A patient’s critique of the Québec health system

I’m going to be pretty critical of the health system here, so let me just preface this all by saying: I love public health care. I don’t think for-profit healthcare should exist. We should be putting our time and energy and money into making access to quality health care a universal human right that we can actually deliver on.

The critiques I’m making here are not because I think we should switch to private care and that would be better; I want to point out the problems the system presents for chronically ill people so that we can fix them.

Background

Coming from the US a bit less than a decade ago, I have to say I found the Canadian healcare system weird. Healthcare is a power delegated to the provinces in the Canadian constitution¹, so Canada in fact has many healthcare systems. But the federal government transfers funding to the provinces for healthcare, and as a condition of that funding, the provincial system has to meet certain standards including public administration and a certain level of accessibility.²

I only have experience with the Québec health system, so while many of the comments here might apply to other provinces as well, I’m not sure.

The good

At least pre-pandemic, my experience with getting acute care here was good. When I had a pretty concerning health issue (two new tumors popping up in the roof of my mouth, after having had a fairly substantial salivary gland tumor removed a few years prior), I was able to see both primary care and specialist doctors quickly, get an MRI within a couple of weeks, and have the minor surgery to remove them shortly after that. The care was good, the system was efficient, no complaints.

Even now, despite a significant shortage of primary care doctors (see next section), it’s quite easy for me to actually see a doctor when I need to. There’s a number I can call for a quick phone evaluation that leads to an appointment within the next few days. (But also see next section: it’s basically starting from scratch every time, with a new evaluation with no prior context, no choice of which doctor to see, no ability to see the same doctor multiple times, and appointment slots that are about 7 minutes long.)

When I moved from the US, I was expecting it to be fantastic that my healthcare would be completely free (and it is!). What I wasn’t expecting was how amazing it is not to have the administrative burden that comes with the US healthcare system. There’s no bills here, no insurance coverage reports where you have to figure out how much you owe and to whom. You scan your healthcare card when you arrive, and that’s it. Test results generally end up in a central system where you can view them yourself, and your doctors can access them too. No trying to find a fax machine or get two doctors with different medical records systems to talk to each other. This is nice in the best of times, and absolutely critical when dealing with chronic illness that makes these kinds of tasks difficult.

When you do end up in a situation where the public system fails you and you want to go to the private system... it’s surprisingly inexpensive?³ I presume this is at least in part due to competition with a public system that in many cases provides high-quality, timely care. I’ve now gotten both a CT scan and primary care privately (fully out-of-pocket) here, and both were comparable to what I might have paid after insurance in the US on a plan with common levels of deductibles and coinsurance.

The bad

The primary care shortage and the GAP

Québec has a pretty serious primary care doctor shortage. There’s a long wait list to be assigned a doctor. When you sign up for the wait list, there’s a box you can check to indicate that you have a chronic illness and a field to indicate what it is, which is supposed to get you priority for assignment. I checked this box (I also have celiac disease), and I’m now in year 6 of waiting.⁴

I don’t have complete context on why this is; it had already started before I arrived in Canada, and it’s pretty far outside my area of expertise. From what I’ve been able to gather, it is in large part due to a succession of center-right and right-wing governments that are friendly to privatizing more of the healthcare system, and that have refused to allocate the funding necessary to have a functioning public primary care system.

Anecdotally, it seems that the waits are longer among people who requested doctors who speak English.⁵ This makes logical sense because doctors who can fully practice in English have many more options to leave the system here and go to other parts of Canada to practice, if conditions there are better. That said, I don’t know of a data source I can use to confirm or refute this claim, and I have greater exposure to the anglophone community and media, so it’s possible this is incorrect and just due to the bias of what I hear about in practice.

For a while, while on the waiting list, my only entrypoint into the healthcare system was via a same-day urgent care appointment, or the ER. The current government introduced a program called the GAP⁶ («guichet d’accès à la première ligne», or “primary care access point”) where you are assigned to a pool of doctors, and to get an appointment you call to get a brief phone screening, and the person on that call then assigns you an appointment with one of the doctors in your pool.

It’s actually pretty easy to see a doctor on short notice, certainly easier than places I’ve lived recently in the US. But that’s about where the nice parts end.

The GAP is totally unacceptable for chronic illness care. Every time you call to get an appointment, you have a fresh phone screen with someone who does not know your medical history, and you get to explain the entire context to them again so that they can once again conclude “oh yes, you do actually need medical care.” Then after you do that (which is usually a 20 minute phone call between intake and hold and explaining yourself to the person evaluating your call... not an easy undertaking for many people with chronic illness!), you get assigned an appointment with one of the doctors from your pool. This appointment is 10-but-actually-7 minutes (because the doctor is potentially seeing a new GAP patient every 10 minutes that day and needs time to jot down a note in the records system and hopefully sanitize their hands before the next appointment). It’s with any of the doctors from your pool, not necessarily one that you’ve seen before, and even if you have seen them before, they don’t remember you because they have potentially seen hundreds or thousands of patients from the pool every 10 minutes since you last chanced onto them months ago.

So the appointment usually goes like: you spend the first 4 minutes trying to fit in the entire history of your chronic illness to that point, the next two minutes being told without evidence by the doctor that you probably are just anxious and should exercise more, and then the final minute argumentatively trying to wrest anything useful out of that appointment at all.⁷ Then, repeat the whole process over from the beginning the next time you decide it’s gotten bad enough that you have to go back.

In theory, the GAP is supposed to be a temporary measure until such time as the government is able to fix the primary care situation. But we’re now in the 6th year of the «on verra»⁸ administration, and on n’a encore rien vu⁹ that could actually fix the problem, so I’m not optimistic. On my most cynical days, which are getting more and more common, the GAP seems rather like the kind of system one might design if one wanted to push the people who most need the healthcare system out of the healthcare system without making it look like that’s what the GAP is for.

I have therefore turned to the private system, which in aggregate with others who have done the same will surely be twisted by the right-wing government into a glowing example of how the private sector provides better care and therefore its role should be expanded (in turn lining the pockets of all their friends in the business). Even on my less cynical days, I believe that this—a greater role in healthcare for the private sector—is one of the outcomes the GAP was designed to facilitate, and it’s completely succeeding at this design goal.

Some other measures a government that was not trying to shift healthcare onto the private sector might have taken:

• paying primary care doctors more so it’s a more attractive specialty and doesn’t haemorrhage doctors to the private sector or other provinces. (This one even works for people who are really into letting markets sort things out!)
• providing better working conditions for primary care doctors. Seeing hundreds or thousands of patients as often as one every 10 minutes, which precludes providing the quality care that most doctors want to provide, is surely burning doctors out or pushing them to the private sector or other provinces or countries. They could stop mandating seeing patients in this way so that doctors could build meaningful relationships with their patients, which is better both for patients and for the retention of doctors.
• mandating that primary care doctors outside of the public system take a certain number of appointments a month for public system patients at public system rates, while a shortage still exists. This reduces the ability of the private sector to profit off the shortage (and also disincentivizes the private sector trying to make the shortage worse to profit more), and reduces the incentive of doctors to jump ship to the private sector. It also reduces the load on the public sector doctors, which hopefully also reduces burn-out and leads to better patient care.

The doctor choice problem

It’s very difficult here to move on from a doctor that’s not providing good care, even putting aside the current crisis level of the primary care shortage. You can request a reassignment of your primary care doctor, but that puts you back on the waiting list.

Even assuming I were to receive a doctor assignment tomorrow, that would be a 6 year wait time, so my “choice” if I don’t like my doctor and don’t think they’re providing me the care I need is to wait another 6 years to try again? With the average ratio of helpful to unhelpful primary care doctors I’ve experienced in my life, my current age of 39, and the fact that I have several potentially serious medical problems, there’s a significant possibility that I would not live long enough to be assigned a helpful primary care doctor.

Outside of crisis times, this would still not be good, even if the wait time were a more bureaucratically reasonable 3 months, for instance. If you’re changing doctors, you already have a medical problem for which you’re not getting the care you need.

This is often touted as one of the advantages of the private, market-based medical system in the US: if you don’t like your doctor, you can just pick a new one! And that is true, if you are very rich, or if for other reasons (like your particular employer) you manage to get one of the very best health plans. Otherwise, you’re stuck in a specific limited network of doctors. The best ones in the network are not taking new patients because people have already flocked to them and stayed there, so you’re likely to end up with an unhelpful doctor anyway.

I don’t know how to solve this, in either the US-style system or in a public system. We have a lot of primary care doctors who are frankly not very good at their jobs, and there is nothing incentivising them to change or pushing them out of the system if they don’t.

The usual discrimination

Like pretty much everywhere, the health system here continues to produce worse outcomes for women, indigenous people, black people, other people of color, trans people, nonbinary people, etc. etc. Basically anyone who is not a cis-het white male.

Being a cis-het white male myself, I can’t really usefully write on this topic on a blog about my own experiences, other than to say that this problem exists and is not acceptable, and that you should listen to the voices of the people being discriminated against.

The long tail list of services not covered

There’s a surprising number of things I’ve run into that are simply not covered by the provincial health plan. These include psychotherapy, take-home testing for sleep apnea, evaluation for ADHD, and until recently the flu vaccine (unless you were in certain high-risk groups). It was the neuropsychological evaluation for ADHD that concluded I likely had long covid brain damage which was the key to convincing a primary care doctor that I did in fact have long covid. That evaluation was not covered by insurance and was very expensive, and I have no idea what I would currently be doing if I had not been able to afford that.

While the rationale for covered vs. not covered services is whether something is supposedly a medically necessary procedure (in the general sense, not in a particular case), they have drawn the line in a very different place than I would have, and I assume there are many people out there not getting some pretty important care for financial reasons.

Fin

I have no particular conclusion here other than that the primary care system here in Québec is a mess, and it’s causing a lot of suffering. Action to fix it is desperately needed, and it needs to happen via the public sector so that health care can be a guaranteed human right for everyone.