Be Open About Health Care Challenges

Debate about health care in Canada would be more enlightening if it focused on the pertinent facts. Unfortunately, this rarely happens.

This week a thoroughly researched Globe and Mail story said that doctors, most frequently in British Columbia, offer patients who have waited far too long for needed surgeries the possibility of treatment in a private clinic.

The patients are charged for this, sometimes quite a lot.

Sometimes, this can be clearly wrong–for example if the physician bills both the province and the patient for the same service. Or if the physician fails to meet her workload commitments to the public system, while using the time instead to provide services for which she charges patients. Or gouging the patient for a fee much higher than the clinic receives when doing the procedure for the government.

These are not at all representative.

Nevertheless, the Globe, in a subsequent editorial, characterizes every incidence of private provision of publicly insured services as “double-dipping” and fulminates that any such practice is illegal and morally dubious.

This is nonsense. Some relevant facts:

(1) Wait times are unacceptably long for many treatments in British Columbia and elsewhere, including Nova Scotia.

(2) This is not because physicians are shirking their duties. Rather it is because the supply of insured services provided by the public system is not driven by demand but rather by what the provinces can afford to pay.

Surgeons are typically restricted to one or two days a week of operating room time.

(3) A surgical procedure costs a lot more than the fee for the physician(s). The special purpose facility is expensive to build and maintain, and there are other health care professionals in the room besides the surgeon, plus those in pre-operative and post-operative care.

(4) The federal contribution to health-care costs is determined by demographics. It turns out to be about 25 per cent of the total but is not linked to demand or to what the province actually spends.

(5) The provinces run the health-care system. Yet the Globe, by no means alone, feels it is for the federal minister to deal with the situation highlighted in its report.

(6) The federal involvement is governed by the Canada Health Act. It does not make extra billing “illegal” but rather provides for possible reductions in funding to provinces if it happens.

It also requires the provinces to “… provide for insured health services on uniform terms and conditions and on a basis that does not impede or preclude … reasonable access to those services by insured persons.”

Unacceptable wait times preclude reasonable access, but there is no talk of deductions from grants to provinces for those.

With this as context, consider what is happening. Private facilities for treatment have become more numerous because physicians have unused capacity due to the restrictions on their operating room time in the public system.

Some of them invest in a private facility, or agree to work at a facility owned by an independent operator. They charge for their time, to the province if it is willing, otherwise to the patient. The patient also must pay a fee for the facility and for the other health care professionals involved. It can add up.

The patient is voluntarily doing in Canada what he could otherwise do in another country. It shortens the lineup for those in the public system.

Providing the service is neither illegal nor immoral. Attacking the practice will not improve the health care that Canadians receive.

Governments can quickly diminish the role of private facilities by making the public system more efficient. In the meantime, they should be glad it is there as an imperfect relief valve.

Some regulation may be necessary to prevent price gouging or other abuses. But a better way to keep prices down is not by regulation but rather by encouraging competition. Some provinces including Nova Scotia use private facilities to provide insured services if it is cheaper.

Perhaps private services could provide a better alternative for the public system, as the Shouldice Clinic, a centre of excellence for treating hernias, does in Ontario.

If so, why limit Canadians’ access to such a system?

Medical tourism could be a great addition to the economy. It would do no harm to the public system, where the limitations are financial, rather than low availability of needed skills.

In a 2005 decision, Chaoulli v Quebec, the Supreme Court ruled that the province could not prevent Chaoulli from buying insurance for private care, given the long wait times in the public system. A similar case involving the Cambie Clinic in British Columbia is now working its way through the courts.

Hopefully the Supreme Court’s response will facilitate a better-informed discussion of our health care system.


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