A Useful Reform in Medicare

Posted: Jan 02, 2006 9:22 AM

Dr. Jacques Chaoulli (pronounced "shao-lee") is a wiry French Canadian physician of 53 who has almost single-handedly poked a huge hole in Canada's vaunted government health-care system. Several years ago, tired of being unable to treat patients outside of the compulsory system (because they were forbidden by law to buy private health insurance wherewith to pay him), he recruited a willing patient and took the government to court.

Under the existing system, Dr. Chaoulli argued, many patients were forced to wait months for treatment, sometimes at the risk of their lives, even though they would gladly have bought private health insurance and paid doctors of their own choice, if it were legal to do so.

On Jan. 9, 2005, the Supreme Court of Canada agreed with him, holding that the law's prohibition against private health insurance was unconstitutional. Henceforth a Canadian who becomes ill can go to a doctor, get treated promptly, and pay him with the help of private medical insurance he has purchased. Or he can wait in line, as before, and accept government-paid care when the doctors in the system get around to him.

Dr. Chaoulli, whose name has become a household word in Canada, is now concentrating on making sure that Canadians who want private health insurance get the best possible bargain for their money, and is devising an accreditation system for that purpose. But he has also looked across Canada's southern border and noticed that the plight of U.S. citizens over 65 is not all that different from the one Canadians used to suffer.

If an American over 65 becomes ill and wants to go to a doctor, he must choose one who is a participant in the Medicare system if he wants the government to pick up the bill. The Medicare bureaucrats, in turn, will decide how much to pay the doctor for his services -- or indeed whether to pay him at all, if they decide the treatment provided isn't "covered" by Medicare.

If the patient chooses a doctor who charges more than Medicare allows, he is technically free to do so -- but the doctor will be penalized by being forbidden to accept any patient under the Medicare system for two years. The doctor, in other words, is compelled to "opt out" of the Medicare system for that period. Some doctors who are in great demand can afford to opt out, but many obviously cannot. Payments to them (under Part B of Medicare) are officially called "voluntary," but clearly are not.

Thus Medicare, Dr. Chaoulli points out, is a de facto monopoly. Why not, he asks, let America's elderly decide which doctors they want, letting them remain "part in, part out" of Medicare? If they choose to go to a doctor for treatment that is reimbursed under the Medicare system, fine. But if they prefer a doctor who charges more than Medicare allows, they should be allowed to pay him without his suffering any penalty. Health insurance to cover such payments would be available.

In Canada, the government was reportedly privately pleased by the Supreme Court's decision, because it offered a way out of the waiting lines that had generated so much criticism. Whether the U.S. government would welcome a comparable reform in Medicare, as outlined above, is an open question. But Dr. Chaoulli anticipates that the American Medical Association would resist it, because it would tend to increase the pressure for better care under the Medicare system.

In any case, Chaoulli believes that the surest road to reform in the United States, as in Canada, is through the courts, rather than the legislature. Congress would be tempted to play with the concept, like a kitten with a toy mouse. The courts, on the other hand, might reasonably be hoped to see that giving the elderly a freer choice of medical care would be a valuable step on the road to contentment.