The Chaoulli decision, which considered the case of Mr Zeliotis having to wait 9 months for a publicly funded hip replacement although he was willing to pay for it sooner, shook the integrity of the Quebec Public Health Act and led to the expansion of private health care in the province.[1-3] Dr Brian Day’s recent BC Supreme Court challenge seeks to do the same in the rest of Canada. Supporters and opponents of private health care are diametrically opposed, but there may be a compromise. 

The Chaoulli case and Dr Day’s challenge involve orthopaedic surgery. The Canadian health care system provides emergent and urgent care in a timely fashion; however, replacing worn-out joints is considered elective. Despite considerable efforts in recent years, only 47% of knee replacements and 61% of hip replacements in BC in 2015 met the benchmark wait times of 6 months.[4] This is occurring despite there being Canadian-trained orthopaedic surgeons who cannot find jobs here. As of June 2016, 182 recently graduated orthopaedic surgeons could not find work in Canada, and 61 had left for jobs in the US and other countries.[5] The Canadian system is not providing the operating room time or hospital beds needed to shorten wait lists. 

Canada Health Act supporters defend the one-tier model at all costs and find the current provision of services by private clinics such as Dr Day’s unethical. However, for a patient in pain and unable to work, waiting months for a consult and a year for surgery is unacceptable. In the words of Chief Justice Beverley McLachlin, “Access to a wait list is not access to health care.”[6] Currently in Canada, such patients face a dilemma: suffer until the public system can treat them or pay for the procedure privately in the US or, increasingly, in Canada. 

By paying for their procedure, patients take themselves off the wait list. Advocates of private health care believe paying privately justifies their “jumping the queue.” But this view is unpalatable to most Canadians for two reasons: they believe that universal health care is a basic Canadian value so jumping the queue seems unfair, and they fear that erosion of resources to the private system will detract from the quality of care in the public system. However, a compromise could address both concerns: one that allows a patient to jump the queue yet strengthen rather than weaken the public health care system.

Such a compromise proposes integrating private and public health care, but to be equitable, two prerequisites must be met. First, a medical practitioner providing a necessary service to an eligible Canadian in a private health care setting must not earn (much) more for that service than they would in the public system, a lesson learned from other jurisdictions. Stark fee differentials between public and private care in the US and Australia have diverted resources and weakened the public system, whereas absence of differentials has maintained equitability in many European systems. Second, universal access should remain a central principle of both private and public health care delivery. All Canadians should have access to necessary services provided in either setting; however, for certain services, expedited care would be available for those able and willing to pay a premium. 

For patients willing to cross the border to the US, two-tier medicine has always existed, and many wealthy Canadians do use the American for-profit system. That results in a lot of dollars leaving the country. In 2013 hospital costs for a hip replacement in the US were $24 000—triple the Canadian costs of $8000.[7,8] The proposed compromise would keep this money at home, allowing patients to jump the queue in Canada and harness the resources to benefit all Canadians.  

Pay a fee to jump the queue
The requirement to jump the queue would be a fee equivalent to the cost of the procedure—enough to pay for the same procedure for another patient on a public wait list. For example, a wealthy patient could pay $16 000 privately to get a hip replacement within weeks in Canada: half would cover his or her surgery, and the other half would provide the same service for another patient on a wait list. This formula would apply to currently rationed services such as MRIs and joint replacements. Emergency and urgent care would not be affected. Few procedures have wait lists long enough to prompt patients to pay privately, and so the system would self-regulate. As private funds expand capacity, wait times would fall and fewer patients would ask to jump the queue.

Funds generated by the surcharge would need to be earmarked for hospital beds and operating room time to provide similar services to other Canadians in need, not become a tax destined to disappear in ever-expanding health care budgets. Third-party payers such as workers’ compensation boards and insurance companies would be required to pay the fee to expedite service for their clients.

Under this plan, whether a surgery would be performed in a public or private facility would be unimportant, provided the fee differential is minimal. Private insurance for expedited nonemergency services would become available, as now exists for private hospital rooms and prescription medications. This would allow some Canadians access to the new tier of care without having to pay out of pocket. There would be challenges of course: ascertaining the costs of procedures, assigning facility fees, addressing geographical inequities, and monitoring the public system to ensure it does not shirk its responsibility onto those Canadians willing to pay. However, the proposal would expand capacity for public patients by accessing private funds currently flowing into private US and Canadian facilities. For a similar or lower price, individuals could access expedited service at home while supporting Canadian patients rather than a for-profit system. 

The dilemma of compromise
This proposed compromise will displease both ardent supporters and opponents of private health care. Jumping the queue means unequal access, which some will find unethical. Paying extra is a tax, which others will oppose. However, the fee would directly benefit another patient and the wait list would shorten by two instead of one. Individuals would be free to access services without waiting longer than they feel is acceptable, and the concerns of the Supreme Court should be allayed. The Charter of Rights defends individual freedoms, not free health care. Taxation is the domain of government.

Saskatchewan recently piloted a similar scheme for privately paid MRI scans:

The province’s MRI Facilities Licensing Act allows private clinics to charge individual patients or third-party organizations—including the Workers’ Compensation Board and the Saskatchewan Roughriders football team—for their scans. The two private clinics in Regina that have joined the program then have to provide a free scan of equal diagnostic complexity to a patient on the public waiting list within 14 days. . . . The program has led to more than 2200 MRI scans in nine months at no cost to the public purse. The waiting list for MRIs was 700 patients shorter in the most recent three-month update than it was the three months before.[9]

Our medical care system needs reform. Current wait lists are not acceptable in many jurisdictions and many Canadians are suffering. Ultimately, the Supreme Court is unlikely to uphold a law that forces them to wait. If we are to avoid expansion of unregulated for-profit health care in Canada, an alternative path is needed. Most physicians do not favor a private system that caters to wealthy patients, but a majority support private insurance for services not provided in a timely fashion by the public system.

Similar to hybrid systems in Europe, a small degree of inequality may be the best way to preserve equitable universal health care. Instead of expanding for-profit health care that erodes our public system, let us use private funds in a not-for-profit fashion to provide better care to all Canadians. Canada has patients in need and idle surgeons—let us use them. 

Competing interests
None declared.

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This article has been peer reviewed.

References

1. Davidson A. Under the radar: Stealth development of two-tier health care in Canada. Healthc Policy 2006;2:25-33.

2. Lett D. Private health clinics remain unregulated in most of Canada. CMAJ 2008;178:986-987.

3. Mehra N. Eroding public medicare: Lesson and consequences of for profit health care across Canada. Ontario Health Coalition; October 2008. Accessed 1 November 2017. www.web.net/ohc/Eroding%20Public%20Medicare.pdf.

4. Canadian Institute for Health Information. Benchmarks for treatment and wait time in British Columbia. Accessed 1 November 2017. http://waittimes.cihi.ca/BC.

5. Canadian Orthopaedic Association. COA Bulletin 115. Winter 2016-17. Accessed 1 November 2017. www.coa-aco/coa-bulletin/issue-115.

6. Chaoulli v. Quebec (Attorney General), [2005] 1 S.C.R. 791, 2005 SCC 35.

7. Molloy IB, Martin BI, Moschetti WE, Jevsevar DS. Effects of the length of stay on the cost of total knee and total hip arthroplasty from 2002 to 2013. J Bone Joint Surg Am 2017;99:402-407.

8. Petis SM, Howard JL, Lanting BA, et al. In-hospital cost analysis of total hip ar-throplasty: Does surgical approach matter? J Arthroplasty 2016;31:53-58.

9. Grant K. Saskatchewan asked to end “two-for-one” MRI program. The Globe and Mail. 28 November 2016.