This week we host Dr. Monika Dutt, Board member of Canadian Doctors for Medicare and a public health and family physician in Nova Scotia. She fills us in on the historic legal challenge to the Medicare program that was just decided by the Supreme Court of British Columbia. The plaintiff, a for-profit surgery clinic, sought to allow patients to pay more for quicker treatment; it would have opened the door to a two-tiered health care system that would draw resources away from the public system and disproportionately affect the most vulnerable patients. Dr. Dutt talks about the ramifications of this victory for Canada’s single payer system and what’s next in the fight for a better Medicare.


Show Notes

Canadian Doctors for Medicare, which Dr. Dutt sits on the Board of, was founded about 10 years ago to defend Canada’s single-payer healthcare system, and also to improve and expand upon it. It may be confusing for some in the United States, but “Medicare” in Canada refers to their entire universal healthcare system, whereas here in the U.S. “Medicare” is a healthcare program only for seniors age 65 and older.

Although the entire system in Canada is referred to as “Medicare,” in reality each province and territory runs their own single-payer health insurance plan. They all have to meet the requirements of the Canada Health Act, though, which outlines the core principles of Medicare, including universality.

While you can buy private health insurance in Canada for services not covered by the public single-payer system (like dental care, some medications, and other specialty services depending on the province), private insurers are not allowed to compete with Medicare by covering the same care that Medicare already covers.

This principle, and what happens when you allow a “two-tier” system of public insurance competing with private insurance, is exactly what was at stake in a major lawsuit that was just ruled on – Cambie Surgeries vs. British Columbia. This case started in 2016, when Cambie Surgeries sued British Columbia’s single-payer system, trying to win the right to do three things:

  1. “Extra billing” (called “balance billing” in the United States), or allowing providers to charge their patients above and beyond the rates they receive from Medicare, which would open the door to preferential treatment for patients able to pay more;
  2. The ability to bill private insurers for basic healthcare that is covered by Canada’s Medicare program, which would allow the creation of a two-tier system where people willing to pay more for private insurance could gain access to better and faster care; and
  3. Allow providers to be reimbursed by both private and public insurance. Providers in BC who participate in Medicare currently cannot accept private duplicative insurance or be paid out-of-pocket for any services covered by Medicare. BC physicians are free to not enroll in Medicare, in which case they can bill patients out-of-pocket, but they cannot also bill the public plan.

If the lawsuit was successful, it would have allowed those who are healthier and wealthier to buy preferential treatment, and to get treated first – exactly as they are allowed to in the United States. However, just this past week British Columbia’s Supreme Court ruled against Cambie Surgeries, relying on a mountain of evidence submitted by experts around the globe showing that allowing two-tier systems undermines care in the public system and… does not improve wait times. (More on this shortly!)

Expert witnesses were brought in from Canada and other countries with single-payer healthcare systems. The Judge’s final ruling, which considered all of that testimony, is 880 pages long (!!), but Canadian Doctors for Medicare has helpfully compiled a 40 page summary of the ruling. The Judge found that, if the court ruled in favor of the plaintiffs, it would make Canada’s healthcare system more inequitable, and would likely increase waiting times instead of decreasing waiting times, particularly for those left in the public system. This is a dynamic that has played out in New Zealand and Australia, where the creation of a two-tier system has led some medical staff to leave the public system for the (higher paying) private system, while patients with greater health needs but less income are left in the public system – creating a spiral of understaffing and under-resourcing of public healthcare.

Here in the United States, we are inundated by messaging in the media that moving to a Medicare for All system would create longer wait times for care. Even so-called “liberal” commentators like Ezra Klein at Vox or Paul Krugman at the New York Times, have claimed that Medicare for All saves money by rationing care, and that if you do create a universal public healthcare system, you would have to also allow private insurance as an “escape valve.” However, after reviewing all the evidence – including comparisons across provinces within Canada, and looking at countries with two-tier systems like the U.K., Australia, and New Zealand – the Supreme Court found that neither of these claims are true.

Dr. Dutt reminds us that the lawsuit was not about reducing wait times for patients – it was about increasing income for (some) physicians, and increasing profits for shareholders of for-profit clinical practices. However, the court’s ruling covered a lot of important academic evidence regarding wait times in Canada. For example, Canada does extremely well on emergency and urgent care. No one in Canada dies on a wait list, because if any condition becomes urgent, they will be seen immediately. Canada does have some wait times in areas considered non-urgent, although they can be very important to people’s lives. Canada has been making progress reducing wait times through steps like centralizing referrals.

If this lawsuit had prevailed, what would the implications have been? It certainly would have been appealed, but if it had gone through it would have led to all of the outcomes that the Judge specifically commented on: increasing inequities, and creating incentives for providers to focus on income and profits instead of patient care. Dr. Dutt works in an area where many of her patients struggle with day-to-day issues like accessing food, housing, etc, and the ruling would have been devastating if their providers could make more money treating the wealthy.

Although the lawsuit, having failed, doesn’t change anything, it has left behind an incredible document compiling all of the evidence for preserving a truly public, single-payer healthcare system, and it will create a strong disincentive to future legal challenges.

So what are some implications of the ruling for the United States, particularly for the argument we see here sometimes that you can get to a universal healthcare system while preserving private health insurance? Dr. Dutt reminds us that winning single-payer healthcare in Canada was also not easy – it took decades of political struggle, including significant opposition from physicians, among others. It is important to have the evidence on our side, but also having the population’s values on our side. This is particularly true during a pandemic, which should make it even more obvious that you need a universal, PUBLIC healthcare system to address even day-to-day health needs, never mind a global pandemic.

So what is the next fight to expand and improve Canada’s single-payer healthcare system? A major focus is on winning universal pharma care, which has been a decades-long fight in Canada. You may get the care you need in the hospital, but if you can’t afford the prescriptions you need when you’re discharged, that’s a major challenge. Winning universal dental care, and also better long-term care, are also key next steps, particularly during a pandemic.

We close by looking forward to a race between which country can win a major improvement to their healthcare system first!

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