Canadian Medical Association Journal 1995; 153: 453-455
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What does the Canada Health Act mean when it stipulates that medicare must be "comprehensive"? The term obviously includes procedures such as vaccinations, emergency surgery, cancer treatment or hernia repairs, but how about ultrasound in a normal pregnancy? Or hip replacement? Or breast reduction? Or a magnetic-resonance-imaging test for a vague headache? Or a reassuring visit to the pediatrician when a youngster has a high temperature and a runny nose?
Canadians may learn the answer to these questions over the coming months, as federal and provincial health ministers negotiate which services must be insured by all provinces. Diane Marleau, the federal health minister, agreed in April to initiate a debate about what the term "medically necessary health services" means. However, few observers expect a quick answer, as Ottawa tip-toes into the area. Marleau faces the challenge of maintaining the federal government's moral authority without risking a damaging confrontation with provinces like Alberta and Quebec.
The issue is about more than legal definitions because it reflects expectations -- the type of health service Canadians want. And if there is one thing politicians have learned in the past couple of years, it is that the centre of gravity in Canadian politics is shifting steadily rightward. Citizens may continue to express undying support for medicare as an "untouchable" public good, but they are less and less willing to pay for it through taxes. As David Peterson, the former Ontario premier, said at a recent conference: "This debate is not about the logic of different proposals. It's about philosophy."
The logic of the current crisis, however, is unassailable. Trouble began when Ottawa started to cut its share of the medicare budget, from 50% of the total in 1977 to about 22% now. Thanks to the February budget, it will further erode by $5.3 billion during the next 3 years. At the present rate of decline, Ottawa's cash transfers to the provinces for health care will reach zero by 2010.
At the same time, rising health care costs in a stagnant economy have driven health care spending from 8.7% of the gross domestic product a decade ago to about 10% today. (Japan, with one of the healthiest populations in the world, spends less than 7%.) Prime Minister Jean Chrétien has mused aloud about cutting that figure to 9%. However, he is in no position to cut costs himself, since health care delivery is a provincial responsibility. So 10 provinces and 2 territories are all looking ways to cut costs, bring new money into the system and maintain services.
Chrétien's musings aside, Ottawa has provided no leadership on this issue. For her part, Marleau has been busy mouthing bromides about the preservation of medicare and defending herself from attacks in the media. So we have a federal government that says it is committed to medicare but is unwilling to enter a debate, and it is facing an increasingly strident lobby that wants to see a parallel private health care system develop. The Privatization Now group is led by Alberta Premier Ralph Klein, but his fellow Conservative, Ontario Premier Mike Harris, is likely to take the same road. Most provinces, particularly those in the east and those with New Democrat governments, endorse the survival of a public health care system, but would be happy to see more nonessential services provided on a user-pay basis.
The main argument for allowing a private sector to flourish is that it will take pressure off the public system. Waiting lists will be reduced as those who can afford to pay for services buy them at private clinics. The efficiencies of entrepreneur-run clinics will be models for the public sector to follow.
In addition, libertarians argue that people should be allowed to pay for their own medical care if they want to, just as they can buy private education or housing. If someone wants to spend money this way to bypass a waiting list, what right does the government have to stop them? Plenty of wealthy Canadians already fly to the U.S. for instant health care. Why not keep those dollars in Canada?
The final debating point for the pro-privatize crowd is that Canadians kid themselves when they talk about universal health care as something crucial to the Canadian identity. First, we already have a two-tier system. Tax dollars only cover 72% of health care costs; the rest of the money is spent on services like dentistry, chronic care, private hospital beds and drug costs that are paid by individuals or workers' compensation boards or through private insurance.
Second, the role medicare plays in our national mythology may have been overstated. "Socialist health care [is not] integral to the Canadian identity," historian Michael Bliss wrote recently. "For a century after Confederation we built a prosperous, free, humane and well-governed society and did our share in the wars of this century, all without universal health insurance." Medicare, argues Bliss, is "no more Canadian than kippered herring or borscht."
Armed with these arguments, Alberta's Klein is putting all kinds of pressure on Ottawa. He has allowed clinics that not only charge user fees but also receive payments through the provincial health plan to flourish. The well-known Gimbel clinic is only 1 of 20 similar entrepreneurial enterprises. For a cataract operation, the Gimbel Eye Centre in Calgary receives $500 from the province and charges each patient a "facility fee" of $1275.
Klein has also proposed selling abandoned hospitals to private groups that would treat rich Americans and Canadians. He contends that there are at least 100 medical services that need not be covered by provinces any longer and should be available on a user-pay basis. He has taken up the demand that the Reform Party has been making for a couple of years: Ottawa has to define "core services" that must be provided under the Canada Health Act, and allow provinces to decide how anything else is provided.
People opposed to private-sector involvement argue that establishment of a parallel private system is not the way to ease the cost squeeze in the public system. Members of Chrétien's National Forum on Health, for example, think that "our $72 billion health system ($52 billion publicly funded, $20 billion private) is big enough." Steven Lewis, chief executive officer with the Health Services Utilization and Research Commission for Saskatchewan and a member of the forum, says that "the principles of our system remain sound . . . [but] we have not achieved all the efficiencies that research suggests are possible." In other words, we don't need new money in the system -- we just need better management.
Several new studies support the contention that huge improvements in efficiency are possible. Sustainable Health Care for Canada, for example, is a study initiated by the Economic Council of Canada. It determined that, using conservative estimates and allowing for transition costs, spending on the health care system could be reduced by 15%, or $7 billion. (Coincidentally, Ottawa reduced federal transfers to the provinces by this amount in its 1995 budget.) The researchers who did the study say these savings could be achieved without adversely affecting the nation's health by substituting less costly types of delivery and forms of treatment in more appropriate settings.
Smaller-scale studies reach the same conclusions. In the Emergency Department of Ottawa Civic Hospital, for instance, tighter rules for dealing with injured ankles reduced the number of "routine" x-rays by 30%. Similar protocols are being established in medical centres across Canada to reduce profligate use of resources.
One of the strongest "save medicare" voices belongs to Robert Evans, a professor of economics at the University of British Columbia who is adamant that privatization would destroy the public health care system. "Two-tier medicine would benefit some Canadians," he says. "That's why they want it -- they always have. An 'upper tier' where the wealthy pay privately for preferred access to publicly insured services would definitely be good for bank presidents and their doctors. Overall, our system would be less equitable, more costly and less efficient. Most of us would lose."
The current pressure on health care spending means that hospital employees are losing their jobs and physicians are seeing their incomes drop. "So they tell us," says Evans, "that our health will suffer unless the money keeps coming." But the reverse is the truth. Once the wealthy are funnelled off into private facilities, there will be less public pressure to keep up quality in the public sector. Alberta's private Gimbel eye clinic is noted for its efficiencies, but one never hears about the backwardness of Alberta hospitals in adopting similar techniques.
The debate on the future of medicare will accelerate over the summer, as Alberta and Ottawa prepare for a crucial federal-provincial health ministers' meeting on Oct. 15. Health Minister Marleau had given Alberta until then to stop funding private clinics that also charge facility fees. If Alberta refuses to comply, its transfer payments from Ottawa will be cut. She has the backing of the prime minister, who recently told an Alberta audience that "there cannot be a two-tier system in Canada. . . . We will not give more flexibility to one province -- why more to Alberta than to the others? If we have a law that applies to Canadians across the land, it has to apply to Albertans like it's applying to the people of Nova Scotia."
Marleau has also announced that she is not prepared to consider a list of officially sanctioned "core services" as demanded by Alberta and requested by General Council during the CMA's annual meeting last year. In fact, the CMA is already hard at work developing its own list. "What's absolutely essential for one person may not be absolutely essential for the other one," says Marleau.
Tub-thumping political rhetoric. But there are aspects of this dangerous game of brinkmanship that must cause the Prime Minister's Office serious concern. Although popular support for medicare remains as high as ever, significant sectors of the population are leaning toward allowing controlled growth of a private market. A poll of physicians by the Angus Reid Group that was conducted for the CMA revealed that 78% of respondents believe it would be acceptable to charge user fees, or charge patients or their private insurance companies to compensate for shrinking government transfers. And 84% wanted a definition of "core services."
Moreover, there are interesting demographic variations in the general public's view of what is happening to health care. A small 1994 poll conducted by Compas on the public's attitude toward user fees and privatization suggested that, when forced to choose, respondents over age 55 preferred user fees. Those under 35 years, however, were more prepared to consider the growth of private services. Compas concluded: "The oldest cohort may be more attached than the youngest to 'socialized medicine' and may see user fees as a way of changing our present health care system the least." Younger Canadians are more open to the idea of a two-tier system.
For a political party already planning to capture the next generation of voters, and unsettled by the success of Privatize Now politicians like Ralph Klein and Mike Harris, that is a significant trend indeed.