Amendments to BC's Medicare Protection Act have produced a surprising debate. On November 17, 2003, Health Minister Collin Hansen issued a short news release that proclaimed "Amendments to B.C.'s Medicare Protection Act will help protect patients from being billed for medically necessary physician and hospital services." In legislative debate on the bill, he concluded:

"Just in summary, what this amendment does is make some relatively minor changes to the Medicare Protection Act to give us tools for investigation that will bring us in line with other provinces. It also provides the kind of clarity that I think we need for patients and physicians in B.C. so that they have certainty around what can and cannot be charged and still ensures that there is compliance with the Canada Health Act as well as the Medicare Protection Act. I think these minor amendments will bring that kind of clarity and bring us in line with the kind of regimes that are already in place in other jurisdictions."

By contrast, Ontario produced similar legislation and trumpeted that it marked the end to "creeping privatization of health care". The difference in rhetoric between Ontario and BC might reflect different stages in their terms or it might reflect a difference in enthusiasm for dealing with violations of the Canada Health Act. I called BC's legislation the "Medicare Weasel Act" because the tone of committee stage legislative debate revealed a government with no enthusiasm for doing anything more than the minimum necessary to receive maximum federal dollars. BC's Act improves the government's ability to investigate when it receives a complaint, but the system remains complaint driven. The BC Nurses' Union has launched a campaign to encourage complaints, but it is doubtful whether patients who are willing to pay a thousand dollars or more are likely to complain about the physician.

As they say in the summary of what happens in the legislature, "Votes & Proceedings", "a debate erupted." On Thursday, December 4th, media across the province carried stories alleging that surgery waiting lists would grow as a result of government's high handed efforts to meddle with private clinics while caving in to Ottawa. The coverage appears to be the result of a news release issued by the BC Medical Association the previous day. That release confirmed cynical interpretations of Hansen's intent when they mentioned an agreement with Hansen to delay implementation of the Act.

Talk shows, letters to the editor and some news articles pose the question "why can't I buy my way to the front of the line?" People who are used to being able to get what they want if they can afford the price, are expressing their frustration with health care delays by saying they deserve the right to jump the queue if they can afford the price. As an apparent afterthought, some argue that their queue jumping will shorten the wait list for everyone else. There is no evidence to support that contention, since no one seems to know how many people have been moved to the front of the line at private clinics based on the thickness of their purse rather than medical need. More importantly, some argue that anything done to take the heat off government will make it easier to lengthen waiting lists; those who can pay would go to private clinics while government further cuts services for everyone else.

The best way to eliminate queue jumping is to make the public health system so good that there is no incentive to look elsewhere. One way of doing that would be for the public system, MSP, to pay the bill when you attend a private clinic just like WCB and ICBC do. That way the market would expand supply so as to satisfy demand. No government appears willing to do that; the Campbell government talks about building a "sustainable" system, meaning one that fits within the limits of their willingness to fund it. Governments fear that allowing supply to meet demand would increase costs; the idea is that rather than having a fixed waiting list, supply creates its own demand - in other words, elimination of today's list results in more procedures being demanded by patients and recommended by physicians.

Freelance columnist Paul Willcocks has contributed two excellent columns to the debate. Most recently he argued since some form of rationing care seems to be necessary the public debate should focus on what that system should be. The Campbell Liberals appear to have answered that question in their New Era Document, the book of election promises. They promised to:

• "Fund health regions at a level necessary to meet the needs of the people who live there, regardless of where a service is provided.", and to,
  
  
• "Fulfill BC's obligations under the Canada Health Act to properly fund and provide access to all medically necessary services."

If the Campbell government is backing away from those promises by inserting a "subject to clause", the challenge posed by Willcocks should be answered. If "sustainable" or "affordable" becomes part of the clause, should those who support massive tax cuts (an average tax cut of $26,000 per year went to the 8,000 BC tax filers with incomes over $250,000 per year), be able to fund their tax cut by making health care harder to get for most people while they pay their way to the front of the line? We should answer the question of how health care should be rationed, but that question cannot be answered without also talking about fair taxation.

Fair taxation is not the whole answer. The original principle behind Medicare was to cover "medically necessary services" with individual physicians determining what is medically necessary subject only to the restrictions of their licensing bodies. Individual physicians are able to determine which of their patients to see first, but they do not have the authority to manage the overall health system. They don't determine how much money gets spent on knee surgeries compared to how much is spent on cataracts. They may have some influence but they don't determine the resource allocation decisions that are put in the hands of health authorities, their executives and the Minster. If those bodies are not going to fund all services that are medically necessary, then they should let the public see what criteria they are using to determine who doesn't receive necessary care. Is government redefining the words "medically necessary" just as it redefined the word "sell"? Does medically necessary now mean whether or not you will die within the day rather than whether or not you lose function or suffer pain? A debate on how health care is rationed is necessary, but first government must come clean on what it is doing.