The Supreme Court ruled that Quebec law prohibiting private medical insurance violated the Quebec Charter of Human Rights and Freedom , opening the door, some believe, for an increased role for private health care in Canada. Beneath a benign façade, Bill 33 sets up fundamental changes to core principles of Quebec's approach to health care.

Up to now, the system has ensured that the great bulk of financial and human resources is channeled toward the public health-care system and grants minimized public support for a private system that caters to only a small portion of the population.

Bill 33 does offer some positive change, with the introduction of centralized wait lists for specialized services and with management of service corridors inside the health-care network. However, other features of the bill are far less reassuring for the future of public health care. Below are four main issues raised by Bill 33 :

First, the bill will legalize "private hospitals," called "Specialized Medical Centers" in the jargon of the bill. These centers will be able to offer what today is delivered by Ambulatory Care Centers (for authorized one-day surgery), hospitals (for authorized services with overnight stay) and private clinics, as we know them across the system. There are two types of these new proposed private hospitals. The first, where services are paid for by taxpayers, will become some sort of a "private extension" of the current hospital. Exclusive five-year contracts will be signed between the private hospital and the current hospital. The centre then becomes what the bill calls an "Associated Medical Clinic." Private laboratories and private doctors can also sign exclusive contracts with hospitals. This delivers, by contract, the provision of public services to for-profit private corporations. This is not benign.

The second type of "private hospital" envisioned by the bill is also a private corporation — but services will have to be paid for out-of-pocket. This hospital will be staffed by opted-out physicians who, from then on, will be able to offer (legally) authorized surgical services, including overnight bed stay. Other aspects of Bill 33 establish conditions that will assist the growth of private hospitals. One provision states that the list of authorized surgical services that may be carried out in Specialized Medical Centers (restricted in the bill to knee and hip replacement and cataract surgery), can be extended in future by simple regulatory changes by the minister of health. Bill 33 will allow private insurance for services carried out in the second type of Specialized Medical Centers (with opted-out physicians). The list of such services could be extended to cover some, or all, of the authorized surgeries in the private hospitals by simple government regulation after discussion by a committee of the National Assembly. Importantly, the private insurance contract will cover both physicians' costs and hospital services associated with overnight stays. This is a major departure from current public policy.

Finally, Bill 33 envisions that compliance with the wait-list guarantee may result in publicly insured patients being sent to private hospitals staffed with opted-out physicians. The Quebec government would like to stress those aspects of the bill that limit, for the time being, the extent of the introduction of private health insurance and the scope of cross subsidization of public and private healthcare systems. No one will be fooled by this. Such drastic changes in the course of health-care delivery and financing could only be done incrementally anyhow.

The structure set in place by Bill 33 lays the cornerstone on which two-tier health care can gradually develop.  We must bear in mind that the argument that Quebec has no other option following the Chaoulli decision is highly debatable. This argument profoundly confuses the roles of the judiciary and parliaments. This, like Bill 33, should be a matter of serious concern to every Canadian citizen.

This article was originally written for and published by the Toronto Star on Nov. 17, 2006. We would like to take this opportunity to thank Prof. Prémont and the Toronto Star for giving us permission to reproduce it here for the benefit of our participants.