Canadian Medical Association

Canada’s health system is broken.

Millions of people can’t get the care they need now, and many are no longer confident the health system they rely on will deliver in the future. The pressure on health workers, meanwhile, is driving record burnout, with some reducing their hours or leaving their jobs entirely.

To address this crisis, governments have been looking at every option – including a shift in the long-held balance of public and private health care in Canada.

Our updated policy addresses this current reality by proposing guard rails to strengthen and safeguard universal access to health care.

Read our policy

This policy was drafted following a national listening tour where we heard from more than 10,000 Canadians about what they want from the health system, where it’s falling short and solutions to bridge the gaps. This included surveys, public events in partnership with The Globe and Mail, and several focused dialogues with physicians and patients from across the country.


We also heard how difficult it can be to make sense of Canada's complex health system, the mix of public and private health services we have now, and how it's changing. You can learn more below, and read highlights from CMA discussions, surveys and a summary of available research evidence.


Understanding our health care system

Click on each card to reveal the facts behind common myths about public and private health care in Canada.

Myth: Health care in Canada is free.

Fact

Myth: Private health care in Canada is new.

Fact

Myth: The Canada Health Act covers every medical condition.

Fact

Myth: Health care is a provincial/territorial issue.

Fact

Myth: Private is better than public health care.

Fact

Myth: All private health care requires patients to pay out-of-pocket.

Fact

Myth: Doctors in Canada are required to work in the public health system.

Fact

Myth: Canada’s health care system lags behind other developed countries.

Fact

Myth: Canada spends less on health care than other countries.

Fact

Reports

Read what Canadians have to say about public and private health care, and key findings from a scan of research evidence.

question marks

Survey results

CMA surveys with members and the general public

The Globe and Mail presents a national town hall series: Public and Private health care, can we find the right balance?

Can we find the right balance?

Town Halls hosted by The Globe and Mail

It's time to talk consultations on public and private health care in canada: What we heard report

It’s time to talk: What we heard

Focused dialogues with physicians and patients

Public and private health care in Canada. What does the evidence say?

What does the evidence say?

Research evidence summary


Dive deeper on public and private health care

A meaningful discussion about the future of our health system depends on a shared understanding of where we stand today.

What is the Canada Health Act and what does it say about private care?

Adopted in 1984, the Canada Health Act is federal legislation ensuring that publicly funded health care insurance, also known as Medicare, is:

  • Universal, provided to all residents of a province or territory.
  • Comprehensive, covering all medically necessary services provided by hospitals, physicians and dentists (when their services must be performed in a hospital).
  • Accessible to any resident with medical needs – unimpeded by discrimination of any kind, including the ability to pay for services.
  • Portable, ensuring care for residents who are travelling within Canada or who move from one province or territory to another.
  • Publicly administered, operated as a non-profit by a government or authority accountable to it.

What prompted the legislation?

At the inception of Medicare in the 1950s and 1960s, decision-makers grappled with how to build universal, publicly funded health care from an existing patchwork system – including private health insurance plans, independent medical practitioners and a network of not-for-profit private hospitals owned by charities and religious orders. 

The solution – first adopted in Saskatchewan and then scaled up nationally with federal financial support – was substantial public financing for health care delivered by private providers.  

By the 1970s, however, shortfalls in government funding led some hospitals and medical professionals to institute patient charges and user fees. As concerns mounted about access to health care, Ottawa passed the Canada Health Act in 1984 to enshrine national standards for publicly insured health services in federal law.

What does the Canada Health Act say about private care?

The legislation doesn’t forbid the provision of health services by private companies (for-profit or not-for-profit), as long as residents are not charged for insured health services. 

In fact, many aspects of health care in Canada are delivered privately, such as lab services, many drugs and therapies, mental health services, and more.

Have there been challenges to the current balance of public and private health care in Canada?

Growing wait times for public health care have prompted two significant legal challenges: 

  • Chaoulli v. Quebec: a challenge to strike down laws prohibiting private insurance for medically necessary services.
  • Cambie Surgeries Corporation v. BC: a challenge to strike down prohibitions on dual physician practice in public and private health systems.

What were the rulings?

The Supreme Court of Canada ruled in favour of Chaoulli, allowing for expanded private health care options. In contrast, BC courts ruled in favour of the government in the Cambie case, reaffirming the fundamental principles of Medicare. 

What’s happening today?

A post-pandemic shortage of health workers and further delays in access to publicly funded health services are again raising questions about the balance of public and private care – including restrictions on private payment, the Canada Health Act’s singular focus on hospital and physician services and jurisdictions’ ability to shift delivery of publicly funded health care to the private sector.  

To expand system capacity, some provinces are funding private for-profit surgical facilities, MRI clinics and virtual care services. The federal government, meanwhile, has launched a new dental care plan and taken steps towards national pharmacare.

How do user fees and out-of -pocket payments for health services affect patient outcomes?

Direct payment for care in Canada

Out-of-pocket payment refers to the amount of money charged directly to patients for health services over and above what’s covered by public or private insurance plans. The Canada Health Act and parallel legislation in provinces and territories largely eliminated user fees and patient charges for hospital and physician services. 

Beyond that, however, there are many examples of direct patient charges. Most public drug plans include deductibles and co-payments. Supplemental private insurance plans typically include deductibles and co-insurance for prescription drugs, vision and dental care, and health services provided by myriad health professionals (e.g., physiotherapists, psychologists, dietitians). 

The pitfalls and benefits of out-of-pocket payment

The main concern is that it may deter some patients – particularly those with lower incomes – from accessing needed health services, which could result in adverse health outcomes. But proponents of user fees argue that they help curb unnecessary use of health care services, controlling costs while also providing an additional source of funding for the health system.  

What the evidence says

According to a summary of the best available research evidence by the McMaster Health Forum, user fees reduce the use of both necessary and unnecessary health services; however, they do not lead to either lower system costs or the adoption of healthier lifestyles. For low-income groups, fees are associated with delayed care, non-adherence to medication plans and poorer health outcomes.

Why are some people opposed to expanding private health care?

The public–private interface in health care speaks to the kind of system we want as a society and how we mobilize the various actors in the system – doctors, nurses, long-term care facilities and a range of other players – to meet the needs of the population.

People opposed to expanding private health care argue that it increases inequities, creating a two-tiered system that negatively affects low-income populations, and diverting staffing and scarce resources from the public system. 

What does research say about the impact of private health care?

International research evidence strongly suggests that for-profit delivery of insured services results in poorer quality and higher costs. Given that the evidence is somewhat dated and largely based on the US experience, however, additional research and analysis in a Canadian context is needed.

How is Canada’s public health system performing right now?

While Canadians have long taken pride in our health care system, too many are now struggling with access to care, with long wait times for everything from a family doctor to surgical procedures.

But according to the latest annual report by Organization for Economic Cooperation and Development (OECD), Canada performs better than average in terms of health status, as well as  quality and outcomes of care, which includes things like routine vaccinations, cancer screening and safe prescribing in primary care. 

For example, life expectancy in Canada is 81.6 years, 1.3 years above the OECD average; and only 2.8% of people rate their health as “bad” or “very bad,” compared to the average of 7.9%. Sixty percent of women were screened for breast cancer, more than the OECD average of 55%.

If a service is already covered by the public health system, does allowing people to pay for it have a negative effect?

Private coverage for a health service already included under a provincial or territorial health plan is called “duplicative insurance.” Five provinces (Alberta, British Columbia, Manitoba, Ontario and Prince Edward Island) prohibit it. The Supreme Court decision in Chaoulli v. Quebec opened the door. 

What are the pros and cons of duplicative insurance?

Opponents of duplicative private insurance are typically concerned about two-tier health care, the negative impact on the public system as health professionals and resources are drawn into the private sector, as well as the potential for increased system costs. Proponents argue that it adds capacity, reduces pressure on the public system and instills a competitive dynamic in a sector that is otherwise not subject to market forces. 

What’s the evidence?

According to a summary of the best available research evidence by the McMaster Health Forum, in countries with duplicative private insurance, patients with private plans reported shorter wait times, increased access to new pharmaceuticals and increased choice in care. Those in the publicly funded system, however, reported longer wait times for primary and specialty care. Some evidence also found that privately funded health services do not reduce pressure on the public system, and may draw resources away it. 

In Canada, it’s notable that even in Quebec, insurers have not expanded their offerings to include coverage for public health services following the ruling on Chaoulli, nor have insurers in other provinces where duplicative private insurance is permitted.

How is access to care affected when doctors are allowed to provide both private and public services?

There isn’t enough large-scale research available to answer this question. 

While dual practice – when doctors or other health professionals deliver care in both publicly funded and privately funded settings – is common internationally, in Canada it is either restricted or banned entirely. 

Most provinces and territories require doctors to either opt into public health insurance or opt out. If they choose the latter, they cannot bill the government for services covered by public health plans. 

The impact of virtual care

The rapid expansion of for-profit virtual care, first through the pandemic and now as a means to fill the gap through ongoing health worker shortages, is complicating this picture. For example, under current rules, doctors can continue to work in the public system in their home province, while delivering privately funded virtual care for patients elsewhere. The federal government has recently indicated that it is working with provinces and territories to address this issue. 

What do experts say about dual practice?

Arguments against dual practice are its impact on access to medical services in the public system, the potential increase in non-priority treatments in private care, duplication of effort between public and private providers and the possibility of conflicts of interest. Proponents, meanwhile, argue that it could improve access to care and provide better work environments for physicians. 


CMA Explains

Understanding public and private health care

Glossary

Common terms of reference in discussions about public and private care

Opting out

Rules around private medical practice across the country

How other countries do it

Comparing Canada to the mix of public and private care in five other OECD countries


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