When you read about Canadians coerced into paying thousands of dollars for quicker access to health-care services that should be available to them at no cost in the publicly funded health system, it is infuriating.
It feels downright un-Canadian.
But, more than anything, the exposé of queue-jumping and double-dipping by The Globe and Mail's Kathy Tomlinson speaks to the impotence of the regulatory regime.
A small number of physicians – let's not lose sight of the fact that the vast majority are honest and law-abiding – are demanding cash payments from patients for quicker access to surgery and, in some cases, being paid for their services by both the public system and private clinics.
This may well be illegal; at the very least it is unethical. Yet there have been virtually no consequences suffered by those who extra-bill and gerrymander their wait-lists.
In the cases highlighted by the Globe and Mail investigation, there were some interesting excuses offered up for this dubious behaviour, among them that waits are too long, operating time is inadequate and the availability of privately funded care takes pressure off the public system.
There is no question that waits for surgery are too long, a problem far more pronounced in Canada than any other developed country. Queue-jumping would be a non-issue if there were no queues.
A common assumption is that waits are due to a lack of surgeons. In fact, many surgeons spend very little time doing surgery. As one noted in the Globe exposé, he was limited to one day of OR time a week.
So do we need more operating suites? That's not clear either. In many hospitals, operating rooms sit empty much of the time, due to rigid contractual rules about how nurses are scheduled and paid, and caps on how many procedures can be done.
In short, waits are due to an array of engineering and administrative shortcomings.
The solution to these problems is to fix the public system, to make it more efficient, not to throw up our hands and tell people that they have no choice but to pay out-of-pocket for private care.
The other fundamental, recurring issue this double-dipping, queue-jumping scandal underscores is the lack of clarity on what is (and should be) paid for in the public system.
The purpose of medicare is to ensure that no one is denied medically necessary care due to an inability to pay. But we have done a terrible job of defining what "medically necessary" means, and an even worse job figuring out what to do about people who have the ability and willingness to pay for more care. Choice shouldn't be a dirty word.
In legislation, all physician and hospital services are deemed "medically necessary," but no one believes that is true. Similarly, some essential services, such as prescription drugs, homecare and long-term care are not officially covered by medicare, but have been added on.
We have also failed utterly to provide consumer protection to patients who access care that isn't officially medically necessary (read: private).
The result is a free-for-all, as amply demonstrated in the Globe stories. Because it is not entirely clear what is covered by public insurance (and it varies by province), when patients are asked to pay, they tend to do so, especially when they're desperate.
Yet, when they pay privately for care – legitimately or otherwise – there is a total absence of regulation, so prices and quality can vary dramatically.
The proponents of more private, for-profit care often argue that European countries have parallel private and public systems, even for physician and hospital services.
That is true, but what is also true is a) waits are uncommon so accessing private care does not mean preferential services, it's more about non-medical perks; b) there is strict regulation so, for example, a physician who does 10 hours of surgery in private clinics must do 10 hours of surgery in public hospitals and physician fees are comparable in private and public clinics; c) the private-public share of insurance is fairly stable across the board, meaning, for example, that if 80 per cent of hospitals services are covered by public insurance so, too, is 80 per cent of prescription drugs and dental care.
In Canada, when we discuss the merits of other countries' approaches, we tend to cherry-pick what we like and conveniently forget what we don't.
The bottom line is that, in countries that deliver care efficiently and cost-effectively, publicly funded care is administered well, and privately funded care is regulated well.
In Canada, we do neither and, unsurprisingly, we get waits, queue-jumping, extra-billing and much frustration.