A landmark case challenging the fundamental principles of Canada’s public health-care system is in its final days before the Supreme Court of British Columbia. Cambie Surgeries Corp., the corporate plaintiff in the case, is attempting to overturn the law that ensures health care is provided first to those who need it most, rather than those who can afford to pay their way to the front of the line.
Wait times are a problem in Canada, but for-profit clinics and private payment — either out-of-pocket or private insurance — are not the solutions. The plaintiffs argue that the public health-care system is unable to reduce wait times, and that the only solution is to overturn three key provisions of the B.C. Medicare Protection Act that protect the health of British Columbians.
The plaintiffs want to eliminate the ban on extra billing (charging patients extra, beyond the fees doctors are paid under the public plan), the ban on private duplicative insurance (to cover medically necessary services already included in the public plan) and the ban on dual practice (precluding doctors from being paid by both the public plan and private payers).
Cambie Surgeries has failed to demonstrate that lifting the province’s ban on these three provisions would reduce wait times for anyone but those who could pay. Meanwhile, there is ample evidence that wait times, and health-care-system costs, would increase under a multi-payer system.
Evidence from other countries shows that when those who can pay are allowed to skip the line for faster care, wait times get longer for those who can’t pay. This is partly because health-care providers may preferentially work in the for-profit clinics.
For nearly 20 years, Australia has used various tools to incentivize Australians to buy private insurance, as a way of adding more money to their system. As a consequence, those with private insurance have had faster access to elective surgery than those without. Yet Australians are increasingly dissatisfied with private health insurance, as premiums are rising much faster than wages or inflation, and taxpayers subsidize the private insurance industry to the tune of about $9 billion every year.
In Germany, publicly funded insurance is mandatory for 90% of the population. Only the 10% whose income is high enough — greater than about $90,000 — are allowed to substitute public insurance for privately funded insurance. But it’s a straight swap: wealthy Germans can substitute private insurance to replace the public plan entirely, for all of their care, not just for faster access to some care. They can’t have both public and private coverage at the same time.
Consequently, those who rely on the publicly funded system wait three times longer, because doctors preferentially treat those who pay privately. There are innovative evidence-based solutions to the problem of wait times that we can implement in Canada without dismantling the laws that protect our rights to care based on need, not ability to pay.
In 2018, the B.C. government launched a new, four-part surgical strategy aimed at reducing wait times for hip and knee surgery. Based on the successful Richmond Hip and Knee Reconstruction project, this strategy is increasing surgical volumes and reducing wait times by adding dedicated operating room time, pre- and post-surgical support, centralized intake, standardized assessment and “first available” surgeon.
Similarly, the RACE program (Rapid Access to Consultative Expertise) allows B.C.’s family physicians to access specialists by phone within two hours for “just in time” advice. This has reduced the need for face-to-face consults with specialists by 60% and emergency-room visits by 32%, with overall satisfaction reported by specialists and family physicians.
Measures such as these, which alleviate wait times while prioritizing the delivery of care based on need, are far better suited to fulfill the principles of our health-care system than making people pay privately for timely care.
Canada’s medicare system defines who we are as Canadians. It is based on the value that we care for each other according to need, not ability to pay. Cambie Surgery’s legal challenge is an attack on those values, and a decision in their favour would unravel our health-care system for the vast majority of us who rely on it.
Dr. Rupinder Brar is a clinical assistant professor in the faculty of medicine at the University of British Columbia and a family physician in Vancouver.
Dr. Richard Klasa is a retired physician at the division of medical oncology, B.C. Cancer Agency, and the department of experimental therapeutics, B.C. Cancer Research Centre.
Both are members of Canadian Doctors for Medicare’s board of directors.
