After nearly three years languishing on the public waitlist for a hip replacement, Cheryl Stewart will finally receive surgery this week.
Stewart told CBC’s The National that her pain wasn’t bad at first, but that as time went on, her hip “got 10 times worse,” until she could barely move beyond a short walk from her bed to her kitchen or bathroom.
She’s one of the Canadians caught in the crossfire as provinces search for ways to reduce wait times that have been a problem for more than a decade.
But in Alberta, where Stewart lives, the province’s latest bid for a solution is introducing a controversial system where doctors can simultaneously work in public hospitals and do private care on the side, a model that health advocates say could not only increase public wait times, but may be in violation of the Canada Health Act.
The new model, which begins rolling out this month for eligible practitioners as part of a suite of changes brought in by Bill 11, is called dual practice. Proponents argue that with proper guardrails, it won’t siphon surgeons from the public care system, but will instead lower wait times for elective surgeries across the board by increasing surgical capacity.
Critics warn that the data doesn’t support this, and say dual practice promotes a system where money, and not medical need, determines who receives care.
Canadian and provincial health-care groups are calling on the federal government to stop Alberta from allowing physicians to practise in both public and private systems. As the CBC’s Troy Charles explains, opponents say new legislation introduced across the Rockies threatens the Canada Health Act.
Those waiting for non-emergency procedures like hip and knee surgeries, which are often delayed, are feeling the brunt. Skipping the line wasn’t an option for Stewart.
“To have to go private and spend $35,000, of which I don’t have a penny of, that would be an impossible thing for me to come up with,” she said.
“It’s a two-tiered system. You certainly don’t feel like you’re in the upper tier, that’s for sure.”
The 77-year-old added that “all of us have worked and all of us have paid our taxes,” and that it seems “unfair” for some people to be able to pay to get seen faster.
Comparing wait times
Data from both within Canada and from international jurisdictions throws cold water on the idea that private care investment frees up resources for the public sector.
Alberta’s proposed system is unique within Canada, but it bears similarities to a model already active in Quebec. There, doctors must notify the government before switching from public to private and, as of last year, receive approval first.
Quebec — where more than 800 doctors have opted out of the public system to operate privately — has the worst track record out of the four largest provinces on wait times for elective surgeries, according to data from the Canadian Institute for Health Information (CIHI).
Canadians are supposed to receive hip and knee surgeries within six months of the surgery being ordered, according to the national benchmark set by CIHI. But according to the latest national data on hip replacements, while 84 per cent of patients in Ontario, where the system remains almost entirely public, get their surgery within that national benchmark time, only 54 per cent of public patients in Quebec meet that benchmark.
Currently, Alberta falls below the Canadian average of 69 per cent, with 63 per cent of patients on the public side receiving their hip replacement surgeries within the benchmark.
Quebec introduced restrictions on the movement between public and private systems last year to curb the exodus of doctors, but the Montreal Gazette found last month that specialists are still pulling out of the public system.
A 2024 study looking at Australia found that when the government tried to push private care to relieve the burden on the public system, it yielded a “limited” real-world impact, only shaving off an average of less than half a day in wait times at public hospitals.
Private practice expansions in Australia, Ireland and the U.K. exacerbated inequalities and increased surgical wait times, a May article in The Lancet noted in reaction to Alberta’s dual-practice proposal.
Alberta insists it will maintain control by imposing strict rules on dual-practice doctors, including mandatory minimum hours in public operating rooms, if needed. Family physicians aren’t eligible for dual practice under the new model.
“We’re going to make sure that doctors who do go into dual practice — and 400 have expressed an interest to do so — that they continue to provide the service to the public system that they historically have,” Alberta Premier Danielle Smith said in a news conference earlier this month, stressing that the intent is to allow surgeons to do more elective surgeries in total by being able to bill privately for extra work on top of their work in the public system.
Private incentives
But experts caution that government oversight of surgeons, who operate as independent contractors, is difficult to enforce.
Karen Palmer, a health policy professor at Simon Fraser University, said these systems simply don’t work.
“There is no country in the world that allows dual practice … that has found a way to eliminate its harmful effects even with regulation.”
Dual-practice models can also create a built-in conflict of interest, she said.
“It incentivizes physicians to increase their public wait times so that patients feel that they sort of have no choice but to pay privately.”
Alberta’s new dual practice health-care model, which allows doctors to work in both the public and private systems, officially launched Tuesday. Premier Danielle Smith says it will relieve strain and reduce wait times, but critics say it will create unequal access to health care.
Alberta physician Dr. Braden Manns said introducing more private options might allow those with funds to get quicker access, but warns it splits focus for doctors.
“If the surgeon can get four times as much to do surgery, private, for-pay surgery, they’re going to prioritize that,” he said.
Manns, who is also the senior associate dean of the Cumming School of Medicine at the University of Calgary, co-authored a recent commentary in the Canadian Medical Association Journal, arguing dual practice will worsen access to public health care.
“We have problems, but these changes are not going to fix them for the public system,” he said. “So the only ones benefiting are the chartered surgical facilities, investors and then the insurance industry.”
‘Literally killing me’
Those stuck in agony may feel they have no other choice.
In Prince Edward Island, wait times can be astronomical for elective surgeries. Charlottetown resident Neil Payne was told he’d be waiting 12 to 18 months for surgery on his deteriorating hip, but after six months of being off work, battling pain that sometimes kept him bed-ridden for hours, he couldn’t take it.
“It was literally killing me,” Payne, who is a father of seven, said.
So he went to a Montreal clinic to pay for surgery — placing him more than $20,000 in debt.
“It’s a big hit, really,” he said. But he has no regrets. “It was life changing for me.”
One physician who works in both the private and public systems in Quebec maintains that private clinics can help public care, while acknowledging that demand for private care spikes when public hospitals are underfunded.
“With guardrails, it absolutely can work as a complement to what’s available for patients,” Dr. John Antoniou said.
Critics say proven public solutions can do a better job.
Nova Scotia’s percentage of elective surgeries delivered within the benchmark has shot up in recent years following the introduction of a centralized waitlist for referrals, the expansion of operating room hours to include nights and weekends, and a push to make hospitals more efficient. Now, 77 per cent of hip replacements are delivered within the national benchmark, compared to 49 per cent in 2022.
Health advocates say the choice shouldn’t be between pain and debt — and they’re calling on the federal government to step in to defend Canada’s public healthcare system from further erosion.
More than 20 Canadian health organizations issued a call to action for Prime Minister Mark Carney and Health Minister Marjorie Michel to review Bill 11 and step in if violations of the Canada Health Act are found.
Michel has previously flagged concerns with Alberta’s new model. But whether Ottawa will take action by clawing back public funds remains to be seen.
The federal health minister has written a letter to the Alberta government to ensure the Canada Health Act is protected when the province rolls out a dual-practice health-care model in September. As Travis McEwan reports, an Alberta cabinet minister is defending the model.
