Fraser Institute
Government meddling contributes to doctor exodus in Quebec
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.
Authors:
Business
Ottawa’s avalanche of spending hasn’t helped First Nations
From the Fraser Institute
By Tom Flanagan
When Justin Trudeau came to power in 2015, he memorably said that the welfare of Indigenous Canadians was his highest priority. He certainly has delivered on his promise, at least in terms of shovelling out money.
During his 10 years in office, budgeted Indigenous spending has approximately tripled, from about $11 billion to almost $33 billion. Prime Minister Trudeau’s instruction to the Department of Justice to negotiate rather than litigate class actions has resulted in paying tens of billions of dollars to Indigenous claimants over alleged wrongs in education and other social services. And his government has settled specific claims—alleged violations of treaty terms or of the Indian Act—at four times the previous rate, resulting in the award of at least an additional $10 billion to First Nations government.
But has this avalanche of money really helped First Nations people living on reserves, who are the poorest segment of Canadian society?
One indicator suggests the answer is yes. The gap between reserves and other communities—as measured by the Community Well-Being Index (CWB), a composite of income, employment, housing and education—fell from 19 to 16 points from 2016 to 2021. But closer analysis shows that the reduction in the gap, although real, cannot be due to the additional spending described above.
The gain in First Nations CWB is due mainly to an increase in the income component of the CWB. But almost all of the federal spending on First Nations, class-action settlements and specific claims do not provide taxable income to First Nations people. Rather, the increase in income documented by the CWB comes from the greatly increased payments legislated by the Liberals in the form of the Canada Child Benefit (CCB). First Nations people have a higher birth rate than other Canadians, so they have more children and receive more (on average) from the Canada Child Benefit. Also, they have lower income on average than other Canadians, so the value of the CCB is higher than comparable non-Indigenous families. The result? A gain in income relative to other Canadians, and thus a narrowing of the CWB gap between First Nations and other communities.
There’s an important lesson here. Tens of billions in additional budgetary spending and legal settlements did not move the needle. What did lead to a measurable improvement was legislation creating financial benefits for all eligible Canadian families with children regardless of race. Racially inspired policies are terrible for many reasons, especially because they rarely achieve their goals in practise. If we want to improve life for First Nations people, we should increase opportunities for Canadians of all racial backgrounds and not enact racially targeted policies.
Moreover, racial policies are also fraught with unintended consequences. In this case, the flood of federal money has made First Nations more dependent rather than less dependent on government. In fact, from 2018 to 2022, “Own Source Revenue” (business earnings plus property taxes and fees) among First Nations bands increased—but not as much as transfers from government. The result? Greater dependency on government transfers.
This finding is not just a statistical oddity. Previous research has shown that First Nations who are relatively less dependent on government transfers tend to achieve higher living standards (again, as measured by the CWB index). Thus, the increase in dependency presided over by the Trudeau government does not augur well for the future.
One qualification: this finding is not as robust as I would like because the number of band governments filing reports on their finances has drastically declined. Of 630 First Nation governments, only 260 filed audited statements for fiscal 2022. All First Nations are theoretically obliged by the First Nations Financial Transparency Act, 2013, to publish such statements, but the Trudeau government announced there would be no penalties for non-compliance, leading to a precipitous decline in reporting.
This is a shame, because First Nations, as they often insist, are governments, not private organizations. And like other governments, they should make their affairs visible to the public. Also, most of their income comes from Canadian taxpayers. Both band members and other Canadians have a right to know how much money they receive, how it’s being spent and whether it’s achieving its intended goals.
Author:
Education
‘Grade inflation’ gives students false sense of their academic abilities
From the Fraser Institute
The average entrance grade at the University of British Columbia is now 87 per cent, up from 70 per cent only 20 years ago. While this is partly because the supply of available university spots has not kept pace with growing demand, it’s also likely that some B.C. high schools are inflating their students’ grades.
Suppose you’re scheduled for major heart surgery. Shortly before your surgery begins, you check into your surgeon’s background and are pleased to discover your surgeon had a 100 per cent average throughout medical school. But then you learn that every student at the same medical school received 100 per cent in their courses, too. Now you probably don’t feel quite as confident in your surgeon.
This is the ugly reality of “grade inflation” where the achievements of everyone, including the most outstanding students, are thrown into question. Fortunately, grade inflation is (currently) rare in medical schools. But in high schools, it’s a growing problem.
In fact, grade inflation is so prevalent in Ontario high schools that the University of Waterloo’s undergraduate engineering program uses an adjustment factor when evaluating student applications—for example, Waterloo might consider a 95 per cent average from one school the equivalent of an 85 per cent average from another school.
Grade inflation is a problem in other provinces as well. The average entrance grade at the University of British Columbia is now 87 per cent, up from 70 per cent only 20 years ago. While this is partly because the supply of available university spots has not kept pace with growing demand, it’s also likely that some B.C. high schools are inflating their students’ grades.
Sadly, grade inflation is so rampant these days that some school administrators don’t even try to hide it. For example, earlier this year all students at St. Maximilian Kolbe Catholic High School in Aurora, Ontario, received perfect marks on their midterm exams in two biology courses and one business course—not because these students had mastered these subjects but because the York Catholic District School Board had been unable to find a permanent teacher at this school.
The fact that a school board would use grade inflation to compensate for inadequate instruction in high school tells us everything we need to know about the abysmal academic standards in many schools across Canada.
And make no mistake, student academic performance is declining. According to results from the Programme for International Assessment (PISA), math scores across Canada declined from 532 points in 2003 to 497 points in 2022 (PISA equates 20 points to one grade level). In other words, Canadian students are nearly two years behind on their math skills then they were 20 years ago. While their high school marks are going up, their actual performance is going down.
And that’s the rub—far from correcting a problem, grade inflation makes the problem much worse. Students with inflated grades get a false sense of their academic abilities—then experience a rude shock when they discover they aren’t prepared for post-secondary education. (According to research by economists Ross Finnie and Felice Martinello, students with the highest high school averages usually experience the largest drop in grades in university). Consequently, many end up dropping out.
Grade inflation even hurts students who go on to be academically successful because they suffer the indignity of having their legitimate achievements thrown into doubt by the inflated grades of other students. If we want marks to have meaning, we must end the practise of grade inflation. We do our students no favours when we give them marks they don’t really deserve.
Just as our confidence in a surgeon would go down if we found out that every student from the same medical school had a 100 per cent average, so we should also question the value of diplomas from high schools where grade inflation is rampant.
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