On the Issues

Towards a two-tier system

Mary Janigan November 13 2000
On the Issues

Towards a two-tier system

Mary Janigan November 13 2000

Towards a two-tier system

On the Issues

Mary Janigan

The health-care policy debate has bogged down over the use and misuse of two highly charged words: public and private. On one side, Alliance campaign co-chairman Jason Kenney has recklessly mused that Ottawa should allow the provinces to provide access to undefined “choices” in health care —as long as everyone has the option of using a “quality universal public health-care system.” All other parties—the Liberals, the Bloc Québécois, the Conservatives and the New Democrats—have pounced, charging that such “choices” would entail the creation of a two-tier scheme that would allow wealthier Canadians to pay private clinics for basic public services, getting faster treatment in more luxurious surroundings. The debate has unfortunately focused on the immediate, but rather far-fetched, prospect of privatization. And it has ignored innocuoussounding planks in the Alliance platform that would be far more likely to diminish Ottawa’s role in health care—and to allow individual provinces to creep towards two-tier care.

The very word “private” has become a hobgoblin—but medicare has always been a mixture of the public and the private. Private providers such as physicians offer publicly funded basic services. If doctors decide to charge private fees for services that would otherwise be publicly funded, they must completely opt out of medicare. Private clinics can provide both publicly funded services, such as basic blood tests—and private services, such as cosmetic surgery, that are not covered by medicare. In Alberta, those private clinics can even provide publicly funded services that entail overnight stays. But it is contrary to theprinciples of the Canada Health Act— and allprovincial health insurance acts—for a clinic to chargepatientsfora medically necessary service that is publicly insured. “The

rubicon is: are you willing to allow private payment for what would be publicly funded services?” says health-care consultant Michael Decter.

The Alliance—and a ratded Kenney— say No: clinics would not be permitted to charge for basic services. The party supports the five principles of the Canada Health Act: universal, portable, accessible, comprehensive and publicly administered. It would even add $400 million to the 2001-2002 cash transfer of $18.3 billion to the provinces. But the prospect of drastic change does lurk behind the Alliance’s soothing phrases. At present, Ottawa decides whether a violation of the Canada Health Act has occurred—and then subtracts penalties from its cash transfers. Under the Alliance, Ottawa would lose that clout: it would set “national standards” with the provinces— and then create an “independent enforcement mechanism” to decide whether a violation had occurred.

In the longer term, the Alliance would transfer tax points to the provinces to replace an unspecified portion of cash transfers: that is, Ottawa would lower its tax rates—and the provinces would raise theirs by an equivalent amount. Although the Alliance insists that a federal cash transfer would still exist, it would obviously be much smaller, and the ability to enforce national standards would be diminished. What happens if a province then decides to change its laws and allow private clinics to charge fees for basic services? Ottawa would have little clout to enforce its will: the issue would lie between the provincial government, which has the responsibility to deliver health care, and its voters. But the Alliance cannot pretend that everything would be the same under its government. It wouldn’t. And its platform’s vague wording can only encourage public unease.

Parts of the Alliance platform will diminish Ottawa’s role