“Healing is a matter of time”

The title above appears to have been adopted as a motto by our governments. If they allow a 12-month waiting period for a particular treatment, are we to deduce that earlier treatment than that is not medically necessary?

Although the Canada Health Act (CHA) requires that all medically necessary procedures be covered, it fails to define the term. This was no error of omission, but rather a clever and deliberate abrogation of decision-making. The Act requires that care must be comprehensive, universal, portable, and accessible as well as being publicly funded and administered. As most physicians are aware, our federal and provincial governments are at least deceiving and perhaps even defrauding the public when it comes to enforcing the first four of these principles.

“We are sorry to inform you that we have determined that a voice is not medically necessary,” wrote a BC Ministry of Health bureaucrat to a cancer patient who had undergone a laryngectomy and was seeking funding for a “voice box.” Several years ago a Province newspaper editorial castigated the so-called right-wing Alberta government for changing its health coverage so that it no longer funded replacement artificial limbs. They failed to research the fact that our (then) NDP government did not even fund the first prosthesis. Poor vision due to loss of elasticity or shape in the lens (refractive problem) is not considered a medically necessary problem, but if the same lens is slightly opaque (cataract), it is. Hearing aids are also not covered by most provincial health plans. As new technologies are introduced, governments are taking the position that, notwithstanding their efficacy, they are uninsured. 

Who determined that disabilities such as being unable to speak, walk, see, or hear are not medically necessary? Who decided that an abscess in the toe that prevents a person from kicking a soccer ball is covered, but one in the tooth that might develop into a brain abscess is not? How can it be that making breasts smaller is medically necessary, but making them bigger is not? In assigning that responsibility to individual provinces, the CHA created a disparity that makes a mockery of the term comprehensive. While we have patients waiting months (or even years) for the treatment of arthritis, cancer, or heart disease, we continue to subsidize less-urgent services (including cosmetic surgery) in our public hospitals. Failure to prioritize now results in acutely ill patients waiting in emergency rooms or for emergency surgery or ambulance service. Does the inability to play tennis, ski, or play hockey constitute a medically essential function? A torn knee cartilage may hurt during activities of daily living in some cases, yet in others only limit a person’s ability to bungee jump, sky dive, or play sports at an elite or professional level. A sprained ankle may be inconvenient to many, but disastrous for a roofer. These examples illustrate why the task of prioritizing will not be easy. Economic reality dictates that governments cannot provide all medically desirable services in unlimited amounts for free. As Clint Eastwood said (as Dirty Harry), “A man’s got to know his limitations.”

Physicians, together with patients, other health workers, and governments must come together to define what is medically necessary. The difficulty of this task was exemplified by the Alberta Health Summit (1999), which failed miserably in its attempt to rank core medical services. Public delegates representing all sectors of society were unable to reach any consensus. “We find everything equally essential,” said delegate Shannen Morris. 

The Oregon Health Plan is the best known attempt to rank core services. While not perfect, it could serve as a template for a similar process in Canada. As in Oregon and as a part of that process, a means test will be required and a greater range of (so-called) free services will be made available to those who are less wealthy. The rich will find themselves with less coverage through the public system. Money will be diverted from them to the less privileged—an act of true socialism. An urgent task force is needed to define core services. The task force should be small and must include a physician with expertise in the evaluation of outcome studies. Alberta has already embarked on such an effort. We will not produce a perfect list of priorities, but it will be easy to improve on the chaos that now exists. 

Expenses are growing faster than revenues, and unless changes are made our health system is headed for bankruptcy. It is the duty of our elected leaders to allocate resources to those areas that are most important. Under the CHA it is the provincial governments’ responsibility to define the term medically necessary. They must act now and we should be there to help them. 

—BD

*Hippocrates