Globe and Mail
Apr. 6, 2004
Private payment: the zombie of health care
By Gordon Guyatt
A number of commentators have issued vigorous calls for a debate on private payment for health care, and the two-tier system that private payment brings. They paint a picture of a cowardly conspiracy of silence in the face of an unsustainable system. However, Canadians have been debating public versus private payment since 1919, when Liberal leader William Lyon Mackenzie King included a form of medicare in his election platform. Five times in Canada’s history, the federal government has asked high-profile political or judicial leaders to debate and resolve the health-funding controversy.
The five reviews all came to the same conclusion: Public funding of health care is more equitable and more efficient. A parallel private system will not only introduce inequities in access to care, but will waste our resources and reduce our international competitiveness.
On each occasion, these august bodies widely publicized the relevant evidence. Before national health insurance, Canada’s poor had limited access to health care. Studies have consistently shown that income no longer limits utilization of care.
Public funding means that the single payer, the government, can exercise a discipline impossible when private insurance pays for a substantial part of care. That’s why Canada’s publicly funded sectors of health care, and physician and hospital services, have managed to contain costs.
Both (recent) reports (Roy Romanow and Michael Kirby) also seriously considered, and rejected, the private-pay option. Paying more to get less, the inevitable consequence of moving away from public pay, didn’t make sense to the reports’ authors.
So, why the amnesia about the prior debates? Almost a decade of provincial and federal tax cuts have left government program spending at the lowest percentage of GDP since the 1950s. For some, the mandate to keep taxes low trumps all other considerations.
If our commitment to maintain or extend tax cuts is absolute, we indeed have a problem. In that ideology, it doesn’t matter if we spend more on health care and receive less. We have no choice but to turn to private pay, two-tier health care.
Canadian health economist Bob Evans has described private-pay advocacy for health care as a zombie: intellectually dead, but destined to keep rising again and again to haunt health-policy debates. The critics’ recent comments suggest that even the weight of five lucid, publicly debated reports and recommendations will not put the zombie to rest.
(Gordon Guyatt is a professor in the faculty of health sciences at McMaster University.)