(Paru dans La Presse, le 27 janvier 2006, p. A-17)
Le gouvernement Charest indiquera bientôt comment il compte donner suite à l'arrêt Chaoulli-Zeliotis, par lequel la Cour suprême a invalidé les articles de loi qui prohibent les contrats privés d'assurance maladie portant sur les soins qui sont également assurés par le régime public.
La Cour suprême a pris cette décision dans un contexte où les patients attendent pendant des délais excessifs, qui selon elles mettent en péril leur santé et leur vie. Ces délais excessifs existent encore aujourd'hui en dépit des centaines de millions de dollars d'argent fédéral et québécois qui ont été ajoutés au budget de la santé depuis quelques années.
La Cour a rappelé à juste titre la hiérarchie des valeurs qui doit nous guider: le droit à la vie prime sur l'objectif de préserver l'intégrité du système de santé public. Lorsque ce système n'arrive pas à répondre à la demande, les gens doivent conserver une sortie de secours. À l'heure actuelle, seuls les gens fortunés - ceux qui ont les moyens de débourser le prix de soins médicaux de leur poche - ont accès à cette sortie de secours dans le privé.
Même à l'intérieur du système public, certains patients sont déjà moins égaux que d'autres dans le système actuel. Ainsi on peut payer de sa poche ou avoir une assurance privée pour subir une radiographie ou des tests médicaux dans le privé, même s'il s'agit de services médicalement requis. Les personnes biens branchées auprès des professionnels de la santé obtiennent des rendez-vous plus facilement que les gens dépourvus de telles relations. Une personne assurée par la CSST ou la SAAQ qui subit un accident au travail ou sur la route est traitée plus rapidement qu'une autre personne subissant la même blessure en d'autres circonstances. Le système de santé se dépêche de traiter ces assurés d'abord car les indemnités d'invalidité coûtent cher à ces assureurs.
Argent frais
Le secteur de la santé englobe les établissements du «réseau» ainsi que tous les prestateurs de soins privés. La levée de la prohibition qui frappe actuellement l'assurance maladie privée permettra l'injection de nouveaux fonds dans le secteur de la santé, en supplément au financement public. Mais il y a aussi lieu, de l'autre coté de l'équation, de libérer l'offre de réserve.
À l'heure actuelle, la loi oblige les médecins à choisir: s'ils veulent exercer contre rémunération de source privée, ils doivent se désengager totalement de l'assurance maladie publique; c'est tout l'un ou tout l'autre. Or, permettre l'assurance maladie privée tout en maintenant cette restriction du coté de l'offre pourrait pousser plusieurs médecins à se désengager du régime public pour se consacrer entièrement aux soins financés privément.
Un tel déplacement de l'offre de soins est à éviter dans l'intérêt des patients qui resteront en attente de soins financés publiquement; c'est une augmentation de l'offre qu'il faut viser. Les médecins participants à la RAMQ devraient donc pouvoir travailler aussi contre rémunération privée, en marge de leur prestation normale de travail au service des patients dont les soins sont financés publiquement.
Accroître l'offre
Contrairement à une idée reçue, il existe bel et bien une offre en réserve. De nombreux chirurgiens opèrent seulement une ou deux journées par semaine en raison des contraintes budgétaires des hôpitaux. D'autres médecins sont limités par les plafonds salariaux. Dans l'ensemble, les médecins québécois travaillent environ 10% de moins que la moyenne canadienne. Tous ces faits indiquent qu'il est possible d'accroître l'offre de services médicaux.
Ces propositions permettraient d'accroître tant le financement que l'offre de soins médicaux, de sorte que plus de soins seraient dispensés chaque année. Elles s'inspirent d'une vision d'un secteur de la santé mixte, englobant un système public égalitaire et un secteur privé innovateur. Elles rapprocheraient le modèle d'assurance maladie québécois de ceux que l'on retrouve en Europe, par comparaison à ceux en vigueur au Canada et aux États-Unis.
vendredi 27 janvier 2006
mardi 17 janvier 2006
Give parents power of choice
(Paru dans le National Post, le 17 janvier 2006)
The type of support promised for childcare services is one of the issues that has defined the three principal political parties during this federal election. Stephen Harper's Conservatives have promised approximately $1,200 per year to families for each child under 6 years of age; the Liberals have promised a national early learning and childcare initiative based on the Quebec model of subsidized childcare; and the NDP have promised a Child Care Act that would reserve federal funds for licensed, high-quality, non-profit childcare centres.
Those who support the Liberals' national program cite the example of the childcare centres set up in Quebec after the quasi-nationalization of day care in 1997. Canadians have been led to believe that the Parti Quebecois (PQ) provincial government in power at the time had found the right formula and that all parents have access to a quality service at the affordable price of $7 per day. However, the situation in Quebec is not nearly as rosy.
The Quebec childcare reform decreased outlays for parents from about $25-30 per day to $7, effectively eliminating cash-flow issues for lower-income families. But the drop in price increased demand and resulted in a shortage of spaces (given the government's limited budget capacity), as well as waiting lists of up to 2 years for subsidized spaces. While waiting, parents who need childcare continue to pay the market price. This has effectively created a system where access to a subsidized space depends neither on parents' financial circumstances, nor on the needs of children who may require special help to prevent learning difficulties later. The only factor that now plays a role is the rank of a child on a waiting list, i.e., bureaucratic convenience.
The way funding is channeled to these childcare centres explains many of the shortcomings of the 1997 reform. Quebec shifted from a system that helped parents buy childcare services to a system of subsidies to the providers of those services. The PQ government limited the purview of childcare centre administrators and began setting the pay of childcare workers. So the salary demands of those workers were then directed to the public treasury rather than to the childcare centre administrators. The negotiation of sector-wide collective agreements has led to strikes, which have caused the loss of 73,000 person-days of work since 1997, more than double the 34,000 person-days lost between 1990 and 1997.
In addition to fostering labour disputes, this system of funding providers instead of parents has also limited parental choice. The childcare centres certainly meet the needs of many parents. But with the growth of freelancing, telework, and sporadic and part-time work, an increasing number of parents are looking for flexible options that these childcare centres are hard-pressed or unwilling to provide.
Several surveys have shown that many Canadian parents prefer to care for their children themselves. Among specialists in early childhood development, some advocate early socialization in group childcare venues, some favour parental care at home at least for children who do not face any specific challenge. Yet all forms of support for childcare by a third party ignore the needs of parents who choose parental home care, for reasons related to their values or their individual economic circumstances.
How can we better acknowledge the range of parental preferences? What would reduce the potential for labour disputes in publicly funded childcare centres? The key is in the allocation of public funds for childcare among the different types of support. If the government simply wants to redistribute wealth to families, cash transfers and tax rebates suffice; there is no need to fund childcare specifically. If government wants to increase the labour supply, then it can help parents purchase childcare services without any restriction as to the type of services provided. If government believes that early socialization is beneficial for children, then it can help parents buy childcare services in centres that have appropriate early learning programs. But none of these policy objectives requires channeling funds directly to childcare service providers.
When purchasing power remains in the hands of those who benefit from a service, providers remain responsive to user needs. When funding for that same service comes from a central authority, conformity to norms often takes precedence.
In the end, there are several good reasons to empower parents through cash transfers, vouchers, or tax rebates for childcare rather than directly subsidizing childcare service providers.
The type of support promised for childcare services is one of the issues that has defined the three principal political parties during this federal election. Stephen Harper's Conservatives have promised approximately $1,200 per year to families for each child under 6 years of age; the Liberals have promised a national early learning and childcare initiative based on the Quebec model of subsidized childcare; and the NDP have promised a Child Care Act that would reserve federal funds for licensed, high-quality, non-profit childcare centres.
Those who support the Liberals' national program cite the example of the childcare centres set up in Quebec after the quasi-nationalization of day care in 1997. Canadians have been led to believe that the Parti Quebecois (PQ) provincial government in power at the time had found the right formula and that all parents have access to a quality service at the affordable price of $7 per day. However, the situation in Quebec is not nearly as rosy.
The Quebec childcare reform decreased outlays for parents from about $25-30 per day to $7, effectively eliminating cash-flow issues for lower-income families. But the drop in price increased demand and resulted in a shortage of spaces (given the government's limited budget capacity), as well as waiting lists of up to 2 years for subsidized spaces. While waiting, parents who need childcare continue to pay the market price. This has effectively created a system where access to a subsidized space depends neither on parents' financial circumstances, nor on the needs of children who may require special help to prevent learning difficulties later. The only factor that now plays a role is the rank of a child on a waiting list, i.e., bureaucratic convenience.
The way funding is channeled to these childcare centres explains many of the shortcomings of the 1997 reform. Quebec shifted from a system that helped parents buy childcare services to a system of subsidies to the providers of those services. The PQ government limited the purview of childcare centre administrators and began setting the pay of childcare workers. So the salary demands of those workers were then directed to the public treasury rather than to the childcare centre administrators. The negotiation of sector-wide collective agreements has led to strikes, which have caused the loss of 73,000 person-days of work since 1997, more than double the 34,000 person-days lost between 1990 and 1997.
In addition to fostering labour disputes, this system of funding providers instead of parents has also limited parental choice. The childcare centres certainly meet the needs of many parents. But with the growth of freelancing, telework, and sporadic and part-time work, an increasing number of parents are looking for flexible options that these childcare centres are hard-pressed or unwilling to provide.
Several surveys have shown that many Canadian parents prefer to care for their children themselves. Among specialists in early childhood development, some advocate early socialization in group childcare venues, some favour parental care at home at least for children who do not face any specific challenge. Yet all forms of support for childcare by a third party ignore the needs of parents who choose parental home care, for reasons related to their values or their individual economic circumstances.
How can we better acknowledge the range of parental preferences? What would reduce the potential for labour disputes in publicly funded childcare centres? The key is in the allocation of public funds for childcare among the different types of support. If the government simply wants to redistribute wealth to families, cash transfers and tax rebates suffice; there is no need to fund childcare specifically. If government wants to increase the labour supply, then it can help parents purchase childcare services without any restriction as to the type of services provided. If government believes that early socialization is beneficial for children, then it can help parents buy childcare services in centres that have appropriate early learning programs. But none of these policy objectives requires channeling funds directly to childcare service providers.
When purchasing power remains in the hands of those who benefit from a service, providers remain responsive to user needs. When funding for that same service comes from a central authority, conformity to norms often takes precedence.
In the end, there are several good reasons to empower parents through cash transfers, vouchers, or tax rebates for childcare rather than directly subsidizing childcare service providers.
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