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Fraser Institute

Government meddling contributes to doctor exodus in Quebec

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6 minute read

From the Fraser Institute

By Bacchus Barua and Yanick Labrie

They have not left Quebec’s health-care system but rather have opted out of the province’s publicly-financed framework to provide care to their patients privately.

Quebec’s health minister recently came under fire after reports revealed a record number of physicians left the province’s public system to practise privately. Less discussed are the reasons why physicians made this choice.

Indeed, it turns out that ill-conceived attempts to protect publicly-funded health care by the Trudeau government and successive provincial governments may have contributed to the increasing numbers of physicians opting-out.

To be clear, the 780 physicians in question account for about four per cent of physicians in the province. However, this represents a 22 per cent increase in the number of physicians leaving the public system compared to the previous year—and is part of a growing trend. More importantly, they have not left Quebec’s health-care system but rather have opted out of the province’s publicly-financed framework to provide care to their patients privately.

Why?

One reason, is because governments have forced them to do so.

Until recently, physicians in Quebec (including those who practiced in the public sector) were allowed to charge patients so-called “accessory-fees” in certain instances—for example, if the service was either not covered or insufficiently reimbursed by the government’s fee schedule.

However, the federal Canada Health Act (CHA) clearly states that “extra-billing” of this nature, when charged by physicians who also bill the public system, must result in dollar-for-dollar deductions in federal health-care transfer payments to the province. In other words, the CHA encourages provincial efforts to effectively force doctors to choose between the public and private system if any out-of-pocket expenses are involved.

And so, under financial threat by the Trudeau government, Quebec eventually clamped down on such fees charged by physicians who worked in the public system.

Consequently, physicians who relied on these payments to cover a portion of their operating costs faced an unfortunate choice—stay in the public system at the risk of financial ruin or opt-out entirely and practise exclusively in the private sector.

For many, the choice was obvious. One study found that by 2019 “an additional 69 specialist physicians opted out after the 2017 clampdown on double billing [sic] than previous trends would have predicted.” Several clinics offering endoscopy and colonoscopy services simply closed their doors. Quebecers also ended up with a less convenient health-care experience following this clamp down, as evidenced by the reduction in clinic-provided services that followed.

This attitude to extra-billing stands in stark contrast to the situation in other universal health-care countries such as Australia where consultations with specialists are usually only partially (85 per cent) covered by the universal plan. In fact, physicians (family doctors and specialists) can generally set fees above the government’s fee schedule so long as they forgo the convenience of directly billing the government (i.e. patients claim reimbursement after the fact). Notably, Australia’s health-care system costs less than Canada’s in total (including these private payments) yet delivers more rapid access to health-care services with a greater availability of medical professionals, hospital beds, and diagnostic and surgical technologies.

More generally, a recent study found 22 of 28 universal health-care countries require patients to share a portion of the cost of treatment (with generous protections for vulnerable groups). These include deductibles (an amount individuals must pay before insurance coverage kicks in), co-insurance payments (the patient pays a certain percentage of treatment cost) and copayments (the patient pays a fixed amount per treatment). Crucially, many of these countries including Australia, Germany, the Netherlands and Switzerland also have shorter wait times than we endure.

In these countries, physicians are also generally allowed to practise both in publicly-funded universal settings and private settings (a policy known as “dual practice”) rather than having their activities restricted to one setting only. In other words, Canada’s federal restrictions on cost-sharing and extra-billing (such as Quebec’s accessory fees) and provincial barriers to dual-practice place our universal system in the minority of a small cohort of countries that are not particularly known for stellar performance.

The looming threat of further reductions in federal cash transfers, under the CHA, has led to provinces such as Quebec imposing increasingly restrictive conditions on physicians in the public system. And in response, physicians—by opting-out—are indicating that they’ve had enough.

It’s ironic that the very groups intent on supposedly “protecting public health care” by forcing physicians to choose between the public and private systems have enforced policies that may very well lead to the public system’s continued demise.

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Fraser Institute

Young people increasingly embrace conservatism

Published on

From the Fraser Institute

By Philip Cross

One of the most intriguing recent political trends in North America is the growing support for conservative parties among young people. Once a reliable source of overwhelming support for the elections of Barack Obama and Justin Trudeau, a rising share of the youth vote is trending towards candidates such as Donald Trump and Pierre Poilievre. Young people voting for conservative politicians could be dismissed as just a backlash against failed economic policies, but there are indications of a more fundamental shift to embracing at least some conservative values.

Canadian youths now support the Conservatives more than any other party, a development not seen in decades, if ever. According to an Abacus poll, 36 per cent of Canadians between 18 and 29 years old would support the Conservatives versus 27 per cent for the NDP and a paltry 19 per cent for the Liberals. Nor is support for Poilievre’s Conservatives just a backlash from the failing fortunes of youths under the Trudeau regime. An Environics polls found young people in Canada would vote for Trump more than any other age group: 28 per cent of Canadians between 18 and 34 years old prefer Trump versus 13 per cent for those 55 and over and 27 per cent between 35 and 54.

Faced with a health-care system that’s clearly broken in Canada, youths have fewer qualms about involving the private sector than older generations who were raised to believe that publicly-provided health care was a fundamental Canadian value. A recent poll by Leger published in Le Journal de Quebec found that 44 per cent of youths 18 to 34 years old support private delivery of health-care services, the mirror image of the views of people 55 and over who oppose it. Meanwhile, youths in the United States identify as having more conservative views than their parents even more than millennials did 20 years ago, with the largest shift among young men.

Rising support for conservative politicians and initiatives among young people reveals several trends. Most obviously is that many of today’s youths reject the radical woke agenda espoused by a small but vocal minority. When confronted with the reality of an economy that’s not generating the jobs, incomes and housing they desire, these youths prioritize results over ideology, especially immigrant youths who came to Canada for economic reasons. The importance attached to results is driving many youths even to question the usefulness of democracy. In his 2023 book The Fourth Turning Is Here, historian Neil Howe cites polls that one in four young Americans would prefer a dictatorial president unconstrained by Congress while only one in 10 Americans over age 65 agree.

Howe’s analysis is based on the proposition that historical movements move in cyclical ebbs and flows rather than by extrapolating straight lines. This is intuitively easy for me to understand after a career specializing in the study of business cycles. It’s well known that there are regular cycles in financial markets and the economy, partly because long periods of prosperity and bullish financial conditions lull the next generation into under-estimating the risks of a downturn. This complacency inevitably precipitates the sort of risky decisions that trigger a slump. As economist Hyman Minsky wrote, “Success breeds a disregard of the possibility of failure… Stability leads to instability. The more stable things become and the longer they are stable, the more unstable they will be when the crisis hits.”

Cyclical analysis is also useful in understanding political trends instead of just assuming history continues on a linear trajectory. For example, for years it seemed inevitable that support for Quebec separatism would rise inexorably until independence was achieved. Instead, support peaked during the 1995 referendum then steadily evaporated as younger generations had more pressing priorities than independence.

We see the same cyclical phenomenon play out in the political preferences of today’s youths, even if conservatives still represent only a minority and their longer-term commitment to conservative values remains uncertain. Instead of reinforcing the left-wing bias of youths that helped propel Obama and Trudeau to power, youths are reacting against the status quo that ignores their pocket-book concerns. These shifting attitudes of young people could help reshape North America’s political landscape in ways few would have thought possible a decade ago.

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Alberta

Lesson for Ottawa—don’t bite the hand that feeds you

Published on

From the Fraser Institute

By Tegan Hill

The Alberta government has launched a campaign to inform Canadians about the negative impacts of the federal government’s cap on greenhouse gas (GHG) emissions in the oil and gas sector, which exempts the other three-quarters of the economy that emit including transportation, buildings and heavy industry.

According to Alberta Premier Danielle Smith, the cap will “kill jobs” and lead to “economic and societal decline” for all Canadians—and she’s right. Any policy that damages Alberta’s economy comes with consequences for all of Canada.

Of course, this isn’t the first Trudeau policy to damage the sector. The list includes Bill C-69 (which imposes complex, uncertain and onerous review requirements on major energy projects), Bill C-48, (which bans large oil tankers off British Columbia’s northern coast and limits access to Asian markets), “clean fuel standard” regulations, numerous “net-zero” targets, and so on.

Again, while these policies disproportionately impact Albertans, they have consequences for all Canadians from coast to coast because of Alberta’s role in the federation. In our current system, Ottawa collects various taxes from Canadians across the country and then redistributes the money for programs including equalization and employment insurance.

For perspective, from 2007 to 2022 (the latest period of available data), Albertans contributed $244.6 billion more in taxes and other payments to the federal government than they received in federal spending—more than five times as much as British Columbians or Ontarians. The remaining seven provinces received more federal spending than they contributed to federal revenues. In other words, Albertans are by far the largest net contributor to Ottawa’s coffers.

Albertans’ large net contribution reflects the province’s comparatively young population (fewer retirees), higher rates of employment, higher average incomes and relatively strong economy.

Alberta’s relative economic strength isn’t new. From 1981 to 2022, the province had the highest annual average economic growth rate in Canada. In 2022, Alberta accounted for 17.9 per cent of Canada’s total economic growth despite being home to just 11.6 per cent of the country’s population. That same year, Alberta contributed nearly one in every five private-sector jobs created in Canada. In fact, Alberta was one of only two provinces (alongside Nova Scotia) where private-sector employment growth (including self-employment) exceeded government-sector employment growth over the last five years (2019 to 2023).

Alberta’s prosperity, which helps finance other provinces, may help explain why 56,245 more Canadian residents moved to Alberta than left it in 2022—a much higher net inflow than in any other province. For decades, Alberta has provided economic opportunities for Canadians from other provinces willing to relocate.

Albertans continue to contribute more to the federation than Canadians in other provinces due to Alberta’s relatively strong and prosperous economy. And Canadians benefit from the economic opportunities Alberta provides. With this in mind, the Trudeau government should stop imposing economically damaging policies on the province—as it costs not just Albertans but all Canadians.

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