Melvin J. Howard’s determination vs Canada’s ambivalence

In their evident ambivalence about a publicly funded, semi-privately delivered health care system, Canadians and their politicians have given an opening to a manic businessman. Arizona health care entrepreneur Melvin J. Howard, who has alerted the world to his bipolar disorder on his Web site, is portraying himself as an underdog in the effort to establish commercial clinics in Canada. He vows to continue his fight “no matter what obstacles get in [my] way.”

In May 2008, Howard wrote on his blog that he would file an investor’s complaint under the North American Free Trade Agreement (NAFTA) because “municipalities or city officials can and have put up numerous roadblocks such as zoning and by law requirements” that prevented his company from establishing a clinic in British Columbia. He cites recent developments in Canada, such as the Supreme Court’s Chaoulli decision and legislation in Alberta, as evidence that the time is ripe for private health care investment in Canada. Who can blame him? The government of BC has all but cheered on the establishment of commercial clinics and for-profit surgical centres

Howard, however, is not content with using the leverage granted investors by NAFTA. In his September 20th blog posting, he wrote, “I am calling on the WTO [World Trade Organization] to wade in on our trade dispute with Canada. In arguing to keep health care off the table Canada claims to have exemptions on their public health care system. At the same time they demand the right to export their own health care services and not allowing any imports; is that sending a message of double standard? I think so.”

Howard is referring to the fact that Canada has included commercial health insurance in its commitment under the General Agreement on Trade in Services (GATS). Canadian multinational insurance corporations have access to foreign health care markets, but foreign insurers are excluded from insuring medically necessary services in Canada. He also points to the existing privatized aspects of the Canadian system including home care and long-term care, laboratory services, and dental care.

As some commentators have pointed out, including Luke Eric Peterson, who broke the story in Embassy newsweekly, Melvin J. Howard’s Centurion is not a huge U.S. health care corporation like Aetna or Tenet. But he’s surely not the only investor who has watched the hypocrisy and complacency unfolding in Canada. The result is murky and confused policy, which may be the intended effect. The province and the country are in the grip of politicians who believe that markets provide solutions; public administrators and governments are impediments, or at best, conduits for the flow of tax payer money to private enterprise.

Nearly every Canadian who advocates for more commercialization of health care also proclaims opposition to a U.S.-style system. U.S. entrepreneurs and investors backed by NAFTA and GATS, however, have no aim other than making money; why should they change their business to accommodate "Canadian values"? Canadians may not be able to have it both ways, and Melvin J. Howard seems to have a personal mission to teach Canada a lesson.

Montreal, Canada's commercial health care capital

In an opinion editorial published in the Toronto Star on September 3 http://www.thestar.com/comment/article/489323, Dr Robert Ouellet, president of the Canadian Medical Association, advances the idea that Canada can develop a European-style health care system with a public-private blend. This fallacy is promoted by politicians and pundits who are enamored of markets as the solution to our problems. But Canada is not in Europe, does not have a European-style social welfare establishment, and is party to a trade treaty with the United States. Once health care becomes a commodity in Canada, U.S. corporations will demand entry under NAFTA and the future of our health care system will be out of our hands, despite Dr. Ouellet's soothing rhetoric.

While it's frustrating for physicians to face an unresponsive bureaucracy, Quebec provides a cautionary tale of what may happen when entrepreneurs take matters into their own hands. Quebec radiologists established imaging clinics independent of the health care system, albeit with the province’s knowledge. The government then let itself off the hook for certain outpatient diagnostic exams, and these medically necessary procedures were delisted (which is illegal under the Canada Health Act). Patients now must pay out of pocket for these tests, and many buy commercial insurance "just in case."

Because markets and investors demand constant growth, established commercial clinics and health insurance will seek to expand into other areas. Dr. Ouellet is a manifestation of this—he is using his influence as the president of the Canadian Medical Association to advocate for more commercialization of health care.

Meanwhile, weeks after neurosurgeon Dr. Phillippe Couillard resigned as the Quebec minister of health, Persistence Capital Partners announced that he had accepted a position as partner. The Montreal firm is, according to its August 18 press release, “Canada’s first private equity fund dedicated to investing in healthcare businesses.”

When publicly questioned about the implications of his hopping from operating room to provincial cabinet to private investment firm, Couillard said, "It's perfectly in line with what I've been advocating for years - a strong public system, well-funded and well-organized." http://www.canada.com/montrealgazette/news/story.html?id=160dd9e1-5407-427e-86e3-6c3d55788825 As his legacy to the well-funded, strong public system, Couillard handed health care investors a gift in Bill 33, which promotes outsourcing to private clinics as a solution to excessive surgical wait times.

Both of these doctors insist that their efforts to commodify medicine demonstrate their devotion to public health care. Some physicians find this disingenuous. Medecins Quebecois pour le regime public issued their response to health care commercialization in Quebec during the August 2008 annual meeting of the CMA in Montreal http://www.medecinspourlacces.ca/position10.php Quebec may be different, but when it comes to health care opportunism in Canada, it is unfortunately not unique.

Randall White, M.D. FRCPC