In Canada, a move toward a private healthcare option
In British Columbia, private clinics and surgical centers are capitalizing on patients who might otherwise pay for faster treatment in the U.S. The courts will consider their legality next month.
By Kim Murphy
September 27, 2009
Reporting from Vancouver, Canada
When the pain in Christina Woodkey's legs became so severe that she could no long hike or cross-country ski, she went to her local health clinic. The Calgary, Canada, resident was told she'd need to see a hip specialist. Because the problem was not life-threatening, however, she'd have to wait about a year.
So wait she did.
In January, the hip doctor told her that a narrowing of the spine was compressing her nerves and causing the pain. She needed a back specialist. The appointment was set for Sept. 30. "When I was given that date, I asked when could I expect to have surgery," said Woodkey, 72. "They said it would be a year and a half after I had seen this doctor."
So this month, she drove across the border into Montana and got the $50,000 surgery done in two days.
"I don't have insurance. We're not allowed to have private health insurance in Canada," Woodkey said. "It's not going to be easy to come up with the money. But I'm happy to say the pain is almost all gone."
Whereas U.S. healthcare is predominantly a private system paid for by private insurers, things in Canada tend toward the other end of the spectrum: A universal, government-funded health system is only beginning to flirt with private-sector medicine.
Hoping to capitalize on patients who might otherwise go to the U.S. for speedier care, a network of technically illegal private clinics and surgical centers has sprung up in British Columbia, echoing a trend in Quebec. In October, the courts will be asked to decide whether the budding system should be sanctioned.
More than 70 private health providers in British Columbia now schedule simple surgeries and tests such as MRIs with waits as short as a week or two, compared with the months it takes for a public surgical suite to become available for nonessential operations.
"What we have in Canada is access to a government, state-mandated wait list," said Brian Day, a former Canadian Medical Assn. director who runs a private surgical center in Vancouver. "You cannot force a citizen in a free and democratic society to simply wait for healthcare, and outlaw their ability to extricate themselves from a wait list."
Yet the move into privatized care threatens to make the delays -- already long from the perennial shortage of doctors and rationing of facilities -- even longer, public healthcare advocates say. There will be fewer skilled healthcare workers in government hospitals as doctors and nurses are lured into better-paying private jobs, they say.
"What it means is that people who have no money, who are chronically ill, disabled, who require medical attention frequently, are going to suffer dramatically," said Leslie Dickout of the B.C. Health Coalition, which is involved in the lawsuit to determine whether the Canadian Constitution guarantees citizens the right to choose their own care.
"There's so much money to be made by the insurance industry," she said. "If this [legal] case succeeds, what we would have is a system of U.S.-style healthcare -- along with a public system that is decimated."
Indeed, an investment group backed by Arizona businessman Melvin J. Howard this year filed a $160-million challenge under the North American Free Trade Agreement, demanding that U.S. healthcare companies gain access into Canada. The consortium hopes to build Canada's largest private health center in Vancouver, offering orthopedics, plastic surgery, general surgery and other services.
In many ways, the prospect of private investment is alluring in British Columbia, where the provincial government, like those all across Canada, funds the healthcare system. Provincial officials recently announced a $360-million shortfall in the $15.7-billion healthcare budget for the fiscal year that ends in March.
The shortage will mean fewer surgeries and longer waits.
The Vancouver Island Health Authority has said it would reduce the number of nonemergency MRIs by 20%; nonemergency patients now are being booked for scans in March.
Vancouver Coastal Health, which serves a quarter of the province's population, said it would eliminate 450 elective surgeries, about 30% of the schedule, during the four weeks of the 2010 Winter Olympics.
And in the rapidly growing suburbs east of Vancouver, the Fraser Health Authority plans to close its spending gap by, among other things, holding the number of MRIs to last year's total, ending $550,000 in service programs for senior citizens and reducing elective surgeries by about 14%.
The authorities also are making administrative cost cuts and looking to pool resources for things like computers and laboratories.
"We need to be crystal-clear. . . . I'm not denying anybody access here to urgent or acute or immediate care," Nigel Murray, the Fraser authority's chief executive, said in an interview. "If our surgeons feel people need access to urgent care, they get it."
The Canadian government has invested a large amount of money nationwide in a successful effort to reduce wait times, especially for life-threatening conditions such as cardiac disease and tumors, and for procedures such as knee replacements and cataract surgery.
Under Canada's system, most doctors run private practices but are paid uniform rates by a government-funded network. (Many Canadians have private or employer-paid insurance that covers things such as dental and eye care, which are not part of the larger plan.)
Murray, a proponent of the system, acknowledged that the growing number of private clinics and public-private partnership hospitals could strengthen government healthcare.
"You can lose staff to the private systems. . . . But the other side of the coin is that you may be keeping nurses in your communities by providing other employment options for them, so that you're adding to the pool of overall healthcare professionals," Murray said. "Additionally, the private system can take some of the strain off the public system."
The heart of the legal case is the 1984 Canada Health Act, which established the framework for the national insurance system known as Medicare. It outlawed most private insurance for essential healthcare and provided the vast majority of Canadians with free medical services.
Canada spends about $172 billion a year on healthcare, which is one reason the nation's taxes are higher than those in the U.S. (Canadians pay about 33% of the gross domestic product in taxes, compared with 28% in the U.S.) British Columbia is the only province that still charges residents an extra health premium of $54 a month, subsidized for those who can't afford it.
The first foot in the door for private medicine came in 2005, when the Supreme Court of Canada struck down the laws in Quebec that banned private insurance. The court found that having people die while on wait lists violated the province's Charter of Human Rights and Freedoms. The ruling does not apply outside the province, because only a minority on the court found that the laws also violated Canada's basic human rights charter.
The case to throw out the law in British Columbia was launched when authorities attempted to audit some clinics that were collecting government payments for surgeries in addition to fees they charged patients for the use of their private operating rooms and nursing staff.
Day's Cambie Surgery Center refused to open its books and filed suit along with other private clinic operators, saying citizens deserved a choice.
"In Canada, the rights of the individual patient are trumped by the welfare of the system," said Richard Baker, who runs a Vancouver-based consulting group that helps patients find quick access to care in private clinics or in the U.S.
"We have patients come from all over Canada, because B.C. has the most liberal rules on private surgical centers, other than Quebec," he said. "They complain, 'They're all jumping the queue!' Well, it's not jumping the queue at all. It's leaving the queue."
In fact, the British Columbian government has been slow to crack down on private clinics. Health Minister Kevin Falcon told the Vancouver Sun newspaper in June: "I don't have an objection to people using their own money to buy private services, just as they do with dentists, just as they do with . . . sending their kids to private school or what have you. I think choice is a good thing, actually."
The outcome of the legal case, most analysts say, probably will determine the future of private healthcare in Canada.
Not all Canadian doctors have flocked to the defense of private clinics; many see the public health system, for all its strains, as a gem that ought to be protected from the out-of-control expenditures and huge inequities that are part of the U.S. healthcare system.
"We can and need to improve [healthcare]. . . . But it's always going to be more effective, and it's certainly going to be more equitable, if it's done within the public system," said Robert Woollard, a longtime family practitioner and member of Canadian Doctors for Medicare, which has applied to join the lawsuit in British Columbia. Woollard said the public system has the nimbleness to provide speedy, quality care to those who truly need it.
"Just six or eight weeks ago, I had a patient come in who needed urgent attention to her knee. She was in severe pain," he said. "She was seen by a [reviewing] team within a week, and she was slated for surgery that will probably happen in the next two to three months."