The private health care ship has sailed

On 6 April 2023, the Supreme Court of Canada announced its decision to not hear an appeal of the landmark Cambie Surgeries Corporation case, effectively closing the door on private care for all but a privileged few, including out-of-province patients, RCMP, injured workers, and certain others. At a media scrum, BC’s health minister celebrated the announcement as “a vindication of the public health care system.” He continued: “My focus continues to be to deliver the best possible service in that system, and that’s, that’s what we’re working to do, and we’ve done that consistently, and that’s what we’re going to continue to do.”[1]

While a measure of self-congratulation is understandable following victory in hard-fought litigation that dragged on for nearly 2 decades, it would have been more reassuring had the minister adopted a humble and solemn tone to mark the occasion. He might have expressed that while he was pleased with the court’s decision not to overturn the law banning private care, he recognized that having eliminated the private option, he and his government bear, more than ever, responsibility for ensuring that essential health care is available to all British Columbians at all times. He might even have expressed sadness that he has failed to meet that goal during his 6-year tenure as health minister.

Why a mea culpa? Because in the last decade, a formerly robust medical care system has been allowed to collapse from the ground up. Historically, most medical services in BC were delivered by family physicians (FPs) who provided comprehensive care and managed their offices, and most of the province’s hospitals, with the pragmatic sensibility of small-business owners, with one eye on the customer and the other on the account books. Now, 20% of residents do not have an FP, forcing them to seek episodic care at overrun clinics and clog dangerously overburdened emergency rooms. In most communities, the only timely pathway to specialist referral is through the emergency room. Specialists are stressed and demoralized by the need to provide ongoing care to patients without an FP, hampering their ability to see new referrals.

Meanwhile, as public health care is tanking, as of 1 April 2023, contraception will be provided free to all. This and other targeted spending initiatives makes me wonder if the government is more concerned with positive polling than ensuring the constant availability of basic care.

The underlying problem is not a lack of resources but rather a failure of health care leadership to level with the public regarding three economic realities:

1. Health care resources are finite; public health spending in Canada has essentially capped out at approximately 12% of GDP, a percentage exceeding that of most comparable OECD countries. Additional funding from the public purse cannot be expected.
2. Twenty-first-century health care has become so technology reliant, complex, and costly that no state-funded-and-run system can possibly deliver all that modern medicine has to offer “for free” to every citizen.
3. Resource limitations in association with ever-increasing demands on the system necessitate preferential allocation of funding to health care that delivers the biggest bang for the buck—comprehensive primary care.

In both rich and poor countries, functional health care systems ensure that, at a minimum, all patients have access to primary and preventive care. Cuba, a developing country with limited financial resources, achieves laudable outcomes by devoting the lion’s share of health spending to such care. Yet in BC, 1 million unattached patients are unable to access longitudinal primary care. Neither patients nor providers are offered any incentive to “choose wisely,” such that duplication and overuse of expensive, low-yield investigations are commonplace, and no-holds-barred medical intervention has become a surrogate for honesty and compassion at the end of life. Patients with primary care issues but no FP flock to the emergency room, where long waits, unfamiliar faces, excessive labs, and unnecessary CT scans provide a costly and unsatisfactory substitute for longitudinal care. At a time when the need has never been greater, ongoing psychiatric care has become virtually impossible to access for all but hospitalized patients and those with severe mental illness managed by community mental health teams.

Former British prime minister Tony Blair stated, “The art of leadership is saying no, not saying yes. It is very easy to say yes.” It is critical that health leaders stop perpetuating the myth that public health care can do everything for everyone. Access to basic care represents a minimum standard when the private care escape hatch has been sealed. We need new leaders with the courage and conviction to look beyond political expediency when allocating resources. The current failure to soundly manage a complex system is destroying the original vision of medicare—essential health care for all citizens irrespective of means.
—David J. Esler, MD

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References

1.    CBC News. Health Minister Adrian Dix calls Supreme Court decision “vindication” of public health-care system. Accessed 14 May 2023. www.cbc.ca/player/play/2192627779602.