Think two-tiered heath care will fix medicare's problems? Think again

A case being heard at the B.C. Supreme Court could determine whether Canadians will soon see private health care alternatives.

When Australia introduced a parallel private-pay system wait times got longer, not shorter

Vancouver General Hospital (CBC)

Most Canadians might be surprised to learn that major decisions about how our health care system will operate in the future could be decided by our courts — and not by our democratically elected parliamentarians. But that's exactly what is happening in British Columbia right now.  

A Charter challenge is underway at the Supreme Court of B.C., championed by Dr. Brian Day, owner of the Cambie Surgical Centre. Day is arguing that the laws prohibiting doctors in Canada from practicing in the public and private health sectors simultaneously should be struck down, along with the prohibition on the extra billing of patients for services already covered by the provincial health plan.

From Day's perspective, such restrictions prohibit patients from seeking the best care possible, thereby violating the Charter of Rights and Freedoms. But critics argue the case is more about doctors' potential to earn more money than patient choice or quality care.

Right now, we have a single tier of publicly funded health care (with a limited private sector covering certain non-insured services).  

If Day succeeds with his challenge, those who are financially able will have access to an "upper" tier of health services too — one where doctors charge whatever they want. Those who lack funds will only have access to the "lower" public tier, where doctors adhere to a provincially mandated fee schedule, much as it is today.

Dr. Brian Day, Medical Director of the Cambie Surgery Centre, sits for a photograph at his office in Vancouver on Wednesday, August 31, 2016. (Darryl Dyck/The Canadian Press)

What's wrong with such a two-tier system?  Evidence from other countries demonstrates it too often benefits only those who can afford to pay, and it makes the publicly-funded system more expensive and less efficient.  

Day and his lawyers argue such a two-tier health system is the solution to medicare's problems. They assert that the creation of parallel private payments will alleviate resource strain on the public tier, ultimately leading to shorter wait times for all Canadians, regardless of which level of care they access.

Unfortunately, it's not that simple. Australia had a publicly funded health care system like Canada's before introducing a parallel private-pay system in 1999. As a result, wait times in the public pay system became longer, not shorter. Turns out, many specialists spend more time in the private pay system than in the public, "cherry-picking" the healthiest, wealthiest and most profitable patients. That leaves the cases and patients that are most complex, vulnerable, sick and costly for the public system to handle.

​European models

The second major argument being waged by Day in his Charter challenge involves a more general claim regarding the viability and desirability of European health care models.

Switzerland has the second-most expensive system in the world, right behind the U.S. Private insurance is mandatory. Out-of-pocket payments are exceptionally high, with low- and middle-income families contributing more to the financing of the system than families in high-income brackets.

The French have a private/public hybrid system, but their private insurance only helps cover the extra billing that was introduced to add more money to the system. They also have some of the greatest financial and geographical inequities in access to health care in Europe.

The German health care system is also a public/private mix, but patients have to choose one or the other. Germans with public health insurance — about 90 per cent of the population — wait three times longer for some care than those with private insurance. More importantly, the private insurance sold in Germany is for those wealthy enough to leave the public system entirely. They can never come back, no matter how expensive their care becomes.

Some believe the UK's National Health Service (NHS) is a comparable system to Canada's. It's not. NHS doctors are salaried employees of the government who must work a 40-hour work week with additional evening and weekend call hours before they are allowed to see private-pay patients on top of their public practice.

Look to Canada

So if Europe doesn't offer an obvious solution to improving Canadian health system performance, where should we turn? Canada has some good home-grown evidence:

These models depend on changing how we deliver care and are about improving quality of care. Our legislators, policy-makers and health practitioners together could help make such Canadian "best practices" a reality across the country.  

Let's not pretend the Day case is about patient choice or "superior" foreign health care systems. We can innovate within Canada's existing approach to patient care in a way that benefits everyone — not just the wealthy.

This column is part of CBC's new Opinion section. For more information about this section, please read this editor's blog and our FAQ.


Monika Dutt is the Chair of Canadian Doctors for Medicare. She is a family physician and public health specialist in Nova Scotia, an adjunct professor at Cape Breton University, and holds a Master of Public Health and Master of Business Administration from Johns Hopkins University. She is also on the Board of Directors of the Broadbent Institute.