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Throughout Canada's health care history, the private sector and those with interest in for-profit services have maintained a position of importance in the system as a whole. Notably, about 30% of health care funding comes from the private sector primarily due to the variation and limits in what medicare covers. As such, despite Canadian health care being predominantly public, the private sector has a significant position in the system.
The Canada Health Act requires the provinces and territories to provide medically necessary services to all residents according to its core criteria: public administration, comprehensiveness, universality, portability, and accessibility. Medicare's limits consist of what is not included in the system and the provinces and territories' ability to independently decide what "medically necessary" means beyond hospital and physician services. This is where the private sector gains access to the system.
Generally, dental, vision, prescription drugs (prescribed outside of hospitals), medical equipment, and care provided by health professionals besides physicians are not covered by medicare, thus highlighting areas where the private sector can establish a presence within a primarily public system. These limitations, combined with variation across the country as to what is covered by the governments, explains why private care plays a notable role in Canada.
Image from Effective Public Healthcare Panacea Project.
Every provincial and territorial government strongly recommends its citizens have supplemental insurance to provide these services. In most provinces and territories, private insurers are not allowed to offer coverage that duplicates publicly funded plans, but they can capitalize on the supplementary coverage market. This creates an environment where private, for-profit companies can compete and flourish. While supplemental insurance is often provided through one's employment benefits, some Canadians (certain low income or senior groups are supported by the federal and provincial governments) must pay out of pocket for these services. This further accentuates a dependence on the private sector.
Throughout its history, those with interests in the for-profit medical industry have expressed opposition to medicare and public health more broadly. Long wait times are a common criticism levelled at the public health system by proponents of private health care. Chaoulli v. Quebec is one case regarding this issue that lent power to discourse in the early 2000s. Dr. Chaoulli took his case to court when he was denied a licence to provide private services to a patient experiencing long wait times in the public system. In a 4-3 decision, the Supreme Court ruled that the prohibitions on private care violated the Quebec Charter of Rights and Freedom. This was a significant win for the private sector and raised vital political and legal questions about the rise of privatized care in a public system.
Dr. Brian Day, a pro-private sector figure discussed in Federal History of Healthcare, was elected president of the Canadian Medical Association in 2007 and launched such a vigorous campaign against Canada's public health system that a split occurred, leading to the formation of the Candian Doctors for Medicare. He continues to be a leading voice in the growing discourse on private health care, and he has been recently associated with the Cambie Surgery Centre Case in British Columbia. Dr. Day pursued a case similar to Chaoulli V. Quebec by arguing that patients should have a right to pay for care if the system lags. However, his case came to a close in 2020 when BC Supreme Court Justice Steeves ruled against Dr. Day, ensuring that access to health care will continue to be based on need and not ability to pay. Nonetheless, Dr. Brian Day's case and opinions illustrate and further the discourse around private health care in Canada.
Photos: Dr. Day's case was met with opposition from public health advocates.
In addition to discourse, the private sector's presence in Canada's public health care system is also growing. In 2010, the OECD estimated that Canada ranked second among member nations for per capita private health insurance expenditures. To better understand the private sector's presence, roughly 60% of Canadians have private health insurance coverage, often from employment benefits, with for-profit firms representing about 80% of this landscape. Similar to the role of insurance in accommodating supplemental care and services not provided by Medicare, budgetary constraints have led some provinces, such as Ontario and Quebec, to alter the services considered "medically necessary," thus providing an in-road to private care. Though the private sector acting on Medicare's limitations was already a reality in Canada's system, this practice, known as "load-shedding," is becoming more frequent due to economic pressures. Moreover, "boutique" and extended services, such as cataract removal and long-term care, are increasingly covered by the private sector, leading to an increase in this commercial industry. In general, the private sector's presence is increasingly observable through partnerships or interactions with the public system as a whole. The neo-liberal response to infrastructure gaps has been to form partnership programs with the private sector. This includes technology updates that the public sector cannot afford and infrastructure updates. While removed from a strictly public system, these interactions demonstrate the increasing presence of the private sector.
The Canadian government maintains that its residents will have access to universal coverage for medically necessary healthcare services based on need rather than the ability to pay. However, health inequalities exist in the system both as a whole, through provincial and territorial variation, and within the provinces and territories, as private health care begins to play more of a role in the otherwise public system. Generally, Canada's wealth disparity has increased significantly since its low point in the 1980s. Rising inequality levels have historically posed a threat to public programs, leading many to worry about Medicare's future, especially considering the growing presence of privatized options. Budgetary constraints have already caused some provinces, those with means, to turn to the private sector for load-shedding or aid in technology and infrastructure upgrades, thus leading to inequalities in the standard of care and resources across Canada. Moreover, studies show that as wealth increases, so do the preferences for the level and quality of care, potentially rising above what the public system can offer. Evidence of an increase in spending from top income earners in Canada on private health care in recent years speaks to this tendency.
Percentage of Canada's wealth each group controls, 2014. Graph from Broadbent Institute.
Despite the restrictions on private companies duplicating public services, the increase in the wealth disparity, combined with the growing presence of the private sector in Canada's health system, has important implications for the future of Medicare and the possibility of increased inequalities in the level of care Canadians can receive. Maintaining equitable care in Canada is of great significance