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Fraser Institute

Government meddling contributes to doctor exodus in Quebec

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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.

Fraser Institute

Here’s your annual bill for public health care

Published on

From the Fraser Institute

By Bacchus Barua

Notably, the amount paid by the average family has increased by 239.7 per cent since 1997 (the first year of available data).

According to a recent survey by Statistics Canada, almost half of Canadians said that rising prices are affecting their ability to meet day-to-day expenses. At the same time, Canadians are increasingly aware of their significant tax burden, with 74 per cent feeling the average family is overtaxed. This is not surprising given the average Canadian family spends more on taxes than food, clothing and shelter combined.

However, one contributor to this growing tax burden remains hidden—the price we pay public health care. You read that right. Public health care is not free—but it’s very difficult to figure out exactly how much we pay for it on an individual or family basis.

This is primarily because our public health-care system is funded through general government revenues. In other words, there’s no dedicated tax that fully funds the system. Our income taxes, sales taxes, business taxes and other taxes get poured into a fiscal vat, from which governments take a generous portion for health care.

While it’s easy enough to gauge total health-care spending by governments ($225.1 billion) or how much was spent per Canadian ($5,614), it remains nearly impossible for Canadian families of different sizes and incomes to calculate how much they contribute towards that vast amount.

But a recent study helps us get a general idea. According to the study, an average family of four (two parents and two children) with an average income of $176,266 will pay an estimated $17,713 (in taxes) for public health care this year. Single Canadians, with an average income of $55,925, will pay $5,629. Of course, these amounts vary by income with the poorest 10 per cent of income earners paying $639 while the top 10 per cent pay $47,071.

Notably, the amount paid by the average family has increased by 239.7 per cent since 1997 (the first year of available data). This increase is 3.1 times greater than the rate of inflation, 2.2 times greater than food cost increases, and 1.6 times greater than housing costs increases. And crucially, the cost of public health care for the average family has increased 1.7 times faster than their average incomes grew during the same period.

These figures are not only important for families who are interested in how their tax dollars are spent, they are one very important side of the equation when trying to understand whether we receive good value for our health-care dollars. Moreover, as politicians continue to promise ever increasing health-care spending to fix our crumbling system, it’s crucial for Canadians to understand exactly how that spending impacts their wallets.

One thing is clear. With nearly an $18,000 price tag for the average family of four, Canada’s public health-care system is anything but free.

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Economy

Energy transition will be much longer and more arduous than they’re telling you

Published on

From the Fraser Institute

By Jock Finlayson

While many Canadian politicians and activists continue to trumpet the “energy transition” and conjure visions of a low-carbon future that supposedly lurks just around the corner, along comes Natural Resources Canada with its latest Energy Fact Book. A careful review of the publication pours cold water on any notion of a rapid shift to a fundamentally different energy system, one that features a much smaller role for the fossil fuels that now supply the vast majority of the energy used by Canadians.

The book contains a wealth of information on Canada’s large and notably diverse energy sector, covering production, consumption trends, investment, and the environmental impact of energy production and use.  Separately, Natural Resources Canada also publishes “energy profiles” for the individual provinces and territories that provide further insight into energy production and consumption patterns across the country.

Starting with energy production (and considering all sources of energy, including uranium), crude oil accounts for about 45 per cent of Canadian energy output, measured in petajoules. Natural gas and natural gas liquids comprise another 32 per cent, with uranium chipping in 11 per cent of primary energy production. Smaller shares come from coal (5 per cent), hydroelectricity (5 per cent) and “other” renewables (3 per cent).

The statistics on energy output confirm that fossil fuels dominate the mix of energy sources produced in Canada. There’s little reason to believe this will change in a significant way in the near term.

Turning to energy consumption, a review of the most recent information leads to a broadly similar conclusion.

Based on Statistics Canada’s latest data, industry, collectively, is responsible for about 35 per cent of final end-use energy demand; this category includes manufacturing, natural resource extraction and processing, and construction. Transportation is the second-largest consumer of energy (29 per cent of final demand), followed by the residential (16 per cent) and commercial sectors (14 per cent).

What about the various sources of energy Canadians depend on for their comfort and well-being and to enable industrial and other business activity? Refined petroleum products rank first, providing about two-fifths of all energy consumed. Natural gas is second (35-36 per cent). Electricity comprises just 16-17 per cent of the energy used in Canada. Overall, fossil fuels still meet more than three quarters of Canadians’ requirements for primary energy.

Some may be surprised that electricity constitutes less than one-fifth of the energy used in Canada. A principal strategy of governments aspiring to slash greenhouse gas emissions is to redirect energy demand to electricity and away from oil, natural gas and other carbon-based energy sources. That makes sense, particularly since Canada’s existing electricity grid is about 80 per cent carbon-free. But a “big switch” to electricity won’t be easy. Consider that, over the first two decades of the millennium, Canadian natural gas consumption jumped by 34 per cent while electricity demand rose by 12 per cent. This underscores the resiliency of household and business demand for reliable affordable energy—of which natural gas is the best example.

Raising electricity’s share of total energy consumption will necessitate an enormous expansion across all segments of the Canadian electricity sector, encompassing not only the development of far more generation capacity but also the construction of additional transmission networks to deliver electric energy to end-users. Industry experts talk of boosting the amount of electricity produced in Canada by up to three times within two decades—a herculean task, assuming it’s even possible.

And, in line with the “net zero” goals espoused by many governments, virtually all of new electricity presumably must come from carbon-free sources (e.g., hydropower, other renewables, biomass, nuclear). There’s also the challenge of replacing the remaining carbon-based electricity still produced in Canada with carbon-free alternatives, as mandated by the Clean Electricity Regulations (CER) recently adopted by the Trudeau government.

Suffice to say the transition away from fossil fuels as the predominant source of energy consumed in Canada will be a lengthy and arduous journey and is sure to encounter more and bigger obstacles than most of Canada’s political class understands or cares to acknowledge.

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