Michael Moore, the CMA and directions for Canadian health care

I just watched Sicko for the second time last night. The catastrophe that is US health care is a clear demonstration that universal, public health insurance works a whole lot better that a system based on for-profit private insurance companies. So, I was thinking about the Canadian system in comparison with Europe, and wondering why we do not have more public insurance than we do.

Our system is universal and free for access to doctors and hospitals; everything else is at the discretion of the provinces, so there is a wide variation in the amount and quality of care for things like home care, long-term care, and pharmaceutical drugs, and almost no coverage at all for things like dental care, physiotherapy and massage therapy. The federal Canada Health Act, while held up as a shrine of sorts, is really just a set of (good) conditions for federal transfers to the provinces for doctors and hospitals.

What stuck to me from Sicko was that in the UK, in contrast, dental care is part of the basic health care package. This is highly sensible: Why should good medical care stop at your teeth? (See this for the case for public dental care.) They also have a standardized price for pharmaceutical drugs, which makes them much more accessible than in Canada. Doctors are on salary, albeit with a new scheme that pays them more for making their clients healthier (thus giving them an incentive for preventative care). And in France they have paid vacations for recoveries from serious illness, and doctors who make house calls in the night – how cool is that?

In Canada, for these areas outside of doctors and hospitals, private insurance companies are big players. This can get complicated as there is generally some public funding, but there are some essential points that are notable. Most of that private insurance is paid for by employers. There are wide variations in the amount of coverage that is included, plus in the deductibles and co-payments. In short, the private insurance for the “extras” operates much like private insurance companies in the US (we just do not get the horrific stories up here, precisely because it does not apply to docs and hospitals).

All of which makes today’s lead story from the Globe and Mail more distressing:

Canada’s doctors want to be able to work simultaneously in both the public and private systems, a flexibility that critics say could lead to queue-jumping and further depletion of public health care.

It’s also a proposal that puts the medical community on a collision course with Prime Minister Stephen Harper, who argues that physicians would have an incentive to stream patients into the private portions of their practice.

In a paper delivered in Charlottetown Monday, the outgoing president of the Canadian Medical Association said his organization “makes no apologies for sparking this necessary debate.”

And that’s not even Brian Day speaking. Day, the extremely outspoken advocate for private care, is the incoming CMA president (see here for more on Dr. Day). The first thing to question is whether we should seriously take policy advice from a group when they have a truly massive financial conflict-of-interest. This is not policy advice like whether children should take aspirin, but a fundamental change in how we provide health care that would line the pockets of doctors and insurance companies.

I doubt Stephen Harper’s sincerity on the incentive problem, but it is, in fact, correct. If doctors can practice in both public and private systems, it is pretty easy for them to tell a patient that they can get an operation tomorrow by forking up the dough, or wait who-knows-how-long to get access in the public system. Do doctors really want to be put in that situation? I would not want to be the patient seeing the good doctor after he learns that fees at the Arbutus Club have just been jacked up.

Anyway, this is just the first step in the game, isn’t it? Once the affluent get used to paying for prompt care in cushy settings with gourmet food, how willing are they going to be to pay higher taxes that support the public system? When doctors can get paid more by switching time to private settings, while the public system gets more and more stretched and stressful, how many will take the plunge?

The Globe story makes it seem like doctors are on one side of the fence, critics on the other. But there is much debate among doctors themselves. For example, there is an alternative group of physicians called Canadian Doctors for Medicare. In their case for medicare, they argue that:

Those doctors who work in privately funded facilities and who value higher incomes over the delivery of equitable care might benefit from privatization if, of course, they can put up with the increased bureaucracy and scrutiny of care that will accompany the introduction of private health insurance. Still, most doctors would not be better off. Conditions in the public system would worsen, the average patient would be sicker and frustrations would be higher. With two tiers of patients there would also be two tiers of physicians. Collegiality would undoubtedly suffer.

The truth is that Medicare is not only good for patients, it’s also good for doctors. The case for Medicare is as strong today as it was in the 1960s, and is now buttressed by strong research and by decades of physician experience and Canadian commitment to the values it represents.

Rather than constantly fighting rearguard actions against measures that will erode our public system, we should instead be seeking to expand the umbrella of public insurance so that we have standardized and high-quality care outside doctors and hospitals. A good place to start would be with drugs, where there are lots of policies that could be put in place to reduce the cost of drugs dramatically (although, the 5 cents in Cuba for a $120 drug in the US is probably a false economy). But this means taking on Big Pharma and Big Insurance, and I do not see any political parties willing to take up that fight.