The Political and Economic Sustainability of Health Care in Canad ...

Traditionally, as Madore has observed: “The public sector refers to governments and government agencies; governments may be national (or federal), provincial or municipal. The private sector is broad and encompasses the corporate for-profit sector, small business and entrepreneurial entities, and voluntary or charitable not-for-profit organizations, as well as individuals and families” (2005). The Canadian health system, however, does not fit this definition very well. It is, on the one hand, largely publicly funded, in a proportion that averages 70 percent of total health-related expenses. But on the other hand, the delivery of care is confined almost entirely to private providers or private organizations. Because the latter are primarily charitable or not-for-profit entities dependent on the public sector for their funding, their status as private organizations is mostly fictitious. But in the case of individual providers, the situation is not so simple: most professionals (e.g., physicians, dentists, pharmacists) are self-employed and are far from mere agents of the government. They often benefit from a regime that combines fee-for-service payments with clinical autonomy, a framework in which they can to a considerable extent decide what they do and where they do it—though in some provinces physicians are constrained by volume-of-service limits.

This does not mean the public system is not regulated. For example, fees paid to physicians are listed on a public schedule that is fixed through negotiations between medical associations and provincial health plans. Moreover, in six Canadian provinces (New Brunswick, Quebec, Ontario, Saskatchewan, Alberta, and British Columbia), physicians who are paid by the public regime are not allowed to provide medically necessary care for private payment. Physicians can, however, opt out of the public system and “go private”—except in Ontario, where the Commitment to the Future of Medicare Act of 2004 now forces physicians to maintain affiliation with the provincial public health plan (Boychuk 2006; Flood 2007). But the decision to leave the public regime does entail financial risks. Six provinces (Prince Edward Island, Quebec, Ontario, Manitoba, Alberta, and British Columbia) prohibit private insurance for publicly insured services, a measure that results, practically, in the elimination of