Canada's health care system is coming apart at the seams, torn between a desire to uphold a monumental principle and the staggering challenge of delivering on that promise.
Equity - the notion that healthcare should be provided to all without regard to income - is medicare's defining feature.
But the lofty principle loses its meaning if the care provided is not prompt, high-quality, co-ordinated and affordable.
On the ground, there is too often a glaring lack of execution: long waits, bed shortages, unequal access to medication. Those failures are compounded by the fact that the ever-rising medicare bill is squeezing out education and other social priorities.
Together they spell inequity and a growing loss of faith in the system.
Medicare's iconic status, coupled with the well-honed rhetoric of those with a vested interest in the status quo - has created a political aversion to reform.
Instead, we get a lot of chatter-heavy inquiries, lawsuits and legislative tinkering that is address fundamental problems only peripherally.
Other countries with universal health systems - notably those in Europe, which are consistently ranked as the most equitable and cost-effective - have not made Canada's mistake of confusing equity with sameness.
Rather, European countries have done what Ottawa and the provinces know they need to do: Adopt a model that pragmatically mixes public and private elements both in funding and delivery while staying true to values.
But to see how Canada's governments have struggled, one need look no further than the Chaoulli decision. In June 2005, the Supreme Court of Canada struck down a ban in Quebec on the sale of private insurance to cover services also covered by medicare. Many predicted this legal victory by Dr. Jacques Chaoulli (who yearned to open a private hospital) would open up a parallel system - one that might have provided a relief valve for the beleaguered public regime.
Five years after that landmark decision, there has been no seismic shift. The status quo reigns even though the financial pressures on medicare keep growing.
That's because Dr. Chaoulli's legal victory came with conditions. Not only did the ruling apply only in Quebec but the court said private insurance could only be offered if waits were unreasonably long in the public system. The provincial government, in the legislation it fashioned in response, restricted the sale of insurance to three procedures - hip and knee replacement and cataracts - and then invested in those three areas to ensure waits would not exceed three months.
"The government opened up the market to the private sector then immediately gutted that market," says Colleen Flood, scientific director of the Institute of Health Services and Policy Research.
This push-me pull-me approach typifies the overly-cautious Canadian approach. "There's no law that says private health care is illegal. What there is instead is a whole bunch of laws that dampen the ability of private care providers to be parasitic on the public system.
The result is an oft-illogical patchwork that has left Canadians - and to a large extent policy-makers themselves - perplexed. To wit: Physician visits are covered by medicare but the drugs they prescribe are not - unless the patient is over 65; physicians cannot bill patients but they can refer them to imaging clinics and laboratories that do; private clinics can offer knee surgery but not heart surgery; a citizen cannot jump the queue for care unless they were hurt on the job and they are the responsibility of Worker's Compensation; homecare nursing is provided by private companies but hospital nursing is not.
"There seems to be confusion about the legitimate role of the private sector in the health system," as the Organization for Economic Co-operation and Development says in a recent report. That's quite an understatement.
In Canada, the debate about the role of the private sector consists largely of exchanges of rhetoric between those with entrenched ideological positions, i.e. any move to private care will destroy medicare vs. a strong dose of private sector medicine will solve all our health system's woes.Report Typo/Error