A constitutional challenge to Ontario health care legislation prohibiting the purchase of private health insurance for medically-necessary healthcare services (dubbed the "Ontario Chaoulli) was announced on September 5^th, 2007. It's another call for increased privatization, based on the misinformed notion that an expanded role for private health insurance will remedy wait times in Canada.

Just last month, the outgoing President of the Canadian Medical Association (CMA), Dr. Colin McMillan, put forward Medicare Plus, the CMA's solution for sustaining our health care system. It proposed expanding the role for private insurance and private payment, and allowing physicians to work for the public system and treat private patients too. After facing a stream of backlash in response to their Medicare Plus report from the Canadian Healthcare Association, the Registered Nurses Association of Ontario, Canadian Doctors for Medicare and others, the CMA responded by saying that Medicare Plus should not be read as an endorsement for a two-tier health system, but that it is time to examine the nature of the public versus private health care debate. Indeed it is. Will their recommendations make Medicare better? The evidence says no.

Currently, Canadian regulations prevent doctors who are paid by public Medicare from also providing medically necessary care for private payment. But, doctors can "opt out" of the public system and "go private" (except in Ontario, which as a result of a recent change goes even further and does not allow doctors to "opt out"). Why do we have this regulation? Because if we didn't, doctors would naturally want to spend much more of their time than they presently do treating private patients - as these patients often have easier conditions to treat and they (or their insurer) will pay more. A doctor, like any normal person, will be attracted to working for more and doing less - who can blame them! So it is not surprising that some members of the CMA like the idea of Medicare Plus; but from the public's perspective, and from the perspective of most patients, it's a bad idea. If you are a patient wealthy enough to be able to pay privately or you have private health insurance, then you may fare better under Medicare Plus. But lines for treatment in the public hospitals will grow longer and longer.

The CMA's recommendation also ignores the simple fact that, in the absence of an increase in the number of doctors (where will we get them from?), the introduction of a parallel private system must mean that the doctors we do have will be distributed between public patients and private patients. Private patients will pay more to have their medical needs met on a preferential basis, leaving public patients on ever growing wait lists. Evidence suggests that allowing doctors to practice in both the public and private sectors will not, as Medicare Plus states, "improve access to services for the entire population."

Other countries that allow doctors to work on an unregulated basis in the public and private sectors - like New Zealand, the UK, and Ireland - currently have, or have had in the past, chronic problems with long wait lists. The evidence doesn't seem to indicate that having parallel public and private health insurance or "Medicare Plus" has been the cure for wait lists in these countries! Where wait lists have been wrestled down - for example, as in the UK - it has been through a huge infusion of public money, improvements in the management of public hospitals, and better management of wait lists. The cure has not come from more private money or private insurance.

Other countries in Europe - such as France - that appear to have a large private sector actually heavily regulate doctors who work privately - including the price they can charge and the number of doctors who are allowed to charge more than the government-set tariff. So what looks on the surface to be "private" is not really: it's quasi-public because of such heavy regulation.

So we could follow the European route - and heavily regulate doctors who "go private" - or we can stick with the cleaner and simpler approach of requiring doctors who are paid by Medicare (public insurance) to only be paid by Medicare but still allowing doctors to "go private" if they are prepared to work completely within the private payment sector. But we still have to recognize that even with European-style regulation we would be embracing the idea that it's fine for folks with more money to jump queues and to pay more money to get preferential treatment from doctors. This is in direct opposition to the principle of equity that has historically guided the Canadian Medicare system, which was created in part to eliminate distinctions between the rich and poor in access to medically necessary health care

Canada's health care system needs reform - but reform based on the best available evidence and guided by Canadian values. For example, on the issue of wait times and access to care, the Canadian Institutes of Health Research's Institute of Health Services and Policy Research contributed to the evidence base by funding research in this area. This research helped establish the first-ever national benchmarks for wait times in December 2005. CIHR-IHSPR is committed to providing evidence-based solutions that will improve the health care system. The CMA's call for an expansion of the private sector will benefit some, but it will come at the expense of the majority of Canadians. Let us not make the mistake of misusing the wealth of evidence that strongly supports a public health care system like Canadian Medicare.

Dr. Colleen Flood is the Scientific Director of the CIHR-Institute of Health Services and Policy Research