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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.

Business

Comparing four federal finance ministers in moments of crisis

Published on

From the Fraser Institute

By Grady Munro, Milagros Palacios and Jason Clemens

The sudden resignation of federal finance minister (and deputy prime minister) Chrystia Freeland, hours before the government was scheduled to release its fall economic update has thrown an already badly underperforming government into crisis. In her letter of resignation, Freeland criticized the government, and indirectly the prime minister, for “costly political gimmicks” and irresponsible handling of the country’s finances and economy during a period of great uncertainty.

But while Freeland’s criticism of recent poorly-designed federal policies is valid, her resignation, in some ways, tries to reshape her history into that of a more responsible finance minister. That is, however, ultimately an empirical question. If we contrast the performance of the last four long-serving (more than three years) federal finance ministers—Paul Martin (Liberal), Jim Flaherty (Conservative), Bill Morneau (Liberal) and Freeland (Liberal)—it’s clear that neither Freeland nor her predecessor (Morneau) were successful finance ministers in terms of imposing fiscal discipline or overseeing a strong Canadian economy.

Let’s first consider the most basic measure of economic performance, growth in per-person gross domestic product (GDP), adjusted for inflation. This is a broad measure of living standards that gauges the value of all goods and services produced in the economy adjusted for the population and inflation. The chart below shows the average annual growth in inflation-adjusted per-person GDP over the course of each finance minister’s term. (Adjustments are made to reflect the effects of temporary recessions or unique aspects of each minister’s tenure to make it easier to compare the performances of each finance minister.)

Sources: Statistics Canada Table 17-10-0005-01, Table 36-10-0222-01; 2024 Fall Economic Statement

By far Paul Martin oversaw the strongest growth in per-person GDP, with an average annual increase of 2.4 per cent. Over his entire tenure spanning a decade, living standards rose more than 25 per cent.

The average annual increase in per-person GDP under Flaherty was 0.6 per cent, although that includes the financial recession of 2008-09. If we adjust the data for the recession, average annual growth in per-person GDP was 1.4 per cent, still below Martin but more than double the rate if the effects of the recession are included.

During Bill Morneau’s term, average annual growth in per-person GDP was -0.5 per cent, although this includes the effects of the COVID recession. If we adjust to exclude 2020, Morneau averaged a 0.7 per cent annual increase—half the adjusted average annual growth rate under Flaherty.

Finally, Chrystia Freeland averaged annual growth in per-person GDP of -0.3 per cent during her tenure. And while the first 18 or so months of her time as finance minister, from the summer of 2020 through 2021, were affected by the COVID recession and the subsequent rebound, the average annual rate of per-person GDP growth was -0.2 per cent during her final three years. Consequently, at the time of her resignation from cabinet in 2024, Canadian living standards are projected to be 1.8 per cent lower than they were in 2019.

Let’s now consider some basic fiscal measures.

Martin is by far the strongest performing finance minister across almost every metric. Faced with a looming fiscal crisis brought about by decades of deficits and debt accumulation, he reduced spending both in nominal terms and as a share of the economy. For example, after adjusting for inflation, per-person spending on federal programs dropped by 5.9 per cent during his tenure as finance minister (see chart below). As a result, the federal government balanced the budget and lowered the national debt, ultimately freeing up resources via lower interest costs for personal and business tax relief that made the country more competitive and improved incentives for entrepreneurs, businessowners, investors and workers.

*Note: Freeland’s term began in 2020, but given the influence of COVID, 2019 is utilized as the baseline for the overall change in spending. Sources: Statistics Canada Table 17-10-0005-01, Table 36-10-0130-01; Fiscal Reference Tables 2024; 2024 Fall Economic Statement

Flaherty’s record as finance minister is mixed, in part due to the recession of 2008-09. Per-person program spending (inflation adjusted) increased by 11.6 per cent, and there was a slight (0.6 percentage point) increase in spending as a share of the economy. Debt also increased as a share of the economy, although again, much of the borrowing during Flaherty’s tenure was linked with the 2008-09 recession. Flaherty did implement tax relief, including extending the business income tax cuts started under Martin, which made Canada more competitive in attracting investment and fostering entrepreneurship.

Both Morneau and Freeland recorded much worse financial performances than Flaherty and Martin. Morneau increased per-person spending on programs (inflation adjusted) by 37.1 per cent after removing 2020 COVID-related expenditures. Even if a more generous assessment is used, specifically comparing spending in 2019 (prior to the effects of the pandemic and recession) per-person spending still increased by 18.1 per cent compared to the beginning of his tenure.

In his five years, Morneau oversaw an increase in total federal debt of more than $575 billion, some of which was linked with COVID spending in 2020. However, as multiple analyses have concluded, the Trudeau government spent more and accumulated more debt during COVID than most comparable industrialized countries, with little or nothing to show for it in terms of economic growth or better health performance. Simply put, had Morneau exercised more restraint, Canada would have accumulated less debt and likely performed better economically.

Freeland’s tenure as finance minister is the shortest of the four ministers examined. It’s nonetheless equally as unimpressive as that of her Trudeau government predecessor (Morneau). If we use baseline spending from 2019 to adjust for the spike in spending in 2020 when she was appointed finance minister, per-person spending on programs by the federal government (inflation adjusted) during Freeland’s term increased by 4.1 per cent. Total federal debt is expected to increase from $1.68 trillion when Freeland took over to an estimated $2.2 trillion this year, despite the absence of a recession or any other event that would impair federal finances since the end of COVID in 2021. For some perspective, the $470.8 billion in debt accumulated under Freeland is more than double the $220.3 billion accumulated under Morneau prior to COVID. And there’s an immediate cost to that debt in the form of $53.7 billion in expected federal debt interest costs this year. These are taxpayer resources unavailable for actual services such as health care.

Freeland’s resignation from cabinet sent shock waves throughout the country, perhaps relieving her of responsibility for the Trudeau government’s latest poorly-designed fiscal policies. However, cabinet ministers bear responsibility for the performance of their ministries—meaning Freeland must be held accountable for her previous budgets and the fiscal and economic performance of the government during her tenure. Compared to previous long-serving finances ministers, it’s clear that Chrystia Freeland, and her Trudeau predecessor Bill Morneau, failed to shepherd a strong economy or maintain responsible and prudent finances.

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Business

Canadians face massive uncertainly and turbulence in 2025

Published on

From the Fraser Institute

By Jock Finlayson

As the new year beckons, Canadian policymakers, workers and consumers are staring at a turbulent and uncertain economic landscape. While the economy has been growing, the population has been increasing faster—leading to a two-year slide in economic output and real income, measured on a per-person basis. The result has been a visible decline in Canadian living standards amid a largely stagnant economy.

Looking ahead to 2025, Canada faces two big uncertainties. The first is linked to the return of Donald Trump who has made a host of jaw-dropping promises including a pledge to slap a 25 per cent tariff on all merchandise imports from Canada and Mexico on day one of his administration. Should he follow through with that plan, our economy will be plunged into recession.

Last year, Canada sold $593 billion of goods to the United States, along with more than $85 billion in “services,” together representing more than three-quarters of our total international exports. The Canadian industries that will take the biggest hit from possible Trumpian tariffs include energy, automobile and parts manufacturing, wood products, all types of machinery and equipment, consumer products, minerals and metals and agri-food.

While the threatened across-the-board tariffs may never materialize, it’s a safe bet that Trump’s presidency portends rocky times for the Canada-U.S. relationship. The near-certainty of increased U.S. restrictions on Canadian exports, coupled with the likelihood of tax cuts and sweeping regulatory reforms, means many larger and mid-sized Canadian companies will be tempted to redirect their capital and business growth ambitions to the south, thereby dampening domestic investment. In response, governments in Ottawa and the provinces should urgently improve the environment for investment at home.

Another source of economic uncertainty is the federal government’s decision to ratchet back immigration. Ottawa’s about-face on immigration ranks as one of the most dramatic reversals of Canadian public policy in half a century. Under the Trudeau Liberals, Canada has become wholly reliant on immigration-fuelled labour-force growth to drive the economy, as productivity—the other key contributor to long-term economic growth—has stalled. Higher immigration has indeed boosted economic activity, albeit without delivering gains in per-person income.

Now, federal policymakers intend to cut permanent immigration, impose sharp curbs on international students, and somehow engineer the departure of 1.3 million temporary residents currently living in Canada—all over the next two years. Exactly how and to what extent this will play out is unclear. After three years of rapid population growth, Canada could experience a flat or even slightly declining population. Lower immigration is necessary after a period of almost uncontrolled inflows, but zero or negative population growth will detract from economy-wide spending and put a dent in labour supply. The outcome will be slower economic growth in 2025-26 than otherwise would be the case.

Closer to home, the Trudeau government presides over a structurally weak economy where much of the growth has been coming from a ballooning public sector while large swathes of the business community shrink or sit on the sidelines. On Trudeau’s watch, government debt has soared, business investment has been chronically sluggish, and Canada’s ranking on surveys of global competitiveness has dropped. We can do better.

Rather than continuing to expand the size of government, policymakers should aim to revitalize the private-sector economy that still produces most of the country’s output and accounts for the bulk of Canada’s jobs, exports and innovations.

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