Privatizing health care isn't the taboo it once was. But would it help Quebec's ailing system?
Political parties float idea of bolstering system with more private options. Experts question the logic
It's nearly noon at the Tiny Tots pediatric clinic in Decarie Square in the Montreal suburb of Côte Saint-Luc, and there's a steady line of parents clutching little hands or pushing strollers as they check in for their child's appointment.
Tiny Tots is part of ELNA Medical's growing network of family medicine and specialty clinics, with some 96 clinics in Canada, including about 25 in Quebec alone.
Although many of the services are covered by public health insurance — in Quebec, through the Régie de l'assurance maladie du Québec (RAMQ) — the clinics are privately owned and run.
If patients need to see a specialist, they can be referred internally to someone working at one of ELNA's clinics. A patient can have tests or procedures done at a public clinic or at ELNA. Some specialty procedures at ELNA are covered by RAMQ, while others are mostly covered by private insurance plans
"It's the same care, except in, shall we say, a better wrapper," said Dr. Benjamin Burko, a pediatrician and the Montreal-based company's chief innovation officer.
Support for such an approach appears to be growing.
A dearth of family doctors, long wait times for surgeries and overwhelmed emergency rooms have made the public thirsty for new ideas to improve Quebec's health-care system — and one of the main alternatives being proposed in this election campaign is opening the network up to further privatization.
Both the Coalition Avenir Québec (CAQ), which holds a commanding lead in the polls, and the Conservative Party of Quebec (PCQ), an upstart right-wing party, have laid out proposals to expand private care.
In an attempt to take pressure off nearby hospitals, the CAQ is proposing a pair of new private medical centres, in Montreal's east end and Quebec City. The privately run "mini hospitals" would be open seven days a week and include a family medicine clinic, a 24-hour emergency room for minor ailments and day surgeries. All this would be covered by public health insurance, according to the CAQ.
The PCQ wants to go farther, and party leader Éric Duhaime has said the "p-word" is no longer taboo when it comes to health care in Quebec.
Duhaime wants private companies to be allowed to operate some hospitals and believes doctors should be encouraged to practise in both the public and private health systems.
Quebecers open to idea
Proponents of more privatization argue it would take pressure off the public system and improve triage care, but many experts say doing so would siphon off resources from the public system, increasing inequity in the process.
"Having a private network that competes with the public system is not the solution for labour shortages in the public system," said Olivier Jacques, an assistant professor in the department of health management at Université de Montréal.
Jacques said private centres like the ones proposed by the CAQ could steal away doctors and nurses. It's unclear whether such a model would lead to a more effective use of taxpayer money, he said.
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But the ideas being floated during the campaign suggest Quebecers aren't as attached to the idea of public health care as residents elsewhere in Canada, Jacques said.
A recent poll by Angus Reid bears that out. It found Quebec residents are among the Canadians with the greatest appetite for more private care, with 40 per cent saying more private care would help. (Quebecers are also among those most dissatisfied with the current system, with three in five polled saying care is poor.)
Similarly, 43 per cent of Quebecers who have taken part in CBC's Vote Compass survey would like to see more private health care, while 26 per cent want the same amount and 31 per cent want less.
Importantly, Jacques noted, "Nobody is saying that people should be paying more themselves for health care. So it's not about the funding of the health-care system, it's about the provision of services, and this is very different."
'Less and less access'
In Canada, health-care spending is divided between the public and private sector at roughly a 75–25 split, according to the Canadian Institute for Health Information (CIHI).
Quebec has a slightly higher proportion of public care, due to its prescription drug coverage and other add-ons.
The CAQ and PCQ proposals have drawn criticism from the Quebec Liberals, but they, too, are promising to allow more private clinics covered by public health insurance to address the surgery backlog.
The Parti Québécois and Québec Solidaire are opposed to expanding private care. Both argue for more funding for the public system.
McGill Prof. Amélie Quesnel-Vallée, who holds the Canada research chair in policies and health inequalities, pointed out the province already has more private care than much of the public realizes — starting with doctors themselves. They are largely self-employed and include some who have opted out of the public system either entirely or on a part-time basis.
In the past five years, the number of specialists and family doctors in the private system has climbed by 35 per cent — by more than 500 doctors, in all. Private clinics are a large part of the province's patchwork of care, strengthened by a landmark 2005 Supreme Court ruling that permitted Quebec residents to have private medical insurance.
Isabelle Leblanc, a family doctor at St. Mary's Hospital who is running for Québec Solidaire in Mont-Royal–Outremont, believes the province has already headed too far in the direction of privatization.
A former president of the advocacy group Médecins québécois pour le régime public, Leblanc is concerned about the erosion of the public health system and what it means for the most vulnerable.
"The main reason is that, you know, a private clinic is there to make profit. It's not there to care for the people, and it's going to choose its patients."
Her party advocates putting more money into CLSCs.
"There's less and less access" to health-care providers such as psychologists, unless you have private insurance or the means to pay out of pocket, Leblanc said.
"It used to be that 15, 20 years ago, people could go to the CLSC and see a physiotherapist, a psychologist or social worker very easily, and they had access. Now the access is very [limited]."
She said money put toward the CAQ's proposed clinic in Montreal's east end should instead be used to revamp Maisonneuve-Rosemont Hospital.
"There needs to be major renovations there," she said.
Privatization demands 'different pace'
Burko started his medical career at the Montreal Children's Hospital, but said he left after he grew frustrated with what he saw as a slow and inefficient system.
For 30 years, he was the CEO and medical director at Tiny Tots, which he sold to ELNA Medical in 2017.
Private clinics operate in a market economy, which he believes encourages a better patient experience. To stay competitive, private clinics have to vie for doctors and make the experience as efficient as possible to keep patients coming back, said Burko.
"Government institutions, like hospital clinics, never have those pressures," said Burko.
"The incentives are not there. It's a different pace, and things are accepted that would never be accepted in a private enterprise."
Given his support of the private system, it may come as a surprise that as a long-time physician, Burko is not a fan of the CAQ's proposal to build privately run super clinics, which he worries will cannibalize staff.
It's "robbing Peter to pay Paul," said Burko. "There aren't enough doctors anywhere, so creating a fancy new building with nice furnishing isn't really going to solve anything. Either it will remain unstaffed or you'll take staff away from other places."
He'd prefer to see the province invest in training more doctors and nurses to address the labour shortage.
The details of the CAQ proposal aren't yet clear — but in general, critics say private health-care providers tend to treat simpler cases, while leaving more complex care to an overloaded public system.
Still, Quesnel-Vallée said the involvement of the private sector could be fruitful, provided it doesn't only exacerbate the shortage of workers.
"We need to have some transparency about what the government is paying for these private services and how it compares to what is currently on offer in the system," she said.