Al Payne thinks the prostate cancer he's currently fighting should have been caught a lot sooner. Had he been living in another province, it might have been.
In early 1998, the 66-year-old Vancouver resident was told by his family physician that the B.C. government wouldn't cover the cost for the prostate specific antigen test if Mr. Payne didn't have noticeable symptoms of the disease. He walked away, figuring it wasn't worth paying for the test out of his own pocket.
But when Mr. Payne's wife told him a year later that an acquaintance died of the condition, he returned to his doctor, who this time did find symptoms and pushed the test through for free. The results were positive, and Mr. Payne struggles with the disease to this day.
"In hindsight, it is easy to see that my cancer should have been discovered much earlier," Mr. Payne said recently. "They don't encourage you to take the test."
B.C.'s approach to the PSA is different from that of some other provincial health systems. Manitoba, for example, does not allow laboratories to charge for the exam, a policy followed by some other provinces.
It's a difference that underscores just how varied Canada's so-called national health-care system can be.
Strictly speaking, the portability principle of the Canada Health Act assures Canadians travelling or living temporarily outside their province that they won't be cut off from care. Practically, however, many Canadians also believe that portability means uniformity across the country. They would be wrong.
While the CHA mandates that all medically-necessary treatments be paid for, many provinces don't fund items like reproductive treatments, some plastic surgeries and some diagnostic tests.
Wide differences also exist in areas such as waiting periods for surgery, lengths of hospital stays and nursing numbers, and in the generosity of various provincial drug and home-care programs. Some provinces pay for eye tests; in others, residents pay premiums.
According to a report by the Canadian Institute for Health Information, the amount of public money spent per person on health care in Canada varies immensely, ranging from a low of $2,181 a year in Prince Edward Island to a high of $2,724 in Manitoba.
Medical experts say the case of the PSA test is a good example of a procedure that provinces are divided over.
Tom Pickles, an oncologist with the B.C. Cancer Agency, said he understands the views of those like Mr. Payne, who want the test to be done routinely. (B.C. men who show no signs of the disease are currently charged about $50 for the test.)
Medical science is debating the effectiveness of the PSA examination.
The test often produces false positive diagnoses, Dr. Pickles noted, and while some individuals may have their cancer detected earlier, in many other cases a false positive can lead to unneeded surgery. That wasn't the case with Mr. Payne, but it has been with other individuals.
Jim Dalton, discipline director for clinical chemistry at Winnipeg's Health Sciences Centre, has studied the way various provincial systems handle the PSA and has noted the differences across the country.
In Manitoba, for example, the government does not allow laboratories like his to charge for the test, while other provinces, such as Alberta, have a policy similar to B.C.'s.
"There is a real lack of consensus on whether or not screening is appropriate, both in guidelines that come from colleges and specialty groups and in the approaches governments have taken to it," Dr. Dalton said.
In his recent report on the Canadian health system, Roy Romanow suggested establishing the Health Council of Canada, with a mandate to examine quality of care issues as well as establishing nationwide indicators and performance measures, including waiting times for certain services. One of the proposed functions of the council would be to facilitate the sharing of information among governments and compare services.
Dana Hanson, president of the Canadian Medical Association, said such an agency would help decision-makers.
"Currently, it's all done in a black box. People don't know who decides," Dr. Hanson said. "If there's solid evidence that the procedure works, then it should be provided from St. John's to Vancouver."
Recently, some experts have begun pointing to the emergence of the positron emission tomography scan (PET), a new tool that helps with diagnoses of cancer. The technology is still relatively young, and there are only three such machines in Canada being used on patients.
Two of those -- located in Hamilton and in Sherbrooke, Que. -- are funded by government, while the third, in Vancouver, requires that patients pay $2,500 a test.
Normand Laberge, chief executive officer of the Canadian Association of Radiologists, believes that Ottawa should insist that the B.C. government immediately begin paying for the tests. Failing to do so will create a precedent under which some provinces will allow private clinics to charge their patients, while other provinces will not.
"The test is efficient, cost effective and medically necessary, and it should be paid for," Mr. Laberge said.
John Smith, vice-president of the company that operates the machine in Vancouver, said he believes B.C. will eventually co-operate with the company in a pilot project that would pay for tests to diagnose certain ailments. Provinces that don't soon do their own analyses of the technology, he added, risk falling behind.
Some health-care experts argue that not all provinces have the fiscal capacity to offer the same services as some of their counterparts, and should not even try. Indeed, creating regional centres for certain procedures would make more sense than having provinces provide a full basket of health-care services.
"We have variations across the country because the provinces are allowed to adapt to local needs and local values," said Pat Armstrong, a sociologist at Toronto's York University.
"It would be dumb, for example, for PEI to do heart transplants."
The same goes for medical schools. New Brunswick receives the bulk of its doctors from Quebec and Nova Scotia because it makes little sense to establish a training facility in such a relatively small province.
Still, Prof. Armstrong said there are some gaps in the system that may require closing.
For example, if disparities in waiting lists become too pronounced, the system will come under attack from patients waiting too long for treatment that can be had quicker in a neighbouring jurisdiction.
It can be difficult to obtain accurate information from province to province on the length of waiting required for surgeries. Some interest groups, however, have produced data that indicate a wide discrepancy.
A survey, for example, of doctors by the Vancouver-based Fraser Institute, a right-wing think tank, suggests that many surgeries have very different waiting times depending on the province in which they take place.
For example, the survey found that the median waiting period for cataract removal ranged from a low of six weeks in Newfoundland to a high of one year in Saskatchewan. Calgary orthopedic surgeon Lowell Van Zuiden, who specializes in knee and hip replacements, said shorter lines in his province sometimes mean patients will come from Saskatchewan for faster access to surgery.
"It comes down simply to the resource availability," Dr. Van Zuiden said. "Certain disciplines just have different access to operating rooms."
In an effort to reduce the lists, a report by the Senate committee headed by Senator Michael Kirby recommends that Canadians be given a guarantee of treatment within a specific period of time.
In a recent interview, Mr. Kirby said the committee's intention was to set maximum waiting times that are consistent across the country. But even he acknowledges that some provinces may argue that such a system will create an unmanageable financial burden on their budgets.
The Kirby and Romanow reports also examined areas that aren't covered by medicare -- such as drugs and home care -- and concluded that the federal government needs to establish at least a minimum level of coverage throughout the country.
On the drug front, almost all provinces currently cover drug costs for social-assistance recipients and seniors, according to the Canadian Institute of Health Information. Again, however, the coverage varies widely.
Quebeckers without private insurance are covered under a public plan that requires a monthly deductible. Other provinces, like Saskatchewan, B.C., and Manitoba, also cover their residents, but require a fairly hefty deductible. In Ontario, only seniors, residents of long-term or special-care facilities and persons receiving home care are covered. The working poor can also apply for help under a special fund, while the rest must depend on their employer, private coverage or their own wallets. Some provinces also cover drugs required for chronic diseases, including HIV/AIDS and diabetes. Here, too, there are differences province to province.
For example, Diamicron, a diabetes drug used to promote the secretion of insulin, is paid for in Alberta but not in Ontario, according to a survey by the Canadian Diabetes Association. Some provinces, such as Ontario, cover the cost of blood glucose strips and insulin injection needs, while others offer neither.
The gap can create a significant hardship for the working poor, said Rhona Lahey, the association's director of public policy and government relations. Moreover, governments that don't pay for such items end up incurring greater costs down the line, particularly if patients become sicker because they went without needed medication. "If you don't pay for these items at the front end, then a province will end up paying for them later, except it will be far more expensive because they will be dealing with it in a catastrophic way," she said.