_{Originally published in Canadian Dimension on February 7, 2023}

An old friend of ours recently confessed to using a private clinic for her cataract surgery. She said that, while she felt guilty, she nonetheless received wonderful care and paid with her health card. When we asked the name of the clinic, she said the Kensington Eye Institute (located on Toronto’s College Street). It is indeed a private clinic that provides vision surgeries for cases considered non-complicated. It has justly received a good reputation. But a critical piece was missing from the ‘private’ label. Kensington is a non-profit, community-based eye surgery centre.

It is this essential distinction that is too often missing from current debates about Canada’s health care crisis, even among those who are usually on top of the issues (including our friend). Indeed, the term ‘private’ is often used to purposely hide distinctions (and consequences), with proponents arguing that our health care system is already mainly private. All those hospitals named after saints are not public in the sense that they are not owned by the government. But they are public because of the fact that they are responsible to the public and, in Ontario, fall under the Public Hospitals Act. Their books and board meetings are public. They report publicly. They do not seek a profit nor are they allowed to earn a profit on care.

When we argue that the primary objective of for-profit care is profit, this is not an ideological argument, as Premier Doug Ford insists. Indeed, it is factual. Businesses that do not make a profit go out of business. Moreover, the primary responsibility of for-profit companies is to their shareholders, not the public. So it is often hard to tell where the profits are coming from and what this means in terms of care and care work.

Take the case of for-profit long-term care homes. We know they make a profit; we know they have a pattern of fewer staff, lower pay, more bed sores and more transfers to hospitals. This reveals some sources of profit, but doesn’t provide a full picture. There is indeed gold in the golden years, but too often not for those needing or working in care.

Ford likes to repeat the line that people will pay for standalone services offered by the for-profit clinics he’s granting a larger role in health delivery with their health card and not their credit card. Not to worry, he says, there will still be access to care without fees. But he fails to tell us what the sources of profits will be. There has been talk about ‘upselling’ services that you may or may not need: special lenses for those cataracts, to take just one example. However, there are some indications that the government will also pay more for services in these clinics than in hospitals, meaning that we may pay for the profits through our tax dollars.

When questions are raised about accountability, the answer has been unspecified regulations. It is a rather ironic answer from a government dedicated to removing ‘red tape.’ Some regulations are obviously necessary but many of these will undoubtedly be required, and at more cost to public funds if they are to be enforced. Effective regulations to prevent the poaching of doctors, nurses, and technologists from public hospitals to new ‘independent’ clinics with shorter hours will be very hard to implement.

Our research on scandals about long-term care homes in various countries shows both that the scandals are more likely to arise in for-profit homes and that in North America especially they are more likely to result in more, but not necessarily more effective, regulation. Unlike in Sweden and Norway where governments cancel their contracts with for-profit owners when scandals are exposed in the media, North American governments choose to regulate. In the US we are repeatedly told that care homes are more regulated than the nuclear industry, but regulation too often mean workers spend scarce care time on filling out forms with little visible improvement in the delivery of care.

A case can be made for specialized clinics. They can make sense in a number of areas such as cataract surgeries. But as doctors’ organizations in Ontario have argued, they make the most sense when they are connected to hospitals so that resources can be shared and complications easily transferred for more advanced care. They also make sense when they are not searching for profit but rather focused on quality care, with oversight from hospitals. And when they are publicly funded, they are publicly accountable, with open board meetings and minutes and enforced regulations about quality care and working conditions. What doesn’t make sense is spending public money on profit. Premier Ford has not even offered a case supporting for-profit care, only for independent clinics.

It is not enough to declare that, given the current crises in health care, the status quo will not do and thus we need to turn to the for-profit sector. Changes that are proposed need to be backed up with evidence-informed arguments. Meanwhile, the evidence indicates that for-profit delivery is less efficient, not more. Experiences ranging from dismal overall health outcomes in the US, to the dismantling and thus fragmenting of the NHS in the UK, to longer wait times for many following the move to for-profit cataract eye surgery in Alberta all make clear.

The crises in health care brought about by years of austerity faced with a pandemic have created the opportunity to build back better. However, it also created the opportunity for those searching for profit in all corners of care, from dental offices to home care, telehealth, colonoscopies, and vaccinations. We are at a critical point in our health care system. Now more than ever we have to make the distinction between private and profit clear. If our friend didn’t see the differences, clearly we have a lot of work to do.

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_{Pat Armstrong is a Canadian sociologist and Distinguished Research Professor at York University. She is a Fellow of the Royal Society of Canada.}

_{Hugh Armstrong is a Distinguished Research Professor and Professor Emeritus of Social Work and Political Economy at Carleton University in Ottawa, Ontario. Dr. Armstrong’s major research interests include long-term care, the political economy of health care, unions and public policy, the organization of work and family and household structures.}