The slow, very public murder of Medicare as a universal, publicly-funded, single-tier health system has been going on for 20 years. The public failed to awaken fully to the murder because the assassins, even as they slowly throttled Medicare, smiled and claimed they were trying to resuscitate it.
Brian Mulroney vowed that Medicare was “a sacred trust” as he planned the murder and took the first steps. Liberal prime ministers and health ministers have declaimed their devotion to Medicare, even as they cut and slashed its funding and refused to enforce the law of the land, The Canada Health Act. Even Roy Romanow, before his recent role as strong defender of Medicare, in his former incarnation as Saskatchewan premier, boasted he was carrying out Tommy Douglas’s second stage of Medicare during his infamous “Health Care Reform,” now recognized as a cover for deep cuts during the 1990s. Stephen Harper wants to quickly finish the job, the only mercy killing he supports, but insists he would resurrect Medicare as a new wonderland of mixed private and public funding. The only truly honest assassin--besides the business lobby and various right- wing think-tanks--is Alberta’s Ralph Klein. He is proud of his role as assassin and laments only that he has not been allowed to finish the job in Alberta.
The public was finally awakened by the June 9th Supreme Court decision in Chaoulli v. Quebec declaring that the prohibition of private health insurance and access to private care under Medicare was a violation of a citizen’s rights under Quebec’s Charter of Rights and Freedoms. Although affecting only Quebec for now, the same arguments would probably succeed in a challenge under the Canadian Charter before these same judges. In this case, a patient had to wait an unreasonable length of time for orthopaedic surgery. The patient argued that he consequently should have access to a separate, private system. One of the lawyers put it bluntly: “I am arguing for the right of more affluent people to have access to parallel health services.”
There were additional wake-up calls in two recent rulings by the Ontario Health Services Appeal Board directing the government to reimburse two patients for private hip replacement surgery in the U.S. These patients did not obtain prior approval, as required--which is routinely denied except in the most exceptional of cases--but simply went and got the surgery and demanded repayment, appealing the government’s initial refusal.
According to recent polls, the public now views the Medicare crisis as the top political issue, focusing mainly on unacceptable waiting times for cancer and heart treatment, access to CAT scans and MRIs for diagnoses, hip and knee replacements, and eye surgery. Two in three Canadians have no confidence that provincial governments will reduce waiting times as they promised in exchange for the extra $41 billion in federal funding. Almost nine in ten Canadians want Ottawa to impose compulsory standards for waiting times on the provinces as a condition of federal funding. The public is awake and angry, but perhaps it is too late. Today’s crisis has been 20 years in the making.
When the neo-conservative agenda of underfunding and cuts began under Mulroney and accelerated under Chrétien and Martin, critics noted that underfunding health care would inevitably lead to declines in quality, the forced de-listing of many procedures, and lengthening waiting lists. As a result, those with the means would seek speedier health interventions by travelling to the U.S., and there would be a growing clamor among more affluent Canadians for some privatization that would allow those with the means to receive more timely care.
Some critics, me among them, argued this was a deliberate political plan to degrade the public health system to the point where public demands for private options would become politically irresistible. All these things have happened: quality has declined; many services have been de-listed and are now user-pay; and waiting lists for procedures have grown to the point of crisis. Alberta, Quebec, and British Columbia have allowed--indeed, encouraged--the development of private, for-profit surgery clinics, primarily for hip and knee replacements and cataract surgery. While these are clear contraventions of The Canada Health Act, Ottawa has looked the other way because of the incredible pressure for such services, much of which resulted from Ottawa’s own funding cuts.
The neo-conservative dream is to move to a comprehensive two-tiered health system, one publicly-funded and accessible to all, the other topped up by private funding and accessible to those with the means to pay extra to obtain speedier and better quality services. Both systems would bill the public Medicare plan for the basic fee, but the private system would be allowed to add extra user charges. This would give the private for-profit, corporate sector the opportunity to ransack the public health treasury. Neo-conservative proponents argue this would retain Medicare’s essentials while taking some of the pressure off the beleaguered public system and providing people with choices. Health experts, however, warn that this approach will lead to an increasingly underfunded, low-grade public system for lower-income Canadians, while attracting the more competent physicians and other health professionals to the more lucrative private tier.
Private health care has been consistently shown to be more expensive and more risky for patients than publicly-funded care. Furthermore, evidence from both Alberta and Australia has clearly demonstrated that opening up private options has not shortened waiting lists in the public system. And the same research shows that private options degrade the public system by bleeding resources and personnel off into for-profit medicine.
The political problem for advocates of a fully developed two-tier health system has been strong public opposition. While desperate Canadians are reluctantly willing to concede some privatization on the margins (hips, knees, cataracts, MRIs) out of desperation due to the incapacity of the public system to provide timely care, they have resisted the siren call for a comprehensive two-tier system.
The Supreme Court has provided the assassins of Medicare with a trump card. Before the Chaouli ruling, they had to lie and weasel about their true intentions: they were reforming, rebuilding, renewing, repairing Medicare even as they strangled it. Now they can wring their hands and weep: “We have no choice, the Supreme Court has ruled. A two-tier health system is a constitutional right.”
This will be another lie. The remedy to the Supreme Court decision is simple: invocation of the notwithstanding clause (Section 33(1), The Constitution Act, 1982). This clause was inserted in the Constitution at the insistence of the premiers, led by Alan Blakeney, for precisely this scenario: when the Supreme Court stupidly does something clearly contrary to the public interest and the democratic will of the Canadian people. All Ottawa has to do is pass a bill through the House of Commons declaring simply: “Notwithstanding The Canadian Charter of Rights and Freedoms, The Canada Health Act shall prevail.” The provinces could follow suit, invoking the clause to exempt all relevant Medicare legislation from The Charter.
Then Ottawa must--and would be free--to impose the law of the land and the will of the people on itself, and on all provincial governments.
(John Conway is a University of Regina political sociologist and the author of The West: The History of a Region in Confederation and Debts to Pay: The Future of Federalism in Quebec.)