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The penalties are assessed on a dollar-for-dollar basis, meaning they are equal to the amounts patients complained about paying for procedures. B.C. and Newfoundland were the only provinces assessed penalties for the last three years. When the 2013-14 annual report comes out soon, B.C. will once again be penalized, this time $224,000, said provincial Health Ministry spokesman Ryan Jabs.

Since 1994, the federal government has docked B.C. $3.2 million, slightly lower than the record-holder Alberta ($3.6 million). Since 1994, provinces have been assessed nearly $10 million in penalties for extra billing charges. A Health Canada spokesman could not explain why Quebec has never been penalized, even though it reportedly has a thriving private medicine sector. Ontario has also not faced any penalties.

The penalty to B.C. is paltry in relation to the province's $20-billion health budget announced Tuesday. It is also insignificant relative to the federal transfer payments B.C. will collect this year ($4.4 billion) and next ($4.7 billion). In 2006, the then-deputy health minister of B.C., Penny Ballem (now Vancouver city manager) questioned whether B.C. was really the only province where extra billing and private sector queue jumping was taking place. Jabs said Wednesday he can't comment on what happens elsewhere.

In 2005, the B.C. government did not submit a dollar value to the federal government for such extra billing, so Health Canada bureaucrats based the penalty sum on news releases from anti-privatization unions and newspaper clippings about patients who accessed the private system. The Sun learned about that through a Freedom of Information request. The story detailed how discretionary the penalties appear to be and that they are based on "guesstimates" of user fees. Provincial Health Ministry officials often base their reports submitted to the federal government on complaints from patients who go to private clinics for expedited care and then try to collect the fees paid from government. One such patient is Mariel Schoof, who had sinus surgery at a private clinic in 2003. She paid $6,150 for the "facility fee" and then tried to recover the fee from the provincial government or the clinic. She is now one of the interveners in a private versus public medicine trial starting March 2 between Dr. Brian Day and the provincial government. Timeline of Canada Health transfer compliance in B.C.

Early 1990s: As a result of a dispute between the British Columbia Medical Association and the B.C. government over compensation, several doctors opt out of the provincial health insurance plan and began billing their patients directly, some at a rate greater than the amount the patients could recover from the provincial health insurance plan. May 1994: Canada Health deductions began and continue until extra-billing by physicians is banned when changes to B.C.'s Medicare Protection Act come into effect in September 1995. In total, $2,025,000 was deducted from B.C.'s cash contribution for extra billing that occurred in the province between 1992-1993 and 1995-1996. These deductions were non-refundable, as were all subsequent deductions. January 2003: B.C. provides a financial statement in accordance with the Canada Health Act Extra-billing and User Charges Information Regulations, indicating aggregate amounts charged with respect to extra billing and user charges during fiscal 2000-2001 totalling $4,610.

Accordingly, a deduction of $4,610 was made to the March 2003 federal transfer payment. 2004: A $126,775 deduction was taken from B.C.'s March 2004 Canada Health Act payment, based on the amount of extra billing estimated to have been charged during the 2001-2002 fiscal year. Since 2005: $786,940 in cash transfer deductions have been taken from B.C.'s federal health transfer payments on the basis of charges reported by the province to Health Canada. January 2011: Vancouver General Hospital begins charging patients a fee when they elect to have robot-assisted surgery versus the conventional surgical alternative for certain medically necessary procedures. 2013: Deductions in the amount of $280,019 are taken from the March 2013 federal transfer payments of B.C. in respect to extra billing and user charges for insured health services at private clinics. Source: Canada Health Act Annual Report 2012-2013

The branch investigates about 30 cases a year of extra billing, usually related to private surgical facilities or expedited visits to specialists. The government is not sure whether it will be penalized in the future for allowing Vancouver General Hospital to charge patients fees for robotic surgery. VGH spokesman Gavin Wilson says since 2012 patients choosing to have surgeons remove their prostates using the robot have been charged on a partialcost-recovery basis. The B.C. government allows the extra billing because robotic surgery is discretionary, not medically necessary, and there are higher costs associated with it. In 2012, however, Health Canada began examining the Canada Health Act implications of patient charges for robotassisted surgeries. The process convinced the health minister that VGH should stop charging for robot-assisted surgeries as of Jan. 1, 2015. Vancouver Coastal Health collected $345,000 a year for the procedures; most recently, the patient fee was $5,700. Sun health issues reporter pfayerman@vancouversun.com

Auditor Calls Quebec Extra Billing Out of Control Doctors Call on Health Minister Jane Philpott to Illegal Billing Practices in Quebec TORONTO (May 12, 2016) – Extra-billing in Quebec medical clinics are “excessive” says Auditor General Guylaine Leclerc, but Federal Health Minister Jane Philpott has yet to act on calls to enforce the Canada Health Act and bring them under control.

However, until now no federal government has had the nerve to take on serial offender Quebec. Quebec has been allowing its doctors and clinics to charge extra user fees since 1979. The province's current health minister, Gaetan Barrette, freely acknowledges this. In some cases, these fees were truly exorbitant. The Montreal Gazette reported last year that some colonoscopy clinics were charging patients an extra $600 for medications - on top of the publicly paid medicare fee. Many Quebecers were outraged. The provincial Liberal government's somewhat peculiar response was to pass a bill codifying the practice of extra-billing but giving itself the authority to regulate it. In March 2015, the then-Conservative government in Ottawa formally notified Quebec that it would be looking into the issue. This March, Liberal Philpott sat down with Barrette to discuss the practice. On Sept. 6, she sent her provincial counterpart a letter threatening cutbacks to Quebec's health transfer. A few days later, Barrette announced that extra billing will end as of next January.

It is hard to gauge the importance of Philpott's threat. User fees have become widely unpopular in Quebec. That alone may have been enough to drive the provincial government to disavow them. Still, it was bracing to see a federal health minister publicly standing up for the principles of medicare. It is not an everyday occurrence. It is particularly interesting that she targeted a province that is notoriously touchy about what it sees as federal interference. Perhaps she will do more. Certainly, more needs to be done. The latest annual report on the Canada Health Act filed with Parliament notes that private MRI clinics in British Columbia, Alberta, Quebec, New Brunswick and Nova Scotia are charging user fees to patients. It says some hospitals are avoiding the ban on charging for drugs by routing the sick through outpatient clinics - which do charge. It also notes that the portability requirement of medicare, which allows Canadians to receive care outside their home provinces, is routinely ignored.

Quebec routinely refuses to fully reimburse other provinces that provide health services to Quebec residents. Yet it has never been penalized by Ottawa for this. Nor have an unspecified number of other provinces that, at one time or another, did the same. Except for Prince Edward Island, the report says, no province appropriately reimburses residents who obtain medical care outside Canada. Such patients aren't necessarily entitled to the full cost of their out-of-country care. But they are entitled to be reimbursed for the amount it would have cost them to be treated in their home province. To work as a national program, Canadian medicare needs two things. First, the federal government must put up enough money to give it a real financial role in the system. The 2002 Romanow royal commission suggested that Ottawa provide at least 25 per cent of medicare funding. That figure still makes sense. Second, Ottawa has to use its financial clout to enforce those few national standards that do exist. A former Liberal health minister, Diane Marleau, tried to do this back in the 1990s. She was sandbagged by Jean Chrétien, the prime minister of the day. Let's hope Philpott has better luck.

It was bracing to see a federal health minister stand up for medicare principles, writes Thomas Walkom.

Reportedly, Dr. Philpott wrote to her counterpart earlier this month, intimating Ottawa would start withholding transfer payments if extra-billing is not addressed. Now Dr. Barrette is making the typical spluttering noises about Ottawa invading provincial jurisdiction and claiming credit. In recent years, the provinces have tended to treat the federal Health Department as a cash machine; the extra-billing skirmish may end up being part of a broader negotiation over a likely reduction in federal transfers.

Let's hope Quebec's decision, and Dr. Philpott's role in it, signal a new era of robust federal defence of publicly funded medicare. With the British Columbia Supreme Court hearing arguments this week in a case that challenges some key pillars of the Canada Health Act, such robustness is needed.

When the Canada Health Act passed in the House of Commons in 1984 with unanimous support from all political parties, its primary purpose was to put an end to extra billing like this. Charging patients at the point of care for medically necessary services strikes at the heart of the principle that access to health care should be based on need rather than ability to pay. It undermines equity, increases system costs and reduces commitment to the public health care system. It's also illegal.

Why are we not hearing resounding denunciations of Barrette's plan from our federal politicians? Research has consistently demonstrated that forcing people with less money to pay a fee to access care means they might not seek out medical attention until later in the course of their illness. This means patient outcomes are likely to be worse and treatment more complicated and costly. Given higher levels of illness among people in poverty, these fees also shift costs to those who use the system most but can least afford to pay.

Doctors in Quebec and across the country have expressed alarm at Barrette's amendment to Bill 20, which regulates extra billing rather than prohibiting it. The Canadian Medical Association, Quebec Medical Association, Canadian Doctors for Medicare, Médecins Québécois pour le Régime Publique, and the Quebec College of Family Physicians have all come out against this decision, joining patient groups, all of Quebec's opposition parties, and Raymonde Saint-Germain, the independent Quebec Ombudsman. The measure was passed on Oct. 7, with no public debate. Bill 20 is currently before the National Assembly and is expected to become law this fall.

Barrette is effectively bringing user fees in through the back door. Rather than introducing user fees charged by government, he would let clinics do so. This further fragments care and makes access even more inequitable.

In this federal election campaign, the talk has been around reducing barriers to access by improving coverage of prescription medicines, home care and mental health care. Yet at the same time that our federal parties are committing to such muchneeded expansion, they are silent on protecting the core of medicare: publicly funded doctor and hospital services.

Any party that claims to be committed to the Canada Health Act should immediately state its position on the amendments to Bill 20 in Quebec. To do less is to skirt the core federal responsibility for medicare in Canada. Ryan Meili is a family physician in Saskatoon and an expert adviser with the Evidence Network. Danielle Martin is a family physician and vice-president Medical Affairs and Health System Solutions at Women's College Hospital in Toronto. Both are members of the board of Canadian Doctors for Medicare.

JACQUES BOISSINOT, THE CANADIAN PRESS / Health Minister Gaétan Barrette has put forward a measure that would regulate extra billing rather than prohibit it. It will become law when Bill 20 is adopted.

QUEBEC — Extra fees charged in private clinics for procedures covered by medicare are not being controlled and may be abusive, the province’s auditor general said in a report Tuesday. Extra billing has been in dispute ever since the government of Quebec adopted Bill 20 in November. The bill aimed, among other things, to regulate add-on fees by creating a standardized price list. The situation remains ambiguous, confusing and misunderstood, auditor general Guylaine Leclerc wrote in her report. Neither the health department nor Quebec’s health insurance board (RAMQ) has a firm grip on these add-on fees, which are estimated at $50 million a year, she noted. For example, the report said, Quebecers are charged between $300 and $400 for a colonoscopy, $125 to $225 for a vasectomy, $51 to $100 for a biopsy and $5 to $50 for an excision, depending on the clinic. 

Lawyer Jean-Pierre Ménard insisted last week Quebec is the worst offender when it comes to over-billing patients, and that the fees are creating a two-tier health-care system that may violate the Canada Health Act. With Ménard’s help, various patients’-rights groups have come together to launch legal action against the federal government to make sure the Canada Health Act is applied in Quebec and other provinces. Reacting to the report Tuesday, Health Minister Gaétan Barrette reiterated his recent promise to abolish add-on fees by possibly rolling them into doctors’ salaries. “For care that is medically required, there won’t be any fees,” he told reporters.

Parti Québécois MNA Diane Lamarre said Barrette’s “about-face” is the result of relentless criticisms by her and the PQ. “When we started studying Bill 20, we were fighting the fact that the minister introduced an amendment that authorized accessory fees,” Lamarre said. “It was a new opportunity to charge, legally, new medical fees. … We asked the minister many times to (scrap) his amendment and he refused. “(It) was a way to introduce accessory fees and make some patients with no money unable to have access to medical services, which is completely against the law. Now we’re proud that he changed his mind,” she said. Both Lamarre and Coalition Avenir Québec MNA François Paradis said they are concerned Barrette will not be able to convince doctors’ associations to include the fees in their remuneration. If doctors’ salaries are boosted by an additional $50 million in the next contract agreement, for example, it will mean that collectively we will all be paying the fees indirectly, Paradis said.

There are about 1,000 health care providers

the program has 10 different types of professionals that work in a team to care for patients

the Health Council of Canada highlighted extra-mural as a best practice in Canada

About 56 per cent of our client population are over the age of 65 and 21 per cent are over the age of 85

extra-mural currently only cares for five per cent of the population

In their recent CMAJ article, Morgan and colleagues present just such a study.2 Using recently available national data on drug use and costs, they report an economic model that estimates the cost of implementing national public drug coverage. The model anticipates several key evidence-based consequences of universal pharmacare. Patients who were previously unable to access drugs would now receive them, which would drive up costs. However, the greatly enhanced purchasing power of a single national third-party payer would be expected to confer an ability to negotiate substantial reductions in the prices of many drugs, as other countries have experienced and as Canadian provinces are already trying to achieve through collaboration. The model also assumes that patients would incur modest copayments, as is the case in other countries with universal pharmacare.

The bottom line? The best estimate would require the federal government to spend an extra $1 billion per year. That’s a lot of money, but considering that federal transfers for health care to the provinces and territories amount to $35 billion — not to mention everything the federal government spends directly on health — relatively speaking, it’s not that much of an increase. As with all modelling studies, these estimates rely on assumptions, and the associated uncertainties mean that costs could be higher — as much as $5.4 billion per year in the worst imaginable case. Equally, though, national pharmacare could well result in net savings for government — perhaps as much as $2.9 billion per year.

Morgan SG, Law M, Daw JR, et al. Estimated cost of universal public coverage of prescription drugs in Canada. CMAJ 2015;187:491–7. Abstract/FREE Full Text

A small number of drug classes are key drivers of overall costs and would continue to be so with or without pharmacare. Some (e.g., biologic agents) represent classes in which many emerging new therapies are expected to arise. Thus, the $1 billion estimate might not be stable going forward. But knowing this information may now enable policy-makers to develop specific interventions focused on reducing the impact of these key cost drivers even further.

Although the Canada Health Act has long enshrined the value of equitable, public health care coverage for all Canadians, its enactment by governments to date has been hypocritical in the absence of pharmacare. Canada has the dubious distinction of being the only country with universal health care coverage, but not universal pharmacare. As we have said before,3 the time to end this hypocrisy is long overdue; all of our peer nations have already done so. The moral case for universal pharmacare has always been apparent. With a strong economic case for pharmacare also evident, there can be no more excuses for delay. In this election year, it is especially timely for Canadians to demand that their next government enact national pharmacare.

Tang KL, Ghali WA, Manns BJ. Addressing cost-related barriers to prescription drug use in Canada. CMAJ 2014;186:276–80. FREE Full Text

Even more striking are the potential benefits to the private sector: no matter what, it would save a lot of money from pharmacare. Currently, nearly half of all drug expenditures in Canada are incurred by the private sector, divided almost evenly between individuals, whose costs would drop by more than half under pharmacare, and private drug plans, whose current costs for nearly all prescription drugs would disappear completely. Of note, a big chunk of public savings would arise from what governments presently spend on private drug coverage, such as for civil servants. With projected savings like these, one would expect that private companies, governments and individuals alike should be clamouring for pharmacare.

tanbrook MB, Hébert PC, Coutts J, et al. Can Canada get on with national pharmacare already? CMAJ 2011;183:E1275. FREE Full Text

And dozens of occupations, some that you've never even heard of, are exempt from basic rights entirely. "Keepers of fur-bearing mammals" have no right to minimum wage. Sod layers have no limits on their daily hours of work. Shrub growers don't get a lunch break. The system is so complicated that the Ministry of Labour has developed a special online tool to help decipher who's entitled to what. But as the province reviews its antiquated Employment Standards Act, critics argue that its confusing web of exemptions makes it harder for the so-called precariously employed to defend their rights - and easier for bosses to ignore them.

"When you distil it down to what these exemptions are seeking to achieve, really they are to give employers more control over work and more control over wages," says Mary Gellatly of Parkdale Community Legal Services. "It sends the message to employers that they can get away without complying." The Act was first introduced in Ontario in 1968 to set basic work standards, especially for non-unionized employees who don't have a collective agreement to provide extra protections. But there are at least 45 occupations in Ontario that are exempt from a variety of its fundamental entitlements, many of them low-wage jobs in industries where precarious work is rife.

The Ministry of Labour says many of the exemptions are "long standing" and related to "the nature of the work performed." But York University professor Leah Vosko, who leads research into employment standards protections for the precariously employed, says exemptions have come at least in part from industry pressure, leaving the Act a "complex patchwork that is difficult for workers and even officials to comprehend." Even when there are clear violations, speaking out can come at a cost. Reprisal is illegal under the Act, meaning bosses can't penalize employees for exercising their workplace rights. But the Act gives workers no protection against wrongful dismissal. Employers do not have to give cause for firing someone.

Unionized employees are generally protected by their collective agreements, and workers can sue employers if they think they have been unfairly terminated. But most precarious, low-income employees are not unionized, and most do not have the money to take legal action against an employer, says Parkdale's Gellatly. "It's the big reason why many people can't do anything if they're in a workplace with substandard conditions, because they can get fired without cause." Linda Wang, who worked at a Toronto cosmetics manufacturer for four years, was fired less than two weeks after asking her employer for the extra pay she was owed for working a public holiday. She says no reason was given for her termination. Wang, a mother of two, claims her employer repeatedly bullied her and her colleagues, and says she believes she was dismissed for asking for the wages.

She has filed a reprisal complaint with the Ministry of Labour, but Wang cannot afford to take her employer to court. "I feel the system is against workers," she says. "It's in favour of employers." "Whatever job you have, you put so much of yourself into it," adds Gellatly. "The fact that employers can just fire you without a reason is incredibly devastating for folks." The Act also contains significant gaps when it comes to sick leave and overtime. The legislation provides most workers with 10 unpaid days of job-protected emergency leave, which means they can't be fired for taking a day off due to illness or family crisis. Critics call this measure subpar by most standards, since it still causes many workers to lose a day's income for being ill. An estimated 145 countries give employees some form of paid sick leave.

"Unfortunately, we stand out for our inadequacy," says Brock University professor Kendra Coulter. But the 10-day protected leave doesn't apply to almost one in three of the province's most vulnerable workers. An exemption that excludes employees in workplaces of fewer than 50 people from that right means 1.6 million workers in Ontario are not even entitled to a single, unpaid, job-protected sick day. Fast-growing, low-wage sectors such as retail, food services and health care are most likely to be exempt according to a recent report by the Workers' Action Centre. While many small businesses voluntarily give their employees paid sick days, the loophole leaves many workers - especially the precariously employed - exposed.

Toronto resident Gordon Butler asked his employer, a small construction company in Markham, for one day off work after he sliced his thumb open on the job. He says his boss told him not to come back. "I didn't believe him," says Butler, 44, who has an 8-month-old child. "I tried to plead with him, and he said 'No, too bad.'" "The way it's stacked up right now is there are very few options for people who are in low-wage and precarious work to actually take sick leave when they're sick," says Steve Barnes, director of policy at Toronto's Wellesley Institute, a health-policy think-tank. "They not only have to worry about lost income, but the potential for losing their jobs," adds Brock's Coulter. "It's unkind and unnecessary." The stress caused by the province's meagre sick-leave provisions is compounded by exemptions to overtime pay, to which around 1.5 million don't have full access.

As a rule, employees should get paid time and a half after 44 hours a week on the job, according to the Employment Standards Act. But in 2014, more than one million people in the province worked overtime, and 59 per cent of them did not get any pay whatsoever for it, Statistics Canada data shows. This, experts say, is partly because enforcement is poor. But in Ontario, a variety of occupations don't even have the right to overtime pay, including farmworkers, flower growers, IT workers, fishers and accountants. Managers are also not entitled to overtime. Vladimir Sanchez Rivera, a 45-year-old seasonal farmworker in the Niagara region, says he has worked 96-hour weeks doing back-breaking labour picking cucumbers and other produce.

We don't have access to protections when we are working in agriculture," he says. "And our employers tell us that." Low-wage workers are even more likely to be excluded from full overtime pay coverage, according to the Workers' Action Centre's research. Less than one third of low-income employees are fully covered by the Act's overtime provisions, compared to around 70 per cent of higher earners, because they are more likely to work in jobs that aren't eligible. Workplaces can also sign so-called "averaging provisions" with their employees, which allow bosses to average a worker's overtime over a period of up to four weeks. That means an employee could work 60 hours one week and 50 the next, but not receive any overtime as long as they don't work more than a total of 176 hours a month.

Critics say the measure means more work for less pay, and paves the way to erratic, unpredictable schedules. "That's a huge impact on workers and their families in terms of lost income and having to work extra hours," says Parkdale's Gellatly. "It's certainly not good for workers, for their families, and it's not good for creating decent jobs in terms of rebooting our economy," she adds. For many of the precariously employed, falling through the gaps ruins lives. "Even now, when I think about the working environment, I feel very depressed," says Wang, who, 10 months later, is still waiting for the Ministry of Labour to issue a ruling on her complaint. "I feel panic."

Sara Mojtehedzadeh can be reached at 416-869-4195 or smojtehedzadeh@thestar.ca. By the numbers 1.6 million non-unionized Ontario employees with no right to an unpaid, job-protected sick day 59%

of Ontario workers who worked overtime in 2014 did not get any pay whatsoever for it 71% of low-wage, non-unionized Ontario employees don't have full access to overtime pay 29%

of high-income employees don't have full access to overtime pay Sources: Workers' Action Centre, Statistics Canada Proposed solutions A recent report by the Workers' Action Centre makes a number of recommendations to rebuild the basic floor of rights for workers. The proposed reforms include: Amending the ESA to include protection from wrongful dismissal

Eliminating all occupational exemptions to ESA rights Repealing overtime exemptions and special rules Repealing overtime averaging provisions Repealing the emergency leave exemption for workplaces with less than 50 people Requiring employers to provide up to seven days of paid sick leave

According to the registry, 527 patients were billed a total of $40,775 between Feb. 15 and Aug. 2015. Respondents noted feeling indignant about the injustice of having to pay amounts they considered exorbitant for medical care. Some said they couldn't afford to pay - they needed the money for groceries or rent. User fees for insured medical services covered by the provincial health insurance board are illegal. But there's a grey zone, and for years many physicians and clinics have quietly been applying extra, arbitrary or excessive fees for exams and medications covered in hospitals. Led by the clinic's Comité de lutte en santé, the registry also showed that rates for medical services levied on patients varied among professionals, the clinic's co-ordinator Luc Leblanc said Sunday.

"It's a two-tiered system. One for those who can pay and one for those who can't," he said. Data analysis shows the average amount demanded by family doctors was $63, and the average for specialists was $91. The biggest category is medications or anaesthetics, followed by administrative charges like photocopies or filling forms. Adopted last week, Quebec Health Minister Gaétan Barrette's Bill 20 included a set of amendments to legalize fees charged to patients in clinics for insured services, commonly called "accessory fees." The list of regulated ancillary fees will come later, after the government hires an independent accounting firm to determine real costs.

But Leblanc noted the public wasn't consulted because "initially Bill 20 made no mention of the possibility of accessory fees," Leblanc said. And there are no prior government studies or surveys to determine the scope or impact of current fees on patients, he added. The introduction of user fees is a serious threat to universal care, critics said, including the Canadian Medical Association, Quebec Medical Association, Canadian Doctors for Medicare, and Médecins québécois pour le régime publique (MQRP), who asked Barrette to hold offon regulating fees in October.

Charging patients at doctors offices and clinics for medically necessary care isn't acceptable, said Isabelle Leblanc, president of the pro-medicare group, Médécins québécois pour le régime publique. It strikes at the heart of the principle that access to health care should be based on need rather than ability to pay, she added. The clinic's health committee is calling on Barrette to suspend extra fees and on the new federal Health Minister Jane Philpott "to act immediately to force Quebec to respect the Canada Health Act," said Louis Blouin of the committee. The committee is continuing to document billing in its online registry. It can be found on the Pointe-Saint-Charles clinic website cfidelman@montrealgazette.com twitter.com/HealthIssues

Dr. Brian Day's court challenge is underway in Vancouver. The main issue is whether Canadians should be permitted to pay privately for "medically necessary services" already covered by their provincial health plan. Is there a need for increased private health care in Canada? If so, can it be implemented without jeopardizing the public system?

Philpott admits "innovation" is required. Yet governments are constrained by blindly adhering to certain parts of the CHA, while ignoring others. As Ben Eisen of the Fraser Institute has emphasized, provinces have been forbidden to experiment with user-fees, copayments, etc. that would encourage individuals to use health services more responsibly. A "two-tier" system has always existed. Federal prisoners, Workplace Safety and Insurance Board patients, members of the military and RCMP, politicians and professional athletes usually obtain more timely care - often at private facilities. For those not near an inter-provincial border and not a member of a "special group," the main option for timely care may be to go to the United States. This provides employment to American doctors and nurses and profits to U.S. hospitals. Wouldn't it make more sense to allow all Canadians to spend their after-tax discretionary income on health in their own province? Frozen hospital budgets have caused excessive wait times for knee and hip replacements as operating rooms often don't function at full capacity. According to a 2013 survey, 15 per cent of Canadian surgeons considered themselves underemployed and 64 per cent cited poor access to ORs. About 25 per cent of nurses in Newfoundland and Labrador work only part of the year.

If orthopedic surgeons had access to additional "private" OR time, wait times could be shortened for all Canadians and new employment would be created for health-care professionals. If hospitals were permitted to operate electively on Americans and other foreign patients, this would bring in extra revenue and relieve the strain on provincial health ministries. So that MDs did not abandon the public system, they could be required to work 25 to 30 hours per week in the public system in order to receive government reimbursement for malpractice insurance. Most MDs would confine their practice to the public system. They deserve fair treatment. Philpott should amend the Canada Health Act to mandate binding arbitration when provincial negotiations fail, as they have in Ontario. Since 1984, the population has grown and aged, new diseases have been recognized, and new drugs and technologies have developed. Some 32 years ago, it was understood that Ottawa would pay half of health costs. Now it covers less than a quarter. We need to amend and modernize the Canada Health Act. Where wait times are excessive, certain diagnostic services and surgical procedures should allow for private access for all Canadians - not just a select few. This would maximally utilize expensive equipment and provide new employment for nurses, technicians and surgeons. It would provide extra revenue that would help to keep universal public health care sustainable and accessible for all Canadians. Ottawa should then enforce all sections of the Canada Health Act on all provinces and territories. Dr. Charles Shaver Ottawa

Ontario Health Minister Eric Hoskins predicted that the reduction in the annual "escalator" to three per cent would result in a "declining partnership." Yet considering Ottawa contributes only 23 per cent of the average provincial health budget, the three per cent difference in the annual "escalator" translates into a reduced rate of increase of only 0.69 per cent! Much of this is mere political bluster! Is it not finally time to revisit the Canada Health Act and fine-tune it?

As Konrad Yakabuski has stated (Globe and Mail, Oct. 19), "As long as the provinces remain bound by the Canada Health Act, which constrains their ability to dramatically alter the way health care is paid for and delivered, any new conditions on the use of federal transfers are only likely to further weigh down an already overly bureaucratic system."

When it was passed in 1984, it was understood that the federal government would pay half of health costs. Now it covers less than a quarter. Thanks to Ottawa's admission of refugees and migrants, overall growth of an aging, sicker population, new diseases, and new technologies, the provinces must shoulder an increasing burden.

Yet as Bacchus Barua (Ottawa Sun, Oct. 21) has stressed, more efficient health care systems in Europe allow a greater role for the private sector, use co-payments and user fees (with exemptions for the poor and elderly) and fund hospitals according to activity, not by global budgets, which have been frozen in many provinces.

MDs could be required to work - perhaps 25 to 30 hours per week - in the public system in order to receive government reimbursement for malpractice insurance. Most MDs would confine their practice to the public system. They deserve fair treatment. Thus Philpott should amend the CHA to mandate binding arbitration when provincial negotiations fail.

For those not a member of a "special group," the main option for timely care may be to go to the United States. This provides employment to American doctors and nurses and profits to U.S. hospitals. Would it not make more sense to allow all Canadians to spend their after-tax discretionary income on their own health in their own province?

Frozen hospital global budgets have caused excessive wait times for knee and hip replacements as operating rooms are often not functioning at full capacity. According to a 2013 survey, 15 per cent of Canadian surgeons considered themselves underemployed and 64 per cent cited poor access to ORs. Hence if orthopedic surgeons had access to additional "private" OR time, wait times could be shortened. If hospitals were permitted to operate electively on Americans and other foreign patients, this would bring in extra revenue for hospitals and relieve the strain on provincial health ministries.

Philpott has vowed to do more than just "open the federal wallet." She admits that "innovation" is required. Yet governments are being constrained by blindly adhering to certain parts of the CHA. Despite denials by politicians, a "two-tier" system has always existed. Federal prisoners, WSIB patients, members of the military and RCMP, politicians and professional athletes usually obtain more timely care - often at private facilities.

When the premiers meet with Prime Minister Justin Trudeau in December, besides discussing funding of the new Health Accord, they need to revisit the CHA and begin putting forth proposals as to how best to amend and modernize it. Where wait times are excessive, certain diagnostic services and surgical procedures should allow for private access for all Canadians - not just a select few.

This would utilize expensive equipment and provide new employment for nurses, technicians and surgeons. It would provide extra revenue - from both inside and outside the country - that would help to keep universal public health care sustainable and accessible for all Canadians. Ottawa should then enforce all sections of the CHA on all provinces and territories.

Ottawa physician Dr. Charles Shaver was born in Montreal. He graduated from Princeton University and Johns Hopkins School of Medicine. He is currently chair of the section on general internal medicine of the Ontario Medical Association.

hospital services be covered by the provincial and territorial health insurance plans, whether the services are provided in a hospital or in a facility providing hospital care. There are concerns about queue jumping and charges to insured persons at private surgical clinics in British Columbia, for services that are covered under its provincial health in

atient charges and queue jumping at private diagnostic clinics also remain issues in some provinces where private clinics are charging patients for medically

services and allowing them to jump the queue for insured health services.