Canada’s Multi-Tiered Medical System

        This is an excerpt from Chapter 11 of my book The Trouble With Canada … Still! (2010). The Chapter is entitled “Medical Mediocrity: An Autopsy on the Canadian “Health Care” System.”

I urge visitors to get the book and read it. Better be sitting down, though.

          I do not publish this bit here to flay my country. I publish it to urge truth-speaking. Canadian politicians, from to bottom, enjoy boasting and preening over Canada’s socialized, State-rationed and State-controlled “health-care” system. I always put the latter phrase in brackets because no nation in the world has a true “health-care” system. They are all “disease-care” systems. They look after you when you are sick, not when you are “healthy”. 

         For the $200  Billion or so per year Canadians cough up for this, there is actually some pretty good care, as you would expect for that kind of money. But the Canadian system has all the typical problems that everyone warned would flow from government control and rationing. Lots of them.

Here is my corrective to the lie that Canada has a egalitarian, “single-tier” system


             Politicians know there is a vast pool of latent citizen envy lurking in the bosom of every nation that is easily aroused with misleading equality–talk. Just so, an unreflective Canadian public has swallowed the politically-promoted belief that Canada has a “single-tier” medical system. It has become such a near-sacred myth that our Governments loudly trumpet “the prohibition of ‘two-tier’ medicine,”[1] and various provincial Acts have threatened physicians and corporations with penalties of a $25,000 fine (more for corporations) and up to 12 months imprisonment for offences.[2] “Two-tier” has become a code accusation of rich privilege. But the truth is, Canada has always had a multi-tiered medical system. Here’s why:

Tier One – Those Wealthy Enough for Medical Tourism

I have seen estimates that every year some 150,000 Canadians who are sufficiently wealthy and motivated enough to locate superior medical treatment outside Canada, drop $1 Billion in the process of getting better and quicker medical care than they can get here. That works out to $6,666 each. Not unreasonable.  If these numbers are even close … but, what about ending our government’s monopoly on medicare so that this money can stay in Canada each year, boosting our own medical profession, research, and technological prowess?

Clearly, if we did not have the best Medical care in the world at our doorstep in America, socialized medicine would never have gotten off the ground here, because the huge numbers of influential Canadians who get there what they can’t get here would have screamed bloody murder and taken the entire system down. Instead, they quietly slip out of the country, get first class care, and as quietly return. They are silent because they are privileged. Some I know of who have done this recently are: myself (for diagnostic tests at Mayo Clinic, denied here); my daughter (who went to Buffalo to get a CT scan of a higher resolution not available here); my Mother-in-Law who went to Seattle for a similar scan not available in Vancouver; my neurosurgeon at Mississauga hospital, (who went to Houston Texas, for aortic dissection surgery not available in Canada); Member of Parliament, Belinda Stronach (for timely breast cancer treatment); Mike Dyon, President of Brooks Canada (for immediate heart surgery, after being told he would have to wait six months here). And so on…

I suspect that most Canadian doctors, higher medical bureaucrats, and top scientists, are in this First Tier. They preach the justice of socialized medicine for everyone else – and it is true some of them insist on waiting their turn, like everyone else. But a lot of them drive high-end cars, live in tier-one homes, and send their kids to tier-one private schools. And my bet is that a lot of them go to the USA for treatment, too.

Tier Two – Those Who Live Far From a Big City

This Tier is comprised of all those Canadians who cannot get medical treatment as conveniently as others because they live far away from the big towns and cities. A person from Inuvik or Elliot Lake, who needs complex surgery or diagnosis will have to travel to get what city dwellers can take a short bus ride to get. They will have incurred considerable expenses for hotel, travel, and food in the process.


Tier Three – Those Highly Educated and Articulate

.           A further cynical consequence of government medicine is the market it creates for various kinds of persuasion and influence. There is overlap with Tier One folks here, but getting into a Canadian hospital quickly has a lot to do with who you may know, whether or not you are wealthy. Here’s a view of this that still rings true from Quebec economist Pierre Lemieux:

In Quebec, you can be relatively sure not to wait six hours with your sick child in an emergency room if you know how to talk to the hospital director, or if one of your old classmates is a doctor, or if your children attend the same private school as your pediatrician’s children. You may get good service if you deal with a medical clinic in the business district.[3]

Lemieux adds the insight that “we often forget that people who have difficulty making money in the market, are not necessarily better at jumping queues in a socialized system.”


 Tier Four:  Those With Influence and Celebrity Status

If  you are a very well-known social figure, an important politician or government figure, or an idolized NHL, basketball, baseball, or football star, or a medal-winning Olympian, you will already know who you have to call to jump the queue. Your adoring fans in the system will pave the way. Most well-known physicians are in this category of stars, too. Medicine is a very close fraternity, and very few medical experts wait for treatment in the hallways of our hospitals.

There is a good argument that important people such as the Prime Minister, perhaps a handful of other key government personnel, police, RCMP, and Military folks should be able to jump the queue because they represent us or protect us and we need them to get well quickly. No argument there. That is a justifiable tier within a tier.


Tier Five:  Those In General Triage Who Are Wait-Listed

This is the Canadian General “Tier-in-Waiting” comprised of the 750,000 mentioned above who do not have enough money, or smarts, or motivation, or influence to make it into Tier One. Mostly they are old people with complex conditions. Many of them are in pain and suffering, and many wait with fear that each day of delay could mean a worsening of their condition. These are obviously not the same people every year. So how many Canadians have been members of this Tier since 1970? About two million would be a good guess.


Tier Six – Triage Within Triage: The Worst-Case Wait-List

A surgeon in B.C. explained how this works. In that province, a surgeon is allotted 6 hours a week of surgery time in hospital. Easy cases (hernias, gall bladders, arthroscopies, and the like) and healthier patients (younger and low risk) are easier to do. So the surgeon will naturally line his patients up in priority from easiest to toughest (most time-consuming) to get as many through in his six hours per week as possible. The tough cases go to the end of the line, and end up waiting the longest for treatment, and get bumped more often. Many patients report being prepped and ready for surgery many times over, only to get bumped yet again. If you are old, unhealthy, or need a difficult surgery, you will wait longest, possibly years.


Tier Seven  – All Who Suffer or Die in the System

This is the smallest, but saddest tier. They live through the horrors of Tiers Five or Six, but never get treated. Some are sent home because while waiting for months on end their conditions worsened so much they become untreatable.  No one has a tally of how many have been dumped into this tier since the 1970s. In Ontario 71 patients died in 1999 while waiting for coronary surgery, and another 121 had gotten too sick for surgery while waiting and had to be sent home.[4] As mentioned at the head of this chapter, there were twelve obese patients in Canada who died in 2007 due to withheld surgery – another instance of death-by-rationing. This is a plain scandal.


Tier Eight – Those Canadians Who Cannot Find a Regular Physician

            Statistics Canada reported that in 2007, nearly 1.7 million Canadians over the age of 12 could not find a regular physician. (See Canadian Community Health Survey, The Daily News (June 18, 2008), at How is health care “accessible” and “universal” if you cannot find a physician?


[1] Ontario’s Ministry of Health and Long Term Care writes on its website…/hu_medicare.html  that one of the purposes of Ontario’s Commitment to the Future of Medicare Act (which became law on June 17, 2004), and which softens the penalty provisions of the Health Care Accessibility Act it replaced, is “strengthening the prohibition of “two-tier” medicine by closing legislative loopholes that allow queue-jumping and extra billing.” The Ministry’s website gives telephone numbers encouraging citizens to report physicians for any extra billing (charging more than the allowable government fee).

[2] These penalties were part of Ontario’s original Health Care Accessibility Act.

[3] Pierre Lemieux, “Socialized Medicine: The Canadian Experience,” in The Freeman (Irvington-on-Hudson: Foundation for Economic Education), March 1988, p. 99.

[4] Richard F. Davies, “Waiting Lists for Health Care: A Necessary Evil?” Canadian Medical

Association Journal 160, no. 10 (May 18, 1999): 1469-70


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