Canada has fewer hospital beds, doctors, and nurses per capita than virtually all western European countries. People are dying or suffering needlessly because they don’t have a family doctor, have to wait for hours or even days in over crowded emergency departments, are on wait visits for vital surgeries which can be 6 months or longer, etc. We have excellent doctors and other health professionals but they are burnt out and retiring as our population ages. At the same time the number of seniors needing care is growing as the baby boomers move into their “Golden” years and are living longer. In short, medical care in Canada is a disaster and getting worse. In Quebec, the situation is even more dire compared to most other provinces.

The solutions proposed by political parties are the same old promises that are never fulfilled. We will give you more family doctors: we need more money from the feds, we will cut wait times, we will centralize, we will decentralize, we will cut bureaucrats. It would be laughable if it were not so tragic.

So, what are real solutions?

A good place to start is to look at how our Medicare system differs from the systems in European countries and other developed nations. They all have universal health care but they also allow private options. In Canada we allow very limited private clinics for some diagnostic tests and doctors can opt out and be 100% private but very few do. Private insurance for services covered by the Canada Health Act is mostly illegal. In 2003, the New England Journal of Medicine wrote that the Canadian system was “unique in the world” in that it banned coverage of core services by private insurance companies.

Would two-tier health care lead to the death of Medicare?

It is a given by many, including most of our political leaders, that allowing private options will mean the death of Medicare because doctors and nurses will leave for more lucrative private practice. Indeed, the B.C. Court of Appeal recently rejected arguments in favor of a private clinic even though they acknowledged that people were dying and/or suffering on waiting lists for the public system. They also recognized this was a violation of the Charter’s right to life and security of person. Still, they said that allowing private clinics would result in a two-tier system where access to life-saving treatment depends on wealth. To the learned Justices it is more important that we all suffer equally than for some who can pay to suffer less. That is a philosophical argument with which one can agree or disagree. But what if a two-tier system actually makes the situation better for everyone (even if more so for the wealthy)?

Supreme Court ruling in 2005 Chaoulli v. Quebec case

In a case where the appellants argued in favor of allowing private insurance to cover services in the public system, the majority found in favor of the appellants. The judgement included several important points which support my arguments in favor of private insurance and more private options. The numbers below are the paragraph numbers from the judgement.

84. It cannot therefore be concluded from the evidence relating to the Quebec plan or the plans of the other provinces of Canada, or from the evolution of the systems in place in various OECD countries, that the Attorney General of Quebec has discharged his burden of proof under s. 9.1 of the Quebec Charter. A number of measures are available to him to protect the integrity of Quebec’s health care plan. The choice of prohibiting private insurance contracts is not justified by the evidence.

140. The evidence adduced at trial establishes that many western democracies that do not impose a monopoly on the delivery of health care have successfully delivered to their citizens medical services that are superior to and more affordable than the services that are presently available in Canada. This demonstrates that a monopoly is not necessary or even related to the provision of quality public health care.

147. After reviewing a number of public health care systems, the Standing Senate Committee on Social Affairs, Science and Technology concluded in the Kirby Report that far from undermining public health care, private contributions and insurance improve the breadth and quality of health care for all citizens, and it ultimately concluded, at p. 66:

The evidence suggests that a contribution of direct payments by patients, allowing private insurance to cover some services, even in publicly funded hospitals, and an expanded role for the private sector in the delivery of health services are the factors which have enabled countries to achieve broader coverage of health services for all their citizens. Some countries like Australia and Singapore openly encourage private sector participation as a means to ensure affordable and sustainable health services.


Stethoscope on top of the Canadian flag

The flaw in arguments against two-tier medicine

The biggest flaw in the arguments of those who say doctors will leave the public system for a private one is that it assumes a fixed number of doctors. However, doctors (and nurses) are well educated and highly mobile. Their services are in great demand everywhere in the world. For example, McGill with a world class medical school, heavily subsidized by Quebec taxpayers, loses at least half of its graduating class each year. I am sure many would stay here if they had attractive private options. The rule preventing doctors from working partly privately and partly under Medicare also encourages doctors to leave. In Quebec forcing most doctors to work in the regions or face a huge cut in pay is another disincentive to staying in Quebec.

On the other side, we could attract doctors from the US and other countries with good private options and if we allowed their kids to be educated in English, if they wished. Further, Bill 21 discourages all immigrants who are Jewish, Muslim or Sikh from coming to Quebec. Some of those potential immigrants are doctors and nurses. In addition, we should fast track acceptance of health professionals from other countries who come here. Currently, it is very hard to have credentials recognized and equally hard to get residency positions. None of these suggestions will cost taxpayers a single penny. Indeed, we will save money.

However, to have more private options the Canada Health Act must be changed to allow private insurance for all health services and to allow private provision of all services including hospitals.

More privatization leads to greater client satisfaction

In Europe many countries have private hospitals. The Netherlands, Germany, Belgium, Norway and Switzerland have over 60% of their hospitals in the private sector. Most of the services are covered by the taxpayers although some are paid for by the client. Other European countries have fewer private hospitals but again services are taxpayer funded for the most part. A study by Dominic Montagu, published online in Frontiers for Public Health in March, 2021 ( reported on a Gallup poll from 2016 that showed that clients in countries with the most private hospitals had the highest levels of satisfaction in their health system at 89.4% vs. 73.2% for the countries with the fewest private hospitals (UK, Ireland, Iceland, Denmark and Sweden). This should come as no surprise. Competition leads to better services in both the public and private sectors. It is also not surprising then that European countries have so many more doctors and hospital beds than Canada. If Canada would open up to private options we would have more doctors, nurses and other health professionals. We would have more medical equipment and more hospital beds.

Another argument in favor of private services paid for by clients is that those using those services drop off the public waiting lists and reduce the costs to taxpayers.

Some would argue that no doctors will work in the public system but there will not be enough demand for client financed services. Why would even a well-off person pay for something that he could get for free. The Supreme Court judgement cited above looked at several OECD countries, all allowing private insurance for services provided for free in the public system. Only a small minority choose to get private insurance. It won’t be different in Canada and with most using the public system and with competition from the private sector, there will be plenty of incentive (more than now) for politicians to spend on the public sector.

There is another reason why doctors will choose to work in the public sector especially if the wait lists and other pressures are reduced by the introduction of private options. Many top doctors do research and that is only available with like minded colleagues in the public sector. Probably many of the best doctors will work mostly in the public system but devote some extra hours in private clinics to increase their take home pay. It is already happening even with the very limited number of private services that are allowed under our current rules.


  1. Thank you for posting this. I really enjoyed reading it, especially because it addressed my question. It helped me a lot and I hope it will help others too.

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Dr. Bill Steinberg

Dr. Steinberg has a BSc from McGill University, a PhD in Psychology from Northwestern University, and was a professor at Concordia University. He was Mayor of the Town of Hampstead for 16 years and led the demerger battle. He was was awarded the Queen Elizabeth Diamond Jubilee Medal and is currently President of the Cochlear Implant Recipients Association.

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