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Com­pe­ti­tion in health care: Let’s have a se­ri­ous de­bate

- Åke Blomqvist Åke Blomqvist is an ad­junct re­search pro­fes­sor at Car­leton Univer­sity and a health pol­icy scholar at the C. D. Howe In­sti­tute. He gave ev­i­dence as an ex­pert wit­ness in the Cam­bie case. Health · Public Health · Society · Canada News · Health Care · Competition · British Columbia · Medicare · United States of America · Canada · Australia · Netherlands · United Kingdom

The long- awaited rul­ing in the Cam­bie case, Dr. Brian Day’s challenge to Bri­tish Columbia’s Medi­care Pro­tec­tion Act, has up­held the rules that ef­fec­tively bar pri­vate pro­vi­sion of pub­licly cov­ered med­i­cal ser­vices. But it does not say whether sup­press­ing pri­vately funded care, as the act seeks to do, is good pol­icy. It is not. Ab­sent some de­gree of com­pe­ti­tion from pri­vate care, the Cana­dian health- care sys­tem will con­tinue to be both ex­pen­sive and medi­ocre in com­par­i­son with those in peer coun­tries other than the United States.

Like the courts in the 2002 Chaoulli case, the judge in this case found that long wait times for care could be con­sid­ered in­con­sis­tent with the Char­ter of Rights and Free­doms’ guar­an­tee of “the right to se­cu­rity of the per­son.” But he also finds that even if the act does de­prive some pa­tients of that right, it is not “con­trary to the prin­ci­ples of fun­da­men­tal jus­tice”: gov­ern­ments believe it is nec­es­sary in order to at­tain two ob­jec­tives that the public wants. The first is to en­sure that “ac­cess to nec­es­sary med­i­cal ser­vices is based on need and not the abil­ity to pay.” The se­cond is to pro­tect the pub­licly funded sys­tem, which might not be “sus­tain­able” with­out laws to sup­press “du­plica­tive pri­vate health care.”

While most Cana­di­ans would cer­tainly agree on the point about ac­cess, it is not clear whether such a con­sen­sus should be taken to im­ply that sup­press­ing pri­vate care is an end in it­self. Sup­pose we have a public sys­tem that is well enough re­sourced and man­aged so that every­one has ac­cess to nec­es­sary med­i­cal care within a rea­son­able time. Should we still have laws that pre­vent any­one from buy­ing care pri­vately? In his rul­ing, the judge con­cludes that, based on the word­ing of the

Medi­care Pro­tec­tion Act, the B.C. govern­ment’s an­swer is “yes.” That is, he con­cludes that sup­press­ing pri­vate care is an end in it­self, though he rec­og­nizes that some ob­servers have in­ter­preted the word­ing dif­fer­ently.

Is this what Cana­di­ans want? Some peo­ple do un­con­di­tion­ally sup­port the prin­ci­ple of not al­low­ing pri­vately funded care, as an end in it­self. There is, after all, an ide­ol­ogy that holds that ac­cess to all goods and ser­vices should be strictly ac­cord­ing to need, not abil­ity to pay. But I believe most Cana­di­ans take a less ex­treme view and see the prin­ci­ple as a means to an end: they sup­port a sin­gle-payer sys­tem be­cause they think that with­out it those with lim­ited abil­ity to pay might not have ac­cess to needed care.

If univer­sal ac­cess to such care were guar­an­teed, I sus­pect most peo­ple would not ob­ject to al­low­ing rich peo­ple to pay for care pri­vately. The quan­tity of health care is not fixed: Canada has more than enough re­sources to pro­duce all the care doc­tors think is med­i­cally nec­es­sary as well as ad­di­tional or faster care for those will­ing to pay for it.

The ar­gu­ment about “sus­tain­abil­ity,” on the other hand, is based on po­lit­i­cal as­sump­tions. It sug­gests that al­low­ing more pri­vately funded care (to go along with the pri­vate fund­ing and in­sur­ance that al­ready ex­ist for drugs and den­tal and op­tom­e­try ser­vices) would cause our public sys­tem to col­lapse. Govern­ment pays for the public health- care sys­tem with tax rev­enue. The case for sup­press­ing pri­vate care rests on the idea that taxpay­ers will not be will­ing to sup­port a univer­sal public plan un­less it is the only le­gal channel for any­one, rich or poor, to get health care.

The logic of this ar­gu­ment is clear, but it is not true in gen­eral. There are many coun­tries, such as Aus­tralia, the Nether­lands, and even the U.K., in which a govern­ment plan guar­an­tees univer­sal ac­cess but pri­vate care and in­sur­ance are avail­able and used by many. More­over, other pro­grams that help the poor (sub­si­dized hous­ing and cash trans­fers to low-in­come groups, for ex­am­ple) are sus­tain­able with­out the kinds of re­stric­tions that sup­port­ers of the sin­gle-payer sys­tem claim are nec­es­sary for health care. Aus­tralia’s mixed model of public and pri­vate in­sur­ance fi­nances a health- care sys­tem that costs sig­nif­i­cantly less per capita than Canada’s and typ­i­cally ranks higher in in­ter­na­tional com­par­isons. If we left as much scope for pri­vately funded health care as the Aus­tralians do, why should we believe the re­sult would be a worse health-care sys­tem than they have?

Bot­tom line? We should take the rul­ing in the Cam­bie case, not as the last word on public-pri­vate com­pe­ti­tion in health care, but as the begin­ning of a more se­ri­ous de­bate about the scope for it.

CANADA HAS MORE THAN ENOUGH RE­SOURCES TO PRO­VIDE CARE FOR ALL.

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