Bill 15 on the Health Quebec agency opens the door to an expansion of the private sector in the health system, warn experts, who demand that this be the subject of a public debate.
“The bill gives […] the impression that it is a Trojan horse for the private sector, ”wrote the Dr Joseph Dahine in a series of tweets on Twitter last week. The doctor, who practices as an intensivist in Laval, holds a master’s degree in health administration. He says he spent three days reading and studying Bill 15.
The bill “has a lot of good,” he says. But Quebecers are missing out on an important debate on the place of the private sector. According to him, “we are building the skeleton” of a possible “parallel network” without imposing limits such as the “notion of pilot project”.
Article 2, for example, stipulates that health services are provided by establishments which “may be either public or private”. However, this is not framed by any beacon, he laments. The same goes for article 23, which gives the agency the power to identify the “private providers” it needs.
“It gives the possibility of developing a parallel network with different rules in terms of accountability,” says Dr.r Dahin.
Separate bill demanded
With its 1180 articles, Bill 15 is one of the largest to have been presented to the National Assembly. He plans to split the Ministry of Health in two to create an agency — Santé Québec — which would be responsible for the day-to-day management of health services.
It also entrusts new “population-based” responsibilities to medical specialists and forces the regrouping of local unions, which would henceforth have only one boss—Santé Québec.
Mr. Dahine has the impression that the private issue “is sandwiched in a project that covers many other aspects of health”. He would have liked the government to table a bill on this, separately, so that it could be the subject of a “substantive debate”.
Concerns shared by François Béland, co-author of the book The private in health. speeches and facts and professor in the Department of Health Administration of the School of Public Health at the University of Montreal.
Mr. Béland points out that he is not a lawyer and that it is difficult to know precisely what is “new” in the bill with regard to the role of the private sector. But the text of Bill 15 raises serious questions, he said.
“Despite any irreconcilable provision”
This is the case in article 194, which regulates recourse to the private sector when the waiting times for patients are too long for an operation, for example.
It is written that the minister can “assume the costs” of care given in a private establishment “despite any inconsistent provision”.
This amounts to giving the Minister of Health the power to authorize doctors to practice both in the public and in the private sector, which is currently prohibited, points out Mr. Béland.
This is already the case for some elective surgeries in specialized medical centers (CMS), he notes. However, the wording of the Act gives Minister Christian Dubé the possibility of using it more broadly. “What we see is that there is a whole structure […] which welcomes the private and not only the private contracted – as in private CHSLDs – but the private-private”, he argues.
In Quebec, physicians wishing to provide private health services must withdraw from the Régie de l’assurance maladie du Québec (RAMQ) and cannot practice in the public network.
Nothing on private mini-hospitals
Recall that on March 7, the Legault government launched two calls for interest to create two private mini-hospitals in Quebec and Montreal. Planned for 2025, they would offer 24/7 front-line service, with the added bonus of radiology and minor operations.
According to Minister Christian Dubé, Bill 15 has no particular effects on these projects. The agency’s management team will see all these needs “served by public establishments” and “if necessary, will use private hospitals in much the same way as we currently use private clinics, because ‘we are not able to catch up on surgeries,’ he replied on this subject at a press conference.
Professor Béland concedes that Minister Dubé may not intend to go beyond the two mini-hospital projects in terms of opening up to the private sector. The problem, he says, is that these successors to the Ministry of Health might see things differently.
He argues that the bill would give a minister a lot of leeway to go further. Section 23, for example, states that the agency may subsidize “private providers” to provide “health and social services”.
Interpreted in the broad sense, this could mean that Health Quebec could “found private hospitals” or make a hospital like Sacré-Coeur a private hospital, “he says.
He also wonders about the impact this may have on social services, which are mentioned in the text of the article.
Bill 15 must be studied in detail by the deputies during a parliamentary committee before being adopted. The Minister expressed the wish that this could be done before the end of the session in June. But the oppositions expressed doubts on the possibility of studying a document of such length by then.