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Quebec User Fees: OPEN LETTER TO THE PRIME MINISTER - April 2010

The Hon. Stephen Harper

Prime Minister of Canada

Office of the Prime Minister

80 Wellington Street Ottawa, ON K1A 0A2


Dear Prime Minister,

In its recent budget, the Government of Quebec proposed introducing a “health deductible” that would cost most residents of Quebec $25 for every visit to a physician.

Two assumptions apparently underlie this proposal. First, the proposal assumes that a significant proportion of patients abuse the health care system. Second, the proposal assumes that the introduction of a user fee would reduce abuse and therefore save money.

Unfortunately, these assumptions are false, and demonstrably so. But far more importantly, the introduction of the fee, flies in the face of the research guiding good health care and violates, directly and clearly, the Canada Health Act – legislation that your government has a duty to enforce.

Employing user fees as a tool to address overuse of the health care system and reduce costs is misguided. User fees affect all patients, including the overwhelming majority who suffer from real illnesses and need medical attention. Furthermore, those of modest means bear the major burden of disease, and user fees would punish, disproportionately, the very people who tend to need help most. Equally important, Canadian and international experience with user fees demonstrates, unequivocally, that they cause those who need health care to forgo or delay visiting a physician.

Whose interests would be served if a patient having a heart attack delayed seeking care because he didn’t want to pay $25? Or the single mother who chose not to immunize her children? Or the middle‐aged immigrant whose diabetes went undiagnosed? Or the patient who elected not to have her heart failure treated optimally because this would have required a dozen or more physician visits each year? Untreated illness typically leads to sicker patients, which leads to more expensive treatment when care is eventually sought.

Most major commissions and task forces that have studied the issue of user fees in Canada have recommended against their adoption.

All of these are reasons the Province of Quebec should set aside the proposed fee.

I am writing to you, Mr. Prime Minister, because there is a reason your government must also act. The Canada Health Act remains clear: extra‐billing and user fees are prohibited. Attempting to bury a user fee in a year-end tax bill is clever, but it violates both the letter and the spirit of the Canada Health Act. In this respect, section 19 precludes “user charges,” which in turn are defined in s. 2 as “any charge for an insured health service that is authorized or permitted by a provincial health care insurance plan that is not payable, directly or indirectly, by a provincial health care insurance plan.” This definition clearly applies to Quebec’s proposed approach, which will both authorize and permit charges for insured health services that the provincial health insurance plan is not paying. Furthermore, section 20(2) compels deduction from an offending province’s federal contribution.

Canadians overwhelmingly believe that access to health care should be based on need rather than ability to pay.


Will your government tell the government of Quebec and Canadians across the country that you will enforce the Canada Health Act and reduce Quebec’s transfer payments dollar‐for‐dollar if this user fee is introduced?

Awaiting your response,




Danielle Martin, MD, CCFP


Canadian Doctors for Medicare

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