The Third Way

The public has had plenty of time to weigh the pros and cons of Premier Ralph Klein's proposal to introduce a two-tier health care system. In the Calgary Sun, the GlobeandMail.com, and TheStar.com, it is argued that a two-tier health care system will have detrimental effects, such as queue jumping, conflicts of interest, attracting rural health care workers to urban locations, and penalties under the Canada Health Act [CHA]. However, the act of listing out cons tends to ignore the assumptions that they are based upon.

First of all, it appears to be unfair to allow people to queue jump for treatment because they possess a greater amount of wealth and are willing to pay the costs of private health care. However, there is a difference between those who are 'willing to pay' and those who are 'rich'. To suggest that queue jumping is something to be frowned upon and only available to the wealthy ignores the possibilities queue jumping offers. One of the main objectives for the Canadian government is to reduce wait times. Queue jumping may contribute to that objective by shunting people who are waiting for a particular treatment to a private alternative, freeing up the public system queue. Although those who receive treatment earlier through the private tier must be willing to pay for it, the strains on the public system are nevertheless alleviated. Ideally the public sector will provide timely service for all types of treatments to all who require it, but there will be situations where even the best standardised wait times deemed appropriate by the government do not suit the needs of the public.

Secondly, the argument that a two-tier system will create a conflict of interest for doctors assumes that patients cannot weigh the advantages and disadvantages between the public and private sector for themselves. Patients can judge the character of the doctor they are seeing and evaluate how their needs can be met by either tier. One possible solution would be to encourage more dialogue between the patient and other health care workers in order to promote accurate information to prevent or minimise abuses. On the other hand, doctors might avoid discussing private alternatives entirely due to the fear of disgruntled patients raising accusations of unethical conduct against them.

Though conflicts of interest are a serious problem with a two-tier system it can possibly provide benefits to health care workers by providing a private alternative for skilled, educated people who are considering a career in the United States for the promise of improved incomes. Young health care workers and doctors can take advantage of the experiences the public sector offers and provide their skills to the private sector while remaining within the country, countering the age-old matter of Canada's 'brain drain'.

As for the penalties that may be incurred under the Canada Health Act 1985 [CHA], it can be seen from the position of Premier Klein that they are clearly not enough to deter a province from pursuing private health care. Moreover, while the Klein government has been criticised for providing vague details of the 'Third Way', the CHA is not without flaws.

Fourthly, the argument that a private health care system will act as a magnet for rural health care workers is doubtful because conflicts always exist between the demands of rural and urban populations. The effects of a two-tier system will certainly contribute to this conflict, but it is premature to argue that the rural health care system will suffer detrimentally due to an increased prevalence of private health care. A two-tier system may create private alternatives that are closer to rural populations rather than force patients to resort to treatments administered in other provinces or states.

One final assumption that seemingly underlies these four disadvantages is that a two-tier approach to health care will essentially create a mirror image where a complete, private system will compete with the public sector. However, it is unlikely and somewhat difficult to imagine this situation due to the competitive advantage of public health care. From the Information Technology for Management Glossary the definition of competitive advantage "is an advantage over a competitor such as lower cost or quicker deliveries." Many public health services are well entrenched, making it difficult for private firms to establish themselves unless they offered something unique. In addition, there will be areas of health care where the skills of the public sector are absolute and will generally be avoided by the private tier. Private tier health care delivery is further restricted due to the fact, "…[i]n practice, few physicians leave the public system because it is hard to attract a sufficient number of patients who want to pay full health-care costs when they also have access to the public system" [The Canada Health Act: Overview and Options (94-4E)]. Essentially the private sector will find opportunities in areas where the public system is relatively slow and bogged down.

It can be seen that privately funded and delivered health care can have positive (heh) effects, but the fact is there will be problems for both single and two-tier systems due to the complexity of delivering health care to an entire country. The very purpose of discussing the 'Third Way' is to explore alternatives to providing timely, quality care to as many people as possible and this requires contemplation upon the possible advantages a private sector approach has to offer.

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3 responses to “The Third Way

  1. “Oh Me, Oh My” indeed. Where to begin?

    Percy, it seems that you’ve slipped far too easily into the “private delivery will magically save us all” argument. Allow me to clarify a bit.

    Queue jumping may contribute to that objective by shunting people who are waiting for a particular treatment to a private alternative, freeing up the public system queue.

    This seems like a perfectly good argument, if you were talking about, say, fast-food restaurants. There is no resource-limitation for fast-food restaurants: there’s a surplus supply of workers (for the most part), and it’s relatively cheap to start up a new franchise.

    For health care, however, the surplus capacity simply does not exist. There is already a shortage of primary-care physicians, family physicians, and specialists. Moreover, there is a major shortage of nursing staff (thanks in part to this government’s brilliant plan in the early 90s to lay off a sizeable number of nurses, most of whom are quite happily settled in Texas.) Private health care delivery cannot wave the magic wand and create health care professionals out of thin air.

    Secondly, the argument that a two-tier system will create a conflict of interest for doctors assumes that patients cannot weigh the advantages and disadvantages between the public and private sector for themselves. Patients can judge the character of the doctor they are seeing and evaluate how their needs can be met by either tier.

    The conflict does not come from doctors siphoning patients from their public practice to a private one per se. The conflict comes from doctors selectively deciding to devote more time to a more profitable and less complicated (medically) private practice to the detriment of the public system. Granted, the Third Way proposes that any private delivery proposal must prove that the public system is not harmed, but unless each proposal can (as above) create professionals out of thin air, the public system will be harmed. Allowing doctors to straddle both systems, then, is the conflict, because it is in their financial interest to go to an easier, more profitable private practice.

    Fourthly, the argument that a private health care system will act as a magnet for rural health care workers is doubtful because conflicts always exist between the demands of rural and urban populations.

    This is perhaps the most dubious of your claims, Percy. Rural Alberta is, at present, desperate for health-care workers. Given that private practices will be most economically feasible in urban centres, and (as above, thanks to a human-resource-limited system) they will take health-care professionals from the public system, the rural system will suffer all the more because of private delivery.

    I do not argue that the system as is is perfect. Far from it. We have many problems that need to be solved. Partitioning the system and dividing our limited resources between two differently-minded paradigms, however, seems to be a spurious solution. It is difficult to perceive a benefit when one considers the source of the wait-time problems.

    Moreover, one aspect of health care that no proposed solution seems to make any substantive contributions to is preventative medicine. We are being faced with an epidemic of obesity and, with it, will face a huge influx of patients into the system with the so-called metabolic syndrome of diabetes, coronary artery disease, dyslipidemia and hypertension. With this comes lifelong prescription drugs, and costs of hospitalization due to heart attacks, strokes, liver disease, kidney disease, peripheral vascular disease, retinal disease and many more expensive medical problems. Even if privatization were to make the system perfectly efficient, the inflow of patients in the next 20, 30, 40, 50 years will overwhelm the system in either case.

    The best way to make the system sustainable in the long run needs to be public health interventions that can make the population healthier, and preventing their entry into the system. I don’t claim to know what the most efficient of these solutions is, but my standard example is using public money to subsidize fresh produce and healthier food options (to make it cheaper than less healthy fast food) and subsidize physical activity programs. If we can make a healthy lifestyle more financially sensible in the short term (as opposed to only in the long term) we can go a long way to a healthier population.

    Of course, preventative medicine is neither sexy nor profitable, so I find it unlikely that politicians will seize upon it.

    God that was long. You see what you’ve done?

  2. Oh, never fear Par, I can say one thing and mean another. A few points before I go: It can be seen that my post appeared to be in favour of a private tier, but only in a limited fashion. A two-tiered system does not necessarily involve the creation of a ‘parallel’ or mirror private system that will compete with the public system for all treatments. Rather, the private tier will most likely operate in profitable areas where the public system is bogged down by virtue of competitive advantage. It is doubtful that a private tier can ‘save us all’, but the issue should be explored for the long-term sustainability of public health care.
    I agree that while discussing two-tier health care, there probably is a commonly held assumption that health care workers will ‘magically’ appear to occupy all of the public and private positions. Although this assumption involves wishful thinking on the part of those who support a two-tier system, this can serve as evidence of the need, as a matter of public policy, to ensure that health care related talent remains in Canada. As you duly point out, the shortage of health care workers has created strains for the health care system and the country can not afford losses similar to the emigration of nurses in the 1990s. Now, whether or not a two-tier system is the answer to this issue is the subject of debate.
    A private solution to health care is not without fault. The government is clearly in a position to control the development of the private tier, but, as you pointed out, the question of what criteria are used to guide the decision as to whether or not a private delivery proposal is harmful to the public system is unknown. Also, even if a private delivery proposal is proven to be harmless to the public system, it is not a guarantee.
    Lastly, to clarify, the promise of higher income from the private sector may not be the sole reason to motivate rural health care workers to migrate to the cities. The promise of higher incomes may be a distinguished motivation but there are probably other factors. I simply disagree that a private tier should be singled-out as the only ‘magnet’. Now whether or not a private tier can bring health care solutions closer to rural populations is a question I would like answered myself, but – even if it is only for the sake of argument – I leave open the possibility that the answer is yes.

  3. When we discussed how to create an incentive for people to exercise, it did not occur to me last night how easy a pay-to-exercise scheme could be set up. The YMCA has installed something called 'FitLinxx' that gym members can sign into to at various machines to monitor their workouts. It's relatively new so I am not sure what features FitLinxx has to offer, but it can easily be used to track workout routine improvements and, for the purposes of incentive, payment. If you ask me, the idea of pay-to-exercise is pretty innovative and edgy.

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