Proposals to make patients pay for medical visits in Quebec meet resistance

BMJ 2008; 336 doi: (Published 28 February 2008) Cite this as: BMJ 2008;336:471
  1. David Spurgeon
  1. 1Quebec

A cross party task force set up to tackle the spiralling costs of Quebec’s provincial healthcare system has recommended an increase in sales tax, introduction of user fees, and greater privatisation.

The much anticipated report from chairman, Claude Castonguay, a former Liberal health minister in 1970 when Quebec joined Canada’s federal health system, proposes among other recommendations a $C25 (£12; €17; $25) fee for each visit to a doctor and an increase of up to one percentage point in the province’s sales tax. The report has encountered considerable resistance.

Quebec’s healthcare costs are increasing by 5.8% a year—surpassing annual government spending increases of 3.9%—and the task force recommends that the province should cap healthcare spending at 3.9% of its total budget.

It also suggests that Quebec residents pay fees of as much as $100 a year to belong to a medical clinic, and that physicians be allowed to practise in both public and private sectors to increase access to services. The Canada Health Act, on which the current national healthcare system is based, prohibits doctors from working in public and private systems simultaneously.

The current health minister, Philippe Couillard, immediately rejected the idea of a tax increase and dismissed many other recommendations. But he said the Liberal government is ready to discuss some of the report’s other recommendations, including the suggestion that hospital management be opened to private companies, although he questioned how this might work.

Opposition parties’ reactions were mixed. The Action Démocratique du Quebec healthcare critic, Éric Caire, said a mixed public-private system would give people more choice. But his party opposes an increase in sales tax because, it says, Quebec residents already pay too much tax. Parti Québécois health critic, Bernard Drainville, supported a sales tax increase, preferring that to charging an annual fee.

Healthcare worker unions warned that the task force’s recommendations would lead to American-style medical care and a two tiered system, but the Quebec Medical Association endorsed the task force recommendations, while its president, Jean-Bernard Trudeau, agreed it was time to review the public health system.

Quebec’s largest labour federation urged rejection of the Castonguay report. The federation’s president, Michel Arsenault, said that in every country that had a two tiered system, “rich people are served first, a lot better, and the poor people or middle-class people are waiting a lot more to get services” (

Quebec was the first province to experiment with private services for some healthcare procedures after a Supreme Court decision in 2005 ruled that Canada’s health laws were unconstitutional because they prevented patients waiting for public system services from buying private insurance cover (BMJ 2005;330:1408 doi: 10.1136/bmj.330.7505.1408). Private insurance is now allowed for some procedures such as cataract operations and knee replacement surgery (BMJ 2006;332:507 doi: 10.1136/bmj.332.7540.507-a).

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