Since the recent Supreme Court of Canada decision that the Quebec government does not have the legal right to prevent people from paying for private insurance coverage for health care services that fall under medicare, for-profit delivery and needs-based approaches have suddenly appeared on the public agenda. The governance of health care in Canada is rather complicated by the competing silos that compete for power and influence. Indeed, within a health care system that is highly divided, and competitive, it has been difficult to come together, form a common perception of current problems and realities, promote shared images and values, and then work together in promoting a common vision. From my perspective, the real crisis in health care is related to the old system of governance and the multiple, cross-cutting, and very competitive systems which continue to operate side by side and have contributed significantly to the acrimonious and dysfunctional debate.
Viewed in this way, the Supreme Court of Canada has highlighted some of the myths associated with medicare that do not reflect current realities. I, like most Canadians prefer a universal, needs-based health care system, but in order to do so, we need to take a realistic look at what we have created, find ways to work across silos and come up with a different conceptualization of health and health care delivery that better reflects citizen priorities. Unfortunately, unless or until we change the system of governance and make it easier for Canadians to form common perceptions of reality, and work together on collective solutions, other options such as privatization will continue to evolve and gain strength.
In many respects, the Supreme Court of Canada responded to a dysfunctional situation where Canadians have been frustrated because their needs and priorities are not being reflected in current health practices. Since myth and realities do not line up, the Court in the 4-3 ruling decided that given the current state in health care delivery, citizens could not be banned from receiving alternative services. Canadian citizens have become increasingly frustrated and cynical about a system that does not provide access to services in a timely way. Nor does it offer a way for citizens to shape or move the system in a new direction. For the most part, they are observers, not participants, and there are few opportunities for Canadians to take ownership of the issue and solve problems based on a collective vision.
Despite the rhetoric of politicians and stakeholders, there are problems with the current system. Unfortunately, the way these issues have been defined or acted upon has done little to promote equity or give other citizens with other perspectives an opportunity to renew governance based on a common vision. The only choice left open to citizens in such a context is to do what ever they have to do in order to survive. This has included gaining access to private care. It is an approach that is more individualistic than collectivist. Whether intentional or not, the reality is that over 31 per cent of the health care system in Canada is already privatized. Even government agencies such as Worker’s Compensation have helped push the privatization option by sending their clients to private clinics. While more services are being privatized or de-listed, several others such as home care, dental, or pharmacare have never fallen under medicare or the Canada Health Act.
A major problem with relying upon such approaches to reform is that they ignore the problems of the poor. Indeed, the court case itself and how the legal issues were framed were done in a way that met the needs of the plaintiff, who happened to be a doctor with an interest in setting up a private clinic. Relying upon the courts to discuss and resolve disputes does not provide a balanced approach for dealing with complex issues, even if it provides an opportunity to debate an issue. Unfortunately, the court case has likely reinforced the power of the already deeply embedded bio-medical model and the institutions, interests that help sustain it. More needs to be done to contest the power of the old regime and the myths that legitimize it.
One myth that tends to reflect power differentials is the idea that improving health services based on the bio-medical model will substantially improve community or individual health. This is a convenient myth for the rich, but ignores the reality that social determinants have a bigger impact on health outcomes. Another problem with the focus on waiting list reform is that things like knee-hip replacements, and cardiac care receive more attention than waiting lists for mental health, despite the fact these are major problem areas. Unfortunately, at a time when the courts are saying we are in a state of crisis and privatization is a possible option open to Canadians, our competitive federal system has divided us and has allowed politicians to defend old monopolies and ideas while blaming each other for the current state of affairs. Unless or until these contextual and institutional settings change, there will be few opportunities for Canadians to come together, institutionalize a new vision of medicare that deals with needs of all Canadians (both rich and poor) and reflects the spirit of Pan-Canadianism.
In the current context, the court decision of the Supreme Court should be seen as an opportunity to renew health care governance, but new ways need to be developed to ensure that all Canadians have an opportunity to define problems and help reconstruct a new vision that truly reflect the spirit or myth of medicare. Every country has its own myths and struggles with the problem of promoting a common identity. The crisis identified by the Supreme Court is real but it is not about waiting lists, or for-profit delivery. Rather, the real issue is the larger system of governance and the need to ensure that the mechanisms and processes we rely upon to define and frame issues (including the courts) do not prevent us from choosing options that reflect the needs of everyone, even those who cannot afford to contest key principles in court, or pay for private care. If we refuse to create a system that is more open to a common Pan-Canadian vision, the outcome will be a system designed to reflect the needs and priorities of those with economic power. From my perspective, this is the wrong approach for reforming the current health care system.