Get your MRI – on a native reserve

Brian Lee Crowley

National Post
Wednesday, April 21, 2004

Despite Paul Martin’s recent brave words about buying change in the health care system with yet more money, everybody who knows anything about the health care system knows he’s just whistling in the dark. The truth is that health care continues to eat up our scarce tax dollars at an unsustainable rate and the problem is that the basic model — a low-performance, public-sector, monopoly-provider of health care services — doesn’t work, so more money can’t fix it. Those of us concerned with a sustainable future for medicare look forlornly for a first minister brave enough to launch a national debate that will allow people to escape the public system, while subjecting it to competition from private providers who live or die by the satisfaction of their customers.

It turns out, however that we shouldn’t be looking to Ottawa and the provinces for change — but to First Nations reserves across the country.

Consider that Canada’s first aboriginal-run MRI clinic is scheduled to open on Muskeg Lake Cree Nation land, in east Saskatoon, in the spring of 2005. The clinic will serve First Nations people, Workers’ Compensation Board clients and patients referred by physicians. So far, it’s an exquisitely polite affair, with everyone saying that all will be done in negotiation with the province.

But what is increasingly exercising the health care establishment is the dawning realization that such clinics on reserves likely cannot be subjected to the provincial legislation that establishes much of the edifice of the public sector health care monopoly in Canada. First Nations across the country are examining the opportunity this unique legal status confers and will likely not be shy in seizing it.

That opportunity is the perfect match for the policy entrepreneurs across the country who are seeking the opening in the medicare system that will allow the emergence of a private sector health care alternative. Only the injection of genuine competition, in which patients have real choices about where and from whom they get health care services, can save the public system. Competition brings accountability because people can vote with their feet when service and quality are not up to standard. And allowing people to opt out of the public system has strengthened, not weakened, national health care systems around the rich industrialized world, creating extra capacity that public systems cannot afford to pay for.

Unlike those other public health care systems, in Canada today escape from poor service and lengthening queues is mostly impossible, unless you have the means to travel to the United States. You cannot spend your own money to buy most medical services, no matter how much pain you may be suffering and no matter how much waiting may cause further deterioration in your health. Because you cannot defect from the system, the provinces and Ottawa can squabble and blame each other for the deterioration of health care while holding you hostage. Because no one is rewarded in the health care system as a result of you being served promptly or efficiently, you must accept what the system decides to dish up.

But imagine if, instead of travelling to the United States, Montrealers could take the bridge to Kahanawake or some other nearby reserve; or Vancouverites could go to Indian reserves on the North Shore or in South Vancouver and visit a modern medical clinic with all the technical and other innovations that our moribund health care system can’t or won’t allow. Appointment times might actually mean something, for example.

Suppose that this clinic allowed you to consult your doctor by phone or e-mail, as well as face to face. Maybe it would permit the kind of efficient division of labour that we see every day in dentists’ offices, with primary care nurses doing jobs that only doctors can now do because medicare will only pay if they’re performed by a physician. Suppose, too, that this clinic gave you access not just to the doctors within its walls, but allowed you to consult some of the world’s leading specialists via video-conferencing from their offices in London, Houston or Tokyo. The clinic doctor might well keep his notes on his PDA rather than on scraps of paper, and be able to e-mail your prescription to the pharmacy of your choice. Finally, suppose that the clinic contracted with the most stringent international certification organizations to guarantee the quality of their service.

Many people would be willing to pay out of their own pockets for such convenience and speedy treatment, and there may well be First Nations entrepreneurs out there willing to test that proposition. Just a few clinics on the edge of major cities across the country, and Canadians would quickly realize that a private parallel system would not spell the end of medicare, but rather the birth of superior service and the sustainability of a public system that could concentrate its scarce resources where they’re really needed. Best of all, such an innovation doesn’t require the agreement of those craven politicians, who will likely rail against it, but be powerless to stop it.

Brian Lee Crowley is president of the Atlantic Institute for Market Studies.