Health-care system might not make sense, but it's oh-so Canadian: Neil Macdonald

As a landmark private health-care case is heard before the B.C. Supreme Court, Neil Macdonald takes a look at what ails the public system that many people think defines us as Canadians.

'They can pay to have their dog's cataracts removed right away, but not their own'

Doctors remove a cyst from a male patient's knee at the Cambie Surgery Centre, a private clinic in Vancouver that's at the centre of a landmark case before the B.C. Supreme Court. (Darryl Dyck/The Canadian Press)

Back in the 1990s, a brilliant, mild-mannered Calgary ophthalmologist named Howard Gimbel was making enemies.

His sin was being a pioneer. He'd invested heavily in a remarkably efficient method of cataract removal called continuous curvilinear capsulorhexis. Basically, he made a small incision, pulverized the cataract with ultrasound and vacuumed it out, then slid in a new lens, all in a couple of hours, with the patient under local anesthetic.

The conventional method at the time was meat-packing by comparison. Doctors would wait until the cataract was advanced and well hardened (and the patient blind), then cut it out and implant a new lens. The patient would spend days in hospital.

Gimbel's patients went home as soon as they were done.

In most countries, he'd have been celebrated for his work. But not in Canada.

Because Canada is the only industrialized nation that outlaws the private purchase of core medical care, and Gimbel, having bought some awfully expensive new equipment to set up his clinic, was charging patients a fee of several hundred dollars for each procedure, above and beyond the amount he billed the Alberta health-care system.
Canada is the only industrialized nation that outlaws the private purchase of core medical care. (Darryl Dyck/The Canadian Press)

In Ottawa, he was regarded as some sort of rogue, a violator of the Canada Health Act. To public-health advocates, he was a threat to the "core Canadian value" that no one should be able to pay for better health care. And of course the Alberta hospitals whose business he was usurping weren't too keen on his innovations, either.

His whole operation was just … un-Canadian.

But he had a champion in then Alberta premier Ralph Klein. When Ottawa levied millions in fines to punish Gimbel's extra billing, Klein chose to pay the fines rather than force Gimbel out of business.
The late Ralph Klein, back when he was premier of Alberta in the 1990s. (Canadian Press)

Eventually, Alberta simply agreed to pay not only for Gimbel's procedures, but for his extra-billed "facility fees" as well.

Gimbel's real champions, though, were his patients. As the clinic's fame spread, people seeking quick, relatively painless cataract removal had begun streaming in, not just from Alberta but from other provinces, and from around the world.

And they certainly didn't seem to mind paying the extra fee.

In Gimbel's waiting room one afternoon, I met a retired Greyhound bus driver sitting with his elderly, near-blind mother.

I don't remember the fellow's name, but I do remember his rather searing question: "If I want to take whatever money I have left after the government gets finished taxing me, and spend it on my mother's eyes, you're gonna tell me I can't do that?"

The answer from Canadian nationalists, who hold this country's one-payer system to be something holy, would be, 'Yes, sorry, my friend, but your mother needs to get in line like everyone else, and suffer for days in the hospital, for the good of us all.'

That is still their answer more than 20 years later. The system is now much more uneven, sclerotic and, in a sense, corrupt (does anyone really believe VIPs spend a lot of time on waiting lists?), but somewhere deep in our Canadian hearts, we cling to the idea that outlawing private delivery of core medical care is something that makes us better than everyone else — certainly better than the dirty market-worshipping Americans, but also better than the French, the Swedes, the Italians, the Finns, the Swiss, the Australians and the British, all of whom allow private care alongside public care.

Private clinic case

This week, that Canadian argument is being tested before the B.C. Supreme Court.

Cambie Surgery Centre of Vancouver, a private clinic, is suing the province on behalf of patients who want to pay for health care out of their own pockets, in order to avoid suffering on long waiting lists.

Dr. Brian Day, who runs the Cambie clinic, says that in the eight years the case has been delayed, two of the six patients involved have died, and one is paralyzed after having spent 27 months on a B.C. children's hospital waiting list, waiting for spinal surgery.
Dr. Brian Day, medical director of the Cambie Surgery Centre, says his court battle is about patients' access to affordable treatment, while his opponents accuse him of trying to gut the core of Canada's medical system. (Darryl Dyck/The Canadian Press)

Day's detractors — and there are many, including the federal government — say he is threatening the very essence of the Canadian system; that if people are allowed to pay for core medical services, it will create yet another hierarchy of privilege based on wealth, and that no one should be able to pay their way to the front of the line.

Supreme Court has spoken

So. A suggestion: How about simply eliminating the lineups?

The Canadian ideal is that in return for the steep taxes we pay, everyone is entitled to timely and publicly insured health care. Well, make it so, as Jean-Luc Picard would say.

The Supreme Court of Canada has already spoken: if governments fail to provide adequate public care, denying people the ability to access private care is unconstitutional.
Supreme Court of Canada in Ottawa. (Albert Couillard/CBC)

The high court found Quebec has failed, and as the boomers age and retire, other failures are inevitable.

Now, it is true that valid research indicates the introduction of private care can be harmful, especially to lower income patients who must continue to rely on the increasingly broken public system.

But the retired Greyhound driver's excellent question, posed so many years ago in Gimbel's clinic, stands.

Deliciously Canadian

And speaking of Gimbel, a postscript:

After the province of Alberta agreed to pay his extra fees, it then quickly decided to ration the number of procedures any Alberta eye surgeon could perform.

As a result, Gimbel's Alberta patients, struggling with encroaching blindness, now face waiting lists of up to two years. At the same time, Gimbel's surgery rooms sometimes sit empty and unused.

Out-of-province patients, meanwhile, can fly in and be treated quickly, so long as they are willing to pay the "facility fee." Gimbel then bills the remainder to the health system in their home province (except the badly broken Quebec system).

Make sense? Not much. But it's all deliciously Canadian.

Dr. Gimbel, a man who is judicious to a fault, says merely: "Well, that's our system, isn't it? Our (Alberta) patients are puzzled, though. They can pay to have their dog's cataracts removed right away, but not their own."

Public vs. private health care?

5 years ago
Duration 10:06
Michael Klein with Canadian Doctors for Medicare and Howard Anglin, executive director of the Canadian Constitution Foundation, explain both sides of the B.C. court challenge. 10:06


Neil Macdonald is a former foreign correspondent and columnist for CBC News who has also worked in newspapers. He speaks English and French fluently, as well as some Arabic.


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