Government meddling contributes to doctor exodus in Quebec

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:

Bacchus Barua and Yanick Labrie

Related Topics:#BacchusBarua #FraserInstitute #YanickLabrie PublicVSPrivateHealthCare QuebecDoctorExodus QuebecHealthCare

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National dental program likely more costly than advertised

Published on July 4, 2025

Todayville

From the Fraser Institute

By Matthew Lau

At the beginning of June, the Canadian Dental Care Plan expanded to include all eligible adults. To be eligible, you must: not have access to dental insurance, have filed your 2024 tax return in Canada, have an adjusted family net income under $90,000, and be a Canadian resident for tax purposes.

As a result, millions more Canadians will be able to access certain dental services at reduced—or no—out-of-pocket costs, as government shoves the costs onto the backs of taxpayers. The first half of the proposition, accessing services at reduced or no out-of-pocket costs, is always popular; the second half, paying higher taxes, is less so.

A Leger poll conducted in 2022 found 72 per cent of Canadians supported a national dental program for Canadians with family incomes up to $90,000—but when asked whether they would support the program if it’s paid for by an increase in the sales tax, support fell to 42 per cent. The taxpayer burden is considerable; when first announced two years ago, the estimated price tag was $13 billion over five years, and then $4.4 billion ongoing.

Already, there are signs the final cost to taxpayers will far exceed these estimates. Dr. Maneesh Jain, the immediate past-president of the Ontario Dental Association, has pointed out that according to Health Canada the average patient saved more than $850 in out-of-pocket costs in the program’s first year. However, the Trudeau government’s initial projections in the 2023 federal budget amounted to $280 per eligible Canadian per year.

Not all eligible Canadians will necessarily access dental services every year, but the massive gap between $850 and $280 suggests the initial price tag may well have understated taxpayer costs—a habit of the federal government, which over the past decade has routinely spent above its initial projections and consistently revises its spending estimates higher with each fiscal update.

To make matters worse there are also significant administrative costs. According to a story in Canadian Affairs, “Dental associations across Canada are flagging concerns with the plan’s structure and sustainability. They say the Canadian Dental Care Plan imposes significant administrative burdens on dentists, and that the majority of eligible patients are being denied care for complex dental treatments.”

Determining eligibility and coverage is a huge burden. Canadians must first apply through the government portal, then wait weeks for Sun Life (the insurer selected by the federal government) to confirm their eligibility and coverage. Unless dentists refuse to provide treatment until they have that confirmation, they or their staff must sometimes chase down patients after the fact for any co-pay or fees not covered.

Moreover, family income determines coverage eligibility, but even if patients are enrolled in the government program, dentists may not be able to access this information quickly. This leaves dentists in what Dr. Hans Herchen, president of the Alberta Dental Association, describes as the “very awkward spot” of having to verify their patients’ family income.

Dentists must also try to explain the program, which features high rejection rates, to patients. According to Dr. Anita Gartner, president of the British Columbia Dental Association, more than half of applications for complex treatment are rejected without explanation. This reduces trust in the government program.

Finally, the program creates “moral hazard” where people are encouraged to take riskier behaviour because they do not bear the full costs. For example, while we can significantly curtail tooth decay by diligent toothbrushing and flossing, people might be encouraged to neglect these activities if their dental services are paid by taxpayers instead of out-of-pocket. It’s a principle of basic economics that socializing costs will encourage people to incur higher costs than is really appropriate (see Canada’s health-care system).

At a projected ongoing cost of $4.4 billion to taxpayers, the newly expanded national dental program is already not cheap. Alas, not only may the true taxpayer cost be much higher than this initial projection, but like many other government initiatives, the dental program already seems to be more costly than initially advertised.

Matthew Lau

Adjunct Scholar, Fraser Institute

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Prairie provinces and Newfoundland and Labrador see largest increases in size of government

Published on July 3, 2025

Todayville

From the Fraser Institute

By Jake Fuss and Grady Munro

A recent study found that Canada has experienced one of the largest increases in the size of government of any advanced country over the last decade. But within Canada, which provinces have led the way?

The size of government refers to the extent to which resources within the economy are controlled and directed by the government, and has important implications for economic growth, living standards, and economic freedom—the degree to which people are allowed to make their own economic choices.

Too much of anything can be harmful, and this is certainly true regarding the size of government. When government grows too large it begins to take on roles and resources that are better left to the private sector. For example, rather than focusing on core functions like maintaining the rule of law or national defence, a government that has grown too large might begin subsidizing certain businesses and industries over others (i.e. corporate welfare) in order to pick winners and losers in the market. As a result, economic growth slows and living standards are lower than they otherwise would be.

One way to measure the size of government is by calculating total general government spending as a share of the economy (GDP). General government spending refers to spending by governments at all levels (federal, provincial, and municipal), and by measuring this as a share of gross domestic product (GDP) we can compare across jurisdictions of different sizes.

A recent study compared the size of government in Canada as a whole with that of 39 other advanced economies worldwide, and found that Canada experienced the second-largest increase in the size of government (as a share of the economy) from 2014 to 2024. In other words, since 2014, governments in Canada have expanded their role within the economy faster than governments in virtually every other advanced country worldwide—including all other countries within the Group of Seven (France, Germany, Italy, Japan, the United Kingdom, and the United States). Moreover, the study showed that Canada as a whole has exceeded the optimal size of government (estimated to fall between 24 and 32 per cent of GDP) at which a country can maximize their economic growth. Beyond that point, growth slows and is lower than it otherwise would be.

However, Canada is a decentralized country and provinces vary as to the extent to which governments direct overall economic activity. Using data from Statistics Canada, the following charts illustrate which provinces in Canada have the largest size of government and which have seen the largest increases since 2014.

The chart above shows total general government spending as a share of GDP for all ten provinces in 2023 (the latest year of available provincial data). The size of government in the provinces varies considerably, ranging from a high of 61.4 per cent in Nova Scotia to a low of 30.0 per cent in Alberta. There are geographical differences, as three Atlantic provinces (Nova Scotia, Prince Edward Island, and New Brunswick) have the largest governments while the three western-most provinces (Alberta, Saskatchewan, and British Columbia) have the smallest governments. However, as of 2023, all provinces except Alberta exceeded the optimal size of government—which again, is between 24 and 32 per cent of the economy.

To show which provinces have experienced the greatest increase in the size of government in recent years, the second chart shows the percentage point increase in total general government spending as a share of GDP from 2014 to 2023. It should be noted that this is measuring the expansion of the federal government’s role in the economy—which has been substantial nationwide—as well as growth in the respective provincial and municipal governments.

The increases in the size of government since 2014 are largest in four provinces: Newfoundland and Labrador (10.82 percentage points), Alberta (7.94 percentage points), Saskatchewan (7.31 percentage points), and Manitoba (7.17 percentage points). These are all dramatic increases—for perspective, in the study referenced above, Estonia’s 6.66 percentage point increase in its size of government was the largest out of 40 advanced countries.

The remaining six provinces experienced far lower increases in the size of government, ranging from a 2.74 percentage point increase in B.C. to a 0.44 percentage point increase in Quebec. However, since 2014, every province in Canada has seen government expand its role within the economy.

Over the last decade, Canada has experienced a substantial increase in the size of total government. Within the country, Newfoundland and Labrador and the three Prairie provinces have led the way in growing their respective governments.