Private healthcare in Canada is varied and growing: report

Private healthcare in Canada is “not a uniform phenomenon,” according to commentary published by the C.D. Howe Institute, and its manifestations are growing.“The intense debate pitting private versus public healthcare in Canada needs a reality check,” wrote Katherine Fierlbeck in her study, The Scope and Nature of Private Healthcare in Canada. She is a professor at Dalhousie University and a senior research fellow at the Healthy Populations Institute.There is no singular model for private healthcare; it varies across the country and depends on each province’s legislative framework, wrote Fierlbeck.She argued that both proponents and detractors of private healthcare should be precise in what they mean when they use the term.“By requiring proponents and opponents to clarify precisely what they mean by ‘private healthcare,’ the potential costs and benefits can be more clearly identified in each case,” she wrote.Private healthcare comes in many forms. For example, ambulance services are often private companies that have negotiated contracts with provinces. There are also private providers of publicly funded services, particularly diagnostic services, as well as procedures like cataract or hip-replacement surgery.What’s pushing the expansion of private healthcareOptions for private healthcare have grown in tandem with supply and demand forces—in particular, the growth in the number of nurse practitioners and the expansion of their scope of practice, coupled with increasing demand from people seeking basic healthcare in an environment where access to primary care providers has decreased considerably, argued Fierlbeck.“Between 2012 and 2021, the number of nurse practitioners in many provinces doubled,” she noted. Between 2020 and 2021 alone, the number grew by 10.7%. On top of that, their scope of practice has widened significantly, to the extent that “they often perform a role similar to general practitioners,” Fierlbeck wrote. “The key issue here is the positioning of these other healthcare professions with regard to the legislated restrictions on the private sector,” she wrote, referring to nurse practitioners as well as healthcare professionals like paramedics and pharmacists, who have also seen an expansion in their scopes of practice.“[T]hese healthcare providers do not always face the same legislated restrictions against working in the private sector that physicians do.”Thus, nurse-practitioner-run clinics, which are increasing in number, can, in some provinces, set their own prices for their services, according to Fierlbeck.“This is possible because, while the CHA stipulates that ‘all insured services’ must be covered publicly, some provinces define ‘insured services’ as ‘services provided by physicians.’”Public-private distinction at the whims of provincial discretion The Canada Health Act stipulates the terms and conditions that provinces must adhere to in order to receive federal funding. But, notwithstanding the provisions against user fees and extra billing, for which the Minister of Health is legally required to impose penalties, the CHA “has no direct legal force on provinces,” wrote Fierlbeck.“Whether Ottawa chooses to penalize provinces for being non-compliant with the CHA beyond user fees and extra-billing remains subject to its discretion and, to date, successive governments have been reluctant in going down this path.”One section of the CHA that raises confusion, according to Fierlbeck, is section 9, which reads:"In order to satisfy the criterion respecting comprehensiveness, the healthcare insurance plan of a province must insure all insured health services provided by hospitals, medical practitioners or dentists, and where the law of the province so permits, similar or additional services rendered by other health care practitioners." [Emphasis added by Fierlbeck.]All provinces except Ontario allow physicians to offer these services privately, the study notes. This raises a question, as posed by Fierlbeck: “If all insured services provided by medical practitioners must be covered publicly, then how is the private provision of publicly listed services in nine provinces compliant with section 9 of the CHA?”In short, provinces are able to remain compliant with CHA because they set their own definitions for who counts as a private provider, as well as their own parameters for what counts as “insured health services.”“Because provinces have considerable authority in determining key terms like ‘medically necessary’ or ‘insured services,’ it is difficult to make justifiable claims against provinces for non-compliance more broadly,” Fierlbeck wrote.Ultimately, each province is the arbiter of how private healthcare is shaped within its borders. “Provinces have the legislative tools to constrain the growth of private healthcare, if that is their objective. Similarly, provinces have considerable authority to increase the scope of private healthcare, if that is their objective (even within the current parameters of the CHA), by revising provincial legislation or regulation.”

Private healthcare in Canada is varied and growing: report

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