Steven Lewis weighs in with some suggestions for both sides of the divide.

A word of caution to the private-clinic owners and National Taxpayers' Federation shills licking their chops over the imminent demise of medicare and the triumph of profiteers: It ain't over 'til it's over.

And despite Thursday's astonishing ruling by the Supreme Court of Canada that opens the door to private health insurance, there may be a silver lining in the havoc wrought by the 4-3 decision. Unpredictability seems to be the order of the day, but there are some likely scenarios.

First, though, a note on the decision itself.

If you never read another Supreme Court judgment in your life, read this one. The court was heatedly divided. The four justices in the majority didn't even agree on all of their findings, while the three dissenters were united in their reasoning. The language in some parts borders on bitchy -- the majority scorning the dissenters as letting their emotions interfere with judicial reasoning, the dissenters snorting that the majority played fast and loose with the evidence and ran roughshod over the entitlement of society and governments to define the public interest.

I'd rather hear the tapes of those discussions over Grewal-Murphy-Dosanjh any day.

I'm no lawyer, but it's bad law. The majority's use of health-systems research was facile at best, glibly accepting that Canadians routinely die while waiting for treatment while, apparently, people elsewhere in the world do not by dint of the availability of private insurance. The decision also roamed far from the facts of the case -- Montreal chemical salesman George Zeliotis' year-long wait for a hip operation -- and essentially turned it into a class-action suit for all Canadians. Instead of presiding over virtual anarchy, the court could have considered many other remedies, such as insisting that provinces establish and monitor wait-time standards, set up rapid appeals tribunals for aggrieved patients, and actively manage their wait lists.

But it didn't, and here we are. So what's next?

There will be at least a short-term burst of private-clinic expansion, financed by investors offering lucrative salaries and spiffy quarters to physicians. It won't be cataclysmic because it's been going on for years, but it could create troublesome shortages in some public practices and institutions for awhile. Later on, the effect may diminish as expanded classes of doctors and nurses graduate.

Some clinics will want status as private hospitals, offering not just day procedures but overnight stays. Some governments will balk and stall. Others, such as Alberta, given Premier Klein's thumbs-up to the SCOC decision, may sign on quickly. If such hospitals emerge in large cities, private insurance will become more attractive in that it would secure a paying patient's access not only to physician care, but to at least some forms of hospitalization.

Blessed by their governments, some hospitals will be tempted to rent their facilities to privately insured doctors and patients to make a buck. They will tell their communities that the money they make will be used to enhance public care. They will assure the public that access will not suffer, and that everyone will win. Should this happen, the realities of two-tier service will be more visible.

Insurance executives are already surveying the market and plotting their strategies but, more importantly, businesses are also plotting theirs. Most private health insurance is employer-based (some is cost-shared). Employee health benefits are already big business in some parts of Canada, but insuring core doctor and hospital services is a major step up in cost and complexity. Canadian corporations, particularly the auto industry, have long recognized the economic advantage of medicare. They will be dragged kicking and screaming, if at all, into the private-insurance morass. But let's take a deep breath. The decision, however perverse, is a wake-up call for governments and citizens devoted to the idea of a single-payer, universal public system. All that is lost for certain is the legal crutch that politicians have leaned on to keep the privatization tide at bay.

Here are some options:

• Make the public system better by doing all the things the quality-improvement gurus have told us to do for years. Manage wait lists properly and make sure waiting patients are followed up regularly. Give pharmacists a greater role in prescribing to reduce the errors and illness caused by doctors. Use nurse practitioners more effectively. It doesn't take more money. It may even take less.
• Refuse to subsidize private care and personnel. Charge medical students $5,000 tuition if they sign contracts to practise exclusively in the public system, and $60,000 (more like the real cost) if they want the option to go private. Do the same for nurses and therapists.
• Strike public-interest bargains with physician unions. It's doctors, not governments, who insist on underpaying primary-care physicians and geriatricians and overpaying ophthalmologists (who do cataracts by the thousand) and gastroenterologists (who earn huge incomes by scoping every available orifice).
• We have, up to now, let the doctors sort out their relative incomes, and it has been a disaster. Enough already.
• Create incentives to provide quality service. Fine doctors who close their office doors at 4 p.m., refuse to provide after-hours service, and punt their patients to emergency rooms. Withhold payments to hospitals and health regions that don't have systems to ensure that wait times are reasonable and that the neediest patients get served first. * Educate the public about how to use a health system effectively and prudently. The privateers treat health care as a commodity and prosper, in part, by ministering to the "worried well". "Care for a full-body CT scan, sir? A few more tests just to be sure, ma'am?" The hawking of services will get worse before it gets better. Governments should deal with it aggressively. Hold media conferences about the dangers and uselessness of over-service. Meet with editorial boards to alert them to scams and shams.
• Publish honest and thorough performance reports about the public system. Be honest about mistakes and limits. Treat the public like adults. Pay attention to complaints and public satisfaction surveys.
• Enlist an unlikely ally -- corporate Canada (minus the insurance companies). Their prosperity is linked to good public health care. Get them involved in the political battle.

And let's get the medicare questions right: How did such a rich and admired system fall prey to an impish display of jurisprudence? Why is primary health care in disarray? How come a 60-per-cent increase in spending since 1997 hasn't bought solutions? Why is the health-care system a non-system, better described as anarchy than orderly and fair?

It's because we mistook a quality problem for a money problem. We allowed too many foxes to guard too many henhouses. We funded but did not really manage. And we expected legions of smart people to do a 21st-century job with 19th-century tools.

There is nothing irretrievably wrong with medicare, but there is no assurance that it will be fixed either. For decades we have shrunk from battles with vested interests that now need to be joined. We have rightly made an icon of the basic structure of the system, but have wrongly taken our eye off its tangible performance. Politicians have found it easier to shovel money and avoid conflict, proving yet again that hope triumphs over experience.

So perhaps a questionable court decision has done us all a favour by conscripting us into the fray. Every provider, every citizen and every politician needs to take a hard look in the mirror. We have all been complicit in the events that have played into the hands of that ever-chirping minority of enemies of public health care. Our values and our tough-mindedness have been put on notice. If we screw this up, the private ship will leave the dock fully booked, and over time there will be an even wider gulf between those that have and those that don't.

The choice is ours: We can be fiddlers or firefighters as Rome is set ablaze.

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