This information is relevant because the British North America Act established the responsibilities between the federal government and the provinces. The BNA Act established the provinces as the responsible government for the provision of health care for most Canadians with a few exceptions.

Today, the federal government controls the delivery of health care through the provinces by the Canada Health Act of 1984. This act succeeds the previous act, the Hospital Insurance and Diagnostic Services Act of 1957, which was the first act to set out full coverage for all hospital services and diagnostic services. This was the start of socialized medicine in Canada.

In 1966 the Medical Care Act was passed and gave the provinces the monopoly on health insurance for medically necessary services. This was the first act to address physician fees and forced physicians to negotiate fees with the only insurer, the provincial governments.

The Canada Health Act today is based on five basic criteria: public administration, comprehensiveness, portability between provinces and territories, universality, unrestricted access. From the time of the Medical Care Act of 1966, rationing of care and services has gradually evolved into a crisis of wait lists for imaging, surgeries, and procedures.

I graduated from medical school in Nova Scotia in 1968 as a general practitioner and came to Vancouver, British Columbia, to work under the Medicare system at the Seymour Medical Clinic, one of the largest clinics in Canada. On a regular basis, I saw 30 to 40 patients a day for an average fee of $30 gross per visit. The clinic’s expenses were high, about 40 percent of revenues. From the early 1980s to the present day, the health care system has worsened on all fronts.

In the 1990s to counter increasing costs, the provincial governments decided to reduce enrollments in Canadian medical schools to save money. At the same time, more women enrolled in medical schools and found after graduation that the conflict between full-time-care medicine and family and child-care responsibilities was more demanding than expected. These physicians, quite correctly in my view, reduced their time caring for patients. Then, the new generation of physicians tended to want more free time as well. The result is overcrowding in emergency rooms and a severe shortage of service providers, diagnostic imaging, acute beds, chronic-care beds, and overall funding for health care in Canada. As a non market-driven system and a rationed system, the crisis continues to this day.

At this time in Ontario, with a population of about 10 million, there are estimated to be 1.2 million people without a family doctor, and they cannot access a specialist directly. Consequently, they flood emergency rooms across the country for primary care. The shortage of primary care physicians in Ontario is estimated to be 2,200. Now medical schools are trying to expand, but only 25 percent of graduates are choosing primary care and only 25 percent of those provide full primary care to clients.

In the mid-1990s, in answer to patient demand, private surgery centers and walk-in clinics started to develop to fill the void. The private surgeries were against the various provincial regulations but could operate on patients exempt from the Canada Health Act and various provincial regulations. Some provinces have shut down the surgeries and imaging centers, but others have ignored them. This started the debate around private vs. public health care.

In the summer of 2005, Don Copeman, a businessman in the health care industry, approached me about his interest in opening a private clinic with an emphasis on excellence in primary care and disease prevention. After several months of working out the details, we opened the Copeman Healthcare Centre in Vancouver in November 2005. Patients are matched to a physician according to their major needs to head up their care and other physicians are consulted in a team concept.

The proponents of private health care believe in the right of choice, and the opponents believe private care is elitism. The debate continues, as clinics such as ours expand across Canada providing private preventive care, which usually is not an insured benefit, and primary care for clients, charging an annual fee. This is perceived by some as being against the principle of equal access for care regardless of ability to pay.

The lead story in the April 2006 issue of MacLean’s Magazine, "The Rise of Private Care in Canada," discussed the situation: At this time in British Columbia and Quebec there are many private surgeries up and running. In the past the federal government has withheld payments to the provinces—called transfer payments—because of breaches of regulations banning private clinic care. This is not likely to be repeated since the new federal government seems more open to change.

Shortages for services are so critical that contracts are being let in increasing numbers by provincial governments to private clinics to perform surgeries and imaging services. More private primary care is being done, as well, and the debate continues.

The provincial governments and the federal government are trying to reassure the public that they are solving the crisis, but it is difficult to convince people that the ones who created the crisis can solve it. Two separate opinion polls taken recently (by Decima Research and COMPAS Inc.) reported that a majority of Canadians now favor the development of a public/private parallel health care system.

References:

http://www.canadian-healthcare.org

This was the founding vision of Tommy Douglas, widely acclaimed as the "Father of Medicare," and it has continued to serve and inspire Canadians, who rightly regard health care as their single most valued social program.

Since its inception half a century ago, however, Medicare’s funding and delivery have been embroiled in conflict. Today there is friction about what services and drugs should be included in the basket of publicly insured health care, and how distressingly long wait times for treatment can be reduced.

Many aspects of health care remain universally inaccessible, but our history still paints a clear picture: Over time, an ever-larger number of Canadians have benefited from an ever-larger scope of publicly provided or subsidized supports, resulting in improved health and quality of life for every successive generation.

Two core Canadian values have infused most health reforms over the past 100 years: fairness and pragmatism. It needs to be said that, despite almost constant squabbling at the political level, these values have stood the test of time.

Public confidence in the system has been regularly tested: before the advent of Medicare in the 1930s during the Great Depression; in the 1950s when negotiations failed to secure the federal government’s participation; in the 1960s when Medicare’s introduction in Saskatchewan was opposed by a doctors’ strike; and in the 1980s when the system was weakened by the imposition of "user fees." Each time, the "right" to health care as a basic right of citizenship was challenged, and each time the fundamental values prevailed.

Canada’s history and experience display a steadfast desire for equal treatment, revealing in the process important lessons about the interface between the health of individuals and the health of their society. We have learned that equity pays off. We have learned that striving for equity means making sure everyone gets access to the same timely and best available care, but that sometimes it means that interventions need to be targeted to the most vulnerable groups.

Publicly insured services have continued to expand in scope—from public health, to doctors and hospitals, to expansion of public drug programs, to more supports for long-term care, home care, and rehabilitation. Public commitments to spending on health care are growing at a rate that outstrips any other service that governments provide. Yet even today some parts of our society are falling behind in their access to health care. Uncertainty festers about what is or should be publicly supported, resulting in the current ill-advised attempts by some provinces to turn more services over to private, for-profit operators.

The push for more private insurance reflects a growing emphasis on individual benefit, and as such defies the simple logic and strength of extending collective benefit.

Health Care is the most solid manifestation of the principle of solidarity, and we are confident this deeply held Canadian value will prevail over the latest aggressive efforts to undermine the most cherished of Canada’s social programs.

The assertion that our single-payer system is administratively efficient is hogwash. Many administrative costs are disguised within government health departments and bureaucracies and do not make it to the health care ledger. A population of 30 million people with 15 government Ministries of Health is a bureaucrat’s heaven. France, with double the population, has one.

 Ten years ago we opened the Cambie Surgery Centre in Vancouver, British Columbia, and today our facility remains unique in Canada. It is a small (19,000 square feet), private, for-profit surgical hospital and is located a block away from the main Vancouver hospital. We opened in the middle of a 10-year term of what many believe was the most left-wing government in Canadian history. The initial shareholders in the clinic were mostly teaching, hospital-based doctors frustrated by the rationing of operating time in public hospitals and the denial of access to new technology. The concept was developed during the time Hillary Clinton was promoting a Canadian-style system as the answer for the United States. An amusing tale surrounds our early efforts to overcome legal obstacles in Canada. I found a site in Blaine, Washington, (immediately south of the border), where we potentially could treat Canadians outside the jurisdiction of Canadian Medicare laws. When I sought the help of a large U.S. health law firm, the senior lawyer began to laugh. "What’s so funny?" I asked. He replied that he had been approached by a group of U.S. clients with a request that they explore the possibility (in the event of the Hillary plan being implemented) of developing a facility immediately north of the border, where they could treat American patients!

We eventually took our chances and built our facility in B.C. In our early years we treated a mix of patients, including workers’ compensation, Canadian armed forces, tourists, and several other groups that were exempt from the Canada Health Act, a federal law that prohibited private treatment for most Canadians. The promise of that Act—universal access to healthcare "free at the point of delivery"—sounded good, but was unsustainable. The inevitable outcome was rationing of services and denial of access to new technologies. All other models of universal health care differed from the Canadian model in one fundamental way: They did not exclude competition from the private sector. Canada shared this distinction with just one other country – North Korea!

 As the rationing that characterizes the Canadian health system worsened (I personally had my access to surgical time at the University Hospital trimmed from 22 to 5 hours a week, and had 450 patients waiting for surgery), our business grew; and two years ago we doubled in size. We now have six operating rooms, including some of the most high-tech operating rooms in North America. We have seven inpatient beds and are designated as a hospital by the city of Vancouver. We treat approximately 6,000 patients a year. We have recently become a part of the "system" through providing contracted-out services to publicly funded patients on government waiting lists. We are designed with efficiency of operation in mind and recognize that patients and doctors are our direct source of revenue. In the public hospital system in Canada, funding is provided by governments in a global manner. There is a reverse financial incentive for hospitals to treat patients. Busy doctors and sick patients use up the hospitals’ money. This often leads to other problems and attitudes in staffing and administration. At our centre we spend only 30 percent of our gross revenue on wages and salaries, compared with 70 percent in the public hospitals, yet we pay our nurses more. Overly generous union contracts for others and increased administrative costs explain much of the disparity. Achieving and maintaining a successful venture in the field of private health care delivery has involved many new initiatives, and we have fought many political battles with organized labor and with federal and provincial governments.

 Governments have been reluctant to address necessary reforms and have spent more and more, without addressing the system’s inherent failings. We went to the Supreme Court of Canada as intervenors in a Quebec case known as Chaoulli-Zeliotis, and argued that our system was unconstitutional. The basis of the case was that when governments promise, but fail to deliver, access to health care, it is unlawful for them to prevent citizens from purchasing private insurance to protect their health. On June 8, 2005, politicians across the country were stunned when the court ruled in our favor. In striking down the existing laws, the judges said, "The evidence shows that delays in the public health care system are widespread and patients die as a result of waiting lists for public health care…. the courts have a duty to rise above political debate." The full impact of this ruling will not become evident until after June 8 of this year, since Quebec asked for and received a one-year delay in implementation.

 Politicians have witnessed increased demands for services and soaring costs to the level that health care is approaching 50 percent of all spending in the provinces, and is draining funds for other important services, including education, the environment, other social services, and law enforcement. Hypocrisy has been a feature of political debate surrounding reform of the system. In a manner reminiscent of the former Soviet Central Party Committee members, union leaders and left-wing politicians demonize the private sector while they engage in queue jumping when their families require care, gaining preferential treatment in the public system. They also use private clinics for themselves. In the recent Canadian federal election, Jack Layton (leader of Canada’s New Democratic Party), criticized the Supreme Court decision and called for the end of private clinics in the system. When it was discovered that he had his own hernia surgery done privately, his answer when asked why he did not disclose the fact was, "Nobody asked me."

 Government health policy decisions based on political considerations often are fiscally irresponsible. In an Ontario example, a procedure not available there (a type of ankle replacement approved in Canada and pending FDA approval in the United States) was contracted out to a private institution in Columbus, Ohio, at a cost of U.S. $35,000. Our centre offered to perform the same procedure for U.S. $13,000 but was rejected on the basis that the Ontario government would not pay a Canadian private provider. In a later twist, because the U.S. facility has used its FDA quota, the patient underwent the surgery at our centre and paid the cost personally.

 Aging baby boomers continue to demand more health care than our governments deliver. The private sector has helped fill the void caused by rationing, but growth was limited by laws (now ruled unconstitutional) that outlawed private medical insurance. A system in which universal care is supplemented by nongovernmental insurance and delivery is coming to Canada and will create tremendous opportunities for both private and public institutions. The latter will be able to generate revenue that can be used to increase and improve services.

While teaching arthroscopy in Cuba several years ago, I learned that the orthopaedic hospital in Havana generated a profit of U.S. $20 million a year by treating nonresidents from Latin America. Draconian Canadian laws have previously outlawed such initiatives. It is ironic that Canada has been unable to pursue entrepreneurial activity that a communist country has shown to be successful. We will soon see a reversal of the multiple-billion-dollar health trade deficit with the United States, as Canadians are able to stay home and be treated.

 The coming changes will create a massive new industry and enable the Canadian health industry and its workers to enter the international health market and participate in the $2 trillion American health economy. On the basis of extrapolations from other countries, we may see $40 billion a year added to the Canadian health system. The opportunity to create long-term employment and at the same time to eliminate many of the woes of our health system, including long waiting lists for necessary care, is something all Canadians will come to welcome.