André Picard ([url]https://www.theglobeandmail.com/authors/andre-picard/)Health[/url] Columnist
Published November 20, 2025
When you introduce a new policy, there are two key questions that need to be asked, and answered: 1) What is the problem you’re trying to solve? and; 2) will the new policy solve it?
Alberta plans to introduce legislation that would allow some doctors to practise simultaneously ([url]https://www.theglobeandmail.com/canada/alberta/article-alberta-defends-public-private-health-care-model-as-experts-say-it/[/url]) in the public and private health systems.
Specifically, surgeons will be allowed to do some elective procedures like cataracts, and hip and knee replacements, and be paid either by public insurance, private insurance or out-of-pocket.
In a video posted on X, Ms. Smith said the approach, known as dual practice, will shorten wait times, reduce wait lists, give consumers more choice, and make doctors happier.
These “steam valve” arguments are well-worn: The claim is that allowing wealthier patients to pay for access to care will remove them from public wait lists and result in faster care for all.
But there little evidence this is true.
A 1998 study in Manitoba examined wait times for cataract surgery based on how ophthalmologists operated their clinics. The dual practices − facilities that offered by both publicly-funded and a privately-funded cataract surgery − had waits that were as much 13 weeks longer than in practices that offered only publicly-funded services.
Why? Because the more lucrative private cases always took precedence. Result: Waits were longer over all.
Ms. Smith said this sort of problem will be avoided by setting “ratios” – meaning surgeons will have to do a certain number of procedures in the public system before they are allowed to do others privately. Other countries have tried this and it requires costly bureaucracy and is hard to police.
The Premier also said surgeons will do private elective surgeries in addition to their regular practice – at night and on weekends. That’s quite an assumption when there is an epidemic of burnout among health workers. And where will the surgical nurses come from at a time when virtually every hospital shift is currently understaffed?
The other main argument Alberta is making for embracing a dual practice model is that other countries do it.
But those jurisdictions have very different systems. Canada is the only country where 100 per cent of hospital and physician care is publicly funded. We even have legislation, the Canada Health Act, that allows the federal government to claw back health transfers if provinces allow private payments for “medically necessary” care. (Are elective procedures medically necessary? Stay tuned for the political bickering and lawsuits.)
Most European and Nordic countries allow dual practice because it allows them to more easily staff public hospitals and clinics, which often compete with private ones. That is not an issue in Canada.
Staffing shortages are not as acute abroad. Nor are wait lists for surgery as extensive as here.
France, for example, pays doctors in public hospitals a salary, while those in private practice get fee-for-service, with both rates set by government. In Spain, doctors can practise in either system, but only those who work exclusively in public practice are eligible for promotion, meaning their wages are 10-15 per cent higher. In Australia, half the specialists work in the public and private systems but there are also many private hospitals, and most people have private insurance. In the U.S., the bastion of free enterprise, dual practice is a rarity; it’s either/or.
The restrictions Alberta is proposing on dual practice are minimal. It’s not even saying what the public-private ratio will be. (In Ireland, fewer than 20 per cent of surgeries are allowed to be privately paid.)
Surgical waits have many causes and how doctors are paid is well down the list. The principal sticking points are lack of OR time, and shortages of nurses.
The reality is that other countries have shorter wait times and better access overall not because they have more private payment and delivery, but because they manage personnel and spending more effectively and efficiently than we do in Canada.
As always, context matters.
What Alberta is proposing may sound good superficially, but it makes no sense in the Canadian context. Rather, it is a classic example of a solution in search of a problem.
Published November 20, 2025
When you introduce a new policy, there are two key questions that need to be asked, and answered: 1) What is the problem you’re trying to solve? and; 2) will the new policy solve it?
Alberta plans to introduce legislation that would allow some doctors to practise simultaneously ([url]https://www.theglobeandmail.com/canada/alberta/article-alberta-defends-public-private-health-care-model-as-experts-say-it/[/url]) in the public and private health systems.
Specifically, surgeons will be allowed to do some elective procedures like cataracts, and hip and knee replacements, and be paid either by public insurance, private insurance or out-of-pocket.
In a video posted on X, Ms. Smith said the approach, known as dual practice, will shorten wait times, reduce wait lists, give consumers more choice, and make doctors happier.
These “steam valve” arguments are well-worn: The claim is that allowing wealthier patients to pay for access to care will remove them from public wait lists and result in faster care for all.
But there little evidence this is true.
A 1998 study in Manitoba examined wait times for cataract surgery based on how ophthalmologists operated their clinics. The dual practices − facilities that offered by both publicly-funded and a privately-funded cataract surgery − had waits that were as much 13 weeks longer than in practices that offered only publicly-funded services.
Why? Because the more lucrative private cases always took precedence. Result: Waits were longer over all.
Ms. Smith said this sort of problem will be avoided by setting “ratios” – meaning surgeons will have to do a certain number of procedures in the public system before they are allowed to do others privately. Other countries have tried this and it requires costly bureaucracy and is hard to police.
The Premier also said surgeons will do private elective surgeries in addition to their regular practice – at night and on weekends. That’s quite an assumption when there is an epidemic of burnout among health workers. And where will the surgical nurses come from at a time when virtually every hospital shift is currently understaffed?
The other main argument Alberta is making for embracing a dual practice model is that other countries do it.
But those jurisdictions have very different systems. Canada is the only country where 100 per cent of hospital and physician care is publicly funded. We even have legislation, the Canada Health Act, that allows the federal government to claw back health transfers if provinces allow private payments for “medically necessary” care. (Are elective procedures medically necessary? Stay tuned for the political bickering and lawsuits.)
Most European and Nordic countries allow dual practice because it allows them to more easily staff public hospitals and clinics, which often compete with private ones. That is not an issue in Canada.
Staffing shortages are not as acute abroad. Nor are wait lists for surgery as extensive as here.
France, for example, pays doctors in public hospitals a salary, while those in private practice get fee-for-service, with both rates set by government. In Spain, doctors can practise in either system, but only those who work exclusively in public practice are eligible for promotion, meaning their wages are 10-15 per cent higher. In Australia, half the specialists work in the public and private systems but there are also many private hospitals, and most people have private insurance. In the U.S., the bastion of free enterprise, dual practice is a rarity; it’s either/or.
The restrictions Alberta is proposing on dual practice are minimal. It’s not even saying what the public-private ratio will be. (In Ireland, fewer than 20 per cent of surgeries are allowed to be privately paid.)
Surgical waits have many causes and how doctors are paid is well down the list. The principal sticking points are lack of OR time, and shortages of nurses.
The reality is that other countries have shorter wait times and better access overall not because they have more private payment and delivery, but because they manage personnel and spending more effectively and efficiently than we do in Canada.
As always, context matters.
What Alberta is proposing may sound good superficially, but it makes no sense in the Canadian context. Rather, it is a classic example of a solution in search of a problem.
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