Monday, April 13, 2009

What do Quebec and Australia have in common? Not much, yet

On March 30, reported that “No one wants Quebec’s limited private health insurance.” The small story said that wait times for the procedures that commercial insurers are permitted to cover—hip, knee, and cataract surgeries—have fallen by six months since the enabling legislation, Bill 33, passed in 2006 consequent to the Chaoulli decision. The shorter waits combined with the expense of the policies killed their market.

An attempt to find coverage of this elsewhere yielded nothing, even in the French media. What prompted to publish the story when it did is unclear, but despite the lack of interest in the media at large, it has important implications.

Quebeckers rejected this insurance because they don’t need it. They were understandably unhappy with the long waits for elective surgeries in the early 2000s, but the situation has changed. Of course, some of these procedures are now outsourced to for-profit clinics, but the funding is public. If public funding can provide adequate care, private funding is superfluous.

Australia provides an instructive contrast. In 1984, universal health care was enacted. Before then, commercial insurance was necessary for most Australians, but in that year, they began to abandon for-profit coverage because their needs were met by the public health-care system. They saw no need to buy duplicative insurance to gain access to private hospitals. The government, however, was determined to maintain a role for commercialized care, and in the late 1990s, it began enacting measures to subsidize private insurance and encourage people to buy it.

Only heroic, expensive government measures kept the private system afloat in Australia, which is the antithesis of the free market. Meanwhile, the publicly funded system has been in slow decline, which also increases demand for commercial alternatives. This incoherent policy and the fragmented two-tier approach have created what one Australian commentator called “a mess, rather than a system.”

So if the Chaoulli decision in Quebec resulted in a situation in which private insurance is unnecessary, why is Brian Day suing the province of British Columbia to enact its own Bill 33? Does he think residents of BC are that much more eager to buy expensive insurance than Quebeckers? Of course they aren’t.

The lessons from Quebec and Australia are clear: commercial health insurance competes poorly with a single-payer scheme unless publicly funded care is deficient, privately funded care is perceived as superior, and commercial insurance is heavily subsidized. Proponents of a universal, equitable health care system have to be on guard for efforts by commercial players to degrade public care and shift tax dollars toward their enterprises.

Randall F. White, MD