AMA Journal of Ethics^®

On June 9, 2005, the Supreme Court of Canada struck down a Quebec law that banned the use of private insurance for publicly insured health services covered under that province's universal health care system, Medicare.¹ The goal of the long-standing ban was to prevent those who could afford it from "jumping the line," and paying for faster service with private insurance rather than waiting their turn for Medicare treatment, as those with less money must do. The historic ruling threatens to alter the country's determined resistance to a 2-tiered system of payment for medical services.

The following comments, based on a discussion with Canadian Medical Association president, Albert J. Schumacher, MD, and a written statement from physicians Sylvia R. Cruess, MD, and Richard L. Cruess, MD, provide some background for the landmark Court decision and some thoughts on its implications for the country's universal health care system.

In a joint statement to the press, the Canadian Medical Association (CMA) and the Canadian Orthopaedic Association expressed concurrence with the fundamental position of the Court's decision that Canadians have the right to timely access to health services.² Quoting from that statement, CMA president Albert J. Schumacher, MD, said that the Court's decision "represents a stinging indictment of the failure of the governments [federal and provincial] to respond to the mountains of studies and years of research" with any real improvements in the system.² Wait times have become so long as to amount to rationing, Schumacher said, adding that patients have died on the wait list.

The Canada Health Act, passed by Parliament in 1984, established universal and mandatory coverage for all citizens and forbade Canadian physicians to accept private funds for medically necessary services. The act listed 5 criteria for the national health care system:

1. Public administration – by a nonprofit public authority appointed by the government of the province;
2. Comprehensiveness – coverage of all services provided by hospitals, medical practitioners, or dentists and, where the law of the province permits, similar or additional services rendered by other health care practitioners;
3. Universality – plan services available to 100 percent of the insured persons of the province;
4. Portability – residency requirement or waiting period of no more than 3 months before residents of a province are eligible for services;
5. Accessibility – provision of services on a uniform basis that does not impede or preclude access through financial or other barriers.

Dr. Schumacher said the Supreme Court decision could have the effect of adding "timely access" as a sixth criterion for the Canadian health plan.³

The CMA and 6 national specialty associations established a Wait Time Alliance to work on timely access to care for Canadian citizens long before the Supreme Court ruling.⁴ The goal of the Wait Time Alliance, which released an interim report on April 3, 2005,⁵ is to determine evidence-based benchmarks for acceptable wait times in 5 areas of medical need—diagnostic imaging (CT scans, MRIs and nuclear medicine), hip and knee replacement surgery, radiation therapy, cataract surgery, and cardiac care. Procedures in these areas of medical need are classified into 3 levels of priority—emergency, urgent/semi-urgent, and routine—with medically appropriate wait times stipulated for each level of priority. The final report of the Wait Time Alliance is due out by the end of summer.

Despite claims by the media and some politicians that the Court's ruling could signal the collapse of universal health care in Canada, Dr. Schumacher doubts that it will open floodgates to a private insurance industry. At most, the decision cracks the door for those instances in which wait time is tantamount to rationing of a needed service. Dr. Schumacher predicts that Canada may migrate, as some European countries have done, toward the existence of a small private health care market that represents a single-digit percentage of the much larger government system.