Trevor Hancock is a professor and senior scholar at the University of Victoria’s school of public health and social policy
Our health care system is not the only, and not even the most important determinant of the health of the population. But it is a determinant, and thus any threat to the proper functioning of the system is a threat to health. One such threat is the court case that started this week in the BC Supreme Court, in which Dr. Brian Day and others are seeking to overturn some of the fundamental principles on which the system is based.
Day co-founded the Cambie Surgery Centre in Vancouver in 1996; in essence it’s a private hospital with a number of operating rooms, offering a wide range of surgical procedures. There is nothing wrong in principle with a private hospital. Most Canadians don’t seem to realise this, but much of our care is provided through privately-owned clinics – that is what your doctor’s office is.
So while the average gross clinical payment per physician was $339,000 in 2014-15, that includes the overhead cost of running their practice – rent or mortgage, equipment, staff salaries and benefits, insurance, as well as their own pensions and educational debts: On average it amounts to a quarter of their gross income.
But they are not allowed to pass those costs on to you. As the 2012 provincial government audit of the Cambie Surgery Centre makes clear, BC’s Medicare Protection Act, with certain exceptions, “prohibits medical practitioners from extra billing beneficiaries for a benefit, or for materials, consultations, procedures, facility use, or for any other matters that relate to the rendering of a benefit”. (A beneficiary is a person covered by Medicare, a benefit is any service that is covered.)
The audit found “significant evidence to indicate extra billing had occurred . . . on a frequent and recurring basis, contrary to the Act”, that “the extra billing would often overlap with physician claims of MSP” and that “charges to beneficiaries for benefits rendered. . . exceeded the value of what the beneficiary could claim from MSP”. (Day might dispute some of these findings.)
Day’s response has been to bring a suit against the province claiming that it is unconstitutional to prevent a doctor charging patients more than MSP allows, to ban private insurance for medically necessary care, and to prevent doctors working in both the public and private system.
If he wins, then as Prof. Colleen Flood (who holds a university research chair in health law and policy at the University of Ottawa) noted in the Globe and Mail in April 2015: “Foundational pillars of Canadian medicare — equitable access and preventing two-tier care — could well be vanquished in the process.”
Her views are reinforced by the expert report the federal government is using to support its intervention in the case. The expert is Dr. John Frank, first Scientific Director of the Institute of Population and Public Health (part of the Canadian Institutes of Health Research) and now a Professor of Public Health Research and Policy at the University of Edinburgh. According to an August 29th CBC News report, he writes that “in my expert opinion,” more private health care would reduce fairness and efficiency and “society as a whole would be worse off.”
If Day and his supporters win, we would have a system where those with money or a private or employer-provided benefits package would do fine, the rest would not, much as is the case for dental care. What does that look like? Well, in 2007-9, 32 percent of Canadians had no dental insurance at all, and that increased to 50 percent among lower-income Canadians. Those without private insurance would all rely on public insurance in a 2-tier system. Is this really what we want our entire health care system to look like?
So there is a lot at stake in this trial. Whoever wins — and I profoundly hope it is not Day — this will almost certainly end up at the Supreme Court of Canada. If ultimately the latter should rule in favour of Day, I can think of no better example of a situation where governments across Canada should invoke the “notwithstanding” clause of the Constitution to protect our health-care system. The public interest far outweighs the private pursuit of profit.
Editor’s note: This blog was originally published as a regular column in the Times Colonist
What you have laid out are the battle lines of a new century debate. We are called upon to assess our experience from the last six decades of applied social democratic theory, and hopefully, to project future policy which will allow us to improve upon that experience.
In order to avoid hyper-partisan response in this forum, allow me to discuss these issues with reference, not to Health Care, but to that other crown jewel of our Canadian system, Public Education.
No one would pretend, I hope, that we do not already have a two tier reality, merely obfuscated in the pretense of a universal system. People with real money buy for their children the very best of international education. What is at stake, is the emergence of a third tier — a sort of educational middle class — which is to say, those of modest means who are not capable of buying purely private education. These people have already paid taxes, both to send their own children to school and to provide the same service for that half of the population which can not contribute in proportion to their utilization of benefits. What these people would like, is to have discretionary access to an amount equivalent to the average spent on all children ; to add something more to that amount ; and hence to be able to buy a superior education.
To complicate things, somewhere along the way, it was suggested with excellent analysis in support, that independent schools responding directly to market demand could provide that better education using only the allocations per child currently provided to public schools. In other words, not only could the middle class create superior schools, but the poorer students also, could buy something better (and with the same money), in such a choice-based voucher system.
The main point in contention, is not whether the state should provide access to quality education for all children. Obviously. But is it the bureaucratic duty to actually produce that service – to build and maintain schools, to pay salaries, to hire and fire –or should it not more rationally provide resources (money) to the citizen consumer who would have the opportunity to maximize it’s benefit, and yes, even to add to it from his own pocket ?
(Even if we admit the existence of an incompetent fraction unable to manage its own affairs, the most reasonable course is to create an exceptional vehicle for their protection, rather than an inefficient system treating the entire population as incompetent.)
This is a deep and serious debate ; it will not be solved with a court case or two ; and there is nothing obvious about either the values involved or the benefits of circling the ideological wagons. What was done with sincere enthusiasm sixty years ago should not now be treated as though permanently carved in stone. Economic Theory, just as Medical Science, has moved a considerable distance since the days of Tommy Douglas.
Feel the Love,
Gordon Friesen, Montreal