A version of this commentary appeared in the Montreal Gazette, Ottawa Life and the Huffington Post

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With a federal campaign in full force grabbing the majority of the headlines, a significant threat to Canada’s most treasured national program is going largely unnoticed.

For many years, certain physicians and clinics have quietly been charging extra fees for health services. In some provinces, the frequency of such charges has been increasing. These include hidden charges for medications that are many times their actual cost or access fees of hundreds of dollars for examinations such as colonoscopies. Because these fees are for services that are covered by the health system, this is in effect extra-billing, a practice that is against federal and provincial law.

In Quebec, Minister of Health Gaetan Barrette has identified these fees as a problem, as have many others for many years. You might expect Barrette – a physician himself — to clearly inform patients and practitioners that this practice is illegal and put an end to it. Instead, he is trying to regulate and “normalize” these fees, in direct contravention of the Canada Health Act.

When the Canada Health Act passed in the House of Commons in 1984 with unanimous support from all political parties, its primary purpose was to put an end to extra billing exactly like this. Charging patients at the point of care for medically necessary services strikes at the heart of the principle that access to health care should be based on need rather than ability to pay.  It undermines equity, increases system costs and reduces commitment to the public health care system. It’s also illegal.

Medicare is a defining program and a source of enduring commitment from coast to coast, and all political parties claim to support the Canada Health Act. Why are we not hearing resounding denouncement of Minister Barrette’s plan from our federal politicians? Who will commit to enforce the CHA in Quebec and elsewhere?

User fees are a deterrent to seeking care by the people who need health care the most. Research has consistently demonstrated that forcing people with less money to pay a fee to access care means they will not consistently choose to do so, and as a result, may not seek out medical attention until later in the course of their illness. This means patient outcomes are likely to be worse and treatment more complicated and costly. Given higher levels of illness among people in poverty, user fees also function as regressive taxation, shifting costs to those who use the system most but can least afford to pay.

Given these well understood problems with user fees, doctors in Quebec and across the country have expressed alarm at Minister Barrette’s proposed amendment to Bill 20, which regulates extra billing rather than prohibiting it. The Canadian Medical Association, Quebec Medical Association, Canadian Doctors for Medicare, Médecins Québécois pour le Régime Publique, and the Quebec College of Family Physicians have all come out against this decision, joining patient groups, all of Quebec’s opposition parties, and Raymonde Saint-Germain, the independent Quebec Ombudsman. The amendment was passed on October 7th, with no public debate.

This is not the first attempt to introduce user fees in Quebec. Each time, such attempts have been beaten back on the basis of solid evidence and thoughtful public debate. A proposed implementation of system-wide user fees was cancelled in 2011when further review showed that these changes would decrease access and not achieve significant system savings. In 2013, the Quebec National Assembly voted unanimously in favour of a motion against extra-billing.

Now, despite these previous decisions, public and expert opinion, and the law, Barrette is effectively bringing user fees in through the back door. Rather than introducing user fees charged by government, he proposes allowing clinics to do so. This further fragments care and makes access even more inequitable.

In this federal election campaign, the talk has been around reducing barriers to access by improving coverage of prescription medicines, home care and mental health care. Yet at the same time that our federal parties are committing to such much-needed expansion, they are silent on protecting the core of medicare: publicly funded doctor and hospital services.

Any party that claims to be committed to the Canada Health Act should immediately state its position on the proposed amendments to Bill 20 in Quebec. To do less is to skirt the core federal responsibility for medicare in Canada.

Ryan Meili is a family physician in Saskatoon, founder of Upstream: Institute for A Healthy Society and an advisor with the Evidence Network. 

Danielle Martin is a family physician and Vice-President Medical Affairs and Health System Solutions at Women’s College Hospital in Toronto.

Both are members of the board of Canadian Doctors for Medicare.

October 2015

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