OPED: The perils of medicare monopoly – Insurance legislation has failed to modernize and adapt to consumer attitudes and health needs

Canada’s federal and provincial governments are contributing to further decline of our health-care system through their reluctance to deal with the freedom-infringing and monopolizing provisions in medicare insurance legislation.

These unnecessary and defective provisions prohibit or discourage the private financing of alternatives in medical and hospital insurance and private medical services in hospitals, even when services covered by medicare are unavailable or unacceptable. This is an infringement on the constitutionally protected right of individuals to life, liberty and security.

The provisions also establish centrally planned provincial government monopolies to finance and control the production, distribution and supply of virtually all physician and hospital services, and insurance, and indirectly control the training and distribution quotas for physicians, nurses and other health professionals.

These inflexible anti-market provisions have sabotaged the humanitarian goals of Canadian health-care policy and medicare, by impeding, rather than facilitating, reasonable access to services. They have prohibited innovation and controlled experiments to test and compare different approaches to financing and delivery of services in the private or mixed sectors. Medicare’s legislation has failed to modernize and adapt to consumer attitudes and health needs of market-oriented Canadians.

Unlike other free world countries, Canada has inadvertently allowed the coercive provisions in medicare legislation to establish a totalitarian-like regime within its liberal democracy, resulting in state control of patients, physicians, and virtually all medical and hospital matters. The Hall Commission (1964) that inspired Canada’s medicare experiment specifically warned legislators against this kind of state regime in medicine and of the necessity for personal freedom of choice.

Thus, Canadians have reason to be cynical about the intentions of political parties in health system reform. For several years now, public surveys have indicated a desire for either fundamental reform or a complete rebuilding of the health system, and for the right of individuals to purchase private alternative medical and hospital insurance and services as long as the public system was not jeopardized.

In spite of this public opinion trend towards accepting alternative market choices, the recent public inquiries into Canada’s ailing health system have ignored the monopolizing provisions in medicare legislation that largely account for the health system’s decline. The inquiries have made no proposals for repeal of these flawed provisions, in order to restore freedom and competition in health financing, and to encourage alternative private and mixed financing approaches as found in successful European models.

The one-man Romanow Commission defended the socialized state monopoly position on health financing in line with publicly funded interest groups such as health services unions and most medical, nursing and hospital associations.

His main proposal calls for a paternalistic government-appointed National Health Council to monitor and report on the quality and availability of services covered by provincial medicare insurance. This shows a surprising lack of confidence in the ability of Canadian consumers of health services to determine whether the access, quality and choices concerning their medical and hospital services were adequate or not.

The Romanow recommendations contain no mechanism for consumers to opt out of selective medicare benefits in return for government vouchers or refundable tax benefits, which would financially empower them to « vote with their feet » and buy alternative health insurance or services in the private sector. By failing to propose the restoration of personal freedom in medical and hospital matters, the Romanow proposals simply prolong the failing provincial experiments with medicare monopolies.

A proposal for fundamental health system reform, based on a politico-economic philosophy totally different than the Romanow approach, was recently published by the Montreal Economic Institute, as Universal Private Choice: Medicare Plus. In this freedom-oriented proposal, individual freedom of choice in all matters of health care and health insurance would be paramount. Universal medicare entitlements would remain as core services. Patients and consumers, whether empowered by public or private funding, would have many options for alternative private or mixed services and insurance.

Implementation of Medicare Plus or similar proposals would require the political repeal of freedom-infringing and monopolizing provisions in medicare legislation, or their judicial invalidation by the Supreme Court. Either the political or judicial remedy could save Canada’s ailing health system and satisfy Canadian public opinion. Both approaches share the following objectives:

• Restore individual freedom, personal choice, and the opportunity for consumers and providers of medical and hospital services to exercise personal responsibility in the financing, insuring, purchasing, and provision of these services, including those covered by medicare.

• Keep medicare, but remove the monopolizing provisions in medicare legislation, and restore the freedom of voluntary non-profit or commercial associations to provide a full range of health insurance services.

• Reassure Canadians that the restoration of freedom, choice and competition in health care and health insurance services will not jeopardize universal access to publicly funded health services.

• Revise the criteria in the Canada Health Act regarding federal cash or tax transfers to the provinces and territories, to enhance freedom, quality, access, choice and competition, in conformity with the proposed changes in provincial health legislation.

Most Canadians like the benefits of medicare when they are readily accessible. But they also want to regain their freedom to choose among public and private alternatives in medical and hospital services and insurance, as Europeans have for decades.

The ongoing Supreme Court challenge of freedom-infringing provisions in Quebec’s medicare legislation should not deter political action in this area of provincial jurisdiction.

Elected politicians, who sometimes complain of judicial activism and encroachment of their legislative turf by non-elected judges, now have an opportunity to use the political process and do the right thing for their electorate.

Automobile manufacturers recall production defects. Canadian politicians should do likewise. They should promptly recall their defective provisions in medicare legislation and restore full freedom in health matters, rather than defer their legislative responsibilities to the overworked judges of the Supreme Court.

J. Edwin Coffey est chercheur associé à l’IEDM.