A recent article in The duty expressed concerns about a certain openness to the private sector in Bill 15, which carries the ambitious reform that should, in particular, lead to the creation of Health Quebec. However, in addition to a few adjustments, this bill merely reproduces various mechanisms that already exist under the current act and which, for better or for worse, allow recourse to the private sector in different forms.
Everything is already in place for the use of private
Thus, the existence of private establishments is nothing new, these being already authorized under the current law (section 97 of the Act respecting health services and social services) and were even authorized under the original, i.e. the one adopted in 1971 and which was the result of the work of the Castonguay-Nepveu Commission (art 8 of the old law). For a long time, there have been private establishments that operate not only accommodation and long-term care centers, under agreement or self-financed (at the full cost of patients), but also hospital centers for convalescents and rehabilitation centers, which are all listed by the Ministry of Health and Social Services.
As for specialized medical centers (CMS) and section 194 of the bill, which allows the Minister to assume the costs of care given in such a private resource “despite any irreconcilable provision”, there again, nothing new. With somewhat different wording, these measures were introduced into the current law in 2006, following the Supreme Court of Canada’s judgment in the Chaoulli case, which had the effect of invalidating certain provisions of the Quebec restricting access to private services.
It was then in particular a question of “guarantees of access” to certain surgical procedures, which were to make it possible to direct a user to a CMS if the waiting times in the public sector exceeded certain thresholds (article 431.2 of the current law). It is unclear whether these safeguards are still in effect, but they still remain posted on the ministry’s website.
As under the current law (article 333), the draft law (articles 500 and 504) provides that there may be “participatory” CMSs in the public health insurance scheme and “non-participatory” CMSs, but does not allow the combination of these statutes, thus consistent with the prohibition of mixed medical practice laid down by the Health Insurance Act. In addition, agreements with various private resources for the provision of services to the population, such as that entered into with Clinique Rockland MD for certain surgeries, are obviously already authorized under the current law (s. 108) and will remain so with the Bill 15 (Section 445).
Ultimately, both under the current law and under the new proposed law, it is and will be possible to set up “private hospitals”, in “mini” format or not, with public funding or not, in addition to subcontracting various services. to the private sector. We can of course be critical in this regard, particularly with regard to the issue of staff retention and the loss of expertise within the public system, in addition to that of cost control over a long period. The safety of services can also be a source of concern, following the record of the experience of the privatization of certain services within the British NHS in the last decade.
The “creeping” privatization of certain services
We do not know whether, in the medium or long term, the current government and its successors will maintain the orientations of the current Health Plan to ensure public financing of the services offered by private resources, and therefore to preserve the principle of accessibility based on need, rather than ability to pay. However, we know that this same principle is already compromised by other measures that have nothing to do with Bill 15 and which lead to a form of “creeping privatization” of certain services.
We are reminded of this by the recent announcement of a $42 million reduction in federal health transfers for Quebec, due to its tacit acceptance of paid access to private diagnostic services (magnetic resonance imaging, for example), for lack of sufficient coverage of these services within the public system, thus contravening the Canada Health Act. Need we remind you that it is Quebec that receives the largest portion of the reductions in federal transfers for these services, while Ontario has no reduction in this regard.
The same applies to other phenomena currently at work, such as the decompartmentalization of professions in the health sector which began several years ago and which should be accentuated according to the Health Plan. Many “medically necessary” services can now be obtained from non-physicians, sometimes outside the public system, at the expense of the patients. It is certainly necessary to continue on the path of this necessary decompartmentalization, but the coverage of the public plan should also be adjusted accordingly. This is also the case for virtual care, already very widely accessible in the private sector, but which remains very little accessible in the public system.
We even note on this subject that, through a recent and discreet regulatory amendment, Quebec has paved the way for private insurers to cover such services for people who are lucky enough to benefit from such social benefits their jobs, thus creating a new inequity in access to health services.
If we have to worry about the role of the private sector in the field of health, perhaps it is best to focus first on the measures that really derogate from the principles of universality and accessibility. These often result from various seemingly innocuous initiatives, sometimes taking the form of a simple regulatory amendment. They thus escape the public gaze because they do not get as much media attention as the major reforms launched at full speed, as is the case with Bill 15.