After 5 contentious years of lobbying and revision, it seems likely that a patients' bill of rights will be signed into law in the United States. The Democrat and Republican versions of the bill both hammer out the same points: health insurance plans must provide prompt access to specialists; access to obstetricians and gynecologists without a referral; and emergency care at the nearest hospital, even one not affiliated with a patient's insurance plan.1 And they give patients the right to sue health maintenance organizations (HMOs).
About 80% of Americans belong to HMOs, mainly through contributions to their employers' health plans. Car manufacturers in the US spend more on health care than on steel; in 1995 General Motors, the largest purchaser, spent US$3.6 billion on health care for 1.6 million people.2 Big employers not only shop around for cheap HMOs, but form “partnerships” with them, finding ways to make health care delivery more efficient. For their part, HMOs seek employers with a healthy workforce and restrict the kind and extent of services they provide. This is fine if you're not pregnant, old or chronically ill. In the end, an insurance contract, not a physician, may decide what tests are ordered, when a referral is made and what treatments are offered.
The impetus for the patients' bill was public dissatisfaction with HMOs, whose fine print on claim forms, discriminatory exclusions (contraception being one), and reputation for inadequacy and heartlessness have made them the most hated institutions in the US. But the bill may be little more than a feel-good solution. It's estimated that legal fees and claims resulting from the patients' bill of rights will boost premiums by 2.9%.3 The fear is that, to hold premiums down, employers will cut benefits, deny coverage to family members and part-time workers, impose longer waits for eligibility, and so on. The ranks of the 44 million uninsured will grow.
Does Canada need a patients' bill of rights? Is each province just a large HMO?4 The Ford Motor Company has a workforce roughly twice the size of the population of Prince Edward Island. Happily, there are some differences between corporate employers and the government of PEI; for one, an elected government has responsibility for all citizens, not just the healthy and wealthy.
The pillars of the Canada Health Act — public administration, comprehensiveness, universality, portability and accessibility — are often invoked as if they constitute some sort of patients' bill of rights. In fact, they do not. The pillars represent what is required of the provinces for them to receive health care transfers from the federal government. Ideologically, the effect is the same. So far, Canadians have gone in for grand principles that are politically (and hence precariously) guaranteed and have not attempted to codify their expectations in law — as the Americans are doing. Until our pillars crumble to the point of collapse, they may be all we need. Since, unlike American auto workers, we have the right to elect the officers of our HMO every 4 or 5 years. — CMAJ