The Alberta government announced the list of surgical procedures that will be included in its plan to build an U.S.-style two-tier system.
These include procedures already performed in for-profit surgical facilities (called chartered surgical facilities), including orthopedic procedures, hip and knee replacements, cataract surgery, some ear, nose, and throat procedures, gynecological surgeries, dermatology, plastic surgery, and other general surgeries such as hernia repair.
Notably, many of these procedures require nurses and anesthesiologists, who are already in short supply in public hospitals. Severe workforce shortages in the public hospital system will worsen as for-profit facilities siphon more public resources. The empirical research evidence shows that a private-pay tier draws resources away from the public sector, increasing public wait times. This is already evident by the ballooning cancer surgery wait times in the province.
Since the Alberta government encouraged greater for-profit surgical delivery under the Alberta Surgical Initiative, median wait times for nine out of 11 key procedures have increased, including all cancer surgeries.
The provincial government has still not released the regulations to accompany its two-tier legislation, Bill 11 (Health Statutes Amendment Act), including the promised guardrails. This summer, the Alberta government will use an expression of interest process to gauge interest from surgeons in participating in two-tier surgical care whereby these surgeons and for-profit facilities (where they may have investment interests) can charge patients whatever rate they choose to facilitate queue jumping.
Let’s be clear. These surgeons already have the choice of un-enrolling entirely from the public system and working on a private-pay basis exclusively. The province is now paving the way for surgeons and the for-profit facilities to benefit from both private payment from wealthy individuals and insurance companies, plus substantial public funding through outsourcing contracts.
The question we need to ask is whether Alberta’s health care system should be redesigned to encourage greed and profiting from the long wait times in the public system because the Alberta government refuses to properly fund it.
Between 2014 and 2023 (the most recent data available), provincial real per capita hospital spending in Alberta declined by four per cent, from $2,252 to $2,169. Alberta was the only large province to experience real, per capita spending cuts over these years.
At the press conference, CBC News asked if a surgeon can explicitly suggest that a patient pay privately in order to expedite their surgery, and Minister LaGrange did not discourage this practice. That’s because this model explicitly encourages this behaviour.
Two-tier health care plays to the greed of some surgeons looking to substantially increase their already generous public compensation. In Alberta, the average gross clinical payments for surgeons was already $704,673 in 2023-24, according to the Canadian Institute for Health Information. For ophthalmologists and orthopedic surgeons, among the specialties that are being encouraged to participate, the average gross payments were $1,519,108 and $550,421, respectively.
Certainly many physicians and surgeons will find the practice of charging patients tens of thousands of dollars—and playing to their fear and pain—to directly contravene professional ethics. Nonetheless, this is the very kind of behaviour that the Alberta government is encouraging with this policy direction.
At the press conference, Minister LaGrange would not rule out hospitals—and surgeons working in public hospitals—being allowed to perform private-pay surgeries, further undermining capacity in the public system to timely access for patients who don’t have tens of thousands of dollars or private health insurance.
The Alberta government uses factually inaccurate information
The Alberta government continues to make international health system comparisons based on factually inaccurate statements.
Alberta is allowing “dual physician practice” by allowing physicians and surgeons to concurrently bill the public insurance plan and work in the private-pay market. Dual physician practice, as proposed in Alberta, is not allowed in Quebec and New Brunswick, despite continued comparisons made by Alberta leadership.
Alberta is the first province to allow dual practice and explicitly encourage an American-style private health insurance market for medically necessary care.
The Alberta government continues to spread inaccurate information that dual physician practice brings Alberta’s health system closer to those in much of western Europe. A previous CCPA analysis of international health systems found the following:
- No other province allows dual practice similar to Alberta’s new model.
- The Alberta government decontextualizes international comparators.
- Australia—the closest to the Alberta model—provides billions in public subsidy to the private insurance industry and has longer wait times than Canada.
- Dual physician practice is limited and highly regulated due to employment contracts as most comparator jurisdictions use employment contracts with surgeons.
- Comparators have lower physician and surgeon compensation. Lower physician compensation allows for more doctors per capita in other countries.
- Public wait times remain a policy challenge in countries with dual practice.
- Comparator countries have a greater share of public spending on health care—not private spending.
Alberta’s two-tier model violates the Canada Health Act:
Previous CCPA analysis and a recent legal opinion by Goldblatt Partners concluded that Bill 11 (the Health Statutes Amendment Act), which establishes the two-tier system violates multiple sections of the Canada Health Act.
Under Bill 11, Alberta became the first province in Canada to legislate two-tier health care in direct contravention of the Canada Health Act.
Specifically, Alberta’s legislation contravenes the requirements that all medically required services are publicly insured (Section 9), there is “reasonable access” to insured services without financial barriers (Section 12), and that people are entitled to them on “uniform terms and conditions” (Section 10).
The legislation also violates prohibitions against user fees and extra billing (sections 18 and 19). These sections prevent patients from being charged out-of-pocket or through private insurance for services that are already covered under the provincial health plan.
The federal government has a statutory responsibility to uphold the Canada Health Act and through its discretionary powers may choose to entirely withhold Alberta’s portion of the Canada Health Transfer, which comprises about 28 per cent of Alberta’s health care budget.
