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Canadians are undergoing a public debate over the future of the countrys universal health care system. At stake is nothing less than a matter of national self-identitywhether to retain free health care for everyone or move to a greater reliance on privatization.

Canada has offered its citizens free universal health care since 1957. The Canada Health Act of 1986 governs the delivery of health care in Canada today under Medicare, a system funded by the federal government and administered by the provinces. All medically necessary services are covered by provincial health plans, so despite lines at clinics and hospitals, eventually everyone receives needed care without paying out-of-pocket. Many Canadians consider free health care a birthright and they are proud of having a system that provides for everyone, considering it a foundation of Canadas egalitarian society.

"Having a universal health care plan that provides fair and equitable health care to everyone is vital to Canada," said First District International Vice President Don Lounds. The IBEW has joined labor groups throughout Canada in a campaign to save Medicare.

The system could be jeopardized if the high-level commission slated to release its long-awaited recommendations in November is swayed by forces campaigning for increased privatization. The Romanow Commission on the Future of Health Care in Canada has been traveling the country and researching the Medicare delivery system for several months. Headed by former Saskatchewan Premiere Roy Romanow, the commissions federal mandate is to address the long-term sustainability of Canadas publicly administered health system.

Many of the problems plaguing the Canadian health care system mirror those in the United States: high doctor workloads, growing demands but less money for hospitals and community health centers, long waiting lists for diagnostic or treatment services, shortages of medical specialists and reports of growing acuity among patients, a likely result of health care system limitations. The systems in the U.S. and Canada are administered quite differently, however, with private health maintenance organizations responsible for administering health care in the United States and the provincial governments responsible for the system in Canada. But while the United States occasionally considers adopting a public health system similar to that in Canada, Canada is contemplating assimilating elements of private health care into its public system.

Possible recommendations include privatizing certain health services, forcing patients to pay by imposing user fees on doctor and hospital visits and allowing for-profit companies to operate hospitals and other health services. In the language of the debate, these possibilities would introduce a "two-tier" system, a for-profit health system alongside the current non-profit one. Critics warn that access to health care would be based on ability to pay rather than according to need.

Arguing such a move would benefit the well-to-do at the expense of poor and moderate-income residents, many in the labor movement are actively lobbying its members, the public and the Romanow Commission against privatization.

"We know there must be compromises. We know we must be realistic," said James Clancy, president of the National Union of Public and General Employees, in the Toronto Star. "But we also know we are the ones who, in the end, pay the freight for everything. Given all that, our first choice still is to reclaim and expand Medicare."

Medicare supporters have accused politicians and insurance companies of conspiring to withhold vital funding to encourage the appearance that Medicare is beyond repair. As a percentage of gross domestic product, Canada spends less on health care today than it did 10 years ago. But recent tax cuts precipitated a revenue decline, making provincial spending on health care a higher share of the budget.

The advocates for repairing the existing system argue that Medicare is sustainable with the necessary resources from the federal government. Some Canadians are even willing to support a tax increase to ensure a universal health care system is maintained and reorganized to be more efficient. They advocate adding prescription drug and home health care benefits for seniors. But consumer and labor groups, including the Canadian Labour Congress, have come out against user fees for physician and hospital visits.

Other supporters call the sweeping public debate a response to a well-orchestrated war on Canadas public health system that includes many provincial governments, representatives of physician organizations, insurance companies and right-wing research institutes.

Calling the United States medical system the most expensive and most commercial in the world, Medicare supporters point south to the pitfalls of a private health care system. Americans spend 14 percent of their gross domestic product on health care. According to the National Union of Public and General Employees, Canadas system is fairer, more cost-efficient and more effective than any private health care system.

By contrast, 40 million Americans, approximately 15 percent of the population, have no health insurance. Another 40 million Americans are "underinsured," only able to afford limited coverage. And the rest who count themselves lucky to have health insurance, may only visit certain doctors and hospitals. Some insurance companies provide no coverage at all for "pre-existing" conditions and health insurance company auditorsnot doctorsdetermine the level of patient care. Many Americans would embrace Canadas universal health care system.

The Canadian Heath Coalition, which includes organizations representing unions, seniors, women, students, consumers and health care professionals from across Canada, says advocates of privatization have shown no evidence that it lowers costs or provides higher quality care.

The Romanow Commission is expected to release its recommendations in November. The liberal federal government will consider those findings before deciding what action to take. For more information on the commissions work, see www.healthcarecommission.ca.