Does the health system need more private care—or less?

The range of reactions people have to “private care” was on display at the CMA’s Health Summit in August in the panel titled “Recognizing the blind spots in the private-public healthcare discussion.” Robin McGee, the patient rep on the dais, simply says "we can't" avoid emotion in the private care debate. It is an issue that cuts right down to our core values and thus inherently emotional. It's almost like the phrase “private care” should be retired in favour of two terms: private delivery and private pay. Profit and not-for-profit companies are everywhere providing services to provincial medicare plans, while out-of-pocket private care happens only in unique circumstances in Canada. Even members of the audience at the Health Summit, after a long discussion about private companies providing services to health plans, would stand at the microphone and observe make a comment outlining their opposition to user fees. Read: New poll shows Canadians think healthcare system is ‘undeniably declining’ Private delivery On the private delivery side, Dr. Hasan Sheikh, an ER doctor in Toronto and board member of Canadian Doctors for Medicare, said he has no problem with non-profit companies providing services to provincial health plans where the public pays nothing out of pocket. He's even willing to entertain that it maybe be worth discussing the role—if any—of for-profit private companies doing this. On private payments or user fees, he is firmly opposed. He pointed out people often compare Canada to some high-performing European health systems, some of which have user fees. He said he finds it odd that critics focus on that and say, “Oh, Canada needs user fees,” but they ignore the fact that those countries have a much higher public-private split than Canada. (Canadians governments pay 72% of all healthcare costs but generally those high-performing European nations pay for pharmacare and dental and home care out of government coffers, so government spending is much higher than Canada’s, proportionally speaking.) Dr. Sheikh gets it when patients are very sick; you focus on yourself in that situation and some say something like, “Well, I can afford it, why can’t I pay out of pocket to get care faster.” But the evidence is private care is not going to help. “We have finite resources," said Dr. Sheikh. “If we allow people to pay to get to the front of the line, we are just rearranging the line.” Letting this happen leads to clearly foreseeable problems. In Quebec, where doctors can opt out of medicare, they often cherry pick the best patients. “The biggest myth that needs to be debunked is that public healthcare is inefficient,” said Dr. Sheikh. A public system has the advantage of having the largest risk pool. Looking at the challenges facing the Canadian healthcare system, “I don’t think it is about money.” He argues, rather, it's about taking ownership. On his ER shift on the Wednesday before he was on this panel, the ER was remarkably quiet—but patients still had a wait 1.5 hours to get taken to the doctors who had plenty of time on their hands because there was no-one working that night to bring patients to their rooms. Pandemic changed people’s views Panelist Erik Sande, president of Medavie Health Services, a non-profit that provides services to Canadian health plans in six provinces, said perhaps user fees will come someday, but now isn’t the time: we need to improve and fix the existing challenges for Canada’s health system first. He argues that the provincial payers look to Medevie Health for speed of execution, accountability and the organizations’ willingness to take on risk. Canadians are fearful they can’t get care. We have even seen a recent provincial election—in Nova Scotia—that was based on healthcare. Sande argued that it was the pandemic that led to a greater number of people saying in terms of its healthcare system, Canada can be doing better. He also said we don’t talk enough about equity; the situation for Indigenous folks and racialized communities lags. “I’d like to see a significant shift into community,” he said, ideally less focus on acute care in hospitals and more home care and outside of hospital care. The patient member of the panel Robin McGee has experience on both sides: she’s a clinical psychologist and has had stage-4 colorectal cancer. “We have a situation where the wealthiest can afford top-notch care.” McGee said looking at ways to improve healthcare, she's a fan of team-based care and thinks the cachement model idea has a lot going for it. Four debates Debating private care is going to be a big issue for the CMA this year. Under new CMA president Dr. Kathleen Ross, the association is holding a series of town halls in different cities with the Globe & Mail (hosted by health writer André Picard) on the subject. But it's always an emotional and divisive topic: when the moderator opened the discussion up to questions from the audience, Ottawa’s Dr. Melanie Bechard said one of the questions for this panel series talked about user fees. She asked given all the evidence against them, why did the CMA include that as topic? One doctor at the panel stood up to say the fact that Canada doesn’t allow people to pay user fees for faster medical care, Canadians with money are going to the U.S. to get care and that is effectively transferring healthcare money from Canada to the U.S. Hopefully this panels will advance the discussion. Dr. Sheikh said: “We don’t want to just have what Canada is famous for: amazing pilot projects that don’t get rolled out wider.” As well, let us hope people becomes more nuanced what they mean by “private care.” The series of town halls available in-person and online begins on Sept. 8 in Toronto, then Oct. 23 in Montreal, Nov. 23 in Vancouver and Jan. 25, 2024 in Halifax. You can register for the panels at the CMA’s It’s Time to Talk website.

Does the health system need more private care—or less?

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