Thursday, August 12, 2004

Two-tier medecine isn't the answer

by Colleen M. Flood

This commentary was first published in the Natinal Post on June 21, 2004

Last week, the Supreme Court of Canada heard a case that could overturn medicare. Quebec doctor Jacques Chaoulli and his patient, George Zeliotis, claim their Charter rights have been violated by a Quebec law prohibiting the sale of private insurance for medically necessary hospital and physician services. They want this law, and similar laws in other provinces, overturned. They want a flourishing private market for health care: a two-tier system where doctors can work in the public sector and top up their incomes in the private sector; and a system where people with private insurance or their own private means can jump queues in public hospitals.

By contrast, arguments for one-tier medicare are often advanced on the grounds of equity; that it is wrong for a rich person with cancer to get a higher standard of treatment than a poor person with cancer. Health care is, after all, the one great leveller. Serious disease can tear families apart, but at least with public insurance it will not destroy them financially.

Advocates of two-tier often contend all Canadians would be better off since those with private resources would no longer burden the public sector and waiting lists would fall. The trouble with this argument, appealing as it may intuitively seem, is that there is no evidence to support it. Countries such as the U.K. and New Zealand, which allow people to buy faster, high-quality hospital and physician services in the private sector, have much longer waiting lists than in Canada. In the U.K. and New Zealand, just under 10% and 35% of the populations, respectively, have private insurance. Everybody else has to put up with long waiting lists in the public sector. And the private sector doesn't do the tough stuff; it doesn't provide the cancer care and the cardiac treatments. It does the easy, high-volume procedures.

Why don't waiting lists fall when people are allowed to buy private insurance? First, there are only a limited number of doctors. If specialists shift their efforts and energies to the private sector to do high-volume procedures such as knee operations, then they have less energy and time for public knees (or hearts, or cancers, etc.) And because it takes a goodly number of public dollars to train doctors (as well as many years), this is not a problem that one can assume the market will respond to. Second, of course, the well-to-do and the well-insured will not continue to lobby governments for improvements in health care. With the political incentive diminished, the public system will wither and waiting lists will grow. Third and finally, in order for the private tier to succeed, the public tier must be second-rate. Otherwise why would anyone purchase care privately?"

Advocates of private insurance often point out that Canada is alone in not allowing private funding for hospital and physician services. But in fact, the public-private distinction is blurred in many countries with enormous tax and public subsidies shoring up the private insurance system and laws trying to prevent private insurers doing what their natural inclination is to do -- avoid risk. Private insurers make money by avoiding risk and thus even being wealthy doesn't assure you of coverage. Ironically, the fact that you need health care, because you have cancer, will mean you can't get private insurance. Even in the United States, they had to bring in medicare for the over 65s -- largely because many of the elderly couldn't get private insurance; they were risk-rated out.

Several groups appearing before the Supreme Court are arguing for a middle ground. These groups include the Canadian Medical Association (CMA) and a number of senators, led by Senator Michael Kirby, who was the chairman of the Senate committee that released a report on medicare in October, 2002. They agree with Messrs. Chaoulli and Zelotis that those laws prohibiting the sale of private insurance breach the Charter unless the Quebec provincial government guarantees timely treatment to its citizens. If the Quebec government does not do this, it must allow its citizens the opportunity to purchase private insurance.

The senators and the CMA appear to be taking the middle ground, but behind their moderate stance is a serious attack on universal access. There is no assurance if they are successful that Quebec or any province will put in place waiting-time guarantees. Alberta and British Columbia may embrace the notion of two-tier and welcome its imposition by the Supreme Court. In pursuit of a policy goal of waiting-time guarantees, both the Senate and the CMA are willing to sacrifice universal health care from coast to coast.

The Chaoulli case (and crumbling political support) has been a wake-up call to the incumbent federal government to do something about waiting times, and that is a good thing. The lesson from examining other jurisdictions is that where there is a political will to do something about timeliness, waiting times can be tackled and lowered. More money is not necessarily needed, but better management is undoubtedly part of the solution. Canadians shouldn't give up on medicare and should rest assured that all health care systems struggle with waiting-time issues. The only country that doesn't is the United States, but it leaves 44 million people uninsured, and these people can only dream of getting on to a waiting list.

People who say private insurance is good say that public waiting lists will diminish if Canadians can purchase private insurance. They are wrong. For most Canadians, a two-tier system will mean an era of more, not less, waiting. When thinking about the pros and cons of two-tier medicare, ask yourself this question: How would your grandmother fare? Could she afford private insurance and would she qualify? Like democracy, our one-tier health care system may indeed be the worst kind of system -- except for all the others.