Opinion

We need to talk about public and private health care in Canada

Canadians are deeply concerned that the health care system is no longer meeting their needs. With the system under significant strain – patients struggling to access care, intermittent emergency department closures, growing surgical backlogs – there have been increasing calls to re-examine how we fund and deliver health-care services.

In a recent survey conducted by the Angus Reid Institute in partnership with the Canadian Medical Association (CMA), 68 per cent of respondents said they believe health care has worsened over the past decade, up from 42 per cent who said the same in 2015. Nearly 70 per cent doubted that things will change for the better in the next two years.

With the health-care system at a crisis point, the need to listen to and incorporate the voices of patients and the providers who deliver care has never been greater.

There is consensus that access to care on many levels must be fixed and that the solution is not just throwing more money at a dysfunctional system. We need actual structural change.

We’re seeing patchwork efforts as political leaders grapple with the gaps. To improve retention and recruitment of health-care workers, British Columbia recently reformed how family physicians are compensated to reflect the increased complexity of primary care work. The Atlantic provinces and Ontario have taken steps to improve physician mobility. Several provinces now allow pharmacists to prescribe medications for common ailments. To date, however, there is no national, coordinated approach that reflects patient and health-care provider input.

Some provinces are proposing or have already increased the role of private providers to expand access to care without increasing out-of-pocket costs to patients. We’re also seeing more for-profit, privately funded corporations providing services across Canadian jurisdictions.

What this means for our public health system – long a source of pride for Canadians – remains to be seen.

Words matter. Being informed matters

It’s important we’re clear about what we mean when we talk about private care. On the one hand are privately delivered, for-profit alternatives that could result in queue jumping for those who can afford to pay their way to the front of the line – a model we’re already seeing in parts of the country. On the other hand are privately delivered, not-for-profit clinics that are being scaled up in some jurisdictions to help reduce backlogs. It’s important we reflect on and discuss these two realities.

The truth is that Canada’s health systems have long featured a mix of both public and private care delivery.

The truth is that Canada’s health systems have long featured a mix of both public and private care delivery. And public health insurance plans – what most of us simply refer to as “public health care” – has always covered a finite list of services provided only in certain settings with certain providers.

Across the country, the balance of public and private care includes care that is publicly funded and delivered; public health care that is outsourced to private providers; and care that is privately paid for and delivered.

It’s confusing to many. But looking at funding, as of 2022, governments paid for 72 per cent of all health care. The rest was paid by patients: out of pocket (11 per cent), through private health insurance (15 per cent) or other sources (2 per cent).

It’s time to talk

Private care in either form is a sensitive subject – one that many people feel challenges their collective values as Canadians. In the Angus Reid Institute survey, 31 per cent of respondents said that more private care would improve health care, while 44 per cent said it would worsen access to care. The percentage of respondents who are “unsure” increased in the past year. It’s a topic we can no longer ignore.

This is a complex, nuanced conversation that Canadians and health-care providers need to have because change will continue to happen with or without our input as jurisdictions grasp for solutions to increase capacity within the system.

It’s within this context that the CMA is launching a national conversation on public and private health care in Canada. The purpose is twofold: to elevate our shared understanding of how care is delivered across Canada and to help shape what happens next. Make no mistake: this will be a challenging, charged conversation. Important conversations often are. However, standing on the sidelines while our health systems continue to deteriorate is simply not an option.

The CMA strongly believes patients across Canada deserve to receive high-quality health care in a timely fashion, regardless of their ability to pay. That belief has not changed. However, the health-care landscape and our shared challenges have. It’s time we have an open and honest conversation about the future of our health system. We’re here to listen. Please join us and add your voice.

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11 Comments
  • James Murtagh says:

    A national conversation is fine, but this won’t be the first significant conversation and, right now, not many people would suggest past conversations have been productive. If we want to have another conversation then make sure it is informed by history. For the most part, history has been absent from the conversation, always pushed aside by the latest cluster of ideas regarding the salvation of our health system. Interestingly, many of the ‘new’ ideas would be well informed by an understanding of the history of healthcare policy in our country. Finally, while many may join the conversation, an abundance of talk and little evidence of progress is a key element in declining trust in our system. I would gladly embrace a conversation after my province introduces a Norway-like healthcare guarantee; can’t deliver services in a timely way then pay for me to access those services wherever I can find them…including private, for-profit clinics, which I would never access if we had a functioning health system!

  • Doug McGregor says:

    When I saw this topic come up on Healthy Debate I was pleased. I see the debate of public vs private health care as critically important so I set the article to one side for a few days until I got a chance to properly sit down and read it.

    My anticipation turned out to ill founded.

    Our healthcare system is not performing well. It is understood why and has been confirmed by lots of data with surveys of clinicians, administrators and the public.

    So why would the CMA publish an article set to out a case for more dialog instead of dealing with the issues?

    The case for expanding the scope of private care in Canada is clear. It’s NOT the public that wants it. Canadians want health care. However, some who can afford it, are having to resort to paying for their health care rather than have none. In other words they are being FORCED to do so.

    To me the choice is very clear. Canada needs to aggressively avoid a healthcare system that emulates either the US system or the UK. Indeed, the very propect detracts from efforts to focus on the problems we are facing.

    I have written for Healthy Debate before about our ailing system before and the perils of private medicine based on personal experience. In those essays I have argued for a clinician led effort, as opposed to government, to develop (and execute) a plan that allows the country to heal our healthcare system using the fixed resources we have. By now I had hoped that message would have taken root.

    So CMA, I question why you would NOT step up and what is your motive in proposing such a dialog.

  • Colleen Fuller says:

    Canada doesn’t now have and never has had a “totally government funded and operated healthcare system”, as so many people seem to believe. The portion of publicly funded care – estimated variously as 70-72% of the total health expenditures – that is subject to the terms and conditions of the Canada Health Act (no user charges or extra billing) was only 42% in the early 2000s and that has shrunk because of delisting and privatization over the last 25 years. Physicians are private practitioners whose main but not only source of income comes out of the public treasury. Almost all hospitals in Canada are private non-profits that are publicly funded (but which are increasingly reliant on private handouts). Prescription drugs and vaccines are mostly paid for privately and almost entirely produced in the private sector with a healthy injection of public money. It’s been a multi-generational struggle to get dental care publicly funded and we’re not there yet. Canadians have seen a range of outpatient services shifted to private pay and delivery during the last 20-25 years, along with eye care, naturopathy, chiropractic care and other services. Long term care and home care are a hodgepodge of private non-profit and for-profit, and all of them impose significant charges on the most vulnerable Canadians. Compared to all but 2 or 3 of our peer countries, Canadians already spend significantly more privately and much less publicly as a percentage of GDP.

    So why is the CMA framing the question of public and private health care as if Canadians have limited experience with private options? Let’s talk about how great it is facing a physio bill you can’t pay or finding out your private insurance plan only funds 6-8 sessions a year with a counsellor when you need 24. Let’s have an honest discussion based on reality not fantasy.

  • John Sherber says:

    There is now an opportunity for patients to take the term partners to a higher level If care is a partnership and a partnership ship is the meeting of equals what is the patient bring to the relationship?
    I have been a patient partner for 10 years and seeing where our system is my opinion is that we need to rethink how we deal with our healthcare system.
    In my opinion, Canadians, especially my group, seniors are entitled. We want to live the life that we want, but also want healthcare that meets every need. Saying this is not being disrespectful. It’s a wake up call that our lifestyles are part of the issue.
    Never before have people been getting hip replacements, all kinds of incredibly serious health care fixes that cost a incredible amount of money, and as we move forward, our generation is only going to increase.
    Look at the CHI high stats 68% increase in 75 and older
    How many people are waiting for long-term care? public long-term care!
    The ratio of workers will drop from 8 to 1 to 4 to 1
    Can you imagine working in an environment every day and you deal with human frailty and you were expected to be at the peak all the time?
    I have a lot of respect for people that work in the system and they need our help. Private care will have to be part of the solution.
    You may talk about Australia, but look at the NHS in England. It is going down faster than you can imagine because there are just too many people and not enough people to do the work.
    There will be so much work to do!
    John

    • Mike Fraumeni says:

      Completely agree John, learn from Australia but just because Australia had problems with a hybrid care introduction doesn’t mean we, here in Canada, can’t learn from the Australian experience and eliminate the mistakes and issues they had introducing a hybrid care model. Absolutely private care will have to be part of the solution. Hybrid doesn’t mean “bad” just due to the Australian experience. Or a “dirty” word, just as Diane O’Leary argues dualism as in a form of property dualism, isn’t “dirty” for healthcare either, eg:

      “In this sense, dualism is no longer a dirty word – it doesn’t mean what it meant to Descartes, that we are made of two separate kind of stuff, a body and a soul. Property dualism suggests that while persons are physical substances, we have both physical properties and experiential properties. This makes it possible to have our cake and eat it too, to accept that persons have subjective experiences without giving up our commitment to science. In the end of the day, there’s really no way to understand medicine’s perspective on the whole person except through some form of property dualism. ”

      https://iai.tv/articles/medicines-bad-philosophy-threatens-your-health-auid-2225

  • Eric Demers says:

    We should not be afraid to discuss the care we collectively want or can afford as a society. We need to establish better definitions of what is medically necessary nationwide. A lot of our healthcare spending could be reduced with better prevention measures, such as adequate housing, access to healthy foods, and prompt access to team-based primary care. The healthcare system(s) need a complete overhaul and shift to a more primary care base than hospital-based care. Quality improvement is difficult with the myriad of collection methods and lack of benchmarks in primary care. Access to information about our public health system should be much easier and not treated as political cabinet confidence. If a provincial health minister has options in front of them, the public should know what those options are and not just what the decision or press release says will happen in 5 to 10 years…hopefully. An example, in BC, surgical wait times are bad for one month, and the next month, the government announces unprecedented successes. Not sure what to believe anymore but the experience for patients speaks to the negative side of the story.

  • Catherine MacNeil says:

    I’m very curious as to why the CMA is traversing the country attempting to drum up support for the privatization of the Canadian health care system .
    After four years of research studying the effects that privatization has on public health care systems the evidence is pretty much unambiguous. Privatization of health care systems cost more, expands bureaucracy , adversely affects outcomes and leaves large swaths of people behind. The Australian system demonstrates that introducing hybridity into a public system creates a competition for Human Resources and publicly funded beds. This leads to a deterioration of the public side rather than an improvement.
    For decades the Canadian Institute for Health Information (CIHI) has listed physician remuneration has either the second or third highest cost driver of national health care expenditures in Canada. Why would an association affiliated with such cost-driving metrics be in a position to tell the funders (taxpayers) that increased privatization is what they need?
    Cathy MacNeil
    Author of:Dying to be Seen: The Race to Save Medicare in Canada.

    • Mike Fraumeni says:

      As this author mentions, I would love to know exactly what “politically acceptable means” entails and exactly how this could be achievable in our Canadian healthcare system.

      “Dr. Brian Day’s case in British Columbia has deep pocketed supporters who would benefit from introduction of private care in Canada. If we are going to preserve Canadian Medicare, we will need to find politically acceptable means of investing in publicly funded care while continuing to improve our system’s efficiency.
      Australia’s hybrid system offers a cautionary tale of what will happen in Canada if we fail to make tough decisions. If wait times and patient experience do not improve, Canadian baby boomers will increase the demand for a hybrid healthcare system.”
      Source: “Does hybrid health care improve public health services? Lessons learned from Australia” By Dr. Bob Bell
      https://drbobbell.com/does-hybrid-health-care-improve-public-health-services-lessons-learned-from-australia/

  • Mike Fraumeni says:

    I’ve mentioned this previously on this site but I think it’s worth repeating that any system that has the sole healthcare insurance, if you will, provided by the government will have limitations on what can be offered to patients as governments will continue to use evidence-based medicine and clinical practice guidelines methodology to limit how physicians and other healthcare providers practice. This is going to be a problem in an increasingly more informed public with access to information via the Internet. This again is worth repeating from Paul Hsieh from south of the border and I’m not necessarily advocating for more private healthcare in Canada, just mentioning the limits to a totally government funded and operated healthcare system. I believe that totally government funded healthcare systems will increasingly force healthcare practitioners to view patients as populations rather than as an individual and as such, healthcare practitioners will increasingly be forced to follow conservative clinical practice guidelines that err on the side of cost containment from a population-based perspective rather than an individual based perspective. And this spells trouble when personalized healthcare with the advancement of technology in healthcare will become more of the norm in progressive healthcare practices.

    “5 Ways To Protect Yourself Against Obamacare”

    “ObamaCare will worsen the current physician shortage. The law will also drive physicians to become hospital employees or to join large Accountable Care Organizations (ACOs), where their treatment decisions will be monitored with mandatory electronic medical records. Government and private insurers will increasingly link payments to adherence to “comparative effectiveness” practice guidelines. Physicians will face significant conflicts-of-interest when their patients might benefit from treatments outside the guidelines, but the physician risks nonpayment (or losing his ACO contract) as a result…. Ask your doctor if he will be joining an ACO. (Not all doctors will.) If so, ask if your personal medical records can be excluded from his ACO practice statistics. If ACO rules allow it, this will help him practice outside the guidelines when medically appropriate (e.g., ordering an MRI scan sooner than usual or prescribing a stronger but more expensive antibiotic) without fear of hurting his overall statistics.”
    Source: https://www.forbes.com/sites/paulhsieh/2012/11/13/5-ways-to-protect-yourself-against-obamacare/?sh=7dfbd5bb1415

  • Barbara says:

    Ordinary Canadians certainly need to be part of this health care system reform debate. By ordinary, I mean lower and middle class Canadians, not just wealthy Canadians. As well, seniors need to be a large part of this debate, because they are likely the most affected by privately funded health services.

Authors

Kathleen Ross

Contributor

Dr. Kathleen Ross is a family physician in Coquitlam and New Westminster, B.C., and the new president of the Canadian Medical Association.

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