Canadians should be thankful for last week’s Supreme Court decision on medicare. It has created the opportunity for an honest debate about how to fix publicly funded health care.
We were gratified by the extent to which the court based its decision on the arguments that the standing senate committee on social affairs, science and technology made in its October, 2002, report.
In it, the committee predicted that unless governments and health service providers acted decisively to substantially reduce waiting times, the courts would intervene — as they should — to protect the Charter rights of individual Canadians.
As our committee said, governments cannot have it both ways — legislating their own monopoly and then failing to deliver timely access to necessary care. The court agreed, ruling that to do so is to violate the Charter guarantee of life, liberty and security of the person.
While the court rightly indicated that the ban on private sector funding cannot be sustained if individual rights are being violated, it did not issue a prescription for solving the problems confronting the system. That’s the responsibility of governments — and the ruling poses significant challenges for them, for direct providers of health care services and for individual Canadians.
Restructuring health care delivery so that Canadians’ Charter rights are no longer infringed does not necessarily require the emergence of a parallel privately funded system for medically necessary services. It is possible to preserve our single-payer publicly funded system — but only if substantial structural change is undertaken:
Recent reports by the Alberta Auditor General on nursing homes and former Ontario and federal minister Elinor Caplan on home care both concluded that there was no evidence that the ownership structure of service providers had any impact on either service quality or price.
It makes little sense to continue to perform cataract operations in tertiary-care hospitals when the same service can be done much more cheaply and with the same quality in stand-alone clinics. This policy change alone would eliminate waiting lines for cataract operations within less than nine months. Similar cost savings and waiting time reductions would occur if many orthopaedic and imaging procedures were contracted out to stand-alone clinics which competed for the business.
In general, it’s critical that as much health care as possible is pushed out of expensive hospitals into lower cost community care facilities.
Continued scaremongering about ownership structure will make it impossible to successfully restructure the delivery system.
Hospitals must be given the flexibility they need to make the most efficient use of their limited resources. That means eliminating the complex and rigid work rules that permeate the hospital sector eliminated. This will require a dramatic attitude shift among all those who work in hospitals — including nurses and other unionized workers.
The time has long since passed for parts of the medical profession, such as the Coalition of Family Physicians in Ontario, to stop dragging their feet on reforming primary care delivery. Every report over the past decade has recognized the critical importance of having primary care services delivered through multi-disciplinary clinics that are mainly funded on a capitation rather than a fee-for-service basis.
All Canadians need to accept two hard realities:
First, in order to make a reformed system work, we’ll all have to make some sacrifices. For example, patients may be required to have tests done at inconvenient hours so that expensive diagnostic equipment can be run 24 hours a day. The trade-off is that no one will have to wait months to find out what’s ailing them.
Second, even after all the inefficiencies have been wrung out of the system, costs will continue to rise in order to meet expanding demand driven by new technology, new drugs and an aging population. That means more money will be required. Politicians must stop pretending that there is a miracle source for this money. There is only one source, and it’s taxpayers.
Unfortunately, in all the reactions to last week’s Supreme Court decision, neither those responsible for funding the system nor those directly involved in service delivery said anything about how they themselves are willing to change in order to save medicare. So it falls on all of us to pressure politicians and providers alike to implement the necessary reforms.
It will take time for our reform strategy to take effect. If progress is too slow, Canadians should demand the enactment of the Senate committee’s proposed “care guarantee,” which would ensure that everyone obtains the treatment they require in a timely fashion — even if public funds must be used to pay for patients to receive treatment in another province or in the United States.
We all owe the Supreme Court a huge debt of gratitude for upholding our Charter rights. No Canadian should suffer unduly — let alone die — because vested interests involved in the health care system refuse to change their attitudes, refuse to make the system more efficient or refuse to fund it adequately. Canadians are entitled to timely care.
The court’s ruling cut through the myths, untruths and distortions on which debates about health care have been based for years. It’s now clear that if waiting times are not reduced so that individual rights are no longer infringed, the result will be a parallel private system.
We hope this threat will force the key players to make the necessary changes to preserve the single-payer system. If not, they will be justifiably blamed for the death of medicare.
Michael Kirby and Wilbert Keon are Canadian senators.
© National Post 2005
