Each year, provincial health departments calculate how many doctors they can afford, and then sets med school admissions on that figure.
This week, NDP Leader Jagmeet Singh tried — and failed — to convene an emergency House of Commons debate on the privatization of Canadian health care.
As the Ontario government of Premier Doug Ford debuted a plan to outsource more health procedures to for-profit clinics, Singh warned that it would serve only to cannibalize the public system.
“Health care is already dramatically understaffed, and for-profit facilities will poach doctors and nurses,” said Singh.
It’s a point on which Singh is probably correct – although he likely disagrees with the remedy.
While Canadians are increasingly warm to the idea of private options to alleviate a worsening crisis of health-care wait times, it won’t do much unless Canada can also break its onerous controls on health-care supply.
At the same time as politicians of all stripes condemn the country’s worsening doctor shortage, it is government policy to keep that shortage in place.
Canada maintains top-down limits on the number of students entering medical school each year. Provinces are also notoriously obstinate about approving foreign credentials in order to avoid overwhelming health-care budgets.
Until that system can be liberalized, any government contracts with for-profit providers will just be drawing from the same artificially small pool of clinics and physicians.
Canada stands alone among developed nations in maintaining an outright ban on private health insurance for anything covered by the Canada Health Act.
This is why Canadians can purchase insurance to cover emergency dental surgery, but if they get cancer they’re restricted either to getting in line – or paying cash in a U.S. hospital.
None of our peer countries do this. Two-tier systems are the norm everywhere from Japan to Belgium to the U.K.
In Australia, an expectant mother can deliver her baby for free in a no-frills public hospital. Or, if she’s got a good health insurance plan, she could opt for premium birthing care at a private hospital. In Canada, only the public option is legal.
These widescale limits on private health insurance are why Canada is particularly uptight about certifying a doctor or greenlighting a clinic, because the assumption is that the public system will have to pay for it.
The most obvious effect of this approach is that Canada maintains a quota system on how many students are allowed to enroll at the country’s 17 medical schools. A recent RBC analysis called the quota system a “choke point” that “limits student admissions to just under 3,000 spots for prospective doctors each year.”
Each year, provincial health departments calculate how many doctors they’ll be able to afford, and then sets med school admissions on that figure. In 2018, for instance, the Government of Quebec cut medical school admissions after they determined that “too many” medical students were graduating.
Basically no other profession works this way. Provinces don’t really care how many lawyers or auto mechanics their schools are producing each year, since it’s not the government’s job to find them work.
But an oncologist can only realistically expect to find employment through the government, which then prompts the government to only train as many on hand as they can afford.
A detailed “quota allocation” published by the University of Toronto Faculty of Medicine shows how the system works. For the 2020 scholastic year, the school was only allowed to train eight cardiologists, four endocrinologists and a single clinical pharmacist. The school also had to scale back its number of graduating family doctors, with one fewer allocation in the realm of “family medicine” than the year before.
It’s in part due to these quotas that in 2011 the Fraser Institute accurately forecast that Canada’s doctor shortage was poised to get exponentially worse.
“Even if government imposed restrictions on the number of doctors being trained in Canada are immediately removed, it won’t have an impact for much of the next decade given the time it takes to train a new doctor,” they wrote at the time.
The import of foreign-trained doctors has been singularly responsible for stopping the physician shortage from becoming an even worse catastrophe, but even then, Canada’s culture of top-down control of the health care supply has sharply limited foreign recruitment.
Canada is notorious for maintaining unusually onerous requirements to certify foreign doctors, with the result that the country is home to more than 13,000 internationally trained doctors who are not able to work as physicians.
At the same time, government quotas on medical residencies have been instrumental at scaring away even Canadians who have obtained medical training abroad.
“The messaging for so long has been that it’s nearly impossible to get a bloody residency in Canada if you’re an international graduate,” reads a recent quote in the Globe and Mail by Peter Nealon, CEO of the Atlantic Bridge Program, a group that slots North Americans into Irish medical schools.
“You tell people to go away long enough, and eventually, they go away.”