New attitudes: Surveys show that Canadian public increasingly wants the freedom to use private health care

Public surveys point to a marked change in the attitude of Canadians regarding the freedom to choose private health-care services and insurance should they wish to enhance or replace the equivalent publicly funded services and insurance from time to time.

Supporting evidence of this majority change in attitude is found in the following surveys:

• In 1998, a Harvard survey found 79% of Canadians favouring either fundamental changes or complete rebuilding of Canada’s health system.

• In 1999, Pollara found 73% of Canadians supporting the right to pay for private health services, if timely access through medicare was denied.

• In 2001, Ipsos-Reid reported 60% Canadian support for “contracting out” of fully funded public health services to the private sector.

• In 2001, HealthInsider found 60% of Canadians, 54.8% of Ontarians and 64.4% of Quebecers supporting the acceptance of private health service enhancements or alternatives to publicly insured services, as long as the public system is not jeopardized.

• In August of 2001, Michael Marzolini, surveying for the federal Liberal government, found “a large majority” of Canadians willing to consider allowing privately provided services in the health-care system and 73% thinking the Canada Health Act should be opened to debate. Ten years ago a strong majority rejected any private involvement.

While such tolerant and liberal arrangements already exist in the health systems of all modern countries except Canada, the growing majority of Canadians who harbour these freedom-enhancing attitudes toward private health services are on a collision course with existing federal and provincial health legislation.

The problem does not lie in the legitimate legislative provisions that establish and describe the publicly funded insurance plans, with their benefits, criteria for funding, and their rules and regulations regarding universality, public administration, etc.

Rather, the problem lies in the exclusionary “non-medicare” provisions of health legislation that have little to do with medicare entitlements and much to do with the protection of government insurance monopolies and special interest groups such as public service and professional unions.

These exclusionary provisions also reflect a political bias against market competition and consumer choice among private or mixed alternatives in health insurance and health-care services. Their bias is against the personal freedom of patients and physicians to voluntarily contract, without penalty, outside of the publicly funded health system, on an individual occurrence basis and irrespective of concurrent public insurance coverage.

For three decades, the exclusionary provisions in health legislation have created a coercive environment within Canada’s health-care and health insurance systems as follows:

• No one is permitted to buy or sell private health insurance to cover private medical and hospital services as an alternative to publicly insured services, even when the latter are inaccessible, unavailable, inconvenient and of inferior quality.

• Patients are not allowed to apply their public insurance benefits toward the cost of medical services of physicians who choose to practise outside the government plan.

• While physicians are permitted to provide private medical services to foreign patients in Canadian hospitals, they are not permitted to provide the same private medical services to Canadians, even though hospitals are allowed to provide private hospital and nursing services to both Canadian and foreign patients.

• Physicians who choose to practise outside the monopolistic public insurance plan may be excluded from hospital staff appointments. Thus, both their Canadian and foreign patients lose the right to receive private medical services from their physician and hospital of choice, unless they switch to a “medicare physician.”

• Within the Canada Health Act, coercive provisions discourage and penalize provinces, and indirectly their citizens, for allowing patients to protect their most valued possession—their life and their health—through additional charges for alternative or enhanced medicare-covered services that patients voluntarily choose for convenience, medical setting and quality.

In view of these serious problems, it is clear that the new freedom-enhancing attitudes and expectations of Canadians are on a collision course with this same legislation.

Three years of consistent public surveys show a marked change in the public attitudes and expectations of the majority of Canadians. They now support or accept parallel public and private systems of health services, as long as these new arrangements do not jeopardize the publicly funded system. In this respect, the attitude of citizens would seem to be light-years ahead of government health policy-makers, health-care interest groups, and health-care and health insurance legislators.

The time is ripe and the risk is small for federal and provincial legislators to respond to this new majority attitude of Canadians. They should amend the exclusionary provisions in health legislation. This would largely correct the associated health system deficiencies in quality, access and choice, and would facilitate the new desires for liberalization in Canada’s health insurance and health-care services.

J. Edwin Coffey MD is an associate researcher with the MEI and co-author of Universal Private Choice: Medicare Plus, A Concept of Health Care with Quality, Access and Choice for All Canadians.