At the heart of Canadian public policy is the guiding conviction that all citizens should have equal access to health care. Individuals should not get whisked to the front of the queue for hip replacements, kidney trans- plants, or ophthalmologic procedures just because they are wealthy or well-known. For many Canadians, publicly fund- ed health care for all citizens is a vital part of the national ethos. ”œUniversal” health care distinguishes Canada from the United States, suggests an egalitarian social ethic and a feeling of community rather than a social order in which individual citizens are left to fend for themselves in times of illness or injury and reveals the sense that some public goods are too important to leave to market forces.

Yet this public philosophy, the moral vision that ani- mates medicare and opposes separate tiers of medicine for rich and poor, now faces significant practical challenges in a world where inexpensive air travel, low-cost telecommu- nications, digitized patient records, medical tourism com- panies and the Internet make international travel for health care an easily arranged option for wealthy and middle-class Canadians.

If all Canadians had timely access to health care, purchasing treatment in other countries would presumably have little appeal. However, with lengthy queues for many medical procedures and numerous effective but expensive therapies that are unfunded by provincial health insurance plans, some Canadians are travelling outside Canada in search of treatment. For Canadians with sufficient econom- ic resources, access to private health care in other countries is one flight and two taxi rides away from home.

Successive federal and provincial governments have struggled to prevent the emergence of a tiered health care system in Canada. Nonetheless, there is an economically stratified international health care marketplace. This global health care bazaar offers everything from spa retreats and wellness packages in Malaysia and Thailand to orthopaedic surgery in Cuba and India and organ transplantation in China and Pakistan. Whether or not private, for-profit health care expands within Canada, citizens with sufficient finances can escape difficulties in accessing treat- ment by purchasing care outside Canada. For many Canadians, the cost of care is a major barrier to entering the global market for health care serv- ices. However, as inexpensive medical facilities receive international accredi- tation, establish a reputation for quali- ty care and become better known in North America, more Canadians are likely to resort to this option.

International travel to obtain health care is becoming commonplace. Australians fly to Bangkok for dental surgery. British citizens tired of waiting for care in the National Health Service journey to India, Thailand and Eastern Europe. Americans living in Texas and Arizona cross into Mexico for inexpen- sive medical interventions, dental care and medications.

Similarly, wealthy Canadians confronted with treatment delays or unable to obtain access to therapies approved for patient use in other countries also travel to medical cen- tres in the United States or abroad. But the out-of-country option is not limit- ed to the uppermost strata of Canada’s economic elite; Canadians travelling outside the country for health care are coming from Main Street and not just Bay Street. Those who have more lim- ited financial resources search for less expensive options in such countries as Cuba and India.

Unable to obtain timely local access to such medical procedures as hip and knee replacements, cancer therapies and diagnostic tests, some frustrated, scared, suffering or simply impatient and annoyed Canadians are exploring alternatives. Some travel out-of-province and purchase care at private clinics within Canada. These facilities do not just offer cosmetic sur- gery and other procedures outside the publicly insured basket of medically necessary therapies. One clinic, with two locations in Quebec, charges approximately $12,000 for hip and knee replacements.

In the United States there is an array of destinations. Some of them have representatives in Canada. In 1996 a medical centre in Char- lottesville generated controversy when it placed advertisements for hip and knee replacements in the Globe and Mail. Over the last decade several American health care facilities have strengthened their ties to Canada. At least three major medical centers now have offices in Canada. And others provide local contacts in several Cana- dian cities.

With a large percentage of Canada’s population located within a short drive to the Canada-US border, and with leading American medical centres having a reputation for inter- national-calibre care, it is not surpris- ing that some wealthy and middle-class Canadians arrange treat- ment in the United States. However, the high cost of care there presumably deters many individuals willing to travel but unable to afford it. A coro- nary artery bypass graft costs over US$55,000 at many medical centres in California. Performed at a specialty hospital in India the same procedure costs US$5,000-10,000. This price dif- ferential is leading uninsured and underinsured Americans to leave the United States for less costly surgical procedures. It might also lead many Canadians to consider doing the same.

Canadians who cannot afford the high cost of care in the United States can now comparison shop in hospitals and clinics in over 35 countries. Just as many auto- mobile factories, textile plants and back offices are now ”œoff-shored” to coun- tries such as China, India, Mexico and Thailand, patients experiencing dif- ficulties in accessing care in their local communities can ”œoutsource” them- selves in an effort to obtain timely, safe and affordable health care. Assuming this practice expands, some Canadian patients will likely obtain excellent health care outside Canada. Others risk receiving inferior care at poorly regu- lated, low-cost health care facilities.

Concerns about cost, professional competence, patient safety, quality of care, continuity of care, separation from family and friends, and reserva- tions about the likelihood of legal redress in the case of negligence or malpractice presumably discourage many individuals from travelling abroad for health care. Other patients weigh the disadvantages of obtaining care overseas against the consequences of waiting for treatment at home, and decide to travel.

Many countries have national ini- tiatives to attract paying patients from other nations. For example, a Singapore government initiative arranges care for individuals at health care facilities throughout the city- state. The Web site enables clients to identify suitable hospitals, contact their international patient centres and even select individual specialists. In Vancouver, the Web site of the Royal Thai Consulate General offers price guidelines for kidney transplants, in vitro fertilization, coronary bypass sur- gery and other treatments available at Thai hospitals.

Around the world, public and pri- vate health care facilities want to increase demand for their services. Such countries as India, Indonesia, Malaysia, the Philippines, Singapore and Thailand all want to become major hubs for international health care. The Czech Republic, Hungary, Poland and Slovakia are attempting the same strategy in Eastern Europe. Closer to Canada, some Caribbean countries recently announced that they will develop medical tourism ini- tiatives. They all hope to build their health care economies by using the doctrine of comparative advantage to attract paying customers from wealth- ier countries.

Although some patients make their own arrangements for care in other countries, medical tourism companies are increasing in number and visibility. These businesses connect patients seek- ing care to health care facilities wanting customers. ”œMedical tourism” is in many ways a deeply mislead- ing phrase more suitable for advertising copy than serious reflection upon the personal, social, legal and economic significance of international travel for health care. Nonetheless, there are vari- ous ways in which health- related travel is packaged to resemble more traditional forms of tourism.

Medical brokerages, medical tourism companies or med- ical travel agencies " there are various labels for these businesses " advertise prompt access to health care at inex- pensive facilities. They are adept at identifying and exploiting supply and demand problems. These out-of-coun- try options for Canadians are becom- ing more visible as companies market a wide range of therapies and health care destinations. At least fifteen com- panies are based in Canada: one is in Alberta, seven are in British Columbia, one is about to open in Manitoba, three operate from Ontario and three are based in Quebec.

These companies arrange diag- nostic tests, surgery and other health care procedures at medical facilities in Central and South America, Europe, the Far and Middle East and Africa. Some companies arrange trav- el to just one medical facility in a par- ticular country. Others arrange trips to multiple facilities in several coun- tries. Many companies focus upon arranging orthopaedic surgery and ophthalmologic surgery. At least two businesses in Canada advertise far more controversial procedures such as sex selection at assisted reproduc- tion clinics in the United States, and costly heart, lung and liver trans- plants at medical facilities in China. One company arranges kidney trans- plants in Pakistan for US$32,000. Some brokerages charge clients a flat- rate commission or a percentage of the total cost of care. Others do not directly charge customers but are paid by the hospitals to which their clients travel for care.

Health care travel packages can include all costs associated with med- ical care, air and ground transporta- tion, hotel accommodation, use of a cellphone in the destination country, practical assistance from a local com- pany representative at the health care facility, travel arrangements for a com- panion, stays in nearby resorts during the post-operative recovery period and side trips to tourist destinations such as the Taj Mahal and the Temple of the Emerald Buddha.

The rapid proliferation of medical tourism companies across Canada sug- gests that the business infrastructure for promoting and facilitating out-of- country health care is now in place. These companies profit by selling packages for treatment outside Canada. They will attempt to expand their client base and convince Canadians of the merits of travelling to inexpensive health care facilities. Their names " Timely Medical Alternatives, Choice Medical Services, MedSolution, Speedy Surgery " pro- vide insight into the slogans used to sell Canadians on the concept of trav- elling elsewhere for health care.

Personal financial assets will play an increasingly significant role in determining whether patients are able to obtain drugs, medical devices and therapies unavailable in Canada or accessible only after long delays. Banks and finance companies based in Canada and the United States offer loans and credit plans for Canadians faced with the challenge of paying out-of-pocket expenses. These finan- cial arrangements will likely become more common as an increasing num- bers of Canadians enter the global health care bazaar.

Some lawyers have developed boutique practices in helping Canadians obtain reimbursement from provincial health insurance plans for medical care purchased outside Canada. One office based in Barrie, Ontario, helps people obtain reim- bursement from the Ontario Health Insurance Plan after they receive care in the United States. In several well- known cases, Canadians received reim- bursement for out-of-country care after their initial claims for reimburse- ment were denied. Moreover, if citi- zens face the risk of incurring death or irreversible tissue damage as a result of treatment delays in Canada, there is the possibility of drawing upon the Supreme Court Chaoulli decision as well as the Canadian Charter of Rights and Freedoms to develop a legal argu- ment for provincial reimbursement of medically necessary care obtained out- side Canada.

If increasing numbers of Canadians leave Canada in search of medical care, the case against private health care within Canada might start to weaken. Proponents of privatization will argue that dollars spent outside Canada are better spent at private health care facilities at home. Consumer safety advocates might argue that Canadian patients can be better protected if they obtain care at private facili- ties governed by Canadian regulatory standards.

No one knows precisely how many Canadians travel abroad for the primary purpose of obtaining health care. Trade organizations do not record the number of people purchasing health care in other countries. Provincial ministries of health document requests for reim- bursement for medical care obtained out of country, but these figures do not identify the patients whose care is covered by private insurers or who pay out-of-pocket for care and do not bother submitting reimbursement forms. Destination facilities publicize how many international patients they treat, but because these figures are often used as marketing devices they must be treated with caution.

Some social observers regard the rise of ”œpatients without borders” as a sign that health care consumers now have better options because they are liberated from regional health care providers and the restrictions of provincial health insurance plans, and they can use the Internet and medical tourism companies to identify their preferred health care providers. More skeptical commentators worry about patient safety, quality of care and con- tinuity of care when patients travel across geographic, cultural and legal boundaries in search of treatment. They also quite sensibly express con- cerns about the long-term sustainabili- ty of publicly funded health care in an economically stratified world where wealthy citizens can buy their way to faster and sometimes better care.

Politicians and health policy- makers pay surprisingly little atten- tion to the ready availability of health care in other countries. However, hospitals in other coun- tries and medical tourism agencies in Canada and elsewhere are aware that many Canadians are frustrated with treatment delays and lack of access to health care and are market- ing out-of-country options to Canadians.

Defenders of publicly funded health care, supporters of privatized medicine in Canada, clinicians, politi- cians, policy-makers and health researchers need to better understand the long-term significance of the glob- al health care bazaar. Opponents of two-tier medicine need to realize that Canadians with sufficient economic resources are free to purchase care wherever they please. No two-tier medicine in Canada simply means that middle-class and wealthy Canadians can purchase care at private facilities in other countries.

On the other hand, advocates of private, for-profit medi- cine in Canada need to realize that if the market for private health care in Canada expands, for-profit facilities in Canada will have to compete with inexpensive health care providers around the world. The business of medicine might not be as lucrative as they believe. Furthermore, intense pressure to lower costs and maximize profits could have a dangerous effect on the quality of care.

Despite federal and provincial efforts to improve access to care, wait times for various procedures and ther- apies have been a problem in Canada for many years and will likely remain a major social problem and public pol- icy issue for years to come. In response to delays in receiving treatment many patients are becoming decidedly impatient. They either cannot or will not wait for the care they require. The global health care bazaar beyond Canada’s borders awaits those who are convinced that they can receive better or faster care outside Canada.

Defenders of medicare will view with great concern an increase in the number of wealthy and middle- class Canadians travelling out-of- country for care. Health equity will suffer if low-income patients wait for treatment while wealthier Canadians purchase expedited access to care. At the other end of the political spec- trum, proponents of free trade, global- ization and open markets will link the popularization of health-related travel to increased choice, freedom, progress and economic development.

Good public policy calls for sound information. In that regard, we need to realize that beyond popular news media coverage, information available on the Web sites of medical tourism companies and a small body of schol- arly literature, little is known about how many Canadians travel out-of- country for care every year, whether that number has increased over time, where Canadians go when they travel elsewhere for care what treatments they obtain outside Canada, how much they pay for care, and whether they experience benefit or harm as a result of the decision to seek care beyond Canada’s borders.

Researchers in provincial min- istries of health, universities and the Canadian Institute for Health Information can help policy-makers by documenting and investigating health-related travel to medical facili- ties outside Canada. As globalization changes the delivery of health care, researchers will need to better under- stand the movement of patients across provincial and national borders.

The lack of research on the expe- riences of Canadians buying treat- ment in the global health care bazaar is perhaps connected to the relatively modest number of Canadians travel- ling beyond Canada’s borders for health care. It is also possible that the purchase of treatment abroad by wealthy and middle-class Canadians poses a direct challenge to Canada’s egalitarian ethos and there is wide- spread reluctance to acknowledge with candour the ease with which upper-income Canadians can escape the queues in which lower-income Canadians wait for care.

 

This article was written while Leigh Turner was a Distinguished Visiting Fellow in the Comparative Program on Health and Society at the University of Toronto’s Munk Centre for International Studies.