Battle lines are being drawn up as health ministers in Ottawa and Alberta begin to square off on health-care reform. The cause? Alberta’s decision to allow doctors to provide care in both public and private settings.
While Adriana LaGrange, Alberta’s minister of hospitals and surgical services, has claimed provincial jurisdiction over the delivery of health-care services, Marjorie Michel, Canada’s federal health minister, has expressed concern about the compatibility of Alberta’s proposal with the reality of the Canada Health Act (CHA).
Lawyers can quibble over who is right, but what Ottawa should be doing is welcoming Alberta’s move and committing to amend the CHA if need be so that the Alberta government can continue to make its health system more like better-performing universal systems in Europe.
Let’s be clear: physicians in Alberta (and indeed most of Canada) are already able to opt out of the public system. However, to do so, they must give up their public role entirely. To continue supporting the public system, few have chosen this path. However, increasing frustration with the government’s approach to health care threatens a potential exodus from public to private settings.
Just ask Quebec, where the increasingly rigid rules to keep physicians stuck in the public system backfired spectacularly and led to physicians applying for jobs in Ontario. Media have previously reported on some Calgary-based physicians travelling to the Caribbean to deliver private care—not to local residents—but to Albertans who fly there with them.
Alberta’s government understands this approach doesn’t make sense, and in fact provincial barriers actually threaten the very system they’re intended to protect by forcing physicians into a binary choice. Enter dual-practice legislation that offers physicians a more flexible option – allowing them to participate in the private sector without abandoning patients in the public queue.
But there’s a catch. Alberta receives billions of dollars in health care funding from Ottawa every year, and therefore needs to play by its rules. The federal Canada Health Act does not explicitly prohibit dual practice, so long as services in public settings continue to adhere to the principles of the CHA. However, there’s enough wiggle-room in the wording that federal politicians, or a special interest group, could politicize the issue, choosing to claim such a change contravenes the principle of Accessibility.
Which is why guardrails are important – restrictions on what can be offered and under which circumstances, safeguards to prevent conflict of interest, commitments to transparency, and guarantees to make sure the public system has enough staff. This is the approach followed by several universal health care systems around the world with dual-practice regulations.
In Germany, physicians must commit to working at least 25 hours for the public system before they can provide private care. In France, it’s five “half-days” per week, with on-site private activity capped at 20% of public-hospital activity. In the United Kingdom, doctors who have contracts with the public National Health Service (NHS) must generally prioritize their duty to the public hospital.
But Alberta understands this, and has already committed to a number of guardrails, with more expected to be announced in the coming weeks. And, one suspects federal Minister Michels understands this as well. In fact, Minister Michel’s statements regarding “ongoing targeted discussions…to mitigate any misalignment with the CHA” may simply be interpreted as a frank assessment of the reality on the ground rather than a warning – though it’s impossible to tell while the specific contents of her letter to the provincial minister remain undisclosed.
Allowing physicians to practice privately without sacrificing their public role is a common-sense approach based on our international peers. If this reform is deemed incompatible with the CHA, it’s not Alberta, but the federal legislation that needs to change.
Bacchus Barua is Research Director at SecondStreet.org
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