The Liberals are taking a pasting in the press for their latest attempt to demagogue the health care issue, once again pretending to be scandalized at the thought of the private sector playing a role in a health care system that has always assigned a large role to the private sector – not least under the Liberals.
Squads of critics have pointed out that nearly a third of Canadian health care spending is private – that medicare only covers a comparatively limited range of “medically necessary” services, while excluding whole categories of care such as vision care, dental care, and drugs (except as dispensed in a hospital).
More to the point, much of what is spent publicly on health care goes to private providers, from the makers of the latest advanced machinery in the hospitals, to the specialized clinics offering diagnostic and other services, to the nation’s doctors, the vast majority of whom are private businesses.
But that’s the point: it’s the government, not the patient, that pays them. The principle on which our health care system is based is public funding, not public provision. There is plenty of room for private providers to operate within the universal, single-payer, free-to-the-patient medicare model.
So when Justin Trudeau warns, darkly, that his opponent would allow “private, for-profit” providers to defile our sacred public health care system, he is only describing the status quo. That the Liberals were caught doctoring a video in which Erin O’Toole professes his openness to private care, as long as “universal access” is maintained, only completes the debacle.
But. Take a closer look at that video. It wasn’t just the concept of private providers Mr. O’Toole endorsed, in a question-and-answer session during last year’s Conservative leadership campaign. It was the specific merits of a Saskatchewan policy allowing private MRI clinics to charge fees, so long as for each scan they charge for they provide another one for free. Mr. O’Toole pronounced it “brilliant.”
The Saskatchewan policy is certainly a wrinkle on the usual user-fee model. But it doesn’t fundamentally alter anything. The private clinic may be returning a part of the revenue from the fee in the form of additional capacity. But it is still offering faster access to a service to some patients than others, based not on need but ability to pay.
More precisely, it is offering faster access to a publicly funded service. It’s one thing for people to pay out of pocket for a service they cannot obtain from the public system, or not on a timely basis. People will do what they have to do for themselves and their loved ones, and it is both heartless and futile to try to stop them. Indeed, the practice is quite legal – so long as the provider has opted out of medicare, and the purchaser pays the full price.
It’s when you mix public and private funding, charging fees for services already covered by medicare, that you run into trouble. The whole point of a publicly funded system is to ensure that ability to pay does not decide who gets care. A system that gives first claim on public dollars to those rich enough to supplement them with their own – that lets them pay for privileged access to services that were meant to be available equally to all – is a contradiction in terms.
This distinction – between private provision and private payment; between charging the government for services versus charging patients for them – is one that seems to elude both sides of the debate. Opponents of “private for-profit” care like to pretend – or perhaps sincerely believe – that if we so much as let the private sector clean the towels in our hospitals we might as well install cash registers in the operating rooms.
But proponents of private care seem prone to the same error. So eager are they to show that private providers are not a threat to universal access that they are willing to overlook practices that are in fact the very antithesis of universal access.
They are right to believe private providers are not, by themselves, a threat; indeed, competition in service delivery, by improving efficiency, can free up the resources needed to shorten waiting lines, making timely access to care, increasingly a theoretical notion over much of the country, more nearly a reality.
But user fees do not confer the same benefit. They may shorten wait times for some – those in a position to pay – but not for the population as a whole. Why? Because health care does not work like other markets: it is not possible for consumers to shop around for the most cost-effective care in the same way as they would for, say, a refrigerator. The patient simply doesn’t have that kind of knowledge.
It’s certainly true that health care should be priced – for without prices, efficient use of resources is impossible. Somebody in the system, at some level, ought to be paying them. But it needn’t, and shouldn’t, be patients. Rather, what’s needed are patient surrogates, empowered to negotiate with hospitals, specialists and other providers on patients’ behalf. And who better to do so than their GPs?
That’s the idea behind the capitation-based models that are slowly being rolled out across the country. Groups of providers are given a block of funds for every patient they enrol (with extra funds for patients from high-risk groups), out of which to pay for whatever services the patient needs.
That distributes decisions about care down to the patient level – rather than remote government health departments, or scarcely-less-remote regional health authorities – without actually requiring the patient to make them.
Here’s the second but: These are, in the end, decisions for provinces to make. User fees may be a bad idea, but the provinces are just as capable of figuring that out as the feds, and there seems no good reason for Ottawa to be second-guessing their decisions in a field that, constitutionally, remains a provincial responsibility.
Once, there might have been an argument for attaching conditions to federal transfers, in the name of national standards. But given the enormous fiscal crisis the provinces are facing, under the pressure of an aging population, the focus should now shift to affording them the flexibility they need to address this challenge: to experiment, to innovate and yes, to make mistakes.
Give them the funds, or better yet give them the taxing power, and let them be accountable to their own citizens for the results. That, not warmed-over scare stories about private care, is the discussion we should be having now.
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