompted me, an economist, to see the documentary. My conclusion? Moore is far less guilty of flawed economics and disregard of relevant facts than is Goodman. Moore is also straightforward about his values and ideology, whereas Goodman masks his as scientific economics. This impels me to defend my profession by exposing the falsity of his claims, and some of the salient facts that he ignores.

Goodman rejects single payer universal coverage health systems, which Moore favors, because they require bureaucratic rationing of medical care, and impose longer waiting periods than do private market health systems. The rationing complaint as such is irrelevant; markets also ration, mostly by the purse. What they have been unable to do is provide universal coverage.

The incentive for private health insurance companies is to maximize profits by insuring low-risk clients and rejecting high risk ones. That incentive promotes /private /bureaucratic rationing of services and intensified screening of applicants. The U.S. public sector and private charities have thus been pressured to finance treatment of some sort for the rapidly rising millions of U.S. uninsured and underinsured. “Sicko” illustrates various aspects of the problem. Goodman gives it no mention whatsoever.

Waiting time is emphasized by Goodman, although he ignores some important dimensions of the waiting issue, and presents biased treatment of others.

Thus the socialized systems of Britain, Canada, Australia and New Zealand assign lower priorities and longer delays to elective (e.g., cosmetic) and non-emergency (e.g., hip replacement) surgery than to emergency (e.g., cardiac or cancer) surgery.

The U.S. has the shortest average waiting time for elective and non-emergency surgery, but is merely in the middle of the Anglo-Saxon group for emergency surgery. The same for delay in seeing a specialist.

Goodman combines the two priorities, lowering the overall U.S. waiting time to first place, which allows him to claim it indicates the extra risk of death that government rationing imposes in emergency cases.

He disregards that the U.S. is the most difficult of the Anglo-Saxon group in getting same-day doctor appointments; shares with Canada the most difficulty in getting treatment on nights and weekends; and that France, Germany, Japan and the Scandinavians have still shorter delays than the Anglo-Saxon group in almost all dimensions of waiting. Implication? Bureaucratic rationing is unavoidable in universal coverage government health programs, but longer waits are not.

Goodman’s data manipulation and his assumption that longer waits have deadly consequences imply that the U.S. should have longer life expectancy and a lower rate of infant mortality than the industrial countries with socialized medicine.

But he doesn’t test that implication, enabling him to ignore that the U.S. has the lowest life expectancy and highest infant mortality rate of the industrialized democracies. Instead, he puzzles over why national health insurance seems so popular in these countries, concluding it’s because their citizenry, unaware that they pay by taxes, think they’re getting something for nothing.

And so to another of Goodman’s major omissions. The overall cost of health, taxes and all, is far higher in the U.S. than in any of the countries with universal coverage socialized health systems. U.S. overall spending on health is pushing 16 percent of its GDP and rising, as are its millions of uninsured. The overall health spending of the countries with socialized health insurance averages around 10 percent of GDP, with none reaching 12 percent, and all providing universal coverage. We pay the most to cover the least.

Can we cover more while paying less? Kenneth Thorpe, perhaps the top U.S. health economist, was recently commissioned by a broad coalition of 90 corporations, unions and advocacy groups to answer the question statistically. His report estimates the annual cost of moving to universal coverage at $75 billion in constant U.S. dollars, but this could be more than offset by reducing administrative costs to the Canadian level, acquiring pharmaceuticals at Canadian prices, and by earlier detection and treatment of patients now priced out of the current health system.

The annual savings in 10 years would reach $125 billion, with the current health system preserved, up to $182 billion if transformed to a single payer insurance system. These numbers estimate what economists call deadweight losses, inefficient uses of resources that reduce national welfare. “Sicko” illustrates such losses in the U.S. system; Goodman ignores them.

Which brings us to the moral issue. The major religions advocate egalitarian distribution of social welfare theologically, whereas libertarian ideology prioritizes free markets and individual choice. Each can become enmeshed by policy conflicts between theology and economic reality.

Health reform is an exception. Moore has the easier advocacy task: his single-payer reform is supported by both “scientific” economics and widely held religious principles.

Goodman must show that socializing health insurance, even if it lowers economic costs while improving health, is morally bad. His critique avoids that question, other than hinting at a slippery slope argument. My conclusion: Moore wins over Goodman on economics and morality.

David Felix of Orono is professor emeritus of economics at Washington University in St. Louis.

David Felix, economist
Bangor Daily News
Wednesday, August 1, 2007

John Goodman summarizes his critique of Michael Moore’s documentary on health care reform (“Sicko is no model for health care reform,” BDN, July 21), as follows: “So what are we to make of Moore and his ‘documentary’? Economists, like other scientists, study reality in order to adapt to it. Artists, by contrast, selectively focus on some facts and ignore others in order to recreate reality.” Bad economics is thus Goodman’s basic charge against “Sicko.”

This charge prompted me, an economist, to see the documentary. My conclusion? Moore is far less guilty of flawed economics and disregard of relevant facts than is Goodman. Moore is also straightforward about his values and ideology, whereas Goodman masks his as scientific economics. This impels me to defend my profession by exposing the falsity of his claims, and some of the salient facts that he ignores.

Goodman rejects single payer universal coverage health systems, which Moore favors, because they require bureaucratic rationing of medical care, and impose longer waiting periods than do private market health systems. The rationing complaint as such is irrelevant; markets also ration, mostly by the purse. What they have been unable to do is provide universal coverage.

The incentive for private health insurance companies is to maximize profits by insuring low-risk clients and rejecting high risk ones. That incentive promotes /private /bureaucratic rationing of services and intensified screening of applicants. The U.S. public sector and private charities have thus been pressured to finance treatment of some sort for the rapidly rising millions of U.S. uninsured and underinsured. “Sicko” illustrates various aspects of the problem. Goodman gives it no mention whatsoever.

Waiting time is emphasized by Goodman, although he ignores some important dimensions of the waiting issue, and presents biased treatment of others.

Thus the socialized systems of Britain, Canada, Australia and New Zealand assign lower priorities and longer delays to elective (e.g., cosmetic) and non-emergency (e.g., hip replacement) surgery than to emergency (e.g., cardiac or cancer) surgery.

The U.S. has the shortest average waiting time for elective and non-emergency surgery, but is merely in the middle of the Anglo-Saxon group for emergency surgery. The same for delay in seeing a specialist.

Goodman combines the two priorities, lowering the overall U.S. waiting time to first place, which allows him to claim it indicates the extra risk of death that government rationing imposes in emergency cases.

He disregards that the U.S. is the most difficult of the Anglo-Saxon group in getting same-day doctor appointments; shares with Canada the most difficulty in getting treatment on nights and weekends; and that France, Germany, Japan and the Scandinavians have still shorter delays than the Anglo-Saxon group in almost all dimensions of waiting. Implication? Bureaucratic rationing is unavoidable in universal coverage government health programs, but longer waits are not.

Goodman’s data manipulation and his assumption that longer waits have deadly consequences imply that the U.S. should have longer life expectancy and a lower rate of infant mortality than the industrial countries with socialized medicine.

But he doesn’t test that implication, enabling him to ignore that the U.S. has the lowest life expectancy and highest infant mortality rate of the industrialized democracies. Instead, he puzzles over why national health insurance seems so popular in these countries, concluding it’s because their citizenry, unaware that they pay by taxes, think they’re getting something for nothing.

And so to another of Goodman’s major omissions. The overall cost of health, taxes and all, is far higher in the U.S. than in any of the countries with universal coverage socialized health systems. U.S. overall spending on health is pushing 16 percent of its GDP and rising, as are its millions of uninsured. The overall health spending of the countries with socialized health insurance averages around 10 percent of GDP, with none reaching 12 percent, and all providing universal coverage. We pay the most to cover the least.

Can we cover more while paying less? Kenneth Thorpe, perhaps the top U.S. health economist, was recently commissioned by a broad coalition of 90 corporations, unions and advocacy groups to answer the question statistically. His report estimates the annual cost of moving to universal coverage at $75 billion in constant U.S. dollars, but this could be more than offset by reducing administrative costs to the Canadian level, acquiring pharmaceuticals at Canadian prices, and by earlier detection and treatment of patients now priced out of the current health system.

The annual savings in 10 years would reach $125 billion, with the current health system preserved, up to $182 billion if transformed to a single payer insurance system. These numbers estimate what economists call deadweight losses, inefficient uses of resources that reduce national welfare. “Sicko” illustrates such losses in the U.S. system; Goodman ignores them.

Which brings us to the moral issue. The major religions advocate egalitarian distribution of social welfare theologically, whereas libertarian ideology prioritizes free markets and individual choice. Each can become enmeshed by policy conflicts between theology and economic reality.

Health reform is an exception. Moore has the easier advocacy task: his single-payer reform is supported by both “scientific” economics and widely held religious principles.

Goodman must show that socializing health insurance, even if it lowers economic costs while improving health, is morally bad. His critique avoids that question, other than hinting at a slippery slope argument. My conclusion: Moore wins over Goodman on economics and morality.

David Felix of Orono is professor emeritus of economics at Washington University in St. Louis.

Naomi Lakritz
Calgary Herald
Thursday, August 02, 2007

It’s been said that during the 12 or so years they spend in medical school, doctors learn to think of themselves as gods.

Well, the gods must be crazy. Or greedy. Or both. How else to explain the Canadian Medical Association’s ridiculous support for physicians’ right to work simultaneously in both a public and private system, including the introduction of private health insurance — and the gall to label this as standing up for their patients?

It is patently obvious they are standing up for their bank accounts, not their patients. That they are so eager to place patients at the mercy of insurance companies, whose subterfuges for skipping out on claims are well-documented in the U.S., shows their patients’ best interests are the last priority.

A recent New York Times article profiled Gordon Hendrickson, 66, of Albuquerque, whose best bet to beat pancreatic cancer was risky surgery performed by a Houston specialist. His insurance company refused to pay for the surgery. Hendrickson had it done anyway. Today, he is cured, but owes $80,000 in medical bills.

Is this what the CMA wants to inflict on Canadians?

“Of the people who go bankrupt in the U.S., 50 per cent of the time it is because of medical bills. Of that 50 per cent, 75 per cent had health insurance,” says Dr. Ida Hellander, executive director of the Chicago-based Physicians For a National Health Program.

Insurance companies are putting the screws to American patients in insidious ways.

In a telephone interview, Hellander says it’s hard to find a policy with a deductible less than $1,000. Some policies have deductibles up to $5,000.

“A thousand dollars is a lot of money. So people have chest pains and they won’t go to the ER because they’ll have to pay that $1,000 deductible,” she says.

Another nasty trend is co-insurance — when you go to the hospital, you pay 20 per cent of the bill before your insurance kicks in.

Insurers have also dropped mental health coverage, so people with mental illnesses are going untreated. Only the most indigent can get their mental health care funded by the government. Also, if you have a pre-existing condition, insurance companies will do their best to link it to everything else you visit the doctor for, in order to avoid paying the bill.

And the CMA wants to subject Canadians to these kinds of nightmares?

Equally absurd is the CMA’s claim that these reforms would allow doctors to spend more time with patients. Sure, they would — with the private patients whose visits are more lucrative for the doctor.

The public patients might be fitted in if there are a few minutes left over in the doctor’s day from filling out the insurance forms for his private patients.

According to an article in the Ventura County Star, 80 per cent of doctors in California are frustrated with the huge amount of time they spend filling out insurance forms.

Don McCanne, a retired family physician and senior health policy fellow with the PNHP, says doctors will be “cream-skimming the more profitable patients,” to the detriment of the public ones.

Economist Paul Krugman, also writing in the New York Times, shatters one of the cherished myths of Canada’s proponents of private health, when he discusses hip replacements. This surgery is always seized upon by the private-health cheerleaders as something for which there is no waiting in the U.S. system:

“There’s a funny thing about that example, which is used constantly as an argument for the superiority of private health insurance over a government-run system: the large majority of hip replacements in the United States are paid for by, um, Medicare.

“That’s right: the hip-replacement gap is actually a comparison of two government health insurance systems. American Medicare has shorter waits than Canadian Medicare because it has more lavish funding.”

Krugman also points out that the insurers themselves cause waiting lists to grow, citing the example of Mark Kleiman, a UCLA professor, who nearly died waiting for a biopsy because his insurance company stalled approving it.

“There’s no question that some Americans who seemingly have good insurance nonetheless die because insurers are trying to hold down their ‘medical losses’ — the industry term for actually having to pay for care,” Krugman writes.

Reached at his home in San Juan Capistrano, Calif., McCanne calls the CMA’s interest in private care “self-serving” at a time when Canada really needs to repair the public system’s flaws.

“Frankly, they’re greedy,” he says. “Private insurance is the worst thing they could do.”

Amen to that, Dr. McCanne.

nlakritz@theherald.canwest.com

By Prof. Gordon Guyatt
The Globe and Mail
01/08/07

Any proposed change to health care implies winners and losers.

Take, for instance, a national Pharmacare program. Winners would include poor Canadians who have difficulty affording drugs, middle income Canadians with high drug costs, and anyone facing catastrophic drug expenditures.
Canadian large industry would also benefit by enhanced competitiveness as a result of lower employee health benefits.

The losers? High income Canadians in upper tax brackets and the insurance industry.

The Canadian Medical Association has recently suggested that provincial governments increase reliance on private, for-profit providers to deliver publicly funded health care. Furthermore, they suggest that physicians be allowed to practice in both for-profit and not-for-profit sectors. Who would win and lose if governments accept the proposal?
The CMA claims that the public would benefit from shorter waiting lists. There are many reasons for skepticism about the claim.

Long wait times and suboptimal care are in considerable part a function of doctor and nursing shortages. For-profit clinics would not lead to the training of a single additional doctor or nurse. Indeed, such clinics would suck desperately needed personnel from not-for-profit hospitals and outpatient facilities.

Physicians practicing in public and private settings they have a vested interest in keeping waiting lists long in publicly funded settings. Why would patients pay extra if waiting lists are under control in publicly funded hospitals and out-patient clinics? They would not. For-profit clinics prosper only so long as non-profit provision suffers unacceptable waits.

Could for-profit clinics shorten waiting lists by creating more resources, such as operating room time? Surely, but the government could create those same resources by investment in hospitals or not-for-profit dedicated surgical and diagnostic facilities.

Investing in not-for-profit provision has a major advantage. For-profit providers need to earn a return — typically 15 to 20% – for their investors. Non-profits can devote that money to patient care. That explains the findings from systematic studies comparing for-profit versus non-profit hospital and dialysis care in the U.S. Higher death rates from cutting corners in for-profit hospitals and dialysis facilities, higher charges to third-party payers in for-profit hospitals.

So, too bad, no public win in terms of wait time reduction.

There would, however, be winners. Physician entrepreneurs like incoming CMA President Brian Day who operates a private hospital facility stand to make large sums of money. Many investors have made huge sums of money in U.S. for-profit health care. The proposal would allow them to exploit the enormous public expenditures on Canadian health care. And, if an associated CMA proposal to expand private insurance comes to pass, the insurance industry will cash in.

The losers? The general public who will end up spending more on health care to feed the investors’ profits and — if that market expands – on administrative costs associated with private health insurance. Those patients who can’t afford the substantial direct charges that — as experience in British Columbia and Quebec has shown — will inevitably come with for-profit health care provision. These losers will suffer the consequences of two-tier health care: the long waits in non-profit facilities necessary to allow the for-profits to charge queue-jumpers.

Other losers? Health workers who believe that ethical medical practice requires treating patients according to need, rather than ability to pay. My many visits to American health care institutions have shown me what it is like to practice medicine in a two-tier system. For doctors and nurses who believe that equity is at the heart of ethical care, it isn’t pleasant.

Consideration of winners and loser reveals a sad conclusion. While many doctors are in strong disagreement with proposals that would undermine public health care, the CMA leadership has chosen self-interest over the public interest.

How will politicians respond to the CMA initiative? Stephen Harper has done nothing to rein in expansions of charge-the-patient for-profit care in Quebec and B.C. On the other hand, the Prime Minister sees the situation as it is. In a letter responding to Ralph Klein’s proposal to allow physicians to practice in public and private systems, Mr. Harper wrote:

“Dual practice creates conflict of interest for physicians as there would be a financial incentive for them to stream patients into the private portion of their practice. Furthermore, dual practice legitimizes queue-jumping as it provides an approved mechanism for patients to pay to seek treatment at the front of the line.”

Whether for political expediency or conviction, the federal government may have nothing to do with the CMA’s proposals. If so, the losers will be the doctors and investors eager to turn health care to profit, and the winners will be the Canadian public.

Gordon Guyatt is a Professor of Medicine at McMaster University

New fight looms over medicare

Toronto Star
EDITORIAL
Aug 01, 2007

Once again the Canadian Medical Association, the national lobby group for Canada’s doctors, has started beating the drums for two-tier health care. In a speech Monday in Charlottetown, outgoing CMA president Collin McMillan set out a plan he calls “Medicare Plus.”

It is a blueprint that would see Canadians being allowed more access to private health insurance that could be used in a private system and which operates alongside medicare’s publicly funded coverage for all Canadians. Also under the plan, as set out in a policy paper released by the CMA, doctors would be free to divide their time as they see fit between public practice and a private one for those Canadians with cash or private insurance.

This is nothing short of a recipe for two-tier medicine.

But it rests on two flawed assumptions: first, that medicare is broken, and second, that it is too expensive for governments to fix.

As former Saskatchewan premier Roy Romanow concluded in 2002 after his exhaustive, 18-month review of Canada’s publicly funded, not-for-profit health-care system, medicare is far from broken. And all the well-known problems with the current system that arose at a time when Ottawa was preoccupied with fighting its deficit can be fixed at a reasonable cost.

In fact, since Romanow reported five years ago, important progress has been made on many fronts, although there is still much to be done.

Both Ottawa and provincial governments have invested heavily in health care, which has resulted in shorter wait times in many key areas, an increase in the availability of sophisticated diagnostic equipment and the introduction of programs of enhanced primary care. These advances, however, have not stopped the champions of private health care from continuing to push for two-tier medicine in Canada.

Indeed, Canada is heading rapidly toward yet another major national fight over the future of medicare.

Defenders of medicare have fought these battles in the past – and will need to speak up again in the coming fight. And they cannot afford to underestimate their opponents.

If anything, McMillan’s speech on Monday is merely the opening salvo in this debate. The next major battleground will be the provincial election in Ontario.

Here, Progressive Conservative Party Leader John Tory’s election platform promises “to involve the private sector where there are opportunities to shorten waiting lists and improve access to high-quality, publicly funded care.” Many in his party want to see widespread use of privately run, but publicly funded clinics. Although such proponents insist that patients would not be allowed to buy their way to the front of the line, their arguments in favour of private delivery have been used repeatedly like a crowbar by those trying to pry open the door to two-tier medicine.

At the national level, the pressure on Ottawa and the provinces to experiment more with private health care will start to increase next month when Brian Day takes over from McMillan at the CMA. A vociferous critic of the public system, Day is also the owner of Canada’s largest private hospital, based in Vancouver.

On the other side of the divide are the vast majority of Canadians, who overwhelmingly support medicare. They will have a critical part to play as this renewed debate unfolds.

To counter those who favour increased privatization, these Canadians must re-energize themselves and prepare once again to take on the claims of affordability and increased efficiency that proponents of private care use to sell their case.

Most importantly, they must continue to press governments to improve the current system and be ready with their own prescriptions for completing the work that still needs to be done to restore the public’s confidence in a system that has served Canada well.

For as Romanow wrote in the introduction to his 2002 report: “Strong leadership and the involvement of Canadians is key to preserving a system that is true to our values and sustainable.”