How do we reconcile medicare and medical tourism?
Seeking an answer to that seemingly simple question careens us into a field of ethical landmines and bedeviling public policy challenges.
Medicare, while fundamentally a public insurance program designed to spread risk, has its roots in social justice - the notion that basic healthcare services should be available to all regardless of ability to pay. Implicit too in the medicare model is that there will be rationing, that the care offered will not be limitless, lest the system become unaffordable.
Medical tourism, on the other hand, epitomizes the commercialization of medicine, the notion that if you have enough money you can get care when or where you want - equity, cost-effectiveness, and sometimes even legal and ethical considerations be damned.
Medical tourism is big business, worth an estimated $80-billion (U.S.) annually and growing.
Because of the high cost of care in the United States, Americans travel in droves. An estimated six million will seek medical care abroad this year. Countries like India, Thailand and Costa Rica woo these patients aggressively.
Should Canada, a country that is a stone's throw away, do the same?
Would selling services to wealthy Americans be a good way of generating money to pay for the soaring costs of medicare?
Our surgical suites and diagnostic imaging equipment often sit idle. But if we sell medical care to foreign citizens, will it drain vital human resources (doctors, nurses, etc.) from the beleaguered public system?
And if we sell medical services to foreigners, can we refuse to sell them to our own citizens, even if they are paying to jump the queue?
Despite our universal health system, a growing number of Canadians are travelling abroad for care.
One of the few studies on the phenomenon, a 2008 report by international consultants McKinsey & Co., found that 7 per cent of medical tourists are Canadians. If you do the math, Canadians are spending around $5-billion a year out-of-country for health care.
If they are willing to throw around that kind of cash, what does it say about perceptions of Canada's healthcare system, and about our ability to pay more domestically?
The McKinsey study found that, globally, 11 per cent of medical tourists travel for plastic surgery, like tummy tucks and facelifts, while more than half travel for general surgery and orthopedic care, new hips, bypass surgery and the like.
The principal reason given for travelling is "enhanced care," meaning that patients feel the technology and skills of surgeons are better than in their home country, and that the care is faster and cheaper.
While a significant number of Canadians travel to the United States for care because they feel the quality is superior (à la Danny Williams), a growing number are heading off the beaten path, where prices are lower and ethics more flexible.
For example, patients with multiple sclerosis have been flocking to clinics in Costa Rica and Poland to undergo "liberation therapy," a controversial procedure to open up veins in the neck. They travel because the surgery is not offered in Canada; it is deemed unproven and hence unworthy of coverage at this time.
Patients are paying in the range of $10,000-$15,000 for this procedure and sometimes doing fundraising events to get the money. Medical tourism is no longer restricted to the ultra-rich but, increasingly, it preys on the desperate.
Canadian patients with spinal cord injuries are travelling to China and Mexico for stem cell transplants, another therapy that has generated glowing testimonials but for which there is little scientific evidence.
With waits stretching years, those in need of a kidney transplant can travel to India or China for instant relief. But where does this supply of organs come from? Are they purchased from the desperately poor for a pittance or harvested from prisoners?
Similarly, when Canadians travel abroad for fertility treatment, they can purchase eggs and sperm and "rent a womb" from surrogates, commercial acts that are not permitted in this country.
If Canada prosecutes those who commit sexual crimes against children abroad, should it also crack down on those who essentially buy body parts and exploit women reproductively (if not sexually)?
A more practical, but no less thorny issue, is who is on the hook for follow-up care?
With a kidney transplant, for example, the surgery is a relatively cheap part of the procedure. It's subsequently, when a person requires a lifetime of anti-rejection drugs and follow-up care, that the costs add up. And what happens when the transplant doesn't take - a not-uncommon problem? Does that patient, who jumped the queue by going to India, now get priority for another kidney in Canada? Or do we have the right - legal and ethical - to send them back to India?
Similarly, if an MS patient travels abroad for an experimental treatment, what happens when he or she suffers a blood clot that requires expensive follow-up care and even additional surgery? Is medicare responsible for those costs, or is the individual? And what are the obligations on a physician called upon to "fix" a dubious procedure that she knows little about in the first place?
If a Canadian breaks his neck while skiing in the Alps and is left quadriplegic, medicare will cover those costs, no questions asked. If that same person seeks an experimental treatment like stem cells in hopes of walking again but instead suffers expensive complications like a brain tumour, should medicare treat him any differently?
There are no easy answers to these ethical quandaries. But there is no benefit either from keeping our heads buried in the sand.
Medical tourism is here to stay, so we need to debate and understand the pros and cons, chief among them the impact on medicare.