Proponents of turning more of Canada’s public Medicare system over to private care providers could only justify such privatization if they could convince Canadians that doing so would improve the quality, accessibility, and affordability of health care in Canada. The onus should be on those who want to privatize delivery and payment to show how investor-owned services and private payment would improve or even maintain the demonstrable advantages the public system has to offer.
There are 10 advantages I see in the public system. The list follows, along with pertinent questions that those who favour privatization should address.
The quality of care is better, in part because the rich must use the same services as the poor and thus have an interest in making sure all services meet a high standard. (Quality has admittedly declined somewhat in recent years, but this has been caused by underfunding and understaffing, not by any inherent flaw in the public nature of the system itself.)
Q. How will the quality be maintained or improved?
Administrative costs are lower. Much less money is spent sorting the deserving from the undeserving (or the affluent from the low-income patients), and less time spent on billing and chasing those who have not paid.
Q. How will these administrative advantages be maintained or improved?
Services can be centrally planned so that they are more fairly allocated across the country, especially in rural and remote areas. While we clearly haven’t been entirely successful—in part because we have left many of the decisions to private agencies--we have reached many who lacked proper health care services before.
Q. How will the distribution of services be maintained or improved, especially for those living outside the larger population centres?
Wait lists can be centrally managed to allow an efficient and needs-based accessibility to services. (Granted, wait times have lengthened in many hospitals, but this too is the result of a failure to fund and staff adequately, not an integral defect in the public system itself.)
Q. How will wait list standards be maintained or improved, and how will it be ensured that those most in need will get priority?
Wasteful duplication of services can be reduced through Medicare’s central planning.
Q. How can we be sure that money and resources are not wasted on advertising, on excess capacity, and on other expenses endemic to investor-driven systems?
Collective, democratic decision-making is possible, if not always practised.
Q. How will citizens who contribute, directly and indirectly, to all health care services have their voices heard in the design of health services, especially the working poor without the means to access private care? Who will decide—the patient with the money or the doctor with the expert knowledge?—and how will a balance between collective and individual rights be maintained? And what about conflict of interest?
Access is based on need, not ability to pay.
Q. How can we be sure that this standard of access is maintained or improved?
Jobs and wages are better in the public sector, especially for the overwhelmingly female labour force that does most of the support work.
Q. Since a high quality of jobs and compensation is central to good care, how can it be maintained or improved for those who provide most of the care, rather than just for doctors, therapists, and technicians?
Employers save a lot of payroll money through a public health care system, which substantially lowers their benefit costs in labour agreements.
Q. How will employers be able to maintain this cost-saving advantage and avoid pressure to cover more private health care?
Innovation on a large scale has been possible in the public system. Insulin, laser, cataract surgery, antibiotics—these and many other breakthrough treatments were developed in the public realm.
Q. How will innovative developments of this kind be supported or enhanced, and how will these new treatments be shared?
Regardless of how the proponents of more privatized health care may answer these questions, the underlying reality is that, under Medicare, costs are shared among all Canadians—and this is especially important for those who become seriously ill. Of course some aspects of care will probably always remain private, but it is illogical to argue that we should have more private care so that more high-income people can push to the front of the line. What happens when more doctors, nurses, and other health professionals trained mainly with public money, seek to work only in private care facilities, thus further reducing resources in the public system?
The advantages of Medicare as a public system are demonstrably clear and substantial. Any decision to increase the already privatized share of health care should be weighed on a scale that recognizes these advantages and should be based on evidence, principles, public participation, and our notion of social justice—not on the basis of power, influence, and ability to pay.
(Pat Armstrong is a professor of sociology and women’s studies at York University.)