Protect Medicare: Don’t Privatize It
A Submission from the
Nova Scotia Citizens’ Health Care Network
To the Minister of Health
Concerning Bill 126
The Health Facilities Licensing and Equitable Access to Insured Services Act
The Nova Scotia Citizens’ Health Care Network is dedicated to protecting, strengthening and expanding Medicare. Since our beginnings in November 1996, the Health Network has grown to become a provincial organization of concerned individuals and organizations representing seniors, women, anti-poverty, persons with disabilities, community groups and labour. We are affiliated with the Canadian Health Coalition and other provincial health coalitions.
We appreciate this opportunity to share our comments and concerns about Bill 126, the Health Facilities Licensing and Equitable Access to Insured Services Act. The Nova Scotia Citizens’ Health Care Network opposes this bill on many fronts and seeks that the bill be completely withdrawn.
The first and foremost concern with this piece of legislation and the accompanying discussion paper is that the former Minister of Health, Jamie Muir, when first announcing there would be legislation to govern private care in 2002, promised that there would be a in-depth public consultation before any legislation was introduced. Public consultation is a requirement before such vast changes can be made to our public health care system.
This bill has many gaps. It leaves the publicly funded and publicly delivered health system open to attack by health privateers. This submission will look at the following key issues that are raised by this bill:
- What is the goal of this bill?
- How will this bill affect wait times?
- Is privately delivered care less expensive than publicly delivered care?
- How do our trade agreements, primarily NAFTA, affect this bill?
- How will this bill be enforced?
- Why are we turning to privatization?
It is our hope that by raising, and responding, to this key questions we will be able to demonstrate just how wrong this bill is for Nova Scotia and for our public health care system.
What is the Goal of this Bill?
Your government’s state objectives is that this bill is designed to regulate the growth of private health care clinics and facilities, while at the same time ensuring that there can be no queue jumping at these private clinics. While we thank you for attempting to address these issues, as we will show, this bill fails to do that.
The question that then arises is why are we looking to regulate the private clinics instead of bringing them into the public system?
There are only three possible responses.
1. To reduce health care wait times
2. To reduce the cost of delivering insured services
3. Due to a belief that the private sector is more efficient and effective.
We do not believe that number 3 is a response because we do not feel that your government wants to see a two-tiered system of health care put in place. We are confident that your government believes in Nova Scotia’s public health care system
This brief will demonstrate that this bill will not help to reduce health care wait times or reduce the cost of insured services. By drawing on example from other provinces, the United States, and Europe the submission will demonstrate that wait times and costs will increase if this bill is passed.
The Question of Wait Times
Wait times in Nova Scotia are too long. However the solution is not to begin allowing private for-profit clinics to operate.
It’s common sense really. Imagine the following scenario: a city has a non-profit hospital, where 100 doctors are employed. At some point, the city under funds or mismanages the hospital, and waiting lists spring up. If that city allowed a for-profit hospital to address the temporary crisis, would it shorten the lists?
No. Because the for-profit institution would need to hire professional staff as well, and would have to do so by poaching doctors and other health professionals from the non-profit hospital. So some people would leave the waiting list to pay their way to see one of the 40 doctors at the for-profit hospital, but because only 60 doctors would be employed in the non-profit institutions (instead of the original 100), there would still be a waiting list for those who can’t pay their way ahead.
In fact, this is what happened in the United Kingdom and New Zealand. Both have significant parallel private hospital systems, and both have longer waiting times than Canada or other countries with a single-payer, universal health insurance program[i].
Waiting lists can, and should be solved in the public, non-profit system. They can be. Canada spent millions on getting a strategy to address waiting times, and it got one: the Final Report of the Federal Advisor on Wait Times, released in June 2006[ii].
The Question of Costs
Advocates of privatization often suggest that procedures are less expensive in private, for-profit facilities than the public system. If reducing costs is one of the goals of this bill, the exhibits below should demonstrate that this is unlikely to happen.
Exhibit A: In the U.S., between 1990 and 1994, private, for-profit hospitals had higher costs ($8,115) for every discharged patient, than private, non-profit hospitals ($7,490) and public hospitals ($6,507)[iii].
Exhibit B: A 2004 analysis involving eight U.S. studies, a median of 324 hospitals per study and over 350,000 patients altogether, demonstrated that in the last 20 years, payment for care at private, for-profit hospitals was 19% higher than in non-profit hospitals[iv].
Exhibit C: In Canada, the fee schedule of public health insurance plans give doctors between $700 and $900 per total hip or total knee replacement. Adding the cost of the consultations, other payments to the anaesthesiologist and the nurses as well as the maintenance and capital costs associated with the facility, we reach a cost of about $8,000[v]. The same procedures in private facilities such as Brian Day’s Cambie Surgery Centre or Mark Godley’s Maples Surgery Centre vary between $14,000 and $18,000[vi].
Exhibit D: A cataract surgery at Winnipeg’s public Pan-Am Clinic costs $700, while it cost $1,000 under its for-profit management[vii]. At Winnipeg’s private Maples Surgical Centre, a cataract surgery costs $2,000[viii].
Exhibit E: The cost of hip replacement in a UK private hospital or clinic varies between £6,000 and £15,000[ix], inclusive of private hospital charges and consultant’s fees. In non-profit hospitals, the cost of a hip replacement varies around £5,000[x]. A coronary bypass operation in the United Kingdom’s for-profit institution costs the public insurance £6,320 in 2002-03. The same procedure cost the public an average of £12,060 in a for-profit setting[xi].
Exhibit F: On October 16, 1996, the QEII Health Sciences announced a one-year pilot P3 project with Health Staff Inc. to take over the recruitment, training, administration, continuing education and payroll of casual nursing staff currently used by the QEII. The pilot project was to begin on April 1, 1997. It was anticipated that direct cost savings of approximately $500,000 would be realized in this arrangement. Instead, the project was discontinued by the QEII in January 1998 before the full year was completed because it was a costly administrative failure in what the Hospital called “some unforeseen circumstances”. The projected savings never materialized and Health Staff ended up costing the Hospital money. It was set up in secret by senior management without any prior consultation with NSGEU on behalf of its nursing members.xii
Our Chairperson has had a number of personal experiences which illustrate the additional costs and other serious problems with private, for-profit facilities compared to the public system:
1. As a cancer patient in Dec. 2002, her oncologist left Halifax for a U.S. Drug Company leaving the cancer centre in dire need. As a result, she had to wait to see another oncologist two months after she had my operation. Thankfully, the results in the final end are good. Too many patients now have to wait too long for treatment, OR beds.
2. As a cancer patient in Dec. 2002, her breast cancer lumpectomy surgery left her needing plastic surgery to make me whole again. Unfortunately, it took a year after her final treatment to get an appointment with her specialist, whom she saw Jan. 2005. She was instructed by the Doctor, that he would see her in one year and that she would get a phone call confirming when. Well, it is now Feb. 2007 and she still has not received a phone call. What she learned was – that the plastic surgeon who opened the private clinic in Halifax was the specialist she saw earlier. Due to this new private facility, the doctor does not see patients at the Dixon Centre everyday as he used to do so, he only sees patients 2 days a week, the rest he sees at his PRIVATE clinic. Needless to say, she has now waited two years for reconstructive surgery and expects to wait a lot longer. Private care doesn't mix with public care.
3. As a cancer patient from Dec. 2002, her knees have been getting progressively worse. She has osteoarthritis with bone spurs in her knees. Both knees recently have been diagnosed with the great possibility of needing knee replacements. In the meantime, her doctor wanted her to receive physio and he brought in a man to talk with her. During our conversation, he asked if she had private insurance. She ignored the question and asked how long did he think it would take her to get into public physio and he said about 1 1/2 to 2 weeks. She said the doctor wants to see her in 2 weeks so she needs to get in right away.
He said he has a private physio clinic just down the street and he could probably get her in there faster. She said she would let him know, but she wanted him to try to get her into the public system first.
The next day, his private clinic called and said they could not schedule her in until about 1 week. She said she needed to get in faster as she had to see the doctor again. They called back giving me a date for 3 days later. She called the private physio closer to home and they could see her that day in the afternoon. Later that same day, she received a call from the PUBLIC physio clinic and got an appointment the next day, so she went to the public clinic.
She has a problem when a health professional encourages you to go to a private clinic then you find out that either they own it or they are a stock holder in the private clinic.
Our Chairperson has other individual cases to report:
1. A report came in from Shelburne that in 2005, an elderly man was charged $1500.00 for a private MRI at the Clayton Park Clinic yet the clinic boasted that the charge was only $725.00. He was too ill to allow us to follow up on this. This is not the first time reports identified various charges from the private MRI clinic.
2. We were contacted by a man from Wolfville whose wife was pregnant. They received a letter from their doctor asking everyone to pay an amount upfront for non-insured services. While the letter indicated that it was optional, it was clear to him (as he stated) that if a patient didn't pay this extra fee, it could affect their service. We reported this to the then Minister of Health, Hon. A. MacIsaac and the Deputy Minister Doiron and they said they would look into this.
The one clear issue that came out of this man's concern was that his wife was "afraid" of their doctor and didn't want to go back to him. Clearly this was/is a violation of the Canada Health Act and to our knowledge, it has never been addressed. The people wished to remain anonymous.
3. We heard from another person who told the Health Network about his earlier experiences with cardiac care both in Canada and the U.S. For monitoring in a cardiac care unit, several days on a medical ward and medication to ease cardiac function, the same tests and medication cost $12,590.34 (US) or over $15,000 Canadian in Southern California compared to $3,500 (US) in Saskatoon whose experiences were described in an article written by his wife.xiii
The Question of Trade Agreements
Unlike Europe, Canada is next to the last remaining Superpower. We also have a trade agreement with that Superpower, NAFTA.
The healthcare sector has been protected from the application of the agreement through Annex II (c), which stipulates that:
Canada reserves the right to adopt or maintain any measure with
respect to the provision of public law enforcement and correctional services, and the following services to the extent that they are social services established or maintained for a public purpose: income security or insurance, social security or insurance, social welfare, public education, public training, health, and child care. (Emphasis ours).
In a widely respected legal opinion written in March 2000xiv, trade expert Steven Shrybman showed that under the current rules of NAFTA, Canada’s health care could come in for a challenge in the future. As provincial governments legislate the existence of private, for-profit medicine, the probability of such a challenge dramatically increases.
A U.S. for-profit healthcare corporation could claim that they are prevented from accessing a market that Canadians have. Because according to NAFTA, Canada must give U.S. companies the same treatment it reserves to its own businesses (the national treatment clause).
Not only would they very likely win, thus creating a parallel private system, but they could also challenge Canada’s public healthcare system, accusing it of unfair competition by virtue of being subsidized. This challenge would be like the one launched by UPS against Canada Post and Purolator.
Sweden, France and the United Kingdom don’t have to contend with this possibility. Canada does.
The Question of Enforcement
One of the goals of this bill, according to your government, is to insure there is no queue jumping. The bill requires health practitioners to report any instances they see of individuals jumping the queue, either for money or because they know the physician.
This bill has no real enforcement mechanism.
Because the bill does not restrict health practitioners to either the public or private system, there is no way to stop a health practitioners from working two day a week in the public system and three days a week in the private, or some similar combination. Essentially, a health practitioner could refer patients that he or she is unable to see in the public system to his or her private practice. At that point there is no way to enforce the legislation against queue jumping because in the private practice the other workers are reliant on the company or individual health practitioner for their livelihood. As such, they may be unwilling to speak out against queue jumping for fear of losing their job.
Additionally, there is little incentive for physicians to stay in the public system full time if they are able to refer patients to their private practice where, as demonstrated earlier in the submission, they will make more money. This also reduces the ability of the government to enforce the bill because physicians will have no incentive to report queue jumping.
Finally, because the College of Physicians and Surgeon is named as a monitoring body for queue jumping, a major conflict of interest arises. Physicians are often the shareholders in private clinics; they are also members of the College. Here, the College would be acting against its members’ interests if it attempted to enforce the bill. This can potentially lead to queue jumping.
Already we see the possibility of queue jumping in areas where private care already exists. This can only get worse as more private facilities and clinics are allowed to operate.
The Question of Privatization
One of the biggest questions that this bill raises is the role of privately delivered health services. Also, the biggest problem with this bill is that it automatically accepts and legitimizes the role of privately delivered health care in our province.
Instead of regulating and slowing the advance of for-profit health services, the provincial government seeks to legitimize them; allowing the first strains of a two-tiered system to emerge.
The advocates of privately delivered health services, including Dr. Jacques Chaoulli, are privateers in the worst sense of the word.
After winning the his case before the Supreme Court of Canada, Dr. Chaoulli ran down to the United States, pledging to single handily destroy Canada’s single-payer health care system. He said to the Heritage Foundation, a far-right think tank, “I have a dream. My dream is to show the world how to get rid of a new and subtle form of tyranny hidden under the cover of a Welfare State's compulsory health care program.”xv Mr. Chaoulli corrupts Dr. Martin Luther King’s speech on equality to attempt to justify his destructive goal of privatizing health care services in Canada.
As the submission has shown, the real tyranny occurs when private companies are allowed to line their pockets with public gold and profit from the illness of all Canadians. The privateers are not seeking to shorten wait times in the public system. They are not seeking to reduce governments health related costs. They are seeking making large sums of money while simultaneously destroying one of the foundations of the Canadian state, Medicare.
Nova Scotia must reject this vision of health care; we must reject private delivery and for-profit health care services. The Health Facilities Licensing and Equitable Access to Insured Services Act should be withdrawn and a new bill created or amendments made to existing legislation.
This bill should:
- Establish a moratorium on the opening of new private health clinics in Nova Scotia
- Enshrine the Canada Health Act in provincial legislation, including a new clause that requires not only Public Administration but Public Delivery
- Require the Minister of Health to set a schedule for bringing the existing private health facilities into the public system
- Eliminate double-dipping by requiring health practioners to work in either the public system or the private system
- Develop a comprehensive, centralized wait list strategy
- Develop an in-depth health human resources strategy
The solutions to the problems confronting public health care are found in the public system. Not the private system.
A clear statement of ten reasons against two-tiered medicine from the
March 13, 2006 edition of the Edmonton Journal is found after the text of this submission. We have also enclosed a copy of our statement to be read on February 9 at a national demonstration outside the Federal/Provincial/Territorial Meeting of Ministers of Health in Toronto and a copy of an open letter dated February 7, 2007 from the Canadian Health Coalition to Federal Health Minister Tony Clement about the need for federal leadership in several key health issues.
[i] Hughes Tuohy C et al. 2004. “How does private financing affect public health care systems? Marshaling the evidence from OECD nations.” Journal of Health Politics, Policy and Law; 29(3): 359-396, http://www.chass.utoronto.ca/cepa/Private.pdf.
[ii] Postl, Brian D., MD, “Final Report of the Federal Advisor on Wait Times”, June 2006, http://hc-sc.gc.ca/hcs-sss/pubs/care-soins/2006-wait-attente/index_e.html
[iii] Woolhandler S and Himmelstein DU. 1997. “Costs of care and administration at for-profit and other hospitals in the United States.” New England Journal of Medicine; 336(11): 769-774, http://content.nejm.org/cgi/content/abstract/336/11/769.
[iv] Devereaux, P.J. et al. (2004). “Payments for care at private for-profit and private not-for-profit hospitals: a systematic review and meta-analysis”, CMAJ 170: 1817-1824, http://www.cmaj.ca/cgi/content/full/170/12/1817.
[v] Canadian Institute for Health information
[vi] Shimo, Alexandra, “Private Medical Care: Medical travel agents - Sun, sea, sand and a new set of knees”, MacLean’s, April 25, 2006, http://www.macleans.ca/topstories/health/article.jsp?content=20060501_125955_125955
[vii] Rachlis, Dr. Michael M., Public Solutions to Health Care Wait Lists. Ottawa: Canadian Centre for Policy Alternatives, 2005, http://www.policyalternatives.ca/documents/National_Office_Pubs/2005/Health_Care_Waitlists.pdf.
[viii] Shimo, Alexandra, “Private Medical Care: Medical travel agents - Sun, sea, sand and a new set of knees”, MacLean’s, April 25, 2006, http://www.macleans.ca/topstories/health/article.jsp?content=20060501_125955_125955
[ix] Private Healthcare UK, “Private hip replacement costs in the UK and abroad”, Accessed January 31, 2007, http://www.privatehealth.co.uk/hospitaltreatment/whatdoesitcost/hip-replacement
[x] Dyer, Owen, “NHS overcharged for private surgery”, British Medical Journal, 2004;328:1158 (15 May), http://www.bmj.com/cgi/content/full/328/7449/1158-e.
[xi] Dyer, Owen, “NHS overcharged for private surgery”, British Medical Journal, 2004;328:1158 (15 May), http://www.bmj.com/cgi/content/full/328/7449/1158-e.
xii Joint News Release – QEII and Health Staff Inc., “QEII Patient and Casual Nursing Staff Benefit from Innovative Pilot Project”, October 11, 1996; News Release, “QEII and Health Staff Inc. Pilot Project Concludes”, January 23, 1998; “Hiring company to manage nurses became a ‘fiasco’, Chronicle-Herald, Thursday, January 29, 1998, A5; “Hospital Scraps Project”, Daily News, January 24, 1998, 7.
xiii Judy Haiven, “MediScare: A Canadian takes on the AMA’s line of bull against her country’s health-care system”, Mother Jones, March/April 1991, 50-69.
xv Chaoulli, Dr. Jacques, Speech to the Heritage Foundation. http://www.heritage.org/Research/HealthCare/hl1892.cfm