Private Health Insurance for Women? Fall-out from the Chaoulli decision

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On 9 June 2005, a bare majority of justices of the Supreme Court (4 of 7) ruled that there was a constitutional right for Quebecers to buy private insurance to obtain medical services available in the public health system. This overturned decisions of two lower provincial courts and, while applying only to Quebec, it nevertheless opened the door for anyone in Canada with sufficient funds to try to buy their way off waiting lines by getting care in the private sector—and to more privatized care in general. The months since the Court decision have shown this to be the case, most clearly perhaps in Quebec and in Alberta where provincial ministers have in the early months of 2006 already proposed measures that allow greater penetration of the private sector in their respective health systems.

These initiatives have been welcomed by some, rightfully criticized by many, but missing in the discussion to date has been attention to their particular—and negative—direct and indirect effects on women. Poorer than men, with jobs that are more often precarious, non-unionized and part-time, and with higher rates of disability, women may feel the effects of these proposed reforms both as users of and workers in the health care system.

Women, as the major users of health services (because of our reproductive roles and higher rates of chronic disease), as the majority of workers in the health system, and as the unpaid providers of care for others have special interests in the expansion of medicare, and not in its reduction or elimination. The Court’s decision, and subsequent provincial proposals, not only ignore these existing gender-based inequities, but open the door for a system that has the potential to increase them. As such, the federal court’s decision does not concord with the Canadian commitment to improving the status of women and the provincial (Quebec and Alberta) responses to date only underline these concerns.

Increasing rates of chronic disease and continuing closures of hospital beds are already off-loading caretaking work to women. And this burden continually becomes heavier as childbearing ages increase and individuals in mid-life are confronted with the difficulties of balancing work and caring both for children and for aging parents, responsibilities which tend to fall disproportionately on women’s shoulders.

Women in Quebec have already been paying the price of the “virage ambulatoire” (cost-reducing policies put in place in the 1990s that sought to reduce hospital care) and reorganizations in provincial health care systems. For over a decade, women—whether as paid healthcare workers, users of the system, or unpaid caregivers—have been disproportionately harmed. The decrease in budgets to the CLSCs (local community health clinics) and hospitals for necessary homecare and postoperative services, for example, have shifted these responsibilities—and their costs—onto women who have been required to “volunteer” their care for others—and themselves. Similarly, fewer physicians at CLSCs, and the still incomplete changes in primary care access, deprive women of the holistic community-based primary care that they need.

Allowing private provision and financing of services, as the provincial responses to the Supreme Court decision are already proposing, makes access to services a matter of ability to pay rather than a matter of need. They exchange inequity for equity and lead to further differentials in status between the rich and the (majority female) poor. With fewer financial resources, women will be precluded from this market but, worse, may face deterioration in the public system on which they count if physicians and nurses leave for higher paying jobs in private clinics. For health care workers, too, expansion of the private system brings risks. Whether or not they are “for profit,” private services offer lower wages and poorer working conditions—both risks to health—to the aides, cleaners, food service providers, etc. the majority of whom are women. And having the possibility to purchase private insurance won’t matter, since this will likely be an option only for those with good jobs, the healthy and the wealthy.

In considering the expected impact of private insurance of health care services on access to care, it is useful to compare it to insurance for items such as automobiles. As with coverage for cars, private medical insurance will generally involve deductibles, exclusion clauses (e.g., for conditions thought to be related to individual responsibility), coverage variations based on one’s capacity or willingness to pay, and premiums set on the basis of (pre-existing) risk. Each of these dimensions will necessarily limit access to services, even for those with the resources to pay for policies. And they will create limits in a much more pervasive and inequitable way than waiting lines for women because of their higher rates of chronic disease and of stress from trying to reconcile paid and unpaid work.

Yet, even if actuarial logic were to be deemed acceptable in our health care system, the analogy to automobile insurance ends completely when we realize that individual health, unlike a car, is invaluable and not a commodity. With private health insurance, a value is set on health, and having health will depend on one’s position and privilege in society. Is this not an inequity Canadians have loudly and consistently rejected? And is this not a gendered inequity?

Of course women (and men) want shorter waits for essential care. But waiting lists increased in the mid-1990s in parallel with the downsizing of health care that followed cuts in federal transfers to the provinces and then with the introduction of the Canadian Health and Social Transfer and concurrent tax cuts to business that deprived governments of funds needed to sustain the public medical system. Recent additions to health budgets may begin to address these lists, but they will likely persist, albeit perhaps for different interventions.

Data suggest that the longest waiting lists tend to be for procedures that have only recently been made available, often without the evidence base to show their legitimate need (e.g., full body CAT scans). Overall, patients are getting necessary heart surgery when it is appropriate. Research on the time to get laser surgery for cataracts in Alberta has shown that waiting lists increase when physicians move into high-paying private practices to care for patients. And overall health care costs can be expected to increase when physicians offer interventions of unproven effectiveness—and patients with adverse effects are sent to the public system for subsequent care.

The Supreme Court’s decision and Quebec’s response to it allowing the purchase of private insurance to cover some elective surgeries, is likely to be especially harsh for those at risk of developing or caring for those with chronic conditions: women. To mitigate this inequity, action must be taken by all provincial governments at least to restrict what physicians can do outside the public system and what they can be paid for these services. We support Quebec’s proposition whereby those who opt to practice privately should be required to relinquish their privileges to work in the public sector. But beyond this basic safeguard, funding must be restored to build up a strong primary care network that will offer all Canadians holistic, comprehensive care and not deflected to private clinics.

Canada has committed to the gender-based analysis of all its policies. Assessing the Supreme Court decision and provincial responses through this lens clearly shows them to fail to respect our equity commitments and the human right to health for women.

Abby Lippman, PhD, is a Professor in the Department of Epidemiology, Biostatistics and Occupational Health at McGill University, and Co-Chair of the Canadian Women’s Health Network. Amélie Quesnel-Vallée, PhD, is an Assistant Professor in the Departments of Sociology and Epidemiology, Biostatistics and Occupational Health at McGill University.