Canada’s single-payer health system is the envy of some Americans. Under Canadian Medicare, every province runs a single public health insurance plan with very low administrative overhead: in this sense, the system is efficient. It is also a natural fit for the goal of health equity: everyone is in the same plan; everyone has the same benefits.
A single-payer system is no panacea, however. Much rides on what the single payer covers and does not cover. For example, Canada scores poorly on international comparisons of health equity. This is largely, but not entirely, the result of what we exclude from Medicare: prescription drugs, as well as non-physician care (physical therapy, dental care, speech language pathology, etc.—any function not performed by physicians), in the community. As a result of these exclusions, Canada has a high rate of private health insurance for extended benefits, and one of the highest levels of private expenditure among universal health care systems. If you need rehab, or have on-going prescription drug costs, moving to Canada might or might not save you from American-style inequities in access to care.
Furthermore, the legal mechanisms that may be used to keep other payers out of the market are diverse and complex, and each has implications for equity and choice. Single-payer systems are not alone in grappling with this. Most European countries assure universal health care by heavily regulated insurance markets with a public mandate, supplemented by a public plan for those who cannot afford insurance or who are not employed by an employer mandated to cover them. (Health care renewal in the US brings the US into this model.)
Every jurisdiction takes on, or rejects, the ethical task of ensuring that the net result of their healthcare system is that physicians see patients based on need and not ability to pay. In Canada, the language of this debate contrasts our “single tier” system with the threat of a “two-tier” system. Some say that we already have a two-tier system (see drug coverage, above); others mobilize to protect the single-tier system we have and seek to extend it to drug coverage and long term care.
There is no single law in Canada, or in each province, that prevents a second tier of access based on ability to pay from developing. Rather, provinces have a variety of laws whose joint effectiveness may rely on culture, market realities, or history, laws that prevent physicians from billing in certain ways, or insurance companies from providing certain products, or facilities from being licensed unless they meet certain standards. One net result of these laws is that, in essence, physicians in Canada practice either in or out of the system for Medicare-insured services. (They may nonetheless practice both in and out of the system by spending some of their time providing publicly insured care, and spending the rest of their time doing enhancement procedures—e.g. assisted reproduction, plastic surgery—or doing assessment and other work for third-party payers.)
Recent decades of growing medical costs and shrinking provincial budgets—not to mention the growing dominance of neoliberal ideology—have placed pressure on our system. In several provinces, private-pay markets in medical imaging, in particular, ultrasound, MRI, and CT scans, are now well-established, circumventing the provincial governments’ attempts to maintain investment in these expensive technologies at levels well below OECD averages. Alberta, British Columbia, and Quebec are known as friendly to the development of private-pay, fast-track MRI and CT facilities. These provinces have forged a path whereby radiologists, unique among Canadian physicians, have the privilege of being able to practice in and out of Medicare at the same time for the same procedures.
Alberta led the pack in private imaging facilities: its first opened in 1993. You might imagine this province as the Texas of Canada, with an oil-patch economy and a history of rugged, American-style individualism. This is certainly how many Canadians picture Alberta. As with all stereotypes, the reality is more complex.
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These developments invite very close attention. The political implications of the core ethical commitments of medicine surface from time to time in history: the founder of modern scientific pathology, Rudolf Virchow, is also known for his statement, “physicians are the natural attorneys of the poor, and social problems fall to a large extent within their jurisdiction.”
So have physicians in the province of Alberta had a conversion experience and embraced social solidarity? Have they adopted socialism, as some commentators are charging?
In context, the College’s move is both less and more radical than it might seem. It is radical because physicians in Canada, speaking through organized medicine and regulatory colleges, have maintained an ambiguous relationship to Medicare—unlike the public, who think of it as our “most cherished social program,” and expect governments across the spectrum to support it. Physician resistance resulted in doctors’ strikes in Saskatchewan in 1962 and Ontario in 1986. Working in a medical school, I often hear physicians exchange their hard-won wisdom from this second strike: “we can have a public voice, and governments will listen, but only when we speak on behalf of patients, not when we are seen to speak on behalf of our own interests.” In myriad ways, I feel I’ve been watching an important stage in the evolution of the profession’s ability to use this voice on behalf of patients. When a physician organization that plays a practical role in articulating standards of practice says that they stand together unambiguously with the public in a commitment to care based on need and not ability to pay, and on reversing the trend towards delisting services and building a second tier, this represents a fresh new perspective in Canadian health care.
It is less radical than it appears in the sense that its source is not so much a sudden conversion of physicians to social solidarity, and more a sense of realism and growing sophistication on the part of physicians about their role in the system. Canadian Medicare, almost paradoxically, combines a single payer with an enormous degree of autonomy for physicians in practice. Every attempt at innovation—in electronic medical records or in centralized wait list management, for example, two huge quality gaps in Canadian health care—faces the daunting problem of an established dysfunctional relationship in which physicians blame the system for being poorly run, and the system blames physicians for not being at the table. Physicians are searching for a new framework from which they can engage constructively, a conversation in which words like “social accountability” and “physician leadership” mean much more than might appear on the surface. From this perspective, the College’s move is one in which the traditional “social contract” view of the professions bears fruit. This is the idea that the professions stand in a social contract with the public, and through their self-regulatory bodies, organize themselves to serve the public interest. It’s as though physicians were looking for a way to engage more constructively with the public and the “system,” studied their Eliot Freidson, and realized that their regulatory colleges could serve an expanded but still traditional role.
This single-payer system is not a paradise for women’s health. Readers will note that I fudged something about “equity” in my first paragraph. In Equity 101, we learn that equity is not equality. A one-size-fits-all approach does not necessarily serve the needs of those “biocitizens” whose bodies don’t fit the assumed white, male, middle class “norm.” Feminists who support Medicare find themselves sometimes with difficult policy choices. There are many communities and one entire province where there are no abortion services: if the public payer makes arcane laws governing payment (as in New Brunswick) or the major non-profit hospital providers, sensitive to community perception, do not provide it (as in PEI), the prohibition on billing privately for what is in this case only theoretically covered publicly becomes a serious restriction on women’s reproductive options. Women’s health pioneer and abortion doctor Henry Morgentaler uncovered the politics behind Nova Scotia’s attempted enforcement of the single tier in 1989: the courts struck the law down after satisfying itself that it was meant as legal pressure directed specifically against abortion, not broadly in pursuit of health equity. The Affordable Care Act will give millions of American women access to birth control that Canadians will continue to pay for out of pocket. Coverage of sex reassignment surgery is subject to the political and clinical winds in each province; consumers can’t shop around for a plan that includes such coverage.
The College’s proposal merits attention from women’s health activists and feminist bioethicists. I believe their efforts deserve our support, but not all feminists may see the issue in the same light. The private market that this proposal addresses also includes ultrasound services, not just the MRI and CT scans we often focus on in accessibility debates. Some feminists, focusing on women’s choice (for 3D ultrasounds; “baby’s first picture”), may opt to defend private access over the gains in equity we stand to make by a new deal on medical imaging. Critical scrutiny of this rhetoric of choice will be essential in the coming months of public debate.
