Privatization of health care

Marcia Angell has made a very timely and important statement on the privatization of health care.1 There are only 2 objections that need to be addressed before they are raised by the proponents of private health care.

First, there is a strong argument that patients have the right to spend their disposable income as they choose and also that physicians have the right to choose their financial arrangements if they are in private practice. Clearly, the private system must not be allowed to undermine the public system. However, I believe that only a small minority of patients could afford to pay for private health care. Consequently, only a small number of physicians would be able to support themselves in private practice. Thus, this may well be a stable, self-regulating and acceptable arrangement. This needs to be researched.

Second, I am concerned that Angell's comparison of 2 very different systems may not be entirely valid. In the recent past the United States has been a much wealthier country than Canada, and, of course, it has a much larger population. These differences may make it difficult to make direct comparisons.

In Canada we have never had a definition of the “medically necessary care” mentioned in the Canada Health Act. When I was a medical student and a young physician in the 1950s and 1960s, the physician decided what care was medically necessary. With the welcome advent of medicare, the definition was increasingly set by the paying agency in negotiation with organized medicine. Now, with an increasing recognition of patient autonomy, the definition tends to be set by the patient. As a result, there has been lobbying by patients for public funding of alternative medicine and other additional services.

My opinion is that the current so-called fee-for-service system is broken and most of it should be discarded. In family medicine the capitation system has much to recommend it, with the addition of a fee schedule for a short list of specific services, such as night services and services that require procedural skills beyond the usual ones.