Stands on medicare muddled

HEALTH-CARE PRIMER

No wonder that the voters are confused. On Thursday, Conservative Leader Stephen Harper — the man many Canadians think of as the great privatizer — announced he was firmly in favour of single- tier universal, public medicare. On Sunday, New Democrat Party Leader Jack Layton, whose party has built its reputation on public health care, said he thinks existing private clinics are all right — as long as taxpayers don’t have to subsidize them. Prime Minister Paul Martin’s exact position? So far, it’s hard to pin down. But, generally, Martin says he and his Liberals love medicare more than anyone — and certainly more than Harper. At first glance, it might seem that the major parties are singing the same tune on something that voters have identified as their number one issue. But they’re not. There are differences. It’s just that they aren’t always easy to spot.

That’s because the leaders ( and we journalists) too often mix up three related but different questions: Who pays for medicare? Who delivers it? What’s covered? Who pays? This is the key to the Canadian system. Medicare is, in the jargon of the trade, a single-pay insurance system. This means that any Canadian resident can receive so-called medically necessary services from a doctor or hospital without paying out of pocket. Instead, they are covered by compulsory government health insurance.

This monopoly element of medicare is kept in place by not only the federal Canada Health Act but a raft of supporting provincial legislation — including bans, in six provinces, on competing private insurance. That’s why the Supreme Court’s decision this summer to overturn Quebec’s insurance ban was so important. The court said the ban made patients wait too long for service. So far, only the Conservatives have addressed the court decision directly. Harper wants a socalled care guarantee to ensure that patients get treatment quickly, paid for by the public system. The NDP has attacked Harper’s idea because it originated with Liberal Senator Michael Kirby. And the Liberals haven’t said much at all.

In general, the single- pay aspect of medicare is politically the least contentious. All parties support it, at least in theory. So when Harper announced Friday that he fully supported a single- tier system for “ core services,” he wasn’t saying anything new. Who delivers? Canadian medicare has always offered choice. Most physicians are private practitioners. Almost all Canadian hospitals are private ( although non- profit).

Radiology and abortion clinics are usually private, as are testing labs. Until recently, none of this was controversial. As long as providers were operating within the ambit of medicare, few cared whether they were private or public. But that changed in the 1990s when Alberta decided to permit anew generation of private clinics. The problem here was that these clinics were offering both medicare and non-medicare services.

In Calgary, for instance, patients who wished cataract surgery could book a medicare appointment and wait weeks. Or they could pay out of pocket and get the service faster.

Technically, this didn’t break any laws because the direct- pay patents were allegedly paying for medically unnecessary extras, including a videotape and a prayer.

In the mid-’90s, Vancouver surgeon Dr. Brian Day opened a private clinic that took advantage of another technicality to let those with money jump the queue. In this case, patients didn’t pay Day directly. Instead, they had friends or relatives write the cheques. By the end of the decade, private MRI clinics in Nova Scotia, Alberta, B. C. and Quebec were offering so- called medically unnecessary scans that allowed patients with money to jump the diagnostic queue, and thereby, the surgery queue. These developments eventually led the NDP to call for limitations on private delivery. Now Layton wants Martin to prevent private clinics from mixing medicare and medically unnecessary services.

If private clinics exploiting this loophole were denied access to medicare patients, the NDP theory goes, they would not be able to survive financially. NDP spokesperson Jamey Heath says that’s what Layton meant this Sunday when he said, in Vancouver, that he wouldn’t close existing private clinics but would starve them by cutting off federal medicare funds.

Harper, by contrast, actively encourages private delivery. He always has. But the Conservative leader has not dealt with the tougher question posed by private MRI clinics: How do you maintain the integrity of singletier medicare if wealthier patients are allowed to have their problems diagnosed first?

Martin’s Liberals say only that they “ prefer” public delivery of medicare services. What’s covered? Technically, the Canada Health Act requires only that medicare cover “ insured” services, leaving it to provinces to decide what that means. The working assumption for medicare’s 37- year history has been that all so- called medically necessary services would be covered.

While all provinces have cut items from their medicare lists, none has yet had the nerve to undertake a drastic cull. As health commissioner Roy Romanow recommended that the act be amended to include diagnostic scans, like MRIs, as medically necessary. The Liberal government ignored that.

Neither of the other big parties has addressed the issue of what should be covered. Harper talks of a universal health- care system that provides “ core” services. But he doesn’t say what he means by this. The NDP doesn’t say much here either.

In the past, both Harper and the NDP have supported the idea of a national drug plan. But they’re not talking about that these days.