The moment doctors can bill both the public and private systems, the public one starts to lose
Alberta has passed legislation allowing doctors to work in both the public system and the private-pay market at the same time. The change, contained in Bill 11, effectively introduces a form of two-tier health care.
Bill 11 allows doctors and for-profit health care facilities to charge patients for the basic health services we all depend on and that the Canada Health Act guarantees access to for free.
Alberta’s new legislation changes everything about health care because, for the first time in Canada, it allows “dual practice”, where doctors can bill the public system and work in the private-pay market simultaneously. In all other provinces where private options exist, doctors must choose between working exclusively in the public or private system.
By encouraging the movement of doctors and surgeons into more lucrative private-pay work—where patients can be charged tens of thousands of dollars for routine procedures—public wait times will balloon. This has been the experience when two-tier health care was introduced elsewhere in Canada.
In the 1990s, Manitoba allowed ophthalmologists to work in the private-pay and public systems simultaneously.
What happened?
A 2005 study found that private-pay patients in that province waited an average of four weeks for surgery, while patients on the public wait list waited 10 weeks.
In Alberta, therefore, allowing “dual practice” is more likely to result in longer—not shorter—wait times, and in higher costs for patients through user fees and private health insurance costs.
As a result, Bill 11 represents a sharp turn away from the assumption that basic health care in Canada should be guaranteed free and universal. In practice, it’s an egregious violation of the Canada Health Act.
The Act requires that provincial public insurance plans adhere to five principles: public administration, comprehensiveness, universality, portability, and accessibility. It also requires that public health care services be available without user fees.
In fact, Alberta’s Bill 11 contravenes multiple provisions of the Canada Health Act, including accessibility and the ban on user fees.
Additionally, the accessibility criteria prohibit the Alberta government—and any provincial government—from making it more difficult to access public health services in a timely manner.
Yet Bill 11 will do just that.
To top it off, the two-tier model has been evaluated and rejected by the courts. A decade-long legal challenge, led by an orthopaedic surgeon and CEO of a for-profit surgery centre in Vancouver, was dismissed by trial and appeals courts in British Columbia.
The trial judge ruled on the large body of evidence and determined that two-tier for-profit health care would unreasonably harm access to patients on the public waiting list.
In the landmark ruling, B.C. Supreme Court Justice Steeves ruled that a two-tier system “would create a second tier of preferential health care where access is contingent on a person’s ability to pay.”
Instead, the judge suggested that the provincial government reduce wait times by improving the public system through creating centralized wait lists and “first available surgeon” models. Despite strong evidence to do so, these efficiencies have not been taken up widely by provincial governments.
So, if the evidence doesn’t support an American-style, two-tier model, why is the Alberta government adopting it?
It’s clear from the public record that the private health insurance lobby has been intimately involved in discussions on the bill and presumably seeks to financially profit from the introduction of Bill 11. This suggests that the Alberta government is working for corporate interests, not the public interest.
Clearly, most Canadians would not support Bill 11 if they understood its implications.
Public opinion polling since 2025 consistently shows that Canadians are united as never before, and even in Alberta, the majority eschew separatism.
And what defines us as Canadians more than our commitment to universal, free public health care? It’s one of the fundamental differences between us and the United States: We are committed to the value of caring for one another, especially through public health care.
Yet, as much as today’s federal government celebrates Canadian values, Prime Minister Mark Carney has yet to defend the principles of public health care, especially in the face of the new threat from Alberta’s Bill 11.
Instead of silence and inaction, we need the federal government to stand up for the Canada Health Act—before it’s too late.
Andrew Longhurst is a senior researcher with the Canadian Centre for Policy Alternatives.
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