Paying for pain

Cal Gutkin

It is happening with almost frightening regularity across the country. Services covered under our single-payer, publicly funded system are being realigned, and as a result patients are experiencing decreased access and often a need for private payment. Physiotherapy, mental health care, audiology, speech pathology, and pain clinics are among services being reduced or eliminated from the publicly funded menu. When added to other items such as prescription medications, dental care, psychology services, home and long-term care, and ambulances, which have never been fully funded under Canada’s Medicare program, the proportion of necessary health care services that are not readily accessible to patients continues to rise.

For years, Canadians have been paying privately for more than 30% of their medical and health care needs. Most have not realized this, believing that Medicare covers everything—or at least that Canada’s Medicare system covers more for them than other countries do for their citizens. Both of the above beliefs are myths, but the details embedded within these myths are usually not openly discussed. While most of the headlines and heated political debates about the potential erosion of our publicly funded system are focused on physician services, hiding deceptively behind the scenes is the reality that it is not physicians but governments that are shifting health care services into the private domain.

A recent example was the announcement in Ontario of government funding limits resulting in cutbacks to several important hospital-based services, including pain clinics. A government spokesperson defended these moves as only affecting services that are not “‘core’ to acute care hospitals,” with assurances that these programs are being closed “only after determining that the same services are available in the community.”1

Community availability might, however, be a convenient figment of governments’ collective imagination. Health care analyst Dr Michael Rachlis indicated that, while community settings are probably more appropriate than acute care hospitals for delivering some of these services, there is little evidence to support the government’s assurances that these replacement services exist. Dr Roman Jovey, Past President of the Canadian Pain Society, said, “Pain management is already such a poorly serviced health care domain in Ontario [that] we can ill afford to lose any pain clinics.”1

These changes also mean many programs will no longer be covered by public funds. The Ontario Health Coalition noted that issues of equity are arising, with many now unable to afford a growing number of services. Hospital and government representatives responded by reminding us that they are “really up against it” as they try to balance the limits of public funding with the need to serve communities.1

Are we running out of creative solutions to our Canadian conundrum? Will new practice models, including those in primary care, achieve the cost efficiencies needed to sustain our single-payer, publicly funded system? Or have our governments decided that the only way they can now manage the financial challenge they face is by moving as many services as possible from the public to the private purse?

Canada’s Medicare program covers 100% of medically necessary doctor and hospital services, but only a small percentage of many others, resulting in less than 70% of all health care services being covered by public funding. Is our 70:30 mix of public-private funding really better than the approach of countries that publicly cover up to 90% of all services, including those of doctors and hospitals? By not encouraging open debate about options, are we just denying ourselves the opportunity to define a better quality and more cost-manageable solution to meet the needs of our population? Why does the extreme concern about the threat to our publicly funded system seem to disappear when governments themselves create shifts from public to private funding for vital services in areas like mental health, speech therapy, or pain management? Should we not be challenging the commitment of those responsible for these decisions, who are often the same public officials who proclaim themselves to be the saviors of Medicare? Are these individuals not saying one thing and doing another? Are they not stabbing our publicly funded system in the back?

Governments are battling an economic recession and must stretch limited dollars to cover needed services not only in health but also in education, social services, defense, and our nation’s infrastructure. Canadians are in pain over threats to the future of our most treasured national program—Medicare. It is time for an open and honest discussion of how we can not only preserve but also bring essential changes to Medicare to ensure coverage of more rather than fewer programs leading to better health outcomes in an equitable and affordable system for all. The people of Canada need to be given a chance to participate in this discussion as part of a national pain management program.