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Hundreds of thousands of patients on B.C. waiting lists know that role is not being fulfilled. The health minister and premier recently admitted that patients were waiting inappropriately long times, and a health region spokesperson reported some "life-saving" procedures were being delayed. Provincial health commissions were the brainchild of Tommy Douglas, who believed they should be chaired by doctors and never subject to political influence. But the MSC is always chaired by a politicallyappointed civil servant. Douglas supported premiums and felt they made the public cost-conscious, creating a sense of individual responsibility. He would never have condoned the practices of raising premiums to compensate for fiscal failures, nor reporting low-income earners, delinquent with their payments, to collection agencies. The commission is wasting health care funds as it displays contempt, in terms of its fiscal and social accountability, toward taxpayers.. In one example of carelessness and incompetence, I received cheques from them totalling hundreds of thousands of dollars, for services on patients that I had never seen. I also received confidential personal information on hundreds of patients unrelated to me or our clinic. When informed of their error, they responded: "Just mail them back." They were not inclined to investigate.

In Canada, health providers are compelled by law to share confidential patient files with government employees armed with the right to inspect and copy patients' files. Your health record is considered public property; you cannot block government access. Consent is not needed, and you are not notified when Big Brother is looking. Privacy rights have been legislated away. I witnessed a defeated provincial cabinet minister's medical file being reviewed by a newly elected government. In the 1989 tainted blood inquiry, Justice Horace Krever was "shocked by the inadequate laws, the abuses of confidentiality, and the fact that so many people - except the patient - had access to medical records." Little has changed.

The MSC is also charged with defining what services are "medically necessary" - and therefore publicly insured. They have never created a definition, but have arbitrarily designated clearly essential services such as ambulance, drugs, physiotherapy, artificial limbs, and dentistry as unnecessary, creating a true two-tier structure of care. The government's last action in delaying our constitutional challenge on patient rights resulted from a "last minute" discovery of 300,000 documents they were legally bound to provide. After a delay of more than seven years, the plaintiffs in the coming June trial will confirm that the Supreme Court of Canada's 2005 finding - that patients are suffering and dying on waiting lists - applies in B.C. Supporters of a system that limits timely access are complicit in such outcomes.

Our public sector health system (MSC included), is grossly overstaffed with non-clinical workers. A 2011 study revealed that Canada has 11 times as many public health bureaucrats per capita as Germany, where there are no waiting lists. Canada has 14 ministries of health, each with bloated bureaucracies and commissions scavenging dollars that should go to patient care. The mentality that cost inefficiencies can be balanced by increased taxes or "premiums" is responsible for our escalating charges. Independent health groups in Europe rated Canada as last in value for money compared to hybrid public-private systems that have accessible public systems. The Commonwealth Fund, a non-profit foundation focused on issues affecting lowincome groups, ranked Canada 10th of 11 health systems in developed nations.

What specific changes would I incorporate if I were minister of health? Apart from incorporating the best practices of other hybrid systems (including private-sector competition), I would dismantle the ministry and its committees and commissions. Then I would resign. The finance ministry could fund patients directly (thus empowering them), and also assign budgets to the newly emancipated, self-regulated health organizations, allowing them to cater directly to patient needs. Maybe our June constitutional court challenge will point us in that direction. Dr. Brian Day is an orthopedic surgeon, medical director of the Cambie Surgery Centre, and a former president of the Canadian Medical Association.

Dr. Brian Day says bureaucrats at the Medical Services Commission sent him cheques totalling hundreds of thousands of dollars for services on patients he had never seen.

Monthly premiums would have ranged from $235 to $391, even as high as $3,000 under some scenarios, the administration said. At those prices, healthy people were unlikely to sign up. Suggested changes aimed at discouraging enrollment by people in poor health could have opened the program to court challenges, officials said.

“If healthy purchasers are not attracted ... then premiums will increase, which will make it even more unattractive to purchasers who could also obtain policies in the private market,”

Sebelius said the administration wants to work with Congress and supporters of the program to find a solution. But in a polarized political climate, it appears unlikely that CLASS can be salvaged. Congressional Republicans remain committed to its repeal.

"When we looked across the for-profit insurers in Canada over the past 20 years, for the plans that are typically bought by individuals and small- or medium-sized employers, there was a pretty dramatic change in the gap between the premiums people paid in and the benefits that got paid back to them," Law said in an interview. "Whereas Canadians were paying in a dollar and getting 92 cents back in 1991, they were paying a dollar and getting 74 cents in 2011."

In the U.S., when a greater share of premium revenues goes toward administration and profits, under the Affordable Care Act, known as Obamacare, the excess has to be rebated to plan members to the tune of $1.1 billion in 2012.

About 17,500 people - one in five seniors - use the Shelter Aid for Elderly Renters which can provide $180 per month to people with incomes below $22,000. The money is available only to those who rent their homes, which is an estimated 20 per cent of B.C. seniors, according to Mackenzie's office. Seniors in Metro Vancouver were more likely to know about the grant, but it's used most within the boundaries of the Interior Health Authority, where half of the seniors surveyed received it. Those who are homeowners can defer property taxes until their home is sold (or until death) via the province's Property Tax Deferment Program. Yet only 40 per cent of senior homeowners with household incomes below $30,000 were aware of the program, compared with 75 per cent of homeowners with incomes greater than $60,000.

Seniors make up 17 per cent of the population, a figure that's expected to double during the next two decades. The B.C. Seniors survey, conducted in conjunction with the B.C. Vital Statistics Office and HealthLink B.C., says its margin of error is plus or minus 4.38 per cent. Susan Moore, director of an information and referral centre run by the West End Senior's Network in Vancouver, said she sees people scrimp on food and medications because they have never asked the government for anything and they don't know there is help available. The full report is available at seniorsadvocatebc.ca.

Consumer health advocates say they aren’t surprised that women’s claims for long-term-care insurance are higher than men’s.Because women typically live longer than men, they frequently act as caregivers when their husbands need long-term care, advocates say, thus reducing the need for nursing help that insurance might otherwise pay for. Once a woman needs care, however, there may be no one left to provide it.

“The Affordable Care Act recognized the gender bias in health insurance,” she said. “The same [rules] should apply to long-term-care insurance.”

A 2012 study by the National Women’s Law Center found that 92 percent of top-selling health plans in the individual market practiced sex-based pricing in states where the practice was allowed. (Fourteen states banned or limited the practice, according to the report.) Nearly a third of plans charged women at least 30 percent more than men for the same coverage, even plans that did not include maternity benefits, the study found.

Insurers that sell individual and small-group health policies on the state-based health insurance exchanges or outside them on the private market in 2014 will be able to vary premiums based only on geography, family size, age and tobacco use. (Plans that have grandfathered status under the law are exempt from these requirements.)

Under federal laws against sex discrimination in the workplace, employers are generally prohibited from charging women more than men for the same health insurance coverage.

"The people that I worry about the most in this are actually the working poor," he said

About 40 per cent of households in the two lowest income groups spent more than five per cent of their total after-tax income on health-care services, compared with 14 per cent of those in the highest income group. The spending increase between 1997 and 2009 was greatest for households in the lowest-income group, at 63 per cent.

Lower-income households were more likely than higher-income households to spend more than five per cent of their after-tax income on health care services, Law and his co-authors found.

"I worry about their ability to access prescription drugs," since they have a "relatively low income" and probably don't have benefits through their work

Throughout the study period, the three largest components of out-of-pocket health-care expenditures were: Dental services. Prescription medications. Insurance premiums. In 2009, household spending in those categories averaged $380 (dental), $320 (medications) and $650 (insurance premiums).

"Faster increases in out-of-pocket spending for lower-income households may have implications for access to health care," the report says."Lack of insurance and the burden of out-of-pocket expenditures have been associated with inequitable use of services such as dental care and prescription medications."

Earlier this month, Robyn Tamblyn of Montreal's McGill University published a study in the Annals of Internal Medicine of nearly 1,600 patients in Quebec who received a first prescription between 2006 and 2009. Overall, 31 per cent of the prescriptions weren't filled within nine months and drugs that cost the most were the least likely to be filled.

While the Affordable Care Act managed to bring basic health insurance to almost everyone in the country — about 90 percent of Americans are covered — for many people it's not enough.

Rising deductibles and copayments can mean people don't get much benefit from paying monthly premiums.

High-deductible plans like Powell's, he said, are now the norm.

The PQ also wants to ensure every Quebecer has a family doctor, something it plans to accomplish in the next four years. To do this it will expand the current model of team-based primary care called groupes de médecine de famille (GMFs) – adding 61 to the current complement of 244 at a cost of $36 million, according to the party’s financial plan.

Furthermore, the PQ wants more emphasis on the health-care “team” by making better use of nurses (including more nurse practitioners), pharmacists and others. The financial plan earmarks another $60 million for additional manpower in GMFs.

The PQ would also move ahead with activity-based funding for hospitals

The PQ has not said categorically that it would do away with the ASSS, but during its time in opposition it said the health ministry is overly involved in day-to-day operations of health care.

One promise that will please taxpayers is the elimination of the provincial health premium – a $200 head tax – that collects about $1 billion a year

The PQ would recoup about 60 per cent of the revenue lost from the premium by adding two new income tax brackets for people earning more than $130,000 and $250,000 per year.

The health care reform law enacted last year calls for cutting more than $400 billion from Medicare over the next decade, primarily by slowing the rate of growth in payments to health care providers and phasing out unjustified subsidies to private Medicare Advantage plans that insure roughly a quarter of all enrollees. Republican leaders, who denounced those cuts in 2010, have since embraced Representative Paul Ryan's proposal, which adopts virtually all of the same reductions. Even these will be difficult to achieve without driving out providers, according to the government's nonpartisan budget analysts.

Since January 2010 the growth in Medicare spending has actually slowed to an annual rate of about 4 percent, less than half the annual rate for the previous decade

The only way to make Medicare sustainable is to have it grow at the same rate as the economy that provides the tax base to support it. In recent years, Medicare spending has been growing faster than gross domestic product, by roughly 1.7 to 2 percentage points.

Policy experts of varied political stripes have proposed a host of ways to eliminate excess spending without harming beneficiaries or the medical system. Some would charge higher Medicare premiums for those able to afford them, or raise the age of eligibility, or increase cost-sharing by beneficiaries to deter unnecessary use of medical care. All such proposals have strengths and weaknesses that need to be carefully analyzed.

A more radical proposal, championed primarily by Republicans, is to stop providing Medicare payments for specified benefits no matter the cost and instead give beneficiaries a set amount of money to buy private insurance policies that might not provide the same benefits. These so-called premium-support or voucher plans come in many flavors - some good, some bad - and would need to be carefully vetted. The most extreme version, proposed by Representative Ryan, would save the federal government a lot of money mainly by shifting big costs to beneficiaries and driving up costs for the rest of the health care system.

Medicare's system for paying health care providers is a big part of its spending problem. The traditional Medicare program pays doctors separate fees for each of 7,000 different services, such as a diagnostic test, office visit or surgical procedure. This encourages excess use of medical tests and procedures

The solution, most experts agree, is to have Medicare pay doctors and other health care providers fixed sums to manage a patient's care and then let the doctors decide which services are truly necessary. Close monitoring would be needed to ensure that doctors don't deny medically important services to improve their bottom lines.

Medicare's coverage has some glaring gaps that need fixing. There is no provision for long-term care in nursing homes or at home, forcing many middle-class people to impoverish themselves to qualify for Medicaid. And patients can be socked with very high or very low rates of cost-sharing depending on whether care is delivered in a hospital, nursing home, by a doctor or at home. This crazy-quilt pattern confuses patients about the costs they will have to pay and almost certainly complicates and drives up the costs of administering the program.

the Canada Health Act is being held hostage

the False Creek Surgical Clinic in British Columbia

it has only

MG: We treat our employees based on merit. Whether they receive perks and raises and also enjoy job satisfaction is very much geared towards their productivity. They get paid really well, so it is a very pleasant working environment for all of us.

three operating rooms and uses the labour force from the public system in their off-times

From the perspective of the Workers Compensation Board, it’s quite hard for them not to send patients to us when you consider that it has been such a success story in provinces. In British Columbia, it is the norm for patients from the Workers Compensation Board to receive care in private facilities.

FC: It is said that one of the reasons the public healthcare establishment is resisting competition is that private clinics are typically not unionized, which means no union dues for public sector union bosses. Your view?

performs over 3,000 procedures a year

MG: I would say that is true.

Seniority and the advancement of an individual because of seniority is simply never going to occur in our system.

FC: The Maples Clinic has become synonymous in Manitoba with a single piece of equipment, your MRI machine.

FC: One of the government’s arguments is that they can produce an MRI scan for $300, compared to your price near $700.

MG: The Workers Compensation Board came up with a plan where they are willing to pay a premium in order to get patients back into the workforce faster. The prerequisite was that patients would be treated within a very short time frame—ten days from the time of consultation to surgery within 21 days—to get people back into the workforce faster. That has resulted in huge savings in lost wages, and that savings was actually expanded to businesses and corporations in the form of lower premiums

How much did they actually save in B.C. by using the False Creek clinic?

over two million dollars

In most other developed countries with universal access, the purchaser of health services is a different entity than the providers.

we should open up Medicare services to private insurers

The fastest growing aspect of private health care insurance is for drugs, with premium inflation set at 12.1% this year.   That is down from 14% last year due reportedly to the implementation of government led generic drug pricing reform and the expiry of  patents for several major drugs.  Apparently, however, this will be offset in the future by the rise in expensive 'biologic' and specialty drugs.

Poor young people with zero disposable income are being asked to pay monthly premiums of $150 and more, and they’re opting out, inevitably sinking Obamacare in the process.

Those young people who actually do buy Obamacare plans—to avoid the “mandate” fine— will be further enraged when they attempt to actually use their “insurance”.   Many of the cheapest plans—the obvious choice for most young people— have $5,000 deductibles before the insurance will pay for anything.   For poor young people this is no insurance at all, but a form of extortion.

At the same time millions of union members are being punished under Obamacare: those with decent insurance plans will suffer the “Cadillac” tax, which will push up the cost of their healthcare plans, and employers are already demanding concessions from union members in the form of higher health care premiums, co-pays, deductibles, etc.

This has the potential to bust the whole Taft Hartley health care system that millions of union members benefit from,

Moore also relies on the trump card argument of the pro-Obamacare liberals: there are progressive aspects to the scheme—such as the expansion of Medicaid— and therefore the whole system is worth saving.

Instead of wasting energy trying to pry Obamacare out of the grip of the corporations, Moore would be better served to focus exclusive energy towards expanding the movement for Medicare For All, which he claims that he also supports, while maintaining that somehow Obamacare will evolve into Single Payer system.

Most developed nations have achieved universal health care through a single payer system, which in the United States can be easily achieved by expanding Medicare to everybody.

However, as a percentage of after-tax income, spending was greatest for lower-income households. In 2009, out-of-pocket health care expenditures represented 5.7% of the total after-tax income of households at the lowest end of the income distribution, compared with 2.6% for households at the highest end.

In 2009, almost 40% of households in the two lowest income quintiles reported this level of out-of-pocket health care expenditures, compared with 14% of households at the top end of the income distribution.

Throughout the 1997-to-2009 period, the three largest components of out-of-pocket health care expenditures were dental services, prescription medications and insurance premiums. In 2009, household spending in these categories averaged $380 (dental), $320 (medications) and $650 (insurance premiums).

Trends in out-of-pocket health care expenditures in Canada, by household income, 1997 to 2009