Medical Device Daily Contributing Writer

The foundations of the Canadian healthcare system were shaken this month when the country’s highest court ruled that a law banning private health insurance in the province of Quebec is unconstitutional. In a narrow 4-to-3 decision, the Supreme Court of Canada said the publicly funded healthcare system had failed to provide timely, reliable access to medical care.

“The evidence in this case shows that delays in the public healthcare system are widespread,” said Chief Justice Beverley McLachlin, “and that, in some serious cases, patients die as a result of waiting lists for public healthcare.”

McLachlin was referring to the case of Quebec resident George Zeliotis, who argued that long waiting lists had impaired his ability to obtain timely heart surgery and hip operations. Jacques Chaoulli, MD, Zeliotis’s doctor, also fought for years to open an independent private hospital so that patients like Zeliotis could obtain more timely medical care than is available in the publicly funded healthcare system.

The Supreme Court ultimately ruled that provisions of the Quebec Health Act preventing residents from obtaining private medical insurance to cover medically necessary treatments violated Zeliotis’s rights under the Quebec Charter of Rights.

While defenders of the Canadian Medicare system argue that the court decision is limited to Quebec, others view it as the thin edge of the wedge that will lift the ban on private healthcare insurance in five other Canadian provinces.

“Now those may well need to be challenged individually,” Albert Schumacher, MD, told Medical Device Daily. “However, the ruling of the Supreme Court certainly supports our side of the debate and there are certainly thousands of other patients like Mr. Zeliotis languishing on waiting lists in these other provinces as well.”

Schumacher is head of the Canadian Medical Association (CMA; Ottawa, Ontario), which represents more than 60,000 physicians, medical residents and students in Canada. Along with the Canadian Orthopaedic Association (Montreal), he was an intervener in the case before the Supreme Court.

The CMA argued that the principles underlying the Canada Health Act – portability, comprehensiveness, universality, public administration and accessibility – remain sound, but should be buttressed by the additional principle of “timeliness.” Adding that sixth tenet to Canadian healthcare is critical to the changes that Schumacher and others say are needed to ensure that Canadians receive adequate medical care.

“I think it is urgent that all of us involved in the healthcare system come together to work to ensure that all Canadians get the care they need, when they need it,” he said.

At the same time, Schumacher insists he and the CMA are strong supporters of a public healthcare system but are more inclined to emulate public healthcare models in countries such as France, Germany and Switzerland.

The Canadian public healthcare system “will continue,” he said, with support among doctors for universal access and coverage. However, the Canadian system, he added, has clearly experienced “a slippage in the kinds of things that are covered,” coupled with excessive wait times for medical care.

No one is more aware of the excessive wait times in Canada than Mark Godley, MD. Godley runs the False Creek Surgical Centre (Vancouver, British Columbia), a privately run clinic that will see about 4,000 patients this year and routinely is accused of breaking the spirit, if not the letter, of the Canada Health Act. Godley hears numerous complaints from patients about lengthy waits for sinus, head and neck and other surgeries under the publicly funded healthcare system.

He told MDD that he’s pleased by the Supreme Court’s decision.

“We’re encouraged by the decision because there is still a big fight ahead of us. I don’t believe for one moment that the other special interest groups, i.e., the unions, which would like to maintain the monopoly for their own benefit, won’t fight this decision. They’re going to fight and they’re going to fight hard.”

Under the Canadian public healthcare system, patients are legally prohibited from paying for “medically necessary” medical procedures. Such procedures must be paid for from the pool of public health insurance dollars. That becomes a problem when waiting lists for publicly funded treatment are backlogged.

The result: many patients travel to other countries such as the U.S. to pay for their medical care from their own pockets – or they go without.

Godley said he is able to “get around” the Canadian Health Act by simply challenging the Canadian government over its interpretation of what constitutes “medically necessary” treatment. Arthroscopic surgery deemed medically necessary by Canadian health authorities, for example, becomes merely “a lifestyle decision” or “a convenience factor” for patients at the False Creek Surgical Centre, he said. The decision to pay for the surgery using private funds is then “acknowledgement by the surgeon and the patient that they are coming to have the surgery done for reasons other than medical necessity.”

The patient wins, the doctor wins, and so too does the healthcare system, he added.

“There is no billing to the health services plan, so it doesn’t affect the plan in any way. It removes the patient from the waiting list, and someone else moves up in the waiting list in the public system.”

One person who could not disagree more is Roy Romanow, author of the 2002 Report on the Future of Health Care in Canada (MDD, Jan. 22, 2003). He believes that if a private system is allowed to take hold in Canada, medical staff and equipment will migrate away from the public system into private facilities, leaving the vast majority of Canadian patients without adequate medical resources. That, he said, could result in a healthcare system closer to the U.S. model – not a desirable outcome, he adds.

“The two-tiering of healthcare represents a march backward in time, to when good healthcare depended on the size of one’s wallet – to a situation like that which currently prevails in the United States, where last year, more than 50% of all personal bankruptcies were due to healthcare expenses,” Romanow said.

If anyone doubts the impact of the U.S. approach, he said, “talk to the directors of General Motors. They just eliminated 25,000 jobs . . . largely due to the company’s burden of healthcare costs.”

Many consider comments such as this to be nothing more than fear-mongering. Still, the overriding impression in Canada is that the U.S. is having far more difficulty ensuring that its citizens obtain adequate medical care than in Canada, or other “First World” countries. And for all their criticism of public healthcare, neither Schumacher nor Godley sees Canada gravitating toward privately funded, American-style healthcare any time soon.

“I don’t think that the system that the States has is in our future or is comparable,” said Schumacher. “There are lots of other jurisdictions that one can look at.”

Godley added: “They have a free market, free-for-all system that obviously doesn’t work. We will not have that in this country.”

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