Politics drives privatization views: half of CPC voters are proponents, most NDP voters are public purists
February 27, 2023 – As the federal government holds one-on-one meetings with the country’s premiers to hash out the details of $46-billion injection of funds into Canada’s health system, the debate over privatization continues with some jurisdictions increasingly exploring private care options as the new money becomes within reach.
A new study from the non-profit Angus Reid Institute finds Canadians divided about privatization – and disagreement over how to define it.
Notably, although the federal government has been explicit that it wants the new money it releases to go to “strengthening the public system,” Prime Minister Justin Trudeau has praised a move to cut wait times in Ontario by publicly funding surgeries at private clinics.
Evaluating and scoring responses from 11 different questions about health-care delivery, the Angus Reid Institute finds that Canadians are of three mindsets about the prospect of increasing privatization in Canadian health care.
Two-in-five (39%) are Public Health Purists: they see little to no place for privatization and say any movement in this direction only exacerbates current challenges within the system.
On the other end of the spectrum, approximately three-in-ten (28%) are Private Care Proponents: they say increasing privatization is a necessary evolution in Canadian health care and are supportive of seeing a host of hybrid care options from other countries such as Australia, Germany, and Britain brought to their own provinces.
In the middle are the Curious but Hesitant (33%), who are sympathetic to elements of both sides of the debate. This group finds potential value in concepts such as contracting for-profit doctors to work in public facilities and paying for operations to be done in the private network through Medicare. They express deep concern, however, about just how far to go, citing concerns about the access of low-income Canadians, and the potential exacerbating of staffing shortages.
As this discussion evolves, definitions are important. Many Canadians are at odds over just what constitutes “privatization” of health care. Though Ontario is the latest province to publicly fund surgeries at private clinics to help eliminate the lengthy wait lists caused by the COVID-19 pandemic, Alberta and Saskatchewan had previously done the same. Half (51%) of Canadians say this decision by these three provinces does constitute privatization. However, one-third (33%) disagree.
Where there is more consensus is on the concept of individuals paying out of pocket for treatment. This is viewed as privatization seven-in-ten (71%) of Canadians. One-in-five (18%) disagree, and another one-in-ten (11%) are unsure.
On both concepts – publicly funding surgeries at private clinics and patients paying out-of-pocket for needed treatments – there is delineation among the three health-care mindsets, but not complete agreement. Nearly all (89%) of Public Health Purists believe the latter should be defined as privatization. More than half (55%) of Private Care Proponents agree, but one-third (36%) say that is not privatization.
There is more division among those groups of Canadians on the issue of publicly funding surgeries at private clinics. Most Public Health Purists (71%) say this is privatization but one-in-five (19%) disagree. There is less consensus among the Curious but Hesitant (39% say it is privatization, 34% not) and Private Proponents (38%, 52%).
More Key Findings:
- Two-in-five in Alberta (43%) and Saskatchewan (42%) and half in Manitoba (49%) and Ontario (54%) believe provinces are intentionally ruining public health care to make private care look better.
- Nearly all (96%) Public Purists believe more private health care will exacerbate staffing shortages in public health care. Three-in-ten (28%) Private Proponents agree, but most (60%) don’t hold that view.
- Three-quarters of those living in households earning less than $100,000 annually believe lower income Canadians will suffer more if privatization increases. Two-thirds in the highest income households agree.
- Two-in-five (42%) say more privatization will increase innovation in health care. This belief is much stronger among Private Proponents (85%) than Public Purists (13%).
About ARI
The Angus Reid Institute (ARI) was founded in October 2014 by pollster and sociologist, Dr. Angus Reid. ARI is a national, not-for-profit, non-partisan public opinion research foundation established to advance education by commissioning, conducting and disseminating to the public accessible and impartial statistical data, research and policy analysis on economics, political science, philanthropy, public administration, domestic and international affairs and other socio-economic issues of importance to Canada and its world.
INDEX
Part One: The health care debate
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Health Care in Canada: Three Mindsets
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Public Health Purists, Curious but Hesitant, Private Care Proponents – who are they?
Part Two: What is private care?
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Half say more private care will worsen the system; one-in-three say it would help
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Disagreement over definitions
Part Three: Gauging private care options
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What if your province allowed pay-for-access?
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Health-Care Delivery in Other Countries
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Australia
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United Kingdom
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Germany
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Part Four: The arguments for and against privatization
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Low-income access, staffing shortages
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Innovation and productivity
Appendix
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Health-Care Mindsets scoring
Part One: The health care debate
Click for Full-Size Image
After years of challenges and little sign of abatement, Canadians are clearly worried about health care. The road to fixing Canada’s health-care system may be a long one, but many are hoping for improvement as a much-anticipated $46-billion funding deal from the federal government was agreed upon by the provinces and territories. But it may only be a start – the premiers are asking for regular reviews of health-care funding and say the new money is not enough to address all of the needs of their health-care systems.
All parties involved will now turn their attention to finalizing individual bilateral agreements with the federal government to receive their additional health transfers. Five of these deals have been agreed to already. As this unfolds, provinces continue to explore privately-delivered, but publicly-funded, health care, leading some to question just where this new funding will go.
Private care already exists in Canada in many forms. In British Columbia, a person can pay outside of the public system for an MRI, CT scan, or ultrasound. In Ontario, the government has introduced plans to offload more public care into the already existing private marketplace – though procedures eligible for this transfer would be covered by the Ontario Health Insurance Plan.
Notably, in one of the earliest cases of private clinics being allowed to perform surgeries covered by the public health system, Quebec lifted the ban on private health insurance for total hip replacement, knee replacement and cataracts in the wake of the 2005 Supreme Court case Chaoulli v. Quebec.
Debates about health care in Canada tend to volley back and forth between privatization and public care – one side or the other. The Angus Reid Institute used responses from 11 different questions about health-care delivery, scoring respondents on their support or opposition to private care, and developed three Health-Care Mindsets that go beyond the black and white. For Index scoring, please view the Appendix.
Health Care in Canada: Three Mindsets:
Public Health Purists, Curious but Hesitant, Private Care Proponents – who are they?
Broadly speaking, there are three groups in Canada when it comes to views of health care and privatization. There are:
- Those who are staunch supporters of current public universal care – the Public Health Purists
- Those who are enthusiastically supportive of privatization efforts – the Private Care Proponents
- Those who see value in both sides of the debate – the Curious but Hesitant.
All three mindsets are found across age, gender, income, education and political demographics. That said, each mindset is home to unique characteristics:
Public Health Purists
- 49 per cent of women aged 55 years and older are in this category
- Two-thirds of past NDP voters (68%) and 52 per cent of past Liberal voters are Purists
- Perhaps in response to recent developments in Ontario, Ontarians are most likely to be Purists relative to any other region or province in the country (47%)
- Half (49%) of those with a university education are Public Health Purists
Private Care Proponents
- Men of all ages more are likely to be Private Care Proponents, including 35 per cent of men 35-54
- Half of past Conservative voters (50%) are Private Care Proponents
- Most likely to be found in Saskatchewan (40%) and Alberta (36%)
- Tend to be higher income: 41% living in households earning $200K+ are in this group
- Evenly distributed across all education levels
Curious but Hesitant
- At least 28 per cent of each age and gender demographic
- 45 per cent of women 18-34 are Curious but Hesitant
- At least one-quarter of all past supporters of Canada’s major political parties
- Most likely to be found in Quebec (45%) – perhaps because of the province’s early dabbling in private care post Chaoulli v. Quebec
- Tend to be lower income: 40 per cent of Canadians in households earning less than $50K are in this group
- More likely to have high school education or less (38%)
Part Two: What is private care?
The Canadians who championed universal public health care, Tommy Douglas, Lester B. Pearson, Woodrow Lloyd, and others are fondly remembered for the legacy they helped to establish. But the picture in Canada is changing as the health care crisis persists.
Since the landmark Chaoulli v. Quebec Supreme Court in 2005, Canadian provinces have begun tapping the private system to provide health-care services historically offered by the public system. Ontario is the latest province to allow private clinics to perform surgeries. Premier Doug Ford’s government believes private clinics can help combat the lengthy waitlists that are a legacy of the early part of the COVID-19 pandemic. Critics, including the opposition Ontario NDP, have raised the alarm, warning the province is on a path to a two-tiered, “American-style model” health-care system, prioritizing care for the rich at the expense of poor Ontarians.
Disagreement over definitions
However, there is a distinct lack of consensus over what “privatization” means. It’s important that public health figures and politicians understand and reflect this in discussions.
To further this point, researchers at ARI asked respondents to tell us whether examples of health-care delivery represent privatization to them or not. See the first example below:
“There’s been a lot of discussion, but less agreement about what it means to “privatize” health care in Canada. Some people say it means patients paying out of their own pockets to receive needed treatment. Others say user fees are already part of the health-care system and this is not what’s meant by privatized care.”
The first question asks about the concept of paying out of pocket for health care. This concept is perceived as privatization by most Canadians, including a majority (55%) of Private Care Proponents. One-in-five (18%) say this doesn’t necessarily represent privatization, because user fees are already a part of the health-care system:
A second example asks about the concept being explored in Ontario currently, using third party private clinics to perform care which is paid for through the public system.
“Some people say when any third party outside of the provincial health system delivers medical care – and it is paid for with public funds – that represents privatized health care, because it’s not being delivered by government. Other people say using public funds to pay third parties to perform health-care services, such as diagnostic tests or surgeries – does NOT represent the privatization of health care.”
On this concept, Public Health Purists and Private Care Proponents disagree, while the Curious but Hesitant lean slightly toward saying that this represents privatization (39%), but with significant groups both in disagreement (34%) and unsure (27%).
Half say more private care will worsen the system; one-in-three say it would help
There is no consensus from Canadians that a shift in approach would help the current conditions. Overall, close to half (45%) say that more private care will only worsen the situation. More than one-in-three (36%) feel that increased private delivery will help. Those who are proponents of either public or private care lean heavily to their own side of the debate on this question, while the Curious but Hesitant are most likely to be uncertain:
Questionnaire order is important. The Angus Reid Institute asked half of respondents this question about private care helping or hurting their province at the beginning of the survey, before discussing some prominent examples of privatization in Australia, Germany, and the United Kingdom. The other half were asked this question after this discussion took place. Those who went through the foreign examples first are less likely to feel privatization would worsen care (see the full questionnaire):
Despite the large part it plays in the legacy of Medicare, Saskatchewan is home to the highest levels of enthusiasm about what privatization could potentially bring to the health-care system. Much of the rest of the country is deeply divided:
Part Three: Gauging private care options
With so many Canadians evidently unsure of what constitutes privatization, concrete examples of hybrid systems in other countries were then presented to gauge support.
What if your province allowed pay-for-access?
As wait times continue to increase, Canadians are seeking private care for operations like knee and hip replacements. While the price tag can be in the tens of thousands of dollars, the juice is evidently worth the squeeze for some. While this band of care already exists in Canada, debate over its expansion continues to occupy many political leaders, advocates, and policy makers.
Canadians themselves are divided. More than two-in-five (43%) say that allowing patients to pay out of pocket for faster access to some surgeries is fine with them, while slightly more oppose this (47%). Notably, however, this idea is supported at higher levels than it is opposed in every region other than Ontario:
The Public Health Purists are heavily against the idea of paying to step out of the public queue, while Private Care Proponents near-unanimously support it. The Curious, are, true to form, open to the idea, but only so much:
For some, there is a time aspect to this debate. Two-in-five (40%), the largest group, say that they support an expansion of private care in the short term only as a tactic to clear the backlog of surgeries and tests. Just 38 per cent say this is fine either in the long term or in both the short and long term, while one-in-five (22%), including half of Public Health Purists (48%) say this is inappropriate at all times:
Health-Care Delivery in Other Countries
Australia
Health care is delivered in myriad forms, with different financing models, policies, and delivery systems from country to country. Many countries have incorporated private care into a hybrid public-private system. The Angus Reid Institute tested several of these concepts to better understand where exactly Canadians draw the line.
Australia is ranked by the Commonwealth Fund as having among the best health care in the world across 71 different measurables. That country also utilizes a hybrid system. The concept of purchasing private health insurance in order to access services that are not offered by the public system, and to have access to private hospitals, is something that divides Canadians. Asked if they would support this model in their own province, 46 per cent say yes and 42 per cent say no.
Another aspect of the Australian system receives more support. Doctors in Australia who work primarily in the private sector are eligible to do contract work in public care as well, if they so choose, allowing governments to increase available care if needed. Thinking again about their own province, three-in-five (60%) would allow this. In Canada, this is currently forbidden – doctors can go private, but have to opt out of the public system.
United Kingdom
The National Health Service in England has taken a battering in recent years, both in outcomes and public opinion. That country, too, continues to debate privatization, though only about seven per cent of public health expenditures are allocated to the private sector. (Notably, this is lower than Canada, where 30 per cent of the money spent on health goes to the private system.) In the U.K., there are, however, private hospitals where some services are available. Half of Canadians support this concept for their own province, including 62 per cent of the Curious but Hesitant:
Germany
Another concept reveals the divide over perceived unequal access to health care based on income. In Germany, every citizen must have health insurance – most of which is through the public care network. That said, Germans who earn above a certain income threshold are able to opt out and purchase a private option. This latter type of insurance covers more services and includes access to private hospitals. As such, those with higher incomes and private insurance tend to have better health outcomes.
This dual system is deeply unpopular with Public Health Purists – nine-in-ten of whom reject the idea for their own province. Further, those who are Curious but Hesitant are also more likely to oppose this, though by a slim margin. Overall, one-in-three (36%) support the German concept while half (52%) reject it:
Part Four: The arguments for and against privatization
There appear to be two significant causes of consternation for those who either oppose privatization or are on the fence about it: access for low-income individuals and the potential exacerbation of already considerable challenges surrounding staffing shortages.
Low-income access, staffing shortages
At least 62 per cent in every region say that they worry about access for lower-income Canadians, and seven-in-ten (71%) say this overall. A similar amount (68%) are worried that expanding private care will only worsen staffing shortages, which have plagued the country’s health-care system in recent years:
Herein lies the root of the “Hesitant” in the group named Curious but Hesitant. While they are generally more supportive of private solutions than the Public Health Purists, they are far more worried about the potential consequences of that transition than Private Care Proponents:
Innovation and productivity
Proponents of private health care often speak to the potential for innovation and productivity gains if for-profit actors are allowed to enter the space. While there is some evidence for efficiency gains in research published by National Center for Biotechnology Information – part of the United States Library of Medicine and funded by the U.S. government – Canadians tend to be less sold on these concepts in their own health-care system. The majority feel that privatization would not increase productivity in health care (56%), though 42 per cent do say that they feel medicine would see greater levels of innovation if private care were increased:
Evidently, many would like to see their own public system improved, with adequate staffing and investment levels. The provinces continue to negotiate with the federal government on the next decade’s worth of health-care funding, all the while a significant proportion of Canadians feel some are dragging their feet to make privatization appear a better option. This is a particularly strong opinion in Ontario and Manitoba, while British Columbians disagree at the highest levels:
Appendix:
For details on the scoring of the Canadian Health-Care Mindset groups, click here.
For the distribution of scores, click here.
Survey Methodology:
The Angus Reid Institute conducted an online survey February 1 – 4, 2023 among a representative randomized sample of 2,005 Canadian adults who are members of Angus Reid Forum. For comparison purposes only, a probability sample of this size would carry a margin of error of +/- 2 percentage points, 19 times out of 20. Discrepancies in or between totals are due to rounding. The survey was self-commissioned and paid for by ARI.
For detailed results by age, gender, region, education, and other demographics, click here.
For detailed tables by Health Care Index, click here
To read the full report, including detailed tables and methodology, click here.
To read the questionnaire in English and French, click here.
Image – Photo 121823129 / Health Care Canada © Viktor Birkus | Dreamstime.com
MEDIA CONTACT:
Shachi Kurl, President: 604.908.1693 [email protected] @shachikurl
Dave Korzinski, Research Director: 250.899.0821 [email protected]
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