In the ongoing public debate aimed at improving Canada's deteriorating health care services, hospital emergency rooms (ERs) have been under the spotlight. Along with hospital waiting list problems, the overcrowded ERs have served as barometers of the dysfunction within the health care system.
ER nurses and physicians know from experience that most of the overcrowding problems are the result of a breakdown in other parts of the health care network. For instance, the percentage of non life-threatening conditions seen in hospital ERs is very high.
Patients often come or are referred to the ER for medical help because regular clinics are closed or unable to care for them in a timely manner or hospital beds are unavailable and the ER becomes a place of last resort. When the hospital ER becomes a substitute for a public or private clinic, genuine emergencies and sick patients who require hospitalization suffer the consequences, along with the ER professionals who try their best to deal with an impossible situation of overcrowding.
More and more people are asking how did the provincially controlled medical and hospital services in Quebec and Canada get into such a serious state of decline. All OECD countries have universal access to public health services, and all except Canada have access to private health insurance as an alternative choice, should the public plan not be satisfactory.
The outstanding difference between Canada's public health insurance legislation and that of other countries is the prohibition, by most provinces, of private health insurance and private medical services in hospitals, for services covered by medicare insurance.
The first health insurance legislation of this nature was enacted by Quebec's Liberal government in 1970, by means of an unnecessary provision in the Act that established medicare insurance, the Quebec Health Insurance Act. This freedom infringing provision was added in the midst of a political environment of excessive pressure on the politicians of the day from union movements. Several other provinces and the Canada Health Act (1984) later copied the notion.
In a 2001 study entitled Universal Private choice: Medicare Plus. A health care concept with quality, access and choice for all Canadians by Dr Jacques Chaoulli and the author, and published by the Montreal Economic Institute (MEI), a brief review is given of things learned from the experience of other countries who, like Canada, have a publicly funded system and universal access to services. Most of them have parallel or mixed systems of public and private funding and delivery of health care and insurance services and continue to experiment with improvements.
Canada, on the other hand, finds itself in an embarrassing situation, prohibited by its own health legislation from doing experiments and pilot projects with alternative and mixed private and public funding and insurance combinations.
However, there is one lesson we can learn from Canada's forty odd years under a model of central health system planning and control of essential medical and hospital services and insurance by provincial government monopolies: it eventually brings impoverishment, scarcity, rationing, deterioration of health care quality and obsolescence of technology. It also brings line-ups for diagnosis and treatment, crowding of facilities, demoralization of nurses and physicians, and the loss of personal freedom to choose, in health care matters.
Now that Canadians are experiencing these distressing results they are more and more inclined to welcome a new approach to health care funding and delivery. This will bring results closer to their expectations and closer to the superior experience of current health systems of Western Europe.
Health care systems of Quebec and the other provinces need fundamental changes in the financing and delivery of medical and hospital services. This conclusion is supported by successive public surveys by the Harvard School of Public Health and the Commonwealth fund. In 1988, 56% of Canadians were generally satisfied with their health care system. In 2001 that satisfaction rate had dropped to 21% and 77% of Canadians felt the need for either fundamental changes or a complete rebuilding of the health system.
Over the past four years Canadian public surveys have also shown a strong majority favouring the right to purchase alternative private health insurance and medical and hospital services covered by medicare but often not readily available. This attitude is generally linked with a proviso that publicly funded medicare insurance must not be jeopardized by the voluntary use of alternative services.
These fundamental changes and rebuilding of the health care system should be focused on the needs and preferences of patients. The objective should be to create a renewed health system environment of personal freedom and choice for patients and providers in all matters of financing, insuring and delivery of services, where quality and ready access is of the highest priority.
Such an approach has been proposed and described in Universal Private Choice: Medicare Plus, a concept of health care with quality, access, and choice for all Canadians. The following objectives of this new approach are found in more detail on the MEI web site www.iedm.org:
- The Universal Private Choice or Medicare Plus concept is based on the assumption that patients, physicians, hospitals, insurers and other health care providers will be freed from prohibitive legislation that now severely limits access to private health insurance and private medical services in hospitals.
- It frees up the innovative and competitive capacities of all, in the service of health care consumers.
- It eliminates the government monopoly in financing, planning and co-ordination of most health care services and takes advantage of market competition and individual planning.
- It retains medicare as a universal health insurance option for basic core services.
- It puts purchasing power in the hands of all consumers of health services, rich and poor alike, and encourages patient participation in the market place for health services. It assists them in making informed choices among health insurance options.
- It gives greater financial and vocational independence to hospitals, and with growing numbers of financially empowered health consumers who are cost conscious and fully informed on hospital matters of quality, access, available technology and professional reputation, hospitals should become more competitive in attracting patients. It will allow hospitals to contract out hotel type services, laboratory and imaging services, and ambulatory surgery to private facilities when waiting lists are too long.
Universal Private Choice allows for a voluntary shift from the predominance of health care financing and monopoly control by government, as insurer, payer and provider, towards a pluralistic approach of financing, insuring, paying and providing, mainly controlled by the patient.
Edwin Coffey, MD, is a co-author of Better Medicine: Reforming Canadian Health Care, and Universal Private Choice: Medicare Plus. He is a former President of the Quebec Medical Association, a retired Associate Professor at McGill University Faculty of Medicine, and Senior Associate Researcher at the Montreal Economic Institute.