the great debate

Recent news from Quebec reminded me that it's been a long time since we talked about health care. Wmtc readership has changed a lot since the last time I blogged about it, so I think it's time to re-open this can of worms.

Last June, when the Canadian Supreme Court ruled that Quebeckers could purchase private health insurance, I was confused by some of the strong reaction - and strange interpretations - to the ruling. I asked for readers' help, and a discussion ensued (a little more here).

Now Quebec has issued its response to the ruling.

The Quebec government promised yesterday to provide hip and knee replacements and cataract surgery within six months of a patient's diagnosis and said it would pay for the procedures to be done at private clinics if necessary.

This would make Quebec the first province to guarantee access to certain health procedures and would open the door to a greater role for private health care in Quebec.

"We're putting the private sector to work for the public," Premier Jean Charest said at a news conference. "What we are announcing today is a new era in the delivery of health and social services for the population of Quebec -- a new era of guaranteed access to care."

The proposals are the government's formal response to a Supreme Court of Canada ruling in June that Quebeckers should be allowed to buy private medical insurance if basic medical care is not provided in a timely fashion. The province was given one year to speed up care or lift the ban on private insurance, a move that would have led to parallel systems of private and government-funded health care.

"We chose to maintain the principles of the public health-care system within which the private sector can play a role," Mr. Charest said, adding that Quebec could serve as a model for the rest of the country. "Other Canadians may choose to go down that route."

Under the proposals, the government promises to provide cataract, hip and knee surgery within six months of the day a specialist recommends the operation. If government-funded hospitals cannot perform the procedure within that time, the government will pay to have it done at certified private clinics affiliated with a hospital.

If the operation cannot be done anywhere in Quebec within nine months, the government will pay to send the patient outside the province, including to the United States.

For many Canadians, the mere mention of the world "private" in the health care debate brings cries of "They're privatizing the system!", or worse, "They're Americanizing it!". To me, this seems short-sighted (not to mention ignorant of what "Americanizing" would mean).

I understand the arguments about a slippery slope - that any introduction of private health care into the public system can be a wedge to drive in more and more, until the system falls apart. But fear of that slope also amounts to fear of change. And change may be necessary. It usually is. If we know what we want to guard against - that is, if we know our priorities - we should be able to avoid the pitfalls.

All countries with national health insurance have a mix of private and public delivery. According to all sources I read, most other countries (the UK, Australia, New Zealand, France, Israel) have a more balanced picture, with a greater percentage of private care in the mix. Yet those countries maintain their public health system, and, to my knowledge, have not been accused of "Americanizing" health care.

If a Canadian wants to shell out her own money for an MRI, or purchase private insurance to fund a hip replacement sooner, then they're no longer waiting, and the queue moves more quickly for those who don't want to or can't afford to do that. And how can a government tell people they can't spend their own money on their own health?

To fears of siphoning off the best doctors into the private sector, leaving the public sector with the dregs, I say, make sure that doesn't happen. One can easily imagine mechanisms to guard against that, such as requiring doctors spend a certain percentage of their time working in the public sector, or some similar means.

Maintaining national health insurance is clearly a top priority for Canadians, as well it should be. And most people agree the system, while an excellent one, needs some improvements. Improvements mean change. Yet say the word change, and people panic.

I find myself out of step with leftist thinking on this one. I'm very interested in hearing your thoughts.

Late addition: This op-ed by two Senators in today's Globe And Mail makes a good case for more solutions like the one proposed in Quebec.

A care guarantee to count on

by Michael Kirby and Wilbert Keon

The myth that the Canada Health Act requires health-care services to be publicly delivered -- not just publicly funded -- is finally dead.

As a result, Canada is on the verge of a truly constructive health debate that holds promise for real progress on what concerns Canadians most -- ensuring they have timely access to quality care when they need it.

This myth, combined with unwarranted fears about an imminent slide into a U.S.-style health-care system, has kept important policy options off the table for far too long.

Roy Romanow perpetuated the myth when he declared that health-care delivery is a "moral enterprise." There is no doubt Canadians cherish their publicly funded single-payer system because it ensures access to health care based on need, not ability to pay. But there is no moral imperative that this care be delivered exclusively by a publicly owned provider.

Beginning with the October 2002 health-care report by the standing Senate committee on social affairs, science and technology, several events have helped dispel the myth. The most important of these was the Supreme Court of Canada's decision last June in the Chaoulli case.

The focus of that case was not the phony issue of who delivers services, but rather the very real one of whether or not Canadians have the right to timely access to the care they need, regardless of the provider -- public or private, for-profit or not-for-profit.

The Supreme Court clearly set out the choices confronting Canadians.

Governments must either live up to their end of the medicare bargain and deliver timely access to care, or they must allow individual Canadians to purchase the medically necessary care they need for themselves. To do otherwise leads to violations of Charter rights that guarantee the security of the person.

In recent weeks, the governments of Alberta, British Columbia and Quebec have all indicated that they recognize their obligation to provide timely service. The health-care discussion paper released last week by the Quebec government is particularly encouraging to us as it embraces precisely the same solution -- a health-care guarantee of timely service -- that the Senate committee recommended in 2002. The care guarantee was also advocated by the Conservative Party in the recent federal election.

A care guarantee ensures that people receive the care they need within evidence-based, clinically determined wait times. It thus prevents two undesirable outcomes. ...

Senator Michael Kirby was the chair of the standing Senate committee on social affairs, science and technology when it released "The Health of Canadians: Recommendations for Reform, in 2002"; Senator Wilbert Keon, a physician, was a member of the committee.

Read more here.