Using American facilities won't harm
the Canada Health Act

By Owen Dyer

It sounds like the ultimate admission of failure: sending patients for treatment in the United States because our health system can't give them timely care. Yet such a proposal was just enthusiastically backed by the president of the Canadian Medical Association, Dr Albert Schumacher, when he spoke to the Quebec Medical Association on April 19th.

In a nutshell, Dr Schumacher said that Canada's health infrastructure is simply not big enough to cope with demand. There is not enough capital equipment such as MRI scanners, not enough "doctors, nurses, technicians, pharmacists to make the system run well," he said. "In Canada, we're only training less than 80% of what we need."

As waiting times have remorselessly crept up the political agenda, particularly out West, Ottawa and the provinces have been forced to accept another unwelcome hike in the health budget. Over the next ten years, an extra $41 billion will be pumped into the system, according to a deal signed by Health Minister Ujjal Dosanjh last September.

A "significant element" of this money will go to equipment and training more health professionals, Mr Dosanjh promises. But this is unlikely to improve the situation much in the short term. Even if Canada can recruit more health workers, and do so at a rate that exceeds the relentless growth of demand, it will take years before the new staff are on the wards treating patients.

Step forward the Canada Health Access Fund, a proposal to allow patients to travel to other regions, and even other countries, to access care at the Canadian taxpayer's expense if they can't get timely treatment near home. Large parts of the plan are uncontroversial, such as the Territorial Health Access Fund, which will provide travel expenses to people in remote areas. That program will soon be up and running. It's the notion of sending patients abroad, still under discussion, that many find upsetting.

HOME SWEET HMO
The most telling argument against the proposal is that Canadian taxpayers would essentially be investing in a foreign health system. Ultimately, we could end up buying a new MRI scanner for an American HMO with money that could have bought a new MRI in Canada. But is that such a bad thing if the American MRI ends up scanning more Canadian patients in a timely manner?

The CMA has been fairly consistent on this issue over the years. They have mostly resisted calls to introduce privatized medicine in Canada as a way of easing pressure on waiting lists. But if they can see a way to address the problem without breaching the principles of the Canada Health Act, they must argue for it. Their primary duty is to treat patients.

The basic purpose of the Canada Health Act was never to centralize all healthcare in a rigid Soviet system of state control. Rather it was to ensure free treatment to all Canadians when and where they need it.

The government's responsibility is to meet that goal while making the most efficient use of resources. And increasingly, large organizations are finding that the best way to maximize efficiency is outsourcing. It's inevitable that in our vast health system, often covering areas of sparse population, some capital-intensive equipment would be underused. A better use of the resources would be to pay for individual patients' treatment in large population centres. And in a few cases, that will mean the US.

A WINNING PRECEDENT
In fact, the question of whether this contravenes the Canada Health Act has already been addressed by a Canadian court. When Quebec colon cancer patient Barry Stein had a third operation cancelled for his metastatic disease, he took his doctor's advice and paid for the surgery out of his own pocket south of the border. When he sought reimbursement from the R�gie de l'assurance-maladie du Qu�bec (RAMQ), he was refused. But Mr Stein, a lawyer, took the RAMQ to the Quebec Superior Court and won his case.

The same dilemma faced Britain's National Health Service four years ago, after the European Court of Justice ruled that five weeks' wait should be the "timeliness norm" for medical treatment. The court decreed that patients should be allowed to seek treatment abroad if they faced "undue delay" at home. Ever since, Britain has been quietly shipping patients to France and Germany, mostly for elective minor surgery, in a program that has worked remarkably well despite language barriers.

In the best of all worlds, we could mix and match our excess capacities with the border states, to the mutual benefit of all our patients. Realistically, that is not on the cards, and our dealings with the US health system will be one-way traffic.

PLAYING POLITICS
Ultimately, the vast bulk of patients transferred under the Health Access Fund will be travelling between Canadian provinces. Even that modest proposal faces some resistance. Dr Schumacher was highly critical of Quebec's reluctance to fully reimburse citizens who seek emergency care while visiting other provinces. "This political phenomenon," he said, "effectively ensures Quebecers are treated like second-class citizens when they travel outside the province."

That issue seems a no-brainer. Unlike opponents of international patient transfers, the RAMQ can't possibly claim that it's sticking up for Canadian healthcare by making difficulties over out-of-province treatment. The RAMQ's position is particularly indefensible, Dr Schumacher pointed out, when one in four Quebecers have difficulty even finding a family doctor. "It's about one in six across the rest of the country."

The RAMQ can't insist on keeping all Quebec patients under its wing when it's failing to treat them properly. That is the CMA's essential message. The Canada Health Act has plenty to say about socialized medicine, but it stands or falls by its ability to protect patients, not its ability to protect the turf of jealous bureaucracies.

When patients like Barry Stein are effectively being told to die for the principles of the Canada Health Act, you just know somebody is reading the document upside down.