For the last nine months, much of the debate over health system reform in the United States reflects a simple question: What is the role of government versus the role of the private sector?

This same question was recently posed at the 142nd annual meeting of the Canadian Medical Assn. that I was honored to attend as the official representative of the American Medical Association.

This question was posed in the form of a resolution: "The CMA supports a requirement that any medical practitioner providing a medically necessary service to an eligible Canadian in a private health care setting not bill or earn more for that service than they would in the public health system."

Driving the resolution was the social contract that the medical profession forged in Canada to provide medical care for its citizens through its own Medicare system, which set up a recession-protected revenue stream to pay for medical care. The CMA's own blueprint for the future of Canadian health care includes the goal of patient-centered care with seamless access and without financial barriers for patients.

Those who argued in favor of the resolution said fee differentials between the public and private system don't constitute patient-centered care but physician-centered care. They noted that fee differentials are divisive, because they benefit nonprimary care specialists and create perverse incentives for patients and physicians.

For patients, it gives incentives to jump ahead of the waiting lines. For physicians, it gives incentives to charge increased billing fees to enhance one's income. (In Canada, physicians have private practices but also bill the government for the professional services. About 20% to 30% of patients also have private insurance.)

Those speaking against the resolution suggested the monopoly power of the government was not friendly to physicians. They noted that because of the inability of the government to provide all services in a timely fashion, that some provincial governments -- Quebec, for example -- had expanded the number of procedures that the government would pay the private sector to provide from three to 56.

Some in the United States who oppose increased federal government involvement in health care point to the number of Canadians who have come to the U.S. to receive medical diagnostic and therapeutics as the reason why such an expansion will not be good for patients. What is not noted are the Americans who leave the United States to receive orthopedic and cardiovascular surgery in Taiwan, India and other nations by American-trained, American-board-certified physicians in Joint Commission International-accredited facilities at half the cost and with similar outcomes. The consulting firm Deloitte estimates that the number could rise to 6 million by the end of next year.

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