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Top ten reasons against two-tier medicine in Canada

We should not run a wealth-care system for essential care

Colleen M. Flood, Terrence Sullivan, Noralou Roos, Steven Lewis and Tom Noseworthy
The Alberta government is proposing to allow doctors work in both the public and the private tiers.

They plan to create a two-tier system where people can pay doctors more to receive quicker treatment and can buy private insurance to cover these services.

They are doing so, they say, because the Supreme Court's Chaoulli decision has opened up the possibilities for more private funding of the system.

Here are the top ten reasons, based on the best research evidence, why Canadians should resist a two-tier system.

10. The Supreme Court decision in Chaoulli only looked at the Quebec law preventing the purchase of private health insurance. It did not strike down the law stopping doctors working in both the public and the private sectors nor did it speak to any law in any other province.

Many countries (e.g. Sweden) and nearly all provinces protect the public system by way of laws preventing doctors being paid both publicly and privately for essential services. The majority judgment in Chaoulli said that the law preventing doctors working in both the public and the private sectors is important to ensure the viability of the public system.

The Quebec government agrees with this and in its proposals is keeping this important law.

Thus the Alberta government is wrong to say that the Chaoulli decision either requires or enables them to allow doctors to work both public and private.

9. More private funding will not improve the sustainability of our system. Countries in which private spending is high spend more in total on health care, not less. The U.S. already spends more public dollars per person than Canada does, but leaves 48 million Americans uninsured. They don't get much more for all this extra spending, but they do pay higher prices for what they get.

8. We have a shortage of doctors and nurses. Most developed countries do. Wealthier provinces are luring doctors from poorer provinces. This problem will be exacerbated if doctors are allowed to top up their public sector incomes by doing less difficult work for higher rates of private pay.

If you were a doctor, wouldn't you? Doctors will spend more and more time in the private system.

In New Zealand, where doctors are allowed to do this, specialists spend less than 49 per cent of their time in public hospitals; the rest of the time they are working in their private clinics.

7. Countries that allow doctors to work in both the public and the private sectors at the same time have long wait lists, e.g. United Kingdom, New Zealand, Ireland, Spain. Why copy them?

European countries like the Netherlands and Germany are different, as they require the wealthy to fully insure themselves by buying private insurance and, even so, there is a lot of regulation preventing inequities. For example, in the Netherlands there is a law that doctors are paid the same fee by private insurers as they are by public insurers -- so they have no incentive to give better treatment to private patients. If Alberta is to have a fair system then it must enact a similar law.

6. In countries that have two-tier systems, only a relatively small percentage of the population holds private health insurance (for example 11.4 per cent of U.K. citizens); typically the wealthiest buy insurance.

In other words, the vast majority of Canadians would not benefit from being able to buy private health insurance as either they will not qualify for it, or they won't be able to afford the premiums.

5. From the perspective of a private insurance company, if you are on a waiting list you do not have an insurable risk. You don't have a risk of disease or illness, you have the disease or illness -- current needs that must be met. If you can't pay cash, the public system is your only option. People presently on wait lists will not be helped by privatization unless they can pay cash.

4. Don't buy the baloney that Canadian medicare is in league with communist states like Cuba and North Korea. We are third in the world in terms of the contribution of private health insurance to the funding of our system. Physicians are not employed by the state and hospitals are not owned by the state.

We already have more private financing and private delivery than many other developed countries. The real question is whether privatizing insurance for essential hospital and physician services will make our system better or worse.

3. NAFTA requires that we must compensate U.S.-based private insurers for denying them access to Canadian "markets" if we subsequently change our mind about the benefits of two-tier insurance.

2. Governments and health-care providers can fix wait lists. Together they have been able to achieve extraordinary improvements, for example, in cardiac care treatments in Ontario and with respect to hip and knee services in Alberta. There is now little or no waiting for diagnosis and treatment; most of these gains have been achieved as a result of better coordination of existing resources and talent. We can and will do it in other areas. We don't need a third way.

1. And the top reason why we shouldn't allow private health insurance for essential services?

Access to essential care should be based on need and not ability to pay. If resources are constricted we should revisit what is essential but not allow a two-tier system for what are core services.

We should run a health-care, not a wealth-care system, for essential care.

Colleen M. Flood, Canada Research Chair in Health Law and Policy, University of Toronto

Terrence Sullivan, President Cancer Care Ontario

Steven Lewis, President, Access Consulting Limited, Saskatoon

Noralou Roos, Canada Research Chair in Population Health Research, University of Manitoba

Dr. Tom Noseworthy, Director, Centre for Health and Policy Studies, Calgary

 The Edmonton Journal 2006