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 Ć¢ā¬ā 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.”
