Shawn Whatley says YES
Physician and author of the report “The Case for User Fees in Canada” (MLI, 2022)
User fees can’t fix all of medicare’s problems. But a properly designed user-fee program would increase efficiency and equity while decreasing overconsumption and waste.
Consider a common example. A mother brings her feverish crying child to a clinic. “Since we’re here already,” mom asks, “Could you see my other children too?” Most parents don’t waste time on minor symptoms. But having made the effort to get one (sick) child to the clinic, parents often want their other (mildly sick) children seen also. On any given day, a few patients will come to clinic with questions they would never have asked if they faced a small user fee.
Canada curbs consumption by rationing access to care. We limit spending and make everyone wait in line. Physicians are forced to say, “I simply can’t see your other kids. You can go to the emergency department if you’re worried.” Physicians get paid to see more patients, but often have no time to do so.
Twenty-nine OECD countries now have universal health care, and 21 of them include a patient fee at the point of service, with exemptions for the elderly, poor and chronically ill. User fees focus limited resources on those who need them most.
They also improve horizontal equity. For example, one patient with early osteoarthritis of their hip will follow instructions about weight loss and exercise to manage symptoms. They’ll get annual checkups, and eventually they’ll get a joint replacement. Another patient, with similar symptoms, will ignore advice, book appointments every few months, demand referrals to multiple specialists and ask for repeat CT scans until they too eventually need surgery. Given similar incomes and expenses, should patients pay the same for medical insurance if they show markedly different choices about medicare resources?
Despite the evidence supporting well-designed user fees, poorly designed fees cause real harm. Canada has already tried several bad designs. Vulnerable patients avoid necessary care and skip treatment with even the smallest fee. For this reason, modern fee programs have robust exemptions for the elderly, poor or chronically ill. Furthermore, fees don’t change patient behaviour for some services. No one seeks open-heart surgery because it goes on sale.
User fees reduce overconsumption and increase equity but don’t work well at raising revenue. In fact, focusing services on patients with the greatest needs might actually increase the cost of care overall. Morality, not economics, drives the case for fees.
Small, flat, easy-to-understand user fees work best. However, even well-designed fees would not be enough without other changes. We already have major barriers to care. Why charge $20 to see a doctor if a patient waits months to get seen?
User fees are like medication: we need the right agent for a particular patient with a specific problem in a defined setting. One size never fits all. Canada ruled out user fees 40 years ago. The latest evidence suggests they might help us today.
Shazma Mithani says no
Emergency physician at Royal Alexandra Hospital and Stollery Children’s Hospital
User fees to improve access to healthcare have been proposed for decades as a “solution” to growing use of the healthcare system. It’s no surprise they’ve come up again in the context of post-COVID healthcare system strain.
At a superficial level, the concept of user fees would make sense to most people. A nominal fee to access the system should prevent patients from overusing the system and lead to decreased emergency department overcrowding, shorter wait times, lower system costs and better patient outcomes, all while putting more money into the system, right?
Turns out it’s a lot more complicated than that. Data from around the world show us the exact opposite. User fees may deter unnecessary care, but they’re also really good at deterring necessary care.
Last year I treated a patient who presented to the ER with symptoms of a heart attack. They were driven to my community ER, where no cardiologist is on site, after deciding against taking an ambulance because of concerns about cost (an ambulance ride in Alberta, even for emergencies, costs about $350). If they had taken an ambulance, they would’ve been diagnosed with a heart attack by the paramedics and taken directly to a larger hospital with cardiology services. Instead I saw this patient in the community ER, diagnosed their heart attack, then had to transfer them to a larger hospital, all of which wasted precious time. As all doctors will tell you, in the context of a heart attack “time is muscle,” meaning that every minute of delay before opening up a blocked blood vessel leads to more heart muscle dying.
Many people think user fees curb “unnecessary” use of the healthcare system. Part of the problem with this narrative is that patients aren’t trained in medicine. It shouldn’t be up to a patient to decide the seriousness of their symptom before deciding whether it’s financially “worth it” to go in. Even for people who can afford to pay, as soon as a fee is involved, it leads to second-guessing, downplaying and, inevitably, delayed care. For almost all medical conditions, early intervention and treatment improves outcomes and ends up decreasing longer-term costs and use of the healthcare system.
When a patient with diabetes delays care and ends up having a severe complication such as diabetic ketoacidosis, what could have been a simple (and cost-effective) visit turns into an emergency resuscitation and multi-day hospital stay. When a patient with blood in their stool ends up waiting for their symptoms to become more severe, what could have been a simple polyp removal turns into months of chemotherapy, surgery to remove their missed colon cancer, and ongoing presentations to the ER with complications of their cancer.
Simply put, user fees lead to delays in care. These delays in care lead not only to increased financial costs, but costs to patient outcomes, quality of life and years of life.
shawn whatley responds to shazma mithani
Patients forgo necessary care if they face large, one-size-fits-all fees. Even small fees cause harm in poorly designed programs. Quebec and Saskatchewan tried ill-formed fee experiments, which caused low-income and elderly patients to skip treatment. Well-designed user fees include exemptions for specific patients and conditions. Clearly, we don’t need a fee on routine immunizations or screening for breast, colon and cervical cancers. Too many patients avoid preventive care already.
The best argument against user fees in Canada is Canadian medicare itself. We are world-famous for wait times and regulation. Adding user fees to medicare would add another roadblock to a system strangled with barriers to care.
This touches something buried beneath the user fee debate. When it comes to decisions about waiting and payment for care, Canada assumes someone other than the patient knows best. Dr. Mithani captures this sentiment when she writes, “Patients aren’t trained in medicine. It shouldn’t be up to a patient to decide the seriousness of their symptoms before deciding whether it’s financially ‘worth it’ to go in.”
Anti-patient ideas run deep in medicare. Dr. Charles Wright, a former Vancouver hospital administrator and wait list consultant said, “Administrators maintain waiting lists on purpose, the way airlines overbook. As for urgent patients on the list who are in pain, the public system will decide when their pain requires care. These are societal decisions. The individual is not able to decide rationally.” A former deputy minister of health of Ontario put it this way: “We have waiting lists for some procedures as a means of better organizing our system.”
The same sentiment applies to payment. A senior Canadian health researcher said, “I think we have to be very careful about empowering the consumer, because they will make choices that are not in their own health interests.” Canada’s foremost health economist, Bob Evans, agrees and writes that the “rational consumer” is a “highly dubious assumption.”
Canada built its system of “free care” in the 1960s, at the end of a peculiar period in history. The average Canadian was in their mid-20s, with few medical concerns. Older patients had survived the Second World War and the Depression. They knew how to protect a shared asset, such as medicare, and trusted government to manage it.
We built an all-you-can-eat health system for a population that ate very little. It now has an almost endless appetite.
Today the average Canadian is in their early 40s. The percentage of people over 65 has doubled. Trust in government has evaporated. Modern Canadians demand convenience, access and excellence in a way older generations never imagined. As a society, we’ve reverted to a more typical attitude towards shared resources, known as “the tragedy of the commons.” This is the tendency to overconsume shared assets to the point of destroying the asset itself. The Depression-era slogan “Use it up, wear it out, make it do, or do without” would never fly today.
This puts Canada in a bind. We built medicare for a population that no longer exists. Having built an all-you-can-eat healthcare system, for a population that ate very little, we now have a population with an almost endless appetite for care. So we scramble to limit access from behind the counter. Note, all countries must limit (ration) the amount of care patients can access. One extreme strategy is to base care entirely on a patient’s ability to pay for it. Canada stands at the opposite extreme: central planners control how much free care citizens are allowed to access.
Herein lies the crux. Health economist Victor Fuchs put it this way 50 years ago: “[A] basic point, often obscured in public discussions, is that the public must pay for care under any system of finance… even when the payment mechanism makes it appear that the bills are being sent elsewhere.” He added, “Financing systems can make a significant difference to families at the highest and lowest levels of income, but the average family will have to pay the same under any system.”
The heart of this debate isn’t about costs, crowding, wait times or outcomes. It’s about control. User fees place a crack in the assumption that planners know best—they’re a step toward a middle ground. User fees shift some decisional responsibility and power away from planners and toward patients themselves. In thousands of small decisions each day across the country, user fees would encourage patients to limit overconsumption and waste. This would improve efficiency and equity, thus improving overall welfare. These improvements remain beyond the reach of rationing or central control. Planners can’t compete with the mass of individual patient decisions.
Other countries find user fees essential. Canada would need a new mindset for user fees to work. Change is hard. But we need to change and consider things such as user fees, or we risk losing medicare itself.
shazma mithani responds to shawn whatley
The term “health care zombies,” which aptly describes terrible ideas in healthcare that refuse to die, was coined in 1998 by Barer et al. Healthcare user fees have long fallen into this category and will continue to do so.
In my opening argument I gave examples of why user fees simply don’t make sense. Patient stories are so valuable at illustrating a point, but as a physician I always look at the data. Dr. Whatley asserts that evidence suggests user fees may help the healthcare system, so let’s take a deeper look into what the evidence does show.
Most proponents of user fees make two main arguments: that fees will decrease use of the system and that they will help put money back into the system. Presumably the goal is to increase sustainability of the healthcare system.
I was happy to see Dr. Whatley acknowledge that user fees don’t serve to raise revenue. In fact the evidence shows that user fees can actually end up costing the system more, because of the administrative costs of collecting and accounting for these fees. A study in Quebec in 2010 showed that in order to generate enough revenue to make sense, fees would need to be quite high (for example, a fee of $65 per visit would have only contributed 2 per cent of that province’s $27-billion health budget). And these are 2010 numbers. In 2023–2024 Quebec’s healthcare expenditure was over $50-billion, meaning that a $65 user fee would now have an even smaller impact in offsetting healthcare costs.
This “revenue” narrative is also a favourite of governments who argue that user fees will help offset growing healthcare costs. The data clearly shows that user fees end up being expensive, inefficient and wasteful. The money used to administer fees could instead be used much more effectively to improve healthcare access. Further, the evidence is irrefutable that primary and preventive care reduces downstream health and hospital costs. Introducing user fees creates barriers to accessing primary care, which only ends up costing the system more in delayed and more complex healthcare.
User fees cause worse patient outcomes and deter patients from using the system when they need it.
As for the argument that user fees decrease healthcare utilization, the evidence is more nuanced than what Dr. Whatley presents. We can look back to when parts of Canada did have user fees. Back in the 1960s, Saskatchewan briefly introduced user fees. Data show that although the use of healthcare services in that province dropped, the decrease was most significant among people who were least able to afford to pay fees but most likely to need healthcare. In fact, contrary to Dr. Whatley’s suggestion that user fees increase equity, the evidence shows that fees actually diminish it.
The argument that user fees reduce healthcare utilization also ignores the fact that they also cause worse patient outcomes and higher mortality rates—far more important metrics to assess. A review from 2018 looks at these. The authors studied 17 countries and assessed whether lower out-of-pocket expenditures led to improved health. Not only did the data show that health outcomes improve when patients face lower out-of-pocket costs, it also showed reduced mortality in several countries. Lower out-of-pocket expenses for patients can literally be lifesaving.
This data should make one thing very clear: user fees deter patients from using the system for unnecessary and necessary reasons. It should never be up to patients to decide whether a visit to a clinic or the ER is warranted or not. And that mother with the feverish child should be able to have all of her other children seen in a primary care setting. Rather than increasing barriers to care or trying to deter people from seeking care, we should be focussed on removing barriers and optimizing access to care.
In particular, the focus should be on improving access to robust primary care. Good primary care prevents worsening chronic health conditions and subsequently reduces use of the healthcare system. When people have access to primary care, all it takes is a handful of appointments per year to manage diabetes, high blood pressure or high cholesterol (at a cost to the system of far less than $1,000/year). When these chronic health conditions are not regularly managed, it puts this same patient at risk of a heart attack, stroke or complications from their diabetes, with each hospital visit costing thousands of dollars per visit and even more when people require admission to hospital.
More work must be done to improve patients’ health literacy so that they better understand what options are available to address their health concerns and are better equipped to make decisions about their care and reduce unnecessary use of the healthcare system.
Is there overuse of the healthcare system? Sure. Are user fees the solution? No.
____________________________________________
