As U.S. Democrats line up behind single payer, some Canadians are suing to allow private insurance

As Republicans flounder in their efforts to repeal and replace the Affordable Care Act, many Democrats and progressive activists have stepped up their calls for adoption of a Canadian-style, Medicare-for-all, public health insurance system.

But not all Canadians think that would be a good idea. A former president of the Canadian Medical Association is spearheading a closely watched constitutional lawsuit that could transform Canada's Medicare system by allowing private insurers to compete for the first time with the provincial public health plans.

The case offers cautionary notes for U.S. single-payer advocates, because the problems with the Canadian system cited in the lawsuit give credence to U.S. conservatives' attacks on the single-payer model. Last month, Vice President Mike Pence pointed to the Canadian system as illustrating "the failings of national socialized healthcare."

Dr. Brian Day of Vancouver is heading the legal challenge. The named plaintiffs include several patients who claim they were hurt by waiting lists for surgery and other care. The massive case, which is expected to return to trial later this month before the British Columbia Supreme Court, centers on whether people in the province have a right under the Canadian Charter of Rights and Freedoms to buy private health insurance as an alternative to public insurance.

Day, an orthopedic surgeon who owns the private Cambie Surgery Centre, argues that letting private insurers compete with the public insurance system would improve healthcare and reduce waiting times. There are nearly 82,000 adults and 4,700 children in British Columbia on wait lists for procedures, according to the provincial government. Ninety percent of all types of cases are completed within about 31 weeks.

Day would like to see Canada shift to a mixed insurance model like that in Germany or Switzerland that combines public and private plans to achieve universal coverage. "We are the only country on earth that makes it unlawful for citizens to have private insurance," he said. "But single payer doesn't work. No monopoly will serve consumers better than a system with competition."

The British Columbia government opposes the move to allow private insurance because it seeks to protect "access to necessary medical care based on need and not an individual's ability to pay," said Ministry of Health spokesman Stephen May.

The Canadian Supreme Court ruled in a split decision in 2005 that people in Quebec had a right under that province's constitution to buy private insurance, but no insurers have offered plans there that compete with the province's public plan. If the plaintiffs prevail in the British Columbia case, however, it could have a more significant impact across Canada because the ruling would be based on the Canadian national constitution.

Even though he's challenging the Canadian single-payer model, Day is no American-style foe of government involvement in healthcare, and he's no fan of the U.S. model. He believes health coverage should be universal, and that Americans would benefit from having public plans competing against private insurers—welcome words to Democrats who favor a public plan option here.

"It's unacceptable for the most powerful and richest country on earth to have uninsured individuals," Day said. "The reason why the U.S. health system is double the cost of other developed countries is lack of competition. State insurance should compete with private insurance and keep everyone honest."

If the British Columbia court rules it's unconstitutional to prohibit private insurance and that decision is upheld by the Canadian Supreme Court, the impact would be dramatic but largely political rather than practical, said Daniel Cohn, a public policy professor at York University in Toronto who supports his country's Medicare system.

In his view, Canadians who are opposed to the country's system of single-payer public health plans in each province, including the retiring premier of Saskatchewan, Brad Wall, would be emboldened to argue for changing it.

"This would be an earthquake decision in terms of politics because opponents of universal healthcare could say it's unconstitutional," Cohn said. "But single-payer, universal health insurance is a settled issue with the Canadian public, and there's no political leader in Canada other than Wall who is enthusiastic about this."

Practically speaking, private insurers are unlikely to start selling plans because they couldn't successfully compete against the dominant public plan on basic physician and hospital benefits, he added. After the Quebec ruling in 2005, Canadian insurers "did the math and decided it didn't make business sense."

Besides, Canadian carriers already have a lucrative niche selling what's called extended insurance. That type of policy, carried by most Canadians, covers benefits not offered by the country's Medicare, including prescription drugs, dentistry, mental healthcare, and medical supplies.

Still, Day's lawsuit highlights the stubborn problem of sometimes-long waits for medical services in Canada, particularly for elective procedures. Even Canadians who strongly support their country's Medicare system are concerned about this issue.

Specialist physicians surveyed by the Fraser Institute reported a median waiting time last year of 20 weeks between referral from a general practitioner and receipt of treatment—longer than the wait of 18.3 weeks reported in 2015.

A 2014 report by the Commonwealth Fund, based largely on satisfaction surveys of patients and providers, ranked Canada 10th out of 11 wealthy countries on healthcare, with only the U.S. rating lower. Canada came in last in timeliness of care.

"It's true that sometimes Canadians wait too long for non-urgent or elective investigations or procedures," Dr. Danielle Martin, vice president of medical affairs at Women's College Hospital in Toronto, recently wrote. "But we don't believe that the solution lies in dismantling universal healthcare and creating a system where some cannot afford the care they need."

The lesson Americans should draw from Day's lawsuit is that the single-payer model isn't a panacea for what ails U.S. healthcare, said Ron Pollack, chairman emeritus of Families USA, who helped build support for passage of the Affordable Care Act.

He warns that single-payer advocates, led by Sen. Bernie Sanders, risk a major political backlash if it becomes apparent that their model wouldn't make healthcare better for the vast majority of Americans.

"To the extent people don't feel they'll get the same access to timely care, that will cause an enormous problem, especially when they will have to pay additional taxes for that," Pollack said.