The Canadian Medical Association and the Role of the Medical Profession
When Premier Tommy Douglas introduced public insurance for physicians' services in Saskatchewan in 1962, doctors went on strike. The Saskatchewan experience showed however that doctors could indeed thrive within a single-payer system. Within just a few years, public health insurance had become a federal program.
However, as doctors' fees fell relative to inflation in the late 1970s and early 1980s, many doctors adopted a practice known as 'extra billing'. These doctors would not only claim fees from the public insurance program but would also charge the patient an extra fee.
The Canada Health Act put an end to this practice, but only after another failed doctors' strike, this time in Ontario, in 1986.
Since then, physician opposition to single payer health care has simmered. While some physicians and physician organizations feel that it is their right to charge patients whatever the market will bear, many physicians are strong supporters of Medicare.
The views of these physicians, along with public support for equitable health care, have discouraged organized medicine from open advocacy of two-tier health care. However, emboldened by the Supreme Court of Canada's 2005 ruling in the Chaoulli-Zeliotis case - striking down the ban on private insurance for medically necessary hospital and medical services in Quebec (See CDM Bulletin on Chaoulli) organized medicine now seems prepared to consider leading, or at the very least supporting, a drive towards two-tier medicine.
The CMA in 2005-2006
At the August 2005 General Council meeting of the Canadian Medical Association, participants debated a number of resolutions regarding what the CMA refers to as the public-private "interface". Among these was a motion reading: "That the CMA endorses the principle that access to medical care must be based on need and not ability to pay". This motion was passed, with 96% of delegates voting in favour.
The failure of a subsequent motion, however, led many observers to conclude that the CMA was not nearly as committed to Medicare as might have been hoped. The second motion read: "That the CMA calls on governments and key stakeholders to work with physicians to ensure that instead of permitting the development of a parallel private healthcare insurance system as a solution to unreasonably lengthy wait lists, Canada maintains a strong, vibrant, publicly funded healthcare system that is capable of meeting the healthcare needs of all Canadians". This motion was defeated, with 67% of delegates voting against.
Many physicians, including CMA delegates, found these two positions impossible to reconcile. Indeed, the two positions were originally part of a single motion, which was unfortunately split during debate on the floor.
The passage of the following resolution sent an even clearer message:
- "That the CMA supports the principle that when timely access to care cannot be provided in the public healthcare system, the patient should be able to utilize private health insurance to reimburse the cost of care obtained in the private sector."
- The CMA concluded the session on the public-private "interface" by striking an ad hoc task force and asking it to prepare a discussion paper - It's about access! that would be used to guide future CMA policy on health care privatization.
CMA Discussion Papers
- 2006 - It's about access!
- private insurance for medically necessary physician and hospital services does not improve access to publicly insured services
- does not lower costs or improve quality of care
- can increase wait times for those who are not privately insured; and could exacerbate human resource shortages in the public system.
- In 2006, after examining all the evidence on private-public systems, the CMA released It's about access! The discussion paper concluded:
- 2007 - It's still about access!
In July 2007, ignoring the findings of its 2006 paper, the CMA released It's still about access! which recommended physicians be allowed to work in the public and private sectors - also known as dual practice - and that Canadians be allowed to buy private insurance to cover medically necessary services delivered in a private system. The CMA qualified its recommendations by asserting we should introduce private insurance only if it benefits all Canadians, results in expanded capacity, and reduces wait times. This is a contradiction in terms since the evidence shows private insurance benefits the wealthy, investors, private hospitals and specialist physicians, to the detriment of the vast majority of Canadians.
The CMA in 2007
At the August 2007 CMA Annual Meeting in Vancouver, Dr. Brian Day, owner of Canada's largest private clinic and advocate of a two-tier system, became President of CMA, and Dr. Robert Ouellet, owner of private MRI clinics in Quebec, President-Elect.
A motion from the OMA caucus to open the Canada Health Act with a view to establishing "co-payments and health savings accounts," was defeated only by the narrowest of margins, with 50% of voting delegates opposed, 48% in favour and 2% abstaining. This despite the overwhelming Canadian and international evidence that user fees/co-payments threaten access to care for the most vulnerable populations, do not decrease "unnecessary" physician visits, and do not curb healthcare costs.
Though the motion didn't pass, it is disturbing to think that nearly half of voting delegates could consider supporting a motion so out of touch with the evidence, with the views of Canadians, and with the values of Medicare. Physicians should not be at the vanguard of advocating measures which are unpalatable to expert bodies, policy-makers and politicians of every stripe.
In spite of the near miss on user fees, many positive motions were passed, including:
- Several motions in support of extended public drug coverage,
- Provision of coverage of all drugs and immunizations to children,
- Social insurance to cover long term care,
- A review of the international evidence on payment by results.
The CMA in 2008
The CMA has invited Claude Castonguay, a former insurance executive and head of the Castonguay Commission on the financing of Quebec health care to speak at the CMA Annual Meeting in Montreal in August. In his controversial report, Castonguay recommended the government introduce user fees and allow doctors to practice in both public and private systems - which could lead to loss of already scarce health professionals to a private system.
Canadian Doctors for Medicare recognizes, as does the Canadian Medical Association, that almost all physicians believe access to care should be based on need and not an ability to pay. Unlike the CMA, however, Canadian Doctors for Medicare believes that thousands of Canadian physicians feel that a parallel private tier would be a disservice to their patients and that the legitimate challenges we face can and should be solved within Medicare. Physicians and policymakers alike also recognize that Medicare is the most cost-efficient way to provide high-quality healthcare to Canadians.