One year after the Supreme Court of Canada’s decision in Chaoulli vs Zeliotis sent shockwaves through the healthcare sector with its nod to private health insurance, there is little change discernible in the Quebec healthcare environment. Not only was the actual application of Chaoulli delayed for 12 months to give the Quebec government time to respond, the response the Charest administration did deliver, in February 2006, surprised many observers with its conservative approach to opening the system to private services.

The Quebec government’s consultation document, Guaranteeing Access: A challenge of equity, efficiency and quality, proposes the introduction of standard waiting times for some common elective operations. These include knee, hip and cataract surgeries, which will be speeded up through the introduction of a “guaranteed access plan.” This plan would ensure that patients have access to services within pre-set timeframes once they have been registered on the official waiting list.

It does not, however, address delays in securing access to a general practitioner and then to a specialist to obtain the initial diagnosis. The short list of treatments with wait list guarantees is likely to grow, as the document indicates that guaranteed access for cancer treatments will be outlined at some future point and leaves the door open for other procedures to be added to the guaranteed access list.

The Quebec consultation document responds to the Chaoulli decision directly by formally introducing the option of private insurance in the province. Private insurance will be permitted for the same three procedures that would have “guaranteed access”—knee, hip, and cataract surgeries—and any insurance policies would have to cover rehabilitation and home support services in addition to the initial surgery or treatment.

How wide the door has been opened depends on who is looking. While some groups say these recommendations don’t truly address the key issues of the Chaoulli decision, other groups, including some unions, say the door to privatization of healthcare has been blown wide open.

Besides union groups and workers affected by the decision, financial service companies may also feel some influence. More likely to dampen insurers’ interest in leaping into this new market are the restrictions outlined to keep private and public systems separate. Private health insurance would only cover procedures carried out in a privately run clinic, staffed by physicians who do not practice in the public system. Physicians who work within the public healthcare system would only be entitled to the compensation provided by the Régie de l’assurance maladie du Québec(RAMQ)for the services they offer, so there would be no incentive to put privately-insured patients ahead of those coming through the public system.

At present, there are very few doctors who have elected to work in the private system—perhaps as few as 100 altogether. The potential market is too small to excite insurers, who are watching and waiting at this point.

As a result, there is little impact on employers at the moment. And most plan sponsors are not taking any steps other than watching to see what further developments may arise while ensuring that their plans, as written, do not allow for unintended private services to be reimbursed.

As for insurers, if the wait time guarantees are met, there would be little reason for patients to consider purchasing additional private health insurance.

As other provinces examine their own approaches to accommodating private healthcare initiatives, the Quebec consultation document and the Quebec experience will be closely examined. Alberta’s proposal to allow doctors to work in both the public and private sectors was widely assailed and
the provincial government is backing away from it.

In the meantime, Quebec’s two-pronged approach of permitting some services to be privately covered while at the same time improving service delivery within the public system has attracted some positive notice from the new Conservative government in Ottawa. Quebec’s cautious, measured response to the Chaoulli decision could end up being more influential than it first appeared.

Michèle Boisvert is Eastern Canada practice leader, Group and Health Care, Watson Wyatt Canada.