Privatized medical care no cure for waiting lists

by Colleen M. Flood and Meghan McMahon

This commentary was first published in the Toronto Star on September 18, 2007.

A constitutional challenge to Ontario legislation that prohibits the purchase of private health insurance for medically necessary health-care services (dubbed the "Ontario Chaoulli") was announced on Sept. 5.

It's another call for increased privatization, based on the misinformed notion that an expanded role for private insurance will remedy wait times in Canada.

Just last month, the outgoing president of the Canadian Medical Association, Dr. Colin McMillan, put forward Medicare Plus, the CMA's solution for sustaining our health-care system. It proposed expanding the role for private insurance and private payment, and allowing physicians to work for the public system and treat private patients, too.

After a stream of backlash from the Canadian Healthcare Association, the Registered Nurses Association of Ontario, Canadian Doctors for Medicare and others, the CMA responded by saying that it is time to examine the nature of the public versus private health-care debate.

Indeed it is. Will the CMA's recommendations make medicare better? The evidence says no.

Currently, Canadian regulations prevent doctors who are paid by public medicare from also providing medically necessary care for private payment. But doctors can "opt out" of the public system and "go private" (except in Ontario).

Why do we have this regulation? Because if we didn't, doctors would naturally want to spend much more of their time than they presently do treating private patients ñ as these patients often have easier conditions to treat and they (or their insurer) will pay more.

A doctor, like any normal person, will be attracted to working for more and doing less ñ who can blame them? So it is not surprising that some members of the CMA like the idea of Medicare Plus.

But from the public's perspective, and from the perspective of most patients, it's a bad idea. If you are a patient wealthy enough to pay privately or you have private insurance, then you may fare better under Medicare Plus. But lines for treatment in the public hospitals will grow longer and longer.

The CMA's recommendation also ignores the simple fact that, in the absence of an increase in the number of doctors (where will we get them from?), the introduction of a parallel private system must mean that the doctors we do have will be distributed between both public and private patients.

Private patients will pay more to have their medical needs met on a preferential basis, leaving public patients on ever-growing waiting lists. Evidence suggests that allowing doctors to practise in the public and private sectors will not, as Medicare Plus states, "improve access for the entire population."

Other countries that allow doctors to work on an unregulated basis in the public and private sectors ñ like New Zealand, the U.K., and Ireland ñ currently have, or have had, chronic problems with long waiting lists.

The evidence doesn't seem to indicate that having parallel private health insurance or "Medicare Plus" has cured waiting lists in these countries. Where waiting-lists have been wrestled down ñ as in the U.K. ñ it has been through a huge infusion of public money and improvements in the management of public hospitals. The cure has not come from more private money or private insurance.

And countries like France that appear to have a large private sector actually heavily regulate doctors who work privately ñ including the price they can charge and the amount of time they can spend treating private patients. So what looks on the surface to be "private" is not really: it's quasi-public because of such heavy regulation.

So we could follow the European route ñ and heavily regulate doctors who "go private" ñ or we can stick with the cleaner and simpler approach of requiring doctors who are paid by public medicare to be paid only by medicare but still allow doctors to "go private" if they are prepared to work completely within the private payment sector.

But we have to recognize that even with European-style regulation we would be embracing the idea that it's fine for folks with more money to jump queues and get preferential treatment from doctors.

This is in direct opposition to the principle of equity that has historically guided the Canadian medicare system, which was created in part to eliminate distinctions between the rich and poor in access to medically necessary health-care

Canada's health-care system needs reform ñ but reform based on the best available evidence and guided by Canadian values. On the issue of waiting times, for example, the Institute of Health Services and Policy Research ñ part of the Canadian Institutes of Health Research ñ funded research that helped establish the first-ever national benchmarks for waiting times in December 2005. CIHR-IHSPR is committed to providing evidence-based solutions that will improve the health-care system. Let us not make the mistake of misusing the wealth of evidence that strongly supports a public health-care system like Canadian medicare.