If their premier, Ralph Klein, has his way (and he probably will), Albertans will soon be able to have their hip replacements and other surgeries performed at public expense in private facilities (see pages 409 and 411). Klein's third attempt to introduce legislation permitting more surgical services to be provided by the private sector has been challenged by federal health minister Allan Rock, who invokes, once again, the treadworn principles of "our single payer, publicly financed, universal system of health care."1
The Alberta plan is simple. Regional health authorities would shorten waiting times for insured surgical services by contracting private clinics to provide them. All Albertans would have access to these private services at no out-of-pocket cost. As proposed, the changes would not compromise the principles of the Canada Health Act. In fact, there are private providers of insured surgical services in many parts of Canada.2
Both governments are failing to inform their constituents of the facts. Alberta has the lowest health care spending (both per capita and as a proportion of provincial GDP) of any province.3 It is not surprising that Alberta has a problem with waiting lists for surgical services: they don't have enough facilities and surgeons. However, to imagine that the private sector will be able to deliver these services more cheaply than public hospitals is delusional. Private health care is always more expensive.4
It is equally delusional for the federal government to pretend that our public health care system is meeting the ideal of comprehensiveness established in the Canada Health Act. In 1996, private expenditures represented 30.1% of total health care expenditures in Canada and were increasing at 5% per year. Public expenditures were flat or even declining.3 Under the terms of the Canada Health Act, fees cannot be charged for medically necessary services. So what precisely are these private expenditures on health care? Are they for medically unnecessary services? No, they represent expenditures for a cornucopia of services ranging from pharmacotherapy to optometry, home care and physiotherapy. Are they really medically unnecessary, or less necessary? Not if one of your patients needs them.
The federal response to the proposed legislation in Alberta touches on primary care reform, home care, information technology and other themes, and expresses the hope that its pet Waitlist Project for the 4 western provinces, whose conclusions are due in June, will make the problem with waiting lists disappear.1 This hope is a faint one. Nor will it solve the problems of Canadians without access to needed medications, dental care, physiotherapy, home care and other services that are uninsured and thereby deemed "unnecessary."
If we want to maintain universal and comprehensive medicare we can do one of 2 things: increase funding, or ration services. If we want to maintain comprehensiveness without increasing spending, then "medically necessary services" will have to be defined and then rationed. And with rationing there are only 2 options: rationing by exclusion on the Oregon model or by "delay and dilution."5 We favour frank discussion about the former. We are already doing the latter and it doesn't work.