Canadian Medical Association Journal 1995; 153: 801-803
[résumé]
A resolution supporting private health insurance may indeed have been the place "where the rubber meets the road," as one physician attending the CMA's August annual meeting stated, but General Council has decided to apply the brakes, at least temporarily, because it wants to discuss with Canadians where the road might lead.
After 3 days of intense debate, council defeated a motion that would have put the CMA stamp of approval on the creation of a private health care system that would operate parallel to the existing public system. The motion, which said all Canadians "must have the right to choose regulated private insurance for all medical services," was defeated by a margin of 20 votes, 88-68. Instead, General Council voted unanimously to lead a national public debate on the advisability of introducing private insurance for all medical services.
Many physicians thought the decision was wise. "This is our opportunity to lead the debate, but not to look like we're in the vanguard of the movement trying to destroy the national system," said Dr. Robert Kimball, past president of the Medical Society of Nova Scotia, who moved the successful motion to lead a national debate.
The decision to move more slowly on the issue appeared to have been accepted with equanimity by proponents of private insurance. "I'll accept the judgement of my peers and work hard to debate the issues," said Dr. Victor Dirnfeld, president of the British Columbia Medical Association (BCMA).
Dr. Bruno L'Heureux, who retired as CMA president during the meeting, compared the decision with the ones physicians make in their practices. "You have to inform the patient and then together you decide what to do," he said in an interview. "Today General Council decided it had to talk to the patient -- the Canadian people -- before it makes a decision." He said the relatively close vote means that doctors want to support medicare "but if government support is not there, we will have to consider alternatives."
"All we were saying is that we wanted to look at this more closely," added Dr. Jack Armstrong, the Winnipeg pediatrician who assumed the presidency during the Aug. 14-16 meeting in his home city. He described the upcoming debate as "some preventive care" for the health care system.
Although the private-insurance motion was defeated, the CMA did pass 16 resolutions on the values, funding and management of the health care system; they now form the core building blocks for its "Blueprint for Action" for protecting and enhancing the existing system. (All 16 resolutions appear in the accompanying issue of CMA News.)
The unprecedented decision to make the future of health care the theme of the annual meeting, and to create the resulting blueprint, had its roots in the federal government's February budget. At meetings in May and June, the Board of Directors decided that if Ottawa was spelling out reasons for its decision to reduce federal funding for health care, the CMA should spell out its views on which directions the health care system should take. It decided to do this via a series of draft statements that, after being debated and amended by the more than 200 members of General Council, would form the Blueprint for Action.
Although 18 resolutions were eventually put to a vote -- two were defeated -- the most controversial concerned private insurance. A statement that all Canadians must have the right to obtain regulated private insurance for noncore (noninsured) services passed quickly. However, the motion to support private insurance for all medical services -- essentially to introduce a second tier of health care -- led to long lineups at all microphones. One notable result was the strong stand several CMA affiliated societies took against the motion.
"We all feel that the house is burning," said Dr. Jean-Pierre Despins, president of the College of Family Physicians of Canada, "and that leaves us with two choices: to leave and rebuild across the street, or to find a way to extinguish the fire." He said his college wanted to extinguish the fire, and save the existing system.
"The young doctors of Canada strongly support the Canada Health Act," added Dr. James Tam of the Canadian Association of Internes and Residents, another affiliate. "We are strongly against this motion."
Dr. Victor Marchessault, executive vice-president of the Canadian Paediatric Society, said the society was against the resolution because the "first to suffer will be the children of Canada."
However, there were also strong voices among the proponents. Dirnfeld said it is "an elitist myth" that only the rich will benefit from widely available private insurance. And Dr. Killian de Blacam of Sudbury, Ont., who described the meeting as "an excellent and well-run conference," said the motion simply stated the obvious: "The Canada Health Act is full of holes. This may be a controversial motion, but it is just a statement of what currently exists."
He was supported by Dr. Derryck Smith of Vancouver, who said a de facto two-tier system already exists because Canadians are spending $1 billion annually buying health care in the US -- a fact that costs Canada many jobs.
The debate on the final set of resolutions was well framed by a series of speakers representing all perspectives. Dr. Ruth Collins-Nakai, a past president of the Alberta Medical Association, probably presented the most stirring defence of the existing system. "Who would benefit from increasing privatization?" she asked. "Those who could afford private health care, and those who provide it, including doctors and insurance companies. But, the majority of people could not afford private care, and they are the vast majority requiring the most care.
"So, the minority of patients, the wealthy, would pay for more choice, and the majority of patients would receive less choice and less quality in the public system as the private system gradually skimmed the best physicians, equipment, facilities and other health care providers to work within the private system."
She was countered by Dr. Ed Coffey, immediate past president of the Quebec Medical Association, who described the existing system as "intellectually bankrupt." During the years "of our booming free-enterprise economy, when inflated tax revenues were pouring in, the governments of Canada and the provinces indulged in the luxury of heavy spending and borrowing to finance their socialized sectors of the economy, such as health care. Now, with our depressed economy and a looming debt crisis, there is wide agreement that Canada's model of health insurance is no longer sustainable."
The difficulty of the decision facing General Council was readily apparent within the CMA Executive Committee, which split its vote. Armstrong, L'Heureux and Dr. Colin McMillan, the board chair, all voted against unlimited private insurance; Honorary Treasurer Michael Thoburn, Past President Richard Kennedy and Dr. Drew Young all voted in favour.
Dr. Hedy Fry, parliamentary assistant to the federal minister of health, smiled when asked if the CMA had made the right decision.
"Let me just say that I think the public would have looked very differently at physicians if this had passed," said Fry, past president of the BCMA. "What the CMA has done is given itself room to manoeuvre -- it has opened up a way to discuss these issues."
The Globe and Mail also looked kindly on the decision. "With aid and expertise of the CMA, provincial governments should be able to decide where to draw lines," its lead editorial said on Aug. 17. "If the medical system is to stay healthy, they must."
There was also irony in the debate. In 1967, when medicare was in its infancy, a worried Dr. Joseph McMillan told a CMA meeting (Can Med Assoc J 97: 1513-1517) that he was concerned because "after 25 years of watching the evolution of medical care . . . [doctors are] not interested in the economics of health care."
Twenty-eight years later his son, Colin, told members of General Council that their 1995 annual meeting would concentrate on the future of the health care system, and particularly on changes that might be needed because of the country's economic problems. The debate about that future, he told a news conference, "starts today."
General Council also found time to debate many other issues during the meeting:
However, Dr. Killian de Blacam said the CMA should be congratulated for its policy and should keep it. If it is not active politically and fails to make contributions to parties, he said, "we're not even in the game." Dr. Albert Schumacher of Tecumseh, Ont., agreed, saying that the CMA is only trying to pursue programs that are already in place in its Ontario and British Columbia divisions.