Canada rethinks its Medicare

Alberta's premier proposes a bigger role for private clinics in

It would be hard to overestimate the importance to Canadians of their universal-access Medicare, both as a valued service in itself and as a symbol of what makes their country a kinder, gentler alternative to their neighbor to the south.

Canada, in fact, is the only major developed country whose basic health-care costs are, nominally at least, shouldered completely by the public system, with no parallel private system. So when Ralph Klein, premier of Alberta, the province often referred to as "Canada's Texas," announced a plan last month to let private clinics perform certain operations hitherto done at only public hospitals, he was blasted for trying to lead the country down the path to a "two-tier" health system.

But however vocal the critics are publicly, many are studying Mr. Klein's proposal carefully. They see it as helping open a much-needed national debate on how to change the system as the population ages and pressures remain to hold overall public spending in check.

"The whole system is in peril," says William Orovan, a surgeon in Hamilton, Ontario, and past president of the Ontario Medical Association. "Some Canadians ... feel that the health-care system has come to define us as a nation. But we shouldn't let our emotional attachment to our current system dissuade us from having the discussion we need to have."

The Quebec Hospitals Association recently called for new ways of financing hospitals, as well as a national debate on whether certain expensive treatments can be cost-justified for elderly patients.

Even federal Health Minister Allan Rock, in a letter seeking clarification on the Alberta proposal, acknowledged that Medicare - the national health service - needs to be "renewed substantially," adding, "I believe the status quo is not an option."

Hospital cuts

Across Canada, hospitals are already in tough financial straits. The governing Conservatives in Ontario have closed 44 hospitals since 1995 and are said to be preparing for another round of cuts. Yet just last week, Toronto hospitals were turning away ambulances, citing overcrowding in their wards.

"If the system is under severe strain in 1999, where is it going to be in 2010, when baby boomers move into their 60s and 70s?" Ottawa political analyst Bruce Campbell asks.

The sense that "something's got to give" is percolating through to the grass roots, too. The national polling firm Pollara found recently that 73 percent of respondents agreed that "Canadians who do not receive timely access to quality care in the public system should have the option" of seeking care elsewhere.

But Don Guy, vice president in Pollara's Toronto office, cautions against seeing this as a vote for private health care. He explains, "The background of this is that most Canadians continue to believe that not enough money is being put into the health-care system.... Governments have been making cuts contrary to public wishes." Indications of public willingness to pay some fees out of pocket to reduce or avoid waiting lists should be seen in this light, Mr. Guy says.

A new study suggests, however, that concerns about waiting lists may be exaggerated. "The key is a properly managed waiting list," says Dale McMurchy, a consultant with the health-care section of PricewaterhouseCoopers LLP in Toronto. Her firm's study, "The Health Insider," found, among other things, that waiting lists "are not the problem they're made out to be." Not that some people aren't waiting longer than they should have to for surgery or diagnostic procedures, she hastens to add. "But that may be a management problem rather than a health-care-system problem."

Federal provisions for care

Analysts have mixed opinions whether the Alberta proposal violates the Canada Health Act, the 1984 federal law that underlies the Medicare system. It provides universal, publicly funded access to "medically necessary" health services.

This may sound simple, but there are complexities. Private clinics also provide services, such as diagnostics, vision and dental care, and outpatient surgery. The costs for these are covered in some cases by public funding and in others by private insurance. Individuals can also opt to pay more for extras such as private rooms in hospitals - in some cases, even in public facilities.

In addition, some provinces routinely send patients to the US for medical treatment - on the Canadian public dime. And many affluent Canadians simply jump the queue by traveling to the US for treatment at their own expense. (The United States, in fact, is the only major developed country without a publicly funded basic health-care system.)

All these extras add up. As a result, Canadians tend to overestimate the degree to which their system is publicly funded - only about $50 billion (Canadian; US$34 billion) out of $80 billion in total health-care costs. (The other $30 billion is paid out of pocket or by insurance.)

The Klein government plans to get its new policy codified into legislation next spring. But right now, Guy of Pollara says, "Health care is not a mature issue yet, in terms of the public debate."

(c) Copyright 1999. The Christian Science Publishing Society

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