Anthony Sanfilippo is a cardiologist, a professor of medicine and a former associate dean at Queen’s University. He is the author of The Doctors We Need: Imagining a New Path for Physician Recruitment, Training, and Support.
Two major forces are currently wreaking havoc within our health care system. One is obvious and very much in the public consciousness: the shortage of family doctors. Most recent estimates set the number of affected Canadians at 6.5 million, or about one in six. Much has been written about the detrimental effect that has on individuals and communities. All provincial governments and political parties have vowed to address the problem. Elections are being contested with this issue at the forefront.
The other force – less discussed, but no less relevant – is economic duress.
For those without a family doctor, or for those with one but wishing to access care more quickly, various options have popped up that provide the ability to purchase a wide variety of medical services, ranging from remote consultations and prescription refills, to complex surgical procedures. Once rare, maligned and somewhat clandestine, these pay-for-care options are widespread, overt and openly promoted as alternatives to the beleaguered public system.
They’re alternatives, of course, only for those who can afford them. The rising use of food banks and expanding presence of homelessness in our communities bear vivid witness to the inflation-fuelled financial constraints experienced by many struggling to meet even basic needs. For them, such health care “alternatives” are truly beyond reach.
All this leaves us with is, in effect, a four-tiered health care system, defined by the intersection of family-doctor availability and financial resources.
Those fortunate enough to have a family doctor and sufficient unencumbered finances have options. They can, if they deem it medically necessary or simply wish to avoid long wait times, access alternative diagnostic services or procedures, often outside their home provinces – which, paradoxically, may limit such options for their own residents while permitting them for non-residents. This can range from crossing the border to get a scan next week rather than next year, to travelling out of province or even out of country to a well-staffed and well-appointed clinic where that joint replacement or cataract surgery can be provided much sooner. Importantly, this phenomenon isn’t limited to the extravagantly wealthy; it more commonly involves individuals with modest savings who prioritize investing in their quality of life – be it improved mobility, enhanced vision, or relief from chronic pain – over other potential uses of their funds.
Those with financial means but without a family doctor can compensate for that deficiency by purchasing some or all of the services that a family physician would normally provide through various agencies, online services or private providers. These have existed for some time in limited roles but are now expanding to meet what is, in effect, an emerging market.
Those with a family doctor but constrained financial resources will be limited to the diagnostic and treatment pathways their physician can navigate within the public health care system, effectively precluding the expedited or alternative medical options accessible to more affluent patients.
The most unfortunate are those experiencing the double whammy of no family doctor and scarce financial resources. These folks have neither access nor alternative options. These individuals, undoubtedly, endure significant hardship and anxiety as they struggle to secure health care for themselves and their loved ones, all while grappling with the looming fear of potential health deterioration and its consequences.
And so, four tiers. Unacknowledged, to be sure, but real nonetheless.
All this certainly speaks to the need to continue in our much-publicized efforts to mitigate the problem and ensure that, as a minimum, everyone has a family doctor and fundamental access to care.
But what about the under-the-counter economic turbocharging of health care? Is it a problem? Are we okay with simply looking the other way as it grows?
It’s been argued that such alternatives drain resources (mainly care providers – nurses, doctors, therapists) from the public sector. Recently, the Quebec government announced plans to pass legislation that would levy heavy fines on provincially trained doctors who elect to practice outside the public system, making the point that the province had invested heavily in their training and deserved some service in return.
Conversely, proponents argue that allowing such alternative, privately funded care pathways can help retain health care providers in their province of training by offering expanded practice opportunities and increased earning potential, while simultaneously alleviating pressure on the publicly funded health care system.
What is indisputable is that the promise of universal, public funding of all possible medical care is becoming increasingly unaffordable and is encroaching on other much-needed obligations such as infrastructure, education, housing and the environment – all of which, by the way, are also important determinants of health. As options for medical diagnoses and therapies expand, pressure on the single-payer, universal-care model will only intensify.
It’s also true that these alternative pathways to care are unlikely to go away. In fact, simple market forces of demand will assure their growth, with or without explicit approval.
And so, what to do? Positions on this contentious issue are becoming increasingly polarized, and perhaps hampered by the assumption that an all-or-nothing solution is the only acceptable kind.
The key question is whether these market-driven alternatives for personal health care can be thoughtfully integrated with the public system, augmenting services while assuring no one is left without access to all aspects of care, including acute, chronic, and preventive. At present, we’re not looking at solutions that reconcile both perspectives. We’re not studying jurisdictions where the two systems seem to work harmoniously with the result that better outcomes are achieved with lower public cost. We’re choosing, rather, to ignore the reality that this is happening organically, without deliberate intent.
One blessing beckons: the intensifying supply and demand for new ideas in health care. The demand for dialogue and consensus on reform is evident, as Canadians increasingly recognize the need for innovative solutions. Meanwhile, the supply of ideas and the willingness to collaborate are abundant among health care professionals, policy-makers, and citizens alike.
Do we care to confront our four-tiered reality, or accept all this as the inevitable, but politically unspoken, evolution of specialized care? Will we continue to avoid dealing with the system’s fundamental problems by using short-term, case-by-case interventions?
In the meantime, it’s four tiers and counting.
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