The Canadian Supreme Court last month struck down a prohibition in Quebec
province on private health insurance, citing the existence of lengthy waiting
lists for services under the country's publicly funded nationalized health
In the case Chaoulli v. Quebec, Canadian citizen George Zeliotis
and physician Jacques Chaoulli, M.D., charged that the prohibition on private
insurance deprives citizens of access to care because necessary services are
not provided in a timely manner under the country's overburdened public
Zeliotis had experienced a number of health problems, including the need
for orthopedic surgery, for which he was placed on a waiting list. Chaoulli is
a physician who tried unsuccessfully to obtain a license to operate an
independent private hospital.
"The evidence shows that in the case of certain surgical procedures,
the delays that are the necessary result of waiting lists increase the
patient's risk of mortality or the risk that his or her injuries will become
irreparable," the court said. "The evidence also shows that many
patients on nonurgent waiting lists are in pain and cannot fully enjoy any
real quality of life. The right to life and to personal inviolability is
therefore affected by the waiting times.
"The evidence also demonstrates that the prohibition against private
health insurance and its consequence of denying people vital health care
result in physical and psychological suffering that meets a threshold test of
seriousness," the justices stated.
The ruling appears to be a blow to Canada's nationalized health service and
was received in some quarters of the United States as a vindication of
arguments against a "single payer" solution for health system
"The Canadian ruling ought to be an eye opener for the U.S., where
`single-payer,' government-run health care is still a holy grail on the
political left...," the Wall Street Journal wrote in an
editorial following the decision. "The larger lesson here is that health
care isn't immune from the laws of economics. Politicians can't wave a wand
and provide equal coverage for all merely by declaring medical care to be a
`right,' in the word that is currently popular on the American
"There are only two ways to allocate any good or service: through
prices, as is done in a market economy, or lines dictated by government, as in
Canada's system," the editorial stated. "The socialist claim is
that a single-payer system is more equal than one based on prices, but last
week's court decision reveals that as an illusion."
In fact, judges in the case focused their decision on the claim that
waiting lists imposed suffering and distress—not on the viability of the
national health service or its goals.
"As we enter the 21st century, health care is a constant
concern," wrote Justice J. Deschamps. "The public health care
system, once a source of national pride, has become the subject of frequent
and sometimes bitter criticism. This appeal does not question the
appropriateness of the state making health care available to all Quebeckers.
On the contrary, all the parties stated that they support this kind of role
for the government. Only the state can make available to all Quebeckers the
social safety net consisting of universal and accessible health care.
"The demand for health care is constantly increasing, and one of the
tools used by governments to control this increase has been the management of
waiting lists," he continued. "The choice of waiting lists as a
management tool falls within the authority of the state and not of the courts.
The appellants do not claim to have a solution that will eliminate waiting
But there is little doubt the ruling will have a profound effect on the
country's nationalized service.
Ray Freebury, M.D., an APA Assembly representative from the Ontario
District Branch, said many Canadians see the decision as opening the window
for the development of a private insurance market that could co-exist with the
public program, helping to ameliorate the problem of waiting lists. But he
expressed some reservations about that prospect, saying evidence from Great
Britain—where a private insurance industry has grown up alongside the
National Health Service—suggests that private insurance tends over time
to degrade the public system.
But Freebury also said the costs of the public program to the government
and tax-payers are growing insupportable, in part because of the expansion of
medical technology and capacity and the aging of the population. "The
cost of the public universal system is so burdensome to government that
eventually [it] will withdraw [its] range of services or allow a partial,
private system," he told Psychiatric News.
He added that he believes the universal, public system is still regarded
with pride by most Canadians. "In general I think the public recognizes
that there are unavoidable issues, and people still think very highly of the
system that we have," he said.
Joseph Berger, M.D., a past president of the Ontario District Branch and a
representative to the APA Assembly, said he "very much" welcomed
the Supreme Court's decision and the introduction of private insurance."
Any country that has tried to rely solely on a government-controlled
monopoly has been highly unsuccessful," he told Psychiatric
News. "Without competition, standards just deteriorate."
He believes a private insurance market can co-exist with the public,
universal program and will make it stronger. "The only effect should be
a positive one," he said. "There is no consideration among the
people I speak with about doing away with the public system or with universal
Pierre Paul Yale, M.D., vice president of the Quebec Association of
Psychiatrists, a branch of the Canadian Psychiatric Association, echoed some
of Freebury's comments and said he welcomes the court's decision and the
introduction of private insurance. "In the long run there will be a
problem with funding the government system—that program will not hold
out another 10 or 15 years unless we have lower-cost treatments and
"Right now we are trying to offer five-star quality medicine, and the
medications are more and more expensive," he said. "So we have to
put a limit somewhere."
Yale, who reported that the average wait for an MRI is six to eight weeks
at least, said he believes the public system could exist side by side with a
private insurance market.
He added that in his city of St. Jeansur-Richelieu, in Quebec, the shortage
of psychiatrists is so severe that the waiting time to see one has been as
long as four years. That is down to eight months now, he said, and in
September a new service would begin in which psychiatrists will provide
consultation to family physicians who provide mental health care in the
primary care setting. The psychiatrist will provide a consultation within two
weeks of the patient entering care and then follow up with the family
physician regarding treatment recommendations, Yale said.
Physicians for a National Health Program (PNHP), an organization of
American physicians advocating for national health insurance, said the
Canadian court's decision could backfire on Canadians.
"Long queues... result from inadequate capacity of the health care
delivery system, not from the method of paying for care," the PNHP said
in a statement. "It defies logic to suggest that private insurance will
correct the capacity deficiencies that result in queues. When a public health
care delivery system has deficient capacity, the role of private insurance, as
defined by this decision, is to authorize a larger payment for the services
than the public insurance provides. This merely jumps those with private
coverage to the front of the queue...."