Public-private health care ...the Canadian way?

Summit, Mar 2004 by Sauve, David

THE REALITIES OF governing Canada in the 21st century oblige Canadian governments to re-evaluate what their priorities will be for the future. Topping the list of important governance issues are water and hydro, infrastructure, education and health care, with health care being the most significant.. .and the most emotional.

The current debates over P3 hospitals are good examples of claims made and battles waged. Proponents of public-private partnerships hold that given the sorry state of public coffers, private investment is needed to help build health care infrastructure. Opponents of P3 hospitals claim publicprivate partnerships will lead to a twotier health care system and eventually the complete privatization of our health care system.

The many arguments for or against P3 hospitals are more than can be covered in this article. However, the above stated positions are usually the two lead arguments advanced by the opposing parties. These competing claims are pronouncements in support of respective spots on the continuum. Some are wrapped in claims of fiscal responsibility and statistics, while others are bursting in the light of crusading zeal. All of these opinions require scrutiny and consideration. Advocates who frame a debate in dichotomous terms, right or wrong, with us or against us, or inject ad hominem material are suspect; their aim is not critical debate, but an emotional triumph of their own position - their degree along the continuum.

Undoubtedly, it is useful to think in terms other than "I want public health care" or "I want private health care." Using devices such as "continuums" encourages critical thinking and reminds us that there are many different ways that our health care system can be structured. Critical thinking and debate are the keys to achieving the best possible health care system the one Canadians say they want. It is important that all health care coalitions, health care organizations, public policy institutions, special interest groups, unions, private corporations, all levels of government, and most importantly, individuals, weigh-in for the debates.

Our health care system is a construct that is malleable and can be shaped to suit the present and future needs of the people of Canada. How, or if it is changed, should be decided through open public debate. Dichotomous thinking, right or wrong, yes or no, and the either-or fallacy, assumes there are only two sides to the debate. Very few important questions can be phrased as such; public health care is not one of them. Health care is a prescriptive issue requiring a panorama of possible alternatives. Dichotomous thinking damages our ability to find better answers by restricting our options. Such rigid thinking over-simplifies a very complex question. A more criticallyengaged discussion would be encouraged by considering public and private health care not simply as either-or absolutes, but also as end points on a continuum.

The starting point for the debate around health care is whether Canadians want public health care, what they want, and how they want those services to be delivered? Although asking whether Canadians want public health care sounds like an easy closed yes or no question, the reality is that the question is difficult and deceptively loaded; the answers are emotional and often based on a narrow range of alternatives. The difficulty is how we define "public" in public health care. Answering the question of how our public health care system ought to be without first considering all available or proposed public models increases the risk of not securing the better system. Failing or refusing to seek out alternatives is to impede critical thinking, weakening democratic public policy debate, and obstructing the development of a health care system that meets Canadian needs.

In the continuum, the left end would be complete government managed, funded and delivered health care within publicly owned and operated buildings. The opposite end of the continuum, the right, would be complete privatization of all health care with no government intervention, no government funding, all privately owned buildings, all health services are privatized and offered at market-bearing rates. Thus we have two extreme positions, with our present health care system positioned somewhere on the continuum.

Given that the left and right extremes are the only purely public and private systems, every other health care system is a hybrid. Our present system of health care is an amalgam of public and private health care.

Although we have what is called universal public health care, we find within this system private businesses operating at public expense. Medical doctors run private businesses out of privately owned buildings, hire private staff, service the public and bill the public system. Other medical professionals are in private practice, but not within the public system. These professionals offer medical care at market value rate, e.g., private nurses, chiropractors, pharmacists, physiotherapists, psychotherapists, and dentists. We also have private clinics that offer a variety of medical services including blood tests, x-rays, medical examinations, and minor surgery; most of these clinics accept our public health cards. A number of people in Canada also enjoy the benefits of private health care insurance constructed to enhance the base level of universal health care offerings. Whether through purchase, employer given, or negotiated through collective bargaining, many people have moved to a tier above the national base by possessing private health care benefits.