| Chapter 1: | Examining Provincial Variability |
These changes are sometimes accompanied by load shedding—that is, removing some services from the basket of necessary health services at the provincial and territorial levels (Deber 2002; Bendrick 1989). Among the items delisted by various provinces are the following: routine circumcision of newborns, eye refractions, chiropractic services, removal of varicose veins, in vitro fertilization, chiropractic surgery, artificial/intrauterine insemination, and otoplasty (Madore 2005). Privatization may also involve changes in the delivery of services, including the use of vouchers and contracting out services, purchase-of-care arrangements, and other public–private associations (Deber 2002; Kamerman and Kahn 1989).
This study focuses on advances that have taken place in the operation of investor-based, privatized commercial provision. Some of these enterprises are engaged in purchase-of-care arrangements under provincial medicare rules while also providing commercial services outside this framework; others operate as commercial services entirely outside of medicare provision of necessary health services. Thus the CIHI data to which we refer with respect to public–private splits in health care expenditures are actually substantial underestimates regarding the activity of commercial for-profit enterprises in the Canadian provincial and territorial health care systems.
A subtle version of the argument for more inclusion of commercial privatization is that the public sector lacks the ability to finance—on its own—the technological advances and the extent of services demanded by Canadian society; thus “publicly regulated” participation by the private sector is needed and desirable (Mackie 2001; Maioni 2001). In this vein, Deber noted the observation of Deng Xiaoping that “it does not matter whether a cat is black or white as long as it will catch mice” (Deber 2002, 2). Though privatization may involve increased use of private, not-for-profit, community-based, nongovernmental organizations (most Canadian hospitals fall into this category), our analysis primarily examines the expansion of private, for-profit, nongovernmental organizations.