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S hould Canadians have the right to use their after tax dollars to purchase essential healthcare services in Canada?Absolutely and emphatically not! Nurses’ response to this question is guided by the evidence and that evidence is unequivocal in its support for single-tier health care. Under the Canada Health Act, essential physician and hospital services are part of the single-payer system. This system offers universal access to health care - care that would otherwise be unavailable to many low-income people.i
OECD countries with parallel private hospital systems have larger and longer public wait lists than countries with a single-payer system
Research has shown that in addition to the obvious advantage of equal access, a single-tier system shortens wait times and saves money in several ways. OECD countries with parallel private hospital systems have larger and longer public wait lists than countries with a single-payer system.ii A UK study found the result also held for regions as it held for countries. The more care provided in the private sector in a given region, the longer the wait times for public hospital patientsiii Parallel private systems do not increase the number of health-care practitioners; rather, practitioners are split between two systems. This, in turn, creates an incentive for doctors to lengthen waiting lists in the public system.iv
There are also enormous savings to a single-payer system. Unlike their American counterparts, Canadian health-care providers only deal with one payer, and remain secure in the knowledge that they will be paid for insured services. In 1999, administrative costs in the U.S. were $1,059 per capita as compared to $307 per capita in Canada. If these costs were streamlined to Canadian levels, far more than enough money would have been saved to provide full insurance coverage for all of the 41.2 million Americans who were uninsured in 2001.vi Overhead costs for Canada’s Medicare system were 1.3 per cent as compared to 13.2 per cent for Canadian private insurers.vii
Those whose aim is to privatize the system often argue that introducing the profit motive in health-care delivery will increase quality and decrease prices. Once, again the evidence shows the opposite - the quality of care in for-profit institutions is lower.viiiixxxixiiThe most conclusive evidence comes from systematic reviews and meta-analyses of all available peer-reviewed literature on for-profit vs. not-for-profit health care. The data found higher patient mortality rates in for-profit as compared to non-profit centres.xiiixiv Furthermore, research finds no trade-off on cost: a systematic review and meta-analysis of all available peer-reviewed literature in the Canadian Medical Association Journal concluded that for-profit hospitals charge a statistically significant 19 per cent more than not-for-profit hospitals.xv We also know that private insurers will “skim” the more profitable patients and burden the public system with chronic and catastrophic care.
... private insurers will “skim” the more profitable patients and burden the public system with chronic and catastrophic care
Anyone who is less than healthy and/or less than wealthy will receive compromised access to health-care services in a for-profit insurance market. The Canadian Medical Association’ s own poll showed that 58 per cent of physicians felt that most of their patients will either not qualify or be unable to afford private insurance.
Canadian evidence, available from the long-term care sector, found that staffing levels were higher in not-for-profit facilities than in for-profit facilities,xvi and health outcomes were better in not-for-profit facilities.xviixviii As one set of researchers concluded, differences in staffing were likely to result in the observed differences in health outcomes.xix A review of North American nursing home studies between 1990 and 2002 similarly concluded that for-profit homes appeared to deliver poorer quality care in a number of process and outcome areas.xx
Those who are seeking to privatize Medicare deny that they are looking for a U.S.-style private, for-profit system, often citing examples of European models that blend the two systems instead. This argument ignores the fact that the many European models are embedded in much stronger welfare states, reflected, for example, in a larger share of national income spent on social programs. It also ignores the reality that Canada is situated geopolitically in this continent, and we are a party to the North American Free Trade Agreement (NAFTA). One of the concerns with NAFTA is that it contains weak protections for our public health care system, and these protections are structured in such a way that they become weaker with any increase in the for-profit component of the system. Thus, the best way to protect it from challenges under the NAFTA is to strengthen public funding and not-for-profit delivery of services.xxi
allowing a private for profit sector to increase their role in Canada will serve to empower financially powerful stakeholder groups, invested in dismantling Medicare
Let us be clear, nurses are unwavering in our commitment to improve access, quality and efficiency of our health-care services. However, we must do so based on the best available evidence.The minute you introduce private insurance into our system, you create two lines of patients.. Those in the first line can afford to pay out-of-pocket and the majority who can not afford it wait in the second line. This is undemocratic and would lead to the destabilization of our health-care system. Moreover, allowing a private for profit sector to increase their role in Canada will serve to empower financially powerful stakeholder groups, invested in dismantling Medicare, now in the periphery to lobby from inside the system, a dangerous step to the majority of us who want to protect and strengthen Medicare for all Canadians.
There are viable ways of easing wait lists and answering the concerns of people who feel they are not getting the timely care they deserve. Key solutions are to ease the nurse and doctor shortage, and enable all health-care professionals to work to their full scope of practice. In fact, already there are numerous examples across Canada in which not-for-profit, specialized clinics are reducing wait times for hip, knee and cataract surgeries. Even Alberta realized this when former Health Minister Iris Evans described their reduction in wait times for hip and knee replacement as a public system triumph. They went from an average of 47 weeks to 4.7 weeks. The recipe for success in Alberta was based on not-for-profit solutions: establishing specialized teams of surgeons, nurses, and physical therapists who worked together to move patients quickly through the system; performing surgeries according to well-managed waiting lists based on medical priorities; and providing nursing and other resources for patient education. In Ontario, we have decreased wait time significantly. Examples include treatment for persons with cancer which is down 17 days (21%), cataracts, down 158 days (50.8%), persons requiring hip replacement, down 116 days (33%), knee replacement is down 110 days (25%). The same is the case for diagnostics with decreased waits for MRIs, CT scans and angiography.
Nurses are unified in our interest to protect the public by strengthening and expanding Medicare for all Canadians. We will continue to build on the public’s values and make the public system even more responsive, efficient and accountable to Canadians. Now is the time to accelerate the positive reforms that are taking root across the nation and right here in Ontario. These reforms are strengthening public hospitals, community health, access to pharmaceutical drugs, and healthy living. These reforms must pick up momentum – and they must serve the needs of all Ontarians, not just those who can afford to pay.
co-written by Doris Grinspun and Dr. Mary Ferguson-Paré for the RNAO
The Registered Nurses’ Association of Ontario (RNAO) is the professional association representing registered nurses wherever they practise in Ontario. Since 1925, RNAO has lobbied for healthy public policy, promoted excellence in nursing practice, increased nurses’ contribution to shaping the health-care system, and influenced decisions that affect nurses and the public they serve.
references
i In the US, 50 per cent of bankruptcies were due in part to medical expenses.See Himmelstein, D., Warren, E., Thorne, D., & Woolhander, S. (2005). Illness and Injury as Contributors to Bankruptcy. Health Affairs Web Exclusive W5, 63 Retrieved March 22, 2007 from http://www.pnhp.org/bankruptcy/Illness
ii Tuohy, C. H., Flood, C., & Stabile, M. (2004). How does private financing affect public health care systems? Marshaling the evidence from OECD nations. Journal of Health Politics, Policy and Law, 29(3), 359-396.
iii Besley, T. et al. (1998). Public and private health insurance in the UK. European Economic Review, 42(3-5), 491-497.
iv Duckett, S. J. (2005). Private care and public waiting. Australian Health Review, 29(1), 87-93.
v Woolhandler, S., Campbell, T., & Himmelstein, D.U. (2003). Cost of Health Care Administration in the United States and Canada. New England Journal of Medicine, 349, 768-75.
vi Himmelstein, D., Woolhandler, S., & Wolfe, S. (2004). Administrative waste in the U.S. health care system in 2003: The cost to the nation, the states and the District of Columbia, with state-specific estimates of potential savings. International Journal of Health Services, 34 (1), 79-86.
vii Woolhandler, S., Campbell, T., & Himmelstein, D. U. (2003). Cost of Health Care Administration in the United States and Canada. New England Journal of Medicine, 349, 768-75.
viii Himmelstein, D. U., et al. (1999). Quality of Care in Investor-Owned vs. Not-for-Profit HMOs. Journal of the American Medical Association, 282(2), 159-163.
ixGarg, P. P., et al. (1999). Effect of the Ownership of Dialysis Facilities on Patients’ Survival and Referral for Transplantation. New England Journal of Medicine, 341(2), 1653-60.
x Rosenau, P. V., & Linder, S. H. (2003). A comparison of the performance of for-profit and nonprofit health provider performance in the United States. Psychiatric Services, (54)2,183-187.
xi Rosenau, P. V., & Linder, S.H. (2003). Two decades of research comparing for-profit health provider performance in the United States. Social Science Quarterly, 84(2), 219-241.
xii Schneider, E. C., Zaslavsky, A. M., & Epstein, A. M. (2005). Quality of care in for-profit and not-for-profit health plans enrolling Medicare beneficiaries. American Journal of Medicine, 118, 1392-1400.
xiii Devereaux, P. J., et al. (2002). A systematic review and meta-analysis of studies comparing mortality rates of private for-profit and private not-for-profit hospitals. Canadian Medical Association Journal, 166(11), 1399-1406.
xiv Devereaux, P. J., et al. (2002). Comparison of mortality between private for-profit and private not-for-profit hemodialysis centers: A systematic review and meta-analysis. Journal of the American Medical Association, 288(19), 2449-2457.
xv Devereaux, P. J., Heels-Andell, D., Lacchetti, C., Haines, T., Burns, K. E. A., Cook, D. J., et al. (2004). Payments for care at private for-profit and private not-for-profit hospitals: a systematic review and meta-analysis. Canadian Medical Association Journal, 170 (12), 1817-24.
xvi The study was based on evidence from British Columbia. See McGregor, M. J., Cohen, M., McGrail, K., Broemeling, A. M., Adler, R. N., Schulzer, M., et al. (2005). Staffing levels in not-for-profit and for-profit long-term care facilities: Does type of ownership matter? Canadian Medical Association Journal, 172, 645-649.
xvii This study is based on evidence from Manitoba. See Shapiro, E., and Tate, R. B. (1995). Monitoring the outcomes of quality of care in nursing homes using administrative data. Canadian Journal of Aging, 14, 755-768.
xviii McGregor, M. J., Tate, R. B., McGrail, K. M., et al. (2006). Care outcomes in long-term care facilities in British Columbia, Canada: Does ownership matter? Medical Care, 44, 929-935.
xix McGrail, K. M., McGregor, M. J., Cohen, M., Tate, R. B., & Ronald, L. A. (2007). For-profit versus not-for-profit delivery of long-term care. Canadian Medical Association Journal, 176, 57-58.
xx Hillmer, M. P., Wodchis, W. P., Gill, S. S., Anderson, G. M., & Rochon, P. A. (2005). Nursing home profit status and quality of care: Is there any evidence of an association? Medical Care Research and Review, 62 (2), 139-166.
xxi Cyrus, T. & Curtis, L. (2004). Trade Agreements, the Health-Care Sector and Women’s Health. Ottawa: Status of Women Canada.
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