In June, 2005, the Supreme Court of Canada issued a landmark judgment, striking down Quebec’s ban on using private insurance for services covered by medicare when waits are unreasonably long.
The court said if the public system cannot deliver care in a timely manner then access to alternatives (that is, insurance and private care) should not be outlawed.
The ruling was a victory for George Zeliotis and Dr. Jacques Chaoulli, who had argued that prohibiting private health insurance jeopardizes the well-being of people who desperately need treatment.
Mr. Zeliotis maintained that long waiting lists for medical services impaired his ability to obtain timely hip surgery. Dr. Chaoulli has fought for years to obtain a licence to operate an independent private hospital.
Despite dire predictions, the decision (known commonly as the Chaoulli case), did not lead to the creation of a parallel private health-care system, nor to the end of medicare.
Technically, the judgment, which was predicated on a lack of respect for Quebec’s Charter of Rights, only applied to that province. But it forced governments across the country to take the issue of wait times seriously.
Four years after the ruling, however, it is worth taking a look at what Quebec has done in response to the Chaoulli ruling.
At first, the government of Jean Charest, offered care guarantees for key procedures such as cancer surgery, heart surgery, joint-replacement surgery, cataract treatment and certain diagnostic tests such as mammography.
It also allowed hospitals to sign contracts with private clinics to ensure that a limited range of elective surgeries could be delivered promptly but paid for on the public tab.
The province also allowed Quebeckers – as the Supreme Court had ordered – to purchase private insurance for a limited number of surgical procedures, such as hip and knee replacements.
The catch was these surgeries could only be practised by physicians who had opted out of the public system, of which there are few.
The legislation allowed the creation of two types of centres médicaux spécialisés (CMS) – a participating CMS for physicians who are part of the public system and bill the state-run insurance program and a non-participating CMS for physicians who have opted out and bill patients directly. Physicians had to choose; they were not allowed to work in both.
The response from Mr. Charest’s government was widely lauded as sensible and adroit – maintaining a strong public health-care system, but allowing the private sector to play a supporting role.
Since then, a few private surgical clinics have popped up in Quebec and some hospitals have availed themselves of the ability to contract out surgeries.
At times, there have been minor public outcries, much of it led by unions angry that the private clinics have non-unionized nurses and support staff.
The provincial ombudsman entered the fray as well, concluding that a contract between Sacré-C{oelig}ur Hospital and the privately-run Rockland MD Surgical Centre was not in the best interest of patients because of the lack of oversight of private clinics. (The government responded with new rules for licensing and inspecting clinics.) What is not clearly understood, in Quebec and in the rest of Canada, is that the provincial government has not yet finished responding to the Chaoulli ruling, and it has gone much further than the Supreme Court demanded.
On Sept. 30, the role of private surgical clinics will be greatly expanded.
The number of surgical procedures that can be contracted out by hospitals to clinics will jump to 56 from three. In addition to hip and knee replacements and cataracts, private clinics will be able to do a wide range of procedures, including mastectomies, hysterectomies and bariatric surgery.
The new regulations will also assign these surgical procedures away from hospitals to the private surgical clinics. Hip replacements, for example, will be done exclusively in clinics.
The Quebec government has backed down on earlier restrictions and will now allow physicians and surgeons to practise simultaneously in both participating and non-participating CMS.
That means, theoretically at least, a surgeon could tell a patient that their surgery is available in three weeks at a publicly-funded CMS but the next day at a privately funded CMS.
And it means that people with the means – cash or private insurance – can jump the queue to get these procedures more quickly.
This is what is traditionally called two-tier health care.
There are, of course, diverging views on the wisdom of approaches like contracting out, mixing private and public delivery of care and extra-billing. British Columbia and Alberta are taking approaches similar to Quebec, and every other province and territory is watching.
But, regardless of where one stands on these matters, the issue here is transparency.
The Quebec government is making sweeping changes to how medical care is delivered under the medicare system, and it is doing so with little scrutiny. The new regulations were adopted just before the summer break, at a time when opposition parties are in disarray, and the media have largely failed to understand how profound the impact could be.
The public deserves better. It deserves a vigorous debate, not a fait accompli.
