The Alberta government has yet to table its healthcare legislation that would allow some physicians to pivot between public and private practice, but already the predictable doomsayers are lining up to proclaim that those changes would mean the death of the public system.
We will wait to see what Alberta actually proposes before venturing an opinion on the particulars, although the idea of allowing surgeons to perform some private procedures while still being required to take part in the public system has promise.
Premier Danielle Smith deserves credit for the political courage to challenge the ossified thinking that has stultified healthcare reform in this country, even as costs soar and outcomes worsen.
Premier Danielle Smith’s government has prepared draft legislation that would allow physicians working in the province’s public health care system to simultaneously offer services in a parallel private market.Jeff McIntosh/The Canadian Press
In doing so, here’s hoping she punctures Canadians’ hermetically sealed sense of superiority about this country’s public system, sustained only because of the ongoing debacle of U.S. healthcare policy. Indeed, Alberta NDP Leader Naheed Nenshi was quick to (predictably) assail the government’s policies as “American-style medicine.”
We would agree with Mr. Nenshi that U.S.-style healthcare is best avoided. But what about Dutch-style care? Or Australian? Or Swedish, French, Swiss, Spanish, British, German, Austrian or Belgian? Among all those countries, Canada is the only advanced economy that prohibits a parallel private healthcare system.
An expensive and failing system
Set aside the intentional myopia and the facts are clear: Canadians pay a lot for a failing system. As the chart below shows, Canada’s healthcare system is top tier, but only when it comes to cost.
In 2024, Canada spent 11.3 per cent of gross domestic product on health care, seventh-ranked among the 38 member countries of the Organization for Economic Co-operation and Development. Exclude the United States, by far the top spender, and Canada is clustered with the advanced economies of Western Europe.
But when it comes to results, Canada is at the back of the pack. A 2024 study by the Commonwealth Fund ranked this country’s healthcare system seventh out of 11 high-income countries. Canada was ranked seventh on access to care.
Australia, which not only allows for private health insurance but fines upper-income residents who fail to purchase it, topped the rankings – including in equity, or whether there are gaps in access due to gender, income or geography.
On the equity measure, Canada’s supposedly universal healthcare system fared poorly – seventh out of 11 countries. But, hey, we beat the Americans.
An ambulance waits outside the Toronto Western Hospital emergency department.
Out of 11 high-income countries, Canada ranked seventh for access to care in a 2024 study by the Commonwealth Fund.Fred Lum/the Globe and Mail
Equal in misery
Those defending the status quo are seemingly deliberately oblivious to the reality that Canadian healthcare is failing to deliver on the promise of universal care.
There is the promise of universal care, and then there is the reality of months-long waiting lists, where treatment is delayed well beyond medical guidelines. No Canadian should have to go without healthcare treatment because they cannot afford to pay.
But the evolutionary dead end of Canadian healthcare policy has meant that Canadians receive equally free, but equally unavailable, care.
Twenty years ago, former Supreme Court justice Beverley McLachlin summed up the contradiction pithily in a key case on health care access: “Access to a waiting list is not access to health care.” She wrote that in the landmark Chaoulli case, which opened the door for private health insurance in Quebec, but nowhere else in Canada.
The phantasmic principle of equality cannot be compromised, even if that means wait lists grow and grow. Better that Canadians suffer together than contemplate any reform that would benefit everyone, but some more than others.
A case in point is Saskatchewan’s decade-old reform that allows residents to pay for a private MRI, after being referred by their physician. (Private MRI clinics must perform one procedure for the public system, free of charge, for each private procedure they sell.)
According to the critics of private care, that should have meant that wait times soared in the public system as resources were siphoned away.
That did not happen. To the contrary, wait times have improved, based on median wait times, and outperformed the national measures, based on the standard of how long 90 per cent of patients wait to receive an MRI.
As this second chart shows, Saskatchewan outperformed the national average on the 90th-percentile measure between 2018 and 2024, according to data from the Canadian Institute for Health Information.
Wait times did rise in Saskatchewan over that period, but only by about a third as much as the national average (which excludes Quebec, New Brunswick and Newfoundland and Labrador). The national statistics only start in 2018, which somewhat distorts the picture, to Saskatchewan’s disadvantage.
Using fiscal 2016 as a starting point gives a clearer (and more favourable) picture of the effect of a parallel private system for MRIs on wait times for public procedures in Saskatchewan. In March, 2016, MRI waiting times (again, on a 90th-percentile basis) were 206 days. As of June, 2025, that waiting time sat at just 173 days, a decline of 16 per cent.
Even that figure doesn’t capture the full extent of the benefit of Saskatchewan’s parallel system, since private procedures are not counted. If they were, the overall waiting time would be far lower, since private procedures can be booked within days.
An MRI unit at Western University’s Centre for Functional and Metabolic Mapping. After introducing its parallel system for access to MRIs, Saskatchewan outperformed the national average wait time on the 90th-percentile measure between 2018 and 2024, according to data from the CIHI.Geoff Robins/The Globe and Mail
Yes, those who paid hundreds of dollars for a private MRI received much faster care than those who were unwilling or unable to do so. Those who remained in the public system also benefited – just not as much.
But that result is anathema to the defenders of Canada’s indefensible status quo, who insist that it is preferable that everyone suffer a precisely equal allotment of misery.
Saskatchewan’s experiment should be celebrated as a major success to be emulated. Instead, Ottawa has opted to fine the province for violating the letter of the Canada Health Act.
A boom in generational inequity
The cost pressure on Canada’s health care system, and the need for reform, are already enormous. But both that pressure and that need will swell in coming years as the Baby Boomers age into their eighties, and the peak of health care expenditures arrives.
And that raises a significant question of generational equity for younger Canadians who already face serious economic disadvantages from precarious employment and stratospheric housing costs.
A fascinating study landing next week from University of British Columbia professor Paul Kershaw explores those generational tensions. (His study, Medical Budgets in an Aging Canada, does not endorse private care as a solution, but instead focuses on raising revenue from wealthy seniors and trimming benefits, such as the Old Age Security income support program.)
The key driver is the declining ratio of working age Canadians to seniors, illustrated in this third chart.
In 1976, there were nearly seven working-age Canadians for each senior. As of 2024, that ratio had declined to just over three.
Prof. Kershaw has also calculated the rising fiscal burden that younger Canadians are bearing as the ranks of senior citizens grows. In 2022, just under 10 per cent of the taxes paid by a 35-year-old in Ontario earning the median income of $53,773 went to cover the health care expenses of the senior population. The equivalent figure in 1976 was half that level.
That bill is bound to grow, as boomers age. A Canadian born in 1956 is only just entering the years in which health care costs mount. According to Prof. Kershaw’s study, average annual medical spending for Canadians aged 65 to 69 is $8,167. By age 80, that figure will have more than tripled, to $18,922.
So how should that cost be borne? The advocates for the status quo would simply raise taxes on working-age Canadians, dumping billions and billions of dollars more into a system little improved by previous billions of dollars, while demanding nothing from wealthy, older Canadians.
No Canadian should go without health care because they are unable to pay. That is a bedrock principle of Canadian health care policy that should never change. But there is a world of experience that shows there are many (and many better) paths to achieve that admirable goal than Canada’s current morass.
Alberta’s proposals may or may not be the answer. But at least the province has dared to ask if there is a different way – a way to deliver on the promise of health care that will be fair for all Canadians.
THE SUNDAY EDITORIAL
The airport of the future has arrived – but its landing is delayed in Canada