A version of this commentary appeared in the Ottawa Citizen, the Huffington Post and Hill Times
On January 26, the Quebec regulation abolishing medical user fees came into effect, bringing the province in line with federal legislation outlined in the Canada Health Act (CHA). According to the CHA, the money that flows from Ottawa to the provinces for health services, known as the Canada Health Transfer, is conditional on the provinces upholding a ban on user fees for publicly-insured, medically necessary procedures.
Provinces that fail to act on user fees expose themselves to claw backs in the transfer by an amount equivalent to the user fees paid by patients in the province.
Quebec was actually one of the first provinces to legally ban users fees in 1970. But decades of public underfunding and benign neglect by both provincial and federal governments to implement the ban led to routine reliance on these fees for many publicly insured health services, particularly in urban centers.
So with the decision to ban user fees, the Quebec government is finally doing the right thing — not to mention the legal one, and other provinces should take notice.
It all started a couple of years ago with the controversial proposal in Bill 20 to “regulate user fees.” A critical report from the Auditor General of Québec followed last spring stating that the province was not fulfilling its supervisory role in regard to user fees. Meanwhile, patients’ rights lawyer, Jean-Pierre Ménard launched legal action against the federal government requesting that it act decisively to uphold the CHA in Quebec in light of these overt violations.
The message must have gotten through, because Federal Health Minister Jane Philpott then threatened Quebec with retroactive claw backs to the Canada Health Transfer if it failed to abolish user fees — estimated to range between $50 million to $83 million annually.
It’s a good news story in many ways.
Abolishing these user fees puts an end to an unfair and inefficient system where money or private health insurance allowed one to jump the queue and get in front of the line, regardless of whether they had more urgent medical needs.
It was also a confusing system for patients, who were confronted — when at their most sick and vulnerable — with fees to pay that they weren’t sure were even legal. And fees sometimes varied wildly for the same procedure, as with the infamous case of ophtalmologists’ eye drops ranging from $20 to $300.
But it’s not all smooth sailing from now on.
In the weeks leading up to the implementation of this regulation, physician unions balked at the abolition. There have been reports of physicians leaving the public system in protest, and testimonies of patients advised to find companies to act as private third party payers on their behalf, in order to circumvent the ban on user fees.
There is also something of a climate of fear and uncertainty in the population, with many concerned that they will ultimately be worse off after the ban on user fees takes effect. What is most unfortunate is that much of this controversy often boils down to money and not patient care.
Given that user fees had been allowed to proliferate in the Quebec system for so long, this change will obviously not happen overnight — and not without some growing pains.
The Quebec government will now have to step up to the plate.
Not only will it need to put extra effort into clarifying matters for both patients and physicians and in monitoring compliance with the regulation, but it has also taken on new responsibilities, notably to sweeten the deal for physicians who stood to lose financially from the ban. For instance, Quebec will now provide physicians with medical materials that they had previously purchased themselves (and were billing patients for).
Still, many physicians have expressed concern that services may be negatively affected, as they have yet to receive the promised material.
The stakes are high.
And there are many ways this ban could fail to produce the expected results of greater transparency and equity in access to health services. Not only is patient access to medically needed services in the balance here, but in the long run, the government could in fact end up pushing ever more physicians and patients toward a parallel private system if it fails to demonstrate a strong commitment to quality public care.
Amélie Quesnel-Vallée is an expert advisor with EvidenceNetwork.ca and the Canada Research Chair on Policies and Health Inequalities at McGill University.