Front Burner - The fight over public/private healthcare in Canada

Episode Date: February 24, 2020

A challenge to Canada’s public healthcare system resumes Tuesday in BC’s Supreme Court. Dr. Brian Day -- who runs two private healthcare clinics in Vancouver -- says Canadians should have the right to pay for private treatment and that a two-tier system will cut down on wait times for everyone. Critics say this could undermine the entire Canadian public healthcare system. The CBC’s Dr. Brian Goldman joins Jayme to explain.

In the Dragon's Den, a simple pitch can lead to a life-changing connection. Watch new episodes of Dragon's Den free on CBC Gem. Brought to you in part by National Angel Capital Organization, empowering Canada's entrepreneurs through angel investment and industry connections. This is a CBC Podcast. Hello, I'm Jamie Poisson. So for over 10 years now, Dr. Brian Day, CEO of the Canby Surgical Corporation in Vancouver, has been arguing for a patient's right to access private health care. And he's taken that fight all the way to the province's Supreme Court.

If a BC resident is suffering on a wait list and the government has promised to treat them in a timely manner and it fails to treat them in a timely manner, should they be allowed to use their own private insurance, extended health insurance, to access that care outside of the government system. This is a case that some critics say could threaten the foundations of Canada's health care system. So, as the court challenge resumes this week, Dr. Brian Goldman, from CBC Radio's White Coat Black Art,

is here to help us navigate the controversial questions that it raises. This is FrontBurner. Dr. Goldman, thank you so much for being with me. Pleasure to be here. This is a tough subject because there's a lot of stuff going on. It is very, very complex, but we'll try to do our best to cover as much of it as we can today in 20 minutes. No, no small feat. You only need 20 minutes. Yeah. Okay. I'd like to go through the arguments at the heart of this case with you today, but let's start here. What does Dr. Brian Day, who is ostensibly the face of this Supreme Court challenge in BC, what does he want? So I'll tell you what Dr. Day wants.

And then remember that there's patients who are the plaintiffs. Yes. So I think we have to distinguish between the two because one is what Day wants. The other is how the legal system will adjudicate this case. It's not based on what Day wants. What Day wants is to be able to bill both the government and patients directly at the same time on the same patient for the same service. He also wants to remove the ban on private insurance to cover hospital and physician services already covered by the public system. So that's what Day wants. To use an analogy,

if you're a mechanic and you had all of these cars that needed to be fixed, and you had all of the staff and resources and the tools to do it, but the government owned the only repair shop in town and wouldn't let you into their repair shop, what that mechanic could do is go out and build his own repair shop. What do the patients who are part of the plaintiffs want? They want to be able to get the medical services that they need within a reasonable period of time so as not to violate the charter provisions for life, liberty and personal safety. Right, because one of the arguments in this case, or the big argument in this case, is that it's a charter violation.

In fact, it will stand or fall on whether or not it's a charter violation by the time it gets to the Supreme Court of Canada, which I think most observers think it will eventually. The idea here being I have a right to life, liberty and personal safety. And if I have to wait, you know, two to three years for a hip replacement surgery or a sinus surgery, then that is infringing on my basic rights. And the interesting thing about that argument is that it is arguable. If we were talking about, you know, I go to the emergency department with right lower quadrant pain and tenderness, and I've got appendicitis, and the surgeons there say, we're fully booked, we'll give you an appointment in three weeks. Myla, I could die waiting for that appendix to be taken out in the same way that a trauma patient could die waiting for bleeders to be tied off and hemorrhaged organs to be removed or sutured up in the abdomen.

So if that was what was going on, then the system would have been deemed irredeemable ages ago. What we're talking about are procedures like waiting for an MRI. We might be talking about waiting for a hip replacement, spinal surgery, where the waits in some parts of Canada are very long. And the lack of provision of life and liberty and personal safety relates more to the amount of pain they're living with, the amount of suffering. In some cases, they can't go to work. And some of these are real and tangible losses, but it's going to be up to the Supreme Court of Canada to decide whether this is a violation of the Canadian Charter of Rights and Freedoms. Okay, and before we keep going with the arguments on both sides

here, I just want to clarify a few things with you. One, you said that Dr. Day wanted the right to bill for the same service, the public system and the private individual. I don't understand that. How does this work? What it means is receiving the agreed upon fee, the standard fee for a service, that service might be taking out the appendix, it might be performing a knee or hip replacement, doing a cataract surgery, whatever. performing a knee or hip replacement, doing a cataract surgery, whatever. So that's the basic fee. And in addition to that, there was a surcharge, you know, an efficiency fee to get you seen sooner. How urgent is it? How quickly do you want to work? You know, do you want to be seen at this hospital or that hospital? I have privileges

of three hospitals. Whatever the rules were at the time, you could bill that extra amount on top of it. Sort of like a jumping the line fee. Yes. Okay. Effectively, certainly that was the reason why the Canada Health Act was enacted. Monique Bégin, and one of the reasons was to reaffirm that one of the principles, one of the key principles of the Canada Health Act is that it be fair and equitable to all Canadians, which means that all Canadians would have equal access to a hip replacement, knee replacement, cataract, whatever, regardless of their ability to pay based only upon medical need. And this is the fundamental argument against the case that is being made. I've just made the case. Yes, I've just made the British Columbia's case. And of course,

they've been joined by a number of stakeholders, including Canadian doctors for Medicare and others. Okay, so we've done it. We can go home. We figured this out, this very complex issue, right? No. Not quite. Not quite. No. Okay. So before we keep going down this track, I also just want to clarify one other thing with you, which is how the system currently works. Because I do know that you can access private medical services like MRIs, for example. And so why am I allowed to do that? And in Quebec, for example, you can get cataract surgeries and pay out of pocket for those as well.

Yeah. So that's where things get a little bit complicated. And so to answer that question, you've got to go back to an important decision in Quebec, Chauville versus Quebec. This is a case from back in 2005. It was a decision by the Supreme Court of Canada in which the court ruled that the Quebec Health Insurance Act and the Hospital Insurance Act prohibited private medical insurance in the face of long wait times and that doing so violated the Quebec Charter of Rights and Freedoms, also the same Canadian Charter of Rights and Freedoms provision that you mentioned, life, liberty, and personal safety. You know, the story of that case is that having suffered in the past from many health problems, including a hip replacement, a 73-year-old salesman, you know, became an advocate for reducing wait times. And Jacques Chauy was the doctor who provided home appointments to patients. He attempted to get a license to offer his services

as an independent private hospital, but was rejected. And hence the case, the court case, the suing of the Quebec government and eventually the Supreme Court of Canada. And I wanted to say that only the federal government has the power to make such a prohibition. Not provincial government. There were a lot of observers at that time that thought that that victory by Shoei was the beginning of the end of Canada's health care system and an open invitation to private insurers and double billing, extra billing, etc.

And it turns out that that's not what happened. You know, there's a lot of moving parts here, but basically what's happened is that the Quebec government retreated and amended legislation to permit Quebecers to purchase some supplementary insurance in very narrow circumstances, in procedures where there were unconscionably long wait lists. Like cataracts.

Exactly. Okay. So something for us to keep in mind as we move forward. I want to get back to the heart of this argument about this being equitable, that we all deserve equitable access to medical treatment. equitable access to medical treatment. Why would allowing some people access private services make it unequitable for other people? Okay. So now we're getting into not only the BC government's argument, but the argument by the stakeholders. And there are a number of problems. Their basic argument is that it would

create two-tier medicine. So what happens is that once you establish a market for private health care and allow physicians and surgeons and nurses and other health care providers to work in both systems, the public system and the private system, the critics say you will see an exodus of the very best and brightest from the public system into the private side where they can make more money seeing fewer patients and have a better lifestyle. So now you'll have shortages of the best and brightest people on the public side. And that means that the queues will get longer, which will water down or dilute the public health care system as it is today. that is created by the end of Medicare and the allowance of a parallel private system is that it would cherry pick less complex and easier to treat patients, leaving the patients with the more complex medical problems, multiple medical problems requiring a lot more time and effort

and complex treatment in the system, in an impoverished system, and they would do even worse. So that's the second issue, objection. The third one is that a hybrid system that has parallel administrative structures would be less efficient than the current system. And there's a lot of evidence to show. We're talking about economies of scale. A hospital, for instance, that does 3,000 knee replacements a year is going to be way more

efficient than a hospital that does 150 a year. And in the same system, if you have a single payer, and there's a lot of evidence to show that this is true, if you have a single payer and a single easy-to-understand administrative system, it's going to be a lot more efficient, which means more bang for the buck. It's going to deliver better care, more care, more services for less money than having, you know, different kinds of private systems, each with its own administrative structure. And then before I forget, there are a lot of fears. This hasn't happened, but there's a lot of, because this case has, we don't have a result of the BC Supreme Court case, We don't have a result of the BC Supreme Court case, let alone what the Supreme Court of Canada would say.

But if we allowed a parallel private system, for-profit private system, as we've been talking about, there are fears that we would end up adopting U.S.-style administration of health care. Okay. And what would that look like? administration of health care. Okay. And what would that look like? Well, it would be confusing. You'd have to hire five billing clerks to be able to navigate through the system. There's a lot of rules and regulations. It's woolly. It's hard to comprehend. It's one of the reasons the United States spends more than Canada spends per capita on health care and doesn't get better results, gets worse results. And one of the reasons why is the high administrative cost in the United States. Now, that won't necessarily happen. If we adopted the U.K.'s administrative system or France's, then that might not happen.

And this is the argument that the proponents of having this two-tiered system are making. They're not saying we should necessarily be like the United States. They're saying we should be more like France, Germany, Switzerland. I'm not advocating for a private health system. I don't believe it needs any more than the 10% or a little bit of competition to expose the inefficiencies of the public monopoly. That's all it needs. And that's what happens in Germany, only 10%. Who is salivating at the opportunity to move into the Canadian market? It's our neighbors to the south.

The proximity of us being so close to the United States. Same language, basically same culture. Of course, it's U.S. providers and insurers who would be at the front of the line. which can lead to a life-changing connection. Watch new episodes of Dragon's Den free on CBC Gem. Brought to you in part by National Angel Capital Organization, empowering Canada's entrepreneurs through angel investment and industry connections. Look, I know this is very complicated, but I wonder what you would say to people who are listening to this and thinking to themselves, you know, our system, though, doesn't feel efficient. No. You know, there are

hospitals that are now treating people in hallways. Right. And our population is only growing older. And and we're waiting for this extra burden that everybody keeps talking about. And when we talk about costs, it's already here. It's already here. It's coming. It's not coming in 10 years. It's already here. So there's that looming crisis. And then when we talk about costs, we're already spending more per person. So 6,448 per person or 10% of our GDP. That's more than... Well, actually more than 10%. It's a hair less than 11%. Yeah, we spend more than the average. The average, according to the OECD, is 8.8%.

And the per capita average by the OECD is 5,200 per person per year. We're spending 6,500. So yeah. And do we get huge bang for the extra buck? No, we don't. We have very mediocre results compared to other OECD countries in terms

of results, in terms of outcomes, in terms of readmissions, waiting times especially. And then, you know, the embarrassment of all embarrassments. We have infant and neonatal mortality and maternal mortality that's far higher than it should be. Right. So what would you say to people that say something needs to be done? It feels like the system that we have isn't working. So the big problem here, in my opinion, it's just my opinion, is that Canada is a federation. And unlike the National Health Service, which runs, owns, and operates on behalf of taxpayers, runs the health care system in the United Kingdom, we have a federation of provinces and territories. the healthcare system in the United Kingdom, we have a federation of provinces and territories. And what works in one province doesn't work in other provinces, or it doesn't get adopted in other provinces. You know, we are suffering from pilot project fatigue, where they try a great idea

in one province, and it doesn't get upscaled to the rest of the country, because there's no, there is no governor of healthcare, federal governor of healthcare, because all the other provinces are going to say hands off. Okay. And, you know, as we move forward with this particular case in BC, you mentioned before that you think it will go all the way to Canada's Supreme Court. Like, what are you looking for next? What I'm looking for next is, you know, I think there's a good chance that it does go to the Supreme Court. And I think what happens at the Supreme Court is that there's a chance, as in the Shoei decision, that BC legislation is quashed and they end up having to go back to the drawing board. And I say that, you know, not with a great deal of fear because

we saw what happened the last time. The last time the province, you know, the provinces will have two options. One of them is to provide better access and maybe allow citizens to purchase supplementary insurance for those procedures that have an unconsciously long waiting list. Right, we talked about those Quebec cataracts. Or the notwithstanding clause. And it would be very interesting to see focus groups and to see polling on how Canadians would feel about the notwithstanding clause being invoked to save Medicare. Essentially that the BC government could come in and say, nope, we reject this court's decision. Why not? And we're going to stick with single payer. Why not? Okay. Something for us to watch out for a bit. Dr. Brian Goldman, thank you so much for wading through this really complex issue with me today. I hope I made it a bit simpler.

It did. This really helped me understand some of the nuances around it. And I also wanted to say, I know you have a new podcast out called The Dose, which is like the front burner of health news. Yes, that's how we patterned it. So thank you very much for your inspiration, Jamie. Basically, we're going to answer one question per week. Our first one was, should I worry about my BMI? You'll have to listen to find out. And we're going to answer one question per week. Our first one was, should I worry about my BMI? You'll have to listen to find out. And we're going to do things like, should I take a tablet of aspirin a day?

And I'm a grown-up. What vaccines do I actually need? Okay. All great questions. You can find The Dose wherever you subscribe to FrontBurner. Dr. Brian Goldman, thank you. My pleasure. So before we go today, a little bit of a left turn. I want to leave you with a clip of David Ayers,

the 42-year-old Zamboni driver for the Toronto Marlies, who on Saturday night suddenly became the emergency backup goalie in a game between the Toronto Maple Leafs and the Carolina Hurricanes. You see, the home team is required to have an emergency goalie in the building in case either team loses their goalies during the game for whatever reason, and there were a bunch of injuries on Saturday night.

And so that is exactly what happened. Ayers had to suit up, and here he is. When I saw the text message, these guys playing with me right now? Like I'm going in? And then they came in, they said, get ready, we're gonna put you in. So let's go. Even though they had a guy from an affiliated team, Ayers, in the other team's net, the Leafs still lost 6-3. That's all for today. I'm Jamie Poisson. Thank you so much for listening to FrontBurner and talk to you tomorrow. For more CBC Podcasts, go to cbc.ca slash podcasts.