The federal government has quietly reimbursed Quebec the almost $10 million it withheld from the province two years ago as punishment for charging patients extra fees to access health services in the province.
But the move has not softened Quebec's position or compelled the province to admit it did anything wrong in allowing doctors' offices to charge as little as $20 for eye drops or as much as $500 for instruments and medication for a colonoscopy.
"I'm sure that we have done absolutely nothing that was against the CHA [Canada Health Act] in the past. We did things that were within CHA. And I think it simply reflects the fact that they agree with us on that," Quebec Health Minister Gaétan Barrette told CBC News.
Federal Health Minister Ginette Petitpas Taylor, however, sees the repayment differently. She issued a statement Thursday saying her department is satisfied that Quebec decided to fall in line with the law.
"We are pleased with Quebec's decision to ban user charges, and note the actions of the government of Quebec to ensure Quebecers have access to health care based on need, and not ability or willingness to pay," the statement said.
In Petitpas Taylor's new mandate letter, Prime Minister Justin Trudeau asks her to "make absolutely clear that extra-billing and user fees are illegal under Canada's public medicare system."
It goes on to say Petitpas Taylor must "develop policies in collaboration with the provinces and territories to improve verification and recourse mechanisms when instances of non-compliance arise."
Reporting user fees
In a statement, Petitpas Taylor's office said that while the legislation is clear, the "levers to enforce it are weak" and up until now it has been left to the provinces to inform the federal government on its own about user fees.
"The current reporting mechanisms are not strong. Moreover, there is no incentive to encourage provinces and territories to report accurately and tackle the issue of patient charges," the statement said.
The topic is expected to come up when Petitpas Taylor meets her provincial colleagues for the first time next week.
Quebec's auditor general reported that the provincial government collected between $9.9 million and $18 million in extra fees from patients in 2015.
The federal health minister sent a letter in the fall of 2016, informing the province that the health transfer it receives from the federal government would be $9.9 million short at the end of the fiscal year to reflect the charges.
The $9.9 million was returned to Quebec after the province in January banned the collection of extra fees from patients paid at doctors' offices.
The Saskatchewan question
In the meantime, Barrette said, the federal government is breaking the Canada Health Act by ignoring user fees being charged to patients in other provinces.
"They know very well that in Saskatchewan there are user fees," he said. "They are letting it go. It's been a year now since they said they would look at it to see if it impedes significantly, or even marginally, access. Cleary it doesn't. But clearly also it is not within the CHA."
Saskatchewan allows patients to pay for an MRI test but in return clinics must offer a scan, free of charge, to a patient on the public waiting list. The provincial government has argued that the process will help with wait times.
When Saskatchewan signed the health accord in January, the federal government said it wouldn't claw back money from the health transfer for a year while it investigated the practice.
An official in Saskatchewan said the province has not heard from Health Canada since then.
Health funding remains an issue
Former federal health minister Jane Philpott reached an agreement with British Columbia in August to audit three clinics there to determine the extent to which extra-billing and user fees have become a barrier to accessing health care services.
"This is the federal government, this is the institution that has to uphold the law and they are holding back," Barrette said.
Barrette said he does not blame other provinces for allowing user fees, saying they are all facing rising healthcare costs and the latest health accord with the federal government does not do enough to deal with the financial strain he says the provinces are under.
"The budgetary issue is still on the table, will remain on the table, and the answers that we have today from Ottawa are certainly not sufficient in my mind," Barrette added.