In our car-centric society, parking matters.
The location of one's parking spot at work and the number of parking spots in your home's garage are status symbols. Urban architectural design seemingly revolves around where and how cars can be parked. "Parking" is often a sexual/relationship milestone. And landing a prime parking spot – close to the door of the mall or a rare meter-less spot downtown – is an exhilarating victory in dog-eat-dog daily life (or humiliating if the spot is stolen from under your nose by someone who is quicker and more ruthless).
One of the few issues that is as emotionally laden as parking in this country is health care.
In other words, the ultimate Canuck hot-button issue has to be hospital parking.
We got a sense of the passion evoked in a recent broadcast of the superb CBC Radio program White Coat, Black Art. Host Brian Goldman told of spending $500 in parking charges over three weeks of visits to his father in the hospital. Many others had similar tales, though many argued against free parking too.
Dr. Goldman said he has rarely seen such a response, and the calls and e-mails from listeners were thoughtful and sincere.
Rajendra Kale, the interim editor of the Canadian Medical Association Journal, took the discussion to another level when he called for the abolition of parking fees at hospitals. The commentary was widely covered by the mainstream media and found echo on social media sites such as Twitter and Facebook.
Dr. Kale argued that parking is essentially a user fee, an unacceptable financial barrier to access to public health care.
The editorial sparked a furious debate, with patients, and to a large extent health-care professionals, lining up to denounce usury parking fees charged by many hospitals as an impediment to good care, and hospital administrators and politicians retorting that parking revenues are an important part of hospital budgets and, without them, care will suffer.
The difficulty is that both sides are right – to a certain extent.
Parking fees – which can be up to $10 an hour at downtown Toronto institutions – really are a burden for many patients and their families, especially if they spend a lot of time in hospital because of a severe illness/injury, or if they visit often for treatment of chronic conditions or rehabilitation.
The glib suggestion that patients take public transit is unrealistic. Most people are not treated conveniently in their neighbourhood, and many travel long distances for care.
Besides, hospitals are a place for treatment of the sickest of the sick. Do we honestly believe that someone is going to hop on the subway or on a Greyhound bus after chemotherapy, or when they are discharged after heart surgery?
That being said, parking fees are not a user fee that violate the terms of the Canada Health Act. To suggest they are is a striking example of how we have truly lost sight of the purpose of medicare.
When Tommy Douglas, the iconic father of medicare, introduced public insurance for hospital care and later physician services, he was clear on one thing: The social program was necessary to ensure that people did not lose their farms/homes to pay for essential medical care. It was never supposed to cover every health cost, direct and indirect, from cradle to grave.
To this day, legislation states that public insurance is designed to cover "medically necessary" services. Medicare was never – and should never be – a program that covers every medical/health intervention, let alone peripheral costs such as parking.
In fact, one of the fundamental problems we have in Canadian health care today is a seeming inability to clearly delineate which services are covered by public insurance and which should be paid with private insurance or out-of-pocket.
Clearly, parking is an out-of-pocket cost that should not be covered by insurance. It is not "medically necessary."
The reality is that being sick can be costly – for the patient and family caregivers alike – and life can get in the way of receiving care in all kind of ways. If you offer free parking, why not pay for everyone's full travel costs (which tend to exceed parking). And why not free daycare or salary replacement when people are in the hospital? And while parking is costly, so too is hospital food.
These are not hidden user fees; they are the costs of daily life and the cost of sickness.
Of course, that position does not preclude the creation of assistance programs for those who cannot afford parking. In fact, many hospitals offer cut-rate or free parking to patients on dialysis or in cardiac rehab programs. Some agencies, such as the Canadian Cancer Society, also have volunteer drivers who bring patients to and from appointments and the society pays their parking.
If you offer free parking at hospitals, what you do, more than anything, is subsidize parking for well-paid health professionals. And if hospitals open up their lots in urban centres, you can guarantee that the spots will be snapped up by local office workers and shoppers. The alternative, validating parking, creates another administrative burden for already stretched hospital workers.
Free hospital parking is a great populist position, but it is fraught with complications.
It's not clear that most patients and family members would be any better off than they are now. Yet, if there is a real benefit that can come from this debate, it will be if it helps us segue into the larger challenge: defining the limits of medicare – a discussion that is long overdue.