There's a ridiculous amount of newsprint been consumed recently regarding the election by the CMA (Canadian Medical Association) of a president who owns a private clinic, in contravention of the Canada Health Act, in Vancouver, BC. Samples: here, here, here, and here. There's also been a fair amount of comment, from both the left and the right.
Here's the gist of what I have to say: everyone's wrong. No, seriously, everyone. The CMA will fall apart before the public system. And, two-tier healthcare is not fair.
Dealing with the first. No one seems to understand that these sorts of professional organizations aren't monolithic and uniform entities. They're cobbled together groupings of smaller, more cohesive groups, that will hold together only so long as the interests served by the larger group are not undermining the interests of the smaller groups. (For example, as we see here, the Professional Associations of Interns and Residents of Ontario (PAIRO) -- future physicians -- is clearly against private healthcare.) Unfortunately, I don't see any information on the demographics of the election, so this is going to get a little speculative. There's usually a split in physicians' groups, in my experience, between the hospital physicians and physicians in private practice. The former, oddly enough, tend to be more money-obsessed than the latter. My explanation for this is that the latter have to see more patients. Physicians who work in hospitals can be more selective in who they see, and usually make their decisions on the basis of who they can bill the most for. By contrast, physicians in private practice will, on the whole, get a better sense of the needs of the general patient population, because they have to see a large number of patients in order to make their overhead. Physicians in private practice will usually favour public healthcare for just that reason -- they know what the general patient population needs, and they know that private insurance would tend to exclude a significant portion of that population. (More on that later.)
I'd also suggest that there may be a split between older and younger physicians. The Canada Health Act was only adopted in 1984. An individual born in 1984 is currently younger than I am -- about 22 years old -- and thus probably not a physician. Which means that most physicians will have grown up in a Canada that did not have public healthcare. To what extent, I wonder, do older physicians tend to favour private healthcare, because it's what they grew up with? Possibly confounding this is the fact that there are foreign-trained and -born physicians practicing in Canada who may have grown up under public systems. Not to mention that, sometimes, people will hate what they are familiar with, rather than being drawn to it. On the whole, though, I would suspect that there is a certain amount of yearning for the "good ol' days" going on.
Furthermore, the formation of Canadian Doctors for Medicare suggests that there are significant numbers of physicians who want an organization that will openly endorse public healthcare. So, far from tolling the end of public healthcare, I'd think that the CMA president endorsing private healthcare would signal the end of the CMA as an organization that represents all Canadian physicians -- if their new president actually uses his position to endorse private healthcare.
And that is a very salient point that, so far, has been completely overlooked. Just because the elected president believes in private healthcare doesn't mean that he's going to use his position to espouse it. Particularly if I'm right on the first point, and there are sufficient splits within the CMA that the organization itself might splinter over the issue of privatizing healthcare.
So, on the whole, there's some important issues that we simply don't know enough about, at this point, to go off half-cocked proclaiming the end of public healthcare -- either as a good thing or a bad thing.
But, that aside, let's consider the issue of public vs. private healthcare. There are really three possible systems: public alone, private alone, and a combination of public and private. Private alone I will reject out of hand. I don't know anyone sane who suggests that there should be entirely private healthcare, leaving even the very poorest and neediest without public support for their medical bills. That leaves either a purely public system or a two-tier system.
There's a couple of defenses of two-tier systems that get trotted out, and they don't really work. The first is that the injection of private money might alleviate the problems facing the public system. This is false. The public system lacks money, that much is true. However, the public system also lacks other resources, particularly healthcare providers. A two-tier system will take healthcare providers out of the public system and put them in the private system. This is a basic logical point -- there's a limited supply of providers, so anyone practicing in one system is therefore not able to practice in the other (at least while they're practicing in the one). Private money might be able to help create more resources; but, then again, public money could do so just as easily. In this respect, publicly- and privately-funded healthcare are on all fours with each other; so, it's no mark in favour of a two-tier system that private money could solve this problem.
(Aside: some practitioners in the public system do not practice year-round, because they hit their provincially-mandated billing caps. That is, there is a limit on how much any physician can bill during a calendar year, and some physicians do hit it. They are thus left with the choice of either not practicing or practicing for free, as they are not legally entitled to charge for covered services. Does two-tier healthcare have a lever here? Simply, no: any physician whose services are genuinely in demand can apply to the provincial government to have the cap removed, thus allowing for unlimited billing. Physicians can also perform non-insured services, such as medico-legal examinations for private auto insurance (in provinces that have them) or worker's compensation systems, for which they can thus bill privately. Therefore, most physicians who do not practice the full year seem to be doing so out of choice, not out of need.)
The second argument that often gets trotted out is that people have a "right" to pay for healthcare if they are able. However, it is, first, utterly bizarre to claim that there is a "right" to buy what one is able to buy. I'm sure there are sufficiently poor people who would sell themselves into slavery to sufficiently rich people, but nonetheless it is obviously wrong to buy a slave. So, really, the "right" being invoked is, as with most rights, a limited one: one can buy whatever there is no good reason to prevent one from buying. In the case of slavery, the autonomy of the individual is sufficiently valuable that it cannot be violated, even if an individual would voluntarily choose to give up his autonomy. That's at least a reason not to allow buying slaves. Similarly, there is a reason not to allow people to buy private healthcare: the competition is necessarily unequal, and thus unfair. The inequality comes from two sources. First, the problem of the uninsurable. As anyone who's tried to buy, say, private auto insurance with a bad driving record can tell you, insurers are risk-averse. That is, they don't like to take on clients that they believe will make large claims and cost them lots of money. This extends to health, as well. Insurers will charge higher premiums to people with expensive chronic conditions (such as AIDS) or with a high likelihood of sustaining serious acute injury (such as the severely mentally ill). In many cases, insurers will either price their premiums sufficiently high to in effect render people uninsurable, or will simply refuse to insure them outright. How can the competition for private insurance be fair if some people are blocked from entering the market? Second, the middle class will continually lose out on access to treatment. The lower classes will be treated publicly, on the basis of need. The upper classes will have quick access to the private system. How can the middle class compete with the lower classes on the basis of need -- particularly if they pass whatever threshold of income is necessary to be excluded from the public system. Similarly, how can the middle class compete with the upper class for access on the basis of income? Thus, when it comes to either the public or the private system, the middle class will tend to be systematically discriminated against. How can this be fair?
So, for all its (reparable) flaws, the public system is still better than a two-tier public/private one.