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Doctor Javier Teijeira is performing an open heart surgery in order to replace a malfunctioning valve. The surgery took about 4 hours and the patient heart stopped for about one hour. (Charles-Antoine Auger/The Canadian Press Images/Charles-Antoine Auger)
Doctor Javier Teijeira is performing an open heart surgery in order to replace a malfunctioning valve. The surgery took about 4 hours and the patient heart stopped for about one hour. (Charles-Antoine Auger/The Canadian Press Images/Charles-Antoine Auger)

Part 2: Canada, it's time to get our Health Act together Add to ...

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.

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