Public healthcare is a national crisis. So why isn't it an election priority?
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Fresh for everyone. Aplican restricciones en combustible. This is a CBC Podcast. I'm Dr. Brian Goldman. This is White Coat Blackheart. The federal election campaign is being framed as a contest to see which party is best able to deal with tariffs and threats of annexation. We think the future of publicly funded family medicine is also a worthy election issue.

Millions of Canadians don't have a family doctor or nurse practitioner, and so they line up for limited appointments at urgent care clinics or wait hours and hours in the ER.

In Quebec, there's another option. As you heard on our show a few months back, in that province, you can make a same-day appointment with a family physician like Dr. Martin Potter. He charges $150 for 15 minutes of his time at the private pay clinic he owns and operates in Vaudreuil, just outside of Montreal.

A lot of patients are very happy to be seen in a timely manner and they're willing to pay because some of them, the only alternative would be to go to the ER and the waiting time is very long. So instead of losing a whole day's pay, yeah, most people are very happy about this option. Is

Is there any going back to the public system for you? Not with the conditions that we are working under now. I don't envision going back into the public unless the government prevents it.

Now, last year, the Quebec government tabled a bill to force physicians to practice in the public system for at least five years after graduating. More recently, it proposed amendments to make it harder for physicians already in practice to go private. But meanwhile, patients like Marlene Harper are all in. She says she's dipped into her retirement savings to pay for private family doctors, and so has her husband. How much is he paying? So a good $1,800. Wow.

Yeah, it is a big amount. But I mean, if it sits in the bank and he's not there anymore, well, that $1,800 is not going to serve us much. No, is it? Did you pay taxes? I understand. You're going to ask me if I'm upset. Of course I'm upset, you know, but my health comes first. When our two shows on private pay family doctors aired last fall, we got a lot of strong reactions, which are even more relevant today, thanks to the federal election.

An online survey of roughly 2,000 Canadians 18 years and older done by Nanos Research for the College of Family Physicians of Canada found that four out of every five surveyed say access to family doctors will be an important factor in how they plan on voting.

Joining me to talk about that and other things is our own Jennifer Warren, who produced both of those shows. Hi, Jen. Hi, Brian. How are you? I'm just fine, and I'm just raring to talk about this with you. We heard, as all of us heard a few moments ago, from Marlene Harper, a patient about private pay family medicine in Quebec.

the matter-of-fact way she and other patients talked about it kind of astonished me. You know, like, this is just what you do in Quebec if you don't want to miss a day of work and avoid a long stay in the ER. What was your reaction? Yeah, I loved your reaction to that initial reporting we did where you said their matter-of-fact attitude frankly astonishes me. You know, I lived in Quebec for almost two decades, right? So I left in 2017, and when I left...

private pay family medicine had already started kind of creeping into the mainstream at that point. I had friends who were paying out of pocket because they had no choice. It took about five months for me to get an appointment with my own family doctor in the public system. So it wasn't new back then? No, it wasn't new, but it wasn't as far along the road as what we're seeing now, right? And I think that's why I wanted to go to Quebec. So

The topic wasn't surprising to me, but I did wonder what our listeners would think. You know, would they shoot the messenger and be mad at us for shining a light on the doctors and the patients who are charging and paying out of pocket for primary care? So what did you hear? Listeners were not angry at us. And in fact, some of our listeners were astonished by your astonishment. Oh, yeah.

I want to start with Beth J. from Half Moon Bay, BC. So she's talking here about access to a specialist, but healthcare is healthcare. And here's what she wrote. From personal experience, when you're desperate, you'll pay. Gladly. Currently, I have an ankle injury. The wait time for the consult is currently 16 to 18 months. What are my options in the private system?

I can have a consult with an out-of-province surgeon for $500 within a week or two. And if surgery is warranted, the time frame is not much longer than that. I can afford it, so the choice seems clear. What does money matter if I can't walk?

And of course, Brian, like that reminds me so much of what Marlene Harper said when you met her, right? Yeah, it's clear that there's a much higher level of resignation that this may be where we're heading even more than I expected. We also heard from Douglas Guptill in Dartmouth, Nova Scotia.

And he said, I believe you said you were surprised that people would pay out of pocket to see a family doctor. Surprised? I would pay $150 for 15 minutes, maybe even double that for quality health care. As one of your interviewees said, the money is no good to us when we're in our grave. I've been on a wait list to see a specialist since fall 2020. I expect to die on that waiting list. Would I pay money to see that specialist again?

Of course. Wow. I reached out to him. He's waiting to see a rheumatologist. Still hasn't seen that person. You know, Jen, one thing I'll say about this. These are still early days in people. And I would suggest that the Canadians who are opting for private homes

are dabbling. And I wonder what it's going to be like for them when the dabbling stops and they realize they've been doing this for the last 10 years and they're going bankrupt. Yeah. And it becomes a way of life, right? Yeah. Yeah. So we also heard from Quebecers who don't want to go private, but they're not exactly being rewarded for supporting the public system. Like Karen Wyatt of Gatineau, who wrote, I am a Quebec resident who chooses not to use private medicine.

My daughters and I have a family doctor, but she took us on when our doctor retired, even with a full roster of patients. Recently, we tried to make an appointment to see her about a physiological issue for my daughter, and it was impossible to get an appointment.

When our doctor retired in January 2023, she told me no one wants to do family medicine. Yeah, and I would say that that's what I hear from family doctors. It used to be that you could sell a practice to somebody else. Now you can't give them away. You couldn't pay enough money for people to take on your panel of patients, which is certainly sobering if you're a Canadian listening to this.

Now, I will say it's a bit of an exaggeration to say that no one wants to do family medicine. Some of them will do it, are willing to do it. The new grads are willing to do it part time. So they don't want to do it, perhaps, as their parents or grandparents might have done it. But

Certainly, Karen White is on to something. In some parts of Canada, fewer med school grads have been choosing residencies in family medicine. The ones who do have been hearing about the problems facing family doctors in practice, among them low pay and onerous administrative paperwork, which we've talked about a lot on White Coat Black Art. The federal government estimates that by the year 2031, Canada will be short nearly 20,000 family doctors.

which means the burden on ERs will continue and may get a lot worse. We also received an email from a newly practicing emergency physician in Ontario. We're not sharing his name as he works in a small community and doesn't want to be penalized for his viewpoint. Here's what he had to say.

I don't know if $150 for 15 minutes is a fair price, yet I also know that it may save an emergency department visit that allows me to better treat the patients most in need of emergency care.

while putting an extra cost on the individual. $150 is also a fraction of the cost for that patient to register and be seen in the emergency department. Now, Jen, I know you've got something you want to say about that, but I just want to make a quick aside. We're not blaming people who don't have a family doctor or who don't have timely access for going to the emergency department.

The problem is that if they had a, you know, the solution is if they had a better place to go, they would go. I just want to make that really clear. For sure. And I think that that's important for us to say. We're not blaming anyone for the choices that they have to make within this broken system. And when we did our reporting on this, we talked to Dr. Bernard Ho.

He's the vice chair of Canadian Doctors for Medicare, and he's also a family and ER physician himself. I want to replay part of what he had to say, because it's relevant to what that ER physician whose email you just quoted from had to say. We know that the private sector siphons resources from the public sector when a

physician opens up a private clinic, they take with them staff from the public system, you know, one less nurse, one less healthcare provider in the public system. We already have a significant staffing shortage across the country in emergency departments and clinics. And so we continue to siphon resources from the public system. We're just going to worsen wait times to see a family doctor, to see an emergency specialist, to see a surgical specialist. And

And that will continue to worsen as we siphon those resources into the private sector. And, and Jen, I want to, I want to echo what Dr. Bernard Ho, by the way, he, he and I are, are, are colleagues. We work in the same emergency department, but so I, I know him, but,

The other point in echoing what he's saying, we're drawing from the same limited pool of human health care resources, physicians, scrub nurses and all the other staff who are involved. So if we're having trouble attracting enough, if we don't have enough resources,

healthcare providers now, then creating a parallel private system will only exacerbate that problem. Right. And the patients who would end up in the public system typically have more complex health needs, which is something you see yourself, right? Yeah, all the time. So, Brian, you know this. A lot of healthcare workers listen to our show. Who'd have thunk it? Here is a voice memo we received from Jenny Foxx.

I'm originally from Alberta, but presently living in Florida. I am a nurse and currently working on my master's in public health.

A move towards increasing health care services to the private sphere is an indication of failure of the Canadian public health system. Having observed the American system of private health care with few public options, I can say that any move towards a private method of health service is to lose a sense of equity, well-being and Canadian identity. It is a slippery slope to looking at patients as a money-making opportunity rather than an individual deserving of care.

We should never require private health care in a strong public Canadian health system. So Jenny just said they're a strong public Canadian health system. And there's the rub, right? Yeah. Do we even have a public Canadian health system per se? Seeing as the provinces are the ones who oversee the delivery of health care, and they do so in ways that often vary quite a bit from one province to the next, right?

You're absolutely right. We don't have a National Health Service, an NHS, as they do in the United Kingdom, warts and all, I might add. And that makes it harder to know what sway, if any, the federal government has over health care. It's something our next guest will help us to navigate.

But in the meantime, thank you, Jennifer Warren, for producing those two shows on private pay family medicine, which we've put back at the top of our white coat feed. And thank you for coming on the show now to bring us some of the immense reaction those shows garnered. Thank you so much. Yeah, thank you, Brian. We'll be right back.

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Fresh for everyone. Aplican restricciones en combustible. I'm Sarah Trelevan, and for over a year, I've been working on one of the most complex stories I've ever covered. There was somebody out there who was faking pregnancies. I started, like, warning everybody. Every doula that I know. It was fake. No pregnancy. And the deeper I dig, the more questions I unearthed.

How long has she been doing this? What does she have to gain from this? From CBC and the BBC World Service, The Con, Caitlin's Baby. It's a long story, settle in. Available now.

You're listening to White Coat Blackheart. This week, we're looking at private pay family doctors as an issue worth examining during the federal election campaign. As I mentioned, in Canada, health care is a provincial responsibility. But the federal government does have a say, thanks to the Canada Health Act, which was enacted in 1984. The act outlines five core principles of Canada's publicly funded health care system. Our next guest is one of Canada's leading experts on the Canada Health Act.

Hi, Brian. My name is Colleen Flood. I'm the Dean of Law at Queen's University, and my area of research and expertise is health law and policy. Colleen Flood, welcome to White Coat Blackheart. Thanks, Brian. I'm really glad to be here. When we featured a private pay family medicine clinic in Quebec, people who listened to the program asked, how is this permitted under the Canada Health Act? So are they correct?

The Canada Health Act doesn't directly regulate anything that happens in a province. The federal government will give money to the provinces if they comply with certain criteria. And one of those criteria is effectively that...

there shouldn't be any private payment for hospital and physician services. But if that happens, the federal government can take back money from the province to, in a sense, persuade them, if you like, to stop that activity within their province. So to make it perfectly clear...

The Canada Health Act does not give the federal government the power to put a stop to private pay family medicine or private pay orthopedic surgery or anything. Have I got that right? Yeah, that's absolutely right. It is possible that the feds could hold back

more money, but they're quite nervous about using a hammer rather than a carrot to get where they want to go in terms of the principles of the Canada Health Act. Does the Canada Health Act provide any other powers? Sure. So the Canada Health Act sets out criteria, accessibility, like reasonable access, which as we know is a bit of a joke at the moment.

Comprehensiveness, so that's hospital and physician services effectively. Portability, so you should be able to get health care where you need it across Canada. And the only way those criteria can be enforced, for example, reasonable access, is if the federal government uses its discretion to withhold money and has never used its discretionary power to keep back money from a province that is allowing wait times to grow significantly.

or not ensuring that, for example, everybody has access to a family doctor. Since you've mentioned reasonable access, and I know you've written extensively on that, can you define it?

Yeah, well, I think you know, I know, we all have a sense of kind of what the bare minimum is, right? So we want access to a family care team, a family care doctor. We all want access to tests and diagnostic methods and specialists and hospitals within some sort of reasonable wait time period, right? So what that is...

It's something that might change over time, but I think we can start to draw some consensus about what reasonable access would mean. That might change in 10 years' time, what we think is reasonable access and reasonable access to what may also change. When I interviewed patients in Dr. Martin Potter's clinic,

The justification again and again for seeking private pay was inordinate lengths of time to see a family doctor in the publicly funded system. Even if they had a family doctor, they couldn't get an appointment, a timely appointment within weeks. Sometimes it was months or they would have to go to the emergency department and spend 24 hours just waiting to get care. So there isn't reasonable access, I guess you would say.

Oh, no, I completely agree. It's not reasonable access. And I think the Canada Health Act needs to be updated to provide for that because currently it's clearly not doing the job that we need it to for Canadians. Which kind of leads me to my next question. You know, we've heard this argument made that allowing private health care frees up space in the public system. You've studied this the world over. So what does the evidence actually say?

You know, the evidence is really clear that that is not correct. It's a bit of a zombie argument and, you know, it just will never die. It just doesn't seem to die. Many people start with that proposition. Surely if we take some patients out of the queue and we put them over here in another queue where they have to pay out of pocket, that's going to shorten the queue in the public system. But what that doesn't account for is the

that we only have a limited number of doctors and nurses. So unless we've got a big steam liner full of doctors and nurses just off the coast of Nova Scotia or something,

They have to come from within our system that we have right now. If you are taking them from the public pay system to the private pay system where they will in more likelihood earn better money and have to treat patients that probably aren't as in dire need, overall, you know, the system would see the transfer of labor from the public system to the private system, which is why

There's evidence from some jurisdictions that the wait times and problems of access and so on continue to go up in the public health care system. This is an election period, and I know that you have written extensively about how the Canada Health Act could be strengthened or at least better enforced. Have a go at that.

Well, that's a lovely, delicious thing to be able to talk about. I think the Canada Health Act has been an incredible tool for Canadians since Monique Vigine brought it to pass, and we're really lucky that we've had it. But it needs to evolve because it's not meeting our needs, and in particular around reasonable access.

I think the Canada Health Act should be overhauled so that the federal government says what we require of provinces is that you have a fair, transparent process to determine within your province what is reasonable access.

What does that mean for us in New Brunswick, in Manitoba, in Saskatchewan? This is what it means in terms of access to a family health care team or a nurse practitioner or a primary care doc.

This is what it means in terms of maximum wait times. This is what it means in terms of coverage. And that this is something that is revisited from time to time to make sure that it's updated to comply with technological changes and to change with our needs because our needs do change.

And we need to figure out a platform, you know, inside the Canada Health Act that will serve us for another 50 years or so and make sure that Canadians have the public Medicare that they deserve and that they pay for. Any idea what the federal parties are saying about what's happening in this current election environment?

Yeah, so obviously with all of the very serious situation in the U.S., health care is unfortunately taking a back seat. And that is a real shame because we are actually in an emergency situation and we really do need the parties to speak to what are their plans,

for improving public Medicare. And Canadians must hold their feet to the fire on this. I really counsel everyone listening to ask their candidates about what they specifically will do to improve public Medicare and to make sure that everybody has access to the care that they need when they need it

A lot of public Medicare, as you well know, Brian, came to pass after the depression and after World War II where people looked around and realized that access to Medicare, it isn't something that should only be a privilege but should be actually available to everybody because no matter who you are, you could fall into a time where you couldn't access the care that you need. So

Maybe there's the prospect that this will actually bring us together more around the importance of public Medicare and that we need to protect it to make sure that it works for all of us. What would you like to see the party leaders saying, contributing to this conversation about the future of health care during this election period? Well, honestly, I'd like to see them say anything.

Anything. Anything about what they will do. So I understand, you know, conservatives may have a different approach to reaching, improving public Medicare and may involve more private for profit care inside public Medicare. The liberals, you know, they may have a different view of protection of public Medicare that may involve more of

of a melange of getting there, the NDP may likely prefer more public hospitals, more perhaps even salaried physicians and moving more to a NHS style system like you see in the UK. Everybody may have their different recipe for improvement and

But I think that's what Canadians need to hear. What are your plans? What will you actually do? And how will you ensure that myself and my family are going to be able to get the care when we need it?

Earlier this season on our show, I went to Denmark. We had Dr. Tara Kieran talking about primary health care in the Netherlands. You've studied the world over, you know, health care systems the world over. Should we, I mean, the common denominator in those two countries is that they pay higher taxes for health care. Should we be doing the same in Canada? You know, we pay quite a bit for public health care relatively. So I think we need to think about

how we organize things. So paying more taxes, I don't think many people are going to sign up for that lickety split. However, if they saw that their taxes were dedicated to public health,

that is one way to go. So in Europe, in some jurisdictions, for example, you pay social health insurance. So the funding that you pay or the amount that you pay, you know, goes to healthcare and not to other things. I think potentially there is more appetite on the part of the public for paying more if they know it is directly going to healthcare. So that is something to consider.

Are there particular models elsewhere in the world that you think Canada should look to for really smart ideas? I think we need to look for sure at smart ideas, but it's not like a shopping cart that you rip around and pull off this and that and think you can just bring it back and plonk it into Canada and it will work. Canada is a complex healthcare system that's grown up over many years and it's not that easy to change it. I think for me, the thing that is clear is that

If you set clear goals and targets about things like wait times, you can achieve them. That is what you see across a number of different countries. But if we make it a goal to actually have reasonable access and we articulate what that reasonable access is,

systems can reorient themselves to achieve that. That is possible. But if we just leave it murky and mushy and wouldn't that be nice? Oh, it's a shame. We can't actually realize that. Oh, that's really too bad. Well, guess what? We're never going to get there. Oh my, I've heard so many conversations that end with the note that you've just actually ended what you just said. I want to close in this election period with,

by asking you what should voters be listening for during this election period when it comes to healthcare? - I think voters should be looking to parties to acknowledge that we are actually in a crisis, we're in an emergency.

and that we need to take very significant steps very quickly to fix public Medicare. It is simply unacceptable that the 6.5 million do not have reasonable access to the most basic of care, family medicine. And it is even worse than that they are desperate for care, clogging up ERs and so on, waiting to a point where the condition that could have been dealt with has got away on them. So

I think what we want to see is that there is a sense that the party is taking this crisis, this emergency, extremely seriously, and they have a serious plan to deal with it. Colleen Flood, thank you so much for speaking with us and helping us unpack some important issues and raising health care at a time when people are concerned about other things. So thank you so much for speaking with us. It's my pleasure, Brian. Thanks for having me on the show.

As Colleen Flood said, the provinces are struggling with providing reasonable access to family medicine right across Canada. She thinks the Canada Health Act needs to be updated to hold the provinces more accountable for providing reasonable access to all publicly funded services, including primary care and ER wait times. She also thinks Canada is in an emergency situation regarding health care. As someone who works in the system, I would agree.

Which is why in two weeks, we'll have our election show in which we talk to the major political parties about where they stand on Canadian health care. That's our show this week. White Coat Black Art was produced by Jennifer Warren with help from Stephanie Dubois and Samir Chhabra. Our digital producer is Ruby Buiza. Our senior producer is Colleen Ross. I'm Brian Goldman, and I'm proud to bring you stories from the Canadian side of the gurney. See you next week.

For more CBC Podcasts, go to cbc.ca slash podcasts.