Quebec is likely to be the first province to slip out of the Canadian medicare scheme. In fact, at present, Quebec’s health care laws and practices do not respect the principles set out in the Canada Health Act. The only hope the people of Quebec have to benefit from a universal, free and comprehensive healthcare system in the future is a strong and swift intervention by the new Trudeau government.

During the past decade, the core principle of medicare – that medically necessary care should be universally covered and free of charge (paid for by public funds) – has gradually eroded in Quebec. The process has been a slow but steady sum of small legislative changes that have benefitted practitioners (and profits) over patients, government tolerance for grey-zone billing practices and impressive fee-charging creativity from medical entrepreneurs.

Hindsight reveals the turning point was probably the Supreme Court of Canada Chaoulli ruling in 2005. While the ruling had only a limited impact on Quebec’s health law, it has fed a steady evolution in the province toward the acceptance and development of a two-tier healthcare system.

The expectation in Quebec that medically necessary care will be free is less and less warranted. For many specialties, some doctors working in public hospitals are known to propose to their patients faster access – for a fee – or less invasive interventions offered in their for-profit clinics. In such clinics, doctors are still paid by public health insurance, but patients are often billed for the rental of the surgery room, for local anaesthetics or for access to more advanced technologies.

While officially illegal, such practices are widespread. Stories about eyedrops or anaesthetics costing the clinics cents yet billing patients hundreds of dollars abound. This situation clearly puts some doctors in a potential conflict of interest where they are in the position to encourage patients in the public system to move over to their profitable private facilities.

Also, in a health system experiencing a significant shortage of practitioners, medical resources are drained away from public hospital-based “free” care and into private purses. It also ties healthcare quality and accessibility to a patient’s wealth – precisely what the Canada Health Act tries to prevent.

This steady disintegration of the principles upon which the Canadian medicare system was built has recently gathered a pace that might make the trend irreversible. The Couillard government is currently adopting Bill 20, which will legalize direct patient billing for medically necessary services provided outside of hospitals, confident that Ottawa won’t intervene to enforce the Canada Health Act in Quebec – as has been the case in the past decade.

It has also emerged that the Montreal Children’s Hospital – one of Montreal’s two pediatric university hospitals – has decided to stop offering many medically necessary services. Instead, it will direct some patients to a brand new outpatient clinic charging fees for many previously insured procedures.

With Bill 20, practices that were initially a grey-zone breach in the universality of our public health system now become legal. This is, de facto, the legalization of a parallel private healthcare system subsidized by public health insurance. In our view, this could be the final blow that would signal the definitive exit of Quebec from the medicare system.

We’ve observed several attempts to undermine the core principles of a free, comprehensive and universal healthcare system in Quebec over the past several years. But the current situation is a turning point. There appears to be an unhealthy coalition that ranges from the Couillard government, private clinic owners, medical federations, private insurers and even some hospital administrators, which is irresistibly pushing to decrease the proportion of care offered in public institutions and to increase the market share of direct payment and privately insured services.

The only chance to save medicare in Quebec is a direct intervention of the federal government.

We, doctors and experts, ask the new prime minister and minister of health to enforce the Canadian Health Act in Quebec and cut federal health transfers until Quebec conforms.

It is the only and last chance that we have in Quebec for free access to medical care for all, which means access to care according to patients’ needs, not their wealth. The rest of Canada should also watch what is going on in Quebec with careful attention. Once one province slips away from the principles of medicare, it is likely only a matter of time for the scent of profit to lure others away from the national compact that safeguards our universal, accessible healthcare system.

Astrid Brousselle is a professor in the Community Health Department, Researcher, Centre de recherche de l’Hôpital Charles-LeMoyne, Université de Sherbrooke.

Damien Contandriopoulos is professor in nursing and researcher at the Public Health Research Institute at the University of Montreal.

This article is also signed by:

Alain Vadeboncœur, emergency physician, author, chronicler and blogger.

Dr. Simon-Pierre Landry, for the Regroupement des médecins Omnipraticiens pour une Médecine Engagée.

Elisa Pucella, family doctor, physician consultant at Laval’s CISSS Public Health division and physician at La Maison de Soins Palliatifs de Laval.

Gyslaine Desrosiers, President and CEO of OIIQ, 1992-2012 (Quebec College of Nurses).

Isabelle Leblanc, Assistant Professor, Department of Family Medicine, McGill University and family physician, St. Mary’s Hospital, for Médecins québécois pour le régime public.

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Jean-Pierre Ménard, lawyer specialized in patient rights cases.

Arnaud Duhoux, professor of Nursing, University of Montreal, Researcher, Centre de recherche de l’Hôpital Charles-LeMoyne.

Mylaine Breton, Professor of Community Health Department, Researcher, Centre de recherche de l’Hôpital Charles-LeMoyne, Université de Sherbrooke.

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