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September 14, 2006

Public or Private Health Care

The private purchase of medical services that are benefits under public plans such as MSP, hospital services and others administered by the health authorities, raises fundamental issues and kicks off the long delayed conversation on health care that Premier Campbell promised last February. For ten years private providers have offered services paid for by WorkSafe BC, ICBC and other public agencies, services which would be covered by MSP and hospital insurance if it weren't for other public insurance plans. The elephant in the room has been the obvious contradiction of having different rules depending on which public plan pays your bills. The blow-up this week, when a courageous former patient revealed that she paid for an MRI that was performed at St. Paul's hospital, kicks off the Premier's conversation on health care in a way that interests the public, not in the controlled way that the government might have had in mind.

It is no wonder that the government is fearful of allowing the legislature to sit. NDP health critic Adrian Dix has put Health Minister George Abbott on the defensive, with Abbott having to admit that queue jumping for a fee at public hospitals clearly violates the Canada Health Act. Can you imagine what question period would be like if the government honoured its legislative calendar and the standing rules of the legislature by calling the House to sit on October 2nd?

Should the Canada Health Act and Medicare Protection Act be changed, or should practice be changed to comply with current legislation? There are a few Neanderthals who have never accepted public health insurance, and who believe that one of the privileges of wealth is better access to health care. Outside of right-wing "think-tanks" it is hard to find anyone who admits to holding that unqualified belief; Dr. Brian Day, the president-elect of the Canadian Medical Association and one of the founders of the False Creek Surgical Centre, says that his real interest is in seeing that patients receive care when they need it by shortening waiting lists, not undermining the public system to the benefit of a private alternative.

As a result of the controversy over St. Paul's hospital of selling MRI procedures during "off-hours" (even though those hours may be in the middle of the day), Vaughn Palmer revealed the existence of Timely Medical Alternatives Inc. which, according to its website, provides accelerated alternatives to waiting for treatment within the public system in Canada. When asked on CKNW's Bill Good show whether St. Paul's is the only hospital that is contracting out services, Rick Baker of Timely Medical Alternatives answered "no". He went on to say: "I don't know how many are doing it. I only know about the ones that I have had dealings with myself." Baker wouldn't name names. His company's website says:

"B.C. residents have more options for private medical services than those in other provinces. Everything from primary medical care (G.P.'s and family physicians) to diagnostic procedures (MRI's, CT scans, PET scans, ultrasound services, nuclear bone scans, gastroscopies, colonoscopies etc), to surgical procedures (cataract surgeries, vertebroplasties, orthopedic surgery, pacemaker implantation, hernia repair, carpal tunnel release, discectomies, etc) is available privately, within B.C., through Timely Medical."

When addressing the question of whether legislation or practice should change, the first question might be whether the public agrees that private medical options should exist. That is no longer a theoretical question, nor does it refer to the fact that dental offices, pharmacies, and the offices of most physicians have always been private. Today's reality is what is described by Timely Medical. If government wants to change that reality, it must make the public system perform sufficiently well so as to substantially reduce the demand for the private options. Attempts to eliminate the private options by enforcing or strengthening current legislation will result in court challenges which, if successful, will simply mean that the alternatives will move to other jurisdictions. So the first question is not whether private options should exist, but whether they should be encouraged to expand or allowed to wither in the face of competition from an improved public system. The public probably wants that improved public system, but individuals who need care also want the private alternatives as long as the public system is inadequate.

The question raised by St Paul's practice of raising revenue by selling services is whether publicly financed institutions should be allowed to cater to the private payment health service market. Global TV broadcast the case of a woman who was flown from New Westminster's Royal Columbian Hospital to Victoria for an MRI because St. Paul's couldn't accommodate her. It is hard to understand how a public hospital can turn patients away while at the same time it accepts privately paying patients. St. Paul's denies that happens and says that no MSP patients are bumped in favour of off-hours third-party patients, but it also says that when a cancellation occurs it takes the first available patient, public or private. It may have been more credible if St. Paul's had claimed that it is limited by budget constraints on how many public procedures it can perform, but that would run in the face of claims by the government that health authorities operate on global budgets rather than on restrictive line-by-line budget authority with no power to shift funds. A full public explanation is necessary on how the number of procedures available to public patients is determined.

There are those who argue that hospitals should be able to sell some procedures to the private market as long as they reinvest the earnings so as to make the public system better. How would anyone know whether the earnings were funding the public health system or simply allowing government to make more corporate tax cuts? Once one starts down that slippery slope it may let the government off the hook rather than raising service standards to the point that few would seek private care.

The new government catch-phrase when talking about health care is to make it "sustainable". The mistake the government makes is to look only at the costs that flow through its books when measuring how much is spent on health care. In the late 1960s and early 1970s, Canada took the step of embracing public health insurance; that is when government spending and revenue increased because money that used to flow into private insurance companies or out of private pockets was redirected through government as a public insurer. Increasing private payments, whether out of pocket or through insurance companies, doesn't lower health costs; it simply means that government spends less while society loses cost control and spends more. We are on the verge of losing control of the health system because an increasing portion of the public is seeking more timely alternatives. In 2001 Gordon Campbell made many bold promises regarding public health care, including assuring that people get the care they need when and where they need it. He forgot to mention that access would depend on one's ability to make private payments on top of public health insurance.


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