Medical Device Daily Contributing Writer

Those who pay attention to Canada's healthcare system – notably doctors, patients and healthcare officials – felt a perceptible shudder beneath the ground this year as three provinces announced new initiatives aimed at shaking up the concept of public vs. private healthcare.

Quebec, Alberta and British Columbia have each concluded that more must be done to eliminate long surgical waiting lists and that this can't be accomplished by too prescriptive a reading of the Canada Health Act, the document which says only public money may be used to pay for medically necessary procedures.

The province of Quebec got the ball rolling early in the year when it decided to lift the ban on private health insurance for several elective surgical procedures and announced it would pay for those surgeries at private clinics.

That announcement came in the wake of a June 2005 Supreme Court of Canada decision striking down a law banning private medical insurance and ordering the province to initiate a reform program within a year.

“The case basically said if the government through the public healthcare system could not provide timely care then they had to provide an alternative,” Dr. Ruth Collins-Nakai, president of the Canadian Medical Association (Ottawa), told Medical Device Daily, “and one of those alternatives was the provision of private insurance for otherwise publicly insured services.”

Collins-Nakai, however, called the court's ruling “very conditional” in that it allows the province to “provide a public alternative as a first line alternative” to private care.

Still, she acknowledges the significance of the province's decision to draft legislation that will for the first time in Canada allow patients to seek private healthcare when benchmarks for timely public health care have been breached.

The second tremor felt across the Canadian healthcare system came in March when the Premier of Alberta threatened changes that could potentially rock the Alberta and Canadian healthcare systems to their foundation – by allowing doctors to work in both private practice and public hospitals.

Ralph Klein quickly backed off after both Canadian Prime Minister Stephen Harper and federal Health Minister Tony Clement expressed concern that such a move could violate the Canada Health Act and force Ottawa to penalize Alberta by withholding federal transfer payments. But most agree with Klein who insists his idea for more private care will become law not long after he leaves office later this year.

“It's being postponed, but someone is going to have to deal with it,” he said.

Klein's proposal is a “direct challenge” to the Canadian Health Act, Dr. Brian Day told MDD, “and very significant” because it would effectively set up what opponents of private healthcare in Canada have long feared: a two-tier system of healthcare.

“It's closer to a European system where there is universal healthcare and a complementary private system running alongside it. They just did a poll in Alberta and there seems to be very strong support for the changes being proposed, by about 70%.”

For his part, Day supports more private Canadian healthcare. His opinion is particularly meaningful because he is B.C.'s nominee to replace Dr. Collins-Nakai when her term expires in 2007.

Co-founder of the private Cambie Surgery Centre in Vancouver, he is also a far more vocal supporter of private care than the current CMA head, arguing that Canadians have been “misled” about the performance of the Canadian public healthcare system and pointing to the World Health Organization (Geneva) as proof: the WHO ranks Canada 30th in the world for quality care and dead last as the most expensive healthcare system per capita than any other nation worldwide.

“And we have two million Canadians in the words of the Supreme Court of Canada “suffering and dying on wait lists,” and yet countries like France and Belgium and Norway have no wait lists, and spend much less than us and are ranked in the top five.”

“If [Medicare] is something we should be clamoring to save,” Day said, “well, I don't understand why. It's a system that's falling apart and it needs massive reform.”

The position of Collins-Nakai's own organization on publicly funded healthcare, she says, is that the CMA supports it.

At last summer's annual meeting the “overwhelming majority” of CMA delegates supported a resolution that Canadian patients “should receive timely access to quality care based on need and not on ability to pay.”

But even Collins-Nakai says the Canadian healthcare system needs fixing.

“Doctors have been concerned about access of patients to quality care for some time because we see what happens to patients who can't get the care and they're left in limbo.”

That concern is shared by the Premier of British Columbia who travelled to Sweden, Norway, France and the UK this spring to see how a mix of public and private healthcare worked there.

While Gordon Campbell has yet to reveal his findings, a question posed in his government's throne speech in February was significant because of its suggestion that in the absence of real high quality patient care, a balance might have to be struck between the principles of public and private healthcare.

“Why are we so afraid to look at mixed healthcare delivery models, when other states in Europe and around the world have used them to produce better results for patients at a lower cost to taxpayers?”

Campbell has promised to enter into a “dialogue” with British Columbians about the future of healthcare in that province, but it's clear, says Day, that the provincial government, like provincial governments elsewhere, is alarmed by the state of healthcare and the ability of provincial coffers to underwrite the cost.

“Healthcare is consuming 45% of the provincial budget in every province pretty well, and it's heading to a 100% if someone doesn't introduce some kind of reform,” he said. “Canadians have been promised everything for free in unlimited mounts and it's impossible. You can't deliver that and they haven't been delivering it, and that's why we have two million Canadians on wait lists.”