Winds of change
Last June's Supreme Court of Canada ruling, coupled with growing wait-time angst have prompted 3 provinces to open the door, at least part way, to the private delivery of health care. The Alberta government has announced it will allow physicians to work in both the public and private sector, while Quebec has pledged to provide hip and knee replacements and cataract operations within a timely 6 months — or it foots the tab at private clinics. British Columbia is also poised to plunge into the privatization fray according to its recent Throne Speech. Read on for the details of this evolving story.
The province of Quebec is proposing a “new era” in health care standards, guaranteeing timely access to ageing Quebecers in need of knee or hip replacements or cataract surgery — and offering a limited role to the private sector to ensure no patient waits for those operations beyond 6 to 9 months.
Premier Jean Charest and Health Minister Philippe Couillard released a policy paper outlining their proposals on Feb. 16. They were responding to June's Supreme Court of Canada ruling, which struck down the province's prohibition on private medical insurance. In a landmark 4–3 decision, the court agreed with Quebec physician Jacques Chaoulli that his patient George Zeliotis's year-long wait for hip replacement surgery in 1997 violated Zeliotis's right to life, liberty and security under Quebec's Charter of Rights.
In a reluctant nod to the ruling, Couillard said the government will allow Quebecers to buy private insurance — but only to pay for hip and knee replacements or cataract removals performed by the few Quebec specialists who have opted out of the public health care system. Such insurance would likely be expensive and therefore an unattractive option for most Quebecers, especially if they are guaranteed access to surgery within a legally proscribed time frame, Couillard acknowledged.
The other option for patients is what Charest calls Quebec's “health guarantee.” It states that if patients awaiting those 3 elective procedures cannot undergo surgery at a public hospital within 6 months, the province will pay to have them treated at a private clinic in the province. The doctors working in these clinics have not opted out of the health care system but they have chosen to expand their practice into a private setting. Establishing these specialized clinics was a key recommendation of Quebec's Clair Commission in 2000.
“These clinics will be partners in the health system,” said Couillard. “They will belong to doctors participating in the Régie de l'assurance maladie (Quebec's health insurance board,) they will be built and equipped by those doctors, and the government will buy their services from them at no extra cost to citizens.”
If those clinics — or other public hospitals in Quebec and elsewhere — are unable to treat a patient within the guaranteed time, then Quebec would pay doctors who have opted out of medicare to perform the surgery.
Quebec will control how many doctors it will allow to withdraw from the public system, like Dr. Nicolas Duval, who runs a for-profit orthopedic surgical centre in Laval, Couillard says.
“How do you set it up so that, from one day to the next, you don't have 100 orthopedic specialists who decide to leave the system?” Couillard asked. The health minister believes most doctors prefer to remain in the public sector. Only 100 of the province's 18 504 practising physicians now work outside the Régie.
The province does not want to provide incentives for doctors to leave the public system, further aggravating Quebec's shortage of specialists and general practitioners. For that reason, says Couillard, doctors will not be allowed to move back and forth between the public health insurance plan and the private sector.
The province plans to hold legislative hearings on its proposals in April, and has invited public comment on the 60-page consultation paper. The plans are due to be finalized before the June 9 deadline that the Supreme Court imposed for implementing its ruling.
Chaoulli says the policy paper is an affront to the people at the heart of the ruling: patients. “The point is not whether the government will be satisfied with the waiting time. The point is whether a given patient considers himself to suffer.”
“What I wanted to see is a movement toward the freedom to choose for the patients — between private health care and public health care.”
Despite Charest's avowed commitment “first and foremost” to the public health care network, too many elements of the plan remain vague, says Michel Venne, the director of l'Institut du Nouveau Monde, the independent organization that hosted a symposium on Quebec's private–public health care debate in February.
Marie-Claude Prémont, an expert on health care law and public policy in McGill University's law faculty, worries Quebec risks opening a Pandora's box by allowing for the possibility of contracting out operations to doctors who have left the public system, even though Couillard insists that is only a last resort.
“It means a physician who opts out no longer has really opted out, if he or she can be paid by public money,” Prémont says.
Rénald Dutil, the president of Quebec's Federation of General Practitioners, said he is pleased the government plans to restrict the right to purchase private insurance. But he said his members have many questions about how the access guarantees will work. Waiting times don't begin the day your name is added to the list for surgery, he says. “What about the time leading up to that?”
The government will have to find a way to take those waiting times into account, he says — and that means tackling the chronic and pressing issue of improving access to family physicians and primary care.
Footnotes
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Loreen Pindera is a journalist with CBC Radio in Montréal.