Health care and the common good

(Aug 15, 2007) -- 'The CMA is undermining the most fundamental premises of our national Medicare system – health care is not a commodity that should be bought or sold. It is a common good and needs to be treated and respected in this manner.'

It’s mid-August and once again and, as in recent years, we find ourselves faced with more distressing news from the Canadian Medical Association on the eve of its annual general meeting.

In particular, I am referring to policy proposals contained in the CMA position paper Medicare Plus: Toward a Sustainable Publicly Funded Health Care System. While it contains some initiatives I support, there is much that is worrisome.

By advocating double-dipping, private insurance and public-private partnerships, the CMA is undermining the most fundamental premises of our national medicare system – health care is not a commodity that should be bought or sold. It is a common good and needs to be treated and respected in this manner.

One of the best critiques of the CMA paper was written by McMaster University professor Gordon Guyatt in a commentary for the Globe and Mail - I reprint it here:

Self-interest over public interest

Prof. Gordon Guyatt
Toronto Globe and Mail, 1 August 2007

Any proposed change to health care implies winners and losers. Take a national pharmacare program: Winners would include poor Canadians who have difficulty affording drugs, middle-income Canadians with high drug costs and anyone facing catastrophic drug expenses.

Large industry would also benefit by enhanced competitiveness as a result of lower employee health benefits.

The losers? Canadians in high tax brackets and the insurance industry.

The Canadian Medical Association has suggested that provincial governments increase reliance on private, for-profit providers to deliver publicly funded health care. They suggest physicians be allowed to practice in both for-profit and not-for-profit sectors. In such event, who would win and lose?

The CMA says the public would benefit from shorter waiting lists.

But long wait times and suboptimal care are, in large part, a function of doctor and nursing shortages. For-profit clinics would not lead to the training of a single additional doctor or nurse. Indeed, such clinics would suck desperately needed personnel from not-for-profit hospitals and clinics.

Physicians practicing in public and private settings have a vested interest in keeping waiting lists long in publicly funded facilities. Otherwise, why would patients pay extra to go private?

Could for-profit clinics shorten waiting lists by creating more resources, such as operating-room time? Yes, but government could create the same resources by investment in hospitals or not-for-profit surgical and diagnostic facilities.

Investing in non-profit facilities has a major advantage. For-profit providers need to earn a return - typically 15 to 20 per cent - for their investors. Non-profits can devote that money to patient care.

So, too bad, no public win in waiting-time reduction.

Others, however, would be winners. Physician entrepreneurs, such as incoming CMA president Brian Day, who operates a private hospital facility, stand to make a lot of money. Many have made huge sums in U.S. for-profit health care. The proposal would allow them to exploit the public expenditures on Canadian health care. And, if another CMA proposal to expand private insurance comes to pass, the insurance industry will cash in.

The losers? The general public, who will end up spending more on health care to feed the investors' profits and on administrative costs associated with private health insurance. Also, those patients who can't afford the direct charges that - as experience in B.C. and Quebec has shown - comes with for-profit health-care provision. These losers will suffer the consequences of two-tier health care: long waits in non-profit facilities to allow for extra charges for queue-jumpers.

Other losers? Health workers who believe that ethical medical practice requires treating patients according to need, rather than ability to pay.

Indeed, while many doctors disagree strongly with proposals that would undermine public health care, the CMA leadership has chosen self-interest over public interest.

How will politicians respond to the CMA initiative? On one hand, Stephen Harper has done nothing to rein in expansions of charge-the-patient for-profit care in Quebec and B.C. On the other hand, the Prime Minister acknowledges the current reality. In a letter responding to Ralph Klein's proposal to allow physicians to practice in public and private systems, Mr. Harper wrote:

"Dual practice creates conflict of interest for physicians as there would be a financial incentive for them to stream patients into the private portion of their practice. Furthermore, dual practice legitimizes queue-jumping as it provides an approved mechanism for patients to pay to seek treatment at the front of the line."

If the federal government decides to have nothing to do with the CMA's proposal, the losers will be the doctors and investors eager to turn health care to profit, and the winners will be the Canadian public.

I raise a small quibble with Dr. Guyatt’s commentary – one I suspect he might agree with me on. When he says that “long wait times and suboptimal care are, in large part, a function of doctor and nursing shortages” he is quite correct, but I would add that there are also serious shortages among a wide range of other health professions.

These health professionals are a vital and important component of our health care system. They are highly trained, often for durations comparable to doctors and nurses, they are also skilled professionals whose work is often the foundation upon which the best diagnosis and treatment depend. The shortage of these workers is a significant contributor to the wait-time problem in our health care system.

Both Dr. Guyatt and I agree that the introduction of more private health provision will likely make the wait-time crisis worse.

Our nation’s health professionals, all of them in all professions, are among the best educated, trained and skilled in the world. And, despite some of the implications of the CMA policy positions, they are deeply dedicated to building and maintaining the common good.

James Clancy
National President