CMA proposes options for private–public split

Canadians and physicians must decide the degree to which they would like to increase private health care financing and delivery in light of the unsustainability of the existing system.

The CMA unequivocally states in its June 7 discussion paper, It's about Access! Informing the Debate on Public and Private Health Care (www.cma.ca), that the status quo is not tenable and delineates 4 options Canadians may consider in reforming the system.

Delegates at the CMA Annual Meeting Aug. 21–23 will be asked to use the paper to reconsider the private–public split. The CMA has traditionally supported a public system.

More privatization, however, may be problematic, the paper states, noting that reform of the system may be all but impossible without a significant increase in the number of physicians.

Drawing on international data and feedback from some 2800 Canadian doctors, the paper sketches 4 possible scenarios for the evolution of the Canadian system:

1. Status quo

2. Medicare plus: Including an evaluation of the basket of insured services, more cost-sharing arrangements (e.g., premiums), allowing physicians to opt out, and allowing Canadians to buy private insurance for some services and to get paid care elsewhere if wait times are exceeded (safety valve)

3. Medicare complemented: Including a safety valve for more procedures, an expanded range of privately funded services (and private insurance for the same), and allowing physicians to deliver medically necessary services under both publicly and privately funded systems

4. Medicare plus parallel private: Public services for all, but Canadians will have the option of private insurance for a full range of hospital and medical services.

None of the scenarios completely meet all the paper's 10 recommended guiding principles for the future of health care, CMA President Ruth Collins-Nakai said during the paper's release.

“At some point Canadians have to decide whether or not they want to continue with a tax-supported collective health care system or whether they wish to go with a more private, individual-rights type of system and ignore the collective. That's what it comes down to. Or whether they want something that is somewhere between those 2 extremes.”

An Ipsos Reid poll released in conjunction with the paper seems to indicate Canadians have already made that choice. Of the 1000 adults polled (accurate ± 3.2%, 19 times out of 20), 30% preferred scenario 3 and 29% preferred scenario 2, 26% the status quo and only 15% scenario 4.

The enhanced medicare scenario consistently garnered the best rating for overall impact (81%), timely access (78%), comprehensiveness (79%) and equity (74%). Scenario 4 had the lowest overall ratings.

Scenario 3 and 4, which advocate an extended role for private financing, will significantly alter the 70:30 public–private funding split that has characterized Canadian medicare financing for the past 3 decades.

The new advocacy group, Canadian Doctors for Medicare, criticized the CMA for even considering scenario 4. Its Chair, Dr. Danielle Martin, says a “duplicate system is basically anathema to Canadians.” The paper itself concludes that in countries with a parallel private system, access is increased for a very small number of people but “significantly compromises access for everybody else.”

Martin says it's incumbent on the CMA to make it clear that it does not support a duplicate system. “Ultimately, the CMA is going to have to lead on this issue. … We'd like to see that commitment made without any equivocating.”

The Canadian Association of Internes and Residents went one step further, calling on the CMA to reject private health insurance outright. President Dr. Jerry Maniate says given the existing human resource shortages, “there is a serious risk that channeling these resources into a parallel privately funded system would, instead of reducing, actually increase wait times for the majority of Canadians, who could not afford private insurance.”

The Fraser Institute, a think tank group, chided the CMA for failing to articulate options that are available other than the 4 scenarios. Director of Health and Pharmaceutical Policy Brett Skinner said the paper's authors overlooked “the most successful model” in the world, the one used in Switzerland, in which all health care is delivered privately, while the system is funded entirely by mandatory public insurance (much like auto insurance in Canada).

Skinner also said the relatively low level of public support for a duplicate system that was evident in the poll was strictly a function of Ipsos Reid having surveyed healthy Canadians, rather than those who are severely ill or who had recent experience with medicare.

The discussion paper was developed in response to resolutions at the August 2005 CMA Annual Meeting that endorsed private health insurance and private-sector health services for patients who don't get timely treatment through the public system. A CMA “blueprint” on the private–public split was promised for February 2006. Collins-Nakai said a paper was presented to the CMA board in February, but they wanted the discussion paper to coincide with the 1-year stay in the Chaoulli Supreme Court decision (see page 17).

With this paper now slated to guide discussion at the CMA Annual Meeting in Charlottetown, Collins-Nakai indicated the physician community appears as split as Canadians on the question of privatization.

Paper coauthor Dr. Robert Hollinshead, a Calgary orthopedic surgeon, said that split is a function of the fact that specialists are “extremely frustrated over the pace of reform.” He added, “We see the potential that the private system, if it was publicly funded, could help deal with these very long waiting lists.”

The paper sketches the experience of the other 30-member countries in the Organisation for Economic Co-operation and Development (OECD) in terms of the public–private characteristics of their health care systems. It states that, “Contrary to popular belief, Canada relies heavily on private spending and private health insurance as a means of financing health services.” Canada's public spending as a share of total health care expenditures is below the OECD average (70.9% compared with 73.5%).

The only countries where private health insurance accounts for a larger share of total health care expenditures are France (12.7%), Germany (12.6%), the Netherlands (15.2%) and the US (35.1%).

Canadians also spend more on private health insurance than the OECD average (11.4% v. 6.3%) although out-of-pocket payments are less (15.8% v. 17.7%).

The paper indicates that it may well be impossible for Canada to adopt any alternative to the status quo without significantly increasing the number of physicians and hospital beds. It states that “All 12 countries with parallel private systems have a higher ratio of practising physicians to population than Canada.” Canada had the lowest ratio of physicians to 100 000 population at 2.1; the highest is 4.4 in Greece.

Collins-Nakai acknowledged that the health human resource (HHR) shortage must first be resolved, but believes a welcome-mat for ex-pat Canadians would help redress the deficiency. She also indicated a national HHR strategy must be developed to ascertain the appropriate physician ratio that Canada needs for each of the 4 scenarios.

Maniate from CAIR says the paper has a “misplaced focus on introducing private insurance [that] deflects attention from the fundamental importance of [HHR].”