Textes d'opinion

The way is not Clair: Health commission’s findings fail to address need for fundamental change

In a 1998 survey by Harvard/Commonwealth Fund researchers, 79 per cent of Canadians felt fundamental changes or a complete rebuilding of the health-care system was needed. Two years later, 88 per cent of Canada’s specialist physicians and 76 per cent of general physicians thought the same thing.

These people, who might have had high expectations for the Clair commission report on financing and organization of Quebec health care, will be disappointed. They will find no recommendations for the necessary fundamental changes and rebuilding.

Most Canadians believe in a basic system of compulsory, tax-based, universal health insurance so that no one would be denied health services because they can’t afford them. But they also long for the restoration of personal choice in private health insurance and services in parallel with the public plans. This would enable them to exercise greater responsibility in protecting their lives and health and that of their loved ones.

Most Enjoy Choice

After all, most people in other counties, even in democratic socialist governments of Europe, Scandinavia and Britain, enjoy such choice in health services. Canada and Cuba remain the only countries where outdated Marxist-inspired health legislation bans private medical and hospital services and private-insurance alternatives to the governments’ monopolistic plans.

To be fair to the Clair commissioners, their mandate was not to explore alternative sources of funding, insuring and providing health services using the private sector. With this constrained mandate, the fundamental causes of health-system deterioration have been largely ignored.

Nevertheless, the commission should be congratulated for making a timid gesture toward the private sector and risking the wrath of medicare purists. This risky but sensible recommendation suggests that hospitals might wish to integrate some private specialty clinics as hospital extensions and contract out certain diagnostic and surgical procedures to shorten the hospital waiting lists. All would be covered by medicare.

The most disappointing aspect of the Clair commission was the failure by its political masters to push Quebec and Canada into the forefront of modern health-system financing reform. This could have been accomplished by encouraging the commissioners to look outside the box. The Montreal Economic Institute, an independent research and educational body, has done just that.

It recently held an international conference on the future of health care in Quebec and published a research study titled Universal Private Choice: A concept of health care with quality, access and choice for all Canadians. The study was co-authored by Jacques Chaoulli and myself.

The study criticizes Canada’s prohibition of voluntary parallel private health insurance and private medical services in hospitals. This precludes all Canadian-based experimentation in these areas. So much for the future of health-systems research in Canada.

The study shows how European countries maintain universal access through parallel private care and insurance systems while avoiding many of the problems of delayed access, declining quality and restricted choice that plague Canada’s health system.

The study then proposes a unique concept of health-care financing and insurance called Universal Private Choice or Medicare Plus. It would preserve the publicly funded plan as a basic core medicare plan, but would offer several optional methods of financing and insuring health services.

While everyone would be required to pay taxes to support medicare, individuals could opt out of certain categories of services such as office visits, hospital, diagnostic and laboratory and drugs and receive an equivalent tax credit or voucher. This credit could only be used for an alternative form of private insurance or a health plan covering that category of service.

Savings plan

One alternative is a Medical Savings Plan, similar to our Registered Retirement Savings Plan. This would be another tax-deductible option for funding routine health services, combined with a low-premium catastrophic health insurance, while paying out-of-pocket for simple health services up to a yearly maximum after which the insurance cover takes over.

Universal private choice would provide wider choices in tax-deductible private health insurance, either of a traditional type or in comprehensive health-service plans formed by regroupings of physicians, hospitals and insurance providers. It would provide for refundable tax credits or government vouchers for low-income individuals and families who prefer to invest in Medical Savings Plans or private insurance as alternatives to medicare.

Group purchasing of health insurance or health plans through member-owned, health-purchasing agencies of 10,000 members is something that should be tried in Canada. The agency would be an information-gathering and negotiating body for its members, ensuring individuals will have some clout in negotiating the purchase of group insurance or health plans.

Hospitals would gradually relinquish their status as quasi-government facilities. They would regain their original status as community-supported facilities and university research and teaching hospital centres serving the public.

The role of government would be reduced and much of the government funding would be passed to patients as empowered consumers, to be used for their choice of health and hospital services.

Before launching such a major health-system reform, governments could consult people through options such as referendums. With any major health reform there should be a set time for evaluation, modification or termination.

An underlying principle of this proposal is its multiple-choice policy of financing, insuring and delivery of health-care services, instead of the single-choice policy of the current medicare monopoly.

This is not an attempt to import either the European or American models of health care, but it does draw on the good features of both. When combined with the good features of Canadian medicare, this medicare-plus concept offers a promising solution to the problems facing our health-care system. Only a rigorous field trial will prove or disprove its claim of improved quality, access and choice for all Canadians.


Dr. J. Edwin Coffey est chercheur associé à l’IEDM et co-auteur de Universal Private Choice: Medicare Plus, A Concept of Health Care with Quality, Access and Choice for All Canadians.

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