Standing up for our public healthcare system

By Adam Hofmann

Canada’s healthcare system is by no means perfect. In recent years, there have been media storms about long waiting times, medications barred from provincial formularies, physician shortages and crowded emergency departments. This deficit has featured in the Quebec media, and has been the subject of several prominent films, including Denys Arcand’s Les Invasions Barbares and Jean-François Pouliot’s La Grande Séduction.

Private for-profit healthcare has frequently been touted as a panacea for our health system’s ills. This insistence has been increasingly vocal in the years following the Supreme Court decision in the Jacques Chaoulli case. The Court decided that Quebecers had the right to purchase private insurance should the public system be unable to accommodate them within a reasonable time. The dissenting judges (the vote was 4-3) wrote the following rationale for their opposition: “Prohibition of private health insurance is directly related to Quebec’s interest in promoting a needs-based system and in ensuring its viability and efficiency.”

Despite this, potential purveyors of private insurance viewed this judicial interpretation of the Quebec Charter of Rights and Freedoms as a “foot in the door.” Critics have noted that, by the time the decision was reached in 2005, it was already outdated, since Quebec had made significant strides in addressing wait times since the case had been launched eight

years earlier.

The steps toward privatization were halting at first. They are currently accelerating apace. Private radiology clinics have been a feature of the Quebec landscape for years. Centurion Health Corporation, an American multinational, has recently filed suit against the government of Canada, under NAFTA, for halting its attempts to build a private hospital in British Columbia. And more worrisome still, the former Quebec Liberal health minister passed a regulation under Law 33 authorizing a large number of surgical procedures to be out-sourced to for-profit clinics. He resigned soon after and within two months was employed by a private firm dedicated to expanding for-profit care in Quebec.

The proponents of privatization are quick to assert that none of their interventions will endanger the public system. They are all “add-ons.” In fact, this is not the case. When for-profit healthcare is parachuted into a public system, studied extensively in the United Kingdom, Australia and New Zealand, several predictable effects occur.

For instance, in nearly every case studied, private health care has an undesirable side effect: the lengthening of wait times. Intuitively, one might infer that more services mean less waiting. In reality, for-profit healthcare drains valuable human resources from the public system, thereby, reducing its efficiency and accessibility. In turn, the recipient for-profit clinics tend to treat the “worried wealthy well.” These people are generally those who need health care the least. This parasitic relationship with the public system keeps valuable doctors and nurses treating the rich in “boutique” clinics. As soon as a case becomes complicated, it becomes unprofitable. The increasingly overburdened public system must then become responsible for a new resource-heavy patient cast adrift by the former insurer.

Predatory insuring practices in the United States have been well described by Dr. Marcia Angell, a professor at Harvard Medical School. She writes in a recent editorial in the Canadian Medical Association Journal: “In fact, the best way for insurers to compete is by not insuring high-risk patients … limiting the coverage of those they do insure … and passing costs back to patients as deductibles, co-payments and claim denials.”

Dr. Angell also points out that for-profit health care is much more costly than public healthcare. In addition to the inevitable profit margin, which must be squeezed out of the healthcare lemon at every level – insurer, clinic or hospital services, and provider salaries – it is costly trying to keep the unwell from being insured.

Overhead costs for U.S. for-profit insurers run at 30 per cent of total expenditures. In contrast, Canada spends only 16.7 per cent on overhead. Moreover, Canada’s public health system spends less than half per capita than the U.S. on healthcare. And in light of those savings, we still rank far higher than the U.S. on nearly every indicator of health.

These sobering statistics come at an important time. Quebecers have newly elected provincial and federal governments, and a wave of for-profit interests encroaching on their public system. McGill must strive for positive public system reform in its affiliated teaching hospital system. McGill physicians must continue to contribute to, increase and improve the teaching of future generations of medical students. And, as Canadians, we must all seek to protect the public healthcare system and the communal values it represents, the inception of which we fought for so ardently only one generation ago.

Adam Hofmann is a Clinical Fellow in the Faculty of Medicine, Division of General Internal Medicine.