G.K.D. Crozier contends that a regulated market in inbound medical tourism in Ontario could be preferable to either a blind-eye approach or a complete ban on the practice.
In November 2014, a coalition of Ontario health professional organizations, including the Registered Nurses Association of Ontario (RNAO), urged the Ontario government to stop “turning a blind eye” to the medical tourism that was taking place in several Ontario hospitals. The RNAO defines medical tourism as “a practice where health-care organizations create for-profit programs to attract patients from other countries to receive healthcare on a pay-for-treatment basis.” As such, medical tourism refers to ‘inbound medical travel’ rather than ‘outbound medical travel’ where Canadians go abroad. It also refers to for-profit and commercialized medical tourism as opposed to humanitarian cases (such as specialized medical care for sick children abroad, or subsidized healthcare for victims of war).
In response to the coalition’s statement concerning medical tourism, Dr. Eric Hoskins, Ontario Minister of Health and Long-Term Care, advised that Ontario hospitals should refrain from using public funds to treat international patients and allowing international patients to displace Ontarians (sometimes referred to as ‘jumping the queue’). Additionally, he advised that Ontario hospitals should reinvest revenue received from international patients into Ontario’s public healthcare system.
While the RNAO praises this step, it has further reinvigorated its opposition to medical tourism, calling for a full ban on this practice within the province. The organization argues that the very existence of medical tourism threatens Ontario’s Medicare system by:
- Allowing international patients to receive immediate medical care while Ontarians are forced to languish on wait lists for scarce resources;
- Setting a dangerous precedent for a two-tiered healthcare system, whereby even wealthy Ontarian patients could demand preferential treatment, effectively ‘jumping the queue’; and
- Treating health as a commodity, which undermines the very nature of Ontario’s public healthcare system.
The central concern implied by the RNAO’s campaign is that medical tourism will open a floodgate of private funding for private care into Ontario’s public healthcare system that will erode the foundation of Medicare.
There is doubtless truth to the claim that the public healthcare systems depend upon the support of the citizenry, and that this support depends upon a widely held commitment to equitable access to medical care for all citizens, regardless of ability to pay. There is also merit in the claim that medical tourism can undermine equitable access to healthcare in countries that permit hospitals to court international patients. Indeed, there is a large and growing body of literature on this subject – some of which has been discussed on this very blog. Although most of that discussion focuses on outbound medical tourism, some of the lessons can also apply to inbound medical tourism.
But the concerns about medical tourism outlined by the RNAO can be addressed without instituting a complete ban on medical tourism. In fact, a peaceful (or even prosperous) relationship between inbound medical tourism and Ontario’s Medicare system may be possible. Such a relationship would require the following:
(A) Income generated from medical tourism would have to be reinvested into Ontario’s Medicare system and in a way that benefits Ontarians. Medical tourism would ultimately have to increase access by Ontarians to medical care and shorten wait lists, rather than the opposite. This would address RNAO’s first objection that allowing medical tourism privileges international patients at the expense of domestic ones. Although Minister Hoskins advises hospitals to reinvest revenue received from medical tourism into Ontario’s public health system, a more precise plan of action and accountability would be required to sufficiently meet this criterion.
(B) Ontarians (and possibly even Canadians living in other provinces) must be excluded from accessing medical resources under the guise of medical tourism, since this would indeed create a truly two-tiered healthcare system. This would address the RNAO’s objection regarding the danger of creating a two-tiered system. Additionally, this criterion would also address the RNAO’s objection concerning commodification of healthcare. While medical care would still be sold to international patients, and thus treated as a commodity, the RNAO’s objection concerning commodification communicates a political commitment to equitable access to medical care among Ontarians. In practical terms, all medical care has a monetary value, and it is impossible to manage it effectively without acknowledging that fact; however, so long as each Ontarian has equitable access to those medical goods and services, and especially if the overall access to those goods and services is increasing as a result of medical tourism, there is no violation of that political commitment.
(C) The medical tourism system must be monitored and information gathered must be publicly accessible to ensure that criteria (A) and (B) are adequately met.
These three criteria might not be sufficient to address all challenges posed by permitting medical tourism in Ontario hospitals. They are, however, all at least necessary. They also collectively answer the objections voiced in RNAO’s recent campaign. Furthermore, they indicate that a principled and empirically grounded (that is, monitored and transparent) approach to inbound medical tourism could strengthen the Ontario public healthcare system more than either a blind-eye approach or a complete ban.
G.K.D. Crozier is an Assistant Professor of Philosophy and the Canada Research Chair in Environment, Culture and Values at Laurentian University