Canada's Public Healthcare System Shrinking

18/05/24
Author: 
Christina Frangou
stethoscope/dollar sign

May 16, 2024

Private Health Care Is Here

A growing number of Canadians pay out of pocket for MRIs, hip replacements, even family doctor visits. How a two-tiered system crept into Canada.

Steven Goluboff has always been an old-school doctor. Over a decades-long career, he’s worked nights and weekends and, on his rare vacations, even taken his computer with him to track patients’ test results. In 2019, at 71 years old, he finally began planning to retire from his Saskatoon family practice. He knew he’d have to find more than one replacement for his patients, however—young doctors want a life outside the office, and they couldn’t be expected to put in the hours he did. So he recruited three replacements and left his practice.

Then, last fall, one of the doctors he’d recruited quit to join a private clinic in Vancouver. Hundreds of patients were left stranded—so Goluboff came back. At age 75, he’s still working full-time and sometimes even pulls night shifts at Saskatoon’s Royal University Hospital. “Hopefully, this is the last tour,” he says. But for now he’ll stay on, providing the kind of care Canadians are desperate for from a health system that is increasingly under strain. One in five of us no longer has a family doctor. Wait times for diagnostics and medical imaging have ballooned. Necessary treatment, in some cases, has become delayed enough to compromise outcomes: British Columbia is even sending cancer patients to Washington state for timelier care. 

But for Canadians who can afford it, some medical care has become easier than ever to access. A growing number of clinics nationwide are selling MRI scans, prescriptions, pap smears and even surgeries—services once considered primarily the purview of the public health sector—to those who pay out of pocket. Canadians are spending in the ballpark of $100 to speak to a nurse practitioner, who will offer the kinds of care a family doctor typically provides; upward of $600 for an MRI on demand, bypassing lengthy waitlists; and $20,000 or more to travel outside their province to see a surgeon for a hip or knee replacement. There’s never been such a willingness to pay for timely medical care in this country—because sometimes it’s the only way to get it.

Privately paid health care is nothing new in Canada. Mental health, dentistry, prescription drugs, optometry and other needs have always been mostly served by the private sector. People have long had to weigh the costs of buying new glasses, of getting their teeth checked or of seeing a psychologist. In February of 2024, nearly one-quarter of Canadians said they had split pills or skipped doses because of drug costs. I know what this is like. As a freelance journalist, I went years without private insurance and skipped out on filling prescriptions. But I was young and healthy. Many aren’t. One in 10 Canadians with chronic conditions say they’ve ended up in the emergency room because they were unable to afford prescriptions. Many of us live on a teeter-totter, trying to avoid a medical catastrophe without spending anything more than we can afford.

 

 

 

Sergio Tercero paid $8,700 for private MRIs and knee surgery in Vancouver.

“About 10 years ago, I tore the meniscus in my right knee playing hockey. I work as an electrician, so losing the use of my knee was devastating, and since the injury happened on my leisure time, it wasn’t covered under B.C.’s WorkSafe program. I had to turn to the public health-care system. I wanted an MRI to see if I needed surgery. My doctor told me MRIs were moving quickly those days—I’d only have to wait a few months. But that was longer than my EI would last me.” 

PHOTOGRAPH BY VISHAL MARAPON


For all that, health care in Canada has traditionally not been big business, especially when it’s urgent and important, such as emergency and life-saving treatments, or access to a family doctor. Working as a journalist covering health care in both Canada and the United States, I’ve always enjoyed the fact that when writing in this country, I’ve rarely had to be a business reporter as well. Covering health in Canada has meant focusing on people, outcomes, systems and laws. It was powerful to write stories, even heartbreaking ones, about Canadian health care, because of the almost mythical ideas of universality, equity and accessibility. There was a feeling of shared investment in protecting the public system. In the U.S., business interests are in play, and financial toxicity—the stress of paying for care—is a major theme when covering it.

All that is changing. Confidence in the publicly funded system has fallen dramatically, the result of decades of political neglect and the aftermath of a crushing pandemic. The Commonwealth Fund, an organization that studies health care around the world, recently ranked Canada 10th of 11 OECD countries in health-care performance, ahead of only the U.S.—even though Canada spends more than the OECD average on health care. And as the gaps in care have widened, the private sector has stepped in to fill them, steadily and stealthily pushing the boundaries of what’s permissible in Canada. 

The growth in private care has mainly been in four areas. There are diagnostic clinics where patients can bypass wait times for imaging tests like MRIs and CT scans. There are primary care clinics, often run by nurse practitioners who provide fast access to consultations, referrals, diagnoses and prescriptions in exchange for fees. There is virtual care, which offers much of the same. And then there are private surgical clinics, where Canadians can get life-changing procedures without waiting months or years.

Purveyors of these services say they can help solve some of Canada’s health-care woes if they’re allowed to do so. They argue that they take pressure off the public system, opening up more room so everyone can get care. Critics say they’re making things worse, creating an inequitable, inaccessible system while drawing scarce professionals away from the public sector and driving up overall costs. But this debate overlooks the root of the current crisis. The simple truth is that no one has done the hard work to fix the glaring holes in Canada’s publicly funded health system. There’s a saying in Canadian politics: health care is the third rail. Touch it and you die. That’s why politicians have mostly steered clear of health reform for decades, deterred by the challenge of modernizing a system that Canadians have long held up as a part of our national identity. 

Our current health framework was created for a very different country. Its founding flaws have grown more apparent with time and have only ever been papered over. The result is what we see in front of us today: 13 public health systems, one for each province and territory, all in a state of crisis; private businesses stepping into the gaps; and more Canadians than ever opening their wallets to pay.

The story of how Canada’s health-care system was born has been told so often it has become part of our national folklore. More than a century ago, a child named Tommy showed up at an outdoor clinic in Winnipeg with a bone infection that could have cost him his leg. An orthopaedic surgeon treated him for free in exchange for using him as a teaching case. Years later, Tommy Douglas became premier of Saskatchewan, promising that no citizen’s access to care would depend on their ability to pay. In 1947, Saskatchewan created the first hospital insurance plan in Canada. The province didn’t take ownership of hospitals, but it did pay citizens’ bills. British Columbia and Alberta followed, and the federal government nationalized the program in 1957, paying 50 cents on every dollar spent by the provinces for hospital care. 

In 1959, Douglas’s government announced phase two: universal physician care, a move that met with instant opposition from physicians themselves. Many of Saskatchewan’s doctors were British expats who’d fled their own country after it created the National Health Service, which made many doctors public-sector employees. They had no interest in seeing the same happen in Saskatchewan, as Douglas’s plan proposed. The government prevailed, but in July of 1962, when the new legislation took effect, doctors walked off the job in an ugly, angry strike. Regina physician Staff Barootes, who later became a senator, recalled people throwing eggs at doctors’ windows and slashing their tires. 

Steven Goluboff was 13 years old at the time, and his father and uncle were both doctors opposed to the plan. That summer, his family went on vacation to the World’s Fair in Seattle to escape the rancour enveloping the province. Their car’s licence plate bore the letters “MD,” indicating it was a doctor’s, and Goluboff’s parents feared for the family’s safety as they drove out of town. The strike ended after 23 days with a compromise that’s had lasting repercussions for Canadian health care: doctors would continue to operate as private business owners, but they would bill the provincial government for treatment provided to patients, in an arrangement now called fee-for-service. In 1966, the federal government implemented the Medical Care Act based on Saskatchewan’s program. (The Royal Commission on Health Services, established in 1961, recommended extending care to pharmaceuticals, home care, vision and dental health, with some user fees to supplement government funding. The government largely ignored those suggestions, leaving the services in question to the private market.)

And yet, even as the ink dried on the act, Canada was changing fast. The contraceptive pill was approved in 1960, and birth rates subsequently plunged. The country’s median age climbed as Canadians lived longer. An older population meant more chronic illness and more people needing sustained medical care, and health-care costs soared. By the early 1980s, most provinces and territories were letting doctors and hospitals charge user fees in an attempt to keep on top of growing costs. That was enough to stir Monique Bégin, minister of health under Prime Minister Pierre Trudeau, to quash the practice. 

That effort took the form of the Canada Health Act, which laid out five principles provinces need to follow to to receive federal health funding: accessibility, universality, comprehensiveness, public administration and portability (i.e., Canadians could travel within the country and receive care anywhere, paid for by their home province). The CHA has become an iconic act of legislation—and one that is poorly understood. It does not make private health care illegal, as some believe. Instead, it states that Canadians must have reasonably timely and free access to “medically necessary” care, and that medically necessary care must be paid for publicly. To ensure compliance, the feds can cut a dollar in federal health transfers to provinces for every dollar provinces allow citizens to spend on fees for those services. But unlike many countries with universal health care, what is and is not publicly supported is not explicitly spelled out at the national level. The CHA leaves it up to each province and territory to define what “medically necessary” means, leading to inconsistent coverage—Alberta and B.C., for example, don’t fund drugs that lessen the side effects of cancer treatment; other provinces do. Some provinces cover IVF treatments; others don’t. And the federal government has mostly been lenient when clawing back health transfers.


 

Hannah and Justin Housey pay $6,000 a year for private clinic memberships

“My family switched to private health care in 2019. My husband, Justin, has Type 1 diabetes and has to check his blood sugar multiple times a day. A new device had recently come out to make sugar monitoring easier. This was a life-changing advancement to treat diabetes, and we didn’t know how to get it. Our endocrinologist hadn’t even heard of it. We called a private clinic outside of Montreal, and my husband got the device within a couple of days. After that, we decided to continue with private health care.”