Public Health or Private Wealth?
Fears rising that our public healthcare system is pushing patients to the private sector
A new semi-private medical centre, the Rockland clinic, has caused an uproar since it opened its doors in Health Minister Philippe Couillard’s own riding on January 22nd of this year. Still under renovation, the large, warehouse-like building in Outremont houses a private family medicine clinic alongside a surgical centre where patients pay ‘accessory fees’ for publicly-funded procedures.
Jacques Benoit, a community organiser from Point St-Charles community clinic considers the new clinic to be shameful. “Access to healthcare shouldn’t depend on money or on individual wealth,” he argues.
The centre’s legality is also being questioned. At the end of January, Couillard asked the Régie de l'assurance maladie to carry out a month-long inquiry to determine whether the Rockland clinic’s ‘accessory fees’ are legal.
Bill 33 opens private clinic
The Rockland clinic opened its doors in the wake of the controversial Bill 33 which was pushed through by the Liberals with restricted debate in the early morning of December 13th, 2006. The goal of Bill 33 is to secure faster access to certain surgeries by having the public system pay for surgeries done in the private sector. The surgeries concerned are hip, knee and cataract, but other surgeries can be added without going through parliament and the Liberals’ platform includes extending the program to all surgeries. The bill also allows for private insurance companies to cover these surgeries when they are not paid for by the government.
Benoit strongly opposes Bill 33 arguing that it is illogical. “[The Liberals made] a law that says that if after 9 months of waiting someone hasn’t been able to get the service in the public system, [they’ll] pay for them to go to a private clinic. This doesn’t change the wait times in the public system,” he says.
Bill 33 was the Quebec government’s response to a Supreme Court ruling in the 2005 Chaoulli case. Dr. Jacques Chaoulli and his 73-year-old patient George Zeliotis, frustrated after having to wait a year for hip replacement surgery, took the matter to court. They argued Zeliotis should be able to get private insurance and have the surgery done in the private sector to skip the hospital waiting lists. The Supreme Court ruled that Quebec had one year to lift its ban on private health insurance in cases where a patient cannot have reasonable access to services in the public system.
Buying & selling health
One of the major questions in the private-public debate is whether healthcare services can be considered a commodity, something that can be bought and sold on the market like jeans or i-pods.
Benoit has seen the language used in healthcare change over the last twenty years. “We no longer talk about patients, we don’t talk about citizens who are sick, we don’t even talk about sick people anymore, we talk about clients and clientele. It’s a lot easier to refuse service to a client than to refuse service to a sick person.”
His office walls are covered in newspaper clippings of marches and press from community actions. In one of them, a man wearing an oversized mask of Health Minister, Philippe Couillard, is walking in front of a crowd of spectators. Benoit points to the picture. “That’s me,” he says, starting to laugh.
The recent events have not come as a surprise to Benoit. Before the Liberals, the Parti Quebecois made major changes to deregulate health and social services, and cut employees and resources. The Liberals were passed the baton and in 2003 approved a series of laws merging community clinics, hospitals and long-term care facilities into large health and social services centres. Their mandate was changed from providing services to coordinating them. The new laws also facilitated outsourcing to private companies and put restraints on unionisation. “It’s amazing when you look at all the laws in chronological order, they are really putting one foot in front of the other [towards privatization],” says Benoit.
Dr. Paul Saba, a physician at Lachine hospital and a member of the group Physicians for Social Justice, experienced the downsizing of his hospital first hand. “In July 2006, the administration, along with the government decided to close our hospital to ambulances, which goes against all common norms in emergency room care,” he says. “We’re fighting to maintain it as a full-service hospital and they’re doing everything possible to turn it into a clinic.”
Quebec ahead of the rest
The Rockland centre is by no means the first private medical centre in the province. Quebec, and Montreal in particular, have been at the forefront of private medicine in Canada. In a 2005 interview with the Canadian Press, Roy Romanow, the former Saskatchewan premier and head of a royal commission on the future of healthcare in Canada, criticized Premier Charest for allowing private clinics to thrive in Montreal.
Dr. Luc Bessette was an emergency physician in a public hospital before he and two colleagues quit the public system and opened a private clinic. “There was no accountability or attention to the care given to people in the public system,” he says.
The fully private MD-Plus clinic that the three doctors opened in 2004 is calm and almost corporate, with coffee, biscuits and internet access in the waiting room. Appointments are scheduled to last 20 minutes. It’s a world away from the public hospitals, but at a price. A regular check-up costs $100.
“[In the public system], you are in a kind of ridiculous situation,” explains Dr. Bessette, “where the physician wants to be more productive and the hospital administration says: if you’re more productive we’re going to be in deficit so we should in some ways limit the offer of services.” He argues that because the hospitals run on limited budgets independent of the needs of patients, they try to limit the services offered, which creates long wait times.
Although they differ when it comes to solutions, both Saba and Bessette agree on the ills of the public system. “The administrators in Quebec are paid millions of dollars in bonuses […] not to provide healthcare to the population,” explains Dr. Saba. The bonuses are instead given for minimizing costs. “In Quebec, we have twice as many administrators as in the other provinces in Canada.”
Wait times for diagnosis and surgeries are long. Many are told they will have to wait six months or more for some examinations and surgeries in the public system and most patients are referred to private clinics to get diagnostic tests such as MRIs done faster.
A young woman from Montreal who wanted to remain anonymous for privacy reasons was recently diagnosed with Multiple Sclerosis. After showing typical MS symptoms, she was told that she would have to wait 6 months to get an MRI in the public system. “They recommended that I go to a private clinic in Westmount because the wait time for that would only be 2 weeks.”
She would have to pay, however, if she wanted to jump the queue. “They quoted the price for the MRIs at $1,500, so I almost fell off my chair because I knew only $500 was covered by my private insurance.” Although the sooner she could have a diagnosis, the sooner she could begin taking medication, she decided to wait.
Still saving lives
Despite many problems in the public system, there are some people for whom it works well. Brianna Hersey is one of those people. At 15, she was diagnosed with ulcerative colitis, a disease that causes inflammation and sores in the colon and rectum. She has had several complex operations including a J-pouch, where the large intestine is removed and replaced with an internal pouch, and an ileostomy, where the small intestine drains into an external bag.
Although she has had her share of long wait times, Hersey has received care when it was most needed. “When I have been really sick, I go into the emergency room, I’m seen within 15-20 minutes. I’ve got a bed. I have care. Emergency surgery happens within 24 hours, 36 hours.”
For Hersey, the affordability of the public system is crucial. “If I’d had to pay for all of the surgeries and hospitalisation that I have undergone in the past 10 years, my family would be bankrupt. We would be in huge debt.”
Hersey explains that she has used the medical system at all different stages of sickness, from minor problems to emergencies. As she describes constant trips to hospitals, clinics and emergency rooms she brings up images of overcrowded waiting rooms, overworked doctors and nurses, feelings of frustration and of gratitude. She wants to see public healthcare improved, not turned into a two-tier system.
For many younger generations, paying for a doctor’s visit would be considered strange. The publicly insured healthcare system in Quebec and in most of Canada has been around for almost half of a century.
Jack Gottheil, an active member of Project Genesis’ Health Action Committee, remembers the days of private healthcare well, a memory that still haunts him. Gottheil found his first job straight out of high school, back in 1934. “It was a period in the depths of the great depression,” he explains, “I landed a job at a collection agency.” Most of the debts that Mr. Gottheil collected were for medical services. “At that time, there was no medicare, you paid for the service.”
Public healthcare advocates such as Gottheil are concerned about the direction that healthcare is heading and especially about the increasing role of private health insurance. According to the Canada Health Act, private insurance should not be allowed to cover duplicate services, that is, services that are covered by public healthcare. Under Bill 33, however, certain publicly covered surgeries will now be fair game for private insurance companies.
Although the surgeries listed in the bill are offered both in the public and private systems, Yves Millette, the vice-president of the Quebec chapter of the Canadian Life and Health Insurance Association (CLHIA) insists that they are not duplicate. “What is permitted by Bill 33 is complementary because it is with doctors that are not participating in the [public] system,” he argues.
Lee Soderstrom, a health economist and professor at McGill University warns against playing word games. “For the three surgeries for which private insurance is allowed, I do not see that there is an issue with respect to whether they are ‘duplicate services,’” he says. “They are duplicates because the same services are available in the public plan.”
Nevertheless, Millette expects more surgeries and medical services will become open to private insurance companies in the near future, particularily for the aging population.
This trend is disturbing for Soderstrom who sees the privatisation of the healthcare system as a highly inefficient one. “There’s a real danger that once you open it up to the private, people are going to be stampeded into using a lot of services that may not matter,” he says. “[In] the public system you have a better ability to control those costs.”
Benoit agrees that although the catch phrase for privatisation is to increase efficiency, the private sector is not cheaper. “The public system aims to offer a service at its price, period. In the private sector, you have the price plus a profit,” he argues.
At a time when the public healthcare dream seems to be more like a nightmare, where long wait times, overcrowded emergency rooms and overworked staff await needy patients, Jack Gottheil leans forward in his chair. He tells me about the desperate years of the Great Depression.
He tells the story of someone who walked to the downtown collection agency all the way from Rosemont, owing a couple dollars for a medical bill, to ask if he could pay 50 cents a week. “I don’t want to see these things coming back,” he insists, “and they can.”