My first experience in lobbying in Washington was to visit the office of a prominent senator regarding that aspect of the Clinton Health Plan which would have made private practice illegal. I was informed by staff in the senator's office that indeed private practice should be illegal, that it was immoral for some people to be able to buy better health care than others. Caught off guard, I replied that I only knew of one group of countries where that was the case, the Communist countries, and the care was indeed equal. It was terrible. When we left the senator's office, my lawyer brother dryly informed me, “Liberal Democratic senators didn't like being called communists.”
This was my first experience in understanding the kind of thinking that underlies the Canadian health-care system, which is easily the leading example of a true “single-payer” system. Since its formation in the 1960s, Canada's publicly financed health insurance system has been at the core of the national identity. In recent years however, with waiting lines growing and costs skyrocketing, the merits of a private alternative to the health-care system has not been the taboo topic it once was.
Spreading dissatisfaction with the system has led to several serious challenges, including a concern by many of the Canadians that if the U.S. goes to a single-payer system they would have nowhere to go for their own health care.
The Canadian experience is of special relevance to us because growing dissatisfaction with our current system is leading to mounting pressure to adopt a “single-payer” system in the U.S. Canada presents us with a kaleidoscope of effects on psychoanalytic practice, because each province deals differently with psychoanalysis. In some, Quebec, for example, it is not covered, resulting in a vigorous private practice. In others, it is fully covered, and private practice is not permitted. “Coverage” applies only to physicians, not psychologists or other mental health professionals, apparently a mixed blessing.
Although 65 percent of Canadians still say they get good health care, dissatisfaction is growing. According to the National Post of Sept. 18, 2006, an estimated 95,000 Canadians sought medical care outside their country in 2005. The cry, “no two-tiered system,” could be replaced by “set our patients free,” stated the lead editorial in that paper.
It appears that the system stands a fair chance of bankrupting the country. According to a lead editorial in the Calgary Sun, the biggest financial drain is the single-payer medical system. “Current model of health-care delivery leading us down the path of financial ruin,” states the editorial. According to a report by the Fraser Institute, 50 percent of Alberta's budget would be consumed by health-care costs by 2016 and health care would devour 100 percent of the provincial budget by 2030, if present trends continue.
Spreading dissatisfaction with the system has led to several serious challenges, including a concern by many of the Canadians that if the U.S. goes to a single-payer system they would have nowhere to go for their own health care.
On June 9, 2006, the Canadian Supreme Court struck down a Quebec law banning private medical insurance, thus dealing what many feel is an acute blow to the publicly financed national health-care system. This was a case brought by a Montreal family doctor, Jacques Chaouilli, somewhat of a character in the sense that he went to law school in order to argue his own case in the Canadian courts, challenging the Canadian system. Chaouilli's argument was that the Canadian system was endangering the health and welfare of its citizens. Chaouilli has long called for Canada to adopt a two-tier, public-private health system similar to those in Europe. Opponents have argued that a two-tier plan would draw physicians away from the public system.
In the Supreme Court ruling, the Court noted, “The evidence in this case shows that delays in the public health-care system are widespread and that in some serious cases, patients die as a result of waiting lists for public health care.” The Court stopped short of striking down the constitutionality of the country's nationwide coverage, but experts say such challenges are simply a matter of time.
Canada's Prime Minister Paul Martin responded to the decision by saying, “We're not going to have a two-tier health-care system in this country. Nobody wants that. What we want to do is to strengthen the public health-care system.” However, legal scholars and health experts predict a slew of lawsuits. The president of the Canadian Medical Association, Elmer Schumaker, told reporters, “This is indeed an historical ruling that could substantially change the very foundations of medical care as we know it.”
Bob Pyles, M.D., is chair of the Committee on Government Relations and Insurance and a past president of APsaA.
In a parallel development, Brian Day, a doctor who operates Canada's largest private hospital in violation of Canadian law, was elected Tuesday to become the next president of the Canadian Medical Association. This move gives an influential platform to a prominent advocate for privatizing Canada's troubled taxpayer financed medical system.
The new president-elect has openly run his private hospital in Vancouver, accepting money from patients for procedures that are available through the public system, which is illegal. Day's election to head the organization, which represents Canada's 62,000 doctors, now puts the question of the two-tier system squarely at the heart of public consciousness.
What seems clear is that the Canadian system, as it presently operates, has failed. The so-called “two-tiered systems,” as described in my earlier article on Germany [see “Politics and Public Policy,” TAP 40/4], seem to be succeeding in providing a basic level of health care to everyone, while affording the opportunity for self-directed health care for citizens who can purchase private insurance or pay privately. Whether it is more or less ethical to allow some citizens to buy better health care or to deny those citizens the opportunity for better health care is at the heart of this debate.
Clearly the experience of other countries has direct relevance to us here in the United States. Since the failure of the Clinton health plan, most health care in this country has been controlled by managed care, a system fraught with conflict of interest, which in its own way seems as equally flawed as the Canadian system. The danger of a single-payer plan in this country is that it might well create a system of capitated cost administered by managed care companies, giving us the worst of both worlds. It would appear that something akin to the government sponsored systems in Germany, England, and other European countries, establishing a reasonable level of care, and encouraging private insurance and a vigorous private practice, stands the best chance of both providing good care, maximum coverage, and a healthy climate for psychoanalysis.