After years of delay, Dr. Brian Day’s case against the BC Government is now being heard in BC Supreme Court.
Day and his private for-profit Cambie Surgery Centre are challenging the parts of the BC Medicare Protection Act that prevent doctors and private clinics from directly billing patients for medically necessary procedures; in other words, the provincial legislation that protects our public health care system by making it illegal to create a parallel private, for-profit system. Day claims these limitations are un-constitutional because they prevent patients from leap-frogging waits in the public health system.
At the heart of the case is the contention by Day that people should be free to spend their money as they wish (either paying for private surgery directly, or purchasing private insurance for that purpose), and that if this were allowed, not only would such people receive faster care, but wait times would also shrink in the public system.
But if Day wins, wait times in the public health care system are actually much more likely to increase. Here’s why.
- There is a finite number of doctors and nurses. If more are recruited into the private for-profit system, fewer of them will be available in the public system.
- The business case for private payment only exists in the face of long waits in the public system; the former requires the latter. In other words, a private system needs long public wait times to attract patients and make money. Think about it. While Dr. Day is fond of claiming that his private-pay “solution” would reduce or even eliminate waits in the public system, why would anyone pay out-of-pocket for surgery or private insurance, if the same timely care was freely available in the public system?
The business case for private payment only exists in the face of long waits in the public system.
Indeed, the research evidence contradicts Day’s claim. Australia (one of Day’s favourite examples) is a country that had a public system much like Canada’s until the 1990s, when it decided to introduce a private second tier. A study conducted by Stephen Duckett, a professor of health policy in Australia, found that the private sector actually reduced the capacity of the public sector to provide for patients, and wait times grew.
- When doctors are allowed to practice in both the public and for-profit systems, it creates a harmful incentive for them to prolong their wait-lists in the public system in order to encourage their patients to switch over to the private option.
Some evidence for this can be found in a Manitoba study, where until 1999, patients could choose to have cataract surgery in a private clinic for an additional “facility fee” (the surgery itself was still covered by the provincial health plan). The Manitoba researchers found that while the fee was in place, patients whose surgeons worked only in public facilities could expect a median wait of 10 weeks in 1998/99. However, patients whose surgeons worked in both public and private facilities could expect a median wait of 26 weeks.
- Allowing multiple clinics and doctors to maintain their own competitive wait-lists gets in the way of efficient and fair management of surgical wait-lists. What the system greatly needs is to move from the current approach where, for the most part, surgeons manage their own wait times, to a “first available surgeon” model where wait-lists for different specialties and surgeries are pooled. Think of the difference between trying to decide which line-up to join at the grocery store (and almost always feeling like you joined the wrong line), versus the single line-ups now employed at most banks and airports. The single line, even though it appears long, moves quickly and equitably. But allowing private clinics and surgeons to compete undermined the implementation of this kind of smart solution.
Allowing private-pay healthcare means those with money will no longer have a stake in demanding improvements to the public system
- But the most important reason that allowing private-pay health care won’t shorten public wait-times is this: in such a mixed system, those with money will no longer have a stake in demanding improvements to the public system. Social solidarity is lost, and those with the most influence no longer feel compelled to make common-cause with the rest of society.
An important concept in democratic theory, developed in the 1970’s by economist Albert Hirschman, is that when people are upset with the quality of something on offer (could be a product or a government service), they can exercise their dissatisfaction by means of either “exit” or “voice”. Meaning, they can either choose not to “purchase” a particular product or policy or political party (i.e. exit), or they can choose to engage and advocate for change or improvement (i.e., voice). The problem is that it tends to be those with more economic and political power in our society who are more inclined and able to exercise both exit and voice.
To see this dynamic at play, simply look at our education system. There, people are “free” to either stay in the universal public system or pay out-of-pocket for private school. And what has transpired? Many of those with more money and influence have abandoned the public system (they have chosen to exit), and as a result, the public system has also lost their voices. The outcome is a public system plagued by under-funding, larger classes, and eroded supports for children with special needs. Private “choice” has most certainly not improved the quality of the public service.That is not the path we want to follow for health care.
Let’s be clear. The wait times for some surgeries in our public health care system remain too long. We must change this. But the cure Dr. Day proposes is worse than the disease against which he rails. There is a better way. The CCPA’s recent report Reducing Surgical Wait Times provides a framework for public innovations that can accomplish this, and more ideas can be found here.
But to see these public solutions realized, all of us—rich and poor alike—will have to advocate for them together.