André Picard, one of Canada’s foremost healthcare journalists, published an article today in which he analyzes the funding rationale for his country’s healthcare system.
Canada has the most singularly bizarre health-funding model in the world. It is, to use the technical term, bifurcated – meaning there are two distinct categories.
“Medically necessary” care, defined as hospital and physician services, is paid 100 per cent from the public purse. Selling these services privately is, with few exceptions, illegal or subject to punishing penalties…
The rest of health care is, by default, not deemed medically necessary, but still gets varying degrees of public funding. Only about 6 per cent of dental care is paid publicly, as are almost half of prescription drug costs, and about two-thirds of long-term care costs.
Given Canada’s perennial healthcare budget deficits and notorious waiting lines for medical care, Picard adds:
Getting the mix of public and private care right means ensuring everyone has access to essential care in a cost-effective manner, and still allowing patients a modicum of choice, and the ability to supplement their publicly funded care with other services.
At some point, we have to make some clear, coherent decisions to ensure that happens. Doing so begins with asking, and answering, the question: What is really “medically necessary”?
The final question Picard asks couldn’t come at a more opportune time.
Earlier this year, the Supreme Court of Canada struck down the ban on physician-assisted suicide (PAS) and gave the federal government one year to come up with legislation on the practice.
Will the government pay for the procedure, and if so, under what rationale?
To justify paying for PAS as a medically necessary service would rightly seem absurd. As Picard has noted, the concept of “medical necessity” is a correlate of licensing laws and derives from the fact that medical needs and care have an objective dimension. But the justification for PAS rests entirely on the principle of patient autonomy. There is no objective fact by which one can determine that a patient needs assisted suicide.
On the other hand, to pay for PAS while maintaining it is not medically necessary would imply that the state is cherry picking the kind of medical procedures it wishes to pay for. A willingness to selectively pay for the final exit of burdensome patients will naturally invite unpalatable conclusions.
I agree with Picard. “What is medical necessity?” is the question of the day.
May we realize that the answer is never entirely in the objectivity of the doctor’s gaze nor completely in the subjectivity of the patient’s mind.