How Canada ended up with private health care

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Jordan: It seems to happen in drips one story or one advertisement or one anecdote at a time. Things that make you wonder, man, shouldn’t that be covered by our universal healthcare system? The truth is, public healthcare in Canada has never been universal. And while the idea of a private system or a two-tiered system has always been horribly unpopular in this country, stop looking at those drips and drops and look at the big picture. That system’s already here, we have it. How did we get here? Well, the same way Hemingway describes going bankrupt. Gradually. Then suddenly, what are we going to do about, it might be a better question, but maybe the best question is this. Why is nobody currently in charge or hoping to be in charge even talking about what we might do about it? Because we’re going to have to do something. I am Jordan Heath-Rawlings. This is The Big Story. Christina Frangou is a health and sciences reporter who wrote about our current two-tiered healthcare system in Maclean’s. She also teaches journalism at the Southern Alberta Institute of Technology and at the University of Toronto. Hey Christina.

Christina Frangou: Hi, Jordan. Thanks for having me.

Jordan: You are most welcome. I think this is a topic that we’ve done a bunch of episodes on and kind of tiptoed around it, but you really sort of put the whole thing in perspective in terms of how quickly this is moving.

Christina Frangou: Yeah, the point of this story, the reason for doing it is that it seemed like everyone I knew was suddenly paying out of pocket to get some kind of medical care, and I just had never seen this in my 20 years of reporting on health systems in Canada. Why

Jordan: Don’t you start by telling us about the system, I guess that we kind of believe we have or used to believe we have, and maybe do that by telling me about Steven Goluboff and sort of the type he represents in Canadian healthcare.

Christina Frangou: Sure, sure. Dr. Goluboff was an absolute pleasure to speak with. He is a 75-year-old family physician in Saskatoon. He grew up in a family of doctors. His father and his uncle were physicians in Saskatchewan in the 1960s, and anyone familiar with Canadian medical history knows that’s the time that doctors in Saskatoon went on strike trying to negotiate a different kind of pay deal for doctors as a medical system came into being. So Steven Goluboff remembers that he was 13 at the time when doctors went on strike. It did not deter him from medicine, and so he has spent his career as a family physician working mostly in Saskatoon, but also taking little planes up into northern Saskatchewan to work on weekends. And a couple of years ago, he decided to retire and he found three young physicians to replace him. He knew he worked really long hours and no one wanted to work the kind of hours he did, but he thought three would be enough. And then over the course of the pandemic, one of them left to go join a private clinic and he decided he would come back for what he calls his last tour. He’s waiting for someone to replace him. So in the meantime, he’s back to working full time and then working one night shift a week at a local hospital.

Jordan: That seems like an awful lot of healthcare work for a 75-year-old man who wanted to retire.

Christina Frangou: Yes, yes. But as he says, he loves his job and he also said as long as he’s still working, he’s still in the system.

Jordan: Right. And that system is I guess what we’re going to talk about today. And I thought he would be a great representative just because when these older doctors are leaving there quite often isn’t anyone else. So maybe you can summarize it a bit just in general, the kind of strain that the public system is under right now and how we can quantify it. How should we think about it? How are we doing?

Christina Frangou: I don’t know exactly how to quantify it. I think everybody knows what crisis our healthcare systems are in. If we look at family physicians, one in five Canadians don’t have a family doctor. If we look at the number of Canadians who are waiting for orthopedic surgery, they often wait a year just to see a surgeon for their first consult and then another 18 months to even two years for surgery. And think about how people suffer in that time while they’re in pain. I spoke to so many people who aren’t even quoted in this story, physicians and healthcare providers and patients about the kinds of weights they’re enduring. One physician told me about coming in on a weekend because he had a patient who needed surgery and they could not get a room, a hospital bed for her. Meanwhile, this physician’s mother was in an emergency department back in Toronto and waited several days to get a bed there. So it is just in a consistent state of crisis across the country.

Jordan: And how have Canadians been coping with that? You mentioned you’ve spoken to a ton of them.

Christina Frangou: Well, more and more Canadians are getting tired of waiting. They can’t wait any longer. And so they are increasingly looking to this growing private health system to try and get care in a timely fashion. And so what we see are Canadians looking to pay for diagnostic imaging. I have a friend here this weekend who just told me she paid $1,300 to get an emergency MRI after a mass was discovered. We see people who are tired of not being able to get a family doctor, and so they’re paying the membership fees at primary care clinics or they’re paying to see doctors virtually. And then we’re seeing Canadians traveling to different provinces or even traveling out of country to get surgery because they’re tired of these long waits.

Jordan: What actually determines what kind of private care is allowed in Canada and what’s not? Is there a line? Is there a distinguishing feature of something that the public system must offer? How do we navigate that?

Christina Frangou: This is a very, very tricky one. And so basically, if a service is provided by the public system in a province, it is not supposed to be offered as a private service. But if you look at what I just said, people are finding ways around that. And so one way is you shouldn’t have to pay for primary care if it’s covered within the province, but the public health system covers doctor and hospital care. It doesn’t cover nurse practitioners in many places. And so if you run a primary care clinic and you work with a nurse practitioner, you can charge those membership fees or a nurse practitioner can bill patients directly in a way that a family physician could not. So it’s finding ways to work around the publicly funded system.

Jordan: You mentioned this off the top a little bit of Canadian medical history, but how did we end up where we are and why doesn’t the public system work anymore and why are so many people turning to the private system? This began, I guess a long time ago.

Christina Frangou: I love this question. I am a real nerd about Canadian medical history. And so the system we have now is really the one that grew out of Tommy Douglas’ vision back in the 1950s. And he, as pretty much every Canadian knows as a child, had seen a doctor in a Winnipeg hospital and the doctors had said, we’re going to have to amputate your leg because he couldn’t pay to have proper care for his leg. That was the only option available to him. And then an orthopedic surgeon came through and said, if I can take you on as a teaching case, I won’t charge your family and I will try not to amputate your leg. And so then Tommy Douglas goes on to become premier in Saskatchewan, and he wants to bring in a publicly funded system, but he can only do it in parts because there’s limited money. And he starts by creating a public insurance system that covers hospital care. So first we have hospital care and then the other provinces say, oh, that’s actually working fairly well. And so then we get a federal program like that, but Canadians are still getting bills. And so the next thing the Douglas government does is bring in coverage for physician care. So covering the services that physicians provide, once again, other provinces see that it works out well, and then the federal government follows suit and brings us in across the country. But so what we end up with is not the kind of system we see in other European countries where there’s a real blend of public and private, but instead we have this public coverage of physician services and hospitals, but everything else has always been private. And then this system is very expensive. And as Canadians changed, birth control came in. We started living longer. We started developing more chronic illnesses that need team-based care, not the kind of thing that you just can be handled by one physician in their office. And so we haven’t really updated the original system. We’re still paying for it, but doesn’t really suit the needs of Canadians today. The one exception being, of course, the big update in 1984 with the Canada Health Act, which was brought in because provinces were allowing user fees on top of these public services in order to sort of bring down the cost being charged to the provinces.

Jordan: So where did those cracks in this system first start to emerge when it became clear that to your point, it wasn’t meeting the needs of modern Canadians and other replacements sort of crept up?

Christina Frangou: So we really saw it beginning with diagnostic clinics. We saw the first private MRI facility in Canada in the 1990s. Not long after that, we have Brian Day who started his Cambi surgical clinic in Vancouver. He was an orthopedic surgeon who just got tired of the wait lists. Even then for his patients. I think his wait list was 450 patients long, and so he started one of Canada’s first private orthopedic surgery facilities. And so we see this time and time again everywhere that services aren’t being met within the public sector, businesses are starting that offer Canadians aversion of these services that they can pay for.

Jordan: Why do we have, I guess, so much emotional pushback against the idea of a two-tiered healthcare system if as we’re discussing right now, it’s always been there?

Christina Frangou: We really do, and this has hampered our ability to start to have a grownup conversation about what we do about the Canadian healthcare system. I think part of it is this mythology of Tommy Douglas and I grew up in Saskatchewan. I am a believer that Canada can have a wonderful publicly funded health system, but in this idea that we were different than the United States, that we had this great public health system, we didn’t set ourself up to have the kind of conversations we really need to have about what is this going to look like and how do we bring in some element of private care that is supportive of what we actually need and then update our public system. There’s a saying in Canadian politics, healthcare is a third rail, touch it and you die and no one wants to do anything about it. So we’ve always just been stuck with the same system, and the conversation often devolves to public versus private, and that doesn’t help us. The conversation that we need to be having is what is going to work best for Canadians that has a blend of both. And I want to say the first part of this has to be fixing the public health system that we have.

Jordan: You spoke to Brian Day. He’s kind of, I guess as you just mentioned, a pivotal figure in all this. What does he think about how both tiers, I guess, of the healthcare system have evolved since he initially started to change it?

Christina Frangou: Well, he says it’s just all the public system has gotten far worse. The things that drove him to start his clinic in I think 1993 have worsened considerably since then, and he’s frustrated with it. He says, why is it that Canadians have to pay for ambulance care? That’s a medically necessary service, but not orthopedic procedures. He argues that if there were more people able to pay privately for surgery, that that would take some of the pressure off of the public system. There’s a lot of people who disagree with that though, in saying that the more we have a growing private sector, the more we will see doctors and nurses leave the public system.

Jordan: Tell me about a woman named Lisa Clark-Musschoot, if I’m saying that right, and how she’s an example of, I guess the next step in private healthcare.

Christina Frangou: Yeah, so Lisa is a nurse practitioner again in Saskatchewan. I went back to my roots a lot for this story. A nurse practitioner has additional training compared to a registered nurse. They do not have the same skillset as a family physician, but they’re allowed to practice independently in a way that other nurses are not. So for years, she works in the Saskatchewan Public Health System. She worked in small clinics in combination with doctors providing supportive care, sometime offering call service to some of smaller these hospitals in small towns, Saskatchewan that had no one to help out on the weekend, and she just was getting very burned out by it. It was a lot of traveling. It was a lot of long hours, and she decided to leave. And so what she’s done is she set up two primary care clinics, one in Regina and one in Saskatoon where she can bill patients directly. So whereas I might go to my doctor here in Calgary and I never see a direct bill for that care, Lisa can provide the same kind of care, but she bill patients directly so she can bill them for mental health consults, she can bill them for pap smears, things that doctors can’t bill privately for.

Jordan: And so those people are paying out of pocket for those services. There’s no way for them to get that money back from the government.

Christina Frangou: No.

Jordan: So far we’ve talked a lot about the private services that are popping up that seem to be necessary for Canadians who can afford them. What happens to the Canadians who can’t right now? At least.

Christina Frangou: They still wait and they struggle to get doctors and they struggle to get care and there’s no, we’re not seeing any improvements for them.

Jordan: I guess the hope is by moving the people who can’t afford it to private that some of these spots will open up.

Christina Frangou: That is the hope, and that’s an argument that proponents of a bigger private health sector would say. But as a counter to that is that we will see doctors and nurses leave the public system for the private, and then the services that are available will be even harder to access. We are already in a workforce shortage when it comes to healthcare workers.

Jordan: The last thing I want to ask about is just from our past coverage of the healthcare system and from your piece and from this conversation, it kind of seems like if we’re not at a real crisis point or tipping point right now, we will be soon. And what has to be done at that point? You mentioned nobody wants to touch healthcare, but eventually it will become unavoidable. And who makes that call and what are their choices?

Christina Frangou: Jordan, I’ve been at this for so long and I feel like we are always on the edge of the tipping point. And then we see small changes that sort of improve things marginally and paper over the most immediate problem, and then just get us to the next crisis. And I think you could make the argument that during the pandemic, we saw a lot of healthcare workers just work harder in order to cover the problems in the health system. And I don’t know if we have any capacity to keep doing that any longer. And so it’s really time to start to have a conversation about how we address this on the political front. When Brian Day took his case to be able to bill patients privately to the Supreme Court, the Supreme Court bounced it back to the politicians. They said, this isn’t a matter for the courts. This is a matter for you. And so someone is going to have to step up. Jane Philpott in her recent book makes this argument as well that there’s room here for federal leadership, but there is also room for a province to step forward and lead this discussion. I mean, it was Tommy Douglas who did this initially, right? There were already conversations going on about a federal public health system, but they weren’t going anywhere. And that’s when Tommy Douglas stepped in. So there is room here. Someone has just be willing to do the work, and I think Canadians as voters have to demand that from their representatives.

Jordan: Has anybody in federal politics right now shown that they are ready to lead on this? I think about Prime Minister Trudeau, who has been on a publicity blitz as of late, and I can’t recall him saying much about making changes to the healthcare system. And as I think of it as I was reading your piece, I honestly can’t recall the last really serious proposal to change this system. I’ve heard from the federal government or any of the members of the opposition,

Christina Frangou: No, I would argue we’re not hearing anything that will bring about substantive change. We have the PharmaCare proposal coming out. It’s something a little more than window dressing, but it doesn’t go merely far enough. What we need to do is have a grownup conversation about what is being funded and how and what a functioning healthcare system ultimately should look like in Canada.

Jordan: Fortunately, we’re so good at having calm grownup conversations in Ottawa, these days.

Christina Frangou: Yeah, pretty depressing.

Jordan: Christina, thank you for this. Thank you for sort of spelling it all out for us, and at least there’s an election in a year and a half. We’ll see if anybody says anything about it, will they?

Christina Frangou: I am working on a story now looking at proposals that people have for the next year and a half, and I see nothing that fills me with Hope, Jordan.

Jordan: Okay. Well, at least you answered the question.

Christina Frangou: Sorry.

Jordan: Christina, thank you so much for this. It’s much appreciated.

Christina Frangou: Thank you so much for having me. I really love to have these conversations about healthcare. So thank you,

Jordan: Christina Frangou writing in Maclean’s. That was The Big Story. For more from us, including previous episodes on private healthcare, the unthinkable in Canada, you can head to TheBigStorypodcast.ca. You can also leave us any kind of feedback you want by emailing us at hello@TheBigStorypodcast.ca or by calling us 416-935-5935 and leaving a voicemail. The Big Story is available on every single podcast player you can think of, and probably many that you can’t. It’s also available on the web, as I mentioned, and it’s on your smart speaker. Just ask it to play The Big Story podcast. Thanks for listening. I’m Jordan Heath-Rawlings. We’ll talk tomorrow. Back to top of page