abortion, privatization and health care in quebec

From the Globe and Mail, August 13.

We need fewer barriers to abortion, not more
By Andre Picard

In recent days, a number of private clinics in Quebec – including the legendary Morgentaler clinic – have said they will stop performing abortions.

That access to abortion should be threatened, after decades of battles in the courts, is a shocking development.

It is also a reminder that the battle for reproductive rights is never done because there are a cruelly endless number of ways to undermine access. Prince Edward Island still offers no abortion services at all. New Brunswick requires referrals from two doctors. Women in rural areas of the country often have to travel hundreds of kilometres for care. Some provinces cover only the cost of abortions performed in hospitals, creating a financial barrier.

In the case of Quebec, the private clinics are reacting to provisions contained in Bill 34, sweeping new legislation whose scope and importance has largely been overlooked outside Quebec.

The new law dramatically expands the number and type of surgical procedures that can be contracted out from hospitals to centres médicaux spécialisés (specialized clinics) – to 56 from three. In addition to hip and knee replacements and cataracts, private clinics will be able to do a wide range of procedures, including mastectomies, hysterectomies and bariatric surgery.

There are, quite appropriately, new oversight measures that will be implemented to ensure these operations are done safely. These include having sterile operating rooms.

There were 96,815 abortions performed in Canada in 2005, the last year for which data are available from Statistics Canada.

Abortions are not done in hospital-like operating rooms. The instruments used are sterile, but the procedure, as with other minor surgery, can be done in a physician's office. Even when abortions are performed in hospitals, they are not done in the operating room; they are done in what is essentially an exam room.

Building a sterile operating room is costly, too costly for the Morgentaler clinic, Fémina and Alternative, the three Montreal clinics that have said publicly they will stop offering abortions if the rules remain. About one-third of the 30,000 abortions performed in Quebec each year are done in private clinics.

The good news is that Quebec Health Minister Yves Bolduc, after initially defending the rules, now appears ready to back down, creating an exemption for abortion clinics so that the status quo remains.

One can only puzzle at why it came to this. But then again, there is nothing quite as strange in this country as Quebec's health politics.

Conspiracy theorists will say that the provincial government was trying to pull a fast one, to limit access to abortion using a back-handed method. A more likely explanation is that Mr. Bolduc got horrible advice from bureaucrats who drafted the regulations, and even worse advice from his political advisers when he tried to defend the indefensible.

Nonetheless, the flip-flopping provided another opportunity for Gaétan Barrette, president of the Quebec Federation of Medical Specialists, to take a few pot shots at the minister.

He called Mr. Bolduc a liar (for saying he was following the advice of doctors in implementing new rules for abortion clinics), and an incompetent, and called for the minister's resignation.

The unfortunate thing is that, amid the insults and confusion about the state of abortion services in the province, there was little real discussion about the role of private clinics in our health system.

Under medicare, the state-financed health insurance program, health care delivery is largely publicly administered. But the services themselves are provided by a mixture of non-profit institutions (hospitals), private providers (physicians) and, increasingly, for-profit providers (stand-alone surgical and diagnostic imaging centres).

With Bill 34, Quebec has gone further than any other province in what is essentially the contracting out of medically necessary care to the private sector.

It remains to be seen what benefits this will provide, but the public-private split is not as black and white as it is often made out to be in political debates.

There is ample evidence that specialization results in better outcomes, from cost-efficiency through to fewer medical errors. But, at the same time, when relatively easy, profitable procedures are contracted out to the private sector, it gives the mistaken impression that public institutions are less efficient.

Abortion clinics are a perfect example of private clinics providing excellent and necessary service. Too often, women who sought abortions in the public system were faced with long waits, lack of privacy and unacceptably moralistic and cumbersome rules.

What private clinics should not do, however, is create a financial barrier. In Quebec, medicare pays for abortions regardless of where they are performed, and it will do so with other procedures as well.

What is essential, though, is having appropriate standards so that the quality of care is as good in private surgical clinics as in hospitals.

With abortion clinics, Quebec imposed regulations that were unnecessary and that created a new barrier to care.

That problem seems to have been resolved, although messily. What is not clear yet is if there will be similar problems with some of the other 55 procedures. In particular, clinics that do biopsies for breast cancer may balk at the regulations, and that would bounce that service back to hospitals.

As it is in the provision of most health care services, the challenge is getting the balance right.