Pierre Poilievre never seems to talk about one of the biggest changes underway in Canadian health care: the growing private market.

When asked by The Walrus about his plans vis-à-vis private health care, his team provided a statement that ignored the questions. It mentioned Trudeau and wait times and the difficulties for ­foreign-trained nurses and doctors in having their credentials recognized. The statement vowed to maintain the 2023 deal on health transfers to provinces and territories, in which the federal government committed to investing $198.6 billion in health care over the next decade.

But on private care, nada.

All the evidence suggests that, under a Poilievre government, the private health care market—which, according to some estimates, accounted for about 29 percent of all health dollars spent in this country in 2023—will flourish, at least by Canadian standards. More people will find themselves paying out of pocket for access to medical services like diagnostic imaging, orthopedic surgery, primary care, and virtual care.

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People often ask: Isn’t private health care illegal here? It’s not. For the most part, provinces and territories decide what their health systems look like. The feds provide funding to provinces and territories in the form of Canada health transfers. In order to receive the full allotment of funds without incurring any deductions, provinces and territories have to meet five principles set out in the Canada Health Act. They must provide medically necessary care that is publicly administered, comprehensive, universal to all residents, portable to other jurisdictions in Canada when residents are travelling, and reasonably accessible.

That leaves a lot of room for interpretation. Who gets to decide what is medically necessary? The New Brunswick government, for one, controversially decided to stop funding surgical abortions performed outside of hospitals. How do we define “reasonably accessible”? Is a five-month wait to see an orthopedic surgeon in Ontario reasonably accessible? How about over fifteen hours in an emergency department in Quebec? Right now, the answer to both of these—somehow—seems to be yes.

The federal government can levy deductions on provinces and territories when they run afoul of the Canada Health Act. But it doesn’t always do that.

Federal funds, as a percentage of overall health funding in Canada, have declined over decades, watering down the federal government’s authority over health care. Provinces are looking elsewhere for help. Entrepreneurs are finding innovative ways to offer private care that skirts the edges of the Canada Health Act—doing things like selling orthopedic surgery procedures to out-of-province residents who pay privately because they’re tired of waiting in pain at home. And many Canadians who’ve become frustrated with the public system are more willing than ever to pay.

The end result: private care is on the rise steadily across Canada, even in terms of medically necessary care. In 2021, Canadians spent $1,168.20 per capita on health care—a 9 percent increase from the year before, according to the Canadian Institute for Health Information.

The Jean Chrétien government allowed the first private diagnostic imaging clinics to flourish in the early 1990s. It later tried to rein in privately paid care by using a carrot—more money to the provinces—but the horse was out of the barn.

The Stephen Harper government—in which Poilievre was a cabinet minister—looked away as private care picked up between 2006 and 2015. It did not levy fines on provinces and territories where residents paid out of pocket for care.

The Trudeau government tried a combination of sticks and carrots. In March 2023, his government levied health transfer deductions worth $82.5 million on provinces that allowed patients to be charged for medically necessary services—representing the first ever penalties given because patients paid for medical imaging like MRIs. In the same month, it also offered a carrot: a new health care deal worth ­nearly $200 billion, including $46.2 ­billion in new funding, over ten years.

What will Poilievre do? For now, it seems he won’t say. His team ignored my question about withholding funds for provinces and territories that run afoul of the Canada Health Act. They also did not respond to a question about whether he plans to update the act to allow Canadians to pay privately for medically necessary care.

Whatever happens with private care will not come as a campaign promise. But it’s not hard to predict. If elected in the near future, Poilievre will walk into the PMO at a time when conservative premiers hold the balance of seats at first ministers’ conferences. They’ve long demanded that Ottawa give money for health care and back out of decision making. From the opposition benches, Poilievre seems to be far less willing than Trudeau to go head to head with this group.

I believe he’ll continue providing health funding to the provinces, yes, but he is unlikely to levy deductions when Canadians pay privately for care.

I’m not here to argue whether private care is good or bad; I’m pointing out that these changes will likely happen by stealth, without a candid discussion about how the private health care sector could and should work in Canada. Instead of an organized system that blends private and public medicine, I can easily imagine Canada’s private health care system will grow without planning, publicity, or proper integration with our public health systems. This is the worst possible option.

Christina Frangou

Christina Frangou is a Calgary-based journalist who has been writing about health care for more than two decades.

Jamie Bennett

Jamie Bennett is an illustrator who has worked for many clients, including Literary Review of Canada, the Washington Post, the New York Times, and Canada Post.