Charlotte Gray is a CMAJ contributing editor.
Canadian Medical Association Journal 1995; 153: 1143-1145
[résumé]
For those of us who weren't in Winnipeg in August, it was hard to tell exactly what was going on at the CMA's annual meeting. At first, press reports implied that the CMA was close to endorsing a two-tier system of health care. The next day, the CMA's commitment to the preservation of medicare made the headlines.
The news release circulated after the meeting triggered more head-scratching. On the one hand, media were told that delegates voted for a ban on "private insurance for medical services." On the other hand, the resolutions passed included one that stated Canadians must have the right to obtain "regulated private insurance for noncore medical services."
So in which direction is the CMA moving? An official answer will not appear for some months, but in the meantime the association has its marching orders from General Council: it is to "lead a national public debate on the advisability of regulated private insurance for all medical services."
Unofficially, however, the emergence of a group of vocal physicians from medicine's right wing is obvious. Sure, a motion declaring that Canadians should have the right to choose regulated private insurance for all medical services was voted down. But with a margin of victory of only 20 votes, 88 to 68, it was a skin-of-the-teeth defeat for doctors who favour a blend of public and private health care.
"I was encouraged that we got 44% of the vote," says Dr. Ed Coffey, immediate past president of the Quebec Medical Association and a strong proponent of a free market in health care services. "If I hadn't been so busy doing media interviews and talk radio shows that I couldn't work the floor, I reckon we might have got the votes we needed."
The mood was triumphant among those who want to see a parallel private health care system blossom, as has already happened in the United Kingdom. Dr. Killian de Blacam, a physician from Sudbury, Ont., whose criticisms of publicly funded health care systems quickly veer into more general attacks on interventionist government, says the profession is finally waking up. "General Council is at last prepared to discuss the issues on a level playing field," he says. "The left-wing health economists, stuck in their academic institutions, have had the field to themselves for too long."
De Blacam is adamant that "the Canada Health Act is meaningless. The only solution is a parallel, nongovernment-run system. I don't want a doctor who's a civil servant treating me; I wouldn't trust him."
Many delegates at the Winnipeg meeting were wary of the views expressed by Coffey and de Blacam. Dr. Robert Woollard, associate head of the University of British Columbia's Department of Family Practice and chair of the CMA's Council on Medical Education, says General Council's animated debate doesn't mean that medicine, and the CMA, is lurching to the right. Instead, he suggests, it reflects the profession's frustration at the way governments are excluding physicians from decisions about health care delivery. "I was very relieved that we did not push the CMA toward making its priority the destruction of medicare rather than protection of our patients."
Woollard acknowledges that the anger with governments that physicians expressed in Winnipeg parallels the current populist mood across Canada -- "the whole Newt Gingrich, angry-white-male thing, and let's face it, medicine is still largely a white-male profession." But it is a huge jump in logic, he argues, to translate widespread, legitimate anger into substantial support for a private parallel system of health care. The consensus that emerged from the Winnipeg meeting is that the status quo is untenable. Some delegates were motivated by the principle of professional autonomy, while others had a public-policy perspective and still others were driven by outrage at what is happening to physician incomes. Coffey agrees that most Winnipeg delegates were very comfortable with the compromise resolution, which asked the CMA to take a leadership role.
"As a profession we're timidly approaching the bonfire," he suggests. "But we're finally engaging the political issue: the question of who will control the new health care system that is inevitably going to emerge."
In the weeks since Winnipeg, senior CMA staff have been brainstorming with a variety of the association's councils and committees, seeking ideas on how the organization might assume its mandated "leadership role." A politically neutral forum, in which the issues can be thrashed out without a lot of political rhetoric, is one option being considered -- a forum at which the CMA, along with organizations respresenting other health care professionals, would meet with representatives of the public and private sectors. "Lots of people are busy raising the issues relating to the public and private mix in the system these days," says Dr. Colin McMillan, chair of the CMA Board of Directors, "but very few people with experience of the system have had an opportunity to define them operationally." A forum might allow the CMA to bring together the payers, providers and consumers.
McMillan says the CMA wants to facilitate rather than dominate: "We can help the debate by leading it, but at the end of the day these are societal decisions."
The CMA is convinced that public debate about these issues has been inadequate. It acknowledges, for example, the reality of the trend toward privatization of health care in Canada as governments bail out of providing certain benefits or medical services. At the same time, it refutes the argument that public-sector spending on health care is out of control.
Bill Tholl, the CMA's director of health policy and economics, says the line between public and private health care is becoming increasingly blurred. Out of 24 countries in the Organization for Economic Cooperation and Development, for instance, Canada ranks 15th in terms of its proportion of publicly financed health care. (Norway ranks first, with 95% of health care paid through tax dollars; the US ranks 24th, with 44% of health care being publicly funded. Canada currently sits at 72%.) Yet political leaders continue to talk about our "single-payer system" and imply that the private health care system in Canada is far smaller than the current 28% level suggests.
"Politicians don't mention these figures because they won't admit that our system is already a mixed public-private system and it is only the physicians who are subject to the single-payer system," says McMillan. "But this silence means key bits of information are missing from the public debate."
The CMA board will look at a variety of options for illuminating the real issues facing a health care system that is already a public-private partnership.
Acknowledgment of the existing public-private partnership may not necessarily lead to more scope for private medicine. A look at the other resolutions from the August meeting suggests fairly strong support for the Canada Health Act. Delegates did vote against two-tier medicine, with the caveat that it may be time to redefine the five principles listed in the act.
The challenge of redefinition of the act is also occupying the attention of the National Forum on Health, appointed by Prime Minister Jean Chrétien a year ago. McMillan suggests that the CMA's "leadership role" will inevitably be seen to rival that of the National Forum, but that this need not be the case. He thinks the CMA's work could more appropriately be seen as a complementary effort that would put alternative proposals before the public.
Many practising physicians regard the forum as a top-heavy gathering of academics that is skewed to the left. "Those people," says de Blacam, "are too busy dressing up in hair shirts and intoning `medicare, medicare, medicare' to ask serious questions."
Diane Marleau, federal minister of health, was not thrilled by what transpired in Winnipeg. "The government believes the National Forum on Health represents an excellent opportunity to address the future of health care in Canada in a comprehensive and open way," she told the Toronto Star, in a carefully worded response that her office now reads verbatim to anyone else who asks questions about the General Council decision. "The issues of choices for medical care funding is being examined by the forum's 'Striking a Balance' group."
The forum's executive director, Marie Fortier, is less defensive. "The forum's mandate is much broader than simply privatization. There's room for a lot of discussion around health care issues, and of course the CMA is perfectly entitled to make its plans."
It may have been coincidence, but within a few weeks of the Winnipeg meeting the forum released its first discussion paper, The Public and Private Financing of Canada's Health System, and announced that it would be holding a series of "study groups" across Canada.
It is generally accepted that if the CMA is to be effective, it must move quickly, because the next federal budget is going to trigger a whole new series of cuts, and those in turn will launch more questions about what Canadians want relative to what they can afford. "We mustn't skip to the politically expedient before a proper examination of a full range of options," says McMillan. This means that if the notion of a CMA-sponsored roundtable or forum of some sort gets board approval, it will probably be held in the spring of 1996.
However, some predict that fundamental disagreements within the profession will accelerate and become increasingly public in coming months. Government cutbacks are not the only cause, according to Dr. Michael Rachlis, a Toronto health policy consultant and coauthor of Strong Medicine: How to Save Canada's Health Care System. "The cap on physician billings has completely changed the dynamics within medical organizations, and made the provincial associations inherently unstable," he argues.
Rachlis suggests that we may see the fragmentation of the profession into different groups, particularly if provinces move to a system of capitation payments for primary care physicians. "There will be increasing tension between fee-for-service specialists and family physicians who want capitation in order to maintain their independence."
The CMA will continue to play a major role, simply because the profession needs a national organization to speak out on issues such as retirement savings, the goods and services tax, abortion and gun control.
Meanwhile, says Woollard, "the CMA must be seen by the public in the same role as they see us as physicians today -- not as patriarchs, but as people with expertise and with the patient's welfare at heart. We can't say, `Trust us, we're doctors.' " Woollard does not see a ground swell of pressure within the profession for a parallel private system -- but "government ideologues will drive us to the right if they're not careful."
He hopes that policymakers have got the message from Winnipeg that the profession is facing severe stress, and has something important to offer. "The thrust of government now is to avoid responsibility and devolve onto the next level. So in a culture of avoidance, governments should be happy that the profession will take responsibility."