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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.

Yet, the reality is that, like it or not, there is already a lot of private care in Canada: About 30 per cent of Canada's $192-billion in annual healthcare costs are paid out-of-pocket or with private insurance.

Moreover, the vast majority of care - about 70 per cent by some estimates - is delivered privately and that includes "medically necessary" services provided by physicians (who, for the most part, are independent contractors) and by healthcare institutions that are almost exclusively not-for-profit corporations.

"People get all tied up in knots about private-public when they should be focusing instead on ensuring we have a system that delivers the highest quality care in a cost-effective manner," said Jeffrey Turnbull, president of the Canadian Medical Association.

As Dr. Turnbull says, it is imperative that Canadians get away from the notion that there is black-and-white choice between public and private.

"There is no one-size-fits-all model for funding and there's no one-size-fits-all model for delivery. There is a spectrum," Dr. Turnbull said.

And in that spectrum lies the opportunity to create a more responsive, innovative health system.

Canadian health care is unusual in that the system is bifurcated. There is virtually no private insurance or private delivery in some areas (like physician services - which are 98 per cent public) and in other areas there is virtually no publicly insured or delivered care (like dentistry - which is only five per cent publicly-funded).

By comparison, in European countries, there is almost always a private option for consumers and, at the same time, there is greater public funding and regulation for every aspect of the health system. For example, in France, only 74 per cent of physician services are paid from the public purse and, in Germany, 68 per cent of dental care is covered by public funding.

This approach, generally speaking, has resulted in lower per capita health costs and better outcomes.

"Canada has the second most expensive health system in the world in terms of GDP but we don't have the second-best health outcomes in the world," said John Manley, president and CEO of the Canadian Council of Chief Executives. "We have an expensive system with mediocre outcomes - it seems to me we can do better."

In its recent review of the state of the Canadian economy, the OECD said bluntly that Canada will not be able to rein in government deficits and debt unless it finds a way to limit public spending on healthcare.

Those financial challenges are widely acknowledged - after all, health accounts for almost half of spending in most provinces - but there has been reluctance to follow the prescription of the OECD and others: to take pressure of the public system by allowing more private care and raising new revenues with measures like user fees.

Whatever the solutions, they will first require policy makers to stop hiding behind the Canada Health Act, legislation that is revered for its principles but which, in practice, has become a paper tiger.

The federal law sets out five criteria that provinces must meet if they want health funding from Ottawa - public administration, comprehensiveness, universality, portability and accessibility. But as federal contributions have diminished - over time Ottawa has gone from paying 50 per cent of medicare costs to less than 25 per cent - so have the government's ability (morally if not legally) and interest in enforcing the law.

The practical result is that provinces are expanding the use of private providers and gradually letting restrictions melt away (often in the face of legal challenges or outright flouting of the rules) while, simultaneously, expanding into areas that were not traditionally covered by medicare like prescription drugs and homecare.

In other words, the private-public mix is changing, but without public discussion, and not always coherently.

Quebec has gone further than any other jurisdiction, quietly becoming the hotbed of private healthcare by adopting legislation that allows 56 surgical procedures to be done in private clinics. They are de facto private hospitals.

But, again, there is a catch: The provincial health insurance plan has priority in these clinics. So, in the end, the government is essentially contracting out services.

At the same time, Quebec is the only province with a universal pharmacare program. The law decrees that everyone must have prescription drug insurance: Employers must provide the insurance to workers, while others must buy private insurance or, if they are seniors or low-income, register for government-sponsored prescription drug insurance.

Armine Yalnizyan, an economist at the Canadian Centre for Policy Alternatives, said the real strength of medicare is the single-payer system that it provides universal coverage for medically-necessary services.

"The quintessential Canadian lesson is: Pool risk. It's not about public or private, it's economies of scale that matter," she said.

If anything, Ms. Yalnizyan said, Canada should be looking to expand large-scale insurance programs into areas like prescription drugs like many European countries have done.

But, at the other end of the spectrum, what role should private (and even private for-profit) entities play? Does allows those who can afford to pay for care actually undermine the principle of equity?

Janice Mackinnon, finance minister in a NDP government of Roy Romanow and now a professor in the school of public health at the University of Saskatchewan, says opposition to private care delivery does not come primarily from the general public. They care not a wit if services are delivered by private entrepreneurs, non-profits or public employees, as long as access to care is fair (not necessarily identical for everyone) and affordable.

She says ordinary people seem to understand better than politicians that public spending needs to be reined in and new approaches are required, while opposition to change comes from well-organized lobby groups representing physicians and nurses.

"These groups are very powerful and politically astute and they like the status quo," she says. "But the status quo isn't working. We need to try some new approaches."

First and foremost, we need to throw off the shackles of the Canada Health Act, a well-meaning law that has become an impediment to reform.

The CHA, in its current form, perpetuates a fundamental absurdity of medicare: The universal single-payer model applies only to "medically necessary" physician and hospital services. Focusing on doctors and hospitals made sense in 1960 but not does not in 2010; and leaving the term "medically necessary" undefined suggests that medicare must provide all care to all people - an unrealistic expectation that has driven costs through the roof.

Similarly, the law suggests that having patients pay for care - out-of-pocket or with private insurance - is unlawful when, in reality, it is commonplace.

While the CHA articulates some fundamental principles, there are also some important ones missing like accountability, sustainability and patient-centeredness.

Adopting those values is a good a way as any to kick-start a much-needed reform of the system. They would remind us that delivering affordable, timely care in practice is much more important than merely doing so in principle.