Edit: Minor image changes

Gallivan Health and TELUS health had a great Valentine’s Day this year. Specifically, it had a good February 13th, in which 7,000 lovestruck students at Western University approved a referendum providing private doctor consultation coverage under their association-administered health plan.

(You can read Marek Brooking, Adshayah Sathiaseelan and Andy Yang’s journalistic coverage at the Western Gazette here and here)

What does this look like? On the surface for students, relatively little. They pay an extra $44 a term, unless they choose to opt out. According to Gallivan, they need a doctor, they log into an app where they can get a diagnosis, a prescription, and referrals in a timely basis.

This is positive in that a doctor’s visit that would normally cost a total of $0 under medicare or UHIP now costs $44. These are the kind of cost savings that… wait? Did I read that right? A student association has intervened to make healthcare more costly? Yep, and its a big story that will soon unfold across the country.

What is the product?

In reality, this coverage is not about access to healthcare in the financial sense, it is about convenient access. Wait times in Ontario can be long, and students are geographically divorced from their primary care physicians, if they have one at all. This is to say nothing of whether international students can find a doctor wishing to see them or is able to overcome linguistic barriers, and Gallivan’s myvirtualdoctor service boasts of available coverage in up to 30 languages.

A non-lawyer’s take on the Canada Health Act

I have to admit I was confused about the legality of the project. The Canada Health Act could possibly be read to prohibit this practice, though it is a bit to navigate.

• physician services are services considered “medically necessary”, which includes supported services
• insured person is a “resident of the province who has not completed such minimum period of residence or waiting period, not exceeding three months, as may be required by the province for eligibility for or entitlement to insured health services”
• insured health services are physician services provided to insured person
• Section 9 mandates comprehensiveness, stating ” the health care insurance plan of a province must insure all insured health services provided by hospitals, medical practitioners or dentists”
• Section 18 prevents provincial governments from giving money to physicians who will charge extra fees to healthcare recipients
• Section 19 prevents provincial governments from accepting Canada Health Transfer fees if they permit physicians charging for services that would normally be an insured health service.

So in theory, offering these products to people in any Canadian jurisdiction could be illegal, under one reading of the law.

But it seems that the real (not amateur) interpretation of the law is that in the case of online providers, there is a loophole around the act. Why? Maple, a competitor to TELUS Health, states that telehealth is “not covered” by provincial insurance plans. This is at the same time as boasting that their practitioners are “the same providers you’d see in person” and “many providers are also licensed to practice in multiple provinces”. (TELUS isn’t quite as explicit about if their providers also have their own professional practices.)

Time will tell where the chips fall here, since in the two weeks between drafting this blog and releasing it, Health minister Jean-Yves Duclos gave his interpretation, and it agrees with mine, so maybe this whole blog will be useless. Keep your eyes peeled for how provinces react!

Implications for Healthcare

This is suddenly an area where those with financial means can pay for more timely access to a physician. This may encourage physicians to work exclusively with telehealth providers who can pay a premium that a non-telehealth provider cannot. Non-telehealth providers, if they want to stay afloat, can only pay a physician as much as the physician pulls in through billing. That amount is normally set out through a provincial schedule of costs. Charging more than that amount for better service might sound familiar to you, and the term is “two-tier healthcare”.

To be absolutely clear healthcare is already private in Canada; physicians are private employees or entrepreneurs. However, the term privatization in the Canadian parlance is usually connected to the idea of two-tier healthcare. And it seems to be arriving in the primary care space with great force.

As primary care physicians are increasingly pulled into digital health networks, the lines for free care will only get longer, and the premiums that providers might be able to levy may increase, especially if these providers amalgamate. What may be $44 now may increase at the next negotiation opportunity, and like all student health plans, if the uptake of the product is popular among a relatively small pools of insurees, the premium will surely go up to compensate for that use.

A Student Association Conundrum

This is an interesting place for student associations to inhabit. On one hand, they can currently provide students with timely access to primary care that they might not otherwise be able to receive. On the other hand, as more and more student associations may turn their eye to Western, Concordia and their like to see how this product plays out, student associations may be an agent for accelerating the adoption of two-tier healthcare, especially with hundreds of thousands of students receiving supplemental healthcare from their student associations nationwide. This is not a small microcosm of the Canadian healthcare market— universities and colleges collectively have millions of students. If these students are immersed in an environment where these service are the norm, that sets and changes the expectations for primary care for the next generation of working Canadians.

Associations are supposed to look out for their members, but they are also situated as part of a broader social movement that has traditionally been aligned with affordability, levelling economic barriers to service, and collective investments in common goods. The Canadian healthcare system purports to do all that, but it has seemed stretched thin, and ideals are thin gruel to students who cannot access services in a reasonable time.

Some student associations may weigh whether they should wade into broader societal healthcare policy—demanding governments fix universal healthcare—but many will not. For those that don’t, they will face a question: if they aren’t going to support a vision for universal healthcare actively, why should they passively turn down two-tier healthcare for their members just out of implicit support of the status quo?

Maybe the associations can separate the concept of staying in their policy lane while still holding that they won’t put their economic wait implicitly behind the two-tier movement.

Maybe they will compensate by endorsing an alternative, like ramping up institutional advocacy for doctors employed by their institutions to address student access.

Or maybe, as I predict, as students from different schools talk about the ease of accessing services, maybe popular student demand for these products will wipe out any room for pro or anti two-tier ideologues to discuss philosophically, with conversations turning to, “how fast can we do it?”, “who will the cheapest vendor be?” and, “what date should we schedule the referendum?”.

Coda

Universal healthcare advocates, if they want to act, should probably act fast to talk to their associations and editorial boards to build political consensus, because their Boards of Directors are probably already being pitched by insurance companies, possibly without any voice to oppose a two-tier vision. Supporters conversely are probably in a place to suggest to their associations to investigate the options if they are not already.

Student associations are at a difficult point as this trend accelerates. Barring intervention from the federal government or provincial governments, student associations will have to choose soon: be part of the new wave, or oppose a force that is undermining a legacy Canadian institution.