Supreme Court rules against bad care, not public care

Looks like the discussion about private healthcare in this country just got honest. In overturning Quebec's ban on private health insurance in Quebec, the Supreme Court cut through all the empty promises, fearmongering and pacifying to reach the core of the debate: on an individual level, citizens cannot be forced to suffer the consequences of an inadequate public health system. That bottom line, more than any compelling evidence that a) people are suffering, or b) the system is inadequate, determined the Supreme Court decision.

Even the three dissenting judges felt that their colleagues were rather loose with evidence on those two key points. There's no data to support the statement that people are dying on waiting lists, and personal factors quite separate from health system inadequacies accounted for a large part of Mr Zeliotis' wait for hip surgery. Research conducted under the umbrella of the Romanow Commission also warns that the introduction of a private option could, under some circumstances, have deleterious effects on the public system.

The judges made clear that provinces capable of proving that their public health services were reasonable stood a better chance of avoiding a ruling such as Quebec's. Independent of any court ruling, providing reasonable public care is by far the best safeguard against an expansion of private alternatives. Given that around 40% of the taxes each of us has recently paid goes to finance our public care, we'd have to feel quite hard done by to be willing to part with even more of our earnings to pay for private insurance or directly for private care.

The judges also didn't object to any of the levers used to discourage private care in many provinces. Extra-billing for medically necessary services is not allowed; doctors are required to opt out of medicare completely in order to charge privately for medically necessary care; public funds cannot be used to subsidize private services. As well, restrictions on what services a private hospital can offer — ie, patients cannot stay overnight, or blood cannot be administered — will curb the possibilities for expansion in the private sector. In BC, the prohibition on charging private citizens more than what the provincial system pays for a service works as a handy damper on the profit-making potential of private care. Our governments need to take these cues and get more active in safeguarding the levers available in provincial and national law and, perhaps most importantly, in our international trade agreements to maintain these dampers on profit in healthcare.

The main fear arising from the Supreme Court decision is a fast and furious expansion of private clinics and an exodus of doctors from the public system. But the market for medically necessary private care will likely remain small, given the present quality of services in Canada and the enormous progress on waiting times evident since the start of 2005 — several provinces have even hinted at a guaranteed time frame for care. In the UK, less than 12% of people have any form of private insurance. That proportion hasn't grown over time and may even be diminishing alongside recent NHS improvements.

That said, we might need to rethink some of the levers we use to impede private care so that a modest expansion of private services does as little harm to our public system as possible. Forcing a physician to choose between private and public care runs absolutely counter to the UK and Australian systems where doctors who provide private care are obliged to also participate in the public system. Our public system needs to become a rewarding workplace where doctors are proud of the care they can provide — because shackling them in place has proven a wholly inadequate means of safeguarding our supply of MDs.

That's where honesty comes in. Legal prohibition on private care and insurance does not guarantee good public care. But good public care will guarantee that private care remains on the periphery. The tax dollars are there, the mandate from Canadians is clear and governments will continue to stand or fall on their public healthcare records.

— Susan Usher, Health Policy Editor

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