Report back: Sticking Up for Public Health Care Townhall

Dr. Saad Ahmed, a board member of Canadian Doctors for Medicare, framed the townhall in the context of a broader national debate about the role of private health care. 

As privatization schemes are rolled out in Canadian provinces like Quebec, Ontario, and Alberta, the Canadian Medical Association has embarked on a national consultation process to revise its position on private health care. The consultation process includes sponsoring a series of town halls hosted by the Globe and Mail, including an event in Vancouver on November 23rd. 

According to Dr. Ahmed, framing a consultation as seeking the right balance of public and private health care is mistaken and an attempt to normalize profit-driven private services in our health care system. Further, it ignores the large body of evidence both domestically and internationally that clearly shows privatization does not work.

Australia introduced two-tiered health care in 1997 in an attempt to improve wait times for the public system. It actually made wait times worse in the public system. The United Kingdom introduced investor-owned private surgery centres in the early 2000s to likewise cut wait times. Instead, itt led to worse mortality and morbidity in the public system. Ontario has had non-profit and for-profit long term care homes for decades now. A study in the CMA’s own medical journal showed investor-owned for profit long-term care homes having double the rate of mortality during COVID-19 than non-profit ones.

When people hear the phrase “private health care”, they most often think of the kind of privately financed health care that exists in the United States, where patients are commonly forced to pay for health care with a credit card or private insurance plan. Canadians experience this form of private care when paying for prescription medication, physiotherapy, or mental health care. 

But another, more subtle form of privatized health care is more common in Canada: publicly funded and privately delivered care and services. 

“The cost of profit-driven care” panel explored the rise of corporate profits as seen in the predominantly private pharmaceutical market, the publicly contracted private long-term care sector, and in primary care. Each of these sectors are strong cautionary tales of what we risk when profit-driven health care is involved.

Big Pharma: private health care spirals out of control 

Nikolas Barry-Shaw, who is the trade and privatization campaigner for the Council of Canadians, shared powerful examples of the lack of equitable access to health that exists due to the lack of a universal public drug insurance plan. From people making choices between groceries and filling prescriptions to drugs that can cost up to $100,000 per year, medications are becoming less and less affordable. 

The root of this unaffordability can be traced to the power of the pharmaceutical lobby, which benefits from a fragmented and highly privatized sector that leaves buyers with no bargaining power. Barry-Shaw spoke of the opportunity for the Federal government to legislate a framework for a universal public pharmacare plan and shared stories of how people across the country are meeting with their MPs to demand change. 

Canada is the only country in the world with a universal health insurance program that does not include prescription medication. While expanding Medicare to include pharmacare was part of the initial vision for Canadian health care, failure to do so has led to a powerful profit-driven private industry that undermines our public health care system. Examining our pharmaceutical sector provides a clear cautionary tale against allowing profit-driven corporations to set the terms in health care. 

Long-term care: publicly funded private profits

Profit-extraction is a priority of corporate providers even when the care they provide is contracted by and paid for by the government. Leslie Gaudette, President of the Council of Senior Citizens Organizations of BC, described how this has been the trend in the contracted private long-term care sector in BC. 

Gaudette shared the results of a recent report by the BC Seniors Advocate, Isobel Mackenzie. The Billions More Reasons to Care report looked at revenue and expenditure reporting by contracted long-term care operators and found that for-profit operators increased their profits by 113% over five years, while under-delivering over half a million of direct care hours they were publicly funded to provide. 

Gaudette dug a bit deeper into the ways that public taxpayer dollars are subsidizing corporate profits. Looking at the public payments private operators receive for building costs, she explained that the province is paying for buildings that ultimately belong to the private partner. She contrasted this with the way road infrastructure functions. While private contractors may be hired to build roads, the infrastructure ultimately belongs to the province. So why do long-term care facilities that are paid for by the province become real estate assets for investor-driven companies? 

These are the kinds of extra costs to the public that come with contracting out care to profit-driven companies. 

Primary care: the rise of corporate providers

Dr. Lindsay Hedden, Assistant Professor of Health Services Research in the Faculty of Health Sciences at Simon Fraser University, has been researching the rise of investor-owned, for-profit corporate delivery of primary care in Canada as well as its implications for our public health care system. 

Large investor-driven companies such as Telus Health, Walmart (Jack Nathan clinics), and Loblaw (Primacy Management), among other large private and publicly traded corporations, have acquired a growing number of primary care clinics and virtual care platforms. According to Dr. Hedden, these companies are quickly becoming more entrenched in our health care system, making themselves indispensable, and developing formal partnerships with provincial governments. 

Dr. Hedden unpacked some of the major implications that come with this shift to corporate delivery of primary care. First, profit-driven companies tend to push the legal boundaries of what’s permitted under provincial and national health legislation to extract profit from either patients or the public purse. This was the case with the Telus Health LifePlus plan. A 2023 audit by B.C.’s Medical Services Commission found that Telus was charging patients in the plan a subscription fee for services covered under MSP such as access to a family doctor. While this tendency can be monitored and regulated, this additional layer of public accountability is a significant burden to the public system and it’s important to consider whether our public institutions are equipped to adequately monitor corporate behaviour on an ongoing basis. 

According to Dr. Hedden, corporations delivering health care also tend to maximize profits through increasing patient volume with an overuse of profitable services that have low value for care. For example, episodic virtual care is a big draw for corporations as a high volume of patients can be seen but they often end up referred to emergency rooms, adding extra visits and costs to a patients’ journey. Corporate employers may also influence physicians to encourage them to upsell private pay services that have little clinical value. 

These changes are happening rapidly and for the most part flying under the radar. Most Canadians don’t understand the large structural transformation that is happening and its implications for health care. Dr. Hedden’s fear is that once the impacts become clear, we won’t be able to put the toothpaste back in the tube. 

With a health care system under pressure often comes calls to turn to the private sector to “fill-the-gaps”. This false narrative both ignores the evidence that shows how privatization deepens the gaps in the system by putting additional strain on the public system providers. It also distracts from having conversations about evidence-based solutions that can make a real difference within the public system. 

The second panel explored some of the solutions that have been slow to implement but could make the greatest difference in terms of access to primary health care and addressing the worker shortages in all health care professions. 

Investing in primary care infrastructure

Dr. Rita McCracken, a family doctor and Assistant Professor in the Department of Family Practice at the University of British Columbia, addressed the roots of our current primary health care access problems. While often framed as a “family doctor shortage”, with one in five Canadians not having access to a primary care provider, Dr. McCracken reminded us that BC currently has more family doctors per capita than ever before. 

According to Dr. McCracken, the real issue isn’t a lack of family doctors but a lack of publicly funded primary care infrastructure. Her research has shown that almost half of family doctors surveyed within Vancouver Coastal Health region said they would prefer to be an employee of a clinic rather than a small business owner. They prefer to be an employee as it would allow them to work in teams, have a stable income, be able to take vacation, and go on parental leave. However, the way that primary care delivery is currently organized does not provide these options for practice. 

An alternative model would be to structure primary health care delivery in a similar way to the public education system. With this approach, residents would fall under a catchment area and have access to their local publicly funded community health centre. In a community health centre, family doctors would be salaried employees that benefit from working with an interdisciplinary team of allied health professionals, an approach that has been shown to improve work satisfaction and reduce burnout. 

Dr. McCracken acknowledged that physicians are most often the only partners invited to help solve issues with primary care access,  but equally important is inviting other voices at decision making tables including allied health professions and patient and community representation. 

You deserve a team: engaging the full team of allied-health professionals

Dr. Kelvin Bei, a Nurse Practitioner at RISE Community Health Centre, shared his experiences working with an interdisciplinary team. He shared stories of working closely with pharmacists to bring a patient at risk of hospitalization back to a stable state or working with a counsellor to support a youth contemplating suicide. He talked about how rewarding it is to work with a team that can address a patient’s holistic needs. He noted that no amount of money could prevent burnout as effectively as the feeling that you are making a difference. 

When asked about the barriers to expanding this model, Dr. Bei reiterated that allied health professionals have long been excluded from decision-making tables. Doctors still act as gatekeepers who must be convinced to direct primary care funding towards team based care. These decision-making structures will need to shift to see any significant change. In order to get to team-based care, we need team-based governance. 

The quality of work is the quality of care

Building on the discussion about the kind of work conditions andenvironment that will help address the worker shortage across our health care system, Ronnie Nicolarosa, Director of Membership Services at the Hospital Employees Union, talked about the difference a good public sector job can make in the lives of frontline workers. 

Nicolarosa was a hospital laundry worker in the early 2000s when the BC Liberals brought in Bills 29 and 94. He shared the devastating impact this legislation had on him and his coworkers, some of which were laid off overnight and offered back the same jobs at half the pay. As a result, he saw colleagues work multiple jobs to make ends meet while struggling to find time to see their families. 

In August 2021, the Government of British Columbia announced that, after almost 20 years, they were bringing thousands of support service workers who were previously contracted out to private companies back to the public sector. Nicolarosa has been working to support this repatriation effort and sees the difference it makes in workers’ lives when they can rely on stable work. 

Workers in stable public jobs are more likely not to cut corners or feel rushed as a result of understaffing. Nicolarosa sees how these better conditions of work directly impacts the quality of care. For example, he shared a story of a contracting company cutting corners with deep cleaning following a patient with an infectious disease. Rather than adequately staffing a shift to ensure hospital cleaners have time to properly disinfect rooms, private employers were caught removing notices that let cleaners know to follow appropriate cleaning protocols. 

While bringing these workers back into the public sector is an important step, more needs to be done to ensure our health care system has the workers it needs. Nicolarosa shared that the Hospital Employees Union recently released results from a poll that showed that almost half of care aides, who deliver the majority of direct care in long-term care and other care settings,  plan to leave the sector. It’s never been more urgent to ensure our health care system offers high quality, attractive jobs to recruit and keep the workforce we need.