Winston Churchill advised us to “never let a good crisis go to waste”. The past two years have burdened health-care systems around the world with an abundance of crises – high death rates among our loved ones, health-care worker burnout, shuttered operating rooms leading to surgical backlogs and surging wait times for suffering patients.
We are now at a crossroads. We either strengthen or surrender one of our greatest assets – our universal, publicly funded health-care system.
More competition is a frequent knee-jerk response to the issues facing our health system. Canadians value Medicare but some believe there should be a parallel private pay option that allows patients or insurance companies to jump the queue for faster care. Yet, creating a hybrid payment system would make Medicare worse for most of us.
Building more for-profit, investor-owned health-care facilities to tackle surgical wait lists sounds like a good idea but who would staff those clinics? Like all countries, Canada has a finite number of physicians, nurses and other health-care workers. If they leave the public system to care for the small number of patients who would be able to pay privately (be it out-of-pocket or through private insurance), it will leave fewer clinicians to care for the majority of patients who would continue to rely on the public health-care system. Ultimately, this would only worsen wait times.
In Australia, where many patients have both public and private insurance, surgical wait times are twice as long for patients with only public insurance than for those with private insurance too. Average wait times for cataract removal, coronary bypass and joint replacements are higher in Australia’s multi-payer system compared to Canada’s single-payer system. Why would we copy a hybrid system that is both unfair and slower?
Multi-payer systems with parallel private insurance cost more to administer than single-payer health systems.
Right now, we don’t have money to waste. Multi-payer systems with parallel private insurance cost more to administer than streamlined single-payer health systems. Administrative costs for health insurance in the United States are almost five times higher than in Canada. We must devote our limited resources to high-value patient care – not to overhead and profit for private insurance companies. Physician time is another limited resource that is used more efficiently in single-payer systems. We are grateful to work in a system where we can devote our energy to patient care instead of spending hours arguing with insurance companies to cover patients’ necessary medical care.
The real solution to our health-system crisis is hiding in plain sight: strengthening our public health-care system. Evidence-based initiatives can improve wait times within our public health-care system. Centralized referral lists and multidisciplinary teams are innovations that have reduced wait times for hernia surgery in Nova Scotia, hip and knee surgery in Toronto and appointments for arthritis specialists in Calgary. Adjusting operating room schedules and reserving rooms for emergency surgeries have helped Toronto’s University Health Network effectively tackle its surgical backlog. Canada’s siloed federal, provincial and territorial health systems are often a barrier to spreading these practical, common sense solutions. It is imperative that health-system leaders learn from one another to implement what works.
We cannot claim that our public health system has failed when we haven’t funded it appropriately. Governments have under-funded our public health care system for decades but perplexingly seem shocked when it then falls short of meeting patient needs. Approximately 69 per cent of health spending in Canada is public through government transfers; this is below the OECD average (71 per cent) spent from public sources as a share of total spending and lower than countries like the United Kingdom (79 per cent), Norway (86 per cent), Sweden (85 per cent) and Denmark (83 per cent). Canada also spends less on hospital care compared to other high-income countries.
The COVID-19 pandemic has caused a reckoning for health-care systems everywhere, including ours. Canadians must not be duped by those advocating for private pay in profit-driven facilities – particularly when those advocates often stand to benefit financially from further privatization. Public health-system solutions have been hiding in plain sight for ages and cannot be ignored any longer.
We must demand more from our political leaders and use this crisis as an opportunity to build back better.
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So how much is “too much” private health insurance? Each country has a system that reflects its history, goals, structures and institutions. Decades ago Canada launched a narrow but deep public system for hospitals and physicians, and then governments failed to consistently update and expand it to ensure universal and equitable support of other necessary health services. That’s not a ringing endorsement of a fully public single-payer system.
The authors assess the system from their perspective is as physicians and they focus primarily on surgery. That’s fine of course, but very limited since hospital and physician spending now consumes less than 40% of total health costs versus 60% in 1975. That’s how far behind the public system is in reflecting today’s needs.
There are not many experts who say a health system that already consumes over 40% of provincial program spending needs even more money at the expense of other social determinants of health.
Rather than assuming Canadians have been “duped” to accept a mixed payer approach to many essential health services that governments have consistently refused to fund, we should pragmatically work to improve the system we have. The mixed-payer system isn’t ideal, but $37 billion of private health insurance spending is not the villain.
While I agree that a knee jerk solution to allow private pay is not the answer, the article neglects to mention that all the countries mentioned (i.e., United Kingdom, Norway, Sweden and Denmark) have private pay in some manner. I have run a for profit healthcare company and I now head a not-for-profit. What I have seen over the last 30 years is unbelievable growth in bureaucratic overhead, overhead that is non-productive, staffed by non-healthcare professionals who, possibly with the best of intentions, incinerate health care dollars. The supposed ills of private care are not based on fact. Further investigation will find a great deal of for-profit components to our health care system. We most certainly need to re-engineer the healthcare system, but we cannot and should not start with opening positions such as “no private pay”.
Canada has significantly more private pay than most of our European counterparts, including the UK (10.4% of GDP public vs 2.3% private), Norway (9.8% public vs 1.6% private), Sweden (9.7% public vs 1.7% private) and Denmark (8.9% public vs 1.7% private). Canadians already pay way too much privately (3.2%) and not enough publicly (7.6%). We should expand our public health care system instead of forcing people to either pay for necessary care such as physiotherapy, counselling, etc., or to go without until they end up in hospital. We also, of course, need and could very well fund national Pharmacare and dental care.