Running head: PRIVATIZATION OF HEALTH CARE

Privatization of Health Care (The Sacred Cow has Clay Feet)
Nursing 438, Assignment #
Athabasca University
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Tutor: Wendy Kemp

Privatization of Health Care
Without exception, the largest issue in Canadian health care (and possibly the entire Canadian psyche), currently, is the debate regarding privatization in health care. There is a growing recognition from all stakeholders (governments, health professionals, and the public) that the Canadian health care system requires meaningful reform to manage growing costs, waitlists, emerging technologies and medical advances. The nature of this reform is contentious, since philosophical and ideological differences abound, financial and political rewards exist, and special interests compete for power and influence within the health care industry.
Consequently, this issue is of interest to nurses who comprise the majority of health care professionals. Nurses are at a crossroads in this debate, since the medical community has taken new steps towards support for privatization during recent developments, public opinion is moving towards support for innovative reform, and governments wax eloquent about future initiatives. Nurse leadership, however, has rejected consideration of private solutions at this time.
This paper will discuss the issue of privatization from several perspectives, analyze how nursing should approach the issue, and offer strategies for resolution. Specifically, this paper will seek to answer the question: “What should be the attitude of nurses towards privatization, and in what way should reform be advocated?”
Historical analysis. All first world countries are challenged to balance adequate, accessible health care with increased costs and limited human and non-human resources. Although Canada is not alone in the consideration of health care reform, out of all Organization for Economic Development and Cooperation (OECD) countries (those that share a commitment to democracy and market economies), Canada is the only one to outlaw private parallel health care (Esmail & Walker, 2005). Despite this, it is claimed by some that the Canadian health system is symbolic of Canadian identity, one that is fair, universal, and accessible (Canadian Nurses Association (CNA), 2001).
Tommy Douglas, the “greatest” Canadian (Canadian Broadcasting Corporation (CBC), 2004), is credited with being the father of socialized health care. His vision of ‘health care for all’, during the 1960’s, led to the creation of the Canada Health Act and its ‘principles’ of public administration, comprehensiveness, universality, portability, and accessibility (Department of Justice Canada, 2004). 
Due to these ideals, many Canadians share the dogma submitted by socialistic institutions such as the Canadian Auto Workers (CAW, 2001, para. 1): “The peoples of Canada believe that health care is a fundamental right of every human being…” These institutions have encouraged some Canadians to substitute their values for a false perception, and this has led to rigid thinking (even by nurses) about the nature of health care reform. Douglas himself could not have envisioned the vast technological advances gained in health diagnostics (and other factors) that challenge the relevancy of the Act’s principles, or the ideological quagmire that stifles meaningful debate, currently. 
Ethical and legal analysis. The CNA (2002) has developed a Code of Ethics, which guides the ethical behavior of registered nurses. These values include: 1) provision of safe, competent and ethical care, 2) promotion of health and well-being, 3) promotion of choice, 4) promotion of dignity, 5) provision of confidentiality, 6) promotion of justice, 7) provision of accountability, and 8) advocating for quality practice environments.
Nurses may face ethical uncertainty, dilemma, or distress (CNA, 2002) in the application of these values to the issue of health care privatization. One example of this regards the ethic of choice, where nurses are admonished to be “…committed to building trusting relations…to ensure that a person’s choice is understood, expressed, and advocated” (CNA, 2002, Code of Ethics, p. 11). Patients who do not trust nurses at large, because they (nurses) advocate for what is essentially a political position (either for or against privatization), are at risk for failure to develop trusting relationships with ancillary benefits.
The holiest of ‘grails’, the Canada Health Act, is widely supported by nurse leadership as having principles that should not be waived. With respect to the principle of universality (as an example), members of the Canadian Forces, ranking RCMP officers, federal prisoners (Department of Justice Canada, 2004), and Worker’s Compensation claimants are excluded from this Act. It is hoped that venerable members of society like soldiers and police officers are not at a disadvantage by being uninsured, and of course they are not; they enjoy expanded access and services not available to the ‘public’. 
If the esteemed individuals within the Canadian Forces, RCMP, and federal penal system benefit from exclusion of the Canada Health Act, then perhaps every Canadian citizen should. How can this disparity, related to class structure, be tolerated in such an egalitarian country as Canada; and how can nurse leadership endorse this disparity by refusing to criticize the Acts’ faulty tenets?
Nursing analysis. Nurses have recognized the failings of the current health system, and agree that reform is overdue (Alberta Association of Registered Nurses (AARN), 1995). They identify the inflexibility of the system, and complain that the status quo is being maintained instead of displaced. Surprisingly, a nurse academic poses one of the most significant observations, which affect this debate. Jan Storch (1998) states “…suggestions [specific to reform] appear to be constrained by the status quo of health care. There is a…need…to question whose interests are being served in keeping the system relatively unchanged since the 1960’s” (as cited in CNA, 2001, brief, p. 12).
Despite this recognition, there remains a decided hostility to the idea of (further) privatization of health care from nurse leadership (CNA, 2001). What is the source of this hostility? Simply, it is a commitment to self-service and steadfast devotion to a particular anticapitalistic ideology: one that ignores reality and relevancy, and chooses to support monopoly and mediocrity. 
Rank and file nurses are being represented by organizations that support and/or affiliate themselves with groups that support antiprivatization ideology. For example, the Friends of Medicare (2005) lists the United Nurses of Alberta (UNA) as one of its supporters. The ‘Friends’(2005) claim that an individuals’ action in obtaining private health insurance is immoral and imply that it is only accessible to the ‘rich’. This imposition of values promotes paternalism and dishonors patient autonomy. Further, this may be a challenge to the nursing ethics of choice and dignity (CNA, 2002). Accordingly, nurses should seek to be ‘friends of patients’ instead of ‘friends’ of a Medicare system. Because of nurses’ lack of choice regarding workplace representation, some nurses who do not support this view are implicit in preposterous ideology by virtue of membership in the UNA. 
The Canadian Medical Association (CMA) supports the principle that private health insurance should be available to patients who cannot access timely care in the public system (2005). By increasing patient autonomy and decreasing wait times, without the wholesale disposal of the public system, this principle appears to be an innovative approach to honoring the Acts’ principle of accessibility; but do nurses agree? CNA president Deborah Tamyln (2005) states, “…we are unequivocally against increased privatization” (News Releases, para.3), in response. It seems steadfastness to the status quo, including further ‘investment’ in the system is the extent of innovation from nurse leadership at large.
Nursing perspectives on health care reform appear contradictory and somewhat irrelevant. Nurse leadership suggestions include self-serving initiatives (‘increase’ the number of nurses), actions which do little for the immediate and short term (increase focus on primary health care), and the predictably tiresome (increase public funding) (CNA, 2005). Although the scope of nursing leadership involves the promotion and advancement of nursing opportunities, it may not be able to separate these aims from truly innovative reforms, as the likelihood of competing interests is clear.
In this way, it is nursing interests that are being maintained (in response to Storch’s assertion) by the status quo in health care. Nurse leadership, challenged to offer innovative and meaningful direction, seems to have followed the path of least resistance instead of “... [possessing] the fortitude to express ideas that run counter to prevailing wisdom” (McIntyre & Thomlinson, 2003, p. 502).
Social and cultural analysis. One individual has authored an historic case for health care reform. George Zeliotis waited for hip replacement surgery for a year (hardly a model for health care accessibility), so he presented a case in court, which appealed for his right to obtain private health insurance. On June 9, 2005, the Supreme Court struck down a Quebec ban on the use of private insurance (CBC, 2005). Zeliotis may have a greater claim as a patient advocate (at least in terms of autonomy) than nurses do, based upon his efforts. This court decision, still in its infancy, may potentiate reforms previously unconsidered in Canada, for the benefit of all patients.
What do the public in general believe about privatization in health care? Seventy-three percent of Canadians agreed that access to private health facilities, paid with private resources, should be available to those who have to wait unreasonably in the public system (Health Canada 2002a). Canadians (88 %) also believe that there is a current or impending funding crisis in the current system, which will not be alleviated by increased funding alone (Health Canada, 2002b). 
Canadian views and values regarding universality in health care are changing. According to Health Canada (Commission on the Future of Health Care in Canada, 2002, para. 6), they “…have increasingly adopted a mentality that expects responsiveness and a high quality of service, delivered in a manner that meets their individual needs”. Canadians are becoming increasingly intolerant towards the rhetoric of equality in health care, and are realizing that they are being denied choice and timely access to the care that they need.
So, if it is true that Canadians, (and the Supreme Court) overwhelmingly support innovative reform (including ‘permission’ to spend their own money on health care), then nurses risk alienating themselves as allies of patients by opposing meaningful health care reform. 
Political analysis. A report to Parliament by the Standing Senate Committee on Social Affairs, Science and Technology (2002) stated that “…Canada’s publicly funded health care system, as it is currently organized and operated, is not fiscally sustainable given current funding levels” (chapt.1, para. 2). The Committee cited the perception of ‘free’ service as one reason why demand could never be met; and offered three options to Canadians, for the sustained future of health care provision. They were: 1) accepting that growing waiting lists are a reality with the current state of affairs (a threat to the principle of accessibility), 2) accepting an increase to government revenue (increased taxation; a threat to the ethical principle of justice) or 3) development of a parallel, privately funded tier of health services, supplementary to the public system (a threat to certain anticapitalistic ideology). The Committee (predictably!) implied that the second choice (the one that increased power to the Federal Government), was most desirable.
Incidentally, the foresight of this Committee in 2002 is remarkable. It predicted that a failure of the Government to manage wait times could lead to a Supreme Court judgment allowing the purchase of private health insurance, which subsequently occurred in 2005, in the previously mentioned Zeliotis case. Alarmingly, the Committee supported patients’ access to health services in other countries, if necessary! 
The Government shares a perspective with nurses, namely, to recognize failings in the system, and then to recommend ‘reforms’ that benefit their own interest instead of pursuing the principle of beneficence for patients.
Critical feminist analysis. Interestingly, for all of the concern that nurses have over patriarchal structures in health care; their organizations appear to subscribe to these self-same patterns. Organization and influence is used to minimize diversity of ideology, and in this way, the status quo in nursing is preserved. In some ways, nurses can be accused of groupthink, where, according to Sullivan and Decker (2005), “Through prolonged close association, group members come to think alike and have similar prejudices and blind spots…” (p. 118). This phenomenon can lead to self-censorship of opposing views, pressure to conform, and apparent unanimity on highly debatable issues (Sullivan & Decker, 2005).
Nursing is currently preoccupied with the achievement of increased power and influence in health care. This may be one of the reasons that nurse leadership is doggedly opposed to increased privatization, where presenting an unwavering ‘principled’ stance creates the perception of power. Although the current health care system has a 30% involvement in funding from the private sector (Romanow, 2002), some nurses have determined that any increase is unacceptable. What is the evidence for this assertion? Why is 30% the standard for appropriate private involvement, and not any more (or less)?
Resolution. The conflict between self-interest and encompassing reform alternatives creates a barrier to the resolution of the privatization issue. Federal and provincial governments are in a perpetual turf-protecting and vote-cultivating struggle, always quick to remind the public what its values are when politically expedient. Nurses recommend reform initiatives that directly increase their own power and influence, and demonize those which appear to be a threat.
Patients and the public may be their own best allies in the procurement of health care reform that truly addresses the deficits in the current system. Fortunately, they are finding collaboration from some in the medical community, but sadly, nurses seem to oppose this cause.  Nurses have an ethical obligation to promote health and well-being, advocate for patients, and promote choice and dignity. They freely acknowledge that the health system is failing patients, but are reluctant to explore all prospects for reform because some options are more self-beneficial.
The Zeliotis case may well be the pinhole in the levee of Canadian public health care, acting as a catalyst in the birth of a new system. Nurses have been admonished by Chow et al. (1999) to “…adopt a new style of leadership to participate in reshaping the delivery of health care” (as cited in McIntyre & Thomlinson, 2003, p. 495). This new style of leadership requires the consideration of alternative ideology at minimum, in order to be relevant and meaningful. 
The adoption of a new leadership style in nursing poses an interesting challenge. Biases and assumption about privatization in health care are being taught to nursing students (McIntyre & Thomlinson, 2003), and this creates ever new disciples of prevailing ideology. Those who differ from this perspective face a risk for “alienation from co-workers and hostility from… administrative officials” (McIntyre & Thomlinson, 2003, p. 10). Still, nurses need to communicate their differences, stay informed about the issues, and seek to influence positive change where the opportunity arises. This can be done by engaging their peers and leaders to consider new ways of thinking though the discourse of ideas.
McIntyre and Thomlinson (2003), (and others) have raised themes of nurses’ desires for increased power, autonomy, and recognition within the health care system, however, these positive aspects will not be realized by virtue of nurses’ static position or wishful thinking. According to Sullivan (2004), “Health care is a perfect example of a fluid, changing system, requiring flexibility, resourcefulness and resiliency from its participants. Nurses who want everything to stay the same… [are subject to] a sorry awakening…” (p. 13).
Conclusion. Despite the politics, economic and social realities are indicating that change must occur. Although nurses are large in number, their influence alone is not likely to affect this issue regarding if privatization will occur. Rather, nurses are much more likely to influence the face of a newly reforming system, and help to guide how change occurs on an organizational level.
It seems clear that resistance to privatization is a losing battle; the pressures for substantial reform are very great and increasing all the time. Nurses currently have a real opportunity to take genuine and meaningful leadership on this issue, helping to guide the merging of a privately funded tier of care with the public system, and safeguarding the values of Canadians.  Nurses should seek to be advocates for patients, not activists for political gain. In order to maintain a positive influence and maintain relevancy, nurses must begin to adjust their attitudes toward the constructive aspects of private involvement in health care, while preserving ethical obligations, values, and public goodwill.
References
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McIntyre, M. & Thomlinson, E. (2003). Realities of Canadian nursing. Philadelphia: Lippincott.
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Sullivan, E. J. (2004). Becoming influential. New Jersey: Pearson.
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